1. Case:
HYPERKALEMIA
Group A2

2. Salient Features 62 y/o Male Diabetic, Chronic Kidney Disease
With proximal weakness
Decreased skin turgor

3. Blood Test Results Normal Values Plasma Na 130 mEq/L K 8.5 mEq/L
Chloride
98 mEq/L
HCO3
17 mEq/L
Creatinine
2.7 mEq/L pH
7.32
Capillary blood glucose
400 mmol/L
Serum acetone +

4. 2. Is this pseudohyperkalemia? Why or why not?

5. Pseudohyperkalemia
An artificially elevated plasma K+ concentration due to K+ movement out of cells
Factors:
Prolonged use of torniquet (with or withour repeated clenched fist)
Hemolysis
Marked leukocytosis or thrombocytosis

6. Our patient is not in pseudohyperkalemia
No leukocytosis
No Hemolysis
In Chronic Renal Failure

7. 4. How would you manage this case?

8. Oliguric Renal failure Stop NSAIDS and ACEI
Rule out:
Pseudohyperkalemia
Trancellular K+ shift
Oliguric Renal failure
Stop NSAIDS and ACEI
Assess K+ secretion
TTKG <5
TTKG > 10
Inc. distal flow
Response to
9α – fludrocortisone
Decreased effective circulating volume
Low – protein diet (decreased urea)
TTKG > 10
TTKG < 10
Primary or secondary hypoaldosteronism
Hypotension
high renin and aldosterone
Hypertension
Low renin and aldosterone
Measure renin & aldosterone levels
Pseudohypoaldosteronism K+ sparing diuretics
Trimethoprim, pentamide
Gordon’s Syndrome
(Cl- shunt)
Cyclosporine
Distal (type 4) RTA

9. I. Evaluate Hyperkalemia
Confirm the presence of hyperkalemia in patient

10. II. Determine Urgency Situation
Emergent: if…
Rapid and recent rise in Serum Potassium
Renal insufficiency
Metabolic Acidosis
EKG changes consistent with Hyperkalemia (life – threatening & may be serious)
Treatment:
Individual Medications:
Calcium gluconate
Insulin and Glucose
Kayexalate
Bicarbonate
Dialysis

11. Calcium gluconate Insulin and Glucose Stabilize myocardium
Initial dose: 10 ml over 2-5 minutes
Second dose after 5 minutes if no response
Further calcium ineffective unless Hypocalcemia
Insulin and Glucose
Temporarily shift potassium into intracellular space
Insulin Regular 10 units IV
Glucose 50% (D50W) 50 ml (25 grams)
Indicated with insulin if serum glucose <250 mg/dl
Give 1 ampule IV over 5 minutes
consider maintenance (e.g. D5 1/2NS 100 cc/h)
Post initial bolus to cover further insulin

12. Nebulized Albuterol Bicarbonate
5 mg/ml
Administer mg over 10 minutes
Serum potassium may increase briefly
Bicarbonate
no longer used unless Metabolic Acidosis
Used before as adjunct to Calcium
Consider in severe Metabolic Acidosis
Sodium Bicarbonate 7.5% (44.6 meq)
Give 1 ampule IV over 5 minutes
May repeat every min if EKG changes persists
May also add to Glucose infusion
Avoid bicarbonate until Hypocalcemia corrected
Risk of Tetany and Seizures

13. Treatment: Enhance postassium excretion
Non – Emergent: if…
Emergent treatment criteria not met
Serum Potassium <6.0
Treatment: Enhance postassium excretion
Kayexalate
gastrointestinal excretion: Sodium Polysterene Sulfonate (Kayexalate)
Cation-Exchange Resin
Dose: 50 grams
Oral: Administer in 30 ml of Sorbitol
Rectal: Enema activity is faster than oral
Onset: Up to 4-6 hours for oral route
Precautions:
Avoid Sorbitol if bowel necrosis risk
use caution if risk of CHF

14. Furosemide Dialysis Renal excretion Last option Dose: 20-40 mg IV
Coadminister normal saline if dehydrated
Dialysis
Last option

15. III. Have a long – term plan
For chronic hyperkalemia patients
Treatment:
Eliminate medication causes of elevated serum potassium
Non-specific therapy
Loop diuretics (Lasix)
Oral Kayexalate chronically
Specific Therapy
Renal Failure (GFR < 10 ml/min)
Restrict dietary Potassium to meq/day

16. Renal Failure and ACE or ARB induced Hyperkalemia
Indications: Metabolic Acidosis
Sodium Bicarbonate
Dose A: 8 meq tabs, 2 tabs twice daily
Dose B: 0.5 to 1 tsp baking soda daily
Hyporeninemic Hypoaldosteronism
Loop diuretics ( Lasix)
Fludrocortisone 0.1 mg daily
Taper gradually as an outpatient
Restart if Hyperkalemia recurs