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Leventoğlu E, Büyükkaragöz B, Gönül İI, Fidan K, Öğüt B, Söylemezoğlu O, Bakkaloğlu SA, Buyan N. An unusual cause of elevated serum creatinine after kidney transplantation in an adolescent: Answers. Pediatr Nephrol 2022; 37:1021-1025. [PMID: 34999982 DOI: 10.1007/s00467-021-05379-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/09/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Emre Leventoğlu
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey.
| | - Bahar Büyükkaragöz
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | | | - Kibriya Fidan
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Betül Öğüt
- Department of Pathology, Gazi University, Ankara, Turkey
| | - Oğuz Söylemezoğlu
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Sevcan A Bakkaloğlu
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Necla Buyan
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey
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Medina-Liabres KRP, Kim BM, Kim S. Biopsy-proven acute phosphate nephropathy: A case report. World J Clin Cases 2020; 8:2585-2589. [PMID: 32607335 PMCID: PMC7322417 DOI: 10.12998/wjcc.v8.i12.2585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acute phosphate nephropathy (APN) is a disease that can occur when exposed to high doses of phosphate. The most common cause of APN is the use of oral sodium phosphate for bowel cleansing preparations. However, there are other less commonly known sources of phosphate that are equally important. To date, our literature search did not identify any report of excessive dietary phosphate as a cause of APN.
CASE SUMMARY We report an unusual case of a 39-year-old diabetic male who presented with epigastric pain and oliguria. Work-up showed elevated serum creatinine, potassium, and calcium-phosphate product, and metabolic acidosis. The patient was admitted in the intensive care unit and received emergent renal replacement therapy. Kidney biopsy revealed tubular cell injury with transparent crystal casts positive for Von Kossa staining, which established the diagnosis of APN.
CONCLUSION This case confirmed that APN may occur with other sources of phosphorus, highlighting the importance of good history taking and kidney biopsy in patients with predisposing factors for APN. Raising awareness on the possibility of APN and its timely recognition and management is imperative so that appropriate measures can be instituted to prevent or delay its progression to end stage renal disease.
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Affiliation(s)
| | - Bo Mi Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si 13620, Gyeonggi-do, South Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si 13620, Gyeonggi-do, South Korea
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Abstract
Importance Chronic kidney disease (CKD) is the 16th leading cause of years of life lost worldwide. Appropriate screening, diagnosis, and management by primary care clinicians are necessary to prevent adverse CKD-associated outcomes, including cardiovascular disease, end-stage kidney disease, and death. Observations Defined as a persistent abnormality in kidney structure or function (eg, glomerular filtration rate [GFR] <60 mL/min/1.73 m2 or albuminuria ≥30 mg per 24 hours) for more than 3 months, CKD affects 8% to 16% of the population worldwide. In developed countries, CKD is most commonly attributed to diabetes and hypertension. However, less than 5% of patients with early CKD report awareness of their disease. Among individuals diagnosed as having CKD, staging and new risk assessment tools that incorporate GFR and albuminuria can help guide treatment, monitoring, and referral strategies. Optimal management of CKD includes cardiovascular risk reduction (eg, statins and blood pressure management), treatment of albuminuria (eg, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers), avoidance of potential nephrotoxins (eg, nonsteroidal anti-inflammatory drugs), and adjustments to drug dosing (eg, many antibiotics and oral hypoglycemic agents). Patients also require monitoring for complications of CKD, such as hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia. Those at high risk of CKD progression (eg, estimated GFR <30 mL/min/1.73 m2, albuminuria ≥300 mg per 24 hours, or rapid decline in estimated GFR) should be promptly referred to a nephrologist. Conclusions and Relevance Diagnosis, staging, and appropriate referral of CKD by primary care clinicians are important in reducing the burden of CKD worldwide.
