J Korean Med Sci.  2009 Dec;24(6):1207-1211. 10.3346/jkms.2009.24.6.1207.

Colonic Mucosal Necrosis Following Administration of Calcium Polystryrene Sulfonate (Kalimate) in a Uremic Patient

• Joo M
• Bae WK
• Kim NH
• Han SR

• KMID: 1783158
• DOI: http://doi.org/10.3346/jkms.2009.24.6.1207

Abstract

Colonic necrosis is known as a rare complication following the administration of Kayexalate (sodium polystryrene sulfonate) in sorbitol. We report a rare case of colonic mucosal necrosis following Kalimate (calcium polystryrene sulfonate), an analogue of Kayexalate without sorbitol in a 34-yr-old man. He had a history of hypertension and uremia. During the management of intracranial hemorrhage, hyperkalemia developed. Kalimate was administered orally and as an enema suspended in 20% dextrose water to treat hyperkalemia. Two days after administration of Kalimate enema, he had profuse hematochezia, and a sigmoidoscopy showed diffuse colonic mucosal necrosis in the rectum and sigmoid colon. Microscopic examination of random colonic biopsies by two consecutive sigmoidoscopies revealed angulated crystals with a characteristic crystalline mosaic pattern on the ulcerated mucosa, which were consistent with Kayexalate crystals. Hematochezia subsided with conservative treatment after a discontinuance of Kalimate administration.

Keyword

Polystyrene Sulfonic Acid; Colon; Necrosis

MeSH Terms

Adult
Colon/*pathology
Gastrointestinal Hemorrhage/etiology
Humans
Hyperkalemia/drug therapy
Intestinal Mucosa/*pathology
Male
Necrosis/*chemically induced/complications/pathology
Polystyrenes/*adverse effects/therapeutic use
Uremia/*physiopathology

Figure

• 

  Fig. 1 A sigmoidoscopy shows diffuse ulceration with pseudomembrane formation in the entire sigmoid colon and rectum.

• 

  Fig. 2 Microphotographs of Kalimate crystals. (A, B) Angulated crystals are seen on the colonic mucosa and admixed within necroinflammatory exudates (H&E stain, ×100 and ×40). The crystals are basophilic on H&E stain (C, ×1,000) and blue on Diff-Quik stain (D, ×1,000). A characteristic crystalline mosaic pattern is better demonstrated with Diff-Quick staining (D).

• 

  Fig. 3 Microphotographs of the follow up colonic biopsy. (A) Colonic mucosa shows crypt regeneration and granulation tissue formation (H&E stain, ×40). (B) The remaining Kalimate crystal (arrow) shows a degenerative appearance with an irregular edge and surrounding inflammatory activity (H&E stain, ×200). (C) Small fragments of crystal are embedded in the inflamed granulation tissue (H&E stain, ×400), crystalloid appearances (arrows) of which are highlighted on Diff-Quick stain (D, ×400)

Reference

1. Lillemoe KD, Romolo JL, Hamilton SR, Pennington LR, Burdick JF, Williams GM. Intestinal necrosis due to sodium polystyrene (Kayexalate) in sorbitol enemas: clinical and experimental support for the hypothesis. Surgery. 1987. 101:267–272.

2. Rashid A, Hamilton S. 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. 21:60–69.

3. Kelsey PB, Chen S, Lauwers GY. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 37-2003. A 79-year-old man with coronary artery disease, peripheral vascular disease, end-stage renal disease, and abdominal pain and distention. N Engl J Med. 2003. 349:2147–2155.

4. Rogers FB, Li SC. Acute colonic necrosis associated with Sodium polystyrene sulfonate (Kayexalate) enemas in a critically ill patient: Case report and review of literature. J Trauma. 2001. 51:395–397.

5. 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. 36:607–609.

6. Abraham SC, Bhagavan BS, Lee LA, Rashid A, Wu TT. Upper gastrointestinal tract injury in patients receiving kayexalate (sodium polystyrene sulfonate) in sorbitol: clinical, endoscopic, and histopathologic findings. Am J Surg Pathol. 2001. 25:637–644.

7. Cheng ES, Stringer KM, Pegg SP. Colonic necrosis and perforation following oral sodium polystyrene sulfonate (Resonium A/Kayexalate) in a burn patient. Burns. 2002. 28:189–190.

8. Ponticelli C, Passerini P. Gastrointestinal complications in renal transplant recipients. Transpl Int. 2005. 18:643–650.

9. Komorowski RA, Cohen EB, Kauffman HM, Adams MB. Gastrointestinal complications in renal transplant recipients. Am J Clin Pathol. 1986. 86:161–167.