Patients undergoing maintenance HD have a high risk of hyperkalemia, generally defined as serum potassium (K+) concentrations of >5.0 mmol/l, even when receiving adequate treatment with 3-times-weekly HD. The US prevalence of 8.9–9.3% among patients with CKD and/or heart failure 1.

Causes of Hyperkalemia in ESRD2–7

Multiple factors are responsible for determining serum K+ concentrations in patients with ESRD, including the individual patient’s diet, the dialysis prescription, medications, and other conditions or comorbidities. Some of the factors are listed below:

  • Prolong fasting
  • Excessive dietary potassium intake
  • Marked catabolism
  • Rhabdomyolysis
  • Mineralocorticoid deficiency
  • Medications
  • Dialysis induced hyperkalemia (rare)
    • High dialysate potassium concentration
    • Hemolysis
    • Accidental potassium infusions


Clinical symptoms related to hyperkalemia are nonspecific and most often, asymptomatic. However, hyperkalemia affects cardiac and neuromuscular cells which are particularly sensitive to changes in serum [K]. In patients with mild to moderate hyperkalemia, patients usually complain of muscle weakness, fatigue, paresthesia’s, palpitations, and cardiac arrythmias. As evidenced by characteristic changes in the electrocardiogram (ECG) that serve as indicators of potential life-threatening arrhythmias, the first sign of increased serum [K] is tenting of the T wave. ECG changes may progress rapidly in conjunction with serum [K] levels. ECG changes include widening of the QRS complex, progressive development of atrioventricular conduction blocks, slow idioventricular rhythm, an ECG tracing that looks like a sine wave, ventricular fibrillation, and finally asystole8.

Management 9

The treatment strategies are designed to intervene at 3 different levels:

  • Effect on the cell membrane polarization
    • Calcium: Stabilizer of cardiac cell
  • Movement of extracellular potassium into the intracellular compartment
    • Insulin
    • Albuterol
    • Sodium Bicarbonate (in acidosis)
  • Removal of potassium from the body
    • Potassium binding resin with sorbitol
    • Hemodialysis:
      • Removes 70 to 150mEq of potassium
      • Used as gold standard when other treatments fail


  1. Mu F, Betts KA, Woolley JM, et al. Prevalence and economic burden of hyperkalemia in the United States Medicare population. Curr Med Res Opin. 2020;36(8):1333-1341.
  2. Bansal S, Pergola PE. Current Management of Hyperkalemia in Patients on Dialysis. Kidney Int reports. 2020;5(6):779-789. Available from: https://pubmed.ncbi.nlm.nih.gov/32518860.
  3. Clausen T. Na+-K+ pump regulation and skeletal muscle contractility. Physiol Rev. 2003;83(4):1269-1324. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14506306.
  4. Allon M, Dansby L, Shanklin N. Glucose modulation of the disposal of an acute potassium load in patients with end-stage renal disease. Am J Med. 1993;94(5):475-482. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8498392.
  5. Allon M, Takeshian A, Shanklin N. Effect of insulin-plus-glucose infusion with or without epinephrine on fasting hyperkalemia. Kidney Int. 1993;43(1):212-217. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8433561.
  6. Brady HR, Goldberg H, Lunski C, Uldall PR. Dialysis-induced hyperkalaemia presenting as profound muscle weakness. Int J Artif Organs. 1988;11(1):43-44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3360512.
  7. Romagnoni M, Beccari M, Sorgato G. Life-threatening hyperkalaemia during a haemodialysis session: an avoidable risk. Nephrol Dial Transplant. 1998;13(10):2480-2481. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9794545.
  8. Parham WA, Mehdirad AA, Biermann KM, Fredman CS. Hyperkalemia revisited. Texas Hear Inst J. 2006;33(1):40-47.
  9. Choi HY, Ha SK. Potassium balances in maintenance hemodialysis. Electrolyte Blood Press. 2013;11(1):9-16. Available from: https://pubmed.ncbi.nlm.nih.gov/23946760.

P/N 103056-01 Rev A 03/2021