Refining the management of hyperkalemia in the Asia-Pacific region: Consensus statements from a multidisciplinary expert panel

20 Jun 2024

Nephrology. 2024

Yap YHD, Ma CWR, Wong CKE, Tsui SHM, Yu YTE, Yu V, Szeto CC, Pang WF, Tse HF, Siu CDW, Tan CBK, Chen WCW, Li CL, Chen W, Chan TM. Consensus statement on the management of hyperkalaemia—An Asia-Pacific perspective. Nephrology. 2024;29(6):311-324.

Hyperkalemia, defined as serum potassium >5.0mmol/L, is a potentially lethal condition as it hinders muscle function and myocardial excitability, which may contribute to arrhythmias and sudden cardiac deaths.1 Epidemiological data suggests the global prevalence of hyperkalemia is around 6.3%, but the prevalence is slightly higher in Asia at 10.4%.1 This regional difference has been attributed to the higher dietary potassium intake common in many Asian countries, where people consume more potassium-rich plant-based foods like roots and tubers.1

In patients with cardiac and renal diseases, hyperkalemia is a common and significant concern, often associated with major cardiovascular events, deterioration of renal function and overall mortality.1 According to the Asian Sudden Cardiac Death in Heart Failure (ASIAN-HF) registry, approximately 7% of patients with heart failure (HF) across 11 Asian countries had hyperkalemia.1 Hyperkalemia is also common in patients with diabetes and advanced chronic kidney disease (CKD), with more than half of such patients experiencing at least one episode of hyperkalemia during a 3.6-year follow-up period in a local population-based cohort study.1 Medications used to treat these chronic conditions, particularly renin-angiotensin-aldosterone system (RAAS) inhibitors, can also increase the risk of hyperkalemia.1 According to local retrospective study reported that 28% of patients on RAAS inhibitors developed hyperkalemia.1

Despite the burden of hyperkalemia, there has been a lack of consensus on its management in the Asia-Pacific region.1 To address this gap, a multidisciplinary expert panel convened and developed a set of consensus statements to guide healthcare professionals in assessing risk factors, treatment approaches, and preventive measures for high-risk individuals in this region (table 1).

Consensus statement on the management of hyperkalemia in the Asia-Pacific region

Risk factors of hyperkalemia and risk stratification of susceptible patients


CKD, HF and DM are important risk factors for hyperkalemia


Common medications that are frequently associated with hyperkalemia include RAAS inhibitors, potassium-sparing diuretics, NSAIDs, beta-blockers and trimethoprim


Hyperkalemia is a major limiting factor for the dosing of RAAS inhibitor therapy in patients with CKD, HF or DM


Dose interruptions of RAAS inhibitors due to treatment-related hyperkalemia are associated with adverse cardiorenal outcomes, disease progression and increased mortality


RAAS inhibitors should be continued for cardiorenal benefits as far as possible when managing mild-to-moderate hyperkalemia in patients with CKD, HF or DM*

Prevention of hyperkalemia for at-risk individuals


After initiation and up-titration of treatment with RAAS inhibitors, serum potassium levels should be measured within 1-2 weeks in high-risk patients with CKD, DM or HF


Serum potassium levels should be monitored regularly in high-risk patients who are receiving RAAS inhibitors


More frequent monitoring should be considered in patients with multiple risk factors, for example presence of mild hyperkalemia at baseline, concomitant use of medications that can increase potassium and treatment with intermittent hemodialysis


Alternative preventive measures should be considered in high-risk patients with prior hyperkalemia, before de-escalating or discontinuing RAAS inhibitors


Dietary modification (e.g., low-potassium diets and avoidance of potassium-containing salt substitutes) can serve as a non-pharmacological preventive measure against hyperkalemia in high-risk patients


Significant metabolic acidosis should be treated to reduce the risk of hyperkalemia


Approved oral potassium binders can serve as an effective preventive measure in patients with a history of RAAS inhibitor-induced hyperkalemia**

Correction of hyperkalemia for at-risk individuals with cardiorenal disease


Pseudo-hyperkalemia should be excluded before treatment initiation***


Treatment of acute hyperkalemia is guided by the severity (serum potassium level) and ECG changes


A stepwise approach that involves stabilization of cardiac membrane, potassium redistribution and elimination of potassium should be adopted in the treatment of acute hyperkalemia

Stabilization of cardiac membrane


Treatment with intravenous calcium is indicated only for hyperkalemic patients with significant ECG changes


Calcium gluconate is preferred over calcium chloride, except for patients with hemodynamic instability or cardiac arrest

Redistribution of potassium


Intravenous insulin/dextrose is effective for shifting serum potassium intracellularly


Add-on intravenous sodium bicarbonate can be considered in hyperkalemia patients with metabolic acidosis


In patients at high risk of hyperkalemia, add-on nebulized salbutamol may be considered for potassium redistribution

