Download Intermediate bioelectrolyte changes after phospho

Nephrol Dial Transplant (2012) 27: 752–757
doi: 10.1093/ndt/gfr189
Advance Access publication 26 May 2011
Intermediate bioelectrolyte changes after phospho-soda or polyethylene
glycol precolonoscopic laxatives in a population undergoing health
examinations
Wei-Chih Kan1,2,*, Hsien-Yi Wang1,3,*, Chih-Chiang Chien1,4, Che-Kim Tan5,6, Ching-Yih Lin6,7 and
Shih-Bin Su8,9
1
Division of Nephrology, Department of Medicine, Chi-Mei Medical Center, Tainan, Taiwan, 2Department of Medical Laboratory
Science and Biotechnology, Chung Hwa University of Medical Technology, Tainan, Taiwan, 3Department of Sport Management,
College of Leisure and Recreation Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan, 4Department of Food
Nutrition, Chung Hwa University of Medical Technology, Tainan, Taiwan, 5Department of Intensive Care Medicine, Chi-Mei Medical
Center, Tainan, Taiwan, 6Institute of Medical Research, Chang Jung Christian University, Tainan, Taiwan, 7Department of
Gastroenterology, Chi-Mei Medical Center, Tainan, Taiwan, 8Department of Family Medicine, Chi-Mei Medical Center, Taiwan and
9
Institute of Biomedical Engineering, Southern Taiwan University, Taiwan
Correspondence and offprint requests to: Shih-Bin Su; E-mail: [email protected]
*These authors have equally contributed to this work.
Abstract
Background. Colonoscopy is a common procedure for
diagnosing and screening colon cancer and other bowelrelated diseases. Many studies have pointed out that using
phospho-soda as a bowel preparation can cause obvious
electrolyte abnormalities or acute kidney injury. Nonetheless, there are few studies related to its prevalence and risk
factors in the population undergoing health examinations.
Our aim was to compare the biochemical and electrolyte
changes after using two commonly used bowel preparation
regimens in this population.
Methods. In this retrospective study, we collected data
about participants who, before a screening colonoscopy,
used oral phospho-soda laxatives in 2006, and those who
used polyethylene glycol-based laxatives in 2005. Several
serum biochemical and electrolyte profiles were compared
between the two groups. Additional risk factors of hyperphosphatemia, a well-known side effect of phospho-soda,
were also derived.
Results. We enrolled a total of 2270 participants (1321 in
2005; 1449 in 2006). The basic demographic data of the two
groups were not statistically different. Nonetheless, between
the two groups, some serum biochemical and electrolytic data
differed significantly: in those using oral phospho-soda
laxatives, we found a higher prevalence of hyperuricemia,
hypocalcemia, hypokalemia, hypernatremia and hyperphosphatemia. Further analyses showed that using oral phosphosoda laxatives was a risk factor for hyperphosphatemia;
conversely, being male was a protective factor.
Conclusions. Oral phospho-soda laxatives indeed influence the biochemical and electrolyte profiles of persons
undergoing health examinations. One should be careful
when interpreting bioelectrolytic data while using phospho-soda as a bowel preparation.
Keywords: colonoscopy; Fleet phospho-soda; hyperphosphatemia;
hyperuricemia; hypocalcemia
Introduction
High-phosphate-containing enemas and laxatives (such as
Fleet phospho-soda, Visicol and OsmoPrep) are widely
used as bowel preparations before colonoscopy due to their
effectiveness and patient compliance [1]. However, recently, there have been many reports of severe complications, such as acute renal failure [2–6] and tetany due to
hypocalcemia [7–9]. For example, in a 71-year-old woman
who developed electrolyte abnormalities and acute kidney
injury (AKI), a renal biopsy revealed different grades of
calcium–phosphate deposition in the distal tubules and interstitial tissue [10]. This case led to a new term: acute
phosphate nephropathy (APhN). A study [11] of 21 cases
found that the patients shared various degrees of renal and
electrolyte abnormalities after taking phospho-soda laxatives. The risk factors included being white, female, elderly
and dehydrated, as well as taking medications that affect
the glomerular filtration rate (GFR), such as diuretics,
angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and nonsteroidal anti-inflammatory drugs.
As many adverse events had been reported [12–18], the
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Bioelectrolyte changes after laxatives
American Food and Drug Administration also disclosed
reports about the side effects of several phospho-soda laxatives [19]. AKI caused by phospho-soda laxatives is rare
but severe, and it can lead to irreversible renal function
declines that require long-term dialysis. Drinking >45
mL of phospho-soda laxatives may cause electrolyte disturbances, such as shifts in serum levels of calcium, phosphate, sodium and potassium, but rarely apparent adverse
events [20, 21].
