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Latest revision as of 01:18, 29 June 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayesha Javid, MBBS [2]

Overview

Phosphate nephropathy is a clinical manifestation of irreversible kidney injury after the consumption of phosphate-containing bowel preparations such as oral sodium phosphate (OSP), leading to acute kidney injury followed by chronic renal failure. It is characterized by diffuse tubular injury with abundant calcium phosphate deposits in the tubules due to which it is also called acute nephrocalcinosis.

Historical Perspective

In 1990, Oral sodium phosphate purgative got acceptance as a bowel preparation agent prior to colonoscopy.^[1]
This was due to the reason that less amount of drug was required leading to increased patient's compliance, less discomfort and improved bowel cleansing as compared to other available bowel purgatives including polyethylene glycol.^[2]
The first case of acute kidney injury followed by chronic kidney disease due to oral sodium phosphate consumption was reported in 1975. In 2003, deposition of calcium phosphate was observed in the renal tubules after the consumption of the drug.^[3]
Due to repeated acute phosphate nephropathy cases after the oral sodium phosphate ingestion, on 11 December 2008, United States Food and Drug Administration prohibited its over-the-counter purchase of and limited its purchase to prescription only. Soon this product was withdrawn from the market and now it is no longer available as an option for bowel preparation before a colonoscopy or any other procedure.^[4]

Pathophysiology

Hyperphosphatemia

Oral sodium phosphate consumption leads to hyperphosphatemia. Particularly, those patients who have to consume a large amount of Oral Sodium Phosphate as a bowel purgative before an elective colonoscopy have markedly elevated phosphate levels in the blood.^[5] This is due to increase phosphate absorption from the small intestine and lack of downregulation of sodium-phosphate cotransporters in the small intestine even when a large amount of phosphate has already been absorbed.^[6]

Hyperphosphatemia affects the kidneys by increasing the intratubular phosphate concentration, resulting in the deposition of calcium phosphate in the distal tubule and collecting duct. It directly damages the tubular epithelial cells and leads to luminal obstruction. The calcium phosphate crystals activate the innate immune system due to recognition by the epithelial TLRs leading to to tubular injury.^[7] ^[8] ^[9]

Volume depletion

Oral sodium phosphate preparations are osmotic purgatives which lead to osmotic diarrhoea.^[9] Consumption of a large amount of oral sodium phosphate bowel purgative prior to elective colonoscopy leads to volume depletion. Also before elective colonoscopy, patients are advised not to consume anything by mouth.^[10]
The volume depletion leads to increased reabsorption of sodium chloride and water via the proximal tubule. Also, there is ongoing water reabsorption in the descending limb of the loop of Henle. The combined effect of these results in increased calcium phosphate in the tubules.^[11]
The volume depletion increases the surface expression of hyaluronan and osteopontin which increases the adherence of calcium phosphate crystals to the distal tubule epithelium leading to precipitation and deposition of calcium phosphate in the lumen of the nephrons.^[12]

Differentiating Acute Phosphate Nephropathy from other Diseases

Acute Phosphate Nephropathy needs to be differentiated from other causes of nephrocalcinosis which are associated with hypercalcemia such as;

It should also be differenitated from a rare case of nephrocalcinosis associated with hyperphosphatemia due to Phosphate supplements for the treatment of hypophosphatemic rickets^[14]^[13]

Epidemiology and Demographics

Gender

Several studies report a higher incidence among females as compared to males.^[2] ^[15] ^[9] ^[16]
It could be related to their smaller heights and subsequently lower GFR as compared to men. Hence the same amount of Oral sodium phosphate could be more harmful to the women than men.^[17]

Age

Several epidemiological studies have identified advanced age as an independent risk factor of acute phosphate nephropathy, particularly age 55 and more.^[2] ^[16] ^[18]

Ethnicity

A higher prevalence has been seen among Caucasians.^[16] ^[2]

Risk Factors

Dose of Oral Sodium Phosphate administered

The risk of acute phosphate nephropathy is directly related to the dose of Oral Sodium Phosphate (OSP) administered. The higher the dose administered, more will be blood phosphate levels and hence there would be a higher chance of harming kidneys and resulting in nephropathy.^[19]

Chronic Kidney disease

A chronic kidney disease patient will have a decrease glomerular filtration rate (GFR). Oral Sodium Phosphate (OSP) administration is seen to increase the creatinine levels further worsening their kidney functions. Therefore, Oral Sodium Phosphate is contraindicated in chronic renal disease patients. Instead, polyethylene glycol (PEG) has been found to be a good alternative. ^[20]

Advanced age

Researchers agree that advanced age is an independent risk factor for acute phosphate nephropathy. One research shows the median age to be 64 years, however, although most studies agree on the advanced age is a strong risk factor, but are unable set a particular age limit.

