K
+
TREATMENT OF HYPERKALEMIA IN CKD
The steps to address hyperkalemia include stabilization, redistribution, and excretion/removal of potassium.
Table 3. Summary of interventions used for acute or chronic treatment of hyperkalemia 6
Treatment
6.8 mmol of calcium, corresponding
to 10 ml CaCl (10%)* or 30 ml
calcium gluconate (10%) solutions
50-250 ml hypertonic saline (3-5%)**
50-100 mmol sodium bicarbonate
10 units of regular insulin
2-receptor agonists:
10-20 mg aerosol (nebulized) or
0.5mg in 100ml of 5% dextrose in
water (intravenous)
40 mg furosemide or equivalent
dose of other loop diuretic. Higher
doses may be needed in patients
with advanced CKD
Fludrocortisone acetate 0.1 mg
(up to 0.4-1.0 mg daily)
Cation exchange resins
Sodium polystyrene sulfonate
25-50 g
Cation exchange polymer
Patiromer 8.4, 16.8, or 25.2 g
Dialysis
*CaCl is caustic and could damage peripheral veins. **Limited data available from clinical studies. ***Clinical studies being done to assess the clinical significance of the in vitro interaction. ****Effects can
last for an unspecified length of time, depending on ongoing potassium intake or cellular redistribution. Abbreviations: CKD, chronic kidney disease; GFR, glomerular filtration rate; GI, gastrointestinal; NA, not
applicable. | Adapted with permission from Kovesdy CP. Management of hyperkalaemia in chronic kidney disease. Nat Rev Nephrol, 2014;10:659-662. Copyright 2014 by Macmillan Publishers Limited.
REFERENCES
1. T
 ran HA. Extreme hyperkalemia. 11. Inker LA, Astor BC, Fox CH, et al.KDOQI U.S. Best Practices in Managing
South Med J. 2005;98:729-732. commentary on the 2012 KDIGO clinical
2. G
 umz ML, Rabinowitz L, Wingo CS.An practice guideline for the evaluation and
HYPERKALEMIA
integrated view of potassium homeostasis. management of CKD.Am J Kidney Dis. May
Route of Onset/ Mechanism Comments N Engl J Med. 2015;373:60-72. 2014;63(5):713-735. in Chronic Kidney Disease
duration 3. A
 lvo M, Warnock DG.Hyperkalemia. 12. M
 ercier K, Smith H, Biederman J.Renin-
West J Med. 1984;141:666-671. angiotensin-aldosterone system
Intravenous (acute) 1-3 min Membrane Does not affect serum potassium level inhibition: overview of the therapeutic
30-60 min potential stabilization Effect measured by normalization of electrocardiographic changes 4. E
 inhorn LM, Zhan M, Hsu VD, et al.The frequency of
use of angiotensin-converting enzyme
Dose can be repeated if no effects noted hyperkalemia and its significance in chronic kidney
inhibitors, angiotensin receptor blockers,
Caution advised in patients receiving digoxin disease.Arch Intern Med. 2009;169:1156-1162.
mineralocorticoid receptor antagonists,
Intravenous (acute) 5-10 min Membrane Efficacy only in hyponatremic patients 5. J ain N, Kotla S, Little BB, et al.Predictors of and direct renin inhibitors.Prim Care.
~2 h potential stabilization hyperkalemia and death in patients with 2014;41:765-778.
cardiac and renal disease.Am J Cardiol.
Intravenous (acute) 5-10 min Redistribution Sodium may worsen pre-existing hypertension and heart failure 13. V
 assalotti JA, Centor R, Turner BJ, et al; U.S.
2012;109:1510-1513.
or oral (chronic) ~2 h Efficacy questioned for acute treatment of patients on dialysis Kidney Disease Outcomes Quality Initiative
6. K
 ovesdy CP.Management of hyperkalaemia (KDOQI).A practical approach to detection
Intravenous (acute) 30 min Redistribution Administer with 50 g of glucose intravenously to prevent hypoglycemia in chronic kidney disease.Nat Rev Nephrol. and management of chronic kidney disease
4-6 h 2014;10:653-662. for the primary care clinician [Epub ahead of
Intravenous or 30 min Redistribution Effect independent of insulin and aldosterone print September 18 2015].Am J Med. 2015.