Research on the adverse effects of phospho-soda is
usually done on patients. There are, however, few published reports of bioelectrolyte and renal function changes
in relatively healthy populations after they have used
phospho-soda laxatives. One large-scale survey of relatively healthy individuals who took oral phospho-soda
laxatives before a screening colonoscopy [22] focused
on the changes in renal function 12–24 months later.
Therefore, because of our desire to prevent possible adverse events or misinterpretation of laboratory data on
health examinations, we conducted a study on a relatively
healthy population to assess the prevalence and severity
of various bioelectrolyte and renal function changes after
the use of phospho-soda laxatives and to identify the characteristics of individuals at high risk for bioelectrolyte
abnormalities.
Materials and methods
In 2006, the Healthcare Center of Chi-Mei Medical Center in Taiwan
introduced a phospho-soda product (Fleet phospho-soda; CB Fleet Company, Inc., Lynchburg, VA) as a substitute for polyethylene glycol
(PEG) laxatives (Klean-prep; Helsinn Birex Pharmaceuticals Ltd, Dublin,
Ireland, UK) for bowel preparation before a health examination. Most of
the study participants were employed at companies that offered annual or
biannual medical screening. We collected data from participants who took
oral phospho-soda laxatives for bowel preparation for a screening colonoscopy and had complete bioelectrolyte analyses in 2006. A group of participants who used PEG laxatives in 2005 served as the control group. The
participants were all relatively healthy and had no known conflicts with the
contraindications of the currently approved phospho-soda bowel preparations: age < 18 years, history of overt renal function impairment or on
dialysis, congestive heart failure, ascites, bowel obstruction, toxic colitis or
megacolon or other acute gastrointestinal problems, such as acute gastrointestinal bleeding or severe inflammatory bowel disease [23]. Participants
who met the above criteria or had incomplete biochemical data were
excluded from the analysis.
This study was approval by the Institutional Review Board of Chi-Mei
Medical Center and complied with patient confidentiality.
Bowel preparation procedure
All participants in the phospho-soda group drank 45 mL of phospho-soda
(each 5 mL contained 2.4 g of monobasic sodium phosphate, 0.9 g of
dibasic sodium phosphate and 556 meq of sodium) at 8 am and 8 pm 1 day
prior to colonoscopy. The patients were asked to take each dose with 360
mL of water, along with 240–480 mL of water per hour thereafter to
prevent dehydration. Participants in the PEG group drank the solution with
one sachet of Klean-Prep in 1 L of cold water, at the rate of 250 mL every
10–15 min, till the bowel content was clear or up to four sachets, since
6 pm 1 day prior to colonoscopy. In these two groups, clear liquid diet
regimens were kept for one whole day before colonoscopy, and blood
sampling was taken at 8 am on the examination day (~24 h after ingesting
the first dose of phospho-soda; 14 h after Klean-Prep). Those who participated in the study completed a basic physical examination, urinalysis,
complete blood count and serum bioelectrolyte analyses. The estimated
GFR (eGFR) was calculated according to the Modification of Diet in Renal
Disease study formula [24, 25]. Demographic and clinical data were collected from the medical records.
753
Statistical analysis
We entered the data into a Microsoft Excel 2007 spreadsheet and imported it to SPSS 17.0 (SPSS Inc., Chicago, IL) for statistical analysis.
Descriptive analyses were done on various serum biochemical and electrolyte abnormalities. For differences between the two groups, ordinal
demographic data were evaluated using the v2 test or Fisher’s exact test,
and continuous data were evaluated using Student’s t-test. Furthermore,
logistic regression analyses were used to estimate the possible risk factors
of bioelectrolyte abnormalities. All tests were performed at a two-tailed
significance level of 0.05.
Results
Excluding patients with incomplete data, data from the records of 2770 participants were studied. Of the 1321 who
underwent health examinations in 2005 [Group 2005: 769
men (58.2%); 927 between 40 and 65 years old (70.2%)],
1253 underwent a colonoscopy (94.9%). In 2006, 1449
patients underwent health examinations [Group 2006:
894 men (61.7%); 1020 between 40 and 65 years old
(70.4%)] and 1394 (96.2%) underwent a colonoscopy.
The two groups did not significantly differ in terms of basic
demographic data (Table 1).
