NDT Plus Advance Access published online on September 18, 2008
NDT Plus, doi:10.1093/ndtplus/sfn152
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Renal failure associated with colonoscopy—what is the link?
1 Centre de Néphrologie et Transplantation Rénale
2 Service de Pathologie, AP-HM, Université de la Méditerranée, Marseille, France
Correspondence: Dr Stéphane Burtey, Centre de Néphrologie et Transplantation Rénale. Hopital de la conception, 147 bd Baille, 13005 Marseille, France. Tel: +33 4913 83043; Fax: +33 4913 83206; E-mail: stephaneb{at}ap-hm.fr
Key Words: colonoscopy • nephrocalcinosis • renal failure
Received for publication June 27, 2008. Accepted for publication August 25, 2008.
In January 2006, a 75-year-old woman presented to her primary care physician with severe arterial hypertension and acute renal failure (ARF). She had been hypertensive for 25 years associated with stage 3 chronic kidney disease (serum creatinine 75 µmol/l and estimated GFR 45 ml/ mn/1.73 m2 in October 2005). Her medical history was remarkable for a colic cancer treated by partial colectomy in 2002. A control colonoscopy was done in November 2005; the preparation was done with a sodium phosphate bowel purgative. Her medications included enalapril, hydrochlorothiazide, amlodipine, atenolol and aspirin. The serum creatinine was 340 µmol/l. All immunological exams were negative, and hormonal assays failed to reveal any hormonal cause for hypertension. A bilateral renal arterial stenosis was excluded by a renal angiography. In April 2006, the renal function was still impaired (serum creatinine 410 µmol/l) and the patient was referred to the nephrology unit. Clinical examination was normal, there was no proteinuria and urine sediment analysis was negative.
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A kidney biopsy was performed (Figure 1).
What is the cause of her renal failure?
The diagnosis: Acute phosphate nephropathy complicated of chronic renal failure.
The kidney biopsy showed, besides mild vascular lesions related to hypertension (Figure 1A), numerous intratubular crystal deposits in the kidney parenchyma (Figure 1A–C). They were stained by Von Kossa (Figure 2), confirming the calcium phosphate nature of the deposits. So ARF was related to nephrocalcinosis, which was related to the ingestion of sodium phosphate purgative. In December 2007, the renal function was still severely impaired with an estimated GFR of 11 ml/min/1.73 m2.
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Colonoscopy is a common procedure in modern health care, and it requires adequate bowel preparation. Sodium phosphate bowel preparations can lead to acute severe complications, hyperphosphataemia associated with severe hypocalcaemia leading to seizures and sometimes death, in patients with mild or severe renal impairment [1]. Besides these acute complications, nephrocalcinosis [2] (also called acute phosphate nephropathy [3]) can lead to chronic renal failure. The renal failure is secondary to intra-tubular precipitation of calcium phosphate crystals. This complication is associated with age [4] and previous renal impairment or the use of medications that may impair renal haemodynamics (diuretics, ACE, sartans and NSAID) [5]. Before using this kind of purgative, GFR must be evaluated. Physicians must be aware of acute and chronic renal insufficiency as a serious side effect of a ‘not at risk’ medication. Previous use of phosphate sodium enema, weeks or months before the discovery of an unexplained acute renal insufficiency, should be systematically searched.
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Conflict of interest statement. None declared.
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References |
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TopDiscussionReferences |
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- Woo YM, Crail S, Curry G, et al. A life threatening complication after ingestion of sodium phosphate bowel preparation. BMJ (2006) 333:589–590.
[Free Full Text] - Gonlusen G, Akgun H, Ertan A, et al. Renal failure and nephrocalcinosis associated with oral sodium phosphate bowel cleansing: clinical patterns and renal biopsy findings. Arch Pathol Lab Med (2006) 130:101–106.[Web of Science][Medline]
- Desmeules S, Bergeron MJ, Isenring P. Acute phosphate nephropathy and renal failure. N Engl J Med (2003) 349:1006–1007.
[Free Full Text] - Hurst FP, Bohen EM, Osgard EM, et al. Association of oral sodium phosphate purgative use with acute kidney injury. J Am Soc Nephrol (2007) 18:3192–3198.
[Abstract/Free Full Text] - Markowitz GS, Stokes MB, Radhakrishnan J, et al. Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. J Am Soc Nephrol (2005) 16:3389–3396.
[Abstract/Free Full Text]
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