7. S
 arafidis PA, Blacklock R, Wood E, et al.
nebulized (both 2-4 h Caution in patients with known coronary artery disease
Prevalence and factors associated with 14. L
 ehnhardt A, Kemper MJ.Pathogenesis,
acute)
hyperkalemia in predialysis patients followed in diagnosis, and management of
a low-clearance clinic.Clin J Am Soc Nephrol. hyperkalemia.Pediatr Nephrol. March
Intravenous (acute) Varies Excretion Loop diuretics for acute intervention 2012;7:1234-1241. 2011;26:377-384.
or oral (chronic) Until diuresis Loop or thiazide diuretics for chronic management; loop diuretic for GFR <40 ml/min/1.73 m2 15
8. T
 urgut F, Balogun RA, Abdel-Rahman 15. S
 arafidis PA, Georgianos PI, Bakris GL.
present or May not be effective in patients with reduced GFR
EM.Renin-angiotensin-aldosterone system Advances in treatment of hyperkalemia
longer
blockade effects on the kidney in the elderly: in chronic kidney disease.Expert Opin
Oral (chronic) NA Excretion In patients with aldosterone deficiency, large doses might be needed to effectively lower benefits and limitations.Clin J Am Soc Pharmacother. 2015;16:2205-2215.
potassium levels Nephrol. 2010;5:1330-1339.
Sodium retention, edema, and hypertension might occur, and acceleration of kidney and 16. U
 .S. Food and Drug Administration (FDA).
cardiovascular disease 9. X
 ie X, Liu Y, Perkovic V, et al.Reninangiotensin Kayexalate. http://www.accessdata.fda.gov/
system inhibitors and kidney and drugsatfda_docs/label/2011/011287s023lbl.
Oral or rectal (either 1-2 h Excretion C
 ases of intestinal necrosis, which may be fatal, and other serious GI adverse events have cardiovascular outcomes in patients with pdf. Updated December 2010. Accessed
acute or chronic), 4-6 h been reported16 CKD: a Bayesian Network meta-analysis of December 22 2015.
with or without May cause hypokalemia and electrolyte disturbances16
randomized clinical trials [Epub ahead of print Hyperkalemia in Chronic Kidney Disease (CKD)
sorbitol Cannot be used in medical emergencies16 17. U
 .S. Food and Drug Administration (FDA). FDA
November 17 2015]. Am J Kidney Dis. 2015.
Caution in patients with heart failure due to sodium load16 approves new drug to treat hyperkalemia. Treatment with RAAS Inhibitors (RAASi) in CKD
10. K
 idney Disease: Improving Global Outcomes http://www.fda.gov/NewsEvents/Newsroom/
Oral (either acute 7h Excretion B
 inds with many other oral medications (in vitro binding studies), separate the dosing of other Diagnosis and Evaluation of Hyperkalemia
(KDIGO) CKD Work Group. KDIGO 2012 PressAnnouncements/ucm468546.htm.
or chronic) ~48 h oral medications by at least 6 hours 17 ***
Should not be used as an emergency treatment for life-threatening hyperkalemia because clinical practice guideline for the evaluation Published October 22 2015. Accessed Treatment of Hyperkalemia in CKD
of its delayed onset of action17 and management of chronic kidney disease. November 24 2015.
May result in hypokalemia or hypomagnesemia17 Kidney Int Suppls. 2013;3:1-150.
Hemodialysis Within Removal Effects of dialysis on serum sodium, bicarbonate, calcium and/or magnesium levels can affect results
(acute or chronic); minutes For chronic hemodialysis, missed treatments and 2-day interdialytic interval may have a
Peritoneal dialysis Until end of negative impact on outcomes.
(chronic) dialysis or This publication has been sponsored and
longer**** developed in collaboration with Relypsa, Inc.
