Potassium & Hyperkalemia Guide for CKD

W.G.M. Rivero MD · FPCP · DPSN · · williamriveromd.com · 2026

Patient Education · Nephrology

Potassium & Hyperkalemia
in CKD

Why potassium rises in kidney disease, how to recognize danger levels, and which Filipino foods are safe — with emergency guidance and medication warnings. Covers all CKD stages, hemodialysis, and peritoneal dialysis.

🍌

W.G.M. Rivero MD
FPCP · DPSN

Nephrologist

williamriveromd.com

3.5–5.0

mEq/L Normal Range

>5.5

mEq/L Danger Zone

↑ Risk

Cardiac Arrhythmia

↓ Intake

Primary Treatment

Hyperkalemia (high blood potassium) is one of the most dangerous complications of CKD — and one of the most preventable with the right diet and monitoring.

1Why High Potassium Is Dangerous in CKD

Healthy kidneys filter excess potassium from the blood every day. When kidneys are damaged, potassium builds up — a condition called hyperkalemia. Even a small rise above normal can disturb the electrical signals that keep your heart beating regularly. At levels above 6.0 mEq/L, the risk of sudden cardiac arrest rises sharply.

❤️ Cardiac Effects of Hyperkalemia

Slows electrical conduction in heart muscle
Causes peaked T-waves on ECG (early sign)
Widens QRS complex → irregular heartbeat
Can progress to ventricular fibrillation
Sudden cardiac arrest — may have NO warning

⚠️ Symptoms Patients May Notice

Muscle weakness or heaviness in legs and arms
Palpitations or irregular heartbeat
Numbness or tingling in hands/feet
Nausea or stomach discomfort
Shortness of breath
Often NO symptoms at all — most dangerous

2Potassium Targets by CKD Stage

CKD Stage	Target Serum K+	Dietary K+ Limit	Key Note
Stage 1–2 (eGFR >60)	3.5–5.0 mEq/L	No restriction needed	Monitor annually; no limit unless K+ is elevated
Stage 3 (eGFR 30–59)	3.5–5.0 mEq/L	2,000–3,000 mg/day	Moderate vigilance; avoid high-K foods if trending up
Stage 4–5 (eGFR <30)	3.5–5.0 mEq/L	1,500–2,000 mg/day	Strict restriction; leach all vegetables; frequent monitoring
Hemodialysis (HD)	3.5–5.5 mEq/L	2,000–2,500 mg/day	K+ rises between sessions; most dangerous the day before dialysis
Peritoneal Dialysis (PD)	3.5–5.5 mEq/L	2,500–3,000 mg/day	Continuous dialysis allows slightly more; monitor monthly

🚨 Critical Warning — Hyperkalemia Can Be Silent

Hyperkalemia can cause sudden cardiac arrest — it may have no warning symptoms at all. Many patients feel completely normal right up to the moment of a dangerous arrhythmia. Never skip lab monitoring. If your nephrologist orders a potassium check, it is not optional.

For educational use only. This guide does not replace individualized dietary advice from your physician or dietitian. References: KDIGO CKD 2024 · NKF KDOQI Nutrition 2020 · FNRI Philippine Food Composition Tables 2023.

williamriveromd.com
Page 1 of 6 · williamriveromd.com/guides/potassium-hyperkalemia-ckd

Potassium & Hyperkalemia Guide for CKD

W.G.M. Rivero MD · FPCP · DPSN · williamriveromd.com · 2026

Hyperkalemia: Mechanism & Cardiac Risk in CKD

Hyperkalemia overview infographic — how potassium rises in CKD and its cardiac effects

Fig. 1 — In healthy kidneys, excess potassium from food is filtered and excreted in urine. When kidney function declines, this filtration fails and potassium accumulates in the bloodstream. As serum potassium rises above 5.5 mEq/L, the electrical balance across heart muscle cells is disrupted — leading to ECG changes (peaked T-waves, widened QRS), arrhythmias, and at levels above 6.5–7.0 mEq/L, potentially fatal ventricular fibrillation. Dietary restriction, potassium binders, and dialysis are the three pillars of treatment.

