Guideline 3.1 – Threshold for treating Hyperkalaemia in the community
We recommend that interventions to lower serum potassium be instituted in patients with a serum K⁺ ≥ 5.5 mmol/l. (1B)
Rationale (Guideline 3.1)
The detection of hyperkalaemia in the community is frequently the result of blood monitoring in relation to RAASi therapy. Outwith this context, most observational studies have based diagnosis of hyperkalaemia on a single blood test. Pseudo hyperkalaemia may occur in the community after long transit time to the laboratory, therefore unexpected results should be repeated.
Approximately 20% of patients with moderate severe CKD develop hyperkalaemia (K⁺ > 5.5 mmol/l) and many have recurrent episodes.1 Data from several studies performed in the general population and in patients with CKD show an increased mortality risk in patients with a serum K⁺ ≥ 5.5 mmol/l.2–7 Mortality risk increases further when the serum K⁺ exceeds 6 mmol/l, therefore measures should be taken to avoid a further rise in serum K⁺ level.
National guidance from the Renal Association and British Society for Heart Failure (2019) provides recommendations to manage hyperkalaemia when the serum K⁺ rises to ≥ 5.5 mmol/l.8 This includes cessation of drugs that potentiate hyperkalaemia (e.g. K⁺ supplements, Trimethoprim, NSAIDs, amiloride), avoidance of over diuresis and dietary advice. Although RAASi and non selective beta blockers can increase K⁺ levels, consider the degree of hyperkalaemia and the indication for use before reducing or withholding the drug.
Similarly, the KDIGO Guideline (2023) have also stated a threshold of K⁺ > 5.5 mmol/l for initiation of strategies to manage hyperkalaemia in the non emergent setting.9 They have described a 3 tier approach to address:
- Correctable factors: Optimise bicarbonate level, optimise glycaemic control, treat constipation and consider loop diuretic and SGLT2i.
- Dietary restrictions: Assess dietary K⁺ intake and consider specialist dietetic referral
- Medications: Consider dose adjustment of K⁺ elevating drugs and consider initiation of K⁺ binder.
Given the importance of optimisation of RASSi therapy, careful consideration is required before down-titration or drug cessation, particularly in patients with mild hyperkalaemia (K+ 5.5 – 5.9 mmol/l). Consider specialist advice to weigh risks and discuss treatment options. See Guideline 10.1 for NICE guidelines (2025) for initiation of sodium zirconium cyclosilicate in patients, which has been revised to include selected patients with mild hyperkalaemia.
References
- Kim, G.H., Pharmacologic Treatment of Chronic Hyperkalemia in Patients with Chronic Kidney Disease. Electrolyte Blood Press, 2019. 17(1): p. 1–6.
- Korganoark, S., et al., Serum potassium and outcomes in CKD: insights from the RRI CKD cohort study. Clin J Am Soc Nephrol, 2010. 5(5): p. 762–9.
- Hughes Austin, J.M., et al., The Relation of Serum Potassium Concentration with Cardiovascular Events and Mortality in Community Living Individuals. Clinical Journal of the American Society of Nephrology, 2017. 12(2): p. 245–252.
- Turgutalp, K., et al., Community acquired hyperkalemia in elderly patients: risk factors and clinical outcomes. Ren Fail, 2016. 38(9): p. 1405–1412.
- Nakhoul, G.N., et al., Serum Potassium, End Stage Renal Disease and Mortality in Chronic Kidney Disease. Am J Nephrol, 2015. 41(6): p. 456–63.
- Horne, L., et al., Epidemiology and health outcomes associated with hyperkalaemia in a primary care setting in England. BMC Nephrol, 2019. 20(1): p. 85.
- Furuland, H., et al., Serum potassium as a predictor of adverse clinical outcomes in patients with chronic kidney disease: new risk equations using the UK clinical practice research datalink. BMC Nephrol, 2018. 19(1): p. 211.
- Clark, A.L., et al., Change in renal function associated with drug treatment in heart failure: national guidance. Heart, 2019. 105(12): p. 904–910.
- KDIGO 2023 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. (draft). July 2023.