Hyperkalemia Treatment Guidelines, Diagnosis And Management

What is the emergency treatment for hyperkalemia? ( hyperkalemia treatment guidelines). Hyperkalemia is an electrolyte disorder that is often found in daily practice. This condition can be mild but can also be an emergency condition. Severe hyperkalemia can lead to death from arrhythmias and the acid-base disorders that accompany it. Also, looking for the etiology or cause of this condition is important to hyperkalemia treatment guidelines in the future.

Potassium Homeostasis

In discussing potassium levels, we must understand that the composition of electrolytes in different compartments of the body is different. There is a condition called trans-cellular shift where electrolytes move from one compartment of the body to another.

Potassium itself is dominant in compartments in cells or intracellularly. The potassium levels that are calculated daily are blood potassium levels or in the extracellular compartment. We can see the balance of daily potassium intake and expenditure through the following picture:

Balance potassium intake and expenditure
Balance potassium intake and expenditure

The excretion of potassium is mainly carried out through the kidneys, especially in the distal nephron (collecting tubules). There the replacement of potassium with sodium occurs. Where sodium ions are drawn in, they are exchanged for potassium ions which are excreted out. This kidney function is influenced by the hormone aldosterone.

Excretion of potassium in the kidneys
Excretion of potassium in the kidneys

Definition and Etiology of Hyperkalemia

Hyperkalemia defines as potassium in the blood ≥5.5 mmol / L. Many conditions can cause hyperkalemia, including the following:

  • Transcellular shift
    Acidemia, insulin deficiency, beta-blockers, digitalis intoxication, massive cell necrosis (tumor lysis, rhabdomyolysis, intestinal ischemia, hemolysis), hyperkalemic periodic paralysis, succinylcholine.
  • Decreased GFR (kidney function)
    Anything that causes oliguric AKI or anuria and terminal renal failure ( end-stage renal disease )
  • Normal GFR but without excretion of potassium from the kidneys
    • Aldosterone function is still normal
      Decreased effective arterial volume (decreased renal excretion due to decreased flow of urine and Na to the distal renal tubules): CHF, cirrhosis.
      Excess potassium intake accompanied by impaired potassium excretion or transcellular shift: for example in a ureterojejunostomy where urinary potassium absorption occurs in the intestine.
    • Hypoaldosteronism: same as the etiology of RTA hypoaldosteronism (RTA type IV)
      Decreased renin: diabetic nephropathy, NSAIDs, chronic interstitial nephritis, normal HIV renin, decreased aldosterone synthesis, ACE-inhibitors, ARBs, heparin.
      Decreased response to aldosterone: potassium-sparing diuretics, TMP-SMX, pentamidine, calcineurin inhibitors, tubulointerstitial disease ( sickle cell, SLE, amyloidosis, diabetes).

Clinical Manifestations of Hyperkalemia

Symptoms include weakness, nausea, paresthesia (numbness), palpitations. The EKG shows a high T wave, PR interval lengthening, QRS lengthening, loss of P wave, sine wave pattern, it can be PEA or VF. Below is a comparative picture of the hypokalemia, normokalemia, and hyperkalemia ECG:

ECG pattern in hypokalemia, normal potassium, and hyperkalemia
ECG pattern in hypokalemia, normal potassium, and hyperkalemia
EKG picture based on the severity of hyperkalemia
EKG picture based on the severity of hyperkalemia
Example of an ECG in hyperkalemia
Example of an ECG of a patient with hyperkalemia. A. 46-year-old female patient with renal failure and 9.4 mmol / L potassium. B. The same patient after receiving calcium gluconate and insulin therapy. Source: Evans KJ, Greenberg A. J Intensive Care Med. 2005;20(5):272–90.

Work Up Diagnosis of Hyperkalemia

Of course, the initial data from hyperkalemia is an increase in potassium levels in the blood. However, don’t forget that hyperkalemia can be caused by artifacts. The artifact means that the measurement of hyperkalemia does not match the true level of hyperkalemia. This is call pseudohiperkalemia.

Therefore, hyperkalemia treatment is important to rule out the possibility of pseudohiperkalemia. Pseudohiperkalemia can occur in conditions of hemolysis, increased platelets, or leukocytes. Apart from pseudohiperkalemia, we also need to think about the trans-cellular shift.

The value of renal filtration function (GFR) is normal. Pay attention to whether there is a decrease in the flow of urine and Na to the distal part of the collecting tubule, i.e. if the transtubular K gradient (TTKG) <6 then the possibility of hypokalemia due to hypoaldosteronism.

