The foremost step in the initial clinical management of hyperkalemia is to decide whether a hyperkalemic patient requires immediate treatment to avoid a life-threatening situation (serum potassium concentration >6.0 mEq/l and EKG changes). When the decision for urgent treatment of hyperkalemia is based on EKG changes, an important caveat for clinicians is that absent or atypical EKG changes do not exclude the necessity for immediate intervention. Once an urgent situation has being handled with intravenous push of a 10% calcium salt, the initiation of short-term measures can be launched by either a single or combined regimen of the three agents that cause a transcellular shift of potassium – insulin with glucose, β2-agonist (albuterol), and NaHCO3. As the first choice among these available options, we favor an intravenous bolus of 10 units of insulin with 50 ml of 50% glucose alone or in combination with 10–20 mg of albuterol by nebulizer. These can be repeated as required until the institution of hemodialysis. The combination of insulin with glucose and NaHCO3 as an another option needs further clarification for its additive effects. However, NaHCO3 has lost its favor because of its poor efficacy as a potassium-lowering agent when used alone. The next step is to remove potassium from the body – diuretics (furosemide), cation exchange resin (kayexelate) with sorbitol, and dialysis (preferably hemodialysis). The final important step for the managements of hyperkalemia is a long-term plan to prevent its recurrence or worsening. In addition to every effort to elucidate underlying causes and pathophysiologic mechanisms for hyperkalemia, an extensive search must be made to uncover overt or sometimes covert medications that may have led to the development of hyperkalemia. Furthermore, one must obtain detailed dietary and medical history of hyperkalemic patients.

Keywords:
Albuterol, Dialysis, Electrocardiogram, Insulin, Sodium bicarbonate
1.
Weiner ID, Wingo CS: Hyperkalemia: A potential silent killer. J Am Soc Nephrol 1998;9:1535–1543.
2.
Dagher G, Vantyghem MC, Doise B, Lallau G, Racadot A, Lefebvre J: Altered erythrocyte cation permeability in familial pseudohyperkalemia. Clin Sci 1989;77:213–216.
3.
Ifudu O, Markell MS, Friedman EA: Unrecognized pseudohyperkalemia as a cause of elevated potassium in patients with renal disease. Am J Nephrol 1992;12:102–104.
4.
Martinez-Vea A, Bardaji A, Garcia C, Oliver JA: Severe hyperkalemia with minimal electrocardiographic manifestations. J Electrocardiogr 1999;32:45–49.
5.
Szerlip HM, Weiss J, Singer I: Profound hyperkalemia without electrocardiographic manifestations. Am J Kidney Dis 1986;7:461–465.
6.
Acker CG, Johnson JP, Palevsky PM, Greenberg A: Hyperkalemia in hospitalized patients: Causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med 1998;158:917–924.
7.
Greenberg A: Hyperkalemia: Treatment options. Semin Nephrol 1998;18:46–57.
8.
DeFronzo RA, Smith JD: Clinical disorders of hyperkalemia; in Narins RG (ed): Clinical Disorders of Fluid and Electrolyte Metabolism, ed 5. New York, McGraw Hill, 1994, pp 697–754.
9.
Clausen T, Hansen O: Active Na-K transport and the rate of ouabain binding: The effect of insulin and other stimuli on skeletal muscle and adipocytes. J Physiol (Lond) 1977;270:415–430.
10.
Goguen JM, Halperin ML: Can insulin administration cause an acute metabolic acidosis in vivo? An experimental study in dogs. Diabetologia 1993;36:813–816.
11.
Allon M, Copney C: Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients. Kidney Int 1990;38:869–872.
12.
Ljutic D, Rumboldt Z: Should glucose administered before, with, or after insulin, in the management of hyperkalemia? Ren Fail 1993;15:73–76.
13.
Montoliu J, Revert L: Lethal hyperkalemia associated with severe hyperglycemia in diabetic patients with renal failure. Am J Kidney Dis 1985;5:47–48.
14.
Bia MJ, Lu M, Tyler K, De Fronzo RA: Beta adrenergic control of extrarenal potassium disposal: A beta-2 mediated phenomenon. Nephron 1986;43:117–122.
