Flow-through peritoneal dialysis in neonatal enema-induced hyperphosphatemia

Abstract

Fleet enemas are hypertonic solutions with an osmotic action and a high concentration of phosphate. When retained in the human body they have a great toxic potential, causing severe hydro-electrolyte disorders in children, especially in newborns. We report the case of a previously healthy 8-day-old newborn who needed neonatal intensive care treatment after the inadvertent administration of an osmotically active hypertonic phosphate enema. Taking into account that phosphate removal by peritoneal dialysis (PD) strongly depends on total dialysate turnover, we chose continuous flow PD (CFPD) as the treatment option, with a successful outcome. Clinical experience with this dialytic modality is limited to a few case reports in pediatric and adult patients. To the best of our knowledge, we report here the first description of CFPD in the setting of acute phosphate nephropathy in the neonatal period. The modality of PD described here has potential as an alternative management option as it is a highly efficient, methodologically simple, and low-cost method without any need for sophisticated equipment. Physicians and parents should be aware of the adverse effects of a hypertonic phosphate enema and should never use these medications in infants and newborns.

Hemodialysis for Near-Fatal Sodium Phosphate Toxicity in a Child Receiving Sodium Phosphate Enemas

“…13 One case report describes the successful use of high flow-through peritoneal dialysis in a neonate with enema-induced hyperphosphatemia by promoting total dialysate turnover. 4 Enteral phosphate binders such as calcium carbonate and calcium acetate can also reduce phosphate absorption from the small intestine in patients with hyperphosphatemia. These agents are most effective when taken before ingestion of foods rich in phosphate and have limited efficacy after systemic phosphate absorption.…”

“…Case reports have described the use of peritoneal dialysis in children with severe sodium phosphate toxicity. [2][3][4] In addition, hemodialysis (HD) resolved sodium phosphate toxicity in a child with chronic renal failure and a permanent dialysis catheter in place. 5 We report a case of severe toxicity due to sodium phosphate enemas in a child with no history of renal failure.…”

Tetania severa por uso de enemas fosfatados, reporte de caso

“…Dehydration secondary to the intraluminal hyperosmolar effect of the solution and hypocalcemia secondary to absorption of high phosphorus content [5][6][7] are the main adverse effects of errors in dosing, administration and elimination of the enema. From the pathophysiological point of view, it is important to note that phosphorus is generally absorbed in duodenum and jejunum, but colonic absorption is possible secondary to high concentrations in the rectum 8 . A rapid increase in phosphorus produces acute hypocalcemia due to chelation of calcium and precipitation of calcium phosphate salts in soft tissues and kidney.…”

“…A rapid increase in phosphorus produces acute hypocalcemia due to chelation of calcium and precipitation of calcium phosphate salts in soft tissues and kidney. Other mechanisms, such as the decrease in the production of 1,25-dihydroxycholecalciferol and the reduction of the absorption of calcium at the intestinal level, are slower to establish and therefore play a secondary role in cases of intoxication 6,8,9 , but may be important in cases of chronic exposure. In addition, excess phosphorus as inorganic acid and loss of bicarbonate in the intestinal lumen produce metabolic acidosis 6 .…”

“…Calcium replacement should be careful, seeking to alleviate symptoms (cramps, convulsions, arrhythmias), and not seeking to correct serum calcium values to normal limits, since in the presence of hyperphosphemia it can cause renal precipatation of calcium salts 8 .…”