Hyperkalaemia: albuterol and insulin together lowered potassium more than either alone in haemodialysis patients

Clinical bottom line (level 4)

  1. In haemodialysis patients with hyperkalaemia, nebulized albuterol combined with intravenous insulin and glucose lowered potassium to a greater extent than either treatment alone.
  2. Combination treatment reduced the hypoglycaemic effects of insulin
Allon and Copkney: Kidney International 1990; 38: 869-872
Expires October 2003

The study

Case-control study with objective outcomes, not adjusted for confounding factors, not validated in an independent set of patients.
Setting: university hospital, USA

12 patients (aged 34 to 72; mean 57, ?% male) on maintenance haemodialysis (3-4 hours of dialysis, three times a week) with pre-dialysis potassium > 5 mmol/L on three separate measurements in 1 month (roughly 5.5-5.9 mmol/L)

Excluded if
  • diabetes
  • on beta-blockers


    • Control Group: (n = 12, 12 analysed): 10 units regular insulin intravenous bolus, followed by 50 mL of a 50% glucose solution IV over 5 minutes
    Experimental Group: (n = 12, 10 analysed): 20 mg albuterol in 4 mL normal saline, nebulized over a 10 minute period
    Experimental Group: (n = 12, 10 analysed): 10 units regular insulin IV bolus, followed by 50 mL of a 50% glucose solution IV over 5 minutes, AND 20 mg albuterol in 4 mL normal saline, nebulized over a 10 minute period

    100% followed for 60 minutes

    The evidence

    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    glucose (mmol/l): insulin v. albuterol 2.8
    (0.3)     		6.8
    (0.5)     		4.0
    (3.6 to 4.2)
    glucose (mmol/l): insulin v. albuterol and insulin 2.8
    (0.3)     		4.7
    (0.7)     		1.9
    (1.4 to 2.4)
    maximal fall in serum potassium: insulin v. albuterol 0.65
    (0.09)     		0.55
    (0.12)     		0.01
    (-0.10 to 0.083)
    maximal fall in serum potassium: insulin v. albuterol and insulin 0.65
    (0.09)     		1.21
    (0.19)     		0.56
    (0.43 to 0.69)

    Comments

    1. Patients acted as their own controls.
    2. Two patients were dropped from the study, leaving only 10 of 12. 4 out of 10 patients had very little change in plasma potassium in response to albuterol.
    3. The study design was poor, being unrandomized, unblinded, and consisting of few patients.

    Citation

    1. Allon M, and Copkney C: Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients. Kidney International 1990; 38: 869-872
    Search Terms: Medline; MeSH terms: hyperkalemia, limited by subgroup "treatment"
    Contributor: Warren Lee and Chris Ball, October 1999
    Reviewer: -

    Clinical Question.
    Patient renal failure on haemodialysis
    Intervention or Exposure albuterol, salbutamol, insulin
    Outcome fall in potassium