Cholestyramine-associated with severe, irreversible, hyperchloremic metabolic acidosis mortality: two related case studies

可利舒Cholestyramine引起嚴重不可逆高血氯代謝性酸中毒死亡：兩個相關病例的研究報告

Wen-Jen Tsai(蔡文仁) ； Ching-Hsiang Lu(盧慶祥) ； Jao-Hsien Wang(王堯顯) ； Cheng-Yao Chen(陳呈堯)

《內科學誌》 35卷5期 (2024/10) Pp. 389-394

https://doi.org/10.6314/JIMT.202410_35(5).07

摘要

Cholestyramine, a chlorinated anion exchange resin, acts as a bile acid sequestrant by forming an indigestible compound with bile acids. It effectively reduces diarrhea by sequestering the bile acid salts in the duodenum. However, the chloride ions of cholestyramine can exchange for bicarbonates (HCO_3^-) in the small intestine, which causes the loss of HCO_3^- and the increase level of free chloride reciprocally in the blood. Two elderly patients diagnosed with the stage 3a~4 of chronic kidney disease (CKD) were on the long-term respirator. These two patients suffered from severe diarrhea and were both treated with cholestyramine. A short course of cholestyramine treatment briefly alleviated patients' diarrhea condition but rapidly led to a more serious hyperchloremic metabolic acidosis (HCMA). Because both patients had a pre-existing CKD condition in conjunction with pneumonia, urosepsis, oliguric acute kidney failure (ARF), and chronic respiratory alkalosis due to long-term use of ventilator, the compensatory function for the HCO_3^- resorption in the kidney may be severely perturbed. The dysfunctional kidney function may further aggravate the cholestyramine-induced HCMA in these two patients. Without the renal dialysis, the conditions of these two patients worsened and eventually caused the death of these two patients. In conclusion, the use of cholestyramine for treating severe diarrhea needs to be cautious, especially for the high-risk patients having a pre-existing kidney disease.

關鍵字

Cholestyramine ； Resin ； Hyperchloremia ； Acidosis ； Hyperchloremic metabolic acidosis

並列摘要

可利舒（cholestyramine）是含氯離子（Cl^-）的交換樹脂，會在十二指腸結合膽酸形成不可分解的化合物，經由降低膽酸的作用而止瀉，而後經糞便排泄。可利舒的氯離子經由小腸吸收，而交換出碳酸氫根離子（HCO_3^-），使人體流失HCO_3^-而增加血中氯。慢性腎臟病stage3a～4期且長期呼吸器依賴的兩位老年病患發生嚴重腹瀉，在短期使用可利舒止瀉後，發生嚴重高血氯代謝性酸中毒。因慢性腎臟病且合併長期呼吸器依賴產生的呼吸性鹼中毒，加上後來病患得到院內感染肺炎、泌尿道感染致敗血症併發寡尿性急性腎衰竭等種種因素，讓正常腎臟HCO_3^-代償機制嚴重受阻，而使可利舒引發的嚴重高血氯代謝性酸中毒更難以大量碳酸氫鈉來中和。因病患久病而家屬拒絕洗腎，最後病患回天乏術。使用可利舒治療需小心謹慎及避免使用在高風險族群，特別是慢性腎臟病患者。