- Case Report
- Open Access
Sodium polystyrene sulfonate (Kayexalate) aspiration
© Gonzalez-Cuyar et al; licensee BioMed Central Ltd. 2008
- Received: 18 January 2008
- Accepted: 17 June 2008
- Published: 17 June 2008
In this short report we illustrate a case of extensive sodium polystyrene sulfonate (SPS) aspiration as an immediate cause of death in a terminally ill patient. SPS is a cation exchange resin utilized to decrease potassium levels in patients with renal failure. When administered rectally in conjunction with sorbitol, colonic necrosis and perforation have been documented. On the other hand, oral administration can be complicated by aspiration, especially in very ill or debilitated patients. In our current report, histological examination of a patient who aspirated SPS shows multiple polygonal to amorphous basophilic crystalline particles deposited intraalveolarly. The purpose of our report is to familiarize pathologists with the histologic features of this rare iatrogenic complication of therapy for hyperkalemia.
- Aspiration Pneumonia
- Ischemic Colitis
- Cation Exchange Resin
- Rectal Administration
We report a case of a 45 year-old male patient with a history of HIV, Hepatitis B, and Hepatitis C secondary to illicit drug use. He also suffered from end-stage renal disease with persistent hyperkalemia which was treated with hemodialysis. The patient was admitted for a total right hip arthroplasty as a treatment for severe osteoarthritis. On post operative day four the patient suffered changes in mental status, fever, and decreased saturations and was treated for a presumptive diagnosis of pneumonia. On post operative day nine potassium levels remained elevated and the patient was administered 15 grams of SPS solution orally. One hour later the patient developed poor saturations, was severely hypoxemic, deteriorated, and expired.
Post mortem gross examination revealed severe pulmonary congestion (right lung 1,260 grams; left lung 1,080 grams) with focal consolidations. There was no evidence of emboli and the airways were free of any gastric contents. Additional pertinent gross findings included a remote left ventricular infarct, cardiomegaly (680 grams), and hepatosplenomegaly (liver 2,240 grams; spleen 430 grams).
The administration of sodium polystyrene sulfonate (SPS) is used extensively for the treatment of hyperkalemia, especially in patients with renal failure [1–3]. Other uses have been reported, however [4–7]. SPS is an ion-exchange resin that exchanges Na+ for K+ in the gastrointestinal tract, especially in the colon, and increases the fecal excretion of potassium ions. It can be administered orally or rectally suspended in sorbitol, water, or dextrose. Historically, reports of ischemic colitis and colonic necrosis after rectal administration of SPS in sorbitol solution are abundant in the literature, but rare for the upper gastrointestinal tract [8–18]. Other complications such as thrombocytopenia  and rectal stenosis  have been reported. Administration of SPS suspended in dextrose or water has been suggested to avoid sorbitol related complications; however, recent reports have shown sorbitol-free SPS enemas to cause similar colonic catastrophes .
SPS aspiration is a potential complication of oral administration, especially in debilitated patients [22, 23]. One study reports an incidence of intestinal necrosis in 1.8% of post operative patients . The aspiration of SPS was first described by Oi  in 1978 in a post term hyperkalemic female infant with meconium aspiration. After a second oral administration the infant became cyanotic, bradycardic, apneic, and expired . The microscopic appearance of the intraalveolar material was then compared to a solution of 25% SPS which yielded similar histological features . In an animal model, Haupt et al  demonstrated that the inflammatory reaction following SPS aspiration is not solely attributed to concomitant aspiration of gastric contents.
The purpose of this report is to document a rare, often undiagnosed, and fulminant cause of death among patients with renal failure under the administration of potassium lowering agents. The particular appearance of SPS on histological sections should highlight it as a possible cause of aspiration pneumonia. In our patient, SPS aspiration superimposed on an already compromised pulmonary function was the immediate cause of death. Both methods of administration of the cation exchange resin have been proven effective, but rectal administration may prove beneficial in avoiding aspiration pneumonitis in chronically ill and debilitated patients.
The author's wish to thank Krista J. Szafranski MS, PA(ASCP) for her thoughtful review and important comments in the preparation of the manuscript.