30 East 33rd Street
New York, NY 10016
800.622.9010
www.kidney.org
2016 National Kidney Foundation, Inc. 02-10-7259_ABG
HYPERKALEMIA TREATMENT WITH RAASi DIAGNOSIS AND EVALUATION
IN CKD IN CKD OF HYPERKALEMIA

The definition of hyperkalemia varies and limits such as >5.5, Studies show that use of ACEIs or ARBs in people with CKD reduces the Hyperkalemia is often asymptomatic, but patients may complain
>6.0, or >7.0 mEq/L are used to indicate severity.1 Repetitive Table 2. Chronic Risk Factors for risk for kidney failure and cardiovascular events, but their use contributes of nonspecific symptoms such as palpitations, nausea, muscle
consecutive measures of serum potassium are needed Hyperkalemia in CKD 5, 6, 7, 8 to hyperkalemia.9The clinical practice guidelines for the use of RAASi in pain, weakness, or paresthesia. Moderate and especially severe
to determine if hyperkalemia is sustained or a transient event. CKD are as follows:10, 11 hyperkalemia can lead to cardiotoxicity, which can be fatal. The
Many factors affect potassium homeostasis.2 cause of hyperkalemia has to be determined to prevent future
KDIGO Guidelines suggest that an ARB or ACEI be used in diabetic episodes. 14
Risk Factor Due To
adults with CKD and urine albumin excretion 30-300 mg/24 hours
(or equivalent). (2D)
Potassium intake Increased dietary potassium intake from
Table 1. Acute Versus Chronic Hyperkalemia 3, 4 salt substitute, potassium-rich heart-healthy
diets, and herbal supplements
KDIGO Guidelines recommend that an ARB or ACEI be used in Emergency diagnostic Elective/etiologic
both diabetic and nondiabetic adults with CKD and urine albumin workup:14 workup:14
Acute Hyperkalemia Chronic Hyperkalemia Metabolic acidosis Potassium shift from the intracellular to the excretion >300 mg/24 hours (or equivalent). (1B)
extracellular space 1. Comprehensive laboratory workup
1. Assessment of cardiac function,
There is insufficient evidence to recommend combining an
kidneys, and urinary tract
Caused by abnormal net release of Caused by impairment of RAASi Treatment with ACEIs and ARBs block the ACEI with ARBs to prevent progression of CKD. (Not Graded) 2. Review of medication used
potassium from cells, often due to potassium excretory process renin-angiotensin system and cause lower 2. Assessment of hydration status
trauma, metabolic acidosis (depends and/or increased potassium load serum aldosterone Subsequent research shows that dual RAAS inhibition with ACEI
on etiology), hemolytic states plus ARB not only fails to improve cardiovascular or renal outcomes, 3. Electrocardiogram
Diabetes Insulin deficiency and hypertonicity caused but predisposes patients to serious adverse events.12
by hyperglycemia contribute to an inability
Requires immediate attention, ie, Requires ongoing management to disperse high acute potassium load into
cardiac monitoring, acute medical to correct the underlying the intracellular space
interventions, possibly dialysis disturbances in potassium balance, Considerations for using an ACEI or ARB in patients with CKD:
ie, nonpharmacological and
pharmacological interventions Heart failure Reduction in renal perfusion, use of RAASi
or MRA Hyperkalemia and worsening kidney function can develop.
Disclaimer:
Management goals: induce Management goals: induce It is important to monitor serum potassium and estimated Information contained in this
Coronary artery and Use of RAASi, oxidative stress,
potassium redistribution and potassium redistribution peripheral vascular disease atherosclerosis glomerular filtration rate (eGFR) within several weeks of starting National Kidney Foundation
excretion, restore normal and excretion to prevent the educational resource is based
electrophysiology of the cell development or recurrence of or escalating a RAASi.13 upon current data available at the
membrane, prevent cardiac hyperkalemia; monitor potassium Advanced age Decreases in plasma renin activity and
time of publication. Information is
arrhythmia intake through diet plasma aldosterone levels with age, as well Discontinuing these drugs is helpful in controlling or treating
as frequent use of NSAIDS in this population.
intended to help clinicians become
hyperkalemia, but the disadvantage is that it increases the risk aware of new scientific findings and
for kidney disease progression and cardiovascular events.6 developments. This clinical bulletin
is not intended to set out a preferred
Abbreviations: ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor
standard of care and should not be
blocker; MRA, mineralocorticoid receptor antagonist; NSAIDS, nonsteroidal anti-inflammatory
drugs; RAASi, renin-angiotensin-aldosterone system inhibitors. construed as one. Neither should
the information be interpreted as
prescribing an exclusive course
of management.
HYPERKALEMIA TREATMENT WITH RAASi DIAGNOSIS AND EVALUATION
IN CKD IN CKD OF HYPERKALEMIA

The definition of hyperkalemia varies and limits such as >5.5, Studies show that use of ACEIs or ARBs in people with CKD reduces the Hyperkalemia is often asymptomatic, but patients may complain
>6.0, or >7.0 mEq/L are used to indicate severity.1 Repetitive Table 2. Chronic Risk Factors for risk for kidney failure and cardiovascular events, but their use contributes of nonspecific symptoms such as palpitations, nausea, muscle
consecutive measures of serum potassium are needed Hyperkalemia in CKD 5, 6, 7, 8 to hyperkalemia.9The clinical practice guidelines for the use of RAASi in pain, weakness, or paresthesia. Moderate and especially severe
to determine if hyperkalemia is sustained or a transient event. CKD are as follows:10, 11 hyperkalemia can lead to cardiotoxicity, which can be fatal. The
Many factors affect potassium homeostasis.2 cause of hyperkalemia has to be determined to prevent future
