Nefropatía aguda por fosfatos secundaria al uso de laxantes con fosfato de sodio: caso clínico-patológico / Acute phosphate nephropathy secondary to the use of oral sodium phosphate laxatives: report of one case

Acute phosphate nephropathy (APN) is an acute renal failure secondary to the use of oral sodium phosphate (OSP) laxatives, with a high risk of progression to chronicity. We report a 60-year-old woman with mixed connective tissue disease whose serum creatinine increased up to 2.0 mg/dL in her regular control tests, without an evident causative factor. Kidney biopsy showed numerous intratubular calcium phosphate deposits, consistent with APN. She had a history of OSP laxative intake, and a sodium phosphate enema was used before a colonoscopy performed six months earlier. The temporal association between the use of OSP laxatives and acute kidney injury, should lead to the suspicion of APN. The urine sediment is generally normal or with mild to moderate proteinuria. The diagnosis is confirmed with a kidney biopsy. Until now, there is no specific treatment for APN, thus prevention is essential. In high-risk patients for developing APN, the administration of these laxatives should be avoided.

Tetania severa por uso de enemas fosfatados, reporte de caso / Tetany secondary to phosphate enema toxicity, case report

Los enemas fosfatados son utilizados frecuentemente en el tratamiento de la constipación. Errores en la posología pueden producir complicaciones graves. Objetivo: Reportar un caso de toxicidad grave por enema fosfatado en un pre escolar sin factores de riesgo. Caso clínico: Paciente de 2 años con constipación funcional, evaluada en servicio de urgencia por dolor abdominal a quién se le diagnosticó un fecaloma impactado. Recibió 2 dosis de enema de fosfato, “medio frasco” de Fleet® adulto (Synthon, Chile) por vez, sin resolución de su fecaloma, decidiéndose hospitalización para proctoclisis. Posterior al ingreso presentó un cuadro clínico de tetania. Ingresó a la Unidad de Paciente Crítico donde se confirmó una hiperfosfemia e hipocalcemia secundaria. Se realizó corrección electrolítica progresiva, retiro de enema fosfatado residual del recto e hiperhidratación forzando diuresis. La tetania cedió 2 horas después del ingreso sin otras complicaciones. Se realizó proctoclisis y fue dada de alta a los 3 días. Conclusión: Los enemas fosfatados pueden presentar complicaciones graves en niños sin factores de riesgo. Errores en la posología son la causa más frecuente de toxicidad en este grupo, pero esta puede estar favorecida también por una administración y eliminación inadecuadas. Pediatras y personal de salud que atiende a niños deben conocer factores de riesgo, signos y síntomas de intoxicación por enemas fosfatados.

Phosphate enemas are frequently used in the treatment of constipation. Errors in dosage and administration can lead to severe complications. Objective: To report a case of severe toxicity of phosphate enemas in a child with no risk factors. Case: 2 years old female, with functional constipation, was brought to emergency department because abdominal pain. She was diagnosed with fecal impaction and received half a bottle of Fleet Adult® (Laboratorio Synthon, Chile) two times, with no clinical resolution, deciding to start proctoclisis in pediatric ward. Soon after admission, she presented painful tetany, but alert and oriented. Patient was transferred to PICU where severe hyperphosphatemia and secondary hypocalcemia were confirmed. Her treatment included electrolyte correction; removal of residual phosphate enema and hyperhydration. Tetany resolved over 2 hours after admission and no other complications. Proctoclisis was performed and patient was discharged three days after admission with pharmacological management of constipation. Conclusion: Phosphate enemas may cause serious complications in children with no risk factors. Errors in dosage, administration and removal of the enema are causes of toxicity in this group. Pediatricians and health personnel must be aware of risks and signs of toxicity of phosphate enema.

Nefropatía asociada a fosfatos posterior a preparación para colonoscopia: dos casos anátomo-clínicos / Acute phosphate nephropathy after bowel cleansing for colonoscopy: two clinical-pathological case reports

Oral sodium phosphate (OSP) solutions are widely used for bowel cleansing before colonoscopy, for stercoral retention phenomena and persistent chronic constipation. Its main risk, is acute phosphate nephropathy (APN), which is a clinic-pathological entity characterized by acute kidney disease secondary to deposition of calcium phosphate crystals in the renal tubules. Its recognition has been documented over the last decade in relation to case reports and the warning of the FDA. This report discusses two cases of APN certified by renal biopsy after the administration of OSP. One of them had an acute symptomatic presentation, and the other one, was a late finding. Both developed renal failure.

