Adverse Gastrointestinal Effects with Kayexalate or Kalimate: A Comprehensive Review

Abstract

Background: Patients with hyperkalemia are commonly treated with Kayexalate or Kalimate. Both drugs are associated with some fatal gastrointestinal (GI) adverse events (AEs). Aim: To assess the clinical characteristics and outcomes of GI AEs induced by Kayexalate or Kalimate from published case reports. Methods: We conducted a systematic review of case reports of Kayexalate or Kalimateinduced GI AEs, from PubMed, Medline, Cochrane Library, Clinical Key, and Google Scholar databases (1948 to March 31, 2020). We analyzed the clinical characteristics, GI AEs, and risk factors of enrolled patients. Results: We identified 41 published articles describing 135 cases of GI AEs induced by Kayexalate (103 cases) or Kalimate (32 cases). The mean age of all patients was 55.5 years. Most patients were male (54.8%). As high as 55.6% preparations were administered with sorbitol whereas 44.4% preparations had no sorbitol. The average time causing GI AEs was 19.8 days. Colon was the most commonly affected site (76.3%). Drug crystals were histopathologically proven in 95.5% of the patients. Meanwhile, mortality was reported in 20.7%. Conclusion: Kayexalate or Kalimate, without or with sorbitol combination, may be related to fatal GI damage. Uremia, hypertension, and transplantation are predisposing factors. Clinicians should be careful in prescribing Kayexalate or Kalimate to patients.

Kalimate (calcium polystyrene sulfonate) and bowel perforation – a cause not to be ignored

“…The most common histopathological findings associated with CER use are intestinal wall ulcerations, necrosis and, less frequently, perforation [3] . Several theories tried to explain the pathogenesis of CERs associated gastrointestinal effects and accordingly to a recent in vitro study, the presence of these crystals can decrease the metabolic activity in situ, which is associated with a neutrophil and monocyte infiltrate, leading to mucosal necrosis.…”

“…Kalimate exchanges potassium ions in the intestine for calcium ions of the medicine, prompts potassium excretion and lowers blood level of potassium [2] . It can be administered orally, by rectal enema or via nasogastric tube [3] .…”

“…A recent study reviewed 135 cases of gastrointestinal adverse events induced by Kayexalate and Kalimate (103 and 32 cases respectively) and concluded that this pathology affects most commonly the colon (76.3%) and has a considerably mortality rate (20.7%) [3] . As mentioned above, the most affected gastrointestinal site is the colon, followed by the small intestine and duodenum, rectum and less frequently the upper gastrointestinal tract (stomach and esophagus) [3] . It may be related with the administration route, with the oral administration explaining the last two mentioned sites [2,4] .…”

“…There are several predisposing factors to develop the gastrointestinal consequences of CER administration, such us CKD, ESRD (end stage renal disease), hypertension, solid organ transplantation and immunosuppression, which can be in part related with the increased risk of developing hyperkalemia in this group of patients, and therefore the need of CER intake [2,3,5,6] .…”

“…There is a well-documented, although rare, relation between Kayexalato (SPS) with and without sorbitol and gastrointestinal adverse events [3,7] .…”