KDIGO Guidelines suggest that an ARB or ACEI be used in diabetic episodes. 14
Risk Factor Due To
adults with CKD and urine albumin excretion 30-300 mg/24 hours
(or equivalent). (2D)
Potassium intake Increased dietary potassium intake from
Table 1. Acute Versus Chronic Hyperkalemia 3, 4 salt substitute, potassium-rich heart-healthy
diets, and herbal supplements
KDIGO Guidelines recommend that an ARB or ACEI be used in Emergency diagnostic Elective/etiologic
both diabetic and nondiabetic adults with CKD and urine albumin workup:14 workup:14
Acute Hyperkalemia Chronic Hyperkalemia Metabolic acidosis Potassium shift from the intracellular to the excretion >300 mg/24 hours (or equivalent). (1B)
extracellular space 1. Comprehensive laboratory workup
1. Assessment of cardiac function,
There is insufficient evidence to recommend combining an
kidneys, and urinary tract
Caused by abnormal net release of Caused by impairment of RAASi Treatment with ACEIs and ARBs block the ACEI with ARBs to prevent progression of CKD. (Not Graded) 2. Review of medication used
potassium from cells, often due to potassium excretory process renin-angiotensin system and cause lower 2. Assessment of hydration status
trauma, metabolic acidosis (depends and/or increased potassium load serum aldosterone Subsequent research shows that dual RAAS inhibition with ACEI
on etiology), hemolytic states plus ARB not only fails to improve cardiovascular or renal outcomes, 3. Electrocardiogram
Diabetes Insulin deficiency and hypertonicity caused but predisposes patients to serious adverse events.12
by hyperglycemia contribute to an inability
Requires immediate attention, ie, Requires ongoing management to disperse high acute potassium load into
cardiac monitoring, acute medical to correct the underlying the intracellular space
interventions, possibly dialysis disturbances in potassium balance, Considerations for using an ACEI or ARB in patients with CKD:
ie, nonpharmacological and
pharmacological interventions Heart failure Reduction in renal perfusion, use of RAASi
or MRA Hyperkalemia and worsening kidney function can develop.
Disclaimer:
Management goals: induce Management goals: induce It is important to monitor serum potassium and estimated Information contained in this
Coronary artery and Use of RAASi, oxidative stress,
potassium redistribution and potassium redistribution peripheral vascular disease atherosclerosis glomerular filtration rate (eGFR) within several weeks of starting National Kidney Foundation
excretion, restore normal and excretion to prevent the educational resource is based
electrophysiology of the cell development or recurrence of or escalating a RAASi.13 upon current data available at the
membrane, prevent cardiac hyperkalemia; monitor potassium Advanced age Decreases in plasma renin activity and
time of publication. Information is
arrhythmia intake through diet plasma aldosterone levels with age, as well Discontinuing these drugs is helpful in controlling or treating
as frequent use of NSAIDS in this population.
intended to help clinicians become
hyperkalemia, but the disadvantage is that it increases the risk aware of new scientific findings and
for kidney disease progression and cardiovascular events.6 developments. This clinical bulletin
is not intended to set out a preferred
Abbreviations: ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor
standard of care and should not be
blocker; MRA, mineralocorticoid receptor antagonist; NSAIDS, nonsteroidal anti-inflammatory
drugs; RAASi, renin-angiotensin-aldosterone system inhibitors. construed as one. Neither should
the information be interpreted as
prescribing an exclusive course
of management.
HYPERKALEMIA TREATMENT WITH RAASi DIAGNOSIS AND EVALUATION
IN CKD IN CKD OF HYPERKALEMIA

The definition of hyperkalemia varies and limits such as >5.5, Studies show that use of ACEIs or ARBs in people with CKD reduces the Hyperkalemia is often asymptomatic, but patients may complain
>6.0, or >7.0 mEq/L are used to indicate severity.1 Repetitive Table 2. Chronic Risk Factors for risk for kidney failure and cardiovascular events, but their use contributes of nonspecific symptoms such as palpitations, nausea, muscle
consecutive measures of serum potassium are needed Hyperkalemia in CKD 5, 6, 7, 8 to hyperkalemia.9The clinical practice guidelines for the use of RAASi in pain, weakness, or paresthesia. Moderate and especially severe
to determine if hyperkalemia is sustained or a transient event. CKD are as follows:10, 11 hyperkalemia can lead to cardiotoxicity, which can be fatal. The
Many factors affect potassium homeostasis.2 cause of hyperkalemia has to be determined to prevent future
KDIGO Guidelines suggest that an ARB or ACEI be used in diabetic episodes. 14
Risk Factor Due To
adults with CKD and urine albumin excretion 30-300 mg/24 hours
(or equivalent). (2D)
Potassium intake Increased dietary potassium intake from
Table 1. Acute Versus Chronic Hyperkalemia 3, 4 salt substitute, potassium-rich heart-healthy
diets, and herbal supplements
KDIGO Guidelines recommend that an ARB or ACEI be used in Emergency diagnostic Elective/etiologic
both diabetic and nondiabetic adults with CKD and urine albumin workup:14 workup:14
Acute Hyperkalemia Chronic Hyperkalemia Metabolic acidosis Potassium shift from the intracellular to the excretion >300 mg/24 hours (or equivalent). (1B)
extracellular space 1. Comprehensive laboratory workup
1. Assessment of cardiac function,
There is insufficient evidence to recommend combining an
kidneys, and urinary tract
Caused by abnormal net release of Caused by impairment of RAASi Treatment with ACEIs and ARBs block the ACEI with ARBs to prevent progression of CKD. (Not Graded) 2. Review of medication used