Las soluciones de fosfato de sodio oral (FSO) son ampliamente utilizadas para la preparación de colon previo a colonoscopia, para fenómenos de retención estercorácea y constipación crónica pertinaz. Su principal riesgo, la nefropatía aguda por fosfatos (NAF), es una entidad clínico-patológica caracterizada por falla renal aguda secundaria a depósito de cristales de fosfato de calcio en los túbulos renales. En la última década se han comunicado reportes de casos clínicos y una advertencia del uso de FSO por parte de la Food and Drug Administration de EE.UU. (FDA). En esta publicación se comunican dos casos de NAF, posterior a la administración de FSO, confirmadas por biopsia. Uno de ellos tuvo una presentación aguda y sintomática y el otro fue un hallazgo tardío. Ambos se acompañaron de falla renal.

Electrolyte Imbalances and Nephrocalcinosis in Acute Phosphate Poisoning on Chronic Type 1 Renal Tubular Acidosis due to Sjogren's Syndrome

Although renal calcium crystal deposits (nephrocalcinosis) may occur in acute phosphate poisoning as well as type 1 renal tubular acidosis (RTA), hyperphosphatemic hypocalcemia is common in the former while normocalcemic hypokalemia is typical in the latter. Here, as a unique coexistence of these two seperated clinical entities, we report a 30-yr-old woman presenting with carpal spasm related to hypocalcemia (ionized calcium of 1.90 mM/L) due to acute phosphate poisoning after oral sodium phosphate bowel preparation, which resolved rapidly after calcium gluconate intravenously. Subsequently, type 1 RTA due to Sjogren's syndrome was unveiled by sustained hypokalemia (3.3 to 3.4 mEq/L), persistent alkaline urine pH (> 6.0) despite metabolic acidosis, and medullary nephrocalcinosis. Through this case report, the differential points of nephrocalcinosis and electrolyte imbalances between them are discussed, and focused more on diagnostic tests and managements of type 1 RTA.

Comparison among Conventional 4 L Polyethylene Glycol, Split Method of 4 L Polyethylene Glycol and Combination of 2 L Polyethylene Glycol and Sodium Phosphate Solution for Colonoscopy Preparation / 대한소화기학회지

BACKGROUND/AIMS: The aim of this study was to compare polyethylene glycol (PEG) 4 L, split method of PEG 4 L and PEG 2 L plus sodium phosphate (NaP) in the aspect of bowel preparation quality, safety, patients' compliance and preference. METHODS: Total 249 subjects were prospectively enrolled and received bowel preparation for colonoscopy from August to October in 2010; PEG 4 L (93 subjects), split method of 4 L PEG (74 subjects) and PEG 2 L plus NaP 90 mL group (82 subjects). To investigate the completion, preference for bowel preparation and safety, a questionnaire survey was conducted before colonoscopy. RESULTS: There were no significant intergroup differences in the aspect of completion of preparation, cecal intubation time and success rate. Satisfaction and preference were higher in PEG 2 L plus NaP 90 mL and split method of 4 L PEG compared with PEG 4 L. In the aspect of the bowel preparation quality PEG 4 L showed significantly higher quality in the morning colonoscopy (p<0.001). However, in the afternoon colonoscopy PEG 2 L plus NaP 90 mL showed better result than PEG 4 L (p=0.009). Hyperphosphatemia was most frequently observed in PEG 2 L plus NaP 90 mL, but no severe adverse events occurred (p<0.001). CONCLUSIONS: PEG 4 L showed better result than split method of 4 L PEG or PEG 2 L plus NaP 90 mL in the aspect of bowel preparation quality and safety.