Among those who did not have a colonoscopy, renal
function indicators and electrolyte levels did not differ between the 2005 and 2006 groups (Table 2). In contrast,
among those who did have a colonoscopy, all the variables
analyzed, except for serum creatinine, eGFR and urinary
parameters, differed significantly between the 2005 and
2006 groups. The prevalence of patients with serum uric
acid levels >9.0 mg/dL differed remarkably between those
given phospho-soda laxatives in 2006 (phospho-soda
group) and those given PEG laxatives in 2005 (PEG group)
(9.9 versus 6.2%, P ¼ 0.001). The phospho-soda group
also had a higher prevalence of hypocalcemia (<8.8
mg%) (12.9 versus 4.9%, P < 0.001), hypernatremia
(145–152 mEq/L) (12.3 versus 4.2%, P < 0.001), hypokalemia (<3.0 mEq/L) (1.1 versus 0.1%, P < 0.001) and
hyperphosphatemia (>4.7 mg%) (30.1 versus 4.5%, P <
0.001); they also had a high calcium–phosphate product
(Ca 3 P > 55 mg2/dL2) (4.2 versus 0.3%, P < 0.001)
(Table 2).
Univariate regression showed that using phospho-soda
laxatives was a risk factor for developing hyperphosphatemia [odds ratio (OR) ¼ 8.95, 95% confidence interval (CI):
6.72–11.92] as was a low body mass index (BMI).
Being male was a protective factor (OR ¼ 0.53, 95%
CI: 0.44–0.65). Multivariate regression showed that using
phospho-soda laxatives was an independent risk factor for
hyperphosphatemia (OR ¼ 9.49, 95% CI: 7.06–12.74),
while being male was an independent protective factor
(OR ¼ 0.49, 95% CI: 0.39–0.62) (Table 3). The differences
in age between those with and without hyperphosphatemia
were not significant.
Discussion
We found that phospho-soda and PEG laxatives led to no
obvious renal function impairments, but they did cause
different serum electrolyte changes, which implies that
754
W.-C. Kan et al.
a
Table 1. Demographic data of the two study groups (n ¼ 2770)
Group 2005b
Group 2006c
All
P
(n ¼ 1321)
Laxative before a colonoscopy
No
68
Yes
1253
Gender
Female
552
Male
769
Age
<40
265
40–65
927
>65
129
BMI
<18.5
47
18.5–24.0
664
24.0–27.0
389
>27
220
%
(n ¼ 1449)
%
(n ¼ 2770)
%
5.1%
94.9%
55
1394
3.8%
96.2%
123
2647
4.4%
95.6%
41.8%
58.2%
555
894
38.3%
61.7%
1107
1663
40.0%
60.0%
20.0%
70.2%
9.8%
302
1020
127
20.8%
70.4%
8.8%
567
1947
256
20.5%
70.3%
9.2%
3.6%
50.3%
29.5%
16.6%
75
735
408
231
5.2%
50.7%
28.2%
15.9%
122
1399
797
451
4.4%
50.5%
28.8%
16.3%
0.084
0.061
0.619
0.191
a
P: v2 test.
Group 2005 used a PEG-based laxative, only if they underwent a colonoscopy.
c
Group 2006 used a phospho-soda laxative, only if they underwent a colonoscopy.
b
the ‘electrolyte loading’ of phospho-soda laxatives exceeded the rate of renal excretion even after 1 day in a
relatively healthy population. It is noteworthy that as many
as 30.1% of the participants had hyperphosphatemia. Previous studies have shown that hyperphosphatemia may occur in healthy individuals, but that it is often transient and
asymptomatic. In one study [26] of seven healthy individuals who used the standard oral phospho-soda regimen,
peak serum phosphate levels were reached 6 h after they
had ingested the first dose, while mild hyperphosphatemia
remained after 24 h. A study [27] of 24 healthy adult volunteers showed that serum phosphate levels peaked at 14 h
and then returned to normal limits within 24 h. The recommended dietary allowance for phosphorus in adults is ~0.7–
1.25 g/day; therefore, a 90-mL dose of phospho-soda has
43.2 g of monobasic sodium phosphate and 16.2 g of dibasic sodium phosphate, equivalent to 11.52 g of elemental
phosphate, which gives the kidney a large phosphate burden. In addition, when a person is dehydrated, the proximal
tubules not only increase the reuptake of water but also of
phosphate, which reduces the excretion of phosphate.