potassium from cells, often due to potassium excretory process renin-angiotensin system and cause lower 2. Assessment of hydration status
trauma, metabolic acidosis (depends and/or increased potassium load serum aldosterone Subsequent research shows that dual RAAS inhibition with ACEI
on etiology), hemolytic states plus ARB not only fails to improve cardiovascular or renal outcomes, 3. Electrocardiogram
Diabetes Insulin deficiency and hypertonicity caused but predisposes patients to serious adverse events.12
by hyperglycemia contribute to an inability
Requires immediate attention, ie, Requires ongoing management to disperse high acute potassium load into
cardiac monitoring, acute medical to correct the underlying the intracellular space
interventions, possibly dialysis disturbances in potassium balance, Considerations for using an ACEI or ARB in patients with CKD:
ie, nonpharmacological and
pharmacological interventions Heart failure Reduction in renal perfusion, use of RAASi
or MRA Hyperkalemia and worsening kidney function can develop.
Disclaimer:
Management goals: induce Management goals: induce It is important to monitor serum potassium and estimated Information contained in this
Coronary artery and Use of RAASi, oxidative stress,
potassium redistribution and potassium redistribution peripheral vascular disease atherosclerosis glomerular filtration rate (eGFR) within several weeks of starting National Kidney Foundation
excretion, restore normal and excretion to prevent the educational resource is based
electrophysiology of the cell development or recurrence of or escalating a RAASi.13 upon current data available at the
membrane, prevent cardiac hyperkalemia; monitor potassium Advanced age Decreases in plasma renin activity and
time of publication. Information is
arrhythmia intake through diet plasma aldosterone levels with age, as well Discontinuing these drugs is helpful in controlling or treating
as frequent use of NSAIDS in this population.
intended to help clinicians become
hyperkalemia, but the disadvantage is that it increases the risk aware of new scientific findings and
for kidney disease progression and cardiovascular events.6 developments. This clinical bulletin
is not intended to set out a preferred
Abbreviations: ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor
standard of care and should not be
blocker; MRA, mineralocorticoid receptor antagonist; NSAIDS, nonsteroidal anti-inflammatory
drugs; RAASi, renin-angiotensin-aldosterone system inhibitors. construed as one. Neither should
the information be interpreted as
prescribing an exclusive course
of management.
HYPERKALEMIA TREATMENT WITH RAASi DIAGNOSIS AND EVALUATION
IN CKD IN CKD OF HYPERKALEMIA

The definition of hyperkalemia varies and limits such as >5.5, Studies show that use of ACEIs or ARBs in people with CKD reduces the Hyperkalemia is often asymptomatic, but patients may complain
>6.0, or >7.0 mEq/L are used to indicate severity.1 Repetitive Table 2. Chronic Risk Factors for risk for kidney failure and cardiovascular events, but their use contributes of nonspecific symptoms such as palpitations, nausea, muscle
consecutive measures of serum potassium are needed Hyperkalemia in CKD 5, 6, 7, 8 to hyperkalemia.9The clinical practice guidelines for the use of RAASi in pain, weakness, or paresthesia. Moderate and especially severe
to determine if hyperkalemia is sustained or a transient event. CKD are as follows:10, 11 hyperkalemia can lead to cardiotoxicity, which can be fatal. The
Many factors affect potassium homeostasis.2 cause of hyperkalemia has to be determined to prevent future
KDIGO Guidelines suggest that an ARB or ACEI be used in diabetic episodes. 14
Risk Factor Due To
adults with CKD and urine albumin excretion 30-300 mg/24 hours
(or equivalent). (2D)
Potassium intake Increased dietary potassium intake from
Table 1. Acute Versus Chronic Hyperkalemia 3, 4 salt substitute, potassium-rich heart-healthy
diets, and herbal supplements
KDIGO Guidelines recommend that an ARB or ACEI be used in Emergency diagnostic Elective/etiologic
both diabetic and nondiabetic adults with CKD and urine albumin workup:14 workup:14
Acute Hyperkalemia Chronic Hyperkalemia Metabolic acidosis Potassium shift from the intracellular to the excretion >300 mg/24 hours (or equivalent). (1B)
extracellular space 1. Comprehensive laboratory workup
1. Assessment of cardiac function,
There is insufficient evidence to recommend combining an
kidneys, and urinary tract
Caused by abnormal net release of Caused by impairment of RAASi Treatment with ACEIs and ARBs block the ACEI with ARBs to prevent progression of CKD. (Not Graded) 2. Review of medication used
potassium from cells, often due to potassium excretory process renin-angiotensin system and cause lower 2. Assessment of hydration status
trauma, metabolic acidosis (depends and/or increased potassium load serum aldosterone Subsequent research shows that dual RAAS inhibition with ACEI
on etiology), hemolytic states plus ARB not only fails to improve cardiovascular or renal outcomes, 3. Electrocardiogram
Diabetes Insulin deficiency and hypertonicity caused but predisposes patients to serious adverse events.12
by hyperglycemia contribute to an inability
Requires immediate attention, ie, Requires ongoing management to disperse high acute potassium load into
cardiac monitoring, acute medical to correct the underlying the intracellular space
interventions, possibly dialysis disturbances in potassium balance, Considerations for using an ACEI or ARB in patients with CKD:
ie, nonpharmacological and
pharmacological interventions Heart failure Reduction in renal perfusion, use of RAASi
or MRA Hyperkalemia and worsening kidney function can develop.