Co-morbid conditions

Co-morbidities such as hypertension and diabetes mellitus have been found to further increase a patient's risk to acute phosphate nephropathy. ^[15] ^[21] ^[22]

Drugs

The following drugs have been found to be a risk factor for acute phosphate nephropathy:^[7] ^[23]

Natural History, Complications and Prognosis

The patient with acute phosphate nephropathy present with the clinical features of acute kidney injury such as oliguria/or anuria, and volume depletion such as hypotension, cold extremities, dry mucous membrane and increased skin turgidity, following the consumption of oral sodium phosphate bowel purgative for the purpose of bowel cleansing prior to colonoscopy.^[24] ^[25]
If left untreated, acute phosphate nephropathy can progress to chronic kidney disease and a patient can die of progressive renal failure.^[26]

Acute phosphate nephropathy leads to irreversible kidney damage hence renal replacement therapies, such as hemodialysis and peritoneal dialysis, and renal transplantation is important.^[13] ^[15]

Diagnosis

Diagnostic Criteria

The diagnosis of acute phosphate nephropathy is made when the following diagnostic criteria is met:^[13] ^[27]

acute kidney injury or chronic renal failure
Histopathological findings of acute or chronic tubular injury and deposition of calcium phosphate in the tubules
History of recent consumption of oral sodium phosphate bowel purgative.

Symptoms

Acute phosphate nephropathy could be asymptomatic due to which it can be undiagnosed until chronic kidney failure occurs.
The following symptoms can occur after consumption of oral sodium phosphate which gives a strong suspicion of acute phosphate nephropathy:

Physical Examination

Patients with [disease name] usually appear [general appearance].
Physical examination may be remarkable for:

Hypotension/hypertension
Pedal and orbital edema
Inspiratory crackles
Distended and tender abdomen without guarding
Tetany is seen in patients with severe hypocalcemia^[28]
Signs of dehydration including; dry mucous membrane, decreased skin turgor, and cool extremities.^[25]

Laboratory Findings

Laboratory findings diagnostic of acute phosphate nephropathy include:

Electrolyte disturbances

Following electrolyte abnormalities are diagnostic of acute phosphate nephropathy after the consumption of oral sodium phosphate bowel purgative.

Urinanalysis

Renal function test

Elevated creatinine
Reduced GFR^[2] ^[31]

Imaging Findings

Ultrasound is the imaging modality of choice for acute phosphate nephropathy.
On renal ultrasound, phosphate nephropathy is characterized by increased echogenicity of the renal cortex. However, the renal contour and size are normal.^[32]
[Imaging study 2] may demonstrate [finding 1], [finding 2], and [finding 3].

Renal biopsy

Renal biopsy is required for the definitive diagnosis of acute phosphate nephropathy.^[29]
The characteristic finding on the renal biopsy is the extensive deposition of calcium phosphate, mostly in the tubular lumen and less commonly in the peritubular interstitium. The calcium phosphate can be identified using von Kossa stain, also they lack birefringence under polarized light.^[33] Other findings can be divided on the basis of the time at which the biopsy is performed:

Early findings (<3 weeks)

The early biopsies show tubular degenerative changes, similar to acute tubular necrosis. Findings include

luminal ectasia, cytoplasmic simplification, loss of brush border, shedding of cell fragments into the lumina, and enlarged nuclei with prominent nucleoli. The tubular degenerative changes and calcifications are accompanied by interstitial edema and mild to moderate interstitial inflammation that is not typically associated with significant tubulitis.^[13]

Late finding (>3 weeks)

