What are the guideline sources, guidelines and references for Hyperkalemia ?
Guideline sources The following summarized guidelines for the evaluation and management of hyperkalemia are prepared by our editorial team based on guidelines from the United Kingdom Kidney Association (UKKA 2020), the American Association of Family Physicians (AAFP 2015), and the Guidelines and Audit Implementation Network (GAIN 2014). 1 1 1 1 2 3 5 5 Definition Hyperkalemia refers to the presence of serum potassium levels > 5.0 mmol/L. 1 Epidemiology Hyperkalemia is caused by excess potassium intake, impaired potassium excretion, or transcellular shifts. The etiology of hyperkalemia is often multifactorial, with impaired renal function, medication use, and hyperglycemia as the most common contributors. 1 Pathophysiology https://web.pathway.md/diseases/recU1AS4qWgwSAVUQ 1/8 6/24/23, 12:45 PM Hyperkalemia Pathway In the United States, the prevalence of hyperkalemia is estimated at 1550 per 100,000 population. 5 Disease course Manifestations of severe hyperkalemia include muscle weakness, ascending paralysis, heart palpitations, and paresthesias. Typical electrocardiographic changes include peaked T waves, P- wave flattening, PR-interval prolongation, widening of the QRS complex, and sine waves. 5 Prognosis and risk of recurrence Severe untreated hyperkalemia can lead to malignant cardiac arrhythmias and cardiac arres. 1 Guidelines 1. Screening and diagnosis Indications for screening: obtain regular blood monitoring at a frequency (2-4 times per year) depending on the level of renal function and degree of proteinuria in patients with CKD, HF and/or diabetes being at risk for hyperkalemia. B Indications for repeated testing: As per UKKA 2020 guidelines: Obtain repeated serum K+ within 3 days or as soon as feasible if an episode of mild hyperkalemia (K+ 5.5-5.9 mmol/L) was detected unexpectedly in the community. B Obtain repeated serum K+ within 1 day if an episode of moderate hyperkalemia (K+ 6.0-6.4 mmol/L) was detected in the community. B As per GAIN 2014 guidelines, obtain a repeat serum potassium urgently in order to exclude pseudohyperkalemia, especially if hyperkalemia is an unexpected or isolated finding. E 2. Classification and risk stratification Severity grading: As per UKKA 2020 guidelines, use an early warning scoring system for urgent clinical assessment to assess the level of acuity in all patients with known or suspected hyperkalemia. B As per GAIN 2014 guidelines, classify the severity of hyperkalemia as follows: Situation Guidance Potassium 5.5-5.9 mmol/L Mild Potassium 6.0-6.5 mmol/L Moderate Severe https://web.pathway.md/diseases/recU1AS4qWgwSAVUQ 2/8 6/24/23, 12:45 PM Hyperkalemia Pathway Potassium 6.5 mmol/L or serum potassium 5.5mmol/L with ECG changes or symptoms (muscle weakness, flaccid paralysis, palpitations, or paresthesias). E 3. Diagnostic investigations Assessment for underlying cause: As per UKKA 2020 guidelines, elicit a comprehensive medical and drug history and perform a clinical examination to determine the cause of hyperkalemia in all patients presenting with hyperkalemia. B As per GAIN 2014 guidelines: Elicit a thorough medical history focusing on a history of renal disease and determination of the medications or fluids prescribed. E Perform a physical examination for causes of post-renal obstruction, such as bladder distension or prostatic hypertrophy. Catheterise if appropriate. E Laboratory tests: measure K+ from an arterial or venous blood sample using a point-of-care blood gas analyzer in emergencies whilst awaiting the results from a formal laboratory measurement. B Show 2 more Electrocardiography: As per UKKA 2020 guidelines, obtain urgent 12-lead ECG in all