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Pharmacol Res. 2016 Nov;113(Pt A):585-591. doi: 10.1016/j.phrs.2016.09.039. Epub 2016 Sep 29.

Emergency management of severe hyperkalemia: Guideline for best practice and opportunities for the future.

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Inserm, Centre d'Investigations Cliniques- 1433, and Inserm U1116, CHU Nancy, Université de Lorraine, Association Lorraine pour le Traitement de l'Insuffisance Rénale, F-CRIN INI-CRCT, Nancy, France. Electronic address:
Department of Anesthesiology, Critical Care and Burn Unit, St. Louis Hospital, University Paris 7 Denis Diderot, UMR-S942, Inserm, France and F-CRIN INI-CRCT Nancy, and GREAT network, Paris, France.
Saint Luke's Mid America Heart Institute and University of Missouri - Kansas City, Kansas City, MO, United States.
Divisions of Cardiovascular Disease and Critical Care Medicine, Cooper University Hospital, Camden, NJ, United States.
Baylor College of Medicine, Ben Taub Hospital, Houston, TX, United States.
Baylor University Medical Center, Baylor Scott & White Health Care, Dallas, TX, United States.
Division of Nephrology and Hypertension, University of Miami, Miller School of Medicine, Miami, FL, United States.
Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, United States.
Department of Cardiology, Cumhuriyet University Faculty of Medicine, Sivas, Turkey.
Departments of Clinical Research and Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, NC, United States.
Département d'Anesthésie - Réanimation - SMUR, Hôpitaux Universitaires Saint Louis - Lariboisière, INSERM - UMR 942, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot, Paris, France.
University of Michigan School of Medicine, Ann Arbor, MI, United States.
Inserm, Centre d'Investigations Cliniques- 1433, and Inserm U1116, CHU Nancy, Université de Lorraine, Association Lorraine pour le Traitement de l'Insuffisance Rénale, F-CRIN INI-CRCT, Nancy, France.


Hyperkalemia is a common electrolyte disorder, especially in chronic kidney disease, diabetes mellitus, or heart failure. Hyperkalemia can lead to potentially fatal cardiac dysrhythmias, and it is associated with increased mortality. Determining whether emergency therapy is warranted is largely based on subjective clinical judgment. The Investigator Network Initiative Cardiovascular and Renal Clinical Trialists (INI-CRCT) aimed to evaluate the current knowledge pertaining to the emergency treatment of hyperkalemia. The INI-CRCT developed a treatment algorithm reflecting expert opinion of best practices in the context of current evidence, identified gaps in knowledge, and set priorities for future research. We searched PubMed (to August 4, 2015) for consensus guidelines, reviews, randomized clinical trials, and observational studies, limited to English language but not by publication date. Treatment approaches are based on small studies, anecdotal experience, and traditional practice patterns. The safety and real-world effectiveness of standard therapies remain unproven. Prospective research is needed and should include studies to better characterize the population, define the serum potassium thresholds where life-threatening arrhythmias are imminent, assess the potassium and electrocardiogram response to standard interventions. Randomized, controlled trials are needed to test the safety and efficacy of new potassium binders for the emergency treatment of severe hyperkalemia in hemodynamically stable patients. Existing emergency treatments for severe hyperkalemia are not supported by a compelling body of evidence, and they are used inconsistently across institutions, with potentially significant associated side effects. Further research is needed to fill knowledge gaps, and definitive clinical trials are needed to better define optimal management strategies, and ultimately to improve outcomes in these patients.


Arrhythmias; Cardiac; Diabetes mellitus; Emergencies; Hyperkalemia; Renal insufficiency

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