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syndrome.hyperkalemia.core.v1PRODUCTION
syndrome.hyperkalemia.core.v1

Hyperkalemia (syndrome aggregator)

nephrologyacutesyndromeadult
Hard-required inputs
0 / 7
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm true hyperkalemia (rule out pseudoK from hemolysis, fist clenching, leukocytosis, thrombocytosis) — KDIGO 2024; Clase KDIGO 2020

Inputs
1
Actions
0
Advance rule
Set
Advance when

True K+ confirmed

Patient inputs (10)

Drug dosing + dialysis access decisions

AKI vs CKD vs ESRD branches treatment urgency + dialysis access

DKA shift; insulin/dextrose dose adjustment if euglycemic

Metabolic acidosis as cause + AEIOU dialysis criterion

ACEi/ARB/MRA/ARNi/K-sparing/TMP/CNI/heparin/digoxin trigger or modify Rx

Severity strata: mild 5.5–5.9 / moderate 6.0–6.4 / severe ≥6.5

ECG changes mandate IMMEDIATE calcium gluconate; defines severe class

CKD stage gates patiromer/SZC vs dialysis decision

Active AKI changes urgency + restricts SZC duration

GDMT preservation goal: patiromer/SZC enables RAASi continuation (DIAMOND, FINEARTS-HF)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningk_over_6_5_or_ecg — UK Renal Association 2023
    K >6.5 OR ECG changes (peaked T, PR, QRS widening, sine) — UK Renal Association 2023
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_hyperK
    K not declining within 60 min of shift therapy — KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcardiac_arrest_hyperK_pattern
    Cardiac arrest in patient with known/suspected hyperkalemia (ESRD missed dialysis, severe AKI, crush, DKA): asystole / PEA / wide-complex bradyarrhythmia — ERC 2021
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdigoxin_toxicity_with_hyperK
    Acute digoxin toxicity with K >5.0 (a poor-prognostic marker in chronic toxicity per Bismuth) — AHA 2020; Levine Clin Toxicol 2011
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverek_6_0_to_6_4
    K 6.0-6.4 with no ECG changes — UK Renal Association 2023
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatek_5_5_to_5_9
    K 5.5-5.9 with no ECG changes — KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpseudohyperK_screen
    K elevated without ECG/cause + concerns for hemolysis/leukocytosis/thrombocytosis — KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

Severity-tiered hyperkalemia management (UK Renal Association 2023 + ESC 2024)
axis: hyperkalemia_severity_tieredstep mild - Mild — K 5.5-5.9 + no ECG changes
Selected step "Mild — K 5.5-5.9 + no ECG changes" — K 5.5-5.9, no ECG changes, asymptomatic
  • discontinue_offenders
    first line
    non_drug
    triggers: drug_induced
    Review ACEi/ARB/MRA/spironolactone/heparin/TMP/NSAID — Clase KDIGO 2020
  • patiromer
    first line
    k_binder
    8.4 g PO daily • PO • daily, titrate to 25.2 g
    triggers: chronic_RAS_use
    OPAL-HK (Weir 2015); permits RAS continuation
    rxcui 1716203

ed playbook — drug actions (6)

  1. 1. calcium gluconate 10%
    1000 mg IV (10 mL) over 5-10 min • IV • repeat q5-10 min if ECG persists
    trigger: ECG changes OR K ≥6.5 — UK Renal Association 2023
    UK Renal Association 2023; membrane stabilization
  2. 2. insulin + dextrose
    10 U regular insulin IV + 25 g D50 • IV • single dose; check glucose q1h × 4 — AHA 2020
    trigger: K ≥6.0 — UK Renal Association 2023
    Cochrane 2015
  3. 3. albuterol nebulized
    10-20 mg neb • inhaled • single
    trigger: K ≥6.0 + no severe tachycardia/CAD — Cochrane 2015; ESC 2021
    Cochrane 2015
  4. 4. sodium bicarbonate
    50-100 mEq IV over 30 min • IV • single
    trigger: pH <7.2 — KDIGO 2024
    Adjunct only if acidotic — Cochrane 2015
  5. 5. sodium zirconium cyclosilicate
    10 g PO • PO • TID × 48h
    trigger: Need ongoing binding — KDIGO 2024
    HARMONIZE (Packham 2015)
  6. 6. IV fluids if hypovolemic
    NS or LR 500-1000 mL • IV • titrate
    trigger: Volume depletion contributing — KDIGO 2024
    Improves renal K excretion — KDIGO 2024

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Serum K+ ≥5.5 mmol/L (mild) / ≥6.0 (moderate) / ≥6.5 or ECG (severe); Peaked T waves / PR prolongation / QRS widening on ECG; Muscle weakness / paralysis / paresthesias.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hyperkalemia (syndrome aggregator)** (syndrome.hyperkalemia.core.v1).
Phenotype framing: Pseudo / intake / shift (DKA, acidosis, succ, BB, digoxin) / decreased excretion (AKI/CKD, drugs, hypoaldosteronism, type-4 RTA) — Clase KDIGO 2020; KDIGO 2024
Scope: Confirm true hyperkalemia (rule out pseudoK from hemolysis, fist clenching, leukocytosis, thrombocytosis) — KDIGO 2024; Clase KDIGO 2020

No severity triggers fired against current inputs.

