Hyperkalemia is a serious, often life threatening complication of diabetes-related kidney disease.

This is one of the most common electrolyte imbalances experienced by people with kidney disease, or diabetic nephropathy. Blood potassium levels are elevated and the body is not able to eliminate or bring back into balance the excess potassium on its own.

This electrolyte imbalance can lead to muscle weakness, pain, and paralysis. At its worst, hyperkalemia can cause abnormal, possibly fatal heart rhythm (arrhythmias), or trigger the need for dialysis.

While the conditions leading to hyperkalemia are well understood, recognizing hyperkalemia and effectively treating it are difficult.

Diabetes kidney disease (nephropathy) has a direct relationship with hyperkalemia.

Nephropathy refers to the deterioration of kidney function. When left untreated it leads to end-stage renal disease (ESRD), more commonly referred to as kidney failure, and death.

Difficult to identify in its early stages, nephropathy shows few symptoms that clearly point to kidney problems. It’s most commonly diagnosed using a combination of blood and urine lab tests that measure glomerular filtration rate (GFR) and the presence of albumin, a protein found in the urine in the early stages of nephropathy.

Compromised kidney function disrupts the body’s ability to eliminate extra potassium from the bloodstream. When this happens the body can experience an electrolyte imbalance and critically important functions are impaired, like waste elimination and blood pressure regulation.

The symptoms of an electrolyte imbalance vary widely. They include:

  • muscle pain
  • cramping
  • heart palpitations
  • shortness of breath

The symptoms can vary and may be difficult to identify, or could come on suddenly and severely.

The effects of hyperkalemia can be present in people with mild to moderate kidney disease. But these effects are more likely to become more severe and life threatening as kidney problems progress.

Being at higher risk for developing kidney disease puts people with diabetes at risk for hyperkalemia. But that’s not the only risk factor people with diabetes need to manage.

People with diabetes are at higher risk for two other main reasons.


Certain diabetes medications have potential side effect of disrupting kidney function and the potassium homeostasis in the body. These include:

  • ACE inhibitors
  • angiotensin-receptor blockers (ARBs)
  • beta-blockers
  • NSAIDs (nonsteroidal anti-inflammatory drugs). These are often taken over the counter for pain relief and carry the warning that prolonged use or misuse can lead to kidney problems.

High glucose levels

The elevated glucose levels that characterize diabetes also disrupt the body’s ability to balance electrolyte levels. Potassium normally is stored in cells throughout the body.

But when glucose levels are high, potassium is blocked from entering the cells and stays in the bloodstream. Insulin is needed to move the potassium into the cells and return the body to balance.

Delivering short-acting regular insulin (insulin R) intravenously is accepted as an effective treatment for hyperkalemia. IV regular insulin lowers serum potassium quickly by opening up pathways for potassium to move out of the bloodstream and into cells.

However, this treatment brings with it the risk of experiencing hypoglycemia (low blood glucose) or hypokalaemia (low potassium). To avoid these risks, dextrose (sugar) might be administered along with the regular insulin or a smaller dose of insulin R administered reducing its overall effect.

There are a number of treatment options for addressing hyperkalemia when kidney disease is also present.

In an emergency, administering IV regular insulin is the likely treatment. If the person is also experiencing kidney failure then dialysis is also possible.

In addition to these emergency measures the following treatments are available:

  • calcium, to reduce the risk of ventricular fibrillation
  • alkalinizing agents, to increase pH and ease potassium into cells
  • beta2-adrenergic agonists, to promote potassium moving into cells
  • diuretics, to promote the elimination of potassium through urine
  • potassium binders, to promote elimination of potassium in the feces

As a protective measure, dapagliflozin (a SGLT2 inhibitor) may be helpful to people experiencing moderately impaired kidney function. It acts as an osmotic diuretic, producing more urine and encouraging elimination.

Once diagnosed, there are effective treatments for diabetic nephropathy hyperkalemia. The likelihood of a full recovery is increased when hyperkalemia is detected earlier and medical attention is sought.

Even after reestablishing potassium homeostasis in the body, actively managing kidney health and potassium levels on an ongoing basis will be needed. This may include making dietary changes and avoiding medications that are linked to a higher risk of kidney damage or hyperkalemia, along with managing glucose levels.

Hyperkalemia is a serious, potentially fatal condition. For people with diabetes experiencing kidney disease, the risk of serious outcomes is high. It’s important to be aware of the signs of hyperkalemia. Just as important, is understanding the positive effect managing dietary potassium, certain medications, glucose levels, and kidney health can have on reducing this risk.