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Incidence and outcome of acute phosphate nephropathy in Iceland.

Pálmadóttir VK, Gudmundsson H, Hardarson S, Arnadóttir M, Magnússon T, Andrésdóttir MB - PLoS ONE (2010)

Bottom Line: One patient reached end-stage renal disease and one patient died with progressive renal failure.The consequences for kidney function were detrimental.This information can be used in other populations to estimate the impact of OSPS.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland.

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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Renal biopsy findings in acute phosphate nephropathy.A) Abundant calcifications are seen within tubules and in the interstitium. Adjacent tubules are athrophic and there is interstitial fibrosis (Hematoxylin and eosin staining, original magnification x 400). B) Positive von Kossa staining in the same biopsy confirms that the calcifications are composed of calcium phosphate (original magnification x 400).
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pone-0013484-g001: Renal biopsy findings in acute phosphate nephropathy.A) Abundant calcifications are seen within tubules and in the interstitium. Adjacent tubules are athrophic and there is interstitial fibrosis (Hematoxylin and eosin staining, original magnification x 400). B) Positive von Kossa staining in the same biopsy confirms that the calcifications are composed of calcium phosphate (original magnification x 400).

Mentions: The renal biopsy findings in patients with acute phosphate nephropathy are shown in Table 3. As could be expected from this cohort of elderly people, global sclerosis of the glomeruli was seen in most biopsies (73%). Sampling for light microscopy included a mean of 20.2 glomeruli (range 5–44), and a mean of 3.7 (18.3%) glomeruli were sclerotic. Other glomeruli appeared normal. Vascular disease was mild or absent in most patient and considered to be moderate in one. The typical findings of acute phosphate nephropathy were present in all patients as shown in Figure 1. Calcium phosphate deposits were found mostly in distal tubules and collecting ducts, located within the cytoplasm of tubular epithelial cells, within tubular lumina, or in the interstitium. The calcifications did not polarize and stained intensely with von Kossa stain, which confirmed their composition as calcium phosphate. The quantity of calcium phosphate deposits was not associated with time after OSPS ingestion, increase in creatinine or the final outcome. Tubular injury was accompanied by interstitial oedema in particular in biopsies of two patients who had a biopsy taken at the earliest interval from OSPS ingestion, 12 and 30 days, respectively. Interstitial inflammation was seen in most biopsies (80%), but there did not seem to be a relationship between the length of time from OSPS ingestion to biopsy and the quantity of inflammation. Chronic, irreversible tubular injury in the form of tubular atrophy and interstitial fibrosis was seen in all biopsies, ranging from 10 to 60% of the cortical area sampled.


Incidence and outcome of acute phosphate nephropathy in Iceland.

Pálmadóttir VK, Gudmundsson H, Hardarson S, Arnadóttir M, Magnússon T, Andrésdóttir MB - PLoS ONE (2010)

Renal biopsy findings in acute phosphate nephropathy.A) Abundant calcifications are seen within tubules and in the interstitium. Adjacent tubules are athrophic and there is interstitial fibrosis (Hematoxylin and eosin staining, original magnification x 400). B) Positive von Kossa staining in the same biopsy confirms that the calcifications are composed of calcium phosphate (original magnification x 400).
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2957439&req=5

pone-0013484-g001: Renal biopsy findings in acute phosphate nephropathy.A) Abundant calcifications are seen within tubules and in the interstitium. Adjacent tubules are athrophic and there is interstitial fibrosis (Hematoxylin and eosin staining, original magnification x 400). B) Positive von Kossa staining in the same biopsy confirms that the calcifications are composed of calcium phosphate (original magnification x 400).
Mentions: The renal biopsy findings in patients with acute phosphate nephropathy are shown in Table 3. As could be expected from this cohort of elderly people, global sclerosis of the glomeruli was seen in most biopsies (73%). Sampling for light microscopy included a mean of 20.2 glomeruli (range 5–44), and a mean of 3.7 (18.3%) glomeruli were sclerotic. Other glomeruli appeared normal. Vascular disease was mild or absent in most patient and considered to be moderate in one. The typical findings of acute phosphate nephropathy were present in all patients as shown in Figure 1. Calcium phosphate deposits were found mostly in distal tubules and collecting ducts, located within the cytoplasm of tubular epithelial cells, within tubular lumina, or in the interstitium. The calcifications did not polarize and stained intensely with von Kossa stain, which confirmed their composition as calcium phosphate. The quantity of calcium phosphate deposits was not associated with time after OSPS ingestion, increase in creatinine or the final outcome. Tubular injury was accompanied by interstitial oedema in particular in biopsies of two patients who had a biopsy taken at the earliest interval from OSPS ingestion, 12 and 30 days, respectively. Interstitial inflammation was seen in most biopsies (80%), but there did not seem to be a relationship between the length of time from OSPS ingestion to biopsy and the quantity of inflammation. Chronic, irreversible tubular injury in the form of tubular atrophy and interstitial fibrosis was seen in all biopsies, ranging from 10 to 60% of the cortical area sampled.

Bottom Line: One patient reached end-stage renal disease and one patient died with progressive renal failure.The consequences for kidney function were detrimental.This information can be used in other populations to estimate the impact of OSPS.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland.

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.

Show MeSH
Related in: MedlinePlus