For educational use only · Not a substitute for individualized medical advice · williamriveromd.com

williamriveromd.com
Page 2 of 6

Filipino Foods — Potassium Content Reference

Color-coded by potassium level · All values per standard serving · FNRI Philippine Food Composition Tables 2023

Page 3 of 6 · williamriveromd.com

Food (Filipino name)	Standard Serving	K+ (mg)	Recommendation for CKD
🔴 HIGH POTASSIUM — >300 mg per serving · LIMIT SEVERELY in CKD 4–5 and Dialysis
Kamote tops / talbos ng kamote	1 cup cooked	950 mg	Avoid entirely in CKD 4–5 and dialysis — extremely high K+
Buko water / coconut water	1 cup (240 mL)	600 mg	Avoid — marketed as "healthy" but very high potassium; dangerous in CKD
Kalabasa / squash (cooked)	1 cup cooked	500 mg	Avoid in CKD 4–5; small amounts (¼ cup) if leached in CKD 3
Avocado / abokado (½ fruit)	½ medium	487 mg	Avoid in CKD 4–5 and dialysis; very high K+ per serving
Banana / lakatan (ripe)	1 medium	422 mg	Avoid in CKD 4–5 and dialysis — one of the highest-K+ fruits available locally
Saging na saba (ripe, boiled)	1 piece	450 mg	Avoid in CKD 4–5; 1 small unripe piece may be OK in CKD 3 with monitoring
Monggo / mung beans (boiled)	½ cup cooked	400 mg	Leach before cooking; limit to ¼ cup in CKD 4–5; discuss with dietitian
Kamote / sweet potato (boiled)	1 medium (150 g)	400 mg	Leach (peel, dice, soak 2 h, boil in fresh water) — reduces K+ 30–50%; avoid baked
Kangkong / water spinach (cooked)	1 cup cooked	350 mg	Leach and boil; discard cooking water; limit portion to ½ cup in CKD 4–5
Calamansi juice (fresh, 1 cup)	1 cup (240 mL)	300 mg	Limit to small amounts (¼ cup) as condiment only; avoid drinking by the glass
Tomato (fresh, medium)	1 medium	290 mg	Limit — 1 slice OK as garnish; avoid tomato sauce, ketchup, and tomato soup
🟡 MODERATE POTASSIUM — 150–300 mg per serving · USE CAREFULLY in CKD 4–5
Ampalaya / bitter melon (cooked)	1 cup cooked	270 mg	Leach before cooking; limit to ½ cup per meal in CKD 4–5
Bangus / milkfish (steamed)	100 g	280 mg	Good protein source; prefer steamed/boiled over fried; discard cooking water
Gabi / taro (boiled)	1 cup cooked	250 mg	Peel and leach; boil in fresh water; limit to ½ cup in CKD 4–5
Okra (cooked)	1 cup cooked	220 mg	Generally safe in CKD 1–3; limit to ½ cup in CKD 4–5; low phosphorus bonus
Sayote / chayote (cooked)	1 cup cooked	200 mg	Moderate K+; safe at 1 cup in CKD 1–3; reduce to ½ cup in CKD 4–5
Pechay / bok choy (cooked)	1 cup cooked	200 mg	Moderate — boil and discard water; limit to ½ cup in CKD 4–5
Egg (large, boiled)	1 large	70 mg	Good low-K protein source; 1–2 eggs/day generally safe in most CKD stages
🟢 LOW POTASSIUM — <150 mg per serving · GENERALLY SAFE for CKD
White rice (kanin, cooked)	1 cup cooked	55 mg	Safest staple — very low K+ and phosphorus; ideal base for a kidney diet
Cassava / kamoteng kahoy (boiled)	1 cup boiled	75 mg	Low K+ when boiled and drained; good kamote substitute for CKD patients
Upo / bottle gourd (cooked)	1 cup cooked	100 mg	Excellent low-K vegetable; safe for all CKD stages; good in sinigang and soups
Alugbati / Malabar spinach (cooked)	1 cup cooked	140 mg	Lower K+ than kangkong; good leafy green alternative for CKD; boil and drain
Sago (cooked, plain)	1 cup	0 mg	Zero potassium; good calorie source for CKD; avoid sweetened versions with milk
Cooking oil (canola, corn)	1 tbsp	0 mg	No potassium; prefer canola or olive oil; limit total fat per physician's advice

K+ values are approximate per serving. Cooking method greatly affects final potassium content — boiling and discarding cooking water reduces K+ by 30–50%. Sources: FNRI Philippine Food Composition Tables 2023 · USDA FoodData Central · NKF KDOQI Nutrition 2020.