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Affiliation(s)
- Teresa K Chen
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Daphne H Knicely
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Morgan E Grams
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Hoffmanová I, Kraml P, Anděl M. Renal risk associated with sodium phosphate medication: safe in healthy individuals, potentially dangerous in others. Expert Opin Drug Saf 2015; 14:1097-110. [DOI: 10.1517/14740338.2015.1044970] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Robijn S, Vervaet BA, D’Haese PC, Verhulst A. Evaluation of intestinal phosphate binding to improve the safety profile of oral sodium phosphate bowel cleansing. PLoS One 2015; 10:e0116590. [PMID: 25790436 PMCID: PMC4366239 DOI: 10.1371/journal.pone.0116590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 12/11/2014] [Indexed: 01/16/2023] Open
Abstract
Prior to colonoscopy, bowel cleansing is performed for which frequently oral sodium phosphate (OSP) is used. OSP results in significant hyperphosphatemia and cases of acute kidney injury (AKI) referred to as acute phosphate nephropathy (APN; characterized by nephrocalcinosis) are reported after OSP use, which led to a US-FDA warning. To improve the safety profile of OSP, it was evaluated whether the side-effects of OSP could be prevented with intestinal phosphate binders. Hereto a Wistar rat model of APN was developed. OSP administration (2 times 1.2 g phosphate by gavage) with a 12h time interval induced bowel cleansing (severe diarrhea) and significant hyperphosphatemia (21.79 ± 5.07 mg/dl 6h after the second OSP dose versus 8.44 ± 0.97 mg/dl at baseline). Concomitantly, serum PTH levels increased fivefold and FGF-23 levels showed a threefold increase, while serum calcium levels significantly decreased from 11.29 ± 0.53 mg/dl at baseline to 8.68 ± 0.79 mg/dl after OSP. OSP administration induced weaker NaPi-2a staining along the apical proximal tubular membrane. APN was induced: serum creatinine increased (1.5 times baseline) and nephrocalcinosis developed (increased renal calcium and phosphate content and calcium phosphate deposits on Von Kossa stained kidney sections). Intestinal phosphate binding (lanthanum carbonate or aluminum hydroxide) was not able to attenuate the OSP induced side-effects. In conclusion, a clinically relevant rat model of APN was developed. Animals showed increased serum phosphate levels similar to those reported in humans and developed APN. No evidence was found for an improved safety profile of OSP by using intestinal phosphate binders.
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Affiliation(s)
- Stef Robijn
- Laboratory of Pathophysiology, University of Antwerp, Antwerp, Belgium
| | | | | | - Anja Verhulst
- Laboratory of Pathophysiology, University of Antwerp, Antwerp, Belgium
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Abstract
Oral sodium phosphate (OSP) solution is commonly used as bowel purgative before colonoscopy. Its safety has recently been questioned with several reports of acute renal failure and chronic kidney disease following its use. All of the cases reported are following bowel preparation for colonoscopy. I present a case of acute renal failure following OSP solution given to relieve constipation. This report further highlights the dangers of OSP and the importance of caution and careful monitoring when OSP solution is used as a cathartic, or for bowel preparation before colonoscopy.
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Affiliation(s)
| | - Malvinder S Parmar
- Northern Ontario School of Medicine, Laurentian & Lakeland Universities, Ontario, P3E 2C6, Canada
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A murine model of phosphate nephropathy. THE AMERICAN JOURNAL OF PATHOLOGY 2011; 178:1999-2006. [PMID: 21514417 DOI: 10.1016/j.ajpath.2011.01.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 01/05/2011] [Accepted: 01/07/2011] [Indexed: 01/16/2023]
Abstract
We established a murine model of phosphate nephropathy with secondary hyperparathyroidism. db/db mice, which develop obesity and type 2 diabetes mellitus, were uninephrectomized at the age of 6 weeks and were fed either standard chow or a phosphorus-rich diet during the next 8 weeks. Thereafter, renal cryosections showed abundant tubular casts with a strong histochemical von Kossa reaction in all db/db mice on the phosphorus-rich diet but none in the controls. X-ray diffraction and Raman spectroscopy proved that these tubular casts consist mostly of hydroxyapatite Ca₅(PO₄)₃(OH). These intraluminal precipitations were located in distal tubuli and collecting ducts and were associated with degenerative tubular changes and peritubular infiltration of T cells and macrophages. In line, kidneys of db/db mice on the phosphorus-rich diet displayed significantly increased mRNA expression of the T(H)1 cytokines interferon γ, IL-6, and tumor necrosis factor α. In addition, mice developed signs of secondary hyperparathyroidism as shown by elevated serum phosphate, decreased serum calcium, and increased parathyroid hormone, osteopontin, and fibroblast growth factor 23 levels. db/db mice on the phosphorus-rich diet also presented with significantly lower body weight, lower homeostasis model assessment of insulin resistance index, and hypertrophic cardiomyopathy. Thus, we provide a murine model of phosphate nephropathy and secondary hyperparathyroidism, which can be used for future pharmacologic and pathophysiologic studies to analyze the effect of hyperphosphatemia on renal, metabolic, and cardiovascular phenotypes.
