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Kayexalate Myths

Anand Swaminathan, MD FAAEM and Mel Herbert, MD MBBS FAAEM
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No me gusta!

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A renal patient who misses diaysis! That never happens and when it does they never come to the ED with serious problems. Can you smell the sarcasm? Smells like victory!

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Chris C., M.D. -

Calcium chloride acting faster than calcium gluconate is a myth see http://academiclifeinem.com/calcium-gluconate-vs-calcium-chloride-myth-busted/

Anand S., M.D. -

@ Chris - Just read this last week as well. Totally agree that the evidence we have shows that gluconate and chloride are equivalent in onset of action. Thanks!

DV -

Had a patient with K+ of 6.2 yesterday, no ECG changes. My staff wanted to give Ventolin, Kayexalate, and admit to medicine. I challenged her based on what I learned from this show. Her retort was that I needed to read up on my hyperkalemia management and read the following article:

Elliot MJ et al. Management of patients with acute hyperkalemia. CMAJ 2010.

There is a small mention of Kayexalate/Resins in this article, but they are clear in stating they found no studies demonstrating a benefit of Kayexalate. Didn't even mention the potentially fatal colonic necrosis part.

Needless to say I ended up getting a terrible evaluation at the end of my shift...

Thanks for this episode.

Anand S., M.D. -

This is the same response I get most of the time as well. I show them the literature and then watch them scratch their heads trying to figure out if they should stick with what some guy taught them in medical school or actual science.
Sorry if it hurt your evaluation.

Matthew T. -

Great summary! Now that kayexylate is of the list of therapeutic options, what are others using to to manage hyperkalemia in the otherwise asymptomatic patient? Yes we temporize with the shifters - insulin, bicarb, albuterol. Lasix? But what if they have poor renal function at baseline? I am not sure if nephrology is going to start dialyzing asymptomatic, non-dialysis patients with a K of 6.5. Thoughts?

Anand S., M.D. -

@ Matt, great point. If they still make urine, I give them fluids and see if the cause (ACEI, NSAIDs etc.) can be reversed. If they have significant renal dysfunction and new hyperkalemia with no other reversible cause, they likely will need dialysis soon.

Patrick V. -

Please add the Nephrology article link if possible.

Thanks! Great program!

PKV

Anand S., M.D. -

@ Patrick here are the original articles about kayexalate:
Flinn RB, Merrill JP, Welzant WR. Treatment of the oliguric patient with a new sodium-exchange resin and sorbitol; a preliminary report. N Engl J Med. 1961;264:111
Scherr L, Ogden DA, Mead AW, Spritz N, Rubin AL. Management of hyperkalemia with a cation-exchange resin. N Engl J Med. 1961;264:115.

Here are the more recent ones saying that it isn't so great
Gruy-Kapral C, Emmet M, Santa Nan 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 1998; 9:1924-1930.
Sterns RH et al. Ion-Exchange Resins for the Treatment of Hyperkalemia: Are They Safe and Effective? J Am Soc Nephrol 2010; 21: 733-5.
and their conclusions:
Conclusions: If kayexlate/sorbitol was brought to the FDA today, it would probably not gain approval as there is no proof of benefit or efficacy. “It would be wise to exhaust other alternatives for managing hyperkalemia before turning to these largely unproven and potentially harmful therapies.”

Sean G., M.D. -

I have always enjoyed a little Kayexalate and scrapple with my eggs in the morning....the perfect elixir after a night of a few too many Aussie beers....

Sunil S. -

One of our providers noted that we do not carry the sorbitol portion with Kayexalate. His question was whether it had the same risks as the Kayexalate/Sorbitol combination. Any thoughts?

Anand S., M.D. -

@ Sunil - check your drug content. I was under the impression that the resin is always paired with sorbitol. The reason is that resin causes concretions of feces and the sorbitol is needed to keep things moving. Because they are always paired, it's unclear which portion causes the colonic necrosis but it's likely the resin since sorbitol is used on its own.

Sunil S. -

Thanks, Anand.

Anand S., M.D. -

@ sunil. Need to retract prior statement. Checked my kayexalate at work and talked to pharmacy. Sorbitol was recently removed as the possible culprit in colonic necrosis so most kayexalate is only the SPS (the binder) which can cause concretions. Additionally, there have been reports of colonic necrosis on the SPS only.
Thanks!

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