- Gerstman BB, Platt R: Use of sodium polystyrene sulfonate in sorbitol in the United States, 1985–1989. Am J Kidney Dis. 1991, 18 (5): 619-20.View ArticlePubMedGoogle Scholar
- Osawa A, Okoshi M, Higuchi J, Yamayoshi W: [Treatment of hyperkalemia in renal insufficiency with cation exchange resin. Experience with use of sodium polystyrene sulfonate]. Hinyokika Kiyo. 1969, 15 (9): 645-51.PubMedGoogle Scholar
- Takasu T: [Treatment of hyperkalemia associated with renal insufficiency – clinical effects and side reactions of positive-ion-exchange resins, sodium polystyrene sulfonate (Kayexalate)]. Nippon Rinsho. 1970, 28 (7): 1941-6.PubMedGoogle Scholar
- Linakis JG, Hull KM, Lacouture PG, Lockhart GR, Lewander WJ, Maher TJ: Sodium polystyrene sulfonate treatment for lithium toxicity: effects on serum potassium concentrations. Acad Emerg Med. 1996, 3 (4): 333-7.View ArticlePubMedGoogle Scholar
- Linakis JG, Hull KM, Lacouture PG, Lockhart GR, Lewander WJ, Maher TJ: Enhancement of lithium elimination by multiple-dose sodium polystyrene sulfonate. Acad Emerg Med. 1997, 4 (3): 175-8.View ArticlePubMedGoogle Scholar
- Linakis JG, Savitt DL, Wu TY, Lockhart GR, Lacouture PG: Use of sodium polystyrene sulfonate for reduction of plasma lithium concentrations after chronic lithium dosing in mice. J Toxicol Clin Toxicol. 1998, 36 (4): 309-13.View ArticlePubMedGoogle Scholar
- Shepherd G, Klein-Schwartz W, Burstein AH: Efficacy of the cation exchange resin, sodium polystyrene sulfonate, to decrease iron absorption. J Toxicol Clin Toxicol. 2000, 38 (4): 389-94. 10.1081/CLT-100100948.View ArticlePubMedGoogle Scholar
- Bennett LN, Myers TF, Lambert GH: Cecal perforation associated with sodium polystyrene sulfonate-sorbitol enemas in a 650 gram infant with hyperkalemia. Am J Perinatol. 1996, 13 (3): 167-70.View ArticlePubMedGoogle Scholar
- Burnett RJ: Sodium polystyrene-sorbitol enemas. Ann Intern Med. 1990, 112 (4): 311-2.View ArticlePubMedGoogle Scholar
- Cheng ES, Stringer KM, Pegg SP: Colonic necrosis and perforation following oral sodium polystyrene sulfonate (Resonium A/Kayexalate in a burn patient. Burns. 2002, 28 (2): 189-90. 10.1016/S0305-4179(01)00099-7.View ArticlePubMedGoogle Scholar
- Gales MA, Gales BJ, Dyer ME, Orr SR: Rectally administered sodium polystyrene sulfonate. Am J Health Syst Pharm. 1995, 52 (24): 2813-5.PubMedGoogle Scholar
- Gardiner GW: Kayexalate (sodium polystyrene sulphonate) in sorbitol associated with intestinal necrosis in uremic patients. Can J Gastroenterol. 1997, 11 (7): 573-7.PubMedGoogle Scholar
- Gerstman BB, Kirkman R, Platt R: Intestinal necrosis associated with postoperative orally administered sodium polystyrene sulfonate in sorbitol. Am J Kidney Dis. 1992, 20 (2): 159-61.View ArticlePubMedGoogle Scholar
- Marion F, Joye F: [Polystyrene sodium sulfonate enema: with or without sorbitol?]. Presse Med. 1999, 28 (7): 338-PubMedGoogle Scholar
- Montagnac R, Mehaut S, Blaison D, Schillinger F: [Colonic necrosis caused by sodium polystyrene (kayexalate) in hemodialysis: myth or reality? Two case reports]. Nephrologie. 2002, 23 (3): 131-4.PubMedGoogle Scholar
- Rashid A, Hamilton SR: Necrosis of the gastrointestinal tract in uremic patients as a result of sodium polystyrene sulfonate (Kayexalate) in sorbitol: an underrecognized condition. Am J Surg Pathol. 1997, 21 (1): 60-9. 10.1097/00000478-199701000-00007.View ArticlePubMedGoogle Scholar
- Rogers FB, 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. 2001, 51 (2): 395-7.View ArticlePubMedGoogle Scholar
- Scott TR, Graham SM, Schweitzer EJ, Bartlett ST: Colonic necrosis following sodium polystyrene sulfonate (Kayexalate)-sorbitol enema in a renal transplant patient. Report of a case and review of the literature. Dis Colon Rectum. 1993, 36 (6): 607-9. 10.1007/BF02049870.View ArticlePubMedGoogle Scholar
- Mogi Y, Kura T, Takimoto R, Muto F, Maeda T, Muramatsu H, Niitsu Y: [Thrombocytopenia associated with sodium polystyrene sulfonate]. Rinsho Ketsueki. 1997, 38 (11): 1224-8.PubMedGoogle Scholar
- Chatelain D, Brevet M, Manaouil D, Yzet T, Regimbeau JM, Sevestre H: Rectal stenosis caused by foreign body reaction to sodium polystyrene sulfonate crystals (Kayexalate). Ann Diagn Pathol. 2007, 11 (3): 217-9. 10.1016/j.anndiagpath.2006.02.001.View ArticlePubMedGoogle Scholar
- Rugolotto S, Gruber M, Solano PD, Chini L, Gobbo S, Pecori S: Necrotizing enterocolitis in a 850 gram infant receiving sorbitol-free sodium polystyrene sulfonate (Kayexalate): clinical and histopathologic findings. J Perinatol. 2007, 27 (4): 247-9. 10.1038/sj.jp.7211677.View ArticlePubMedGoogle Scholar
- Chaplin AJ: Histologic occurrence of polystyrene sulfonates. Arch Pathol Lab Med. 1997, 121 (10): 1029-30.PubMedGoogle Scholar
- Idowu MO, Mudge M, Ghatak NR: Kayexalate (sodium polystyrene sulfonate) aspiration. Arch Pathol Lab Med. 2005, 129 (1): 125-PubMedGoogle Scholar
- Oi RH: The microscopic appearance of a sodium-potassium exchange resin in histologic sections. Am J Clin Pathol. 1978, 69 (3): 359-61.PubMedGoogle Scholar
- Haupt HM, Hutchins GM: Sodium polystyrene sulfonate pneumonitis. Arch Intern Med. 1982, 142 (2): 379-81. 10.1001/archinte.142.2.379.View ArticlePubMedGoogle Scholar
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