This is usually unnecessary in patients with intact renal function. Patients with predictably transient hyperkalemia can usually be maintained at acceptable potassium levels by using a combination of glucose-insulin, sodium bicarbonate, and forced diuresis, possibly supplemented with b 2 agonists. In patients where these methods fail and in those with established acute or acute-on-chronic renal failure, hyperkalemia usually reflects a generalized metabolic disturbance and is an indication to start renal replacement therapy. In extremis, peritoneal dialysis has been used successfully in the management of hyperkalemic cardiac arrest pending institution of more conventional treatments.
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