Case report
A 72-year-old female patient was admitted to the nephrology department due to inadequately controlled arterial hypertonus, non-dipper type, and declined function of a renal transplant. The patient has chronic renal failure secondary to type 1 diabetes. The patient began hemodialysis in 2007. She was treated with the phosphate binder lanthanum carbonate for 6 years, with a daily dose of 2000 mg/day orally. The patient received a combined pancreas and renal transplant in 2013. After the transplantation, immunosuppressive therapy with Tacrolimus (0,5mg/d) and Mycophenolat (1000mg/d) was started, and lanthanum carbonate was no longer taken. The pancreas transplant was explanted due to a T-cell-mediated rejection.
During the inpatient stay the patient developed bilious emesis without enteritis and without signs for an infectious genesis. A sonography of the abdomen was performed. It showed an empty stomach and distended, up to 31 mm, small bowel filled with fluids. An abdominal radiograph showed the bowel to be filled with stool and little gas with few air-fluid-levels in the central and right upper abdomen. No free abdominal gas was seen. The patient showed signs of coprostasis, and the diagnosis of a subileus was suspected. An upper gastrointestinal endoscopy was performed the next day. A reddened mucosa and hematin fragments were seen and a hemorrhagic gastritis was described. Biopsies were taken from the antrum and corpus of the stomach. Histologic evaluation of gastric biopsies showed near normal antral mucosa without significant inflammation. Notably, helicobacter-associated gastritis was not present. Gastric biopsies from the fundus displayed patchy fibrotic areas, preferentially underneath and between the foveolar epithelium. Here, histiocytes containing crystalline material were present without significant infiltrates of lymphocytes, plasma-cells, or granulocytes (Fig. 1 and 2). The specialized fundic glands were well preserved. The findings were considered typical for lanthanum-induced gastropathy.
After an enema the gastrointestinal symptoms were reduced. During the inpatient stay the arterial hypertonus was successfully managed and thus the edema and proteinuria could be reduced.