Hyperkalemia is an excess of serum potassium. Most potassium in the body (98%) is found within cells. Small changes in extracellular potassium levels can disturb the cellular membrane potential, with profound effects on the cardiovascular and neuromuscular systems. Excess potassium is ordinarily excreted in the urine, and hyperkalemia is most often a result of renal insufficiency. It may also be precipitated by conditions that cause the release of potassium from the cells into the bloodstream, such as tissue trauma. Untreated, hyperkalemia may be associated with up to 67% mortality, mainly due to the effect of the potassium imbalance on cardiac function.

• Renal insufficiency
• Acidosis (e.g., diabetic ketoacidosis)
• Increased potassium intake
• Hypoaldosteronism (Addison's disease)
• Rhabdomyolysis
• Hemolysis (sickle-cell disease, venipuncture, blood transfusions, burns, tumor lysis)
• Side effect of some medications

• Renal failure (acute or chronic)
• Trauma, especially crush injuries or burns
• Diet high in potassium (bananas, oranges, tomatoes, high protein diets, salt substitutes)
• Use of medications such as potassium supplements, potassium-sparing diuretics, digoxin, nonsteroidal anti-inflammatory drugs, cyclosporine, succinylcholine, heparin, ACE inhibitors, and beta-blockers

• Fatigue
• Weakness
• Paresthesia
• Paralysis
• Palpitations
• Difficulty breathing

• Pseudohyperkalemia—e.g., from hemolysis during phlebotomy, erythrocyte fragility disorders
• Laboratory error—False high potassium reading may occur in patients with high platelet or white cell count.
• Other neurologic syndromes
• Heart disease/congestive heart failure

Assess for weakness and paresthesia. Check for evidence of dialysis sites and signs of trauma. Deep tendon reflexes or motor strength may be decreased. Pulse may be slow or irregular.

• Potassium level—upper limit of normal is 5 to 5.5 mEq/liter
• Digoxin level
• Calcium level—hypocalcemia exacerbates cardiac effects
• Glucose level—if patient has diabetes
• BUN and creatinine—to evaluate renal status
• Arterial blood gas—if acidosis suspected

Assess patient's overall condition and stability. Perform blood workup and monitor cardiac and renal function.

Electrocardiography should always be performed and may reveal the following anomalies, usually in order of progression. Note that life-threatening cardiac arrhythmias can occur without warning at almost any level of hyperkalemia.

• Peaked T-waves, shortened QT interval, ST-segment depression
• Widening of QRS complex, increases in PR interval, P-wave flattening
• P-wave disappearance, QRS widening to sine wave
• Ventricular fibrillation, asystole

Hyperkalemia is a life-threatening condition, and treatment must be prompt and aggressive. Patients presenting in the emergency room should be evaluated as to cardiac status and held under continuous electrocardiographic monitoring with frequent checks of vital signs. If renal failure is detected, admit patients to the ICU and consult a nephrologist. Treatment is aimed at stabilizing cardiac function, promoting movement of potassium from the extracellular environment to the cells, and encouraging excretion of excess potassium. Once the acute condition is stabilized, the root cause of the hyperkalemia should be determined and treated. Dialysis may be indicated if more conservative treatments fail.

• Calcium—Works quickly to stabilize membrane resting potential, ameliorating cardiac and neuromuscular effects. However, calcium does not lower potassium level and its effects last only about one hour, so other treatment must be started as well. Give 10 ml of 10% calcium gluconate solution IV over two minutes, or 5 ml of 10% calcium chloride solution IV over two minutes. Contraindicated in hypercalcemic patients.
• Insulin—Promotes potassium shift intracellularly. In normoglycemic patients, 10 units IV with 1 ampule D 50 to prevent hypoglycemia
• Sodium bicarbonate—Promotes potassium shift intracellularly; 1 mEq/kg, up to 50 to 100 mEq, slow IV or continuous drip. Caution required in patients with renal failure due to high sodium and fluid load.
• Beta agonists—Promote potassium shift intracellularly; 2.5 mg albuterol mixed with saline via high flow nebulizer every 20 minutes as tolerated. Safety in pregnancy is not established. Monitor for tachycardia and nervousness.
• Diuretics—Cause potassium excretion from kidneys but effects may be slow and inconsistent; furosemide (Lasix) 40 mg IV push. Dose may need to be doubled for patients with renal failure. Safety in pregnancy is not established. Contraindicated in hypovolemic patients.
• Binding resins—Promote potassium/sodium exchange in gastrointestinal system; sodium polystyrene sulfonate (Kayexalate) 15 to 30 g (4 to 8 tsp) in 50 to 100 ml of 20% sorbitol orally every 3 to 4 hours, or retention enema 50 g in 200 ml of 20% sorbitol for 30 to 60 minutes every four hours. Sorbitol contraindicated in post-op patients; may cause colonic necrosis. Caution required in patients with renal failure due to sodium load. Safety in pregnancy is not established.

