# Hyperkalemia: Protect, Shift, Remove

For dialysis patients, review attendance, access delivery, diet, constipation, medications, and the long interdialytic interval rather than only changing one bath value.

![Infographic: Hyperkalemia: Protect, Shift, Remove](https://urinenephrology.org/visual-reference/images/mastery-hyperkalemia.png?v=20261003c)

## Danger depends on context

Potassium can rise through reduced excretion, cell shifts, tissue breakdown, and medications. The pace of change and underlying physiology affect risk.

## Confirm without delaying care

Consider sample artifact when findings are unexpected, but do not postpone treatment for a clinically unstable patient with a credible dangerous result.

## Assess electrical and systemic effects

Obtain an ECG and evaluate symptoms, kidney function, acid–base status, glucose, and ongoing potassium release. A normal ECG does not exclude serious risk.

## Protect, shift, then remove

IV calcium stabilizes cardiac membranes when indicated; it does not lower potassium. Insulin with glucose and an inhaled beta-agonist can shift potassium temporarily. Removal requires urinary excretion when feasible, a potassium binder in an appropriate setting, or dialysis. Arrange definitive removal while temporary measures act.

## Watch for rebound and hypoglycemia

Repeat potassium after temporizing therapy and continue surveillance when release or impaired excretion persists. Insulin-related hypoglycemia can occur after the initial glucose has fallen, particularly in kidney failure; follow a scheduled glucose-monitoring protocol. A transient potassium decrease does not prove the total-body excess has been removed.

## Address the longer interval

For dialysis patients, review attendance, access delivery, diet, constipation, medications, and the long interdialytic interval rather than only changing one bath value.

## Supporting evidence

- [Supporting guideline or source](https://www.ukkidney.org/health-professionals/guidelines/treatment-acute-hyperkalaemia-adults-0)

## Source lessons

- [hyperkalemia treatment](https://urinenephrology.org/mastery/electrolytes-advanced/hyperkalemia-treatment.html)
- [hyperkalemia hemodialysis](https://urinenephrology.org/mastery/maintenance-hd/hyperkalemia-hemodialysis.html)

Read alongside the full lessons; the findings and decisions shown here require the stated clinical context.