Kayexalate - No Clear Benefit, Rare Harm

 

WHAT ARE THE KEY STEPS TO ACUTE HYPERKALEMIA MANAGEMENT?

 https://en.wikipedia.org/wiki/Hyperkalemia

https://en.wikipedia.org/wiki/Hyperkalemia

  • Stabilize the cardiac myocytes with calcium gluconate/chloride

  • Shift K into the cells

    • Insulin and dextrose

    •  Albuterol

    • Sodium Bicarbonate

  • Get the K out of the body

    • Dialysis is the gold standard

    • Lasix

    • What about Kayexalate?


WHAT IS KAYEXALATE®/SODIUM POLYSTYRENE SULFONATE (SPS)?

kayexalate drug.jpg
  • Kayexalate/SPS is a resin
  • Binds potassium in the large intestines, it is excreted in the stool
  • Most formulations contain sorbitol
  • Approved by the FDA as a treatment for hyperkalemia in 1958 (4 years before manufacturers were required to prove safety and effectiveness of drug)
  • In 2009, citing reports of colonic necrosis, FDA issued a warning against use of sorbitol with SPS powder resin

o   Premixed Kayexalate suspension with 33% is excluded from FDA warning (common US formulation)


IS THERE EVIDENCE FOR USING SPS/KAYEXALATE TO TREAT HYPERKALEMIA?

There are no good studies and no good animal data that show efficacy of SPS or SPS/sorbitol in treatment of hyperkalemia in the acute setting


WHAT IS THE HARM OF GIVING KAYEXALATE/SPS?

  • Many case reports of colonic necrosis

  • McGowan CE, Saha S, Chu G, Resnick MB, Moss SF. Intestinal Necrosis due to Sodium Polystyrene Sulfonate (Kayexalate) in Sorbitol. Southern medical journal. 2009;102(5):493-497.

    •  11 cases of colonic necrosis associated with oral SPS/sorbitol at a single center over a nine-year period

    • Four fatalities

    • Some of these patients did receive the SPS with 33% sorbitol

  • Harel, Ziv, et al. "Gastrointestinal adverse events with sodium polystyrene sulfonate (Kayexalate) use: a systematic review." The American journal of medicine 126.3 (2013): 264-e9.

    • Systematic review, literature search 1948 to 2011

    • 30 reports describing 58 cases of injury to patients after receiving SPS with sorbitol (44) and SPS alone (17) 

    • 44 cases colonic injury (36 cases of transmural necrosis)

    • 33% mortality in colonic injure

  • Incidence of colonic necrosis is unclear but is likely very low in patients that receive SPS

    • 0.14% - 0.3% in some studies 

  • Sterns RH et al. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective? J Am Soc Nephrol. 2010 May;21(5):733-5.
    • “Clinicians must weigh uncontrolled studies showing benefit against uncontrolled studies showing harm.  It would be wise to exhaust other alternatives for hyperkalemia before turning to these largely unproven and potentially harmful therapies.”

 

Management of Hyperkalemia Summary

  • Give calcium
  • Give insulin, D50, albuterol and Sodium bicaronate 
  • Look for a reversible cause
  • Give NS – increased renal perfusion and renal excretion of K+
    • Consider loop diuretic
  • Call your nephrologist - Dialysis is the gold standard
 

tired of Reading?  Watch Dr. Nelson Review the Literature on the Efficacy of Using Kayexalate to Treat Hyperkalemia

 

Written by Sara Nelson, MD

Edited and Posted by Jeffrey A. Holmes, MD

          

Other FOAMed Resources

1.  Myths in Emergency Medicine: Kayexalate for Hyperkalemia Unproven and Ineffective with One Mean Side Effect.  Emergency Medicine News

2.  Is Kayexalate Useful in the Treatment of Hyperkalemia in the Emergency Department? on Rebel EM

3.  Is Kayexalate Useless? on EM Crit

4.  BE SKEPTICAL… EM MYTHS AND THEIR EVIDENCE on EM DOCS


REFERENCES

1.  Flinn RB et al. Treatment of the oliguric patient with a new sodium-exchange resin and sorbitol; a preliminary report. N Engl J Med. 1961 Jan 19;264:111-5.

2.  Scherr L et al. Management of hyperkalemia with a cation-exchange resin. N Engl J Med. 1961 Jan 19;264:115-9.

3. Gruy-Kapral C et al. Effect of single dose resin-cathartic therapy on serum potassium concentration in patients with end-stage renal disease. J Am Soc Nephrol. 1998 Oct;9(10):1924-30.

4.  McGowan CE, Saha S, Chu G, Resnick MB, Moss SF. Intestinal Necrosis due to Sodium Polystyrene Sulfonate (Kayexalate) in Sorbitol. Southern medical journal. 2009;102(5):493-497.

5.  Harel, Ziv, et al. "Gastrointestinal adverse events with sodium polystyrene sulfonate (Kayexalate) use: a systematic review." The American journal of medicine 126.3 (2013): 264-e9.

6.  Sterns RH et al. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective? J Am Soc Nephrol. 2010 May;21(5):733-5.