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Hyperkalaemia

UK Kidney Association Clinical Practice Guidelines Treatment of Acute Hyperkalaemia in Adults. Published: Oct 2023.

Background Information

Hyperkalaemia is defined as ≥5.5 mmol/L

Classification of severity:
 

Severity Potassium concentration (mmol/L)
Mild 5.5 - 5.9
Moderate 6.0 - 6.4
Severe   ≥6.5 
 

Drugs commonly implicated in hyperkalaemia
  • RAAS inhibitor
    • ACE inhibitor
    • ARB
    • Mineralocorticoid receptor antagonist (i.e. aldosterone receptor antagonist like spironolactone and eplerenone) 
  • Potassium-sparing diuretics
  • NAIDs
  • Non-selective beta blockers
  • Trimethoprim / Co-trimoxazole
  • Potassium supplements

  • Acute and chronic kidney disease
  • Hyporeninaemic hypoaldosteronism (Type IV renal tubular acidosis)
  • Adrenal insufficiency
  • Pathological cell lysis
    • Rhabdomyolysis
    • Tumour lysis syndrome
    • Haemolysis

  • Dialysis dependency
  • Heart failure
  • Diabetes 
  • Liver disease

Progressive ECG changes seen in hyperkalaemia:
 
Associated potassium levels ECG changes
≥6.0 mmol/L
  • Tall, tented T waves
≥6.5 mmol/L
  • Flat p waves
  • Prolonged PR interval
≥7.0 mmol/L
  • QRS widening
  • Sine wave
  • Arrhythmias and cardiac arrest
 

Definition:
  • Falsely elevated potassium levels
  • Defined by serum potassium being >0.4 mmol/L than plasma potassium

If pseudohyperkalaemia is suspected:
  • Send paired blood samples in 1) a clotted tube (serum) and 2) a lithium heparin tube (plasma)

Causes:
  • Prolonged transit time to laboratory / poor storage conditions - most common
  • Difficult venepuncture
  • ↑ Platelet count
  • Haemolysis
  • Erythrocytosis

Management Guidelines

Refer to hospital immediately if severe hyperkalaemia (≥6.5 mmol/L)


Other patients:

  • Medication review (see above for drugs implicated in hyperkalaemia)
  • Low potassium diet
  • Consider diuretic
  • Monitor serum potassium
 

Potassium binders (calcium resonium / sodium zirconium cyclosilicate / patiromer) can be considered in:

  • Moderate hyperkalaemia, and
  • Patient with CKD 3b-5 (not on dialysis) or heart failure

Note that potassium binders should only be initiated in secondary care

This table summarises the 3 main steps in the management of hyperkalaemia, in order of urgency:
 
Step Aim and description Recommended treatment
1 (cardiac protection) Stabilises the cardiac membrane by increasing the action potential threshold to reduce the risk of arrhythmia

Note that this step does NOT lower potassium level, it mainly buys time until potassium can be shifted or removed
  • IV calcium chloride (10%) - preferred in cardiac arrest / peri-arrest
  • IV calcium gluconate (10%)
2 (potassium shifting) Temporarily shifts potassium from extracellular to intracellular compartment to reduce potassium concentration
  • IV insulin-glucose infusion
  • Nebulised salbutamol (adjunct - not to be used as monotherapy)

Do not routinely give IV sodium bicarbonate (it has limited role in metabolic acidosis)
3 (potassium removal) Removes potassium from the body

Definitive correction of hyperkalaemia		 Potassium binders:
  • 1st line: sodium zirconium cyclosilicate
  • 2nd line: Patiromer 
  • Calcium resonium (UKKA recommends not to use routinely)

Other options:
  • Loop diuretics - only consider if fluid overloaded
  • Haemodialysis - last resort
 

This section applies to BOTH moderate and severe hyperkalaemia (≥6.0 mmol/L)
  • If there is severe hyperkalaemia (≥6.5 mmol/L), senior input should be sought early
  • Mild hyperkalaemia (5.5-5.9 mmol/L) does not require any specific treatment

 

If the patient develops cardiac arrest → ALS algorithm takes priority but treat the underlying hyperkalaemia in a similar fashion as below.

Perform an ECG urgently
  • If any ECG changes are identified → give IV calcium gluconate / chloride

This step applies to ALL patients with moderate and severe hyperkalaemia (≥6.0 mmol/L)
  • Give insulin-glucose IV infusion
  • Consider nebulised salbutamol
  • Consider potassium binders (sodium zirconium cyclosilicate / Patiromer)
  • For refractory hyperkalaemia: seek expert help and consider haemodialysis

Monitor serum potassium and blood glucose throughout

References

Author: Adams Lau
Reviewer:
Last edited: 16/08/25