Pathology of resin-induced gastrointestinal damage: report of 15 cases and review of literature

Abstract

Objective: Medication resins such as Kayexalate and Sevelamer used in the setting of chronic kidney disease for the correction of hyperkalemia and hyperphosphatemia are associated with gastrointestinal mucosal injury. In this study we describe the clinico-pathological features of Resin-induced gastrointestinal mucosal injury highlighting the histo-morphological appearances and differential diagnoses. The aim of this study is to increase the awareness of pathologists and clinicians alike to an under-reported etiology and pattern of intestinal mucosal injury related to medical resin therapy which may at times pose a clinical emergency. Material and Method: The archives of the Department of Histopathology, Mubarak Al Kabir hospital were analyzed for cases of resin-induced gastrointestinal mucosal injury between 2013 and 2018. Results: Of the 15 cases, Kayexalate crystals were identified in 7 cases, Sevelamer in 5 cases and both together were seen in 3 cases. Resin crystals were identified in the gastric antrum&duodenum (3 cases), colon (9 cases in the left colon, 2 cases in the right colon) and anal canal (1 case). The histological tissue reactions included mucosal necrosis (1 case), inflammatory polyps (2 cases), mucosal ulcerations with granulation tissue formation (10 cases), perforation (1 case) , and luminal crystals (1 case). Conclusion: Accurate and timely recognition of the resin crystals in biopsy samples with clinical correlation is mandatory to avoid serious complications.

Sevelamer-Induced Gastrointestinal Disease in 12 Patients with End-Stage Renal Disease: A Case Series

“…Two mechanisms seen in the literature that may increase risk of adverse events are preexisting loss of mucosal integrity and increased length of exposure ( 7 , 8 , 10 , 11 , 17 ). Chronic conditions contributing to intestinal hypoperfusion such as diabetes, chronic liver disease, and heart failure can also adversely affect mucosal integrity over time ( 17 ).…”

“…Of the several existing case reports, few have reported evidence of postdiscontinuation healing as observed by repeat endoscopy ( 5 , 6 ), rather most make inferences based on improvement of symptoms or do not address resolution of symptoms at all. Other case series demonstrate GI damage in the setting of sevelamer use and positive histology findings but do not comment on length of sevelamer use before diagnosis or resolution following discontinuation ( 7 , 8 ). A large randomized trial is not reasonable to perform because of the risks that would be imposed on the study groups; thus the existing pool of data is restricted to anecdotal evidence and observational studies.…”

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

“…George, et al [18] reported 15 cases of resin associated GI injury, 8 of which were associated with sevelamer (patient age 45-77; 2 female, 6 male). All of the cases involved the lower GI tract; sevelamer crystals were associated with abnormal findings including ulcerations of the colon or anal canal, pancolitis, inflammatory polyps, or diverticulitis with perforation.…”

Calcium Polystyrene Sulfonate Crystal-related Airway Obstruction

“…These resins exchange sodium for potassium (SPS), and calcium for potassium (CPS) in the large bowel. Several gastrointestinal (GI) mucosal injuries after their utilization have been reported, including GI bleeding, necrosis, perforation, and pseudotumor (1)(2)(3)(4). The SPS/CPS-induced mucosal injuries were identified as basophilic mosaic crystals in the epithelium.…”