FNRI Philippine Food Composition Tables 2023 · KDIGO CKD 2024 · NKF KDOQI Nutrition 2020 · Educational use only.

williamriveromd.com · Page 3 of 6

Reducing Potassium Through Cooking · Daily Meal Planning

Leaching technique · Food swaps · Sample low-potassium Filipino day

Page 4 of 6 · williamriveromd.com

🍳 The Leaching Technique — How to Reduce Potassium in Vegetables

①

Peel & Cut Small

Peel vegetables and cut into small thin pieces. More surface area = more potassium released into water.

②

Soak 2+ Hours

Soak in a large amount of water (10:1 ratio). Change the water at least once during soaking.

③

Drain & Rinse

Drain completely and rinse well with fresh water. Discard all soak water — it is now loaded with potassium.

④

Boil in Fresh Water

Boil in a new large pot of water. Discard the cooking water too — do not use as broth or soup base.

⑤

30–50% Reduction

Leaching reduces potassium by 30–50% depending on the food. Best for root crops and leafy vegetables.

⚠️ Important: Leaching Limits

Leaching works best for root crops (kamote, gabi, cassava) and leafy vegetables (kangkong, pechay, ampalaya). It does NOT work well for fruits — avoid high-potassium fruits entirely if your potassium level is elevated. Leaching also reduces some vitamins — compensate by eating a varied diet of approved low-K foods.

🔄 Food Swap Guide — High-K Foods → Lower-K Alternatives

Instead of (High K+)	K+ (mg)	Choose This (Lower K+)	K+ (mg)	Notes
Saging na saba (1 piece)	450	Cassava / kamoteng kahoy (boiled, 1 cup)	75	Good carb swap; boil and drain thoroughly
Avocado (½ fruit)	487	Papaya (small serving, ½ cup)	~180	Papaya is still moderate-K; limit to ½ cup in CKD 4–5
Kamote tops / talbos (1 cup)	950	Upo / bottle gourd (1 cup cooked)	100	Excellent low-K leafy substitute; safe for all CKD stages
Buko water (1 cup)	600	Plain water or tap water	0	Buko water is NOT safe for CKD — avoid completely
Monggo soup (½ cup cooked)	400	Sayote + tofu (½ cup each, leached)	~200	Lower K+ protein-vegetable combo; leach sayote before use
Banana / lakatan (1 medium)	422	Canned fruit in own juice (drained, ½ cup)	~100	Draining canned fruit removes additional K+; avoid syrup packs

🍽 Sample Low-Potassium Filipino Day — For CKD Stage 4–5 / Hemodialysis

Meal	Food	K+ (est.)	CKD Notes
Breakfast	1 cup white rice + 1 boiled egg + sautéed upo (½ cup, boiled and drained) + water	~200 mg	Very low K+; excellent kidney-safe breakfast
Snack	Sago (½ cup, plain, unsweetened) + plain water	~5 mg	Zero K+ snack; good calorie source without potassium burden
Lunch	1 cup white rice + grilled bangus (100 g) + leached sayote (½ cup boiled) + pechay (½ cup, boiled, water discarded)	~500 mg	Moderate — acceptable at lunch; leach all vegetables
Afternoon	Canned fruit (drained, ½ cup) in own juice — not syrup	~100 mg	Draining canned fruit removes K+; avoid heavy syrup packs
Dinner	1 cup white rice + steamed tilapia or galunggong (100 g) + stir-fried alugbati (½ cup, boiled first, water discarded)	~400 mg	Low-K dinner; always discard all cooking water
TOTAL	Full day — kidney-safe low-potassium Filipino menu	~1,205 mg	Well within 1,500–2,000 mg limit for CKD 4–5

🩺 Individualized Restriction — Do Not Self-Restrict Unnecessarily

Potassium restriction is individualized — your nephrologist sets your limit based on your current serum K+ level and CKD stage. Do not restrict severely if your potassium is normal (3.5–5.0 mEq/L). Too-low potassium (hypokalemia) is also dangerous. Always follow your doctor's specific dietary instructions.

