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Abstract: SA-PO313

I Am in a Crystal Bind! A Case that Gave Us Ulcers

Session Information

Category: Bone and Mineral Metabolism

  • 502 Bone and Mineral Metabolism: Clinical

Authors

  • Elkalashy, Ahmed, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
  • Abdallah, Ahmed, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
  • Bashtawi, Yazan Ali, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
  • Bin Homam, Wadhah Mohammed, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
  • Gokden, Neriman, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
  • Singh, Manisha, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
  • Karakala, Nithin, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
Introduction

In patients with ESKD, hyperphosphatemia has been shown to increase mortality. Common complications include vascular and heart calcification, as well as hyperparathyroidism. Managing hyperphosphatemia includes dietary modifications as well as phosphate binders. Sevelamer, a non-calcium phosphate binder, is commonly prescribed and usually well tolerated. Side effects of sevelamer are generally nonspecific and limited to nausea and gastrointestinal discomfort.

Case Description

A 37-year-old man with ESKD on intermittent hemodialysis, hypertension, congestive heart failure, and recent mitral and aortic valve repair presented with hematochezia and fatigue. His hemoglobin level was 5.9mg/dl upon admission. He was transfused and underwent an urgent colonoscopy, which revealed ulcerative mucosal injuries in the colon. Biopsy showed mucosal ulcers with sevelamer crystals. The patient was taken off sevelamer, stabilized, and switched to sucroferric/lanthanum for hyperphosphatemia and is stable at follow-up.

Discussion

Hyperphosphatemia is a common complication of end-stage kidney disease (ESKD) due to decreased renal elimination and continued intestinal absorption of dietary phosphate. Sevelamer, a non-calcium phosphate binder, is commonly used to control hyperphosphatemia. We present a case of a patient with ESKD on sevelamer, with lower gastrointestinal bleeding and endoscopic finding of colonic mucosal injuries with sevelamer crystals. Though reported in gastrology literature, nephrology reports show a paucity of discussion around this increasingly common adverse effect and the need for vigilance in ESKD.

Colon biopsy shows ulcerative mucosal injuries with typical reddish-brown crystals with a characteristic “fish-scale” pattern, described for sevelamer crystals.