Ischemic colitis in association with sevelamer crystals

Abstract

Sevelamer is an important drug used to lower serum phosphate levels in advanced kidney disease and in patients on dialysis. This drug is generally well tolerated but some patients report mild gastrointestinal distress as a side effect. Although regulatory agencies, such as Food and Drug Administration, list bowel ischemia and necrosis as potential and rare side effects, there are few case reports describing these adverse effects. We present a 35-year-old HIV patient with end-stage renal disease on hemodialysis who developed colonic hemorrhage and perforation. Imaging showed ischemic gangrene of bowel wall. Histopathology was consistent with transmural ischemic necrosis with deposition of fibrin thrombi and sevelamer crystals.

Sevelamer-Induced Ischemic Enteritis

“…If sevelamer is not stopped, complications such as ischemia, ulceration, acute anemia, stricture formation, and perforation may occur. [1][2][3][4][5][6]…”

“…1 SC deposition has been associated with mucosal ulceration, bleeding, ischemia, perforation, and postinflammatory strictures. [1][2][3][4][5][6] This case report describes a young patient with ESRD on peritoneal dialysis who developed hematochezia found to be secondary to sevelamer-induced ischemic enteritis. We aimed to highlight the patient presentation and critical findings of a common medication's rare yet clinically significant complication.…”

Sevelamer Associated Gastrointestinal Complications in Kidney Transplant Recipients: Case Reports and Review of the Literature

“…Since FDA approval and widespread use of sevelamer as a phosphate binder in CKD patients there have been several case reports of more severe GI complications associated with the use of sevelamer including gastrointestinal bleeding, colonic ulceration, colitis, and perforated diverticulum. The majority of reports are of colonic pathology associated with sevelamer crystals, but also several cases involving upper GI or small bowel pathology [4][5][6][7][8][9][10][11][12][13][14][15][16].…”

“…In pre marketing clinical trials, GI complaints were the most common side effects of sevelamer and lead to drug discontinuation in a minority of patients [3]. In post marketing experience, there have been reports of more significant GI pathology including gastrointestinal bleeding, colonic ulceration, colitis, and perforated diverticulum in association with the use of sevelamer in CKD patients as well as the more benign side effects seen in premarketing studies [4][5][6][7][8][9][10][11][12][13][14][15][16]. GI symptoms and complications occur with some frequency in kidney transplant recipients with a complex spectrum of causes of which side effects of immunosuppression medications and infectious disease problems are contributing factors.…”

New Kids on the Block

“…[1][2][3][4][5][6][7][8][9] As detailed in this review, some agents are critical to recognize because of their association with significant background mucosal injury, such as yttrium 90 ( 90 Y) microsphereassociated radiation 1,10,11 or sodium polystyrene sulfonateor sevelamer-associated mucosal ulcers, ischemia, and pseudotumors. 8,[12][13][14][15][16][17][18][19][20][21][22] Other foreign materials are inconsequential, such as pharmaceutical fillers or bile acid sequestrants (BASs), but awareness of their typical histologic appearance is important to prevent misdiagnosis and triggering of unnecessary additional studies. 2,4,7 Recognition of these agents can also serve as a helpful clue to carefully screen for other related processes, such as prompting consideration of amyloid in patients with lanthanum carbonate deposition, sodium polystyrene sulfonate, or sevelamer, as these agents are only prescribed in the setting of renal failure.…”