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.