Summary Of Exposure |
A) USES: Sodium polystyrene sulfonate is used to enhance potassium excretion in the treatment of hyperkalemia.
B) TOXICOLOGY: The resin passes along the intestine or can be retained in the colon after administration by enema, the sodium ions are partially released and are replaced by potassium ions. Electrolyte imbalances including hypocalcemia, hypokalemia, hypomagnesia and significant sodium retention may occur during therapy with sodium polystyrene sulfonate.
C) EPIDEMIOLOGY: Sodium polystyrene sulfonate is commonly prescribed for the treatment of hyperkalemia.
D) WITH THERAPEUTIC USE
1) ADVERSE EFFECTS: Nausea, vomiting, colonic necrosis, anorexia, diarrhea, constipation, hypokalemia, hypocalcemia, hypomagnesemia, and sodium retention may occur. Intestinal obstruction from aluminum hydroxide concretions has occurred when administered in combination with sodium polystyrene sulfonate. GI necrosis has been documented in both the upper and lower GI tract, and the presence of sorbitol, along with sodium polystyrene sulfonate, may be an important factor in inducing necrosis. Weight gain, hypertension, hypernatremia, and worsening of left ventricular failure with congestive heart failure were reported in 2 patients with renal failure and congestive heart failure, following excessive sodium overload secondary to sodium polystyrene sulfonate therapy.
E) WITH POISONING/EXPOSURE
1) OVERDOSE: Sodium polystyrene sulfonate generally has minimal toxicity since it is a cation exchanger and is not absorbed. Medically significant hypokalemia is possible.
2) MILD TO MODERATE TOXICITY: Sodium polystyrene sulfonate aspiration has been reported in several patients; acute bronchitis and bronchopneumonia were reported in patients who had taken the resin by mouth.
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Cardiovascular |
3.5.2) CLINICAL EFFECTS
A) CONGESTIVE HEART FAILURE 1) WITH THERAPEUTIC USE a) SUMMARY: Because of significant sodium retention, especially in patients with impaired renal function, severe congestive heart failure and severe edema may occur (Prod Info sodium polystyrene sulfonate oral suspension, rectal suspension, 2012).
b) One report describes 2 renal failure patients with left ventricular failure, and one with associated right-sided failure, following excessive sodium overload secondary to sodium polystyrene sulfonate therapy. Total sodium load was estimated to be 590 to 1000 mEq over a 4 to 10 day period and resulted in weight gain, hypertension, hypernatremia, and worsening of left ventricular failure with congestive heart failure. In the case of a 19-year-old man, the sequelae were severe enough to contribute to the patient's death (Berlyne et al, 1966).
B) HYPERTENSIVE EPISODE 1) WITH THERAPEUTIC USE a) SUMMARY: Because of significant sodium retention, severe hypertension may occur in patients at risk (Prod Info sodium polystyrene sulfonate oral suspension, rectal suspension, 2012).
b) CASE REPORT: A 25-year-old woman with chronic glomerulonephritis and pyelonephritis developed gross peripheral edema and an increase in blood pressure to 190/130 mmHg from a baseline of 110/70 mmHg within 2 weeks of resin therapy. The patient experienced severe headaches and hypertensive encephalopathy with the elevated blood pressure (Berlyne et al, 1966).
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Respiratory |
3.6.2) CLINICAL EFFECTS
A) SUFFOCATING 1) WITH POISONING/EXPOSURE a) Two cases of sodium polystyrene sulfonate aspiration were reported, occurring in a 3-day-old neonate and a 4-year-old girl. Both patients had been administered sodium polystyrene sulfonate for hyperkalemia. The crystalline, plate-like particles in the alveoli showed a characteristic basophilic polygonal pattern without associated inflammation of the tissues. Fourier transform infrared microspectrophotometry confirmed the identity of the foreign-body material as sodium polystyrene sulfonate (Fenton et al, 1996).
b) Acute bronchitis and bronchopneumonia were reported in 3 patients who had taken the resin by mouth. At autopsy, particles of sodium polystyrene sulfonate were found in the lungs. Aspiration was not observed as a direct cause of death in these cases (Haupt & Hutchins, 1982).