Experimental antegrade enema: effects on water, electrolyte and acid-base balances with different solutions

PURPOSE: To study the effects on the water, electrolyte, and acid-base balances in rabbits submitted to antegrade enema with different solutions through appendicostomy. METHODS: Forty male New Zealand rabbits were submitted to appendicostomy, and distributed in 4 groups, according to the antegrade enema solution: PEG group, polyethylene glycol electrolyte solution (n=10); ISS group, isotonic saline solution (n=10); GS group, glycerin solution (n=10); SPS group, sodium phosphate solution (n=10). After being weighed, arterial blood gas analysis, red blood count, creatinine and electrolytes were measured at 4 times: preoperatively (T1); day 6 postop, before enema (T2); 4h after enema (T3); and 24h after T3 (T4). RESULTS: In PEG group occurred Na retention after 4h, causing alkalemia, sustained for 24h with HCO3 retention. In ISS group occurred isotonic water retention and hyperchloremic acidosis after 4h, which was partially compensated in 24h. GS group showed metabolic acidosis after 4h, compensated in 24h. In SPS group occurred hypernatremic dehydration, metabolic acidosis in 4h, and hypokalemia, hypocalcemia, hypomagnesemia, and metabolic alkalosis with partially compensated dehydration in 24h. CONCLUSIONS: All solutions used in this study caused minor alterations on water, electrolyte or acid-base balances. The most intense ones were caused by hypertonic sodium phosphate solution (SPS) and isotonic saline solution (ISS) and the least by polyethyleneglycol electrolyte solution (PEG) and glycerin solution 12 percent (GS).

OBJETIVO: Estudar os efeitos no equilíbrio hídrico, eletrolítico e ácido-base, do enema anterógrado com diferentes soluções em coelhos através de apendicostomia. MÉTODOS: 40 coelhos Nova Zelândia, machos, submetidos a apendicostomia, distribuídos em quatro grupos segundo a solução de enema: grupo PEG (n = 10) solução de polietilenoglicol com eletrólitos; grupo SF (n = 10) solução fisiológica; grupo SG (n = 10) solução glicerinada; grupo FS (n = 10) solução de fosfato de sódio. Realizou-se pesagem, gasometria arterial, série vermelha, creatinina e ionograma, em quatro tempos: TI (pré-operatório); T2 (6o PO antes do enema); T3 (4h após enema); T4 (24h após T3). RESULTADOS: No PEG ocorreu retenção de Na em 4h, com alcalemia por retenção de HCO3, mantida por 24h. No SF ocorreu retenção hídrica isotônica e acidose hiperclorêmica em 4h, resolvidos parcialmente com 24h. No SG ocorreu acidose metabólica hiperclorêmica em 4h, compensada com 24h. No FS ocorreu desidratação hipenatrêmica, acidose metabólica com ânion gap elevado em 4h, hipopotassemia, hipocalcemia, hipomagnesemia e alcalose metabólica com recuperação parcial da desidratação em 24h. CONCLUSÕES: Todas as soluções empregadas neste estudo causam alterações de pouca intensidade no equilíbrio hídrico, eletrolítico ou ácido-base. As mais intensas foram causadas pela solução de fosfato de sódio e solução fisiológica, e as menos intensas pela solução de polietilenoglicol com eletrólitos e solução glicerinada.

Hiperparatireoidismo associado à osteomalacia hipofosfatêmica do adulto: relato de caso e revisão da literatura / Hyperparathyroidism associated with hypophosphatemic osteomalacia: case report and review of the literature

A osteomalacia hipofosfatêmica é uma doença rara caracterizada por hipofosfatemia, níveis elevados de fosfatase alcalina e diminuição da densidade óssea. O tratamento é realizado com suplementação oral com fosfato e vitamina D e, nos casos de osteomalacia oncogênica, com a ressecção do tumor. Relatamos o caso de uma paciente que apresentou quadro de osteomalácia hipofosfatêmica de causa indeterminada. Apesar de extensivamente procurado, nenhum tumor produtor de substância hipofosfatêmica foi localizado. A paciente foi tratada como suplementação de fosfato e vitamina D por longo período, evoluindo com quadro de hiperparatireoidismo terciário. A retirada de três paratireóides não normalizou os níveis de PTH e a paciente recusou-se a continuar a investigação e o tratamento. Após dez anos de tratamento irregular, foi internada por insuficiência respiratória causada por colabamento do arcabouço costal e múltiplas fraturas, evoluindo para o óbito. Os autores discutem a relação entre osteomalácia e hiperparatireoidismo e o curso agressivo da doença.