Elimination of potassium


The routine use of SPS in the management of hyperkalemia, especially when treatment duration is prolonged, is not advisable^


Novel oral potassium-binding resins can serve as an effective treatment for acute hyperkalemia§, ‡,¶


Add-on loop or thiazide diuretics can be considered to facilitate potassium elimination in hyperkalemic patients#


Hemodialysis can be considered to eliminate serum potassium in patients who have severe hyperkalemia (especially in those with stage 5 CKD) or are refractory to medical therapies


In patients with acute hyperkalemia, serum potassium levels should be reassessed 2-4 hours after administration of potassium-lowering therapies§


Table 1. Consensus statement on the management of hyperkalemia in the Asia-Pacific region

CKD: Chronic kidney disease; CPS: Calcium polystyrene sulfonate; DM: Diabetes mellitus; HF: Heart failure; ECG: Electrocardiographic; NSAID: Non-steroidal anti-inflammatory drug; RAAS: Renin-angiotensin-aldosterone; SPS: Sodium polystyrene sulfonate; SZC: Sodium zirconium cyclosilicate
*Serum potassium levels of 5.0mmol/L-5.4mmol/L, 5.5mmol/L-5.9mmol/L and ≥6.0mmol/L can be considered as mild, moderate and severe hyperkalemia, respectively
**SZC and patiromer are available options; the choice depends on local access and resources
***Pseudo-hyperkalemia is defined as an increase in serum potassium while plasma potassium is normal, and is associated with CKD stage ≥ 3 and delayed laboratory processing time
†Calcium gluconate is associated with a lower risk of tissue necrosis in the event of extravasation
^SPS is associated with potential harm and lack of efficacy
§SZC and patriomer are viable options, with the choice depending on availability. For example, in Hong Kong, only SZC is registered
‡SZC is associated with a far lower risk of gastrointestinal upset compared with SPS
¶SPS/CPS can be a short-term treatment option for mild-to-moderate hyperkalemia if novel oral potassium-binding resins are not available
#Add-on loop or thiazide can be used to treat concomitant hypervolemia or hypertension
§The aim is to verify the achievement of normokalemia (serum potassium <5.0mmol/L)



In a subsequent interview with Omnihealth Practice, Dr. Yap, Yat-Hin Desmond, a nephrology specialist and the first author of the consensus, provided insights into current approaches and future prospects for treating hyperkalemia in Hong Kong.


Question 1: What factors may contribute to differences in the prevalence of hyperkalemia observed between Hong Kong and other parts of the Asia-Pacific region?

Dr. Yap: The prevalence of hyperkalemia in Hong Kong is lower than 5%, which is lower compared to other parts of the Asia-Pacific region. Aside from factors like age and underlying medical conditions, the use of potassium-sparing medications and dietary differences, such as the consumption of potassium-rich foods like bananas, nuts, spinach, and root vegetables, may have contributed to the observed epidemiological differences.

Question 2: How should physicians manage the risk of hyperkalemia when prescribing RAAS inhibitors, in order to balance mitigating this adverse effect while preserving the established clinical benefits of these medications?

Dr. Yap: The primary goal when prescribing RAAS inhibitors is to maximize their well-established cardiorenal protective benefits. However, the risk of hyperkalemia poses a persistent challenge, as it can be a dose-limiting factor and cause of treatment intolerance. Studies estimate that around 27% of patients on RAAS inhibitors may develop hyperkalemia, with an even higher risk in those receiving dual RAAS blockade.

While implementing remedial measures for hyperkalemia is important, complete discontinuation of RAAS inhibitor therapy should generally be avoided, as this would lead to an elevated risk of adverse cardiovascular and renal outcomes, as well as increased mortality. Instead, a more prudent approach is to implement continuous monitoring of serum potassium levels in patients on RAAS inhibitors.

Question 3: What ongoing research or emerging approaches for managing hyperkalemia associated with RAAS inhibitor therapies do you believe could be particularly impactful for the healthcare landscape in Hong Kong?

Dr. Yap: The development of consensus-based hyperkalemia monitoring and management algorithms is an important step, but there remains room to further refine and standardize these protocols for optimal implementation in Hong Kong.

Additionally, novel hyperkalemia therapies, such as potassium-binding agents, warrant deeper investigation. Leveraging these emerging strategies could help minimize the need to interrupt RAAS inhibitor treatment, thereby preserving the established cardiorenal benefits.

Tailoring the integration of these newer hyperkalemia management approaches into cohesive, evidence-based care pathways for the local clinical context could have meaningful positive impacts on patient outcomes in Hong Kong. Continued research in this area will be crucial for guiding future practice improvements.



  1. Yap DYH, et al. Consensus statement on the management of hyperkalaemia—An Asia-Pacific perspective. Nephrology. 2024;29(6):311‐324.

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