Table 2.

Strategies to urgently treat hyperkalemia

Steps	Clinical Question	Strategy
1. Increase urinary potassium losses	Is the patient volume contracted or euvolemic?	Yes, administer trial of volume expansion with or without loop diuretic
	Is the patient volume overloaded or hypertensive?	Yes, stratify and treat:
	a. eGFR>60 ml/min per 1.73 m2 and diuretic-naïve	Start low dose loop or thiazide-like diuretic
	b. eGFR<60 ml/min per 1.73 m2 and diuretic-naïve	Start moderate dose loop diuretic
	c. currently taking diuretics	Double existing diuretic dose and/or add  loop diuretic, thiazide-like diuretic, or carbonic  anhydrase inhibitor
2. Increase gastrointestinal potassium elimination	Does the patient have a contraindication (recent abdominal surgery, ileus, obstipation, history of ischemic bowel) to cathartics?	No, consider a limited trial of patiromer, ZS-9, or SPS
3. Mineralocorticoid replacement	Does the patient have a contraindication (greater than stage 1 HTN, volume overload, history of heart failure) to mineralocorticoid administration?	No, consider a trial of fludrocortisone 0.1 mg daily × 3–5 d (In patients with moderately advanced CKD consider maintaining or increasing diuretics in tandem)
4. Dialysis optimization or initiation	Is the patient currently on maintenance dialysis?	Yes, optimize dialysis delivery:
		Assess delivered dialysis dose, duration, and frequency
		Screen for patient noncompliance with dialysis and  patient/caregiver burnout
		Address any access dysfunction including poor blood  flows, recirculation
		Assess dialysate K+ and HCO3− concentrations
		No, revisit steps 1–3 and consider hospitalization and urgent dialysis initiation if hyperkalemia persists

SPS, sodium polystyrene sulfate; HTN, hypertension.