• 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 mellitus
  • 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).

Last reviewed: 27/04/2023

Next review date: 30/04/2026

Author(s): NHS Highland Renal Department.

Version: 2

Approved By: TAM subgroup of the ADTC

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

Document Id: TAM290

Related resources