15.
Allon M, Dunlay R, Copkney C: Nebulized albuterol for acute hyperkalemia in patients on hemodialysis. Ann Intern Med 1989;110:426–429.
16.
Liou HH, Chiang SS, Wu SC, Huang TP, Campese VM, Smogorzewski M, Yang WC: Hypokalemic effects of intravenous infusion or nebulization of salbutamol in patients with chronic renal failure: Comparative study. Am J Kidney Dis 1994;23:266–271.
17.
Ahmed J, Weisberg L: Hyperkalemia in dialysis patients. Semin Dial 2001;14:348–356.
18.
Schwarz KC, Cohen BD, Lubash GD, Rubin AL: Severe acidosis and hyperpotassemia treated with sodium bicarbonate infusion. Circulation 1959;14:215–220.
19.
Fraley DS, Adler S: Correction of hyperkalemia despite constant blood pH. Kidney Int 1977;12:354–360.
20.
Iqbal Z, Friedman EA: Preferred therapy of hyperkalemia in renal insufficiency: Survey of nephrology training-program directors. N Engl J Med 1989;320:60–61.
21.
Blumberg A, Weidmann P, Shaw S, Gnadinger M: Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure. Am J Med 1988;85:507–512.
22.
Blumberg A, Weidmann P, Ferrari P: Effect of prolonged bicarbonate administration on plasma potassium in terminal renal failure. Kidney Int 1992;41:369–374.
23.
Kim HJ: Combined effect of bicarbonate and insulin with glucose in acute therapy of hyperkalemia in end-stage renal disease patients. Nephron 1996;72:476–482.
24.
Allon M: Hyperkalemia in end-stage renal disease: Mechanisms and management. J Am Soc Nephrol 1995;6:1134–1142.
25.
Flatman JA, Clausen T: Combined effects of adrenaline on excitation-induced stimulation of the sodium potassium pump in rat soleus muscle. Nature 1979;281:580–581.
26.
Allon M, Shanklin N: effect of bicarbonate administration on plasma potassium in dialysis patients: Interactions with insulin and albuterol. Am J Kidney Dis 1996;28:508–514.
27.
Emmett M, Hootkins RE, Fine KD, Santa Ana CA, Porter JL, Fordtran JS: Effect of three laxatives and a cation exchange resin on fecal sodium and potassium excretion. Gastroenterology 1995;108:752–760.
28.
Hou S, McElroy PA, Nootens J, Beach M: safety and efficacy of low-potassium dialysate. Am J Kidney Dis 1989;13:137–143.
29.
Sherman RA, Hwang ER, Bernholc AS, Eisinger RP: Variability in potassium removal by hemodialysis. Am J Nephrol 1986;6:284–288.
30.
Kamel KS, Ethier JH, Quaggin S, Levin A, Carlisle EJ, Halperin ML: Studies to determine the basis for hyperkalemia in recipients for a renal transplant who are treated with cyclosporine. J Am Soc Nephrol 1992;2:1279–1284.
31.
Arrizabalaga P, Montoliu J, Martinez Vea A, Andreu L, Lopez Pedret J, Revert L: Increase in serum potassium caused by beta-2 adrenergic blockade in terminal renal failure: Absence of mediation by insulin or aldosterone. Proc Eur Dial Transplant Assoc 1983;20:572–576.
32.
Martin RS, Panese S, Virginillo M, Litardo M, Gimenez M, Arrizurrieta E, Hayslett JP: Increased secretion of potassium in the rectum of man with chronic renal failure. Am J Kidney Dis 1986;8:105–110.
33.
Gifford JD, Rutsky EA, Kirk KA, McDaniel HG: Control of serum potassium disposal in men with end-stage renal disease. Kidney Int 1989;35:90–94.
34.
Serra A, Uehlinger DE, Ferrari P, Dick B, Frey BM, Frey FJ, Vogt B: Glycyrrhetinic acid decreases plasma potassium concentrations in patients with anuria. J Am Soc Nephrol 2002;13:191–196.
© 2002 S. Karger AG, Basel
2002
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.