B) ACUTE LUNG INJURY 1) WITH THERAPEUTIC USE a) CASE REPORT: An elderly, debilitated woman, with a history of COPD and heart disease, developed acute respiratory distress syndrome following the aspiration of a single dose (30 g) of sodium polystyrene sulfonate. Shortly after this episode, the patient had a sudden onset of hypoxemia and cardiac arrest followed. Cardiopulmonary resuscitation efforts were successful. There was also radiographic evidence of new pulmonary infiltrates and polystyrene sulfonate crystals in the alveoli. Despite supportive respiratory measures, the patient continued to be hypoxic (ie, oxygen saturation remained at 80 to 85%) and symptoms progressed to multiorgan failure and refractory shock. At this time, a decision was made to provide supportive care only with no further resuscitation efforts; the patient died a short time later (Duggal et al, 2014).
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Neurologic |
3.7.2) CLINICAL EFFECTS
A) CENTRAL NERVOUS SYSTEM FINDING 1) WITH THERAPEUTIC USE a) CASE REPORT: A 25-year-old woman with chronic glomerulonephritis and pyelonephritis developed gross peripheral edema and an increase in blood pressure to 190/130 mmHg from a baseline of 110/70 mmHg within 2 weeks of resin therapy. The patient experienced severe headaches and hypertensive encephalopathy with the elevated blood pressure (Berlyne et al, 1966).
b) RARE: Grand mal seizure has been reported in a patient with chronic hypocalcemia of renal failure given sodium polystyrene sulfonate with magnesium hydroxide (Prod Info sodium polystyrene sulfonate oral suspension, rectal suspension, 2012).
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Gastrointestinal |
3.8.2) CLINICAL EFFECTS
A) NAUSEA AND VOMITING 1) WITH THERAPEUTIC USE a) Nausea and vomiting may occur with therapeutic use (Prod Info sodium polystyrene sulfonate oral suspension, rectal suspension, 2012).
B) CONSTIPATION 1) WITH THERAPEUTIC USE a) Constipation (Prod Info sodium polystyrene sulfonate oral suspension, rectal suspension, 2012) and fecal impaction are not uncommon, and may be minimized by use of a laxative (Scherr et al, 1961).
C) DIARRHEA 1) WITH THERAPEUTIC USE a) Diarrhea may occur occasionally during treatment with sodium polystyrene sulfonate (Prod Info sodium polystyrene sulfonate oral suspension, rectal suspension, 2012).
D) NECROSIS 1) WITH THERAPEUTIC USE a) Necrosis of the gastrointestinal tract caused by sodium polystyrene sulfonate in sorbitol is well documented in uremic patients (Daram et al, 2012; Rogers & Li, 2001; Dardik et al, 2000; Scott et al, 1993) (Gerstman et al, 1992) (Wootton, 1989) (Lillemoe et al, 1987). In some cases, this effect can lead to death, and is thought to be under recognized and under reported (Rashid & Hamilton, 1997). Necrosis has been documented in both the upper and lower GI tract, and the presence of sorbitol, along with sodium polystyrene sulfonate, is apparently an important factor in inducing necrosis (Rashid & Hamilton, 1997). b) UPPER GI NECROSIS 1) CASE REPORT: A 59-year-old woman with end-stage renal disease on chronic hemodialysis and receiving Kayexalate(R) oral suspension presented with coffee-ground emesis. Endoscopy revealed that the mucosa of the gastric body was ulcerated with oozing of fresh blood. Acid-fast staining revealed dark purple crystals consistent with Kayexalate(R) crystals. Long-term opiates in this case may have contributed (ie, a decrease in gastric motility) to an increase in mucosal contact time with Kayexalate(R) (Daram et al, 2012).