If the time between consumption of Oral sodium phosphate and renal biopsy is more than 3 weeks, then less severe and more localized degenerative changes are observed.
The findings include, chronic inflammation, extracellular matrix deposition, tubular atrophy and interstitial fibrosis.^[13] ^[9]

Acute Phosphate Nephropathy-Calcium Phosphate deposition dark blue coloured on H&E stain^[34]

Treatment

In patients with cardiovascular collapse and severe electrolyte abnormalities, immediate fluid resuscitation and rapid correction of electrolytes is required.
It is followed by renal replacement therapy such as haemodialysis or peritoneal dialysis in order to decrease the calcium phosphate deposition process.^[28]
Renal transplantation is also required in some patients.^[13]

Prevention

Prevention of acute phosphate nephropathy could be achieved by:

Identify the higher risk groups and avoid oral sodium phosphate bowel purgative. The higher risk groups include:^[35]

Age >55 years
Hypovolemia
Previously existing kidney disease
Intestinal obstruction
Active colitis
Drugs which decrease renal perfusion and function, including diuretics, angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and nonsteroidal anti-inflammatory drugs (NSAIDs)

Oral sodium phosphate are absolutely contrandicated in these patients:

Pregnancy
Age <18 years
Stage 3 to 5 chronic kidney disease (glomerular filtration rate [GFR] <60 mL/min/1.73 m2)
Inability to maintain adequate fluid intake
Pre-existing electrolyte disturbances
Ascites
Symptomatic congestive heart failure, and
recent (within <6 months) symptomatic ischemic heart disease (unstable angina or myocardial infarction).^[36] ^[37]

The relative contraindications include,

Advice good amount of hydration before, during and after the use of oral sodium phosphate.
Increase the time gap between the doses.
Ask patient to avoid the following drugs on the day before and the day after the colonoscopy procedure:

Order renal function test and serum electrolyte levels after the procedure, in order to look for any renal or electrolyte abnormalities.^[39]