hospitalized patients with a serum K+ 6.0 mmol/L. B As per GAIN 2014 guidelines, obtain a 12-lead ECG in all patients with hyperkalemia. E 4. Medical management Indications for outpatient treatment: Initiate interventions to lower serum potassium in patients with a serum K+ 5.5 mmol/L. B Guide outpatient treatment of hyperkalemia by its severity and clinical condition of the patient. B Indications for urgent treatment: As per UKKA 2020 guidelines, admit patients with severe hyperkalemia (K+ 6.5 mmol/L) detected in the community for urgent hospital assessment and treatment. A Show 3 more As per AAFP 2015 guidelines, initiate urgent treatment for hyperkalemia in patients with any of the following: serum potassium > 6.5 mmol/L https://web.pathway.md/diseases/recU1AS4qWgwSAVUQ 3/8 6/24/23, 12:45 PM Hyperkalemia Pathway ECG changes physical signs or symptoms possible rapid-onset hyperkalemia underlying kidney disease, heart disease, or cirrhosis. B As per GAIN 2014 guidelines, initiate urgent treatment if the serum potassium is 6.5 mmol/L or hyperkalemia is accompanied by ECG changes or symptoms. E Discontinuation of contributing medications: As per UKKA 2020 guidelines: Withhold RAAS inhibitors during acute intercurrent illness (such as sepsis, hypovolemia and/or AKI) at all severities of hyperkalemia. B Discontinue RAAS inhibitors in patients with serum K+ 6 mmol/L not meeting the criteria for treatment with patiromer or sodium zirconium cyclosilicate. B As per GAIN 2014 guidelines: Discontinue all medications that can contribute to hyperkalemia, including: ACEIs ARBs potassium-retaining diuretics potassium-containing laxatives. E Discontinue -blockers and digoxin, if safe and feasible, as they prevent intracellular buffering of potassium and reduce the effectiveness of insulin-glucose and -2 agonists. E Intravenous calcium: As per UKKA 2020 guidelines, administer IV calcium chloride or calcium gluconate at an equivalent dose (6.8 mmol) in patients with hyperkalemia in the presence of ECG evidence of hyperkalemia. B As per AAFP 2015 guidelines, administer IV calcium in patients with manifestations of hyperkalemia on electriocardiogram. B As per GAIN 2014 guidelines: Administer 10 ml of IV calcium gluconate 10% over 2 minutes in patients with hyperkalemia with ECG abnormalities. E Consider administering additional 10 ml of IV calcium gluconate 10% every 10 minutes if improvement does not occur, until the ECG normalizes. Recognize that patients may require up to 50 ml of IV calcium gluconate and the effect of this intervention is transient (approximately 30-60 minutes). E Intracellular shifting, insulin/glucose: As per UKKA 2020 guidelines, administer insulin/glucose (10 units soluble insulin in 25 g glucose) by IV infusion for the treatment of severe hyperkalemia (K+ 6.5 mmol/L). B Show 2 more As per GAIN 2014 guidelines, administer 10 units of rapid-acting insulin combined with 50 mL of 50% glucose solution (25 g of glucose) by slow IV injection over 5 minutes. Recognize that the https://web.pathway.md/diseases/recU1AS4qWgwSAVUQ 4/8 6/24/23, 12:45 PM Hyperkalemia Pathway potassium-lowering effect occurs within 15 minutes and lasts at least 60 minutes, and the reduction in potassium observed ranges from 0.6 to 1.0 mmol/L. E Show 4 more Intracellular shifting, salbutamol: As per UKKA 2020 guidelines, administer nebulized salbutamol 10-20 mg as an adjuvant therapy in patients with severe hyperkalemia (K+ 6.5 mmol/L). B Show 2 more As per GAIN 2014 guidelines: Administer salbutamol (10 mg via nebulisation). Potassium-lowering effects occurs within 15- 30 minutes and lasts at least 2 hours. The reduction in potassium observed ranges from 0.5 to 1.0 mmol/L. E Avoid using salbutamol as a single