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Case Report

A brief grief over bowel relief

[version 1; peer review: 2 approved]
PUBLISHED 29 Jan 2013
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OPEN PEER REVIEW
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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.

Case report

A 72-year-old woman with essentially unremarkable past medical history fell and sustained back injury and was noted to have a T11 compression fracture without any neurovascular compromise. The patient received Tylenol#3 for pain relief and was sent home. A few days later, she returned with ongoing vague lower back and abdominal discomfort and was noted to be constipated. Tylenol#3 was stopped and she was given a laxative - oral sodium phosphate solution (OSP, 45 ml, Pharmascience, Montreal, Canada) to treat constipation.

Three days later, she returned to the local emergency department with feeling of generalized weakness, numbness around her lips, ongoing vague abdominal discomfort and nausea, but denied vomiting or diarrhea. Her intake had been poor since the fall and she noted decreased urine output. There is no history of diabetes or hypertension. Her medication was rabeprazole 20 mg a day and acetaminophen as required.

Investigations at the local emergency department revealed low hemoglobin of 109 g/L, normal white blood cell count WBC of 4.5, elevated blood urea nitrogen BUN of 9.4 mmol/L with serum creatinine of 345 μmol/L, and serum potassium of 3.4 mmol/L. The old records showed that her BUN was 6.1 mmol/L with serum creatinine of 74 μmol/L in December 2007. She was transferred for further management of acute renal failure.

Physical examination was remarkable for a woman of stated age with mild decreased skin turgor, blood pressure of 106/60 mmHg without orthostatic changes and regular rate of 72 beats per minute. Lungs were clear and heart sounds were normal. Abdominal examination revealed a soft abdomen with mild diffuse tenderness without rebound. There were no masses, renal angle fullness or tenderness. There was mild tenderness in the lower thoracic area. There was no pedal edema and neurological examination was non-focal. She had a Foley catheter with small amount of concentrated urine in the bag.

Investigations in our emergency department revealed low hemoglobin of 112 g/L, normal WBC of 4.9, elevated BUN of 9.4 mmol/L with serum creatinine of 419 μmol/L, serum potassium of 3.4 mmol/L, low serum calcium of 1.85 mmol/L (2.02–2.60 mmol/L) with serum albumin of 36 g/L, low ionized calcium of 0.85 mmol/L (1.15–1.29 mmol/L) and elevated phosphate of 3.68 mmol/L (0.87–1.45 mmol/L) and creatine kinase [CK] of 349. A urinalysis showed a concentrated urine with specific gravity of >1.030, 1+ protein and trace of blood with few white and red blood cells with few hyaline casts. Random urine sodium was 64 mmol/L with urine creatinine of 5330 μmol/L. A urine culture was negative. An abdominal ultrasound showed normal size kidneys without obstruction. The hospital course is shown in Table 1.

Table 1. Showing the hospital course of the patient.

Normal range9-months beforeDay 1Day 2Day 5Day 10Day 21
BUN2.6–7.7 mmol/L6.19.911.3Hemodialysis × 26.4
Serum creatinine35–97 μmol/L7441948667520098
Serum potassium3.6–5.0 mmol/L3.63.8
Serum calcium2.02–2.60 mmol/L1.851.661.922.202.24
Ionized calcium1.15–1.29 mmol/L0.850.941.071.16
Serum albumin38–46 g/L3338
Serum Phosphate0.87–1.45 mmol/L3.683.593.391.121.18

This patient presented with acute kidney injury (AKI) and the differential diagnosis included ischemic acute tubular necrosis (poor intake, decreased skin turgor, FENa of 3.78%), rhabdomyolysis (history of fall, elevated phosphate). The likelihood of vasculitic process was low in view of bland urine sediment and negative antinuclear and anti-neutrophilic cytoplasmic antibodies. However, significant hyperphosphatemia and hypocalcemia within 72-hours of standard dose (45 ml) of OSP [21.6 gm of monobasic sodium phosphate monohydrate and 8.1 gm of dibasic sodium phosphate heptahydrate] suggests the high probability of acute phosphate nephropathy (APN)1 that results from deposition of calcium-phosphate crystals in renal tubules and parenchyma (nephrocalcinosis)2. A kidney biopsy confirmed findings of acute phosphate nephropathy with acute tubular necrosis (Figure 1). She required supportive dialysis treatment twice.

c85e7ea1-66bb-4abc-818d-06890c3b0a0c_figure1.gif

Figure 1. Kidney biopsy – showing numerous tubules with calcification (black arrows) (PAS stain, magnification x100) [Courtesy: Andrew Herzenberg (deceased) and John Rohan, University Health Network, Toronto, Ontario, Canada].

Discussion

OSP solution is commonly used as a bowel purgative before colonoscopy3. Its safety has recently been questioned15 with several reports of AKI and chronic kidney disease following its use. All of the cases reported occurred after bowel preparation with OSP for colonoscopy but AKI in this woman occurred after its use to relieve constipation. Decreased kidney function, use of renin angiotension aldosterone system (RAAS) blockers and older age and female gender are the most probable risk factors for APN, but other contributing factors are - use of non-steroidal anti-inflammatory agents, diuretics, history of hypertension, diabetes or heart failure35. Women, because of their smaller body mass, are more sensitive to fluid loss. Adequate fluid intake4 is important to prevent AKI when OSP is used as a bowel purgative. Poor oral intake since the fall in this woman likely contributed to both ATN and APN after OSP use. Although most patients recover renal function, some may have persistent chronic kidney disease4.

This report further highlights the need for vigilance when using OSP solutions for bowel preparation or to relieve constipation. Alternative solutions should be considered, especially in elderly and high-risk individuals5.

Key Points

1. Consider acute phosphate nephropathy in the presence of acute renal dysfunction, hyperphosphatemia and hypocalcemia.

2. Consider alternate agents to oral phosphate solutions for bowel preparation or for relief of constipation, especially in elderly patients and in patients with chronic kidney disease.

3. Ensure adequate hydration, if and when these agents (OSP) are used.

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Parmar KS and Parmar MS. A brief grief over bowel relief [version 1; peer review: 2 approved]. F1000Research 2013, 2:26 (https://doi.org/10.12688/f1000research.2-26.v1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 29 Jan 2013
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3
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Reviewer Report 05 Nov 2013
Luan D. Trong, Houston Methodist Research Institute, Houston, TX, USA 
Approved
VIEWS 3
In this manuscript entitled “A Brief Grief over Bowel Relief,” by K.S. Parmar and M.S. Parmar, the authors describe a patient with acute renal failure after oral sodium phosphate administration for constipation.

As the authors mentioned, this type of renal failure ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
D. Trong L. Reviewer Report For: A brief grief over bowel relief [version 1; peer review: 2 approved]. F1000Research 2013, 2:26 (https://doi.org/10.5256/f1000research.1178.r2323)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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5
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Reviewer Report 18 Mar 2013
Christina Yuan, Walter Reed Army Medical Center, Washington, DC, USA 
Approved
VIEWS 5
This is a case report of acute kidney injury (requiring dialysis) after use of OSP for constipation in an elderly woman. The patient had a kidney biopsy demonstrating findings consistent with acute phosphate nephropathy. This is a valuable reminder that ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Yuan C. Reviewer Report For: A brief grief over bowel relief [version 1; peer review: 2 approved]. F1000Research 2013, 2:26 (https://doi.org/10.5256/f1000research.1178.r844)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 1
VERSION 1 PUBLISHED 29 Jan 2013
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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