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World J Transplant. Sep 18, 2024; 14(3): 95905
Published online Sep 18, 2024. doi: 10.5500/wjt.v14.i3.95905
Table 1 Causes of hyperkalemia in kidney transplant recipients
Category
Examples
Type of transplantCombined kidney-pancreas
Immunosuppressive medicationsCyclosporine
Tacrolimus
Non-immunosuppressive medicationsAngiotensin-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
OthersInterstitial fibrosis and tubular atrophy
Delayed graft function
Dietary indiscretion1
Hyperglycemia
Metabolic acidosis
Type 4 renal tubular acidosis
Urinary tract obstruction
Table 2 Causes of hypokalemia in kidney transplant recipients
Category
Example
Potassium loss
GastrointestinalVomiting
Diarrhea
Intestinal malabsorption
Colostomy
RenalHyperkalemia
Hyperreninemia
Hyperaldosteronism
Renal tubular acidosis (Type 1, 2)
Hypomagnesemia
MedicationsSirolimus
Everolimus
Loop diuretics
Thiazide diuretics
Mineralocorticoids
Inadequate Potassium IntakePoor oral intake
Dietary indiscretion1
Total parenteral nutrition
Intracellular Potassium ShiftMetabolic alkalosis
Dextrose solution
Insulin therapy
OthersDialysis using low potassium bath
Peritoneal dialysis
Plasmapheresis
Table 3 Common examples of food sources containing potassium
Potassium content1
Low
Medium
High
Apple juiceGrape juiceOrange juice
Cranberry juiceGrapefruit juicePrune juice
Lemon juicePineapple juiceApricots
Peach nectarAppleBanana
Pear nectarCherriesBreadfruit
BlackberriesLycheesAll dried fruits
BlueberriesPlumGuava
RaspberriesPearHoneydew
StrawberriesPomeloJackfruit
AsparagusStarfruitKiwi
Bamboo shootsArtichokeMango
BroccoliBeetsNectarine
CabbageCarrotPapaya
CucumberCauliflowerPersimmon
EggplantCornPomegranate
BeansKaleLentils
LettuceMustard greensMushrooms (cooked)
Mushrooms (raw)PeasOkra
OnionSpinach (raw)Potatoes
PepperZucchiniSpinach (cooked)
RadishCustardSweet potato
RhubarbCream soupTomato
TofuIce creamWater chestnut (fresh)
TurnipMilkWinter squash
Water chestnut (canned)YogurtYam
Table 4 Common preventive and management strategies for post-transplant hyperkalemia and hypokalemia

Hyperkalemia
Hypokalemia
Pre-transplantHold ACE inhibitor or ARBHold loop and thiazide diuretics, if applicable
Add extra session of hemodialysis
Early post-transplantObtain ECG and administer IV calcium gluconate if appropriateObtain ECG and administer IV potassium chloride if appropriate
Add extra session of hemodialysisUse high K+ bath for hemodialysis if needed
Correct insulin deficiencyAdd KCl to replacement fluid
Correct metabolic acidosisCorrect metabolic alkalosis
Add loop diureticAvoid loop diuretic
Avoid potassium-sparing diureticsAdd oral potassium supplement
Address constipationConsult dietician
Minimize use of heparin
Delay introducing sulfa antibiotic
Consult dietician
Late post-transplantReduce or hold ACE inhibitor or ARB, potassium-sparing diureticCorrect underlying cause, e.g., diarrhea
Rule out obstructionAdd ACE inhibitor or ARB, potassium sparing diuretic
Reduce or hold sulfa antibiotic, or switch to another prophylactic drug for Pneumocystis jiroveciiAdd oral potassium supplement
Add fludrocortisoneIdentify and correct magnesium deficiency
Correct metabolic acidosisConsult dietician
Optimize glycemic control
Add oral patiromer or sodium zircomium cyclosilicate
Consult dietician