Author Recommendations for Management of Acute and Chronic
Hyperkalemia in Kidney Transplant Recipients
Management of Acute Hyperkalemia in Kidney Transplant
Recipients
Hyperkalemia may manifest as an acute or chronic condition. A logical
5-step approach to treat acute hyperkalemia should be followed (Figure
1). In patients with a serum potassium concentration > 6.5
mmol/L or > 6.0 mmol/L with EKG changes, calcium gluconate
should be administered to stabilize cardiomyocyte membranes. The dose
should be repeated if there is no effect within 5-10 minutes. Second,
shift potassium into cells using intravenous insulin 5-10 units along
with dextrose 25 g ± a nebulized beta-2 agonist. Consider sodium
bicarbonate if acidosis is present without volume overload. Third,
remove potassium from the body with a potassium binder ± diuretics. ZS9
is the preferred potassium binder in acute hyperkalemia due to its
relatively fast onset of action. Drug-drug interactions with
anti-rejection medications and cost should be evaluated when ZS9 is
chosen. Fourth, monitor serum potassium concentration at 1 - 2 hours
after the initiation of treatment and blood glucose, if insulin-glucose
therapy is used, hourly for up to six hours. Fifth, prevent recurrence
by initiating a low potassium diet (< 1-3 g/day),
discontinuing medications known to cause hyperkalemia (when possible),
and/or continuing a potassium binder. Dialysis should serve as the last
resort when hyperkalemia does not respond to the above therapies or when
rapid potassium removal is deemed necessary.
Management of Chronic Hyperkalemia in Kidney Transplant
Recipients
Patients with chronic hyperkalemia warrant a review of medications and
dietary intake. Metabolic acidosis should be corrected with sodium
bicarbonate and initiation of a potassium binder or loop diuretics may
be helpful. Patients with a serum potassium concentration ≥ 6.5 mmol/L
may require hospital admission for emergency treatment.