Hyperkalemia is a common clinical problem that is most often a result of impaired urinary potassium excretion due to acute or chronic kidney disease (CKD) and/or disorders or drugs that inhibit the renin-angiotensin-aldosterone axis. Therapy for hyperkalemia due to potassium retention is ultimately aimed at inducing potassium loss [1,2].
In some cases, the primary problem is movement of potassium out of the cells, even though the total body potassium may be reduced. Redistributive hyperkalemia most commonly occurs in uncontrolled hyperglycemia (eg, diabetic ketoacidosis or hyperosmolar hyperglycemic state). In these disorders, hyperosmolality and insulin deficiency are primarily responsible for the transcellular shift of potassium from the cells into the extracellular fluid, which can be reversed by the administration of fluids and insulin. Many of these patients have a significant deficit in whole body potassium and must be monitored carefully for the development of hypokalemia during therapy. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment", section on 'Potassium replacement'.)
The treatment and prevention of hyperkalemia will be reviewed here. The causes, diagnosis, and clinical manifestations of hyperkalemia are discussed separately. (See "Causes and evaluation of hyperkalemia in adults" and "Clinical manifestations of hyperkalemia in adults".)
URGENCY OF THERAPY
The urgency of treatment of hyperkalemia varies with the cause and the presence or absence of the symptoms and signs associated with hyperkalemia. In addition, patients with marked tissue breakdown (eg, rhabdomyolysis, crush injury, tumor lysis syndrome) release large amounts of potassium from the cells, which can lead to rapid and substantial elevations in serum potassium. Thus, these patients should receive aggressive therapy to remove potassium even if there is only a mild degree of hyperkalemia. (See "Crush-related acute kidney injury (acute renal failure)" and "Tumor lysis syndrome: Definition, pathogenesis, clinical manifestations, etiology and risk factors" and "Prevention and treatment of heme pigment-induced acute kidney injury (acute renal failure)".)
The most serious manifestations of hyperkalemia are muscle weakness or paralysis, cardiac conduction abnormalities, and cardiac arrhythmias, including sinus bradycardia, sinus arrest, slow idioventricular rhythms, ventricular tachycardia, ventricular fibrillation, and asystole. These manifestations usually occur when the serum potassium concentration is ≥7.0 meq/L with chronic hyperkalemia or possibly at lower levels with an acute rise in serum potassium. (See "Clinical manifestations of hyperkalemia in adults".)