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.