agent for the treatment of hyperkalemia, as it may not lower potassium in all patients. Response is weakned in patients taking -blockers, digoxin, and in patients on chronic dialysis. D Intracellular shifting, bicarbonate: As per UKKA 2020 guidelines: Administer sodium bicarbonate in patients with CKD with a serum bicarbonate level < 22 mmol/L with or without hyperkalemia. B Do not administer routine IV sodium bicarbonate infusion for acute treatment of patients with hyperkalemia. D As per GAIN 2014 guidelines, consider not using hypertonic sodium bicarbonate as a treatment for hyperkalemia, as many studies show that sodium bicarbonate fails to lower the serum potassium. D Gastrointestinal excretion (sodium polystyrene): consider using sodium polystyrene sulfonate (Kayexalate) to lower total body potassium in patients with subacute hyperkalemia. C Gastrointestinal excretion (sodium zirconium cyclosilicate): Administer sodium zirconium cyclosilicate as an option for the management of persistent hyperkalemia with a confirmed serum K+ 6.0 mmol/L in patients with CKD stage 3b-5 (not on dialysis) or HF receiving a suboptimal dose of RAAS inhibitors. Administer sodium zirconium cyclosilicate only in secondary care. A Discontinte sodium zirconium cyclosilicate if renin-angiotensin-aldosterone-system inhibitors are stopped. A Gastrointestinal excretion (calcium polystyrene): Consider administering calcium resonium as a short-term measure to lower serum potassium to a level of 5 mmol/L in patients with mild-to-moderate hyperkalemia. C Avoid using calcium resonium for emergency management of patients with severe hyperkalemia, but consider administering it in patients with moderate hyperkalemia. D Gastrointestinal excretion (patiromer): administer patiromer as an option for the management of persistent hyperkalemia with a confirmed serum K+ 6.0 mmol/L in outpatients with CKD stage https://web.pathway.md/diseases/recU1AS4qWgwSAVUQ 5/8 6/24/23, 12:45 PM Hyperkalemia Pathway 3b-5 (not on dialysis) or HF receiving a suboptimal dose or not receiving RAAS inhibitors due to hyperkalemia. Administer patiromer only in secondary care. A Show 2 more Renal excretion (loop diuretics): consider administering loop diuretics as an adjunct therapy in non-oliguric and volume replete patients with chronic hyperkalemia. C 5. Inpatient care Laboratory monitoring: As per UKKA 2020 guidelines, monitor serum K+ closely in all patients with hyperkalemia to assess efficacy of treatment and to monitor for rebound hyperkalemia after the initial response to treatment wanes. B Show 3 more As per GAIN 2014 guidelines, monitor urea, electrolytes and glucose at regular intervals. Consider additional blood investigations, including blood gas analysis, as appropriate. E Cardiac monitoring: As per UKKA 2020 guidelines, obtain a minimum of continuous 3-lead ECG monitoring, ideally in a higher dependency setting, in all patients with a serum K+ 6.5 mmol/L, patients with features of hyperkalemia on 12-lead ECG, and in patients with a serum K+ 6.0-6.4 mmol/L if clinically unwell or rapid rise in serum K+ is anticipated. B As per GAIN 2014 guidelines, initiate cardiac monitoring in patients with severe hyperkalemia (serum potassium 6.5 mmol/L). E Show 2 more 6. Nonpharmacologic interventions Low-potassium diet: As per UKKA 2020 guidelines: Advise a low potassium diet in outpatients with persistent hyperkalemia with a serum K+ > 5.5 mmol/L. B Administer a low potassium diet in hospitalized patients with moderate-to-severe hyperkalemia. B As per GAIN 2014 guidelines, place the patient on a low potassium diet, avoiding fruit juice, fruits, chocolate, fruit gums, biscuits, coffee or potatoes. E 7. Therapeutic procedures Hemodialysis: As