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Acute kidney injury post‐colonoscopy

A 78-year-old man presented to the emergency department with acute kidney injury 9 days following colonoscopy. Phosphate bowel preparation had provoked severe diarrhoea with 3 kg of weight loss. Subsequent blood tests demonstrated creatinine 610 umol/L, urea 29.9 mmol/L, potassium 5.2 mmol/L, bicarbonate 25 mmol/L and phosphate 1.88 mmol/L, and he was advised to present to the emergency department. Colonoscopy was done to investigate per rectal bleeding and demonstrated haemorrhoids. Other background included rheumatoid arthritis, ischaemic heart disease, aortic stenosis, mitral valve prolapse, hypertension and hypercholesterolaemia. Regular medications included colchicine, methotrexate, telmisartan and hydrochlorothiazide (which were subsequently withheld), ezetimibe, aspirin, atenolol, atorvastatin, folic acid, risedronate, cholecalciferol and calcium. Renal ultrasound showed echogenic kidneys with preserved corticomedullary differentiation. Creatinine peaked at 660 umol/L on the day of presentation. Baseline creatinine was 100 umol/L. There was no pyuria, haematuria or proteinuria. Antinuclear antibodies and antineutrophil cytoplasmic antibodies were negative. Creatinine improved to 307 umol/L with intravenous fluid rehydration, and he was discharged home. Over the next 2 months creatinine reached as low as 222 umol/L but did not return to baseline, therefore renal biopsy was arranged. Renal biopsy demonstrated chronic tubulointerstitial nephritis with nephrocalcinosis characterised by tubular calcium phosphate deposition consistent with a diagnosis of phosphate nephropathy (Fig. 1). Colonoscopies are frequently performed in Australia with 568 208 Medicare-funded colonoscopies performed in the 2013–2014 financial year. Bowel preparation-induced phosphate nephropathy was first documented in 2003 by Desmeules et al. There have been case reports and a case series of 31 patients leading to phosphate bowel preparation being taken off the market in the USA; however, it is still available in Australia. This is the first reported case of phosphate nephropathy in Australia. Several potential risk factors for phosphate nephropathy have been identified including older age (>65 years), pre-existing renal failure, cardiac failure, hypertension, diabetes and use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics or non-steroidal anti-inflammatory drugs. Guidelines recommend that phosphate bowel preparation be avoided in patients with these risk factors and that for other patients the following precautions be taken: the minimal effective dose of phosphate bowel preparation