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:

1. Levine M, Nikkanen H, Palin DJ. The effects of intravenous calcium in patients with digoxin toxicity. J Emerg Med 2011;40:41-46.
2. 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.
3. Scherr L, Ogden DA, Mead AW, et al. Management of hyperkalemia with a cation-exchange resin. N Engl J Med 264: 115-9, 1961.
4. 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.
5. 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.
6. Mahoney BA, Smith WAD, Lo D, et al. Emergency interventions for hyperkalaemia (review).
   Cochcran Database of Systematic Reviews 2005, issue 3, 2009.
7. Kamel K, Wei C. Controversial issues in the treatment of hyperkalaemia. Nephrol Dial Transplant 18: 2215-8, 2003.
8. 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.
9. Nyirenda MJ, Tang JI, Padfield PL, Seckl JR. Hyperkalaemia. BMJ 339: 1019-24, 2009.
10. Bomback A, Woosley JT, Kshirsagar AV. Colonic necrosis due to sodium polystyrene sulfate (kayexalate). Am J of EM 27: 753.e1-753.e2, 2009.
11. Welsberg LS. Management of severe hyperkalemia. Crit Care Med 36: 3246-51, 2008.
12. 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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Scott Weingart

An ED Intensivist from NY.

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