5 versus 10 Units of Intravenous Insulin for Hyperkalemia in Patients With Moderate Renal Dysfunction

J Emerg Med. 2022 Mar;62(3):298-305. doi: 10.1016/j.jemermed.2021.10.027. Epub 2022 Jan 17.


Background: A reduced dose of 5 units of intravenous (i.v.) insulin has been widely accepted for treatment of hyperkalemia in those with end-stage renal dysfunction. However, there remains a dearth of data for patients with moderate renal dysfunction (estimated glomerular filtration rate 15-59 mL/min/m2).

Objective: Describe the incidence of hypoglycemia and relative change in serum potassium when using 5 vs. 10 units of insulin for hyperkalemia in patients with moderate renal dysfunction.

Methods: This was a single-center, retrospective study evaluating adult patients with moderate renal dysfunction who received i.v. insulin for treatment of hyperkalemia. Patients were analyzed based on whether they received 5 or 10 units of i.v. insulin. The primary outcome was the rate of hypoglycemia in each group. Secondary outcomes included rate of relative potassium-lowering effect and incidence of severe hypoglycemia.

Results: Hypoglycemia occurred in 12 patients who received 5 units of i.v. insulin and 16 patients who received 10 units of i.v. insulin (6.5% vs. 8.4%, p = 0.476). Serum potassium was significantly reduced when utilizing 10 units over 5 units of i.v. insulin (-0.9 mmol/L vs. -0.63 mmol/L, p = 0.001). Severe hypoglycemia was seen in two encounters in both the 5-unit and 10-unit groups (1.1% vs. 1.0%, p = 0.979).

Conclusion: There was no difference in hypoglycemic events among patients with moderate renal dysfunction receiving 5 vs. 10 units of i.v. insulin for hyperkalemia. However, 10 units of i.v. insulin lowered serum potassium significantly more than 5 units of i.v. insulin.

Keywords: hyperkalemia; hypoglycemia; insulin; pharmacy; renal dysfunction.

MeSH terms

  • Adult
  • Female
  • Humans
  • Hyperkalemia* / complications
  • Hyperkalemia* / drug therapy
  • Hypoglycemia* / chemically induced
  • Hypoglycemia* / drug therapy
  • Insulin / adverse effects
  • Kidney Diseases*
  • Male
  • Potassium
  • Retrospective Studies


  • Insulin
  • Potassium