Hyperkalaemia (Guidelines)

What's new / Latest updates

Updated guideline adapted from the 2020 UK Kidney Association Hyperkalaemia Guideline
New product for insulin-glucose infusion: glucose 10% 250mL (new volume of infusion bag).
Advised for peripheral veins instead of glucose 50% 50mL due to reduced extravasation risk.
10% glucose infusion for 5 hrs following insulin/glucose infusion if a pre-treatment blood glucose <7 mmol/L, to prevent hypoglycaemia.
This is because there have been multiple reports of a high incidence of iatrogenic hypoglycaemia following the administration of insulin/dextrose.
New formulary product: potassium binder, sodium zirconium cyclosilicate. To be considered for K ≥ 6.0 mmol/L with ECG changes.

Audience

HHSCP only
Secondary care only

This guideline has been adapted from the 2020 UK Kidney Association Hyperkalaemia Guideline (see resources).

MHRA Drug Safety Update June 2023: Calcium chloride, calcium gluconate: potential risk of underdosing with calcium gluconate in severe hyperkalaemia

Emergency management of acute hyperkalaemia in adults (not DKA)

Haemodialysis patients

Inform the renal team immediately if a dialysis patient presents with hyperkalaemia as medical treatments will only temporarily control K+ level.

Signs and symptoms

Often non-specific and may include:

ECG abnormalities (see below) *requires urgent treatment*
Fast irregular pulse
Chest pain
Muscle weakness and paralysis
Muscle cramps
Palpitations

Causes of hyperkalaemia include:

Acute Kidney Injury or Chronic Kidney Disease
Dialysis dependency (haemodialysis or peritoneal dialysis)
Metabolic acidosis
Rhabdomyolysis
Tumour lysis syndrome
Burns/trauma
Hypoaldosteronism
Insulin deficiency DKA in patients with diabetes
Pseudohyperkalaemia. Possible causes:
- Test tube haemolysis
- Prolonged tourniquet time
- Marked leucocytosis and thrombocytosis (measure whole blood potassium in lithium heparin tube in these disease states)
- EDTA contamination (from FBC sample tube)

Medication causes:

The medication history is an important part of determining the aetiology of hyperkalaemia. Ask about current medication, recent changes and the use of over the counter medicines. (N.B. this list is not comprehensive)

Consider stopping or withholding:

ACE inhibitors/Angiotensin II receptor antagonists
Mineralocorticoid Receptor Antagonists e.g. spironolactone, eplerenone
Non-steroidal anti-inflammatory drugs (NSAIDs)
Beta-blockers such as bisoprolol
Trimethoprim, co-trimoxazole
Potassium oral supplements and IV infusions and salt substitutes (e.g. LoSalt)

The following must NOT be stopped or withheld without senior advice:

Heparin and enoxaparin used in VTE prophylaxis or treatment of DVT/PE
Tacrolimus and ciclosporin used for immunosuppression

A LOW POTASSIUM DIET is recommended for patients with persistent hyperkalaemia
See dietary advice sheet (resources).

Hyperkalaemia algorithm

To print a copy of 'the emergency management of hyperkalaemia', click here.

User guide for sodium zirconium cyclosilicate and calcium resonium

	Sodium zirconium cyclosilicate	Calcium resonium
Mechanism of action	Non-absorbed, non-polymer inorganic powder. Highly selective for K+ ions.	Non-specific cation binder. Entraps K⁺ in exchange for Ca²⁺
Site of action	Entire GI tract	Distal colon
Formulation	LOKELMA® 10 g powder for oral suspension	300g powder pack
Administration	Add to 45 ml of water, drink while cloudy. If the powder settles, the liquid should be stirred again and taken.	Oral (rectal not recommended). Add to 45 to 60mL water.
Dosing in acute hyperkalaemia	10 g three times daily for up to 72 hrs. If normokalaemia is not achieved after 72 hours of treatment, other treatment approaches should be considered. Maintenance therapy not Highland Formulary approved.	15g three to four times daily The supplied scoop contains 15g of powder when filled level.
Renal/hepatic impairment	No dose adjustments needed, including haemodialysis patients.	No info. Licensed to treat patients requiring dialysis.
Blood monitoring	Check K⁺ level daily.	Check K⁺ level daily.
When to stop	Discontinue when normal serum K⁺ level achieved (K⁺ 5.0 or less)	Discontinue when normal serum K⁺ level achieved (K⁺ 5.0 or less)
Drug/drug interactions	Administer at least 2 hours before or 2 hours after oral medications with clinically meaningful gastric pH dependent bioavailability Examples: Azole antifungals (ketoconazole, itraconazole and posaconazole), anti-HIV drugs (atazanavir, nelfinavir, indinavir, ritonavir, saquinavir, raltegravir, ledipasvir and rilpivirine) and tyrosine kinase inhibitors (erlotinib, dasatinib and nilotinib).	Avoid other oral medications for 3 hours before and after administration
Onset of effect	1 hour after first dose.	Over 4 hours to days
Efficacy	Normokalaemia can be achieved typically within 24 to 48 hours.	Unpredictable and variable.
Common adverse effects	GI disorders (mild/moderate). Oedema: reported in 5.7% of patients treated with SZC during maintenance phase of clinical trials. Hypokalaemia: reported in 4.1% of patients treated with Lokelma in clinical trials. Xrays: SZC may be opaque to Xrays. Consider when evaluating abdominal films.	GI disorder, especially constipation. Tolerability concerns. Hypokalaemia. Other electrolyte disturbances eg hypercalcaemia & hypomagnesaemia. Intestinal ulceration or necrosis (rare).

References

Lokelma (Astra Zeneca): Summary of Product Characteristics. 15/2/23. Lokelma 10 g powder for oral suspension - Summary of Product Characteristics (SmPC) - (emc) (medicines.org.uk)
Calcium resonium (Sanofi): Summary of Product Characteristics. 03/8/22 Calcium Resonium 99.934% w/w Powder for Oral/Rectal Suspension - Summary of Product Characteristics (SmPC) - (emc) (medicines.org.uk)

Last reviewed: 27/04/2023

Next review date: 30/04/2026

Author(s): Renal Department.

Version: 2

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Dr S Lambie, Consultant Nephrologist, J Garrod, Area Renal Pharmacist.

Document Id: TAM290

Related resources

UK Kidney Association Hyperkalaemia Guideline
Dietary advice sheet
MHRA Drug Safety Update June 2023 : Calcium chloride, calcium gluconate: potential risk of underdosing with calcium gluconate in severe hyperkalaemia