References

↑ Vanner SJ, MacDonald PH, Paterson WG, Prentice RS, Da Costa LR, Beck IT (1990). "A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy". Am J Gastroenterol. 85 (4): 422–7. PMID 2183591 PMID: 2183591 Check |pmid= value (help).
↑ ^2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 Markowitz GS, Perazella MA (2009). "Acute phosphate nephropathy". Kidney Int. 76 (10): 1027–34. doi:10.1038/ki.2009.308. PMID 19675530 PMID: 19675530 Check |pmid= value (help).
↑ Davies MRP, Williams D, Niewiadomski OD (2018). "Phosphate nephropathy: an avoidable complication of bowel preparation for colonoscopy". Intern Med J. 48 (9): 1141–1144. doi:10.1111/imj.14015. PMID 30182391 PMID: 30182391 Check |pmid= value (help).
↑ "International colloquy on the management of intrauterine fetal death". Int J Gynaecol Obstet. 25 (3): 185–97. 1987. PMID 2886377 PMID: 2886377 Check |pmid= value (help).
↑ Lieberman DA, Ghormley J, Flora K (1996). "Effect of oral sodium phosphate [[colon]] preparation on [[serum]] [[electrolytes]] in patients with normal serum [[creatinine]]". Gastrointest Endosc. 43 (5): 467–9. doi:10.1016/s0016-5107(96)70287-0. PMID 8726759 PMID 8726759 Check |pmid= value (help). URL–wikilink conflict (help)
↑ Murer H, Hernando N, Forster L, Biber J (2001). "Molecular mechanisms in proximal tubular and small intestinal phosphate reabsorption (plenary lecture)". Mol Membr Biol. 18 (1): 3–11. doi:10.1080/09687680010019357. PMID 11396609 PMID 11396609 Check |pmid= value (help).
↑ ^7.0 ^7.1 Heher EC, Thier SO, Rennke H, Humphreys BD (2008). "Adverse renal and metabolic effects associated with oral sodium phosphate bowel preparation". Clin J Am Soc Nephrol. 3 (5): 1494–503. doi:10.2215/CJN.02040408. PMC 4571150. PMID 18596115 PMID 18596115 Check |pmid= value (help).
↑ Hebert LA, Lemann J, Petersen JR, Lennon EJ (1966). "Studies of the mechanism by which phosphate infusion lowers serum calcium concentration". J Clin Invest. 45 (12): 1886–94. doi:10.1172/JCI105493. PMC 292874. PMID 5953818 PMID 5953818 Check |pmid= value (help).
↑ ^9.0 ^9.1 ^9.2 ^9.3 Heher EC, Thier SO, Rennke H, Humphreys BD (2008). "Adverse renal and metabolic effects associated with oral sodium phosphate bowel preparation". Clin J Am Soc Nephrol. 3 (5): 1494–503. doi:10.2215/CJN.02040408. PMC 4571150. PMID 18596115 PMID: 18596115 Check |pmid= value (help).
↑ Parra-Blanco A, Ruiz A, Alvarez-Lobos M, Amorós A, Gana JC, Ibáñez P; et al. (2014). "Achieving the best bowel preparation for colonoscopy". World J Gastroenterol. 20 (47): 17709–26. doi:10.3748/wjg.v20.i47.17709. PMC 4273122. PMID 25548470 PMID: 25548470 Check |pmid= value (help).
↑ Asplin JR, Mandel NS, Coe FL (1996). "Evidence of calcium phosphate supersaturation in the loop of Henle". Am J Physiol. 270 (4 Pt 2): F604–13. doi:10.1152/ajprenal.1996.270.4.F604. PMID 8967338 PMID 8967338 Check |pmid= value (help).
↑ Verhulst A, Asselman M, De Naeyer S, Vervaet BA, Mengel M, Gwinner W; et al. (2005). "Preconditioning of the distal tubular epithelium of the human kidney precedes nephrocalcinosis". Kidney Int. 68 (4): 1643–7. doi:10.1111/j.1523-1755.2005.00584.x. PMID 16164641 PMID 16164641 Check |pmid= value (help).
↑ ^13.0 ^13.1 ^13.2 ^13.3 ^13.4 ^13.5 ^13.6 ^13.7 Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD (2005). "Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure". J Am Soc Nephrol. 16 (11): 3389–96. doi:10.1681/ASN.2005050496. PMID 16192415 PMID: 16192415 Check |pmid= value (help).
↑ Alon U, Donaldson DL, Hellerstein S, Warady BA, Harris DJ (1992). "Metabolic and histologic investigation of the nature of nephrocalcinosis in children with hypophosphatemic rickets and in the Hyp mouse". J Pediatr. 120 (6): 899–905. doi:10.1016/s0022-3476(05)81957-2. PMID 1317418 PMID: 1317418 Check |pmid= value (help).
↑ ^15.0 ^15.1 ^15.2 ^15.3 Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD (2005). "Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure". J Am Soc Nephrol. 16 (11): 3389–96. doi:10.1681/ASN.2005050496. PMID 16192415 PMID 16192415 Check |pmid= value (help).
