Elsevier

Human Pathology

Volume 35, Issue 6, June 2004, Pages 675-684
Human Pathology

Original contribution
Renal failure due to acute nephrocalcinosis following oral sodium phosphate bowel cleansing

https://doi.org/10.1016/j.humpath.2003.12.005Get rights and content

Abstract

Nephrocalcinosis is a chronic tubulointerstitial nephropathy characterized by tubular calcium phosphate deposition and slowly progressive renal insufficiency. We report a novel association of acute nephrocalcinosis and acute renal failure (ARF) with colonoscopy preceded by a bowel-cleansing regimen consisting of oral sodium phosphate solution (OSPS). A cohort of 5 patients (mean age, 69.2 years) had normal renal function (mean serum creatininem 0.9 mg/dL) before colonoscopy and presented with ARF (mean serum creatinine, 4.9 mg/dL) from 3 days to 2 months postcolonoscopy. Past medical history included hypertension in all 5 patients. Medications included an angiotensin-converting enzyme (ACE) inhibitor (ACE-I) or angiotensin receptor blocker (ARB) in 4 patients and diuretics in 2 patients. In all patients, colonoscopy was preceded by bowel cleansing with OSPS; OSPS was contraindicated in a single patient with hyperparathyroidism and was used at excessive doses in another. Renal biopsy specimens obtained from all 5 patients revealed diffuse tubular injury and abundant tubular deposition of calcium phosphate. Although the tubular injury involved all tubular segments, lectin and immunohistochemical staining disclosed calcium phosphate deposition confined to distal tubules and collecting ducts. At a mean of 5.8 weeks of postbiopsy follow-up, renal function was unchanged in 4 patients and mildly improved in 1 patient. We conclude that acute nephrocalcinosis is a seemingly rare complication of bowel cleansing with OSPS. The pathophysiology of acute nephrocalcinosis after treatment with OSPS likely involves transient hyperphosphatemia; volume depletion exacerbated by intercurrent ACE-I, ARB, and diuretic use; and elevated distal tubular phosphate and calcium concentrations. Greater awareness of this entity is needed to identify potential risk factors.

Section snippets

Case 1

A 69-year-old Caucasian male presented with nonoliguric ARF. Past medical history was significant for hypertension for 2 years, a recent history of carcinoma of the prostate treated with radiation seed implants, radiation proctitis, and mild hyperparathyroidism. The patient’s only medications were losartan 100 mg once a day (QD) and folic acid 1 mg QD. Laboratory evaluation performed 6 weeks before the development of ARF revealed a serum creatinine level of 1.2 mg/dL, calcium level of 10.1

Results

The clinical findings in the 5 patients with ARF after use of OSPS are summarized in Table 1. The cohort comprised 2 males and 3 females, with a mean age of 69.2 years. All 5 patients had a past medical history of hypertension, and 2 had diabetes mellitus. Of note, patient 1 also had a history of hyperparathyroidism, a relative contraindication to the use of OSPS, although he had no evidence of hypercalcemia before colonoscopy. At the time of colonoscopy, 4 of the 5 patients were receiving

Discussion

Fleet Phospho-soda (CB Fleet) is an over-the-counter OSPS that is used both as a laxative and as a purgative for bowel cleansing before colonoscopy. When used as a purgative, the recommended regimen consists of 2 45-mL doses taken 12 hours apart, the night before and the morning of the colonoscopy procedure. Each 45-mL bottle contains 18.8 g of monobasic sodium phosphate and 4.3 g of dibasic sodium phosphate. Given the relatively small volume of OSPS required and the resultant effects, which

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