Disclaimer:
Management goals: induce Management goals: induce It is important to monitor serum potassium and estimated Information contained in this
Coronary artery and Use of RAASi, oxidative stress,
potassium redistribution and potassium redistribution peripheral vascular disease atherosclerosis glomerular filtration rate (eGFR) within several weeks of starting National Kidney Foundation
excretion, restore normal and excretion to prevent the educational resource is based
electrophysiology of the cell development or recurrence of or escalating a RAASi.13 upon current data available at the
membrane, prevent cardiac hyperkalemia; monitor potassium Advanced age Decreases in plasma renin activity and
time of publication. Information is
arrhythmia intake through diet plasma aldosterone levels with age, as well Discontinuing these drugs is helpful in controlling or treating
as frequent use of NSAIDS in this population.
intended to help clinicians become
hyperkalemia, but the disadvantage is that it increases the risk aware of new scientific findings and
for kidney disease progression and cardiovascular events.6 developments. This clinical bulletin
is not intended to set out a preferred
Abbreviations: ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor
standard of care and should not be
blocker; MRA, mineralocorticoid receptor antagonist; NSAIDS, nonsteroidal anti-inflammatory
drugs; RAASi, renin-angiotensin-aldosterone system inhibitors. construed as one. Neither should
the information be interpreted as
prescribing an exclusive course
of management.

TREATMENT OF HYPERKALEMIA IN CKD
The steps to address hyperkalemia include stabilization, redistribution, and excretion/removal of potassium.
Table 3. Summary of interventions used for acute or chronic treatment of hyperkalemia 6
Treatment
6.8 mmol of calcium, corresponding
to 10 ml CaCl (10%)* or 30 ml
calcium gluconate (10%) solutions
50-250 ml hypertonic saline (3-5%)**
50-100 mmol sodium bicarbonate
10 units of regular insulin
2-receptor agonists:
10-20 mg aerosol (nebulized) or
0.5mg in 100ml of 5% dextrose in
water (intravenous)
40 mg furosemide or equivalent
dose of other loop diuretic. Higher
doses may be needed in patients
with advanced CKD
Fludrocortisone acetate 0.1 mg
(up to 0.4-1.0 mg daily)
Cation exchange resins
Sodium polystyrene sulfonate
25-50 g
Cation exchange polymer
Patiromer 8.4, 16.8, or 25.2 g
Dialysis
*CaCl is caustic and could damage peripheral veins. **Limited data available from clinical studies. ***Clinical studies being done to assess the clinical significance of the in vitro interaction. ****Effects can
last for an unspecified length of time, depending on ongoing potassium intake or cellular redistribution. Abbreviations: CKD, chronic kidney disease; GFR, glomerular filtration rate; GI, gastrointestinal; NA, not
applicable. | Adapted with permission from Kovesdy CP. Management of hyperkalaemia in chronic kidney disease. Nat Rev Nephrol, 2014;10:659-662. Copyright 2014 by Macmillan Publishers Limited.
