Exploring the Underdiagnosis of Hyperkalemia

EP: 1.Risk Factors, Epidemiology, and Patient Burden Associated With Hyperkalemia

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EP: 2.Exploring the Underdiagnosis of Hyperkalemia

This content is a production of Drug Topics; this Pharmacist Video is supported by funding from AstraZeneca. AstraZeneca was not involved in the creation of the content for this Video.

Hyperkalemia is often underrecognized in clinical practice due to its largely asymptomatic nature, similar to other silent conditions like chronic kidney disease (CKD) and hypertension. Even moderate to severe elevations in potassium may not produce clear symptoms until levels exceed 5.5 or 6.0 mmol/L, and even then, signs such as electrocardiogram changes may be the first clinical indication. Because there’s often no immediate symptomatic impact, both patients and clinicians may fail to prioritize it. Hyperkalemia poses a unique risk due to its U-shaped mortality curve: Both low and high potassium levels are dangerous. This makes maintaining potassium balance critical, particularly in patients with CKD or heart failure, who are often on medications like renin-angiotensin-aldosterone system inhibitors that can further increase potassium levels.

The kidneys play a key role in potassium homeostasis, handling up to 90% of potassium excretion. In CKD, especially in later stages (stage 3-5 or end-stage renal disease), the kidneys lose the ability to effectively eliminate potassium, increasing the risk of hyperkalemia. Heart failure compounds this risk, as poor cardiac output can reduce renal perfusion and activate the renin-angiotensin-aldosterone system, which further disrupts potassium balance. Importantly, medications used to treat both conditions—while essential for improving survival—can also elevate potassium levels. Thus, treatment must be carefully individualized, balancing the benefits of these therapies with the risk of inducing hyperkalemia.

Pharmacists play a crucial role in preventing and managing hyperkalemia, especially in high-risk patient populations. They proactively monitor potassium trends, particularly during medication adjustments or acute care admissions, and help prevent complications like muscle weakness, paresthesia, and life-threatening arrhythmias. Pharmacists also play a key role in using or advocating for newer potassium-binding agents, even though access can vary due to formulary or insurance limitations. In acute care settings, they are often among the first responders to hyperkalemia, ensuring rapid and appropriate treatment to stabilize patients and prevent sequelae.