Hyperkalemia medical therapy: Difference between revisions

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Latest revision as of 03:14, 6 September 2022

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2] Jogeet Singh Sekhon Syed Ahsan Hussain, M.D.[3]

Overview

Treatment of hyperkalemia includes lowering of serum potassium levels,cardiac membrane stabilization and removal of excess potassium from the body.When arrhythmias occur, or when potassium levels exceed 6.5 mmol/l, emergency lowering of potassium levels is mandated. Several agents are used to lower potassium levels. Choice depends on the degree and cause of the hyperkalemia, and other aspects of the patient's condition.Treatment also depends on the cause of hyperkalemia.

The treatment of hyperkalemia is CKD has been reviewed^[1].

Medical Therapy

Pharmacological therapy in hyperkalemia is dependent on serum potassium levels and the development of symptoms.^[2]
Therapy 1 is used in hyperkalemic emergency(emergency lowering of serum K+ required) which is :
- Serum potassium level >6.5 mEq/L
- ECG changes present.
- Serum K+ >5.5 mEq/L and patient has severe renal impairment.
Therapy 2 is used when emergency lowering of potassium levels not required:

Medical management

1.Hyperkalemic emergency

1.1. Pharmacotherapy

1.1.1. Cardiac membrane stabilization

Preferred regime:Calcium gluconate 10% 0.5ml/kg IV loading dose.(contraindicated in digoxin toxicity and hypercalcemia)^[3]

Alternate regime:Magnesium sulfate 2gm IV over 5 minutes(in digoxin toxicity and hypercalcemia)

1.1.2. Increase potassium shift from extracellular to intracellular spaces

Preferred regime(1):IV insulin with 2.5-5 ml/kg/h 20% dextrose (0.5-1 g/kg/h) with insulin 0.2 units for every gram of glucose administered..^[4]^[5]

Preferred regime(2):Salbutamol nebulization: 2.5 mg if <25 kg and 5 mg if >25 kg.
Alternate regime:Sodium bicarbonate 8.4%- 1-2 mmol/kg IV over 30-60 min only in cases of acidosis.

1.1.3. Loop diuretics^[6]

Preferred regime:Furosemide 40mg IV laoding dose and then 1-2mg/kg/day tillpotassium levels <5.1 mEq/L.

1.2 Renal replacement therapy.^[7]

Haemodialysis ( when renal function is impaired)

2.When emergency lowering of serum K+ not required.

2.1. Pharmacotherapy

2.1.1. Gastrointestinal cation exchangers

Preferred regime:Polystyrene sulfonate (Calcium Resonium, Kayexalate) given 1g/kg/ PO till serum k+ <5.1 mEq/L.

2.1.2. Loop diuretics

Preferred regime:Furosemide 40mg/kg PO till serum K+ <5.1 mEq/L.

2.2 Renal replacement therapy

Haemodialysis(when renal function is impaired)

Contraindicated medications

Hyperkalemia is considered a relative contraindication to the use of the following medications:

Hyperkalemia (Serum potassium >5.5 mEq/L) is considered an absolute contraindication to the use of the following medications:

References

↑ Sarnowski A, Gama RM, Dawson A, Mason H, Banerjee D (2022). "Hyperkalemia in Chronic Kidney Disease: Links, Risks and Management". Int J Nephrol Renovasc Dis. 15: 215–228. doi:10.2147/IJNRD.S326464. PMC 9356601 Check |pmc= value (help). PMID 35942480 Check |pmid= value (help).
↑ Allon M (1995). "Hyperkalemia in end-stage renal disease: mechanisms and management". J Am Soc Nephrol. 6 (4): 1134–42. PMID 8589279.
↑ Ingelfinger JR (2015). "A new era for the treatment of hyperkalemia?". N Engl J Med. 372 (3): 275–7. doi:10.1056/NEJMe1414112. PMID 25415806.
↑ Alvestrand A, Wahren J, Smith D, DeFronzo RA (1984). "Insulin-mediated potassium uptake is normal in uremic and healthy subjects". Am J Physiol. 246 (2 Pt 1): E174–80. doi:10.1152/ajpendo.1984.246.2.E174. PMID 6364842.
↑ Blumberg A, Weidmann P, Shaw S, Gnädinger M (1988). "Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure". Am J Med. 85 (4): 507–12. PMID 3052050.
↑ Blumberg A, Weidmann P, Ferrari P (1992). "Effect of prolonged bicarbonate administration on plasma potassium in terminal renal failure". Kidney Int. 41 (2): 369–74. PMID 1552710.
↑ Allon M, Shanklin N (1995). "Effect of albuterol treatment on subsequent dialytic potassium removal". Am J Kidney Dis. 26 (4): 607–13. PMID 7573015.

[pmid35942480-1] Sarnowski A, Gama RM, Dawson A, Mason H, Banerjee D (2022). "Hyperkalemia in Chronic Kidney Disease: Links, Risks and Management". Int J Nephrol Renovasc Dis. 15: 215–228. doi:10.2147/IJNRD.S326464. PMC 9356601 Check |pmc= value (help). PMID 35942480 Check |pmid= value (help).

