Fig. 5

First-line treatment of hyperkalemia. During hyperkalemia with ECG modifications, first-line therapy should consist on cardiomyocyte stabilization using calcium salt or hypertonic sodium (red panel), second line therapy on treatment leading to a fast transfer of potassium from extracellular to intracellular space using either insulin–glucose i.v, aerosol of β2 agonist and/or sodium bicarbonate (in case of metabolic acidosis and hypovolemic patient) depending of the patient’s comorbidities and clinical status. Insulin–glucose is recommended as the first-line treatment in severe hyperkalemia (i.e., above 6.5 mmol/L) but close glucose monitoring is mandatory. β2 agonists can be used in spontaneously breathing patients but with safety concerns in patients with unstable angina or cardiac failure. Hypertonic sodium bicarbonate should probably be restricted to hypovolemic patients with metabolic acidosis (blue panel). Strategies increasing potassium renal excretion decreases the total potassium pool (i.e., hemodynamic optimization and correction of acute kidney injury or loop Henle diuretics in patients with fluid overload) (green panel). Indications of renal replacement therapy are patients with severe acute kidney injury associated to severe hyperkalemia or persistent hyperkalemia despite first-line medical treatment