Fluoride kinetics in saliva after the use of a fluoride-containing chewing gum

Há uma relação entre o uso de fluoretos, a redução na cárie e o aumento da fluorose dentária. O objetivo deste estudo foi analisar a cinética do flúor na saliva após o uso da goma de mascar Happydent®, que contém 3,38 mg de flúor como monofluorfosfato. A saliva foi coletada de 15 voluntários entre 7 e 9 anos de idade, durante 3 minutos nos intervalos de 0, 3, 6, 9, 15, 30 e 45 minutos. Inicialmente, a coleta foi realizada com o Trident® (controle) e, após 24 h, a coleta foi repetida com a goma de mascar Happydent®. O flúor foi analisado com um eletrodo íon-específico (Orion 96-09) após a realização da hidrólise ácida. Os dados foram analisados através da análise de variância a dois critérios e pelo teste de Tukey (p < 0,05). A quantidade média ± dp (mg) de flúor liberado na saliva foi 0,276 ± 0,126 e 0,024 ± 0,014 para o Happydent® e o Trident®, respectivamente. A quantidade de flúor nas amostras de saliva após o uso do Happydent® foi significativamente maior do que após o uso do Trident® em todos os tempos experimentais, com exceção dos períodos de 30 e 45 minutos. A alta quantidade de flúor na saliva após o uso do Happydent® poderia ser eficiente na prevenção da cárie dentária, o que deveria ser avaliado clinicamente. Por outro lado, essa goma de mascar deveria ser evitada por crianças na idade de risco para a fluorose dentária.

Bowel preparation for colonoscopy: comparison of mannitol and sodium phosphate: results of a prospective randomized study

METHOD: Eighty patients were prospectively randomized for precolonoscopic cleansing either with 750ml of 10 percent mannitol (Group M) or 180ml of a sodium phosphate preparation (Group NaP). Laboratory examinations before and after preparation on all patients included hemoglobin, hematocrit, sodium, potassium, phosphorous, calcium and serum osmolarity. A questionnaire was used to assess undesirable side effects and patient tolerance to the solution. The quality of preparation was assessed by the endoscopist who was unaware of the solution employed. RESULTS: Statistically significant changes were verified in serum sodium, phosphorous, potassium and calcium between the two groups, but no clinical symptoms were observed. There were no significant differences in the frequency of side effects studied. Six of the eight patients in Group NaP who had taken mannitol for a previous colonoscopy claimed better acceptance of the sodium phosphate solution. The endoscopic-blinded trial reported excellent or good bowel preparation in 85 percent prepared with sodium phosphate versus 82.5 percent for mannitol (p=0.37). CONCLUSIONS: Quality of preparation and frequency of side effects was similar in the two solutions. The smaller volume of sodium phosphate necessary for preparation seems to be related to its favorable acceptance. Nevertheless, the retention of sodium and phosphate ions contraindicates the use of sodium phosphate in patients with renal failure, cirrhosis, ascites, and heart failure.

Influência dos fosfatos de alta energia na fnçäo ventricular em pacientes com infarto do miocárdio avaliada pela ressonância magnêtica / Influence of high energy phosphate metabolism in postishemic myocordial dysfunction, using magnetic resonance spectroscopy

Resumo: Uma das teorias para explicar a disfunçäo do miocárdio pós-isquêmico (miocárdio atordoado) é a produçäo insulficiente de energia pela mitôcondria, levando a uma depleçäo dos níveis de ATP. Utilizando a espectroscopia de ressonância magnética aplicada a pacientes com infarto miocárdio, avaliamos a influência do metabolismodos fosfatos de alta energia na disfunçäo pós-isquêmica domiocárdio. Foram estudados 29 pacientes na fase aguda e 21 destes apósmédia de 39 dias (fase tardia). A funçäo ventricular regional foi avaliada pela cinerressonância e o metabolismo dos fosfatos de alta energia pela espectroscopia do fósforo-31, obtendo-se a relaçäo fosfocreatina/ATP miocárdio. O ''miocárdio atordoado'' foi confirmado pela melhora da contratilidade dos segmentos relacionados ao infarto na fase tardia. Näo foi observada diferença significativa (151 + ou - 0,17 vs. 1,53 + ou - 0,17; p = 0,6) na relaçäo fosfocreatina/ßATP entre a fase aguda e a tardia. Este estudo sugere que eventual déficit do metabolismo dos fosfatos de alta energia durante a reperfusäo näo exerce papel fundamental na gênese do fênomeno do ''miocrdio atordoado'' em pacientes com infarto da parede anterior.

