Disorders of potassium homeostasis after kidney transplantation

Table 1 Causes of hyperkalemia in kidney transplant recipients

Category	Examples
Type of transplant	Combined kidney-pancreas
Immunosuppressive medications	Cyclosporine
	Tacrolimus
Non-immunosuppressive medications	Angiotensin-converting enzyme inhibitors
	Angiotensin II receptor blockers
	Beta-blockers
	Steroidal mineralocorticoid antagonists (eplerenone, spironolactone)
	Non-steroidal mineralocorticoid antagonists (finerenone)
	Potassium-sparing diuretics (amiloride, triamterene)
	Heparin
	Mannitol
	Non-steroidal anti-inflammatory drugs
	Pneumocystis jirovecii pneumonia prophylactic agents (pentamidine, trimethoprim-sulfamethoxazole)
	Succinylcholine
Others	Interstitial fibrosis and tubular atrophy
	Delayed graft function
	Dietary indiscretion1
	Hyperglycemia
	Metabolic acidosis
	Type 4 renal tubular acidosis
	Urinary tract obstruction

¹In combination with at least one other factor.

Table 2 Causes of hypokalemia in kidney transplant recipients

Category	Example
Potassium loss
Gastrointestinal	Vomiting
	Diarrhea
	Intestinal malabsorption
	Colostomy
Renal	Hyperkalemia
	Hyperreninemia
	Hyperaldosteronism
	Renal tubular acidosis (Type 1, 2)
	Hypomagnesemia
Medications	Sirolimus
	Everolimus
	Loop diuretics
	Thiazide diuretics
	Mineralocorticoids
Inadequate Potassium Intake	Poor oral intake
	Dietary indiscretion1
	Total parenteral nutrition
Intracellular Potassium Shift	Metabolic alkalosis
	Dextrose solution
	Insulin therapy
Others	Dialysis using low potassium bath
	Peritoneal dialysis
	Plasmapheresis

¹In combination with at least one other factor.

Table 3 Common examples of food sources containing potassium

Potassium content1
Low	Medium	High
Apple juice	Grape juice	Orange juice
Cranberry juice	Grapefruit juice	Prune juice
Lemon juice	Pineapple juice	Apricots
Peach nectar	Apple	Banana
Pear nectar	Cherries	Breadfruit
Blackberries	Lychees	All dried fruits
Blueberries	Plum	Guava
Raspberries	Pear	Honeydew
Strawberries	Pomelo	Jackfruit
Asparagus	Starfruit	Kiwi
Bamboo shoots	Artichoke	Mango
Broccoli	Beets	Nectarine
Cabbage	Carrot	Papaya
Cucumber	Cauliflower	Persimmon
Eggplant	Corn	Pomegranate
Beans	Kale	Lentils
Lettuce	Mustard greens	Mushrooms (cooked)
Mushrooms (raw)	Peas	Okra
Onion	Spinach (raw)	Potatoes
Pepper	Zucchini	Spinach (cooked)
Radish	Custard	Sweet potato
Rhubarb	Cream soup	Tomato
Tofu	Ice cream	Water chestnut (fresh)
Turnip	Milk	Winter squash
Water chestnut (canned)	Yogurt	Yam

¹Specific amounts allowed should be discussed with a transplant dietician as part of an overall management plan.

Table 4 Common preventive and management strategies for post-transplant hyperkalemia and hypokalemia

	Hyperkalemia	Hypokalemia
Pre-transplant	Hold ACE inhibitor or ARB	Hold loop and thiazide diuretics, if applicable
	Add extra session of hemodialysis
Early post-transplant	Obtain ECG and administer IV calcium gluconate if appropriate	Obtain ECG and administer IV potassium chloride if appropriate
	Add extra session of hemodialysis	Use high K+ bath for hemodialysis if needed
	Correct insulin deficiency	Add KCl to replacement fluid
	Correct metabolic acidosis	Correct metabolic alkalosis
	Add loop diuretic	Avoid loop diuretic
	Avoid potassium-sparing diuretics	Add oral potassium supplement
	Address constipation	Consult dietician
	Minimize use of heparin
	Delay introducing sulfa antibiotic
	Consult dietician
Late post-transplant	Reduce or hold ACE inhibitor or ARB, potassium-sparing diuretic	Correct underlying cause, e.g., diarrhea
	Rule out obstruction	Add ACE inhibitor or ARB, potassium sparing diuretic
	Reduce or hold sulfa antibiotic, or switch to another prophylactic drug for Pneumocystis jirovecii	Add oral potassium supplement
	Add fludrocortisone	Identify and correct magnesium deficiency
	Correct metabolic acidosis	Consult dietician
	Optimize glycemic control
	Add oral patiromer or sodium zircomium cyclosilicate
	Consult dietician

ACE: Angiotensin-converting enzyme; ARB: Angiotensin II receptor blockers; ECG: Electrocardiogram.