Transtubular K gradient (TTKG) = (U K / P K ) / (U osm / P osm )

Note that for a correct TTKG reading, the Na level must be more than 25 mEq / L. Also, urine osmolality must be equal to or greater than serum osmolality. After removing the artifacts and obtaining TTKG data, in looking for the etiology of this hyperkalemia, you can follow the path below:

Algorithm for determining the etiology of hyperkalemia
Algorithm for determining the etiology of hyperkalemia. Source: Kogika MM, de Morais HA. Vet Clin North Am – Small Anim Pract. 2017;47(2):223–8.
Hyperkalemia diagnostic approach
Hyperkalemia diagnostic approach

Hyperkalemia Treatment

Hyperkalemia Therapy
* Potassium chloride contains more calcium and is used only when very urgent (risk of tissue necrosis)
  • The rate of onset is important in determining the treatment plan.
  • Calcium helps prevent and treat heart complications, should be given first, especially if there is a problem with the EKG.
  • To lower plasma potassium, insulin, bicarbonate (especially if acidemia), and beta 2-agonists are administering.
  • Therapy to reduce the amount of potassium in the body includes diuretics, potassium absorbent resin (Kayexalate / Kalitake), and if necessary hemodialysis.

For bicarbonate administration, the following calculations can be made:

Amount = (20 – blood bicarbonate level) x 3 x body weight

From the percentage obtained from the above equation. Then break two, 50 percent is given in 100-250 mL of D10 solution in 2 hours, while the remaining 50 percent is given in 100-250 mL of D10 solution in 4 hours. Repeat the AGD examination after giving bicarbonate.

Keep in mind that bicarbonate is a concentrated alkaline solution. This solution can cause tissue necrosis. Make sure the intravenous line is not jam or leaking or given a central venous line.

Read also: What Is The Treatment For Hyperkalemia? Symptoms And Cause

Foods with High Potassium Content

In hyperkalemia conditions, of course, you must avoid intake of high potassium foods. The meaning of low potassium intake is a maximum of 2000 mg per day. In normal circumstances, the intake of potassium from food is 3500-4500 mg per day. Below is a list of foods high in potassium (more than 200 mg per serving; 1 serving = half a glass = 125 ml, unless otherwise noted):

Vegetables

  • Apricots, raw (2 medium), dry (5 parts)
  • Avocado (¼ fruit)
  • Banana (½ fruit)
  • Cantaloupe
  • Dates (5 pieces)
  • Dried fruit
  • Melon
  • Kiwi (1 medium)
  • Mango (1 medium)
  • Nectarine (1 medium)
  • Orange (1 medium)
  • Orange juice
  • Papaya (½ fruit)
  • Pomegranate (1 piece)
  • Pomegranate juice
  • Prunes
  • Prune Juice
  • Raisins

Fruit

  • Pumpkin seeds
  • Bamboo tillers
  • Boiled peanuts
  • Fried peanut
  • Beet, fresh and cooked
  • Broccoli, cooked
  • Brussels Sprouts
  • Chinese cabbage
  • Carrots, raw
  • Dried beans
  • Green vegetable
  • Nuts
  • Legumes
  • White mushrooms, cooked (½ cup)
  • Okra
  • Radish
  • Sweet and white potatoes
  • Pumpkin
  • Rutabaga
  • Spinach, cooked
  • Tomatoes and their derivatives
  • Vegetable juices

Others

  • Bran
  • Chocolate (1.5-2 ounces)
  • Granola
  • Milk, all types (1 cup)
  • Sugar drops (1 tsp)
  • Nutritional supplements
  • Peanut butter (2 tbsp)
  • Salt / Lite Salt substitute
  • Broth
  • Yogurt
  • Chewing tobacco

Apart from reducing the types of foods above, peeling fruits or vegetables can also reduce potassium levels. Keep in mind that although peeling can reduce potassium levels, eating peeled foods should also limit.

Conclusion

Hyperkalemia is common and requires immediate treatment because it can be life-threatening. Apart from lowering the blood potassium level immediately. Decreasing the total potassium level in the body and finding the etiology are important steps in the management of further hyperkalemia treatment.

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Reference

  • Evans KJ, Greenberg A. Hyperkalemia: A review. J Intensive Care Med. 2005;20(5):272–90.
  • Hollander-Rodriguez JC, Calvert JF. Hyperkalemia. Am Fam Physician. 2006;73(2):283–90.
  • Kogika MM, de Morais HA. A Quick Reference on Hyperkalemia. Vet Clin North Am – Small Anim Pract. 2017;47(2):223–8.
  • Sabatine MS, editor. Pocket medicine. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2014.
  • Rossignol P, Legrand M, Kosiborod M, Hollenberg SM, Peacock WF, Emmett M, et al. Emergency management of severe hyperkalemia: Guideline for best practice and opportunities for the future. Pharmacol Res. 2016;113:585–91.
  • https://www.kidney.org/atoz/content/potassium

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