Primary prevention

Take the following steps to avoid occurance of hyperkalemia.

In patients who are not on long-term dialysis:

  • Perform regular blood monitoring in patients at risk (e.g., chronic kidney disease, heart failure, diabetes, patients on renin-angiotensin-aldosterone system inhibitors [RAASi] or aldosterone antagonists)

  • Review the patient’s drug history and avoid drug combinations that potentiate hyperkalemia

  • Monitor renal function before initiation, 7-10 days after initiation, and after every dose increase in patients receiving RAASi or aldosterone antagonists

  • Provide dietary advice in patients with chronic kidney disease

  • Advise patients to withhold drugs that may contribute to acute renal injury and hyperkalemia during acute illness.

In patients undergoing hemodialysis:

  • Institute a low-potassium diet in dialysis patients at risk of hyperkalemia. In patients with end-stage kidney disease on dialysis, low potassium diet and compliance with dialysis are key in preventing hyperkalemia.[13][14][15]​

  • Perform regular blood monitoring (e.g., in practice, this is performed monthly in the UK in dialysis units).

  • Monitor dialysis adequacy, ensure good dialysis access, and minimize recirculation.

  • Avoid prolonged fasting or give parenteral dextrose infusions during fasting when this is unavoidable.[14][15]​

    • Note that the use of nonselective beta-blockers also augments fasting hyperkalemia in patients on hemodialysis.[63]

Secondary prevention

​Follow all steps as per primary prevention above in patients who have experienced a previous episode of hyperkalemia. In addition:

  • Perform a drug review in patients with a previous episode of hyperkalemia. If possible, avoid drugs that raise serum potassium levels. However, the use of these drugs is essential for the treatment of some conditions, and where the use of a drug that raises serum potassium is unavoidable, the risk of hyperkalemia can be minimized by:

    • Avoiding the concurrent use of agents that decrease the excretion of potassium

    • Restriction of dietary potassium

    • Use of low initial doses of drugs that can raise serum potassium levels.

  • Consider adding a cation-exchange resin/polymer in patients with chronic kidney disease stage 3b-5 or heart failure who are not on dialysis with a confirmed serum potassium level of ≥6 mEq/L (≥6 mmol/L) who are not taking or are taking a reduced dose of RAASi due to hyperkalemia.[87][88]​​

  • Consider adding a diuretic in patients with heart failure or chronic kidney disease, particularly if there is evidence of volume overload.[33]

  • Advise patients to withhold drugs that may contribute to acute renal injury and hyperkalemia during acute illness.

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