2) MIXED NECROSIS: Roy-Chaudhury et al (1997) reported combined gastric and ileocecal toxicity (serpiginous ulcers) following the oral use of sodium polystyrene sulfonate in sorbitol. The authors suggested that sorbitol rather than Kayexalate is toxic to bowel mucosa, causing colonic necrosis.
c) COLONIC NECROSIS 1) COLONIC NECROSIS was described in 5 uremic patients who received sodium polystyrene sulfonate (Kayexalate(R)) in sorbitol enemas, with 4 of these patients eventually dying. Extensive ischemic necrosis was present in all specimens as well as Kayexalate(R) crystals in the intestinal lumen (Lillemoe et al, 1987).
2) CASE REPORT: A case of colonic necrosis associated with the administration of Kayexalate(R) and sorbitol enemas in a 48-year-old white man with end-stage renal disease, secondary to rapidly progressive glomerulonephritis, has been reported. The patient had been given a Kayexalate(R) enema (50 mg in 200 mL 20% sorbitol) upon admission to the hospital to lower his serum potassium (6.1 mmol/L) prior to kidney transplant surgery. The procedure was uneventful, however, the serum potassium had remained elevated at 6.7 mmol/L necessitating the administration of 3 additional resin enemas. Complications led to the removal of a 58 cm of colon. After a difficult hospital course, the patient was eventually discharged (Wootton et al, 1989). A similar case was reported by other authors (Scott et al, 1993).
3) In one case report, the colonic necrosis extended down to the anal verge, a richly vascularized area of the colon usually not prone to ischemia (Rogers & Li, 2001).
E) INTESTINAL OBSTRUCTION 1) WITH THERAPEUTIC USE a) CASE REPORT: A 54-year-old man was successfully resuscitated following a history of constrictive effusive metastatic pericarditis secondary to lung cancer, but developed acute renal failure. Hyperkalemia was treated with insulin, beta agonists, and 30 g of sodium polystyrene sulfonate (sorbitol free) 3 to 4 times daily for 10 days via a nasogastric tube. Hemodialysis was considered but it was determined that the patient was too hemodynamically unstable. On day 12, the patient died. Upon postmortem examination, a huge nonobstructive bezoar was found in the stomach (ie, the stomach was dilated but not damaged) and diagnosed as a sodium polystyrene sodium bezoar. Although the exact mechanism remained unknown, decreased gastric mobility secondary to mesenteric ischemia, reduced gastric secretions leading to crystallization, high dose of therapy, and redissolution of sodium polystyrene solution were suggested as possible causes of upper gastrointestinal injury in a critically ill patient (Croitoru et al, 2015).
b) CASE REPORT: Intestinal obstruction due to a medication bezoar has been reported in a 27-year-old woman receiving a total of 200 g of sodium polystyrene resin and 30 to 60 mL of aluminum hydroxide suspension every hour for 5 days. Surgical removal of the solid concretion in the small bowel was required in the management of this patient (Townsend et al, 1973).
F) LOSS OF APPETITE 1) WITH THERAPEUTIC USE a) Anorexia may occur with therapeutic use (Prod Info sodium polystyrene sulfonate oral suspension, rectal suspension, 2012).
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Acid-Base |
3.11.2) CLINICAL EFFECTS
A) ALKALOSIS 1) WITH THERAPEUTIC USE a) CASE REPORT: A 49-year-old man with chronic glomerulonephritis became severely alkalotic after the administration of magnesium hydroxide and sodium polystyrene sulfonate combination therapy. While on magnesium hydroxide alone, the patient's acid-base balance was stable, but 1 day following initiation of resin therapy, the CO2 content rose greater than 40 mEq/L. Magnesium hydroxide was discontinued and serum CO2 content values returned to near baseline. It was suggested that the metabolic disturbance was due to magnesium binding to the resin resulting in excess sodium bicarbonate being reabsorbed, thus leading to metabolic alkalosis (Zeissman, 1976).
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