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)

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

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.”

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