Hyperkalaemia in adults

​Hyperkalaemia typically presents with no symptoms or with non-specific features only. However, be aware that some patients with significant hyperkalaemia 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 hyperkalaemia. Confirm hyperkalaemia if serum potassium is ≥5.5 mmol/L (≥5.5 mEq/L) and check that this is not due to pseudohyperkalaemia.

Obtain an urgent 12-lead ECG in all hospitalised patients with a serum potassium ≥6.0 mmol/L (≥6.0 mEq/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 hyperkalaemia requiring emergency management is present. Target treatment to remove/eliminate potassium from the body, as well as treating the underlying cause of hyperkalaemia and any associated disorders.

​Hyperkalaemia is an electrolyte imbalance characterised by abnormally high levels of potassium in the serum or plasma. There is no universally accepted definition of hyperkalaemia; however, the European Resuscitation Council defines hyperkalaemia as a serum potassium (K+) level ≥5.5 mmol/L (≥5.5 mEq/L). Hyperkalaemia is generally further classified by severity as mild (5.5 to 5.9 mmol/L [ 5.5 to 5.9 mEq/L]), moderate (6.0 to 6.4 mmol/L [6.0 to 6.4 mEq/L]), or severe (≥6.5 mmol/L [≥6.5 mEq/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 categorising severity; on the KDIGO scale a serum potassium level of 6.0 to 6.4 mmol/L (6.0 to 6.4 mEq/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 hyperkalaemia in the community is often described as chronic hyperkalaemia.[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 hyperkalaemia.[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 hyperkalaemia 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 hyperkalaemia is not covered in this topic. See Cardiac arrest.