Kayexalate Colitis: Correlation of the Pathological, Clinical and Pharmacological Features

Kayexalate, a common therapy for hyperkalemia, has been implicated in bowel necrosis including cases of perforation and death. Despite the seriousness of this effect, the literature describing the pathological and clinical features is very limited, and the dose and time course of the Kayexalate administration is not well characterized. The goal of this study is to assess the association between Kayexalate and the development of bowel necrosis and to describe all cases of Kayexalate-associated injury encountered at our health system. Design: A retrospective review of electronic medical records was performed in a large health system over a six year period (2012- 2018). Clinical record was reviewed for all patients in whom Kayexalate crystals were identified in their pathology report. Patients were tabulated to analyze clinicopathological features, demographics and patient risk factors. Pharmacy records were reviewed to confirm drug administration and to assess time and number of doses. Results: 48 patients were identified to have Kayexalate crystals in their pathology report. Only 16 of those had drug administration confirmed in the pharmacy records, (Table 1). 14 were surgical cases and 2 were autopsy cases. The surgical cases all had ileocolonic involvement, while the autopsy cases were both upper GI. All but two cases had Kayexalate-associated injury, including ischemic-colitis pattern, active colitis, and ulcer. In the remaining two, both with multiple doses, crystals were associated with a tubular adenoma and gastric mucosa with no associated injury, respectively. The last dosage was within five days of procedure in 13 cases (80%). Conclusions: These findings highlight the complexity of Kayexalate diagnosis. Crystal deposition in the GI tract is sometimes a nonpathogenic, incidental finding. The 32 cases in which crystals resembling Kayexalate were found without record of drug administration raise the possibility that there may be unknown drug mimics. Autopsy data is a useful, under-recognized source of information that can be used to determine whether a finding can exist in asymptomatic patients. In our cases, crystals were more likely to be pathogenic when found in the colon and less likely when found in the stomach, but the number of doses did not correlate with extent of injur

Measuring What Matters: How the Laboratory Contributes Value in the Opioid Crisis

With over 20 years of the opioid crisis, our collective response has evolved to address the ongoing needs related to the management of opioid use and opioid use disorder. There has been an increasing recognition of the need for standardized metrics to evaluate organizational management and stewardship. The clinical laboratory, with a wealth of objective and quantitative health information, is uniquely poised to support opioid stewardship and drive valuable metrics for opioid prescribing practices and opioid use disorder (OUD) management. To identify laboratory-related insights that support these patient populations, a collection of 5 independent institutions, under the umbrella of the Clinical Laboratory 2.0 movement, developed and prioritized metrics. Using a structured expert panel review, laboratory experts from 5 institutions assessed possible metrics as to their relative importance, usability, feasibility, and scientific acceptability based on the National Quality Forum criteria. A total of 37 metrics spanning the topics of pain and substance use disorder (SUD) management were developed with consideration of how laboratory insights can impact clinical care. Monitoring these metrics, in the form of summative reports, dashboards, or embedded in laboratory reports themselves may support the clinical care teams and health systems in addressing the opioid crisis. The clinical insights and standardized metrics derived from the clinical laboratory during the opioid crisis exemplifies the value proposition of clinical laboratories shifting into a more active role in the healthcare system. This increased participation by the clinical laboratories may improve patient safety and reduce healthcare costs related to OUD and pain management