Limpieza colónica mecánica, polietilenglicol vs. una nueva preparación de bajo volumen: evaluación prospectiva, randomizada y ciega / Colonic cleasing: polyethilenglicol vs. minimum volume solution: prospective, randomized and double blind study

Introducción y objetivo: el método para lograr una adecuada limpieza colónica debe ser eficaz, seguro, bien tolerado y de fácil implementación. Muchas variantes han sido probadas, siendo actualmente la solución de polietilenglicol (PEG) la más utilizada. Su principal desventaja es el volumen que debe ingerirse (4 litros). Esto motivó la introducción de una solución de bajo volumen (90 ml) a base de fosfatos sódicos (FS). El objetivo del presente trabajo fue el de comparar ambas soluciones en términos de eficacia, tolerancia y costos. Material y método: entre Setiembre de 1995 y Marzo de 1996, 373 pacientes que debían someterse a videocolonoscopia, colon por enema o cirugía colorrectal fueron randomizados para recibir solución de PEG (n = 188) o de FS (185). En el mismo período, a 42 pacientes que habían recibido previamente PEG y debían repetir la preparación se les indicó FS. La tolerancia fue evaluada a través de cuestionarios completados por los mismos pacientes y la eficacia por médicos endoscopistas, radiólogos o cirujanos que no conocían la solución administrada. Resultado: la proporción de limpieza aceptable (excelente o buena) fue similar en ambos grupos (PEG: 88,2 por ciento), FS: 82,2 por ciento, p > 0,05). Considerando los grados de tolerancia "excelente" y "buena" en conjunto, no hubo diferencias entre los grupos (PEG: 65 por ciento, FS 65,5 por ciento), p > 0,05). Tampoco la incidencia de efectos adversos fue significativamente diferente (PEG: 60 por ciento, FS 58 por ciento, p > 0,05). Sin embargo, una menor proporción de pacientes pudieron completar la ingesta de PEG (PEG: 71 por ciento, FS 88 por ciento, p < 0,01). Ademas, 41 de los 42 pacientes que habían recibido previamente PEG evaluaron al FS como "mejor" o "mucho mejor". No se registró ninguna complicación grave atribuible a las diferentes preparaciones. La diferencia en el costo total durante el período de estudio fue de 5858,33 pesos a favor del FS. Conclusiones: la presente es la primera evaluación comparativa prospectiva, randomozada y ciega entre las soluciones de PEG y FS para la preparación colónica en estudios endoscopicos, radiológicos y quirúrgicos. La nueva preparación se mostró tan efectiva y segura como la de PEG. Si bien la tolerancia y el desarrollo de efectos adversos fueron similares en ambos grupos, los pacientes que habían tomado PEG previamente mostraron una marcada preferencia por el nuevo preparado. La reducción del costo es una ventaja adicional para la...

Fluorose em ratos induzida pela ingestäo contínua dos fosfatos brutos de rocha: morfologia do dente e osso alveolar / Fluorosis in rats due Brazilian rock phosphates: tooth and alveolar bone morphology

Avaliaram-se os efeitos do flúor, presente em fosfatos brutos de rocha, sobre o dente e osso alveolar de ratos (Ratus ratus), alimentados com uma dieta básica acrescida dos fosfatos de Araxá, Patos de Minas e Tapira, em dois níveis de fósforo disponível (0,15 e 0,25 por cento). Os animais controle receberam a mesma dieta básica, mas sem qualquer suplementaçäo de fósforo. Independente da fonte testada, todos os animais apresentaram lesöes típicas da fluorese dentária e comprometimento do osso alveolar

Effect of ammonia, urea and diammonium phosphate (DAP) on lung functions in fertilizer plant workers.

