How Hyperkalemia Is Treated

Hyperkalemia occurs when you have too much potassium in your blood. Because hyperkalemia is a sign that something else is going on in your body, treatment depends on what's causing it and whether the level of potassium in your blood is judged to be an emergency or not. Methods of treatment may include intravenous therapies, dialysis, diuretics, potassium-removing agents, albuterol, and diet modification.

Therapies and Procedures

There are a number of therapies your doctor may use to treat your hyperkalemia, depending on the cause and whether or not you need immediate treatment.

Intravenous Therapies

Intravenous (IV) calcium immediately counteracts the effects that high potassium levels have on your cell membranes and stabilizes the electrical systems in your heart, nerves, and muscles. Because the effects only last up to 60 minutes, to work most effectively, it needs to be combined with IV insulin and glucose, which help push the potassium back into your cells. These IV therapies are used when you're in an emergency situation and need to get your levels down fast.

Your doctor may also give you IV sodium bicarbonate if you're having a hyperkalemic emergency, but this would be in addition to the calcium and insulin with glucose. You may also be given sodium bicarbonate when you need to get your levels down fairly quickly but it's not an emergency, especially if you have hyperkalemia due to too much acid in your body (acidosis), which can happen when you have severe kidney disease or when your diabetes is poorly controlled or uncontrolled.

Dialysis

If your kidney function is severely impaired, and especially if your potassium is at emergency levels, your doctor will likely put you on hemodialysis. In this procedure, your blood is filtered through a machine outside of your body, called an artificial kidney or dialyzer, to remove salt, waste, extra water and excess chemicals, including potassium, from your blood.

Hemodialysis is the preferred method of dialysis to remove potassium because it's much faster than peritoneal dialysis, a procedure that works the same way but does it inside your body. You may need to keep having dialysis to prevent hyperkalemia.

Prescriptions

There are several prescription medications you may be given to treat hyperkalemia. Again, this depends on your situation and what's causing it.

Diuretics

Also known as water pills, diuretics work by increasing the amount of potassium your body excretes into your urine. They're prescribed for both emergency and non-emergency hyperkalemic situations if you have normal or mild to moderately impaired kidney function, but not for severely impaired kidney function.

You will be given a loop diuretic, a thiazide diuretic, or both depending on the underlying cause of your hyperkalemia. Your doctor may also prescribe these to you in the long-term, especially if you have chronic kidney disease or you're taking angiotensin-converting enzyme (ACE) inhibitors.

Examples of loop diuretics include:

  • Bumex (bumetanide)
  • Edecrin (ethacrynic acid)
  • Lasix (furosemide)
  • Demadex (torsemide)

Examples of thiazide diuretics include:

  • Diuril (chlorothiazide)
  • Thalitone (chlorthalidone)
  • Microzide (hydrochlorothiazide)
  • Zaroxolyn (metolazone)

Potential side effects of diuretics include increased urination, hypokalemia (low blood potassium levels), hyponatremia (low blood sodium levels), dizziness, headaches, dehydration, cramps in your muscles, joint disorders, and erectile difficulties.

Potassium-Removing Agents

Potassium-removing agents work by binding potassium and exchanging it for other minerals like calcium or sodium. The two that are available to treat hyperkalemia in the United States are Veltassa (patiromer) and Kayexalate (sodium polystyrene sulfonate). These medications are used to treat hyperkalemia in a variety of situations, from a hyperkalemic emergency to maintenance therapy.

Patiromer is made of a polymer that passes through the gastrointestinal tract, sucking up potassium and exchanging it for calcium. In clinical trials, patiromer is shown to be effective in reducing hyperkalemia in people with diabetes, high blood pressure, heart failure, and in those taking renin-angiotensin-aldosterone system (RAAS) inhibitors, which include ACE inhibitors and angiotensin II receptor blockers.

RAAS inhibitors spare potassium from being excreted in your urine, the opposite of how patiromer works. They are typically prescribed to people with heart failure, diabetes, and chronic kidney disease.

No serious side effects have been found with patiromer so far. Common side effects include constipation, diarrhea, vomiting, nausea, stomach pain, and flatulence. Patiromer may be prescribed as a maintenance therapy, especially if you have chronic kidney disease or diabetes and need to take RAAS inhibitors.

Sodium polystyrene sulfonate, or SPS, has been around since 1958 and works by swapping sodium for potassium in your intestine, binding the potassium and excreting it in your feces. It's used less often since patiromer came out on the market, but is recommended in certain situations, usually when all other therapies have failed. Side effects are similar to those found in patiromer, but SPS can also cause intestinal necrosis (death of most or all of the intestinal cells) and hypokalemia.

