Letter to the Editor
Colonic mucosal ulceration following administration of calcium polystyrene sulfonate
Úlceras en el colon tras la toma de resina de poliestireno sulfonato cálcico
Lucía Álvarez Santamarta
Corresponding author
Área de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
Adela Alonso Fernández-Velasco
Servicio de Anatomía Patológica, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
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"etiqueta" => "a" "identificador" => "aff0015" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "etiqueta" => "b" "identificador" => "aff0020" ] 2 => array:3 [ "entidad" => "Red de Investigación Renal (REDINREN), Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0025" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Úlceras en el colon tras la toma de resina de poliestireno sulfonato cálcico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 510 "Ancho" => 1700 "Tamanyo" => 274419 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Colon biopsy. A) H&E<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10: mucosal inflammation, atrophy, and ulceration (black arrows). Resin deposits (red arrows). B) H&E<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40: polygonal crystal deposit with mosaic or “fish scale” pattern (black arrow). C) PAS<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40: polygonal crystal deposits with reddish staining (red arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Polymeric cation-exchange resins, which can be sodium or calcium polystyrene sulphonate, are the usual treatment for chronic hyperkalaemia. In the last 25 years, several complications associated with its use have been described, with intestinal obstruction and colon necrosis being the most serious and lethal<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 57-year-old man with chronic kidney disease (CKD) with an estimated glomerular filtration rate of 23<span class="elsevierStyleHsp" style=""></span>ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>. In the presence of hyperkalaemia (K<span class="elsevierStyleSup">+</span> 5.7<span class="elsevierStyleHsp" style=""></span>mmol/l), treatment with calcium polystyrene sulfonate resin was prescribed. After one month, the patient developed rectal bleeding without systemic implications. A colonoscopy showed ulcers on the colon mucosa. A complete loss/atrophy of the epithelial component (surface and glandular) and associated ulceration were observed in the biopsies; the lamina propria showed a moderate acute and chronic inflammatory infiltrate, reaching the <span class="elsevierStyleItalic">muscularis mucosae</span> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A); characteristically, deposits with a mosaic pattern or “fish scales” that turn purplish/basophilic with haematoxylin-eosin (H&E) staining (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) and reddish with periodic acid Schiff (PAS) staining (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C) were observed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The findings described were compatible with calcium polystyrene sulfonate crystals/resins and the atrophy, inflammation and ulceration described could be a consequence of such drug treatment.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Given the clinical and hemodynamic stability, and without having observed major complications in the colonoscopy, conservative management was decided by discontinuing the cation-exchange resin. The clinical course was favourable.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Cation exchange resins have been used for the treatment of hyperkalaemia since 1975<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. Its action takes place mainly in the colon. They are formulated to be administered orally or rectally in aqueous solution<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. When constipation became apparent, a treatment was prescribed consisting of dissolving the potassium captor in sorbitol, an osmotic laxative, was prescribed. Subsequently, the side effects of sorbitol advised against its widespread use<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Given its physicochemical characteristics, the resin can crystallize and deposit on the intestinal wall leading to an acute inflammatory reaction. Sorbitol causes vasoconstriction with decreased intestinal blood flow, as well as cellular dehydration due to its osmotic capacity, it also has a direct toxic action on the intestinal mucosa by increasing inflammatory mediators such as prostaglandins (PG). Therefore, although the underlying pathophysiological mechanism is not clear, after reviewing the literature, both components, whether associated or individually, can cause intestinal necrosis regardless of the route of administration. The most commonly affected areas of the gastrointestinal tract are the distal ileum and the colon<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Various risk factors that favour this complication have been described, such as CKD, arterial hypotension, hypovolemia, inflammatory bowel disease, drugs that decrease intestinal motility, solid organ transplantation, and immunosuppressive treatment. Patients with CKD are more prone to intestinal necrosis due to different causes such as intradialytic hypotension, increased PG production or hyperreninemia that favours non-occlusive mesenteric ischemia mediated by angiotensin II<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnosis must be established through a biopsy. The presence of polygonal basophilic crystals should be observed with H&E staining and a mosaic or “fish scale” pattern and reddish crystals with PAS staining<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Referring to our case, the patient had CKD as a risk factor, but he did not receive sorbitol laxative. However, reviewing his chronic treatment, he was taking Distraneurine® (clomethiazole), with sorbitol being an excipient of it, the dose of which had recently been increased, which makes us think that it may have contributed to the process.</p><p id="par0050" class="elsevierStylePara elsevierViewall">After prescribing a cation-exchange resin, we recommend close monitoring of the patients, since gastrointestinal toxicity may initially be mild and allow a conservative attitude by discontinuing the drug, as we have described in our case.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In recent years, 2 drugs have been synthesized to treat hyperkalaemia: patiromer<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and sodium zirconium cyclosilicate<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. Their efficacy has been demonstrated through randomized clinical trials, and they seem to have fewer gastrointestinal adverse reactions. Both have already been approved by the European Medicines Agency, so they could replace cation-exchange resins.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Álvarez Santamarta L. Úlceras en el colon tras la toma de resina de poliestireno sulfonato cálcico. Med Clin (Barc). 2020;156:40–41.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 510 "Ancho" => 1700 "Tamanyo" => 274419 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Colon biopsy. A) H&E<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10: mucosal inflammation, atrophy, and ulceration (black arrows). Resin deposits (red arrows). B) H&E<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40: polygonal crystal deposit with mosaic or “fish scale” pattern (black arrow). C) PAS<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40: polygonal crystal deposits with reddish staining (red arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cation Exchange Resins and Colonic Perforation. What Surgeons Need to Know" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.R. Rodríguez" 1 => "E. Férnandez" 2 => "J.E. Guarneros" 3 => "J. Tueme" 4 => "J.R. 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| 2023 March | 3 | 5 | 8 |
