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Treatment and prevention of hyperkalemia in adults

INTRODUCTION

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 meq/L with chronic hyperkalemia or possibly at lower levels with an acute rise in serum potassium. (See "Clinical manifestations of hyperkalemia in adults".)

                               

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Literature review current through: Nov 2014. | This topic last updated: Dec 3, 2014.
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References
Top
  1. Mount DB, Zandi-Nejad K. Disorders of potassium balance. In: Brenner and Rector's The Kidney, 8th ed, Brenner BM (Ed), WB Saunders Co, Philadelphia 2008. p.547.
  2. Kamel KS, Wei C. Controversial issues in the treatment of hyperkalaemia. Nephrol Dial Transplant 2003; 18:2215.
  3. Winkler AW, Hoff HE, Smith PK. Factors affecting the toxicity of potassium. Am J Physiol 1939; 127:430.
  4. BRAUN HA, VAN HORNE R, BETTINGER JC, BELLET S. The influence of hypocalcemia induced by sodium ethylenediamine tetraacetate on the toxicity of potassium; an experimental study. J Lab Clin Med 1955; 46:544.
  5. Ferrannini E, Taddei S, Santoro D, et al. Independent stimulation of glucose metabolism and Na+-K+ exchange by insulin in the human forearm. Am J Physiol 1988; 255:E953.
  6. Pergola PE, DeFronzo R. Clinical disorders of hyperkalemia. In: The Kidney: Physiology and Pathophysiology, Seldin DW, Giebisch G (Eds), Lippincott Williams & Wilkins, 2000. Vol 2, p.1647.
  7. Allon M, Copkney C. Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients. Kidney Int 1990; 38:869.
  8. Allon M. Hyperkalemia in end-stage renal disease: mechanisms and management. J Am Soc Nephrol 1995; 6:1134.
  9. Goldfarb S, Strunk B, Singer I, Goldberg M. Paradoxical glucose-induced hyperkalemia. Combined aldosterone-insulin deficiency. Am J Med 1975; 59:744.
  10. Nicolis GL, Kahn T, Sanchez A, Gabrilove JL. Glucose-induced hyperkalemia in diabetic subjects. Arch Intern Med 1981; 141:49.
  11. Magnus Nzerue C, Jackson E. Intractable life-threatening hyperkalaemia in a diabetic patient. Nephrol Dial Transplant 2000; 15:113.
  12. Ahmed J, Weisberg LS. Hyperkalemia in dialysis patients. Semin Dial 2001; 14:348.
  13. Kim HJ, Han SW. Therapeutic approach to hyperkalemia. Nephron 2002; 92 Suppl 1:33.
  14. Lens XM, Montoliu J, Cases A, et al. Treatment of hyperkalaemia in renal failure: salbutamol v. insulin. Nephrol Dial Transplant 1989; 4:228.
  15. Emmett M. Non-dialytic treatment of acute hyperkalemia in the dialysis patient. Semin Dial 2000; 13:279.
  16. Blumberg A, Weidmann P, Shaw S, Gnädinger M. Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure. Am J Med 1988; 85:507.
  17. De Wolf A, Frenette L, Kang Y, Tang C. Insulin decreases the serum potassium concentration during the anhepatic stage of liver transplantation. Anesthesiology 1993; 78:677.
  18. Alvestrand A, Wahren J, Smith D, DeFronzo RA. Insulin-mediated potassium uptake is normal in uremic and healthy subjects. Am J Physiol 1984; 246:E174.
  19. Goecke IA, Bonilla S, Marusic ET, Alvo M. Enhanced insulin sensitivity in extrarenal potassium handling in uremic rats. Kidney Int 1991; 39:39.
  20. Clausen T, Everts ME. Regulation of the Na,K-pump in skeletal muscle. Kidney Int 1989; 35:1.
  21. Gosmanov AR, Wong JA, Thomason DB. Duality of G protein-coupled mechanisms for beta-adrenergic activation of NKCC activity in skeletal muscle. Am J Physiol Cell Physiol 2002; 283:C1025.
  22. Liou HH, Chiang SS, Wu SC, et al. Hypokalemic effects of intravenous infusion or nebulization of salbutamol in patients with chronic renal failure: comparative study. Am J Kidney Dis 1994; 23:266.
