Real World Evidence for Treatment of Hyperkalemia in the Emergency Department (REVEAL–ED): A Multicenter, Prospective, Observational Study

Background: Contemporary emergency department (ED) standard-of-care treatment of hyperkalemia is poorly described. Objective: Our aim was to determine the treatment patterns of hyperkalemia management in the ED. Methods: This multicenter, prospective, observational study evaluated patients aged ≥ 18 years with hyperkalemia (potassium [K⁺] level ≥ 5.5 mmol/L) in the ED from October 25, 2015 to March 30, 2016. K⁺-lowering therapies and K⁺ were documented at 0.5, 1, 2, and 4 h after initial ED treatment. The primary end point was change in K⁺ over 4 h. Results: Overall, 203 patients were enrolled at 14 U.S.-based sites. The initial median K⁺ was 6.3 (interquartile range [IQR] 5.7–6.8) mmol/L and median time to treatment was 2.7 (IQR 1.9–3.5) h post-ED arrival. Insulin/glucose (n = 130; 64%) was frequently used to treat hyperkalemia; overall, 43 different treatment combinations were employed within the first 4 h. Within 4 h, the median K⁺ for patients treated with medications alone decreased from 6.3 (IQR, 5.8–6.8) mmol/L to 5.3 (4.8–5.7) mmol/L, while that for patients treated with dialysis decreased from 6.2 (IQR 6.0–6.6) mmol/L to 3.8 (IQR 3.6–4.2) mmol/L. Hypoglycemia occurred in 6% of patients overall and in 17% of patients with K⁺ > 7.0 mmol/L. Hyperkalemia-related electrocardiogram changes were observed in 23% of all patients; 45% of patients with K⁺ > 7.0 mmol/L had peaked T waves or widened QRS. Overall, 79% were hospitalized; 3 patients died. Conclusions: Hyperkalemia practice patterns vary considerably and, although treatment effectively lowered K⁺, only dialysis normalized median K⁺ within 4 h.