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232 KAYEXALATE-ASSOCIATED COLONIC NECROSIS: A CASE REPORT AND REVIEW OF THE LITERATURE C Teshima, L Jewell, G Sandha AIM: Necrosis and ulceration of the gastrointestinal (GI) tract following oral/rectal administration of sodium polystyrene sulfonate (Kayexalate) in sorbitol is uncommon. We present a case report with endoscopic and histologic findings along with a review of the literature.
University of Alberta Hospital, Edmonton, Alberta
METHODS: A 75-yr-old woman was admitted to UAH with inflammatory arthritis and acute-on-chronic renal failure. She received 2 oral doses of Kayexalate for hyperkalemia and subsequently developed rectal bleeding. Colonoscopy revealed deep ulcers throughout her colon. Biopsy showed necrosis of the colonic mucosa with Kayexalate crystals. The rectal bleeding resolved spontaneously and colonoscopy confirmed ulcer healing. CMV inclusions were noted on the second endoscopy but were not felt to be clinically relevant. A literature search was performed on MEDLINE using the search terms: Kayexalate, sodium polystyrene sulfonate, sorbitol, intestinal necrosis, mucosal necrosis. Relevant articles were also obtained by cross-referencing the bibliography of identified papers.
RESULTS: Kayexalate is a cation-exchange resin used for the treatment of hyperkalemia. It is administered as a suspension in hypertonic sorbitol and facilitates the excretion of K+ in the stool. The first report of intestinal necrosis following Kayexalate administration was in 1987. Since then, there have been 3 small case series describing colonic necrosis after rectal administration and colonic and upper (GI) necrosis following oral administration. There have also been additional case reports. The patients described in these papers were ill, often requiring colectomy and had mortality rates in excess of 50%. Patients with upper GI involvement had better outcomes and were less likely to need surgery. A study in a rat model has shown that sorbitol, not Kayexalate, is in fact the cause of the intestinal necrosis. The mechanism by which sorbitol induces this intestinal necrosis is unknown although certain risk factors have been identified. Biopsy of affected areas reveals mucosal necrosis with deposits of Kayexalate crystals.
CONCLUSION: Intestinal necrosis following Kayexalate (in sorbitol) administration is a rare condition that may have significant morbidity and/or mortality. This therapy must be used with caution in ill patients who may be unable to withstand GI tract injury.