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

Abstract 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.