In EMCrit Podcast 32, we discussed the management of hyperkalemia. Of course, I recommended kayexalate (sodium polystyrene sulfonate) in the treatment regimen. It is standard of care, right? So I thought, until I heard a brilliant piece by Dr. Siamak (Mak) Moayedi, MD. Dr. Moayedi reviewed the evidence and he found nothing to indicate that kayexalate is effective for the acute management of elevated potassium.
This was too good not to share with you folks, so first I got permission from Amal Mattu (EKG deity). Dr. Mattu had interviewed Dr. Moayedi for this piece and had placed it on the February episode of his excellent EMcast podcast. I also got permission from Rick Nunez, MD who runs the incredible educational resource, EMEDhome.
For more from Dr. Moayedi, listen to his fantastic piece on how to teach procedures from Rob Roger's, EM:RAP Educators Edition.
References Mentioned in the Piece:
- Levine M, Nikkanen H, Palin DJ. The effects of intravenous calcium in patients with digoxin toxicity. J Emerg Med 2011;40:41-46.
- Sterns RH, Rojas M, Bernstein P, Chennupati S. Ion-exchange resins for the treatment of hyperkalemia: Are they safe and effective? J Am Soc Nephrol 21: 733-5, 2010.
- Scherr L, Ogden DA, Mead AW, et al. Management of hyperkalemia with a cation-exchange resin. N Engl J Med 264: 115-9, 1961.
- Flinn RB, Merrill JP, Welzan WR. Treatment of the oliguric patient with a new sodium ion exchange resin and sorbitol: A preliminary report. N Engl J Med 264: 111-5, 1961.
- Gruy-Kapral C, Emmett M, Santa Ana CA, et al. Effect of single dose resin-cathartic therapy on serum potassium concentration in patients with end-stage renal disease. J Am Soc Nephrol 9: 1924–30, 1998.
- Mahoney BA, Smith WAD, Lo D, et al. Emergency interventions for hyperkalaemia (review).
Cochcran Database of Systematic Reviews 2005, issue 3, 2009. - Kamel K, Wei C. Controversial issues in the treatment of hyperkalaemia. Nephrol Dial Transplant 18: 2215-8, 2003.
- Rogers BR, LI SC. Acute colonic necrosis associated with sodium polystyrene sulfonate (kayexalate) enemas in a critically ill patient: Case report and review of the literature. J Trauma 51: 395-7, 2001.
- Nyirenda MJ, Tang JI, Padfield PL, Seckl JR. Hyperkalaemia. BMJ 339: 1019-24, 2009.
- Bomback A, Woosley JT, Kshirsagar AV. Colonic necrosis due to sodium polystyrene sulfate (kayexalate). Am J of EM 27: 753.e1-753.e2, 2009.
- Welsberg LS. Management of severe hyperkalemia. Crit Care Med 36: 3246-51, 2008.
- Sood MM, Sood AR, Richardson R. Emergency management and commonly encountered outpatient scenarios in patients with hyperkalemia. Mayo Clin Proc 82: 1553-61, 2007.
Review
J Am Soc Nephrol. 2010 May;21(5):733-5. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective?
If you want to just hand the Gen Med Residents a Single Article:
Then I think this one by Sterns et al. is the one.
Update:
Systematic review of adverse events caused by kayexalate (The American Journal of Medicine Volume 126, Issue 3 , Pages 264.e9-264.e24, March 2013)
Here is the Audio:
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I love the revisiting of topics that we all take for granted on a daily basis. Kudos to Dr. Moayedi for turning on the light in an unused bedroom.
This is a very interesting discussion! I don’t think it matters if the patient is a dialysis patient or not. In the setting of hyperkalemia the patient generally either has a reversible cause for hyperK or else they are going to dialysis anyways. Examples of reversible causes would be some causes of acute renal failure, DKA, adrenal crisis, medication with K sparing diuretic, etc. In all of these cases you are either going to be able to fix the underlying problem, or the patient is going to go to dialysis anyways. Since we have effective therapies to treat hyperkalemia acutely the real question is can we use potassium/cation binding resin to reduce the need for dialysis in the group of patients who have potentially reversible cause for their hyperkalemia. I am not aware of any studies that suggest that kayexalate use in hyperkalemia reduces the need for dialysis, and since that is really the only thing I think may even be a possible theraputic target I don’t use it. In my own practice I treat hyperK mainly with calcium, insulin and glucose (perhaps bicarb for the significantly acidotic patient, occasionally with albuterol). If I believe the underlying cause can be… Read more »
good sense indeed! I wish someone would do a head to head kayexylate to lactulose.
Great review and I agree with everything said. It’s amazing that our practice is based on those poorly conducted studies. That being said, I can’t imagine I can stare at a potassium of 8.6 and not give kayexalate. Has anyone actually not given it?
I have not had the courage yet, Rahul.
I RARELY give it. I see no benefit and many potential harms.
If the inpatient team really wants it, they can order it.
If the renal guys are insistent and on their way with HD, then I order it but make no effort to make sure it happens. Usually the 15g I order never is given anyway. And 15g isn’t much.
HH
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Scott,
I enjoyed the kayexalate talk, but if I remember correctly, it was focused on hyperkalemic patients going (eventually) to dialysis. This is not generally the patients that I see. It’s not clear to me that kayexalate is “bad” for the more typical patient with, say, a K of 6.6, maybe some EKG changes, but not a dialysis patient, and unlikely to go to dialysis. Would you still forego the kayexalate on these folks?
Thanks.
Michael,
I think this is a very good point and I’ll tell you, I don’t know quite how to process this kayexalate stuff yet.
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Can u speak a little more re dog toxicity and ca? Levine a article as retrospective chart review leaves me un impressed with wushu washy conclusion that maybe it’s safe
Can u speak a little more re dog toxicity and ca? Levine a article as retrospective chart review leaves me un impressed with wushu washy conclusion that maybe it’s safe
all I can tell you is that there is no credible evidence of harm
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