Hyperkalemia is an acute, life-threatening condition requiring immediate and aggressive medical intervention. Alternative therapies may be appropriate for concurrent support and in treatment of the underlying cause once the patient has been stabilized.

• Avoid alcohol, caffeine, refined foods, sugar, and saturated fats (meat proteins and dairy products). In addition, eliminate high potassium foods, such as bananas, from the diet.
• Increase water intake, as dehydration can exacerbate hyperkalemia
• Eat small amounts of protein and favor vegetable proteins and fish over chicken and red meats.
• Small, frequent meals can help prevent hypoglycemia. Insulin release potentiates intracellular potassium shift.
• Magnesium (200 mg bid to tid) is essential for the sodium-potassium pump. It also has vasodilatory effects and may help stabilize cardiac arrhythmias.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Of primary concern is the effect of hyperkalemia on the heart. While most kidney tonics are rich in potassium and should be avoided, some cardiac glycosides and flavonoids have a neutral effect on potassium levels and are protective of cardiac function.

• Hawthorn (Crataegus monogyna) increases cardiac output without increasing cardiac load. It has a mild vasodilatory effect, helps to stabilize cardiac arrhythmias, and also supports liver function. Compromised liver function and poor fat digestion can exacerbate hyperkalemia. Drink 3 to 4 cups of tea/day. Hawthorn is a relatively safe herb and may be used long-term.
• Lily of the valley (Convalleria majalis) increases cardiac output and has a regulating effect on heart rhythm. It is a secondary diuretic which relieves edema and has a neutral to slightly lowering effect on sodium and potassium. This herb has toxic side effects and should not be used without physician supervision.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency.

Contrast hydrotherapy. Alternating hot and cold applications brings nutrients to the site and diffuses metabolic waste from inflammation. The overall effect is decreased inflammation, pain relief, and enhanced healing. Use the applications over the kidneys. Alternate 3 minutes hot with 1 minute cold. Repeat three times to complete one set. Do two to three sets/day.

Acupuncture may be helpful in supporting normal kidney function and minimizing the effects of hyperkalemia.

Swedish massage may help to stimulate the kidneys; whether this is appropriate for a particular patient depends on his or her condition and the underlying cause of the hyperkalemia.

Continue cardiac monitoring; track serum potassium levels while patient remains in hospital. Measure urine output and potassium excretion levels. Repeat potassium tests 2 to 3 days after discharge. Monitor for renal insufficiency.

Patients should be advised to avoid foods high in potassium. Medications should be reviewed to avoid those which predispose to hyperkalemia. If the problem was precipitated by noncompliance with a dialysis schedule, encourage the patient to make this a priority.

Severe hyperkalemia is itself a life-threatening emergency that can lead to cardiac and/or respiratory arrest. Over-correction of the potassium level must also be guarded against.

Many of the therapies for hyperkalemia discussed above begin to work in about half an hour. However, they address only the immediate ion balance and not the root cause of the hyperkalemia. The prognosis depends on treating for such conditions as renal failure or diabetic ketoacidosis.

Hyperkalemia in pregnancy is a medical emergency.

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Zwanger M. Hyperkalemia. Emergency Medicine Online Text. 1998. Accessed at http://www.emedicine.com/emerg/topic261.htm on February 13, 1999.