NKF KDOQI Nutrition 2020 · KDIGO CKD 2024 · FNRI 2023 · Educational use only.

williamriveromd.com · Page 4 of 6

Recognizing Hyperkalemia · When to Seek Help · Medications

Symptoms · Emergency thresholds · Drugs that raise or lower potassium

Page 5 of 6 · williamriveromd.com

⚠️ Symptoms of Hyperkalemia — Know the Warning Signs

💪 Muscle Weakness / Fatigue Heavy, weak feeling in arms and legs — especially thighs. May feel like you cannot stand or climb stairs. Often the earliest symptom patients notice.	💓 Palpitations / Irregular Heartbeat Fluttering, pounding, or skipping sensations in the chest. Irregular heartbeat (arrhythmia) — may feel like the heart is "jumping." Seek care immediately.	🖐️ Numbness / Tingling Pins-and-needles sensation in hands, feet, and around the mouth. High potassium disrupts nerve signal transmission throughout the body.
🤢 Nausea Stomach discomfort, nausea, or vomiting — non-specific but often accompanies elevated potassium, especially in acute rises.	😮‍💨 Difficulty Breathing Shortness of breath at rest or with minimal activity — can indicate severe hyperkalemia affecting respiratory muscles. Seek emergency care immediately.	❗ NO SYMPTOMS — Most Dangerous Many patients with K+ above 6.0 mEq/L feel completely normal. Sudden cardiac arrest can occur without any warning. This is why lab monitoring is non-negotiable.

🚑 Go to the Emergency Room Immediately If:

Chest pain or pressure
Irregular heartbeat or palpitations that do not stop
Severe or sudden muscle weakness — cannot move legs/arms normally
Difficulty breathing at rest
Serum K+ >6.0 mEq/L on home or clinic monitoring
You missed a dialysis session and feel any of the above symptoms

💊 Medications & Potassium — What Raises and What Lowers K+

🔴 Drugs That RAISE Potassium — Monitor Carefully
Drug (Generic Name)	Filipino Brand / Note
ACE inhibitors enalapril, lisinopril, captopril	Vasotec, Zestril, Capoten — essential for CKD but block K+ excretion; monitor K+ monthly
ARBs losartan, valsartan, telmisartan	Cozaar, Diovan — similar to ACE inhibitors; never combine ACEi + ARB in CKD
Potassium-sparing diuretics spironolactone, eplerenone	Aldactone — blocks aldosterone; use with extreme caution in CKD 4–5
NSAIDs mefenamic acid, ibuprofen, naproxen	Ponstan, Advil — reduce kidney K+ excretion AND worsen kidney function; avoid in CKD
Trimethoprim (in co-trimoxazole / Bactrim)	Blocks K+ excretion like a diuretic; monitor K+ during use
Potassium supplements KCl oral tablets/solutions	Kalium Durules — never self-supplement in CKD; only take if prescribed

🟢 Treatments That LOWER Potassium — Only as Prescribed
Treatment	Notes
Sodium polystyrene sulfonate (Kayexalate)	Oldest binder; exchanges sodium for K+ in gut; available locally; take with water; not for long-term use
Patiromer (Veltassa)	Newer K+ binder; exchange resin; well-tolerated; limited availability in Philippines
Sodium zirconium cyclosilicate (Lokelma)	Newer zirconium-based binder; fast-acting; once daily; limited availability locally
Loop diuretics furosemide, torsemide	Lasix — increases K+ excretion via urine; used in CKD with residual kidney function
Sodium bicarbonate	Corrects acidosis which causes K+ to shift out of cells; used in CKD with metabolic acidosis
Dialysis (HD or PD)	Most effective K+ removal — HD removes 40–80 mEq per session; never miss sessions

🔑 Key Medication Rule for CKD Patients

Never stop a prescribed ACE inhibitor or ARB on your own — they protect your kidneys even though they raise potassium slightly. Instead, manage potassium through diet and discuss with your nephrologist whether a potassium binder is needed. Never take NSAIDs (mefenamic acid, ibuprofen) without your doctor's approval — they worsen kidney function AND raise potassium simultaneously.