K
+
REFERENCES
1. T
 ran HA. Extreme hyperkalemia. 11. Inker LA, Astor BC, Fox CH, et al.KDOQI U.S. Best Practices in Managing
South Med J. 2005;98:729-732. commentary on the 2012 KDIGO clinical
2. G
 umz ML, Rabinowitz L, Wingo CS.An practice guideline for the evaluation and
HYPERKALEMIA
integrated view of potassium homeostasis. management of CKD.Am J Kidney Dis. May
Route of Onset/ Mechanism Comments N Engl J Med. 2015;373:60-72. 2014;63(5):713-735. in Chronic Kidney Disease
duration 3. A
 lvo M, Warnock DG.Hyperkalemia. 12. M
 ercier K, Smith H, Biederman J.Renin-
West J Med. 1984;141:666-671. angiotensin-aldosterone system
Intravenous (acute) 1-3 min Membrane Does not affect serum potassium level inhibition: overview of the therapeutic
30-60 min potential stabilization Effect measured by normalization of electrocardiographic changes 4. E
 inhorn LM, Zhan M, Hsu VD, et al.The frequency of
use of angiotensin-converting enzyme
Dose can be repeated if no effects noted hyperkalemia and its significance in chronic kidney
inhibitors, angiotensin receptor blockers,
Caution advised in patients receiving digoxin disease.Arch Intern Med. 2009;169:1156-1162.
mineralocorticoid receptor antagonists,
Intravenous (acute) 5-10 min Membrane Efficacy only in hyponatremic patients 5. J ain N, Kotla S, Little BB, et al.Predictors of and direct renin inhibitors.Prim Care.
~2 h potential stabilization hyperkalemia and death in patients with 2014;41:765-778.
cardiac and renal disease.Am J Cardiol.
Intravenous (acute) 5-10 min Redistribution Sodium may worsen pre-existing hypertension and heart failure 13. V
 assalotti JA, Centor R, Turner BJ, et al; U.S.
2012;109:1510-1513.
or oral (chronic) ~2 h Efficacy questioned for acute treatment of patients on dialysis Kidney Disease Outcomes Quality Initiative
6. K
 ovesdy CP.Management of hyperkalaemia (KDOQI).A practical approach to detection
Intravenous (acute) 30 min Redistribution Administer with 50 g of glucose intravenously to prevent hypoglycemia in chronic kidney disease.Nat Rev Nephrol. and management of chronic kidney disease
4-6 h 2014;10:653-662. for the primary care clinician [Epub ahead of
Intravenous or 30 min Redistribution Effect independent of insulin and aldosterone print September 18 2015].Am J Med. 2015.
7. S
 arafidis PA, Blacklock R, Wood E, et al.
nebulized (both 2-4 h Caution in patients with known coronary artery disease
Prevalence and factors associated with 14. L
 ehnhardt A, Kemper MJ.Pathogenesis,
acute)
hyperkalemia in predialysis patients followed in diagnosis, and management of
a low-clearance clinic.Clin J Am Soc Nephrol. hyperkalemia.Pediatr Nephrol. March
Intravenous (acute) Varies Excretion Loop diuretics for acute intervention 2012;7:1234-1241. 2011;26:377-384.
or oral (chronic) Until diuresis Loop or thiazide diuretics for chronic management; loop diuretic for GFR <40 ml/min/1.73 m2 15
8. T
 urgut F, Balogun RA, Abdel-Rahman 15. S
 arafidis PA, Georgianos PI, Bakris GL.
present or May not be effective in patients with reduced GFR
EM.Renin-angiotensin-aldosterone system Advances in treatment of hyperkalemia
longer
blockade effects on the kidney in the elderly: in chronic kidney disease.Expert Opin
Oral (chronic) NA Excretion In patients with aldosterone deficiency, large doses might be needed to effectively lower benefits and limitations.Clin J Am Soc Pharmacother. 2015;16:2205-2215.
potassium levels Nephrol. 2010;5:1330-1339.
Sodium retention, edema, and hypertension might occur, and acceleration of kidney and 16. U
 .S. Food and Drug Administration (FDA).
cardiovascular disease 9. X
 ie X, Liu Y, Perkovic V, et al.Reninangiotensin Kayexalate. http://www.accessdata.fda.gov/
system inhibitors and kidney and drugsatfda_docs/label/2011/011287s023lbl.
Oral or rectal (either 1-2 h Excretion C
 ases of intestinal necrosis, which may be fatal, and other serious GI adverse events have cardiovascular outcomes in patients with pdf. Updated December 2010. Accessed
acute or chronic), 4-6 h been reported16 CKD: a Bayesian Network meta-analysis of December 22 2015.
with or without May cause hypokalemia and electrolyte disturbances16
randomized clinical trials [Epub ahead of print Hyperkalemia in Chronic Kidney Disease (CKD)
sorbitol Cannot be used in medical emergencies16 17. U
 .S. Food and Drug Administration (FDA). FDA
November 17 2015]. Am J Kidney Dis. 2015.
