title: Treatment of hyperkalemia: something old, something new.
abstract: Treatment options for hyperkalemia have not changed much since the introduction of the cation exchange resin, sodium polystyrene sulfonate (Kayexalate, Covis Pharmaceuticals, Cary, NC), over 50 years ago. Although clinicians of that era did not have ready access to hemodialysis or loop diuretics, the other tools that we use today-calcium, insulin, and bicarbonate-were well known to them. Currently recommended insulin regimens provide too little insulin to achieve blood levels with a maximal kalemic effect and too little glucose to avoid hypoglycemia. Short-acting insulins have theoretical advantages over regular insulin in patients with severe kidney disease. Although bicarbonate is no longer recommended for acute management, it may be useful in patients with metabolic acidosis or intact kidney function. Kayexalate is not effective as acute therapy, but a new randomized controlled trial suggests that it is effective when given more chronically. Gastrointestinal side effects and safety concerns about Kayexalate remain. New investigational potassium binders are likely to be approved in the coming year. Although there are some concerns about hypomagnesemia and positive calcium balance from patiromer, and sodium overload from ZS-9 (ZS Pharma, Coppell, TX), both agents have been shown to be effective and well tolerated when taken chronically. ZS-9 shows promise in the acute treatment of hyperkalemia and may make it possible to avoid or postpone the most effective therapy, emergency hemodialysis.
authors.affiliation: Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, Rochester General Hospital, Rochester, New York, USA. Electronic address: richard.sterns@rochesterregional.org.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Sterns
authors.affiliation: Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, Rochester General Hospital, Rochester, New York, USA.
authors.forename: Marvin
authors.initials: M
authors.lastname: Grieff
authors.affiliation: Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, Rochester General Hospital, Rochester, New York, USA.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Bernstein
mesh_terms: D000818:Animals; D015415:Biomarkers / Q000097:blood; D002411:Cation Exchange Resins / Q000009:adverse effects / Q000627:therapeutic use*; D002614:Chelating Agents / Q000009:adverse effects / Q000627:therapeutic use*; D004232:Diuretics / Q000009:adverse effects / Q000627:therapeutic use*; D015536:Down-Regulation; D006801:Humans; D006947:Hyperkalemia / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy*; D011188:Potassium / Q000097:blood*; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D002411:Cation Exchange Resins; D002614:Chelating Agents; D004232:Diuretics; D011188:Potassium
keywords: cation exchange resins; hyperkalemia; insulin; potassium; renal dialysis; sodium bicarbonate