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

Abstract

Hemodialysis can safely be used as an adjunctive therapy in sodium phosphate toxicity to rapidly reduce serum phosphate levels and increase serum calcium levels in children not responding to conventional management.

Tetania severa por uso de enemas fosfatados, reporte de caso

“…Thus, they produce a great movement of fluids towards the intestinal lumen, developing a third space that allows the emptying of the sigmoid-rectal fecal contents. 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. 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 .…”

“…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 . Phosphate enemas are more frequent in pediatrics, especially in children younger than 5 years and with risk factors such as kidney failure (decreased phosphorus clearance), altered bowel motility (paralytic ileus, Hirschsprung's disease, myelomeningocele , Colostomy), but is exceptional in children with no underlying pathologies.…”

“…These symptoms may occur suddenly between 30 min and 4 hours after administration of the enema [5][6][7] .…”

“…With adequate renal function, hyperhydration and diuresis (phosphorus removal is mainly renal) should be performed 5,6 . The use of phosphorus binders to promote digestive elimination, such as calcium carbonate or calcium acetate, can be performed enterally to reduce phosphorus reabsorption from the intestinal lumen 6 and calcium 7 should be provided in case of symptomatic hypocalcemia.…”