A spirometric study (FVC, FEV1 & PEFR/Min) was carried out in workers exposed to fertilizer chemicals (91) as a whole, out of which 31 were Ammonia, 30 Urea and 30 DAP plant workers, and 68 were controls belonging to the same age, sex, body surface area and socio-economic status. This study showed significant reduction in both PEFR/min and FEV1, the reduction being more in PEFR/Min., seems to indicate obstructive type of lung changes affecting the larger air-ways first, followed by bronchospasm. But FVC showed a significant reduction only after more than 10 years of exposure, probably causing restrictive changes only after prolonged exposure. Out of the 3 chemicals, DAP affected all the 3 parameters most, followed by Ammonia and Urea affected the least.

Technical problems related to the analysis of the effects of inorganic phosphate on cardiac muscle

We describe how potential artifacts (due to solution composition, buffering capacity of the bathing medium, size of the skinned fiber preparation, permeability of the sarcoplasmic reticulum (SR) vesicles, and proper Kd for Ca2+ of the fluorescent indicator used to measure Ca2+ transport can be avoided in order to determine the effects of inorganic phosphate (Pi, or any other ion) on m,aximum Ca2+ activated force (Fmax) and Ca2+ sensitivity of skinned cardiac muscle fibers, and Ca2+ -ATPase activity and uptake properties of isolated cardiac SR-enriched vesicles. To maintain the ionic strengh of the bathing medium constant when adding Pi, other ions must be removed. We found that because some salts have a depressant effect on Fmax independent of increaqsed ionic strength (e.g. KCl) while others do not (e.g. Na-acetate), the salt used to adjust ionic strength influences the measured depressant effect of Pi on Fmax. The sensitivity to Ca2+ of the contractile apparatus depends on the sum of the [Na+] and [K+] in the bething medium. However, we found that the effect of Pi on Ca2+ sensitivity was not significantly influenced by the small changes in the sum of [Na+] and [K+] that were associated with the addition of Pi. The skinned fiber preparations were approximately cylindrical bundles with diameters ranging between 100 and 250 um. We found that the effect of Pi on Fmax was not influenced by diffusion limitations over this range of bundle diameters. The pH buffering capacity of the bathing solution affects Fmax at pH 6.6. We found that the buffering effect of Pi can influence the mechanical response of skinned fibers independent of a Pi on the contractile apparatus when the buffering capacity of the control solution is low. When the Ca2+-ATPase of isolated SR vesicles is activated by Ca2+ and MgATP, the vesicles accumulate Ca2+. Unless the vesicles are permeabilized with a Ca2+ ionophore (ionomycin) and the pH adequately buffered, maximum ATPase activity will be underestimated, the broadness of the curve relating Ca2+ - ATPase rate overestimated, and the sensitivity to Pi overestimated. The ionic milieu of isolated SR vesicles changes the apparent dissociation constant (Kd) of Ca2+-Fura-2, a fluorescent dye used to quantify SR Ca2+ transport rates. In order to accurately measure the inhibitory effect of Pi on Ca2+ uptake, the influence of Pi on the Kd of Fura-2 for Ca2+ must be taken into account

Metodo direto para dosagem de fosfato inorganico no soro e urina (Metodo MCL) / Direct method for inorganic phosphate assay in serum and urine

Apresentamos um metodo colorimetrico direto, simples, sensivel, preciso e exato para a determinaçao do fosfato inorganico em amostras de soro e urina. Os reagentes sao estaveis, facilmente preparados e economicos. A reaçao se passa entre o fosfato e a soluçao molibdico-sulfurica para formar o complexo de fosfomolibdato, que e reduzido a azul de molibdenio pelo sulfato de p-metilaminofenol (ELON) na presença de dietanolamina, um potente solubilizante do precipitado formado. Os resultados de dosagens obtidos com o novo metodo apresentam excelente correlaçao com os do metodo de desproteinizaçao de GOMORY (6-7) e com 2 tecnicas diretas industrializadas