Management of patients with acute hyperkalemia

A 72-year-old man presents to his family physician for follow-up of hypertension, reporting fatigue and generalized weakness. His medical history also includes peptic ulcer disease, type 2 diabetes mellitus and chronic kidney disease. The estimated glomerular filtration rate is 30 mL/min per 1.73 m(2). His medications include metformin, lansoprazole, acetylsalicylic acid, hydrochlorothiazide and ramipril, the dose of which was increased two weeks earlier to address suboptimal blood pressure control. Blood work at the time of the current presentation shows that the serum potassium level is 6.7 (normal range 3.3-5.1) mmol/L from a non-hemolyzed sample. The patient's family physician refers him to the emergency department urgently. In the emergency department, the patient is hemodynamically stable, with blood pressure 124/70 mm Hg and heart rate 80 beats/min (regular). Repeat testing shows a potassium level of 6.9 mmol/L, and electrocardiography shows sinus rhythm with peaked T waves, prolonged PR interval (240 milliseconds) and a narrow QRS interval. This patient requires urgent treatment of hyperkalemia. What therapeutic options are available, and what is the evidence supporting their use?