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syndrome.hyperkalemia.core.v1

Hyperkalemia (syndrome aggregator)

nephrologyacutesyndromeadultacuteinpatientoutpatient
Start encounter →Print handoutPRODUCTION

Manifest typed DISEASE because PathwayManifest lacks SYNDROME engine_type; conceptually a syndrome aggregator routing to AKI/CKD/RAASi/TLS/rhabdo/adrenal/DKA upstreams. Acute regimen drugs (Ca gluconate, regular insulin, salbutamol, sodium bicarbonate) lack RxCUIs in manifest — pending validation via scripts/research/rxnav-validate.ts before further promotion. RxCUIs that ARE present in this dossier rely on cross-engine reuse and need re-verification: 1895 (calcium), 253182 (regular insulin), 4815 (D50), 435 (salbutamol), 2103178 (SZC), 1996253 (patiromer), 1546437 (SPS / sodium polystyrene sulfonate), 203394 (NaHCO3). Trial PMIDs added 2026-05-12: HARMONIZE (25415807), OPAL-HK (25415805), DIAMOND (35900838), Cochrane K-shift Cochrane 2015 (15846652), Levine 2011 calcium-in-digoxin (19201134). Cardiac-arrest + digoxin-toxicity severity triggers added 2026-05-12 per ERC 2021 and Levine 2011 (calcium controversy in digoxin toxicity is overstated, but Fab is definitive Rx). ECG morphology SNOMED codes (164863001 peaked T, 270492004 PR prolongation, 164909002 wide QRS, 164854001 sine wave, 410429000 cardiac arrest) added to terminology block. No targeted disease test file (covered by tests/dossiers/integration/syndrome-hyperkalemia-integration.test.ts).

Entry points (3)

  • lab_abnormality
    Serum K+ ≥5.5 mmol/L (mild) / ≥6.0 (moderate) / ≥6.5 or ECG (severe)
    k_high
  • imaging
    Peaked T waves / PR prolongation / QRS widening on ECG
    ecg_peaked_t
  • symptom
    Muscle weakness / paralysis / paresthesias
    weakness

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Drug dosing + dialysis access decisions
  • potassiumrequired
    lab • used at ENTRY
    Severity strata: mild 5.5–5.9 / moderate 6.0–6.4 / severe ≥6.5
  • creatininerequired
    lab • used at CONTEXT
    AKI vs CKD vs ESRD branches treatment urgency + dialysis access
  • glucoserequired
    lab • used at CONTEXT
    DKA shift; insulin/dextrose dose adjustment if euglycemic
  • bicarbonaterequired
    lab • used at CONTEXT
    Metabolic acidosis as cause + AEIOU dialysis criterion
  • ecgrequired
    imaging • used at RED_FLAGS
    ECG changes mandate IMMEDIATE calcium gluconate; defines severe class
  • current_medsrequired
    medication • used at CONTEXT
    ACEi/ARB/MRA/ARNi/K-sparing/TMP/CNI/heparin/digoxin trigger or modify Rx
  • ckd
    history • used at CONTEXT
    CKD stage gates patiromer/SZC vs dialysis decision
  • aki
    history • used at CONTEXT
    Active AKI changes urgency + restricts SZC duration
  • heart_failure
    history • used at CONTEXT
    GDMT preservation goal: patiromer/SZC enables RAASi continuation (DIAMOND, FINEARTS-HF)

12-phase flow (12)

  1. 1FRAME
    Confirm true hyperkalemia (rule out pseudoK from hemolysis, fist clenching, leukocytosis, thrombocytosis) — KDIGO 2024; Clase KDIGO 2020
    inputs: potassium
    advance: True K+ confirmed
  2. 2ENTRY
    Stratify severity by K+ + ECG (UK Renal Association 2023 v2.0): mild / moderate / severe
    inputs: potassium, ecg
    advance: Severity tier assigned
  3. 3CONTEXT
    Capture renal function, glucose, acid-base, full med list, etiology hints (AKI/CKD/RAASi/TLS/rhabdo/DKA/Addison) — KDIGO 2024; Clase KDIGO 2020
    inputs: creatinine, glucose, bicarbonate, current_meds, ckd, aki, heart_failure
    advance: Comorbidity + drug review complete
  4. 4RED_FLAGS
    ECG changes (peaked T → PR → QRS → sine → arrest) → IMMEDIATE Ca gluconate; severe acidosis; arrhythmia — UK Renal Association 2023; AHA 2020
    inputs: ecg, potassium
    actions: protocol.hyperkalemia
    advance: Membrane stabilized + shift therapies started if severe
  5. 5INITIAL_WORKUP
    Repeat K (rule out pseudoK), BMP, glucose, ABG, urinalysis, urine K + osm for TTKG — KDIGO 2024; Clase KDIGO 2020
    inputs: potassium, creatinine, bicarbonate
    actions: panel.renal, workup.hyperkalemia
    advance: Etiology workup sent
  6. 6BRANCHING_WORKUP
    Mineralocorticoid axis (cortisol, aldosterone, renin) if drug-RAS not adequate; CK if rhabdo; uric acid + LDH if TLS suspected — KDIGO 2024
    advance: Etiology established
  7. 7DIFFERENTIAL
    Pseudo / intake / shift (DKA, acidosis, succ, BB, digoxin) / decreased excretion (AKI/CKD, drugs, hypoaldosteronism, type-4 RTA) — Clase KDIGO 2020; KDIGO 2024
    advance: Mechanism class assigned
  8. 8RISK_STRATIFICATION
    Severity tier + ECG status + renal function determine inpatient vs outpatient, dialysis need — UK Renal Association 2023; KDIGO 2024
    inputs: potassium, creatinine
    advance: Disposition tier set
  9. 9TREATMENT
    Acute: Ca gluconate (or chloride central) → insulin 10U + D50 25g → albuterol neb 10–20mg → bicarb if acidotic → patiromer/SZC for binding → dialysis if refractory or AEIOU — UK Renal Association 2023; AHA 2020. Chronic: patiromer/SZC enable GDMT preservation — DIAMOND (Butler 2023); OPAL-HK (Weir 2015).
    inputs: potassium, glucose, bicarbonate
    actions: protocol.hyperkalemia
    advance: K+ trending down + cause addressed
  10. 10DISPOSITION
    ICU/telemetry if ECG changes or K ≥6.5; nephrology if dialysis; HF clinic if GDMT-related — UK Renal Association 2023; KDIGO 2024
    advance: Disposition set
  11. 11MONITORING
    K q1–2h until <5.5 — UK Renal Association 2023; glucose q1h ×4 after insulin — AHA 2020; telemetry until K <6.0; BMP q6h × 24h; recheck after any med change — KDIGO 2024
    inputs: potassium, glucose
    actions: panel.renal
    advance: K stable <5.5 + monitoring plan documented
  12. 12FOLLOWUP
    Outpatient BMP within 1 week if RAASi resumed — KDIGO 2024; finerenone 2/4-week cadence — FINEARTS-HF (Solomon 2024); dietary K education; reconcile contributing meds — Clase KDIGO 2020
    advance: Follow-up scheduled