Which is the first-line step in managing hyperkalemia with ECG changes in CKD?

• A. IV calcium to stabilize the myocardium, followed by measures to shift and remove potassium.
• B. Immediate dialysis without stabilization.
• C. IV bicarbonate only.
• D. Potassium-sparing diuretics first.

Answer: (A)

When hyperkalemia is causing ECG changes, the immediate priority is to protect the heart. Administer intravenous calcium to stabilize the myocardium; calcium raises the threshold for depolarization and reduces myocardial excitability, buying time to lower the potassium. After stabilization, you address the potassium level by shifting potassium into cells (for example, insulin with glucose, and, if appropriate, a beta-agonist like albuterol) and by removing potassium from the body (diuretics if there is urine output, potassium-binding resins, or dialysis in CKD). In CKD with ECG changes, calcium stabilization must come first, then the team proceeds with measures to shift and remove potassium, with dialysis available as a definitive step if potassium remains high or removal is urgently needed. Dialysis without stabilization is not the initial move, bicarbonate alone is not sufficient for immediate stabilization, and potassium-sparing diuretics would worsen hyperkalemia.