Table 13: Suggested management approach for hyperkalemia, according to severity

There are additionally some common effects of Guideline-directed medical therapy (GDMT) requiring active surveillance and management. A suggested approach to hyperkalemia is presented in Table 13.

Severity of hyperkalemia*: Mild (serum K+5.0-5.5 mmol/L)
Initial management
Continue all RAAS unless new and major increase in K+ (if so, stop most recently added RAAS agent) Reinforce potassium restriction Avoid other sources of K+ Ensure patient is not hypovolemic Review all medications
When to recheck electrolytes and potassium
Routine measurement unless K+ has been gradually increasing over time If RAAS agent has been stopped, recheck within 72 hours
When to restart and/or re-titrate RAAS inhibitors
Usually not applicable If RAAS agent has been stopped, restart when serum potassium decreases to within the patients usual level, or < 5.0 mmol/L, (whichever is higher) AND Any concomitant condition contributing to recent changes is under control

Severity of hyperkalemia*: Moderate (serum K+ 5.6- 5.9)
Initial management
Continue all RAAS at half previous dose unless K+ has been increasing over time or major increase in K+ (if so, stop most recently added RAAS agent) Reinforce potassium restriction Avoid other sources of K+ Ensure patient is not hypovolemic Review all medications
When to recheck electrolytes and potassium
Recheck K+ and renal function within 72 hours With repeated K+ > 5.5, stop at least 1 RAAS agent and repeat measurement within 72 hours With a second K+ > 5.5, consider calcium or sodium polystyrene 30 g administration
When to restart and/or re-titrate RAAS inhibitors
When serum potassium decreases to within the patients' usual level, or < 5.0 mmol/L, (whichever is higher) AND Any concomitant condition contributing to recent changes is under control RAAS medications should usually be reintroduced 1 at a time with intervening measurement of renal function and electrolytes

Severity of hyperkalemia*: Serious or severe (serum K+ > 5.9)
Initial management
Contact patient to proceed to health centers for clinical assessment and 12-lead electrocardiogram Patient to undergo treatment according to local protocols for serious hyperkalemia Hold all RAAS inhibiting agents until reassessment Review all medications
When to recheck electrolytes and potassium
Within 4-24 hours, depending on local acute hyperkalemia protocol (when symptomatic or if there are electrocardiographic changes consistent with hyperkalemia) Again approximately 72 hours later
When to restart and/or re-titrate RAAS inhibitors
When serum potassium decreases to within the patients' usual level, or < 5.0 mmol/L, (whichever is higher) AND Any concomitant condition contributing to recent changes is under control RAAS inhibiting medications should usually be reintroduced 1 at a time with intervening measurement of renal function and electrolytes

*The above actions are suggested based on the assumption that the potassium level is correctly measured. For instance, hemolysis of blood might occur, which falsely increases the potassium level. In this instance, a repeat measure is necessary.

RAAS, renin-angiotensin-aldosterone system.