Guideline 1.1
Monitoring of patients at risk of Hyperkalaemia in the community
We recommend that patients known to have CKD, heart failure, and/or diabetes, who are at risk of hyperkalaemia, undergo regular blood monitoring at a frequency (2–4 times per year) dependent on the level of renal function and degree of proteinuria. (1B)
Guideline 1.2.1
Monitoring of patients after an episode of mild hyperkalaemia detected in the community
We recommend that the serum K+ is repeated within 3 days, or as soon as feasible, if an episode of mild hyperkalaemia (K+ 5.5–5.9 mmol/l) is detected unexpectedly in the community. (1C)
Guideline 1.2.2
Monitoring of patients after an episode of moderate hyperkalaemia detected in the community
We recommend that the serum K+ is repeated within 1 day of an episode of moderate hyperkalaemia (K+ 6.0–6.4 mmol/l) when detected in the community. (1C)
Guideline 1.2.3
Monitoring of patients after an episode of severe hyperkalaemia detected in the community
We recommend that patients with severe hyperkalaemia (K+ ≥ 6.5 mmol/l) are admitted for immediate assessment and treatment. (1B)
Guideline 2.1
Assessment of patients prior to initiation of ACE I or ARB
We recommend that urea and electrolytes should be assessed prior to initiation of ACE I or ARB, and these drugs should be used with caution if the serum K+ is > 5.0 mmol/l. (1A)
Guideline 2.2
Assessment of patients prior to initiation of Mineralocorticoid Receptor Antagonists (MRA)
We suggest that initiation of MRAs should be avoided in patients with a baseline serum K+ > 5.0 mmol/l or eGFR < 30 ml/min. (1B)
Guideline 2.3
Monitoring of patients after initiation of ACE I and ARB
We recommend that urea and electrolytes should be assessed at 1–2 weeks after initiation of ACE I or ARB and after every dose titration. (1A)
Guideline 2.4
Monitoring of patients after initiation of MRAs
We recommend that urea and electrolytes should be assessed at 1 week after initiation of MRA or after dose up titration, then monthly for the first 3 months, 3 monthly for the first year, and 4 monthly thereafter. (1A)
Guideline 2.5
Management of hyperkalaemia in patients treated with RAASi drugs
We suggest increased frequency of monitoring in patients with a serum K+ between 5.5–5.9 mmol/l and consideration of dose reduction of RAASi drugs (ACE I, ARB, MRA). (1B)
Guideline 2.6
Management of hyperkalaemia in patients treated with RAASi drugs during acute illness
We recommend that RAASi drugs be withheld during acute intercurrent illness (e.g., sepsis, hypovolaemia, and/or AKI) at all severities of hyperkalaemia. (1D)
Guideline 2.7
Cessation of RAASi drugs in patients with moderate or severe hyperkalaemia
We recommend cessation of RAASi drugs in patients with serum K+ ≥ 6.0 mmol/l and treatment with patiromer or sodium zirconium cyclosilicate. (1B)
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)
Guideline 4.1
Indication for assessment in hospital for patients with severe hyperkalaemia detected in the community
We recommend urgent hospital assessment for all patients with severe hyperkalaemia (serum K+ ≥ 6.5 mmol/l) detected in the community. (1A)
Guideline 4.2
Indication for assessment in hospital for patients with mild moderate hyperkalaemia detected in the community
We suggest hospital assessment for acutely unwell patients with mild (serum K+ 5.5–5.9 mmol/l) or moderate hyperkalaemia (serum K+ 6.0–6.4 mmol/l), particularly in the presence of an acute kidney injury. (1B)
Guideline 5.1
Dietary Intervention for managing Hyperkalaemia in the community
We recommend that dietary strategies to modify potassium intake be instituted for patients with CKD and persistent hyperkalaemia with a serum K+ > 5.5 mmol/l after non dietary causes of hyperkalaemia (e.g., constipation, acidosis, poorly controlled diabetes) have been addressed. (1B)
Guideline 5.2
Role of Specialist Dietician in managing Hyperkalaemia
We recommend that a registered or specialist renal dietician provides expert assessment and advice on dietary strategies to modify potassium intake in patients with CKD and persistent hyperkalaemia with a serum K+ > 5.5 mmol/l. (1B)
Guideline 6.1
Sodium bicarbonate for management of Hyperkalaemia in the community
We recommend that sodium bicarbonate is used in CKD patients with a serum bicarbonate level < 22 mmol/l with or without hyperkalaemia. (1B)
Guideline 7.1
Use of diuretics for managing Hyperkalaemia in the community
We suggest that loop diuretics may be a useful adjunct for the treatment of chronic hyperkalaemia in patients who are non oliguric and volume replete. (2C)
Guideline 8.1
Calcium Resonium for the management of Hyperkalaemia in the community
We suggest that calcium resonium is no longer used to treat chronic hyperkalaemia. (2C)
Guideline 9.1
Patiromer for the management of Hyperkalaemia in the community
We recommend that patiromer is an option in the management of persistent hyperkalaemia with a confirmed serum K+ ≥ 5.5 mmol/l in patients with CKD or heart failure receiving a sub optimal dose or not receiving RAASi therapy due to hyperkalaemia. (1A)
Guideline 9.2
Patiromer for the management of Hyperkalaemia
We recommend that treatment with patiromer is discontinued if RAASi therapy is stopped. (1A)
Guideline 9.3
Patiromer for the management of Hyperkalaemia
We recommend that patiromer is initiated in secondary care only. (1A)
Guideline 10.1
Sodium Zirconium Cyclosilicate for the management of Hyperkalaemia
We recommend that Sodium Zirconium Cyclosilicate (SZC) is an option in adults for the management of persistent hyperkalaemia with a confirmed serum K+ ≥ 5.5 mmol/l in patients with CKD Stage 3b-5 (not on dialysis) or heart failure receiving a sub-optimal dose of RAASi therapy. (1A)
Guideline 10.2
Sodium Zirconium Cyclosilicate for the management of Hyperkalaemia
We recommend that treatment with sodium zirconium cyclosilicate (SZC) in adults is discontinued if RAASi therapy is stopped. (1A)
Guideline 10.3
Sodium Zirconium Cyclosilicate for the management of Hyperkalaemia
We recommend that Sodium Zirconium Cyclosilicate (SZC) may be initiated in Primary or Secondary Care to support RAASi optimisation. (1A)
Guideline 11.1
Prevention of Hyperkalaemia in the community: Monitoring
We recommend monitoring of renal function in patients at risk of hyperkalaemia with known CKD, heart failure, diabetes, and in any patient taking RAASi medication. (1A)
Guideline 11.2
Prevention of Hyperkalaemia in the community: Prescribing
We recommend caution in prescribing trimethoprim to patients with renal impairment or those taking RAASi drugs. (1A)
Guideline 11.3
Prevention of Hyperkalaemia in the community: Sick day rules
We recommend that healthcare professionals provide advice to patients regarding the risks of AKI and hyperkalaemia during acute illness and measures to avoid these complications. (1B)
Guideline 12.1
Treatment Algorithm for Hyperkalaemia in the community
We recommend that the treatment of hyperkalaemia in patients in the community and outpatient setting is guided by its severity and clinical condition of the patient as summarised in the treatment algorithm. (1B)