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Key Clinical Updates in Hyperkalemia

Small studies have suggested utility of patiromer and sodium zirconium cyclosilicate in acute hyperkalemia; if administered for hyperkalemic emergency, sodium zirconium cyclosilicate is preferred due to its more rapid onset of action.

Rafique Z et al. Acad Emerg Med. [PMID: 31599043]

Peacock WF et al. Acam Emerg Med. [PMID: 32149451]


  • Serum potassium > 5.2 mEq/L (5.2 mmol/L).

  • Check medications carefully. Hyperkalemia may develop from ACE inhibitors, ARBs, and potassium-sparing diuretics, most commonly in patients with kidney dysfunction.

  • The ECG may be normal despite life-threatening hyperkalemia.

  • Rule out pseudohyperkalemia and extracellular potassium shift from cells.


Hyperkalemia is a rare occurrence in normal individuals due to adaptive mechanisms designed to prevent accumulation of potassium in the extracellular fluid, mainly via rapid urinary excretion. Persistent hyperkalemia generally requires an impairment in renal potassium excretion due to impaired secretion of or hyporesponsiveness to aldosterone, impaired delivery of sodium and water to the distal nephron, or kidney disease (acute or chronic) (Table 21–4). Transient hyperkalemia suggests shift of potassium from inside cells into the extracellular fluid, which can occur in the context of tissue damage (rhabdomyolysis, tumor lysis, massive hemolysis, and trauma) or metabolic acidosis.

Table 21–4.Causes of hyperkalemia.


A. Symptoms and Signs

The symptoms of hyperkalemia are due to impaired neuromuscular transmission. The most serious manifestations are cardiac conduction abnormalities and neuromuscular manifestations, such as muscle weakness, which may be profound. This generally occurs with potassium concentrations above 7 mEq/L, though it can vary depending on the acuity in development of hyperkalemia. Hyperkalemic period paralysis is a rare genetic disorder characterized by episodes of painless muscle weakness precipitated by potassium ingestion, rest after heavy exercise, and cold exposure. Hyperkalemia additionally impairs urinary ammonium excretion and may lead to metabolic acidosis.


ECG is an unreliable method for detecting hyperkalemia; clinical studies show poor correlation between serum potassium and cardiac manifestations. The rapidity in ...

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