VCOM Research Day Program Book 2023

Medical Resident Research Case Reports

07 Fleets Enema-Induced Acute Phosphate Nephropathy

William Arvan, MD, PGY2 Corresponding author:

SOVAH Health Internal Medicine Residency Program

patient's hyponatremia was likely the result of SIADH in the setting of small-cell lung carcinoma seen on CT imaging as a mediastinal mass and which was biopsied while in the hospital. During the hospital stay, the patient developed bright red blood per rectum with concern for GI bleeding and was evaluated by a GI specialist with EGD and sigmoidoscopy demonstrating severe candidiasis of the esophagus as well as ischemic colitis. In preparation for this sigmoidoscopy, the patient received Fleet enemas x2, 30 minutes apart, resulting in a significant increase of the patient's serum phosphate as well as a moderate rise in serum creatinine with acute kidney injury, likely as a result of phosphate nephropathy in the setting of Fleets enema administration. Overall, the patient's condition improved, and the patient was discharged with multiple appointments with specialists, including a pulmonologist, hematologist/ oncologist, nephrologist, and gastroenterologist, for the continued care of the conditions treated in the hospital. Conclusion: This case highlights the rare side effects of Fleet enemas, which can be seen in the hospital setting or present with the over-the-counter use of such enemas containing sodium phosphate. This case hopes to raise awareness of the possible side effects of Fleets enemas, as these enemas are commonly prescribed and used in the hospital and

outpatient settings. The result of rapid administration can result in a transient and potentially severe increase in serum phosphate and volume depletion from the bowl purgative itself. While the mechanism of kidney injury is not entirely understood, histological evidence from kidney biopsy provides insight. Calcium phosphate deposition into the kidney tubular epithelia and interstitium, along with tubular injury and inflammation is hypothesized to play a role. As a result of these mechanisms, the patient can present with an acute reversible kidney injury, or an acute phosphate nephropathy. The latter may occur within days to months following administration of the Enema containing sodium phosphate. Treatment strategy is mainly focused on avoiding bowel purgative containing oral sodium phosphate, especially in high-risk patients. If recognized early such as in this case, permanent injury can likely be avoided by providing adequate volume resuscitation to maintain adequate renal perfusion and urine output. If hyperphosphatemia is severely elevated, hemodialysis may be required.

Context: Fleets enema-induced acute phosphate nephropathy is a rare condition. Hyperphosphatemia can occur in the following ways: (1) excessive ingestion of phosphate over a short period, (2) massive release of intracellular phosphate in the setting of tumor lysis syndrome or rhabdomyolysis, (3) phosphate ingestion in the setting of impaired GI motility leading to increased absorption time, and (4) renal dysfunction leading to reduced excretion. Rarely excessive phosphate can be introduced into the patient's system by Fleet enemas (oral sodium phosphate rectal enema) which is the focus of this case presentation. Case presentation: 69-year-old Caucasian male presented to the emergency room for further evaluation of abnormal labs seen on routine evaluation at his primary care physician's office. The patient's sodium was severely decreased to 117. Additionally, the patient was complaining of shortness of breath with wheezing. The patient was managed in the hospital initially in the intensive care unit setting with fluid resuscitation, breathing treatments for chronic obstructive pulmonary disease exacerbation, and steroid therapy. The patient's hyponatremia was challenging to treat, prompting the involvement of Nephrology and therapies, including 3% saline and tolvaptan 1-time dose, which improved and normalized serum sodium. The


Made with FlippingBook Digital Proposal Maker