Therefore, current known risk factors for developing hyperphosphatemia include age [28], dehydration [29], drugs
that affect the GFR [30], diabetes mellitus [31], and chronic
kidney disease [32]. Additionally, a marked increase of
phosphate causes calcium deposition within blood and tissues, causing distal renal tubule obstruction (i.e. APhN) or
obstruction of small arteries [33], which may be evaluated
by the calcium–phosphate product (Ca 3 P). In current
practical guidelines, this value is suggested to be <55
mg2/dL2 [34]; otherwise, the risk of coronary arterial and
ectopic calcification (calciphylaxis) increases significantly
[11, 35–37]. Therefore, we use the product of 55 as a cutoff
point of calcium–phosphate deposition. In our study, the
values of Ca 3 P among the participants using phosphosoda were also significantly higher than for the PEG
group, even 24 h after use. Although the duration of a
high Ca 3 P product is uncertain, it may cause more
obvious calcium–phosphate deposit in the distal renal tubule,
and this can lead to APhN. Moreover, phospho-soda contains large amounts of sodium and so serum sodium rises
[27]. If patients have edema or heart failure, symptoms of
fluid overload can worsen; our data showed that 12.3% of
participants developed hypernatremia. Furthermore, the
risks of hypocalcemia and hypokalemia also increased with
phospho-soda use. Our results for phospho-soda agreed with
those of other studies [38].
Interestingly, we found that, regardless of univariate and
multivariate regression analyses, being male was a protective factor against the development of hyperphosphatemia
(OR ¼ 0.49, 95% CI, 0.39–0.62). Another study [10] also
found that women were predominant among patients with
APhN. One possible explanation is that women have lower
body weight and BMI than men but took the same
phospho-soda dose [39]. However, the eGFR value was
higher in women than in men in our study population (Table 4), and a higher eGFR reflects a higher capacity for
phosphate excretion. Therefore, dosage alone does not
completely explain this phenomenon. A previous study
[40] offers a possible explanation: in a rabbit model, female
hormones, such as estradiol-17, estrone and estriol, stimulated the reuptake of phosphate in the proximal tubule. The
authors concluded that at biological levels, female hormones stimulated proximal tubular reuptake of phosphate
via an estrogen receptor-mediated pathway. Perhaps this
explains, in part, why men excrete more phosphate, thus
reducing the elevation of serum phosphate, and have a
lower risk of APhN.
Our study has some limitations. (i) The participants were
fee-paying patients undergoing health examinations.
Although no obvious renal function deterioration was
detected after taking the phospho-soda laxatives, we
had no available baseline creatinine clearance rate data;
thus, ‘minor’ AKI in the participants might have been
underestimated. (ii) Because it was a retrospective
study, and some of the measured parameters are weak
Bioelectrolyte changes after laxatives
755
a
Table 2. Comparison of renal function and bio-electrolyte changes between Group 2005 and Group 2006 (n ¼ 2770)
Participants who took a laxative bowel preparation
before a colonoscopy (n ¼ 2647)
Participants not undergoing colonoscopy and took no
laxative bowel preparation (n ¼ 123)
P
Variable
Group 2005
Group 2006
0.98 6 0.21
0.99 6 0.25
Group 2005
Serum creatinine
(mg/dL)
Renal function
(eGFR: mL/
min/
1.73m2)
<30
30–60
>60
Uric acid
(mg/dL)
<7.0
7.0–9.0
>9.0
Serum calcium
(mg/dL)
<8.8
8.8–10.4
>10.4
Serum phosphate
(mg/dL)
4.7
>4.7
Ca 3 P
(mg2/dL2)
55
>55
Serum sodium
(mEq/L)
125–130
130–145
145–152
Serum potassium
(mEq/L)
<3.0
3.0–5.0
>5.0
USG
<1.005
1.005–1.030
>1.030
Urine protein
Negative
Trace
11
21
31
2
69
1182
0.2%
5.5%
94.3%
7
78
1309
P
%
0.06b
0.356
0.5%
5.6%
93.9%
%
Group 2006
0.96 6 0.21
%
0.18b
0.446c
1.02 6 0.27
0
3
65
0%
4.4%
95.6%
1
4
50
1.8%
7.3%
90.9%
53
12
3
77.9%
17.6%
4.4%
33
18
4
60.0%
32.7%
7.3%
4
63
1
5.9%
92.6%
1.5%
2
51
2
3.6%
92.7%
3.6%
0.001
770
405
78
61.5%
32.3%
6.2%
780
475
138
56.0%
34.1%
9.9%
<0.001
61
1185
7
4.9%
94.6%
0.6%
180
1210
4
12.9%
86.8%
0.3%
95.5%
4.5%
975
419
69.9%
30.1%
66
2
97.1%
2.9%
52
3
94.5%
5.5%
0.447c
<0.001
1249
4
99.7%
0.3%
1335
59
95.8%
4.2%
1
1199
53
0.1%
95.7%
4.2%
0
1223
171
0%
87.7%
12.3%
<0.001c
68
0
0
63
5
100%
0%
0%
92.6%
7.4%
54
1
98.2%
1.8%
0
52
3
0%
94.5%
5.5%
0.1%
98.7%
1.2%
16
1370
8
1.1%
98.3%
0.6%
44
841
328
3.7%
69.3%
27.0%
45
922
395
3.3%
67.7%
29.0%
903
164
96
18
12
75.7%
13.7%
8.0%
1.5%
1.0%
1036
176
101
14
13
77.3%
13.1%
7.5%
1.0%
1.0%
0.73c
1.00c
<0.001
1
1237
15
0.652c
0.656c
<0.001
1197
56
0.106c
0
68
0
0%
100%
0%
0
55
0
0%
100%
0%
0.417c
0.516
3
41
22
4.5%
62.2%
33.3%
1
40
14
1.8%
72.7%
25.5%
49
8
6
1
1
75.4%
12.3%
9.2%
1.5%
1.5%
44
6
5
0
0
80.0%
10.9%
9.1%
0%
0%
0.793
0.768c
a
USG, urine specific gravity; P, v2 test.