[pmid8589279-2] Allon M (1995). "Hyperkalemia in end-stage renal disease: mechanisms and management". J Am Soc Nephrol. 6 (4): 1134–42. PMID 8589279.

[pmid25415806-3] Ingelfinger JR (2015). "A new era for the treatment of hyperkalemia?". N Engl J Med. 372 (3): 275–7. doi:10.1056/NEJMe1414112. PMID 25415806.

[pmid6364842-4] Alvestrand A, Wahren J, Smith D, DeFronzo RA (1984). "Insulin-mediated potassium uptake is normal in uremic and healthy subjects". Am J Physiol. 246 (2 Pt 1): E174–80. doi:10.1152/ajpendo.1984.246.2.E174. PMID 6364842.

[pmid3052050-5] Blumberg A, Weidmann P, Shaw S, Gnädinger M (1988). "Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure". Am J Med. 85 (4): 507–12. PMID 3052050.

[pmid1552710-6] Blumberg A, Weidmann P, Ferrari P (1992). "Effect of prolonged bicarbonate administration on plasma potassium in terminal renal failure". Kidney Int. 41 (2): 369–74. PMID 1552710.

[pmid7573015-7] Allon M, Shanklin N (1995). "Effect of albuterol treatment on subsequent dialytic potassium removal". Am J Kidney Dis. 26 (4): 607–13. PMID 7573015.