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El-Husseini A, Sabucedo A, Lamarche J, Courville C, Peguero A. Acute kidney injury associated with tumor lysis syndrome: a paradigm shift. Am J Emerg Med 2011; 30:390.e3-6. [PMID: 21296524 DOI: 10.1016/j.ajem.2010.12.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 12/18/2010] [Indexed: 01/21/2023] Open
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Pálmadóttir VK, Gudmundsson H, Hardarson S, Arnadóttir M, Magnússon T, Andrésdóttir MB. Incidence and outcome of acute phosphate nephropathy in Iceland. PLoS One 2010; 5:e13484. [PMID: 20976065 PMCID: PMC2957439 DOI: 10.1371/journal.pone.0013484] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 09/23/2010] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Oral sodium phosphate solutions (OSPS) are widely used for bowel cleansing prior to colonoscopy and other procedures. Cases of renal failure due to acute phosphate nephropathy following OSPS ingestion have been documented in recent years, questioning the safety of OSPS. However, the magnitude of the problem remains unknown. METHODOLOGY/PRINCIPAL FINDINGS We conducted a population based, retrospective analysis of medical records and biopsies of all cases of acute phosphate nephropathy that were diagnosed in our country in the period from January 2005 to October 2008. Utilizing the complete official sales figures of OSPS, we calculated the incidence of acute phosphate nephropathy in our country. Fifteen cases of acute phosphate nephropathy were diagnosed per 17,651 sold doses of OSPS (0.085%). Nine (60%) were women and mean age 69 years (range 56-75 years). Thirteen patients had a history of hypertension (87%) all of whom were treated with either ACE-I or ARB and/or diuretics. One patient had underlying DM type I and an active colitis and one patient had no risk factor for the development of acute phosphate nephropathy. Average baseline creatinine was 81.7 µmol/L and 180.1 at the discovery of acute renal failure, mean 4.2 months after OSPS ingestion. No patient had a full recovery of renal function, and at the end of follow-up, 26.6 months after the OSPS ingestion, the average creatinine was 184.2 µmol/L. The average eGFR declined from 73.5 ml/min/1.73 m(2) at baseline to 37.3 ml/min/1.73 m(2) at the end of follow-up. One patient reached end-stage renal disease and one patient died with progressive renal failure. CONCLUSION/SIGNIFICANCE Acute phosphate nephropathy developed in almost one out of thousand sold doses of OSPS. The consequences for kidney function were detrimental. This information can be used in other populations to estimate the impact of OSPS. Our data suggest that acute phosphate nephropathy may be greatly underreported worldwide.
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Abstract
Efficient cleansing of the colon before a colonoscopy or a radiological examination is essential. The osmotically acting cathartics (those given the Anatomical Therapeutic Chemical code A06AD) currently used for this purpose comprise products based on three main substances: sodium phosphate, combinations of polyethylene glycol and electrolyte lavage solutions (PEG-ELS), and magnesium citrate. All these preparations give adequate cleansing results and have similar profiles in terms of the frequency and type of mild to moderate adverse effects. However, serious adverse events, such as severe hyperphosphatemia and irreversible kidney damage owing to acute phosphate nephropathy, have been reported after use of sodium-phosphate-based products. The aim of this Review is to provide an update on the potential safety issues related to the use of osmotically acting cathartics, especially disturbances of renal function and water and electrolyte balance. The available evidence indicates that PEG-ELS-based products are the safest option. Magnesium-citrate-based, hypertonic products should be administered with caution to elderly individuals and patients who are prone to develop disturbances in water and electrolyte balance. Sodium-phosphate-based products can occasionally cause irreversible kidney damage and should not be routinely used in bowel-cleansing procedures.
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Abstract
Acute phosphate nephropathy (APhN) is a clinical pathological entity characterized by acute and subsequent chronic renal failure following exposure to oral sodium phosphate (OSP) bowel purgatives. Renal biopsy findings include acute and chronic tubular injury with prominent tubular and interstitial calcium phosphate deposits. Risk factors for APhN include older age, female gender, hypertension, chronic kidney disease (CKD), and treatment with angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics. The pathomechanism of APhN involves hypovolemia-induced avid proximal salt and water reabsorption, delivery of a large phosphate load to the distal nephron, and precipitation of calcium phosphate in the distal tubule and collecting duct. To date, 37 cases of biopsy-proven APhN have been reported, and epidemiologic studies have produced inconsistent results regarding the incidence of acute kidney injury (AKI) following the use of OSP purgatives. OSP solution was withdrawn from the market in December of 2008, but OSP tablets, offered by prescription only, remain available. Prevention of APhN is best achieved by avoiding OSP in high-risk patients, aggressive hydration before, during, and after OSP administration, minimizing the dose of OSP, and maintaining a minimum of a 12 h interval between OSP administrations.
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