Electrolyte Abnormalities
Rapid identification and tiered treatment of common imbalances. Select an electrolyte to load its severity tiers, causes, clinical signs, and treatment ladder.
Dietary restriction; consider K⁺ binder
Shift K⁺ into cells; add binder
Emergent: stabilize, shift, remove
Causes
- CKD/AKI with reduced excretion
- ACEi/ARB, K⁺-sparing diuretics, NSAIDs
- Tissue breakdown: rhabdo, tumor lysis, hemolysis
- Metabolic acidosis (intracellular shift out)
- Adrenal insufficiency (Addisonian crisis)
Clinical Signs
- Muscle weakness progressing to paralysis
- Paresthesias
- Nausea, abdominal pain
- Cardiac arrhythmias — potentially fatal
Kidney-disease-specific workup steps for this imbalance. Tags indicate the renal context each step addresses.
Rule out pseudohyperkalemia (hemolysis, fist clenching, severe leukocytosis) on a free-flowing repeat sample.
Peaked T waves, PR/QRS widening, or sine wave = emergent — stabilize myocardium before further workup.
Compare creatinine to baseline, urine output, FENa/urine Na; abrupt rise + oliguria favors AKI.
Stop ACEi/ARB, K⁺-sparing diuretics, NSAIDs, beta-blockers, heparin, calcineurin inhibitors; reassess after K⁺ controlled.
Metabolic acidosis (common in CKD/AKI) extrudes K⁺ from cells — correct with bicarbonate if HCO₃⁻ low.
Missed/inadequate sessions, high-K diet, constipation (colonic K⁺ absorption) — emergent hemodialysis if severe or refractory.
Cortisol/ACTH for adrenal insufficiency; renin/aldosterone if hypertensive.
Stage-specific treatment guidance for this imbalance across the renal disease spectrum.
- Stabilize myocardium (Ca²⁺ gluconate) if ECG changes; shift with insulin/dextrose + albuterol.
- Remove K⁺ with loop diuretics only if producing urine; reverse cause (rhabdo, TLS, acidosis).
- Correct metabolic acidosis with bicarbonate (reduces extracellular K⁺ shift).
- Emergent dialysis if oliguric/anuric, refractory, or severe with ECG changes.
- Dietary K⁺ restriction (2–3 g/day); avoid salt substitutes and hidden K⁺ sources.
- Patiromer or sodium zirconium cyclosilicate for chronic control; avoid chronic kayexalate.
- Continue ACEi/ARB if tolerated with close monitoring; review trimethoprim/heparin.
- Oral NaHCO₃ for metabolic acidosis; loop diuretics to enhance excretion if not anuric.
- Dietary restriction + treat constipation (colonic K⁺ excretion matters on dialysis).
- Adjust dialysis prescription: K⁺ bath, longer/more-frequent sessions for chronic elevation.
- Emergent hemodialysis for severe/refractory; peritoneal dialysis is inadequate for acute K⁺ removal.
- Add binders (patiromer/SZC) between sessions; review missed or shortened treatments.
- 01KDIGO Dyskalemia Clinical Practice Guideline — Kidney International (2024)
- 02European Clinical Practice Guideline on Hyponatremia — Spasovski G et al., Eur J Endocrinol (2014)
- 03Hypernatremia — Adrogué HJ, Madias NE, N Engl J Med (2000)
- 04Hyponatremia — Adrogué HJ, Madias NE, N Engl J Med (2012)
- 05KDIGO Consensus on Metabolic Acidosis in CKD — KDIGO (2022)