Novel Approaches to Management of Hyperkalaemia in Kidney Transplantation

John Rizk; David Quan; Steven Gabardi; Youssef Rizk; Kamyar Kalantar-Zadeh


Curr Opin Nephrol Hypertens. 2021;30(1):27-37. 

In This Article

Nonpharmacological Management


Haemodialysis is rarely required, especially if allograft function is preserved.[19] It is the method of choice for removing potassium when pharmacological therapies fail to sufficiently lower and eliminate potassium,[20,21] and in patients with delayed graft function or allograft failure.[2] Haemodialysis is preferable over cation exchangers in cases of hyperkalaemic emergencies, and is a reasonable option in kidney transplant recipients, as these patients are likely to have dialysis access. However, if haemodialysis cannot be performed promptly (e.g. within 6 h), a gastrointestinal cation exchange therapy, preferably not sodium polystyrene sulfonate (SPS), should be used, which is then followed by haemodialysis as soon as it is available.[22]


Dietary modification has been traditionally recommended for kidney transplant recipients with renal dysfunction who are placed on a CNI. However, it is likely rare for hyperkalaemia to occur exclusively due to excessive potassium intake, especially from a plant-dominant diet, although this has been previously demonstrated in the literature.[23] Although fresh fruits and vegetables should not be avoided given their high antioxidant vitamins and high dietary fibre content that enhances bowel movements and resolves hyperkalaemia,[24–26] certain foods (e.g. dried fruits and dried vegetables especially with added potassium-based preservatives) and herbal supplements (e.g. noni juice, alfalfa, dandelion, horsetail, nettle) should be cautiously avoided during the perioperative period.[27] A potassium-restricted diet (<2 g/day) in the immediate posttransplant setting might be useful in limiting the occurrence of hyperkalaemia, although there are no convincing data to support this traditional practice. However, the benefit of restricting dietary potassium may be less that the potential harm by depriving patients from eating healthy potassium-rich foods with more fibres to lessen the risk of constipation, which can worsen hyperkalaemia.[24–26]