Pediatric Hyperkalemia Treatment & Management

Updated: Dec 30, 2019
  • Author: Michael J Verive, MD, FAAP; Chief Editor: Timothy E Corden, MD  more...
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Approach Considerations

Hyperkalemia, by itself, is not a disease and is generally the result of underlying causes, [21] such as congenital adrenal hyperplasia, acute renal failure, rhabdomyolysis, or tumor lysis syndrome.

Hyperkalemia is a true medical emergency, with three primary goals of immediate management (in addition to prompt discontinuation of potassium-containing fluids and medications that lead to hyperkalemia), as summarized under Medical Care. [22, 23]

Close electrocardiographic monitoring is warranted.

Surgical intervention

Tumor debulking may be considered to decrease the risk of hyperkalemia from tumor lysis syndrome for solid tumors. [24]

Outpatient monitoring

Continuing care relates to the basic disease process that led to the hyperkalemia.

In patients with salt-wasting congenital adrenal hyperplasia, corticosteroid and mineralocorticoid supplementation are necessary.

Continued renal replacement therapy may be needed for patients with acute renal failure.

Patients with chronic mineralocorticoid deficiency require mineralocorticoid supplementation (eg, fludrocortisone).


Medical Care

Goals of management

Stabilization of myocardial cell membrane

Stabilize the myocardial cell membrane to prevent lethal cardiac arrhythmia (and to gain time to shift potassium intracellularly and enhance potassium elimination: Intravenous (IV) calcium chloride or gluconate

Enhancement of cellular uptake of potassium

This achieved with the following:

  • Sodium bicarbonate IV

  • Regular insulin and glucose IV

  • Beta-adrenergic agents, such as albuterol (used to manage hyperkalemia with variable results), terbutaline, dobutamine

Enhancement of total body potassium elimination

This achieved with the following:

  • Sodium polystyrene sulfonate (Kayexalate) orally (PO)/rectally (PR) (Note: Sodium polystyrene sulfonate may not be an appropriate first-line agent in children with severe acute hyperkalemia who require a >25% reduction in serum potassium levels or those at high risk for cardiac arrhythmias. [25] )

  • Furosemide (only if renal function is maintained)

  • Emergent hemodialysis

Clinical management

Arrhythmias due to hyperkalemia are very difficult to treat with defibrillation, epinephrine, or antiarrhythmic drugs without emergently lowering the serum potassium level.

After initial stabilization, further workup should be performed to diagnose the etiology of the hyperkalemia. Children with acquired Addison disease or other primary adrenal disease require stress-dose steroid supplementation and children with hypoaldosteronism require mineralocorticoid supplementation.

Emergent hemodialysis is sometimes necessary to treat severe symptomatic hyperkalemia that is resistant to drug therapy, particularly in patients without adequate renal function.

Even in patients with severe hyperkalemia and a high gradient, peritoneal dialysis (PD) is not as efficient as hemodialysis in the removal of potassium. Rates of removal with PD are almost equal to the removal rate using sodium polystyrene sulfonate (Kayexalate).

Continuous arteriovenous hemofiltration with dialysis (CAVHD) or continuous veno-venous hemofiltration with dialysis (CVVHD) have also been used to remove potassium. However, potassium removal with these methods is similar to that of PD and sodium polystyrene sulfonate (Kayexalate). CVVHD or CAVHD may be used for long-term removal of potassium, but in acute, severe, life-threatening hyperkalemia unresponsive to medical therapy, hemodialysis remains the procedure of choice.

Following emergent management and stabilization of hyperkalemia, the patient should be hospitalized, and further workup should be initiated to determine the inciting cause and to prevent recurrence.


Patients with acute life-threatening hyperkalemia should receive care in a pediatric or neonatal intensive care unit capable of providing emergent hemodialysis.

Any child who develops hyperkalemia as a result of renal failure should be referred to a pediatric nephrologist for continuing care.


Potassium intake must be closely monitored (and possibly restricted) in patients with renal failure.



Consultations with the following specialists may be necessary in cases of hyperkalemia that result from certain conditions or disease states:

  • Pediatric intensivist or neonatologist: Management of life-threatening hyperkalemia (hyperkalemia with ECG changes)

  • Nephrologist: Hyperkalemia associated with renal failure

  • Hematologist/oncologist: Hyperkalemia resulting from tumor lysis syndrome

  • Social services specialist: Children who develop hyperkalemia following unintentional ingestions or poisonings

  • Nutritional support specialist: Particularly for patients whose hyperkalemia is caused by renal failure, which requires close regulation of potassium and sodium intake

  • Endocrinologist: Patients with suspected mineralocorticoid abnormalities such as congenital adrenal hyperplasia