Management of Hyperkalemia in an Emergency Situation: Best Practices Recommendations Driven by Consensus Methodology

Abstract

Introduction: Hyperkalemia (HK) is characterized by elevated serum potassium levels and is common in patients
with chronic kidney disease, diabetes mellitus and cardiovascular diseases. Severe hyperkalemia increases the risk of cardiac disturbances and mortality. Real-world studies and international expert groups highlight the urgent need to optimize hyperkalemia management however, consensus in this area is lacking, especially concerning new drugs. We aim to establish a consensus among healthcare professionals in Portugal regarding the effective management of HK in emergency settings. Additionally, we aim to provide recommendations for the adoption of best practices in emergency care.

Methods: This qualitative study was based on Delphi consensus. A panel of experts collaboratively identified and
discussed five main topics related to HK management and
defined 25 treatment statements. An online questionnaire was distributed to doctors who frequently handle emergencies between July and August 2023. A consensus was defined when at least 65% of respondents indicated agreement or strong agreement with a statement. The initial round produced high agreement levels, obviating the need for additional survey rounds.

Results: A total of 63 specialist doctors participated in the online questionnaire. There was a very high consensus, with over 90% of participants either agreeing or strongly
agreeing with 19 of the 25 statements. These establish that
HK is a critical concern for patients with chronic kidney disease, particularly those with a lower estimated glomerular filtration rate (eGFR), elderly population and patients on medications such as inhibitor renin–angiotensin–aldosterone system (iRAAS), angiotensin II receptor blockers ( ARBs), mineralocorticoid-receptor antagonists (MRAs), or potassium- sparing diuretics. They also agree that HK is associated with higher mortality risk, which increases in individuals with underlying conditions or prolonged HK. Statements regarding potassium management involving sodium zirconium cyclosilicate (SZC), patiromer, scavengers in patients on iRAAS, and related to insulin treatment had the lowest consensus levels.

Conclusion: A robust consensus among Portuguese healthcare professionals regarding effective HK management in emergency settings was achieved. Experts collaboratively formulated recommendations covering key aspects of the management of HK in emergency settings. Implementing these recommendations will enhance the delivery of harmonized evidence-based medical care and the improvement of clinical outcomes.