  23. Sowinski KM, Cronin D, Mueller BA, Kraus MA. Subcutaneous terbutaline use in CKD to reduce potassium concentrations. Am J Kidney Dis 2005; 45:1040.
  24. Ahee P, Crowe AV. The management of hyperkalaemia in the emergency department. J Accid Emerg Med 2000; 17:188.
  25. Allon M, Shanklin N. Effect of albuterol treatment on subsequent dialytic potassium removal. Am J Kidney Dis 1995; 26:607.
  26. BURNELL JM, SCRIBNER BH, UYENO BT, VILLAMIL MF. The effect in humans of extracellular pH change on the relationship between serum potassium concentration and intracellular potassium. J Clin Invest 1956; 35:935.
  27. SCHWARZ KC, COHEN BD, LUBASH GD, RUBIN AL. Severe acidosis and hyperpotassemia treated with sodium bicarbonate infusion. Circulation 1959; 19:215.
  28. Fraley DS, Adler S. Correction of hyperkalemia by bicarbonate despite constant blood pH. Kidney Int 1977; 12:354.
  29. Gutierrez R, Schlessinger F, Oster JR, et al. Effect of hypertonic versus isotonic sodium bicarbonate on plasma potassium concentration in patients with end-stage renal disease. Miner Electrolyte Metab 1991; 17:297.
  30. Blumberg A, Weidmann P, Ferrari P. Effect of prolonged bicarbonate administration on plasma potassium in terminal renal failure. Kidney Int 1992; 41:369.
  31. Allon M, Shanklin N. Effect of bicarbonate administration on plasma potassium in dialysis patients: interactions with insulin and albuterol. Am J Kidney Dis 1996; 28:508.
  32. Reardon LC, Macpherson DS. Hyperkalemia in outpatients using angiotensin-converting enzyme inhibitors. How much should we worry? Arch Intern Med 1998; 158:26.
  33. Ingelfinger JR. A New Era for the Treatment of Hyperkalemia? N Engl J Med 2014.
  34. Kosiborod M, Rasmussen HS, Lavin P, et al. Effect of sodium zirconium cyclosilicate on potassium lowering for 28 days among outpatients with hyperkalemia: the HARMONIZE randomized clinical trial. JAMA 2014; 312:2223.
  35. Packham DK, Rasmussen HS, Lavin PT, et al. Sodium Zirconium Cyclosilicate in Hyperkalemia. N Engl J Med 2014.
  36. Weir MR, Bakris GL, Bushinsky DA, et al. Patiromer in Patients with Kidney Disease and Hyperkalemia Receiving RAAS Inhibitors. N Engl J Med 2014.
  37. Sterns RH, Rojas M, Bernstein P, Chennupati S. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective? J Am Soc Nephrol 2010; 21:733.
  38. Joshi P, Beaulieu J, Shemin D. The effect of a single dose of polystyrene sulfonate (SPS) in hyperkalemic patients with kidney disease (abstract). J Am Soc Nephrol 2008; 19:335A.
  39. Gruy-Kapral C, Emmett M, Santa Ana CA, et al. Effect of single dose resin-cathartic therapy on serum potassium concentration in patients with end-stage renal disease. J Am Soc Nephrol 1998; 9:1924.
  40. Gales MA, Gales BJ, Dyer ME, Orr SR. Rectally administered sodium polystyrene sulfonate. Am J Health Syst Pharm 1995; 52:2813.
  41. SCHERR L, OGDEN DA, MEAD AW, et al. Management of hyperkalemia with a cation-exchange resin. N Engl J Med 1961; 264:115.
  42. FLINN RB, MERRILL JP, WELZANT WR. Treatment of the oliguric patient with a new sodium-exchange resin and sorbitol; a preliminary report. N Engl J Med 1961; 264:111.
  43. FLEISHER DS. Cation exchange resin therapy for hyperkalemia in infants and children. J Pediatr 1961; 58:486.
  44. Gerstman BB, Kirkman R, Platt R. Intestinal necrosis associated with postoperative orally administered sodium polystyrene sulfonate in sorbitol. Am J Kidney Dis 1992; 20:159.
  45. McGowan CE, Saha S, Chu G, et al. Intestinal necrosis due to sodium polystyrene sulfonate (Kayexalate) in sorbitol. South Med J 2009; 102:493.
