Nondialysis Management of Severe Hyperkalemia With ECG Changes

Mark Hanna and others from the UMass Chan School of Medicine/Baystate Medical Center, in Springfield, Massachusetts, discussed the case study of a patient with life-threatening hyperkalemia (HK) treated successfully without dialysis. They presented their findings during the National Kidney Foundation Spring Clinical Meetings 2024.

The patient was female, 90 years old, with chronic kidney disease stage 4 (Cr 1.8) and presented with serum potassium of 9.3 mEq/L due to a 10-day course of Bactrim therapy. She demonstrated bradycardia of 30 beats/minute with sinus waves on electrocardiogram (ECG). Electrolytes were Na, 131 mEq/L; K, 9.3 mEq/L; bicarbonate, 13 mEq/L; glucose, 160 mg/dL; BUN, 111 mg/dL; and creatinine, 3.17 mg/dL.

The patient’s family wanted her condition to be managed medically, without dialysis. She was given one ampoule of calcium gluconate every 5 minutes to correct her ECG to sinus rhythm, and one ampoule was repeated in 6 hours. Intravenous isotonic sodium bicarbonate was started at 125 cc/hour, made with sodium bicarbonate 150 mEq added to D5W 1000 ml. The patient also received eight units of regular insulin (weight-based) along with D50 25 g every 4 hours for three doses, and kayexalate 60 g every 6 hours for four doses.

The patient’s serum potassium decreased from 9.3 mEq/L to 5.5 mEq/L within 14 hours, and her renal function returned to baseline within 48 hours.

The researchers noted that the case suggests several nondialysis therapy options for life-threatening HK: repeated doses of intravenous calcium gluconate every 5 minutes; repeated doses of weight-based insulin (0.1 units/kg) with D50 25 g; and sustained infusion of isotonic sodium bicarbonate. In sum, they wrote, “This case demonstrates the efficacy of medical management in the treatment of severe hyperkalemia with ECG changes without the use of hemodialysis.”

Source: Hanna M, Fatima S, Braden G. Severe hyperkalemia with EKG changes treated with medical management avoiding hemodialysis. Presented at the National Kidney Foundation Spring Clinical Meetings 2024; May 14-18, 2024; Long Beach, California.