Albuterol

Albuterol isn't used often and never by itself. But, it can work to lower potassium levels in people whose symptoms of hyperkalemia aren't getting any better despite treatment with calcium and insulin with glucose or for whom dialysis isn't an option.

It's typically administered with a nebulizer, which takes saline and albuterol and sprays it into a fine mist that you breathe in. If you can't tolerate a nebulizer, it can be administered through an IV instead. Using albuterol can make you shaky and make your heart beat faster.

Home Remedies and Lifestyle

Lowering your potassium levels by reducing the potassium in your diet is a common way to treat hyperkalemia that isn't an emergency. Though hyperkalemia rarely occurs simply from ingesting too much potassium, if you're on RAAS inhibitors, have kidney disease, or hypoaldosteronism (an endocrinological disorder), a diet that's too high in potassium can cause hyperkalemia because you're already at high risk for developing it. Often, if you simply decrease how much potassium you eat, you can go back on RAAS inhibitors if you had to stop due to hyperkalemia.

Foods that are high in potassium include:

  • Many vegetables, like potatoes, carrots, spinach, and tomatoes
  • Many fruits, such as bananas, kiwi, pears, and apricots
  • Dairy products, with the exception of cheese and sour cream
  • Whole grains, like bran and oats
  • Dry beans and nuts, such as pinto beans, kidney beans, peanuts, and lentils
  • Red meat
  • Salt substitutes

You can lower your intake of potassium by avoiding or decreasing your intake of these foods and concentrating on foods that are low in potassium. Green beans, cabbage, broccoli, apples, grapes, strawberries, cheese, eggs, fresh chicken, and fresh pork are all safe to eat when you're on a low-potassium diet. Your doctor may recommend that you work with a dietician to help you plan your diet.

Treatment by Situation

Your doctor's approach to treatment will depend on how serious your situation is and what's causing your hyperkalemia.

Hyperkalemic Emergencies

Signs of a hyperkalemic emergency include weakness or paralysis of your muscles and heart abnormalities that can be picked up on an electrocardiogram (ECG), such as the electrical impulses in the heart being affected or a heart arrhythmia (abnormal heartbeat). Even if you don't have any symptoms of hyperkalemia, if your blood potassium level is greater than 6.5 mEq/ L, it will be treated as an emergency.

In an emergency situation, you will need quick treatment to get your potassium level lowered. This includes intravenous (IV) calcium and IV insulin with glucose which is given to everyone with severe hyperkalemia, no matter their underlying cause. You may also be treated with a diuretic if your kidney function is still adequate.

If your kidney function is seriously impaired, along with calcium and insulin with glucose, you may be treated with Veltassa (patiromer) or Kayexalate (sodium polystyrene sulfonate), and/or dialysis. Additionally, you may receive either IV or inhaled albuterol and/or IV sodium bicarbonate, both of which help push potassium back into your cells.

Your doctor will monitor your heart closely, most likely performing multiple ECGs and testing your blood periodically to make sure your potassium levels have gone down and that your glucose levels stay normal. If you're on any medications that contribute to high potassium levels, your doctor may have you discontinue them, at least temporarily.

Prompt Treatment

Sometimes you may not have a hyperkalemic emergency, but it's still important to get your potassium levels down fairly quickly. This can happen if you're a hemodialysis patient in between hemodialysis treatments, if you're hyperkalemic and need to get your levels down in preparation for surgery, or if your kidney function and/or urine output is marginal.

In cases where kidney function is severely impaired but rapid-acting treatments like calcium and insulin aren't required, dialysis, preferably hemodialysis, is recommended. If for some reason dialysis can't be performed immediately, you may be given patiromer or sodium polystyrene sulfonate until you can have dialysis.

If your hyperkalemia is moderate, meaning your serum potassium level is greater than 5.5 mEq but less than 6.5 mEq, and you have normal kidney function or your kidney function is only mildly to moderately impaired, dialysis usually isn't necessary. The majority of people in this situation will receive patiromer along with additional treatments to target what's causing the hyperkalemia in the first place.

For instance, medications that you're taking to treat another problem but that are known to increase potassium levels, like RAAS inhibitors, might be temporarily discontinued. If your hyperkalemia is due to too much acid in your body, you may be treated with sodium bicarbonate. If you developed hyperkalemia because you have too much fluid in your blood (hypervolemia), you may be treated with diuretics.

Slower Treatment

If your hyperkalemia isn't severe and you're able to work on gradually lowering the amount of potassium in your blood, your doctor will start by having you reduce the amount of potassium in your diet. If you have high blood pressure or hypervolemia, you may also be given diuretics to help keep your levels low. For people who have hyperkalemia from taking RAAS inhibitors, a diet low in potassium and regular diuretic therapy can help keep hyperkalemia at bay.

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