The Diagnostic Approach to Hyperkalemia - Flowchart
The Diagnostic Approach to Hyperkalemia - Flowchart
«Flowchart»

Hyperkalemia (Serum K+  5.5 mmol/L)

Hyperkalemia (Serum K+  5.5 mmol/L)

Hyperkalemia (Serum K+  5.5 mmol/L)

Hyperkalemia +

End

End

End

Emergency therapy

Emergency therapy

Emergency therapy

Yes

Yes

Yes

No

No

No

Treat accordingly and reevaluate

Treat accordingly and reevaluate

Treat accordingly and reevaluate

Yes

Yes

Yes

No

No

No

Treat accordingly and reevaluate

Treat accordingly and reevaluate

Treat accordingly and reevaluate

Yes

Yes

Yes

No

No

No

No further action

No further action

No further action

Yes

Yes

Yes

No

No

No

K+  6.0 or ECG changes

K+  6.0 or ECG changes

+ K[+] >=6.0

Pseudohyperkalemia?

Pseudohyperkalemia?

Pseudohyperkalemia?

History, physical examination, and basic laboratory tests

History, physical examination, and basic laboratory tests

History, physical examination, and basic laboratory tests

Evidence of increased potassium load

Evidence of increased potassium load

Evidence of increased potassium load

Evidence of transcellular shift

Evidence of transcellular shift

Evidence of transcellular shift

Decreased urinary K+  excretion (<40 mmol/d)

Decreased urinary K+  excretion (<40 mmol/d)

Decreased urinary K+  excretion (<40 mmol/d)

+

Decreased distal
Na+  delivery

Decreased distal
Na+  delivery

Decreased distal
Na+  delivery


+

Urine electrolytes

Urine electrolytes

Urine electrolytes

Urine Na+  <25 mmol/L

Urine Na+  <25 mmol/L

+ Urine Na[+] <25 mmol/L

TTKG

TTKG

TTKG

Reduced distal K+  secretion (GFR >20 mL/min)

Reduced distal K+  secretion (GFR >20 mL/min)

Reduced distal K+  secretion (GFR >20 mL/min)

+

>8

>8

>8

<5

<5

<5


Hypertonicity (e.g., mannitol)
Hyperglycemia
Succinylcholine
!!epsilon!!-Aminocaproic acid
Digoxin
-Blockers
Metabolic acidosis (non-organic)
Arginine or lysine infusion
Hyperkalemic periodic paralysis
Insulin
Exercise


Hypertonicity (e.g., mannitol)
Hyperglycemia
Succinylcholine
!!epsilon!!-Aminocaproic acid
Digoxin
-Blockers
Metabolic acidosis (non-organic)
Arginine or lysine infusion
Hyperkalemic periodic paralysis
Insulin
Exercise


Hypertonicity (e.g., mannitol)
Hyperglycemia
Succinylcholine
!!epsilon!!-Aminocaproic acid
Digoxin
-Blockers
Metabolic acidosis (non-organic)
Arginine or lysine infusion
Hyperkalemic periodic paralysis
Insulin
Exercise


Hypertonicity (e.g., mannitol)
Hyperglycemia
Succinylcholine
!!epsilon!!-Aminocaproic acid
Digoxin
-Blockers
Metabolic acidosis (non-organic)
Arginine or lysine infusion
Hyperkalemic periodic paralysis
Insulin
Exercise

ACEI, angiotensin-converting enzyme inhibitor; acute GN, acute glomerulonephritis; ARB, angiotensin II receptor blocker; ECV, effective circulatory volume; LMW heparin, low-molecular-weight heparin; PHA, pseudohypoaldosteronism; TTKG, transtubular potassium gradient.

ACEI, angiotensin-converting enzyme inhibitor; acute GN, acute glomerulonephritis; ARB, angiotensin II receptor blocker; ECV, effective circulatory volume; LMW heparin, low-molecular-weight heparin; PHA, pseudohypoaldosteronism; TTKG, transtubular potassium gradient.

ACEI, angiotensin-converting enzyme inhibitor; acute GN, acute glomerulonephritis; ARB, angiotensin II receptor blocker; ECV, effective circulatory volume; LMW heparin, low-molecular-weight heparin; PHA, pseudohypoaldosteronism; TTKG, transtubular potassium gradient.

Reduced tubular flow

Reduced tubular flow

Reduced tubular flow

Advanced kidney failure (GFR 20 mL/min)

Advanced kidney failure (GFR 20 mL/min)

Advanced kidney failure

Reduced ECV

Reduced ECV

Reduced ECV

Low aldosterone

Low aldosterone

Low aldosterone

Drugs


Amiloride
Spironolactone
Triamterene
Trimethoprim
Pentamidine
Eplerenone
Drospirenone
Calcineurin inhibitors

Other causes


Tubulointerstitial diseases
Urinary tract obstruction
PHA type I
PHA type II
Sickle cell disease
Renal transplant
SLE

Drugs


Amiloride
Spironolactone
Triamterene
Trimethoprim
Pentamidine
Eplerenone
Drospirenone
Calcineurin inhibitors

Other causes


Tubulointerstitial diseases
Urinary tract obstruction
PHA type I
PHA type II
Sickle cell disease
Renal transplant
SLE

Drugs

Drugs


Amiloride
Spironolactone
Triamterene
Trimethoprim
Pentamidine
Eplerenone
Drospirenone
Calcineurin inhibitors


Amiloride
Spironolactone
Triamterene
Trimethoprim
Pentamidine
Eplerenone
Drospirenone
Calcineurin inhibitors

Other causes

Other causes


Tubulointerstitial diseases
Urinary tract obstruction
PHA type I
PHA type II
Sickle cell disease
Renal transplant
SLE


Tubulointerstitial diseases
Urinary tract obstruction
PHA type I
PHA type II
Sickle cell disease
Renal transplant
SLE

9-Fludrocortisone

9-Fludrocortisone

9-Fludrocortisone

TTKG <8 (tubular resistance)

TTKG <8 (tubular resistance)

TTKG <8

TTKG 8

TTKG 8

TTKG >=8


Primary adrenal insufficiency
Isolated aldosterone deficiency
Heparin/LMW heparin
ACE-I/ARB
Ketoconazole


Primary adrenal insufficiency
Isolated aldosterone deficiency
Heparin/LMW heparin
ACE-I/ARB
Ketoconazole


Primary adrenal insufficiency
Isolated aldosterone deficiency
Heparin/LMW heparin
ACE-I/ARB
Ketoconazole


Primary adrenal insufficiency
Isolated aldosterone deficiency
Heparin/LMW heparin
ACE-I/ARB
Ketoconazole


Diabetes mellitus
Acute GN
Tubulointerstitial diseases
PHA type II
NSAIDs
-Blockers


Diabetes mellitus
Acute GN
Tubulointerstitial diseases
PHA type II
NSAIDs
-Blockers


Diabetes mellitus
Acute GN
Tubulointerstitial diseases
PHA type II
NSAIDs
-Blockers


Diabetes mellitus
Acute GN
Tubulointerstitial diseases
PHA type II
NSAIDs
-Blockers

Renin

Renin

Renin

High

High

High

Low

Low

Low