9. Summary of Audit Measures

The UK Kidney Association encourages non-renal specialties to record audit measures for all patients diagnosed with hyperkalaemia, irrespective of whether or not they are referred to renal services. Hospital laboratories should provide data to help audit compliance with these guidelines.

Recommended Audit Measures

1. Frequency of hospital admission for severe hyperkalaemia (serum K⁺ > 6.5 mmol/L) detected on routine blood tests in the community.
2. Frequency of blood monitoring for patients receiving RAASi drugs in the community.
3. Proportion of patients admitted to hospital with severe hyperkalaemia detected in the community who subsequently did not warrant emergency treatment on repeat testing.
4. Proportion of patients with moderate hyperkalaemia who have received dietary potassium advice in the renal outpatient setting.
5. The proportion of adults with moderate hyperkalaemia (serum K⁺ 6.0–6.4 mmol/L) treated with patiromer who achieved a serum K⁺ ≤ 5.0 mmol/L within 1 week in the outpatient setting.
6. The proportion of adults who achieve maximal dose RAASi therapy after initiation of patiromer in the outpatient setting.
7. The proportion of adults with mild (serum K⁺5 – 5.9 mmol/l) and moderate hyperkalaemia (serum K⁺ 6.0 – 6.4 mmol/l) treated with SZC who achieved a serum K⁺ ≤ 5.0 mmol/l within 48 hours in the outpatient setting.
8. The proportion of adults who achieve maximal dose RAASi therapy after initiation of SZC in the outpatient setting.
9. Proportion of patients with severe hyperkalaemia (Serum K⁺ ≥ 6.5 mmol/L) on admission to hospital who had been provided with ‘Sick Day Rules’ advice.
10. Length of hospital stay and in-hospital mortality of patients admitted with hyperkalaemia.
11. Proportion of patients with a serum K⁺ level ≥ 6.0 mmol/L who had a 12 lead ECG recorded before and after treatment for hyperkalaemia.
12. The frequency of ECG changes in patients treated with intravenous calcium salts.
13. The proportion of patients with severe hyperkalaemia (K⁺ ≥ 6.5 mmol/L) treated with insulin glucose infusion.
14. The proportion of patients with acute severe hyperkalaemia (serum K⁺ ≥ 6.5 mmol/L) treated with Sodium Zirconium Cyclosilicate.
15. The proportion of hospitalised patients with moderate hyperkalaemia (serum K⁺ 6.0–6.4 mmol/L) treated with Sodium Zirconium Cyclosilicate.
16. The proportion of hospitalised patients with acute hyperkalaemia (serum K⁺ > 6.0 mmol/L) treated with Patiromer.
17. The proportion of patients in whom serum K⁺ was measured at least once within 2 hours of treatment for severe hyperkalaemia [Audit Standard: 100%].
18. The proportion of patients who have at least one blood glucose test performed within 1 hour of completion of insulin glucose infusion [Audit Standard: 100%].
19. The frequency of hypoglycaemia occurring in patients receiving treatment with insulin glucose for hyperkalaemia.
20. The incidence of patients requiring emergency dialysis for severe hyperkalaemia.
21. The frequency of hyperkalaemia developing beyond 24 hours of hospital admission.
22. The frequency of prescribed drugs potentially contributing to hyperkalaemia.
23. All cardiac arrests should be audited – hospital participation in the National Cardiac Arrest Audit is encouraged as part of quality improvement and benchmarking.
24. The proportion of patients treated with intravenous calcium for hyperkalaemic cardiac arrest.
25. The proportion of patients treated with sodium bicarbonate for hyperkalaemic cardiac arrest.
26. The number and outcome of patients with refractory hyperkalaemic cardiac arrest treated with dialysis initiation during CPR.

Future Research

There are numerous unanswered questions about the treatment of patients with hyperkalaemia. Areas for future research include:

1. The optimal dose of insulin and glucose to treat acute hyperkalaemia required to minimise iatrogenic hypoglycaemia without compromising efficacy in prospective studies.
2. The efficacy of potassium binders (patiromer and sodium zirconium cyclosilicate) in combination with insulin glucose infusion in the treatment of severe hyperkalaemia in hospitalised patients.
3. The efficacy of sodium bicarbonate in the treatment of severe hyperkalaemia in patients with AKI.
4. The incidence and outcome of hyperkalaemic cardiac arrest.

Future Developments

Development of ready-to-use preparations of 10% (250 ml) and 20% (125 ml) glucose solutions in volumes appropriate for the treatment of hyperkalaemia.

• Hyperkalaemia is a medical emergency, therefore ease of administration is key.
• The delivery of a specified dose of glucose is dependent on the available preparations.
• The only preparation available that provides the required amount of glucose (25 g) is the 50% solution. Unfortunately, this preparation can potentially cause tissue injury if extravasation occurs, therefore has become less readily available in clinical areas.