Abstract Introduction Sodium polystyrene sulfonate (Kayexalate) is commonly used to treat hyperkalemia in patients with chronic and end-stage renal disease (ESRD), but its use can cause rare yet serious gastrointestinal complications, including ulceration, necrosis, and perforation. Although colonic injury is the most frequently reported complication, involvement of the small bowel and upper gastrointestinal tract is less recognized. We report a case of Kayexalate-induced jejunal necrosis in a young dialysis patient, highlighting the diagnostic challenge and clinical significance of this rare life-threatening complication. Description A 26-year-old man with refractory hypertension, diastolic heart failure, pulmonary hypertension, and ESRD on hemodialysis presented repeatedly with severe abdominal pain, nausea, and vomiting. Initial imaging revealed ileitis, raising suspicion for Crohn’s disease, however, serial CT scans and enterography were inconsistent with Crohn’s. Serial endoscopies demonstrated chronic gastritis, duodenitis, and gastric ulcers, while colonoscopy was unremarkable. Biopsies were negative for amyloid, lymphoma, celiac disease, H. pylori, and CMV. Given ongoing enteritis, he underwent rheumatologic and angiographic assessments for vasculitis and autoimmune disease and porphyria screening, which were all negative. Subsequent push enteroscopy identified severe jejunitis with ulceration, and histopathology revealed necroinflammatory exudates with kayexalate-type crystals. His recurrent abdominal pain led to missed dialysis sessions and hypertensive emergencies with hyperkalemia, for which he repeatedly received kayexalate. These findings raised concern for Kayexalate-induced intestinal necrosis, a rare but serious complication identified after an exhaustive diagnostic workup. Discussion Though it is rapidly becoming a second-line treatment, Kayexalate continues to be widely used for hyperkalemia management. Population-based studies and meta-analyses have demonstrated a significantly increased risk of ischemia, ulceration, and perforation, independent of renal function or comorbidities. The true incidence is likely underestimated, as diagnosis relies on pathological confirmation, and upper GI involvement is often underreported. Histopathologic identification of Kayexalate crystals within areas of mucosal injury remains the diagnostic hallmark but can be challenging due to variable morphology and misattribution to other etiologies. Given that mortality has been reported in up to 33% of cases, this case emphasizes the importance of maintaining a high index of suspicion for Kayexalate-induced injury in patients with unexplained abdominal pain and resin exposure. It also highlights the possible long-term health effects, patient safety, and deterioration in patient’s quality of life. This abstract is funded by: None
Umra et al. (Fri,) studied this question.