KDIGO CKD 2024 · NKF KDOQI Nutrition 2020 · MIMS Philippines 2025 · Kovesdy CP et al. JASN 2022 · Educational use only. Medication advice must be individualized by your physician.

williamriveromd.com
Page 5 of 6 · williamriveromd.com/guides/potassium-hyperkalemia-ckd

Quick Reference · Key Takeaways · When to Call Your Doctor

Summary card · Most important rules · Monitoring schedule

Page 6 of 6 · williamriveromd.com

🚦 Quick Reference — Potassium Level Action Guide

Serum K+ Level	Status	What to Do
3.5–5.0 mEq/L	✅ Normal	Continue current diet. Recheck as scheduled (every 1–3 months in CKD).
5.1–5.5 mEq/L	⚠️ Mild High	Tighten dietary restriction. Review all medications. Recheck in 1–2 weeks. Call your nephrologist.
5.6–6.0 mEq/L	🔶 Moderate	Contact nephrologist same day. Strict dietary restriction. May need potassium binder. ECG monitoring.
>6.0 mEq/L	🚨 Danger	Go to the EMERGENCY ROOM immediately. Risk of sudden cardiac arrest. Call for help — do not drive alone.
>6.5 mEq/L	🚑 Life-threatening	Medical emergency. IV calcium gluconate, IV insulin + glucose, emergency dialysis may be needed.

✅ Key Takeaways — The Most Important Rules

🍌 The "Banana Rule" for CKD Patients

Bananas, buko water, and kamote tops are the three most common potassium mistakes Filipino CKD patients make — all are perceived as "healthy" but are among the highest-K+ foods available. Avoid all three if your potassium is elevated. Also avoid sports drinks (Gatorade, Pocari Sweat) and salt substitutes — both contain potassium.

⚠️ Never Miss Dialysis

For dialysis patients, skipping even one session allows potassium to accumulate to dangerous levels — especially over the Monday–Wednesday gap (3 days off). Restrict potassium most strictly during the longest inter-dialytic gap. The day before dialysis is the highest-risk period.

🧂 Hidden Potassium Sources

Salt substitutes (NoSalt, Nu-Salt) — contain potassium chloride; dangerous in CKD
Sports drinks (Gatorade, Pocari Sweat) — contain added K+
Fruit juices and smoothies — concentrated K+ from multiple fruits
Herbal supplements and "natural" health drinks — may contain high K+

🌾 Safest Filipino Staples for CKD

White rice — lowest K+ of all staples; ideal base food for any CKD stage
Upo / bottle gourd — excellent low-K vegetable; good for soups
Cassava (boiled and drained) — good carbohydrate alternative to kamote
Sago (plain, unsweetened) — zero K+; good calorie source
Alugbati — safer leafy green alternative to kangkong
Eggs (1–2 daily) — low-K protein; generally safe in most CKD stages
White fish (steamed or boiled) — moderate K+; always discard cooking water

📅 Monitoring Schedule

CKD Stage 1–3: Serum K+ every 3–6 months
CKD Stage 4–5: Serum K+ every 1–3 months
Hemodialysis: Pre-dialysis K+ every session (3× per week)
Peritoneal Dialysis: Serum K+ every 1–2 months
If K+ was recently elevated: recheck in 1–2 weeks
After changing diet or medications: recheck in 2–4 weeks

📞 Call Your Nephrologist If:

K+ result is above 5.5 mEq/L on any lab result
New muscle weakness or palpitations develop
You started a new medication (especially ACEi/ARB or NSAID)
You are unsure if a food or supplement is safe to eat
You have had severe vomiting, diarrhea, or inability to eat

Dr. W.G.M. Rivero MD · FPCP · DPSN ·
Nephrology & Internal Medicine · williamriveromd.com
This guide is for patient education only. Potassium targets and dietary limits are individualized — always follow your nephrologist's specific instructions. References: KDIGO CKD 2024 · NKF KDOQI Nutrition 2020 · Kovesdy CP et al. JASN 2022 · FNRI Philippine Food Composition Tables 2023 · MIMS Philippines 2025.

For educational use only. This guide does not replace individualized care from your nephrologist or dietitian. Potassium targets, medication decisions, and dietary limits must be set by your physician based on your lab results. References: KDIGO CKD 2024 · NKF KDOQI Nutrition 2020 · FNRI 2023.

williamriveromd.com
Page 6 of 6 · williamriveromd.com/guides/potassium-hyperkalemia-ckd