Hyperkalemia in adults

Hyperkalemia typically presents with no symptoms or with nonspecific features only. However, be aware that some patients with significant hyperkalemia may present with cardiac arrest, which is not covered in this topic.

Take a detailed past medical and drug history to check for features that increase the risk of hyperkalemia. Confirm hyperkalemia if serum potassium is ≥5.5 mEq/L (≥5.5 mmol/L) and check that this is not due to pseudohyperkalemia.

Obtain an urgent 12-lead ECG in all hospitalized patients with a serum potassium ≥6.0 mEq/L (≥6.0 mmol/L; or use the threshold in your local protocol) to check for ECG changes that will help to determine the urgency and type of treatment.

Employ rapidly-acting therapies if hyperkalemia requiring emergency management is present. Target treatment to remove/eliminate potassium from the body, as well as treating the underlying cause of hyperkalemia and any associated disorders.

​Hyperkalemia is an electrolyte imbalance characterized by abnormally high levels of potassium in the serum or plasma. There is no universally accepted definition of hyperkalemia; however, the European Resuscitation Council defines hyperkalemia as a serum potassium (K+) level ≥5.5 mEq/L (≥5.5 mmol/L). Hyperkalemia is generally further classified by severity as mild (5.5 to 5.9 mEq/L [ 5.5 to 5.9 mmol/L]), moderate (6.0 to 6.4 mEq/L [6.0 to 6.4 mmol/L]), or severe (≥6.5 mEq/L [≥6.5 mmol/L]).[1]Alfonzo A, Harrison A, Baines R, et al; UK Kidney Association (formerly the Renal Association). Clinical practice guidelines: treatment of acute hyperkalaemia in adults​. June 2020 [internet publication]. https://ukkidney.org/sites/renal.org/files/RENAL%20ASSOCIATION%20HYPERKALAEMIA%20GUIDELINE%20-%20JULY%202022%20V2_0.pdf [2]Rafique Z, Peacock F, Armstead T, et al. Hyperkalemia management in the emergency department: an expert panel consensus. J Am Coll Emerg Physicians Open. 2021 Oct;2(5):e12572. https://www.doi.org/10.1002/emp2.12572 http://www.ncbi.nlm.nih.gov/pubmed/34632453?tool=bestpractice.com [3]Lott C, Truhlář A, Alfonzo A, et al. European Resuscitation Council Guidelines 2021: cardiac arrest in special circumstances. Resuscitation. 2021 Apr;161:152-219. https://www.doi.org/10.1016/j.resuscitation.2021.02.011 http://www.ncbi.nlm.nih.gov/pubmed/33773826?tool=bestpractice.com ​ However, Kidney Disease: Improving Global Outcomes (KDIGO) guidelines include ECG changes when categorizing severity; on the KDIGO scale a serum potassium level of 6.0 to 6.4 mEq/L (6.0 to 6.4 mmol/L) with ECG changes is classed as severe.[4]Clase CM, Carrero JJ, Ellison DH, et al. Potassium homeostasis and management of dyskalemia in kidney diseases: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) controversies conference. Kidney Int. 2020 Jan;97(1):42-61. https://www.doi.org/10.1016/j.kint.2019.09.018 http://www.ncbi.nlm.nih.gov/pubmed/31706619?tool=bestpractice.com

The presence of persistent or recurrent hyperkalemia in the community is often described as chronic hyperkalemia.[1]Alfonzo A, Harrison A, Baines R, et al; UK Kidney Association (formerly the Renal Association). Clinical practice guidelines: treatment of acute hyperkalaemia in adults​. June 2020 [internet publication]. https://ukkidney.org/sites/renal.org/files/RENAL%20ASSOCIATION%20HYPERKALAEMIA%20GUIDELINE%20-%20JULY%202022%20V2_0.pdf There is no consensus on the magnitude, duration, and frequency of elevated potassium values that define chronic hyperkalemia.[4]Clase CM, Carrero JJ, Ellison DH, et al. Potassium homeostasis and management of dyskalemia in kidney diseases: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) controversies conference. Kidney Int. 2020 Jan;97(1):42-61. https://www.doi.org/10.1016/j.kint.2019.09.018 http://www.ncbi.nlm.nih.gov/pubmed/31706619?tool=bestpractice.com [5]Palmer BF, Carrero JJ, Clegg DJ, et al. Clinical management of hyperkalemia. Mayo Clin Proc. 2021 Mar;96(3):744-62. https://www.doi.org/10.1016/j.mayocp.2020.06.014 http://www.ncbi.nlm.nih.gov/pubmed/33160639?tool=bestpractice.com ​​​ Chronic hyperkalemia is often asymptomatic.[5]Palmer BF, Carrero JJ, Clegg DJ, et al. Clinical management of hyperkalemia. Mayo Clin Proc. 2021 Mar;96(3):744-62. https://www.doi.org/10.1016/j.mayocp.2020.06.014 http://www.ncbi.nlm.nih.gov/pubmed/33160639?tool=bestpractice.com

The management of patients in cardiac arrest due to hyperkalemia is not covered in this topic. See Cardiac arrest.