Diagnosis and management of acute hyperkalaemia

Hyperkalaemia is a common and potentially life threatening electrolyte abnormality because of its association with malignant cardiac arrhythmias and sudden cardiac arrest. This condition is frequently encountered across acute and chronic care settings and disproportionately affects patients with comorbid conditions like chronic kidney disease, heart failure, diabetes mellitus, and those receiving drugs that impair renal potassium excretion. The most frequent causes of hyperkalaemia include impaired renal potassium elimination, from chronic kidney disease or pharmacological inhibition of the renin-angiotensin-aldosterone system, and transcellular potassium shifts resulting from metabolic acidosis, tissue breakdown, insulin deficiency, or hypertonic states. Despite its prevalence and clinical importance, substantial variability exists in the approach to diagnosis and management of hyperkalaemia, reflecting differences in definitions, risk stratification, and therapeutic approaches across clinical settings. Management strategies have evolved in recent years with improved understanding of potassium physiology and the availability of newer potassium binding agents, necessitating an updated synthesis of the evidence. In this state of the art review, we summarise contemporary data on the epidemiology and pathophysiology of hyperkalaemia, identify key risk factors and diagnostic considerations, and review evidence based approaches to acute and chronic management, with particular attention to special populations and high risk clinical scenarios.