Plan

Regimen axis: **Severity-tiered hyperkalemia management (UK Renal Association 2023 + ESC 2024)** — step "Mild — K 5.5-5.9 + no ECG changes".
1. discontinue_offenders (non_drug, first line) — Review ACEi/ARB/MRA/spironolactone/heparin/TMP/NSAID — Clase KDIGO 2020
2. patiromer 8.4 g PO daily PO daily, titrate to 25.2 g (k_binder, first line) — OPAL-HK (Weir 2015); permits RAS continuation

Setting playbook (ed) — Recognize severity, protect myocardium, shift K intracellularly, remove K, decide ICU/dialysis — UK Renal Association 2023; KDIGO 2024
3. calcium gluconate 10% 1000 mg IV (10 mL) over 5-10 min IV repeat q5-10 min if ECG persists — ECG changes OR K ≥6.5 — UK Renal Association 2023 (UK Renal Association 2023; membrane stabilization)
4. insulin + dextrose 10 U regular insulin IV + 25 g D50 IV single dose; check glucose q1h × 4 — AHA 2020 — K ≥6.0 — UK Renal Association 2023 (Cochrane 2015)
5. albuterol nebulized 10-20 mg neb inhaled single — K ≥6.0 + no severe tachycardia/CAD — Cochrane 2015; ESC 2021 (Cochrane 2015)
6. sodium bicarbonate 50-100 mEq IV over 30 min IV single — pH <7.2 — KDIGO 2024 (Adjunct only if acidotic — Cochrane 2015)
7. sodium zirconium cyclosilicate 10 g PO PO TID × 48h — Need ongoing binding — KDIGO 2024 (HARMONIZE (Packham 2015))
8. IV fluids if hypovolemic NS or LR 500-1000 mL IV titrate — Volume depletion contributing — KDIGO 2024 (Improves renal K excretion — KDIGO 2024)

Non-pharmacologic actions:
- Continuous ECG monitoring — UK Renal Association 2023
- STAT nephrology consult if K ≥6.5 or ECG changes — KDIGO 2024
- Vascular access prep if RRT needed — KDIGO 2024
- Review and hold offending medications — Clase KDIGO 2020

AVOID / contraindication checks:
- Calcium via central line if chloride — UK Renal Association 2023
- Insulin monitor glucose q1h x4 — AHA 2020
- Salbutamol caution if coronary disease — ESC 2021
- Szc monitor na volume — HARMONIZE (Packham 2015)
- Patiromer separate from other oral meds 3h — OPAL HK (Weir 2015)
- Sps block if postop ileus or bowel obstruction — KDIGO 2024
- Bicarb not monotherapy for hyperK — Cochrane 2015

Monitoring

Regimen monitoring:
- K q1-2h until lt5.5 — UK Renal Association 2023
- glucose q1h x4 after insulin — AHA 2020
- continuous telemetry until K lt 6 — ESC 2021
- BP volume status for szc — HARMONIZE (Packham 2015)

Setting (ed) monitoring:
- K q1-2h until <5.5 — UK Renal Association 2023
- Glucose q1h × 4 after insulin — AHA 2020
- Continuous telemetry until K <6.0 — ESC 2021
- ECG repeat after each shift therapy — UK Renal Association 2023

Follow-up plan: 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
- Close-out criterion: Follow-up scheduled

Monitoring phase: 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

Disposition

Current setting: ed — Recognize severity, protect myocardium, shift K intracellularly, remove K, decide ICU/dialysis — UK Renal Association 2023; KDIGO 2024

Disposition criteria:
- Discharge: K <5.5, no ECG changes, etiology addressed, follow-up within 48-72h — KDIGO 2024
- Admit ward: K 5.5-6.0 stable, etiology being treated — UK Renal Association 2023
- Admit ICU: K ≥6.5 not responding, ECG changes, pending dialysis — KDIGO 2024

Escalation triggers (move to higher acuity):
- No K response within 60 min → STAT dialysis — KDIGO 2024
- Persistent ECG changes despite Ca + shift → ICU + emergent RRT — UK Renal Association 2023
- Cardiac arrest → ACLS + IV calcium chloride — ERC 2021

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] K >6.5 OR ECG changes (peaked T, PR, QRS widening, sine) — UK Renal Association 2023
- [LIFE_THREATENING] K not declining within 60 min of shift therapy — KDIGO 2024
- [LIFE_THREATENING] Cardiac arrest in patient with known/suspected hyperkalemia (ESRD missed dialysis, severe AKI, crush, DKA): asystole / PEA / wide-complex bradyarrhythmia — ERC 2021

Citations

- UK Renal Association Clinical Practice Guideline: Treatment of Acute Hyperkalaemia in Adults 2023 v2.0 + KDIGO 2024 CKD (hyperkalemia management) + 2023 ACC/AHA/HFSA HF Focused Update + 2024 ESC Hyperkalemia Consensus + ERC 2021 Cardiac Arrest in Special Circumstances [PMID:37775712](https://pubmed.ncbi.nlm.nih.gov/37775712/)
- Cited evidence (PMID 26371733) [PMID:26371733](https://pubmed.ncbi.nlm.nih.gov/26371733/)
- Cited evidence (PMID 25415807) [PMID:25415807](https://pubmed.ncbi.nlm.nih.gov/25415807/)
- Cited evidence (PMID 25415805) [PMID:25415805](https://pubmed.ncbi.nlm.nih.gov/25415805/)
- Cited evidence (PMID 35900838) [PMID:35900838](https://pubmed.ncbi.nlm.nih.gov/35900838/)

Last reconciled with current guidelines: 2026-05-12.
References
  • UK Renal Association Clinical Practice Guideline: Treatment of Acute Hyperkalaemia in Adults 2023 v2.0 + KDIGO 2024 CKD (hyperkalemia management) + 2023 ACC/AHA/HFSA HF Focused Update + 2024 ESC Hyperkalemia Consensus + ERC 2021 Cardiac Arrest in Special Circumstances — PMID:37775712
  • Cited evidence (PMID 26371733) — PMID:26371733
  • Cited evidence (PMID 25415807) — PMID:25415807
  • Cited evidence (PMID 25415805) — PMID:25415805
  • Cited evidence (PMID 35900838) — PMID:35900838