  46. Lillemoe KD, Romolo JL, Hamilton SR, et al. Intestinal necrosis due to sodium polystyrene (Kayexalate) in sorbitol enemas: clinical and experimental support for the hypothesis. Surgery 1987; 101:267.
  47. Rashid A, Hamilton SR. Necrosis of the gastrointestinal tract in uremic patients as a result of sodium polystyrene sulfonate (Kayexalate) in sorbitol: an underrecognized condition. Am J Surg Pathol 1997; 21:60.
  48. Abraham SC, Bhagavan BS, Lee LA, et al. Upper gastrointestinal tract injury in patients receiving kayexalate (sodium polystyrene sulfonate) in sorbitol: clinical, endoscopic, and histopathologic findings. Am J Surg Pathol 2001; 25:637.
  49. Ng YY, Wu SC, Cheng CT, et al. Reduction of serum calcium by sodium sulfonated polystyrene resin. J Formos Med Assoc 1990; 89:399.
  50. Berlyne GM, Janabi K, Shaw AB. Dangers of resonium A in the treatment of hyperkalemia in renal failure. Lancet 1966; 1:167.
  51. Scott TR, Graham SM, Schweitzer EJ, Bartlett ST. Colonic necrosis following sodium polystyrene sulfonate (Kayexalate)-sorbitol enema in a renal transplant patient. Report of a case and review of the literature. Dis Colon Rectum 1993; 36:607.
  52. Wootton FT, Rhodes DF, Lee WM, Fitts CT. Colonic necrosis with Kayexalate-sorbitol enemas after renal transplantation. Ann Intern Med 1989; 111:947.
  53. Cheng ES, Stringer KM, Pegg SP. Colonic necrosis and perforation following oral sodium polystyrene sulfonate (Resonium A/Kayexalate in a burn patient. Burns 2002; 28:189.
  54. Goutorbe P, Montcriol A, Lacroix G, et al. Intestinal Necrosis Associated with Orally Administered Calcium Polystyrene Sulfonate Without Sorbitol (February). Ann Pharmacother 2011.
  55. Rugolotto S, Gruber M, Solano PD, et al. Necrotizing enterocolitis in a 850 gram infant receiving sorbitol-free sodium polystyrene sulfonate (Kayexalate): clinical and histopathologic findings. J Perinatol 2007; 27:247.
  56. Joo M, Bae WK, Kim NH, Han SR. Colonic mucosal necrosis following administration of calcium polystryrene sulfonate (Kalimate) in a uremic patient. J Korean Med Sci 2009; 24:1207.
  57. Nolph KD, Popovich RP, Ghods AJ, Twardowski Z. Determinants of low clearances of small solutes during peritoneal dialysis. Kidney Int 1978; 13:117.
  58. Blumberg A, Roser HW, Zehnder C, Müller-Brand J. Plasma potassium in patients with terminal renal failure during and after haemodialysis; relationship with dialytic potassium removal and total body potassium. Nephrol Dial Transplant 1997; 12:1629.
  59. Allon M. Medical and dialytic management of hyperkalemia in hemodialysis patients. Int J Artif Organs 1996; 19:697.
  60. De Nicola L, Bellizzi V, Minutolo R, et al. Effect of dialysate sodium concentration on interdialytic increase of potassium. J Am Soc Nephrol 2000; 11:2337.
  61. Redaelli B, Locatelli F, Limido D, et al. Effect of a new model of hemodialysis potassium removal on the control of ventricular arrhythmias. Kidney Int 1996; 50:609.
  62. Allon M, Takeshian A, Shanklin N. Effect of insulin-plus-glucose infusion with or without epinephrine on fasting hyperkalemia. Kidney Int 1993; 43:212.
  63. Palmer BF. Managing hyperkalemia caused by inhibitors of the renin-angiotensin-aldosterone system. N Engl J Med 2004; 351:585.
  64. Knoll GA, Sahgal A, Nair RC, et al. Renin-angiotensin system blockade and the risk of hyperkalemia in chronic hemodialysis patients. Am J Med 2002; 112:110.
  65. Castellino P, Bia MJ, DeFronzo RA. Adrenergic modulation of potassium metabolism in uremia. Kidney Int 1990; 37:793.