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Nephrology · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation CKD 4 on ramipril and spironolactone; weak and nauseated; K⁺ 7.1; ECG: peaked T waves, wide QRS
Red flags Wide QRS, sine wave, bradycardia K⁺ ≥6.5 Anuria Muscle weakness/paralysis Differential diagnosis Pseudohyperkalaemia (haemolysis, thrombocytosis) AKI/CKD Drugs Rhabdomyolysis, tumour lysis, haemolysis Adrenal insufficiency, DKA When to admit, call ICU or discharge Admit: K⁺ ≥6.0, any ECG change, AKIICU: ECG changes, arrhythmia, refractory K⁺Dialysis: Refractory K⁺, anuric AKI, severe acidosis or TLSKey points Calcium works in 1–3 minutes but lowers K⁺ not at all. Insulin–glucose causes hypoglycaemia in up to 1 in 5 — hourly glucose for 6 h. Commonest ward cause: AKI plus RAAS blockers, spironolactone, NSAIDs or trimethoprim. Never Treat the number and ignore the ECG (or the reverse) Only shift K⁺ without removing it — it rebounds in 4–6 h Give calcium through the same line as bicarbonate Use sodium polystyrene (Kayexalate) acutely Common mistakes Shifting without removing Missing hypoglycaemia Kayexalate Not stopping the cause Disposition and follow-up Monitored bed for ECG changes; ICU/dialysis if refractory. K⁺ recheck within a week.
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