Caution in patients with heart failure due to sodium load16 approves new drug to treat hyperkalemia. Treatment with RAAS Inhibitors (RAASi) in CKD
10. K
 idney Disease: Improving Global Outcomes http://www.fda.gov/NewsEvents/Newsroom/
Oral (either acute 7h Excretion B
 inds with many other oral medications (in vitro binding studies), separate the dosing of other Diagnosis and Evaluation of Hyperkalemia
(KDIGO) CKD Work Group. KDIGO 2012 PressAnnouncements/ucm468546.htm.
or chronic) ~48 h oral medications by at least 6 hours 17 ***
Should not be used as an emergency treatment for life-threatening hyperkalemia because clinical practice guideline for the evaluation Published October 22 2015. Accessed Treatment of Hyperkalemia in CKD
of its delayed onset of action17 and management of chronic kidney disease. November 24 2015.
May result in hypokalemia or hypomagnesemia17 Kidney Int Suppls. 2013;3:1-150.
Hemodialysis Within Removal Effects of dialysis on serum sodium, bicarbonate, calcium and/or magnesium levels can affect results
(acute or chronic); minutes For chronic hemodialysis, missed treatments and 2-day interdialytic interval may have a
Peritoneal dialysis Until end of negative impact on outcomes.
(chronic) dialysis or This publication has been sponsored and
longer**** developed in collaboration with Relypsa, Inc.
30 East 33rd Street
New York, NY 10016
800.622.9010
www.kidney.org
2016 National Kidney Foundation, Inc. 02-10-7259_ABG

TREATMENT OF HYPERKALEMIA IN CKD
The steps to address hyperkalemia include stabilization, redistribution, and excretion/removal of potassium.
Table 3. Summary of interventions used for acute or chronic treatment of hyperkalemia 6
Treatment
6.8 mmol of calcium, corresponding
to 10 ml CaCl (10%)* or 30 ml
calcium gluconate (10%) solutions
50-250 ml hypertonic saline (3-5%)**
50-100 mmol sodium bicarbonate
10 units of regular insulin
2-receptor agonists:
10-20 mg aerosol (nebulized) or
0.5mg in 100ml of 5% dextrose in
water (intravenous)
40 mg furosemide or equivalent
dose of other loop diuretic. Higher
doses may be needed in patients
with advanced CKD
Fludrocortisone acetate 0.1 mg
(up to 0.4-1.0 mg daily)
Cation exchange resins
Sodium polystyrene sulfonate
25-50 g
Cation exchange polymer
Patiromer 8.4, 16.8, or 25.2 g
Dialysis
*CaCl is caustic and could damage peripheral veins. **Limited data available from clinical studies. ***Clinical studies being done to assess the clinical significance of the in vitro interaction. ****Effects can
last for an unspecified length of time, depending on ongoing potassium intake or cellular redistribution. Abbreviations: CKD, chronic kidney disease; GFR, glomerular filtration rate; GI, gastrointestinal; NA, not
applicable. | Adapted with permission from Kovesdy CP. Management of hyperkalaemia in chronic kidney disease. Nat Rev Nephrol, 2014;10:659-662. Copyright 2014 by Macmillan Publishers Limited.
K
+
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November 17 2015]. Am J Kidney Dis. 2015.
Caution in patients with heart failure due to sodium load16 approves new drug to treat hyperkalemia. Treatment with RAAS Inhibitors (RAASi) in CKD
10. K
 idney Disease: Improving Global Outcomes http://www.fda.gov/NewsEvents/Newsroom/
Oral (either acute 7h Excretion B
 inds with many other oral medications (in vitro binding studies), separate the dosing of other Diagnosis and Evaluation of Hyperkalemia
(KDIGO) CKD Work Group. KDIGO 2012 PressAnnouncements/ucm468546.htm.
or chronic) ~48 h oral medications by at least 6 hours 17 ***
Should not be used as an emergency treatment for life-threatening hyperkalemia because clinical practice guideline for the evaluation Published October 22 2015. Accessed Treatment of Hyperkalemia in CKD
of its delayed onset of action17 and management of chronic kidney disease. November 24 2015.
May result in hypokalemia or hypomagnesemia17 Kidney Int Suppls. 2013;3:1-150.
Hemodialysis Within Removal Effects of dialysis on serum sodium, bicarbonate, calcium and/or magnesium levels can affect results
(acute or chronic); minutes For chronic hemodialysis, missed treatments and 2-day interdialytic interval may have a
Peritoneal dialysis Until end of negative impact on outcomes.
(chronic) dialysis or This publication has been sponsored and
longer**** developed in collaboration with Relypsa, Inc.
30 East 33rd Street
New York, NY 10016
800.622.9010
www.kidney.org
2016 National Kidney Foundation, Inc. 02-10-7259_ABG