Kayexalate - No Clear Benefit, Rare Harm
/WHAT ARE THE KEY STEPS TO ACUTE HYPERKALEMIA MANAGEMENT?
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/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?
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.
10 patients with oliguria SPS or SPS/sorbitol
All received low potassium diet
Potassium fell by 0.5 mEq in a day and 1 mEq in 2 days
Scherr L et al. Management of hyperkalemia with a cation-exchange resin. N Engl J Med. 1961 Jan 19;264:115-9.
32 patients with renal failure given oral or rectal SPS
All received low potassium diet
Potassium fell by 1 mEq in one day
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.
Six patients with renal failure and normokalemia received SPS
No change in potassium at 12 hours
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.