Student’s t-test.
c
Fisher’s exact test.
b
indicators (e.g. urinary specific gravity), some findings of
bioelectrolyte abnormalities in our study seemed difficult to
illustrate (e.g. hyperuricemia).
In conclusion, new generation high-phosphatecontaining laxative preparations offer more convenient
and comfortable bowel preparation for patients undergoing a routine preventive colonoscopy. Although the
bioelectrolyte changes after phospho-soda were obvious,
their effects seemed transient and mostly asymptomatic
in a relatively healthy population. Still, after the study,
we reminded our staff to pay more attention to the pos-
sibility that patients who take Fleet phospho-soda might
develop hyperphosphatemia. In addition, the increased
incidence of bioelectrolyte disturbance may not only
cause physicians to misinterpret the biochemical and
electrolyte results but could also increase the risk of
calcium–phosphate deposition, especially in the distal
renal tubule, and this can lead to APhN. Thus, due to
the high incidence of phospho-soda-related bioelectrolyte problems, it is important to make adjustments to
the bowel preparation protocol for colonoscopy, such
as identifying risk factors in high-risk groups by closely
756
W.-C. Kan et al.
Table 3. Predictors of hyperphosphatemia (serum P > 4.7 mg/dL) via
univariate and multivariate analysesa
2.
Laxative
PEG
Phospho-soda
Gender
Female
Male
Age
<40
40–65
>65
BMI
<18.5
18.5–24.0
24.0–27.0
>27
OR (95% CI)b
AOR (95% CI)c
1
8.95 (6.72–11.92)*
1
9.52 (7.12–12.72)*
1
0.53 (0.44–0.65)*
1
0.49 (0.39–0.61)*
1
1.08 (0.84–1.39)
1.15 (0.78–1.69)
1
1.21 (0.92–1.60)
1.25 (0.82–1.91)
1
0.71 (0.46–1.09)
0.48 (0.30–0.75)*
0.49 (0.30–0.80)*
1
0.88 (0.55–1.41)
0.67 (0.40–1.11)
0.67 (0.39–1.14)
3.
4.
5.
6.
7.
a
P, phosphorus; AOR, adjusted OR.
b
Univariate logistical regression.
c
Multivariate logistical regression, with independent variables: laxative,
gender, age and BMI.
*P < 0.05.
8.
9.
Table 4. Body weight (BW), BMI and eGFR among participants (by
gender) taking phospho-soda laxativea
BW (kg)
BMI (kg/m2)
eGFR (mL/min)
a
Male
Female
70.07 6 10.75
24.42 6 3.21
78.20 6 12.1
55.83 6 9.07
22.70 6 3.76
82.90 6 17.2
P
<0.001
<0.001
<0.001
P, Student’s t-test.
10.
11.
12.
13.
monitoring electrolyte and renal function profiles, giving
adequate fluid replacement and withholding drugs that
affect glomerular filtration during laxative use. Because
of our study findings, we had to pay much attention to
these potential hyperphosphatemic participants after
they had used Fleet phospho-soda, for fear that they
would probably develop APhN in the following weeks.
Additional monitoring of bioelectrolytic data should be
considered for women. It is also important to modify the
current phospho-soda regimen, such as decreasing the
phospho-soda dose or increasing the time interval between doses [41, 42], which should help prevent not only
misinterpretation of bioelectrolytic data but also the risk
of kidney injury.
14.
15.
16.
17.
18.
19.
Acknowledgements. The study was supported by grant CMFHR-9758
from Chi-Mei Medical Center.
20.
Conflict of interest statement. None declared.
21.
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Received for publication: 23.11.10; Accepted in revised form: 17.3.11