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 {| class="infobox" style="float:right;"
 |-
-| [[File:Siren.gif|30px|link=hyperkalemia resident survival guide]]|| <br> || <br>
+| <figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline>[[File:Siren.gif|link=hyperkalemia resident survival guide|41x41px]]</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline>|| <br> || <br>
 | [[Hyperkalemia resident survival guide|Resident <br> Survival   <br> Guide]]
 |}
 {{Hyperkalemia}}
-{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]
+{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com] [[Jogeet Singh Sekhon]] {{SAH}}
 ==Overview==
-When arrhythmias occur, or when potassium levels exceed 6.5 mmol/l, emergency lowering of potassium levels is mandated. Several agents are used to lower potassium levels. Choice depends on the degree and cause of the hyperkalemia, and other aspects of the patient's condition.
+Treatment of hyperkalemia includes lowering of serum potassium levels,cardiac membrane stabilization and removal of excess potassium from the body.When [[Cardiac arrhythmia|arrhythmias]] occur, or when potassium levels exceed 6.5 mmol/l, emergency lowering of potassium levels is mandated. Several agents are used to lower potassium levels. Choice depends on the degree and cause of the hyperkalemia, and other aspects of the patient's condition.Treatment also depends on the cause of hyperkalemia.
+The treatment of hyperkalemia is [[CKD]] has been reviewed<ref name="pmid35942480">{{cite journal| author=Sarnowski A, Gama RM, Dawson A, Mason H, Banerjee D| title=Hyperkalemia in Chronic Kidney Disease: Links, Risks and Management. | journal=Int J Nephrol Renovasc Dis | year= 2022 | volume= 15 | issue=  | pages= 215-228 | pmid=35942480 | doi=10.2147/IJNRD.S326464 | pmc=9356601 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35942480  }} </ref>.
 ==Medical Therapy==
-* [[Calcium]] supplementation (calcium gluconate 10% (10ml), preferably through a [[central venous catheter]] as the calcium may cause [[phlebitis]]) does not lower potassium but decreases [[myocardium|myocardial]] excitability, protecting against life threatening [[arrhythmias]].
+*Pharmacological therapy in hyperkalemia is dependent on serum potassium levels and the development of symptoms.<ref name="pmid8589279">{{cite journal| author=Allon M| title=Hyperkalemia in end-stage renal disease: mechanisms and management. | journal=J Am Soc Nephrol | year= 1995 | volume= 6 | issue= 4 | pages= 1134-42 | pmid=8589279 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8589279  }} </ref>
-* [[Insulin]] (e.g. intravenous injection of 10-15u of (short acting) insulin (e.g. Actrapid) {along with 50ml of 50% dextrose to prevent hypoglycemia}) will lead to a shift of potassium ions into cells, secondary to increased activity of the [[sodium-potassium ATPase]].
+*Therapy 1 is used in hyperkalemic emergency(emergency lowering of serum K+ required) which is :
-* [[Bicarbonate]] therapy (e.g. 1 ampule (45mEq) infused over 5 minutes) is effective in cases of metabolic acidosis.  The bicarbonate ion will stimulate an exchange of cellular H<sup>+</sup> for Na<sup>+</sup>, thus leading to stimulation of the [[sodium-potassium ATPase]].
+**Serum potassium level >6.5 mEq/L
-* [[Salbutamol]] (albuterol, Ventolin<sup>®</sup>) is a β<sub>2</sub>-selective catacholamine that is administered by nebuliser (e.g. 10-20 mg).  This drug promotes movement of K into cells, lowering the blood levels.
+**ECG changes present.
-* [[Polystyrene sulfonate]] (Calcium Resonium, Kayexalate) is a binding resin that binds K within the intestine and removes it from the body by defecation. Calcium Resonium (15g three times a day in water) can be given by mouth. Kayexelate can be given by mouth or as an [[enema]]. In both cases, the resin absorbs K within the intestine and carries it out of the body by [[defecation]].  This medication may cause diarrhea.
+**Serum K+ >5.5 mEq/L and patient has severe renal impairment.
-* Refractory or severe cases may need [[dialysis]] to remove the potassium from the circulation.
+*Therapy 2 is used when emergency lowering of potassium levels not required:
-* Preventing recurrence of hyperkalemia typically involves reduction of dietary potassium, removal of an offending medication, and/or the addition of a [[diuretic]] (such as [[furosemide]] (Lasix<sup>®</sup>) or [[hydrochlorothiazide]]).
-* [[Patiromer]] anion is a potassium binding ion cation exchange polymer that increases the [[gastrointestinal]] excretion of potassium ( it is available in 8.4, 16.8, and 25.2 gram powder in packets).  [[Patiromer]] should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action.
+=== Medical management ===
+==== 1.Hyperkalemic emergency ====
+.1. Pharmacotherapy
+.1.1. Cardiac membrane stabilization
+*Preferred regime:Calcium gluconate 10% 0.5ml/kg IV loading dose.(contraindicated in digoxin toxicity and hypercalcemia)<ref name="pmid25415806">{{cite journal| author=Ingelfinger JR| title=A new era for the treatment of hyperkalemia? | journal=N Engl J Med | year= 2015 | volume= 372 | issue= 3 | pages= 275-7 | pmid=25415806 | doi=10.1056/NEJMe1414112 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25415806  }} </ref>
+*Alternate regime:Magnesium sulfate 2gm IV over 5 minutes(in digoxin toxicity and hypercalcemia)
+.1.2. Increase potassium shift from extracellular to intracellular spaces
+* Preferred regime(1):IV insulin with 2.5-5 ml/kg/h 20% [[dextrose]] (0.5-1 g/kg/h) with insulin 0.2 units for every gram of glucose administered..<ref name="pmid6364842">{{cite journal| author=Alvestrand A, Wahren J, Smith D, DeFronzo RA| title=Insulin-mediated potassium uptake is normal in uremic and healthy subjects. | journal=Am J Physiol | year= 1984 | volume= 246 | issue= 2 Pt 1 | pages= E174-80 | pmid=6364842 | doi=10.1152/ajpendo.1984.246.2.E174 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6364842  }} </ref><ref name="pmid3052050">{{cite journal| author=Blumberg A, Weidmann P, Shaw S, Gnädinger M| title=Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure. | journal=Am J Med | year= 1988 | volume= 85 | issue= 4 | pages= 507-12 | pmid=3052050 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3052050  }} </ref>
+*Preferred regime(2):Salbutamol nebulization: 2.5 mg if <25 kg and 5 mg if >25 kg.
+* Alternate regime:Sodium bicarbonate 8.4%- 1-2 mmol/kg IV over 30-60 min only in cases of [[acidosis]].
+.1.3. Loop diuretics<ref name="pmid1552710">{{cite journal| author=Blumberg A, Weidmann P, Ferrari P| title=Effect of prolonged bicarbonate administration on plasma potassium in terminal renal failure. | journal=Kidney Int | year= 1992 | volume= 41 | issue= 2 | pages= 369-74 | pmid=1552710 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1552710  }} </ref>
+* Preferred regime:Furosemide 40mg IV laoding dose and then 1-2mg/kg/day tillpotassium levels <5.1 mEq/L.
+.2 Renal replacement therapy.<ref name="pmid7573015">{{cite journal| author=Allon M, Shanklin N| title=Effect of albuterol treatment on subsequent dialytic potassium removal. | journal=Am J Kidney Dis | year= 1995 | volume= 26 | issue= 4 | pages= 607-13 | pmid=7573015 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7573015  }} </ref>
+*Haemodialysis ( when renal function is impaired)
+==== 2.When emergency lowering of serum K+ not required. ====
+.1. Pharmacotherapy
+.1.1. Gastrointestinal cation exchangers
+*Preferred regime:[[Polystyrene sulfonate]] (Calcium Resonium, Kayexalate) given 1g/kg/ PO till serum k+ <5.1 mEq/L.
+.1.2. Loop diuretics
+*Preferred regime:Furosemide 40mg/kg PO till serum K+ <5.1 mEq/L.
+.2 Renal replacement therapy
+* Haemodialysis(when renal function is impaired)
-====Contraindicated medications====
+==== Contraindicated medications ====
 {{MedCondContrRel|MedCond = Hyperkalemia|Amiloride|Triamterene|Potassium chloride}}
 {{MedCondContrAbs|MedCond = Hyperkalemia (Serum potassium >5.5 mEq/L)|Eplerenone|Spironolactone|Hydrochlorothiazide}}
 ==References==
-{{reflist|2}}
 [[Category:Potassium]]
@@ Line 36: / Line 66: @@
 [[Category:Intensive care medicine]]
 [[Category:Needs overview]]
-{{WH}}
+<references />
-{{WS}}