Reversible nephrotoxicity after overdose of colloidal bismuth subcitrate

Abstract

Although toxicity due to acute and chronic use of bismuth salts is well known, nephrotoxicity after ingestion of colloidal bismuth has been reported in few cases so far. Here we report the first case of acute renal failure (ARF) due to colloidal bismuth subcitrate overdosage in childhood. A 2-year-old boy was admitted to the hospital 6 h after ingestion of 28 De-Nol tablets (colloidal bismuth subcitrate 8.4 g). On admission, physical examination was unremarkable and he showed no signs of encephalopathy. Initially gastric lavage was performed then appropriate fluid therapy was started. ARF associated with uremia and oliguria developed on day 2 and peritoneal dialysis therapy was prescribed on day 4 for 10 days. Blood and urine bismuth levels were 739 micrograms/l and 693 micrograms/l, respectively, 10 days after the pills had been taken. His urine volume gradually increased and plasma BUN and creatinine levels decreased during peritoneal dialysis. On day 20 post-admission, plasma BUN and creatinine were 14 mg/dl and 0.7 mg/dl, respectively. Blood bismuth levels were 96 micrograms/l on day 60 and 12 micrograms/l on day 105. Now the patient is well and has no problem. This case suggests that ARF may develop in children following colloidal bismuth subcitrate overdosage; the prognosis is good, and peritoneal dialysis may be useful in these cases.

Acute renal failure after overdose of colloidal bismuth subcitrate

“…Clear- ance of bismuth from tissues via hemodialysis was inadequate, and their patient had detectable blood bismuth levels 2 or 3 months after the agent was ingested. Islek and colleagues [10] reported a 2-year-old patient with colloidal bismuth overdose who was treated with peritoneal dialysis alone. They observed that removal of bismuth via this method was also slow.…”

“…To date, acute renal failure after overdose of colloidal bismuth has been reported in five adults and two pediatric patients (Table 2) [8,9,10,11,12,13,14]. In three of these seven cases renal biopsy showed acute tubular necrosis [11,12,13].…”

“…In three of these seven cases renal biopsy showed acute tubular necrosis [11,12,13]. One patient was succesfuly managed strictly with fluid therapy, furosemide, dopamine, and mannitol [12], whereas the other six were treated with dialysis (five hemodialysis and one peritoneal dialysis) [8,9,10,11,13,14].…”

“…The reported toxic effects caused by overdose of bismuth compounds include encephalopathy, nephropathy, osteoarthropathy, gingivostomatitis, and colitis. These problems are rarely seen with normal use of bismuth salts because only small amounts of these compounds are absorbed from the gastrointestinal tract [3,4,5,6,7,8,9,10,11]. Colloidal bismuth has greater bioavailability than other bismuth salts; thus treatment with this form carries higher risk of toxicity.…”

“…Chronic exposure to high levels of bismuth salts results in encephalopathy, whereas acute toxicity manifests as nephrotoxicity. To date only a few reports have documented nephrotoxicity after ingestion of colloidal bismuth [8,9,10,11,12,13,14]. We present the case of an adolescent girl who developed acute renal failure due to an overdose of colloidal bismuth subcitrate.…”