per UKKA 2020 guidelines, decide on timing, suitability and modality for initiation of RRT urgently by a nephrologist or critical care specialist in patients with life threatening hyperkalemia, https://web.pathway.md/diseases/recU1AS4qWgwSAVUQ 6/8 6/24/23, 12:45 PM Hyperkalemia Pathway either from the outset or resistant to initial medical therapy. B As per GAIN 2014 guidelines, consider initiating hemodialysis in patients with severe hypokalemia in whom other first-line agents have been unsuccessful, or if there is ongoing tissue damage and continued release of intracellular potassium is expected. E 8. Specific circumstances Patients on RAASi therapy: obtain urea and electrolytes before initiating ACEI or ARB. Be cautious if serum K+ is > 5.0 mmol/L. A Show 4 more Patients on digoxin: Administer IV calcium slowly (e.g. over 20 minutes) in patients taking digoxin in whom IV calcium is indicated, as as rapid calcium administration may precipitate myocardial digoxin toxicity. E Consider initiating hemodialysis and administration of digoxin antibody fragments in patients with hyperkalemia due to digoxin toxicity. Consult with a local expert. E Patients on hemodialysis: perform urgent dialysis in hemodialysis patients with severe hyperkalemia (K+ 6.5 mmol/L). A Show 3 more Patients with cardiac arrest (diagnosis): suspect hyperkalemia in all patients with cardiac arrest, as part of identifying and treating a reversible cause using the 4Hs (hypoxia, hypokalemia/hyperkalemia, hypothermia/hyperthermia, hypovolemia) and 4Ts (tension pneumothorax, tamponade, thrombosis, toxins) approach. A Patients with cardiac arrest (prevention): Treat hyperkalemia urgently in patients with severe hyperkalemia (K+ 6.5 mmol/L) and in patients with ECG changes suggestive of severe hyperkalemia. B Obtain continuous cardiac monitoring in patients with severe cardiac hyperkalemia (K+ 6.5 mmol/L) in a setting appropriate for the level of care required. B Patients with cardiac arrest (management): use a treatment algorithm providing guidance on the medical therapies and the need for initiation of RRT during CPR for the management of patients with cardiac arrest attributable to hyperkalemia. B Show 4 more Patients with cardiac arrest (resuscitation): use standard advanced life support practice in patients with cardiac arrest requiring dialysis. A Show 2 more 9. Preventative measures https://web.pathway.md/diseases/recU1AS4qWgwSAVUQ 7/8 6/24/23, 12:45 PM Hyperkalemia Pathway Prevention: monitor renal function in patients at risk of hyperkalemia with known CKD, HF, diabetes or taking RAAS inhibitors. A Show 3 more 10. Follow-up and surveillance Referral to renal/critical care services: consider referring patients with severe hyperkalemia (K+ 6.5 mmol/L) to their local renal or critical care team for an urgent opinion, guided by the clinical scenario and its persistence after initial medical treatment. C Show 6 more References 1. Anthony J Viera, Noah Wouk. Potassium Disorders: Hypokalemia and Hyperkalemia. Am Fam Physician. 2015 Sep 15;92 6 487 95. Open 2. Annette Alfonzo, Alexander Harrison, Richard Baines et al. Clinical Practice Guidelines Treatment of Acute Hyperkalaemia in Adults. The Renal Association. 2020 Jun. Open 3. McVeigh G, Maxwell P, O'Donell S et al. Guidelines for the Treatment of Hyperkalaemia in Adults. GAIN Sub-Group on the Treatment of Hyperkalaemia in Adults. Open 4. Ashish R Panchal, Jason A Bartos, Jos G Caba as et al. Part 3 Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S366 S468. Open 5. Keith A Betts, J Michael Woolley, Fan Mu et al. The prevalence of hyperkalemia in the United States. Curr Med Res Opin. 2018 Jun;34 6 971 978. Open https://web.pathway.md/diseases/recU1AS4qWgwSAVUQ 8/8