Colonic Mucosal Ulceration and Gastrointestinal Bleeding Associated with Sevelamer Crystal Deposition in a Patient with End Stage Renal Disease

Abstract

End stage renal disease (ESRD) population account for 1.9 per patient year of hospital admissions annually. ESRD population are at increased risk of bleeding secondary to use of anticoagulation during hemodialysis and uremia induced platelet dysfunction. Gastrointestinal bleeding accounts for 3–7% of all deaths in ESRD population. Lower gastrointestinal bleeding refers to blood loss from a site in the gastrointestinal tract distal to the ligament of Treitz. It is usually suspected when a patient complains of hematochezia. It is different from patients presenting with hematemesis that suggests bleeding from upper gastrointestinal tract. Common causes of lower gastrointestinal bleed include diverticulosis, ischemia, hemorrhoids, neoplasia, angiodysplasia, and inflammatory bowel disease. ESRD patients are known to retain phosphate alone or in combination with calcium which has been associated with high mortality. Sevelamer is a phosphate binder used widely in ESRD population. The known side effects of sevelamer include metabolic acidosis, vomiting, nausea, diarrhea, dyspepsia, abdominal pain, constipation, flatulence, fecal impaction, and skin rash. We are reporting a unique case of a 56-year-old female with end stage renal disease on sevelamer hydrochloride who presented with gastrointestinal bleeding and underwent a right hemicolectomy found to have sevelamer-induced mucosal ulceration and crystal deposition in the colonic mucosa. This case report highlights the fact that, with widespread use of this medication in the patients with chronic kidney diseases, physicians should be aware of this underrecognized entity in the differential diagnosis of gastrointestinal bleed in ESRD patients.

Sevelamer crystals—an unusual cause of large bowel obstruction

“…Similarly, Nambiar et al. reported a patient with Sevelamer-related hepatic flexure ulceration [ 4 ].…”

“…Sevelamer is a non-absorbable ion-exchange resin that binds phosphate in the gastrointestinal tract [ 2 ]. Known side-effects include nausea, vomiting and abdominal pain [ 3 , 4 ]. Rarely, Sevelamer crystals deposit in the gastrointestinal tract causing mucosal ulceration or colonic obstruction.…”

Drug Crystal-Related Gastrointestinal Complications Involve Crystal-Induced Release of Neutrophil and Monocyte Extracellular Traps

“…To investigate whether crystals of ion-exchange resins can cause cell death in intestinal epithelial cells and therefore contribute to the intestinal complications observed in patients [ 22 , 23 , 24 , 25 ], including our case, we stimulated Caco2 and HCA7 cells with different concentrations of sevelamer, polystyrene sulfonate, cholestyramine, patiromer, and monosodium urate crystals as a control for 24 h, and performed cytotoxicity assays. Only a very high concentration of sevelamer crystals induced a significant increase in the percentage of cytotoxicity in Caco2 cells compared with the medium and other drug crystals ( Figure 3 A).…”

Angiodysplasia in Renal Disease Patients: Analysis of Risk Factors and Approach to Manage Such Patients

“…Sevelamer is well known to be associated with the deposition of its crystals in the GI tract, vascular calcification, and endothelial damage. Coincidental sevelamer deposition on a previously injured area along with foreign body reaction observed strongly suggests casualty [9].…”