Thank you for your letter and very appropriate comments regarding the use of resins. In our paper we report the results of a CQI project whereby we attempted to educate residents regarding a sequential and logical approach to treating hyperkalemia. While we completely agree with your comments, and the lack of evidence regarding the use of resins, we were faced with the pragmatic difficulty of “standard of care” in the context of a large medical service with multiple attending physicians. 

Since use of resins is still in common practice, irrespective of data to the contrary which you so elegantly describe, we sought not to change that practice, but rather to improve understanding of the need for a more logical step-wise approach to this common problem of hyperkalemia in hospitalized patients (in which use of any binder is unlikely a reasonable approach). 

As the data show there is a reduction in testing and use of interventional therapies when house staff have an algorithm to follow and have been educated. You are correct that the next step is to develop a non-resin-based intervention and test the utility of that in the context of this kind of initiative.

The real message is not about use of resins, but rather the systematic approach to the finding of elevated potassium in patients, and how to rationally care for them. Note that our data show a reduction in use of this intervention, as the real problem is that of understanding the usual transient nature of hyperkalemia in a hospital setting. Thank you for pointing out this important point, and we may well work on this as our next project!
—Adeera Levin, MD, FRCPC
Professor of Medicine and Head of the UBC Division of Nephrology
Executive Director, Provincial Renal Agency 
Secretary, General International Society of Nephrology