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11. Section II Management of Hyperkalaemia in Hospital

11. Section II Management of Hyperkalaemia in Hospital

Introduction

Hyperkalaemia is a potentially life-threatening medical emergency. The incidence in hospitalised patients ranges from 1 – 10%.1 5 It is associated with increased hospitalisation and mortality,6 9 and the risk of death increases with worsening severity of hyperkalaemia.10 Patients with a diagnosis of heart failure, CKD/ESRD, AKI or type 2 diabetes have a 28.9% relative increase of prevalence of hyperkalaemia and a 4% higher inpatient mortality.11 The higher prevalence of hyperkalaemia in this patient population is largely attributable to the widespread use of RAASi drugs for cardiorenal protection.

Despite the clinical importance and increasing frequency of hyperkalaemia, there is limited evidence to guide treatment. This may account for the observed variability in the treatment of patients with hyperkalaemia, even within the same hospital.12 Therefore, guidance on the treatment of hyperkalaemia based on the current evidence is needed.

The most serious consequences of hyperkalaemia are arrhythmias and cardiac arrest. The risk of these events increases with K⁺ level ≥ 6.5 mmol/L and even small elevations in K⁺ above this concentration can lead to rapid progression from peaked T waves to ventricular fibrillation or asystole.12 The longer a patient has a high K⁺ level, the greater the risk of sudden deterioration.13 Urgent treatment can avoid life threatening complications.14,15

The threshold for emergency treatment varies, but most guidelines recommend that emergency treatment should be given if the serum K⁺ is ≥ 6.5 mmol/L with or without ECG changes.14,16,17 It is also accepted that emergency treatment should be initiated before serum biochemistry is known if hyperkalaemia is suspected on clinical grounds or in the presence of ECG changes.18

The evidence base for drug treatment in hospitalised patients is limited. Indeed, the Cochrane review for treatment of acute hyperkalaemia in adults included only 7 studies.16 Intravenous calcium salts (gluconate and chloride) are life saving, but there are no clinical trials to prove efficacy.16 Insulin glucose infusion is the most effective treatment to lower serum K⁺, but the optimal dose of Insulin to reduce the risk of hypoglycaemia without compromising efficacy is unknown. Beta agonists appear to be effective in lowering serum K⁺, but some patients are unresponsive. Sodium bicarbonate was frequently used in clinical practice, but there is little favourable evidence of its efficacy in treating acute hyperkalaemia.16,19

Over the past 5 years, there has been some progress in the treatment of hyperkalaemia relating to management in hospitalised patients, but addressing iatrogenic hypoglycaemia remains a major goal. A low pre treatment blood glucose may be the most appropriate starting point to identify patients at risk. Clinical experience with the use of the novel K⁺ binders is growing but their efficacy in the acute setting has not yet been definitively proven.

The management of acute hyperkalaemia in hospital requires a systematic and consistent approach. This section of the guideline reviews clinical assessment, ECG and laboratory tests, the 5 step approach to treatment, timely specialist referral, escalation of care and prevention in hospitalised patients.

References

  1. Moore, M.L. and R.R. Bailey, Hyperkalaemia in patients in hospital. N Z Med J, 1989. 102(878): p. 557 8.
  2. Paice, B., et al., Hyperkalaemia in patients in hospital. Br Med J (Clin Res Ed), 1983. 286(6372): p. 1189 92.
  3. Shemer, J., et al., Incidence of Hyperkalemia in Hospitalized Patients. Israel Journal of Medical Sciences, 1983. 19(7): p. 659 661.
  4. Conway, R., et al., Serum potassium levels as an outcome determinant in acute medical admissions. Clin Med (Lond), 2015. 15(3): p. 239 43.
  5. Fleet, J.L., et al., Validity of the International Classification of Diseases 10th revision code for hyperkalaemia in elderly patients at presentation to an emergency department and at hospital admission. Bmj Open, 2012. 2(6).
  6. Palaka, E., et al., Associations between serum potassium and adverse clinical outcomes: A systematic literature review. Int J Clin Pract, 2020. 74(1): p. e13421.
  7. Collins, A.J., et al., Association of Serum Potassium with All Cause Mortality in Patients with and without Heart Failure, Chronic Kidney Disease, and/or Diabetes. Am J Nephrol, 2017. 46(3): p. 213 221.
  8. Thongprayoon, C., et al., Admission Serum Potassium Levels in Hospitalized Patients and One Year Mortality. Medicines (Basel), 2019. 7(1).
  9. Hougen, I., et al., Hyperkalemia and its Association With Mortality, Cardiovascular Events, Hospitalizations, and Intensive Care Unit Admissions in a Population Based Retrospective Cohort. Kidney Int Rep, 2021. 6(5): p. 1309 1316.
  10. Wetmore, J.B., et al., Development and outcomes of hyperkalemia in hospitalized patients: potential implications for care. Am Heart J, 2021. 241: p. 59 67.
  11. Tecson, K.M., et al., Inpatient hospitalisation and mortality rate trends from 2004 to 2014 in the USA: a propensity score matched case control study of hyperkalaemia. BMJ Open, 2022. 12(5): p. e059324.
  12. Acker, C.G., et al., 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(8): p. 917 24.
  13. Sood, M.M. and R.P. Pauly, A case of severe hyperkalemia: fast, safe and effective treatment is required. Journal of Critical Care, 2008. 23(3): p. 431 433.
  14. Singer, A.J., H.C. Thode, Jr., and W.F. Peacock, Rapid correction of hyperkalemia is associated with reduced mortality in ED patients. Am J Emerg Med, 2020. 38(11): p. 2361-2364.
  15. Lott, C., et al., European Resuscitation Council Guidelines 2025 Special Circumstances in Resuscitation. Resuscitation, 2025. 215 Suppl 1: p. 110753.
  16. Batterink, J., T.A. Cessford, and R.A.I. Taylor, Pharmacological interventions for the acute management of hyperkalaemia in adults. Cochrane Database of Systematic Reviews, 2015.
  17. Maxwell et al. Guidelines for the Treatment of Hyperkalaemia in Hospitalised Adults. The Regulation and Quality Improvement Authority (RQIA). March 2021.  http://www.rqia.org.uk
  18. Gupta, A.A., et al., Dispelling myths and misconceptions about the treatment of acute hyperkalemia. Am J Emerg Med, 2022. 52: p. 85-91.
  19. Lim, A.K.H., et al., The Effect of Patient Factors and Cotreatments on the Magnitude of Potassium Lowering with Insulin-Glucose Treatment in Patients with Hyperkalemia. Epidemiologia (Basel), 2021. 2(1): p. 27-35.