↑ ^16.0 ^16.1 ^16.2 ^16.3 Abcar A, Hever A, Momi JS, Sim JJ (2009). "Acute phosphate nephropathy". Perm J. 13 (3): 48–50. doi:10.7812/tpp/08-069. PMC 2911810. PMID 20740089 PMID: 20740089 Check |pmid= value (help).
↑ Fenton A, Montgomery E, Nightingale P, Peters AM, Sheerin N, Wroe AC; et al. (2018). "Glomerular filtration rate: new age- and gender- specific reference ranges and thresholds for living kidney donation". BMC Nephrol. 19 (1): 336. doi:10.1186/s12882-018-1126-8. PMC 6249883. PMID 30466393 PMID: 30466393 Check |pmid= value (help).
↑ Hurst FP, Bohen EM, Osgard EM, Oliver DK, Das NP, Gao SW; et al. (2007). "Association of oral sodium phosphate purgative use with acute kidney injury". J Am Soc Nephrol. 18 (12): 3192–8. doi:10.1681/ASN.2007030349. PMID 17978311 PMID 17978311 Check |pmid= value (help).
↑ Vanner SJ, MacDonald PH, Paterson WG, Prentice RS, Da Costa LR, Beck IT (1990). "A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy". Am J Gastroenterol. 85 (4): 422–7. PMID 2183591 PMID 2183591 Check |pmid= value (help).
↑ Russmann S, Lamerato L, Motsko SP, Pezzullo JC, Faber MD, Jones JK (2008). "Risk of further decline in renal function after the use of oral sodium phosphate or polyethylene glycol in patients with a preexisting glomerular filtration rate below 60 ml/min". Am J Gastroenterol. 103 (11): 2707–16. doi:10.1111/j.1572-0241.2008.02201.x. PMID 18945285 PMID 18945285 Check |pmid= value (help).
↑ Russmann S, Lamerato L, Marfatia A, Motsko SP, Pezzullo JC, Olds G; et al. (2007). "Risk of impaired renal function after colonoscopy: a cohort study in patients receiving either oral sodium phosphate or polyethylene glycol". Am J Gastroenterol. 102 (12): 2655–63. doi:10.1111/j.1572-0241.2007.01610.x. PMID 17970832 PMID 17970832 Check |pmid= value (help).
↑ Khurana A, McLean L, Atkinson S, Foulks CJ (2008). "The effect of oral sodium phosphate drug products on renal function in adults undergoing bowel endoscopy". Arch Intern Med. 168 (6): 593–7. doi:10.1001/archinte.168.6.593. PMID 18362251 PMID: 18362251 Check |pmid= value (help).
↑ Ainley EJ, Winwood PJ, Begley JP (2005). "Measurement of serum electrolytes and phosphate after sodium phosphate colonoscopy bowel preparation: an evaluation". Dig Dis Sci. 50 (7): 1319–23. doi:10.1007/s10620-005-2780-9. PMID 16047480 PMID 16047480 Check |pmid= value (help).
↑ Santos P, Branco A, Silva S, Paiva A, Baldaia J, Maximino J; et al. (2010). "Acute phosphate nephropathy after bowel cleansing: still a menace". Nefrologia. 30 (6): 702–4. doi:10.3265/Nefrologia.pre2010.Jul.10544. PMID 21113224 . PMID: 21113224 . Check |pmid= value (help).
↑ ^25.0 ^25.1 "StatPearls". 2020. PMID 29939592 PMID 29939592 Check |pmid= value (help).
↑ Tan JJ, Tjandra JJ (2006). "Which is the optimal bowel preparation for colonoscopy - a meta-analysis". Colorectal Dis. 8 (4): 247–58. doi:10.1111/j.1463-1318.2006.00970.x. PMID 16630226 PMID: 16630226 Check |pmid= value (help).
↑ Markowitz GS, Whelan J, D'Agati VD (2005). "Renal failure following bowel cleansing with a sodium phosphate purgative". Nephrol Dial Transplant. 20 (4): 850–1. doi:10.1093/ndt/gfh718. PMID 15772276 PMID: 15772276 Check |pmid= value (help).
↑ ^28.0 ^28.1 ^28.2 ^28.3 Santos P, Branco A, Silva S, Paiva A, Baldaia J, Maximino J; et al. (2010). "Acute phosphate nephropathy after bowel cleansing: still a menace". Nefrologia. 30 (6): 702–4. doi:10.3265/Nefrologia.pre2010.Jul.10544. PMID 21113224 PMID: 21113224 Check |pmid= value (help).
↑ ^29.0 ^29.1 Pálmadóttir VK, Gudmundsson H, Hardarson S, Arnadóttir M, Magnússon T, Andrésdóttir MB (2010). "Incidence and outcome of acute phosphate nephropathy in Iceland". PLoS One. 5 (10): e13484. doi:10.1371/journal.pone.0013484. PMC 2957439. PMID 20976065 PMID: 20976065 Check |pmid= value (help).
↑ Ori Y, Herman M, Tobar A, Chernin G, Gafter U, Chagnac A; et al. (2008). "Acute phosphate nephropathy-an emerging threat". Am J Med Sci. 336 (4): 309–14. doi:10.1097/MAJ.0b013e318167410c. PMID 18854672 PMID: 18854672 Check |pmid= value (help).
↑ Russmann S, Lamerato L, Marfatia A, Motsko SP, Pezzullo JC, Olds G; et al. (2007). "Risk of impaired renal function after colonoscopy: a cohort study in patients receiving either oral sodium phosphate or polyethylene glycol". Am J Gastroenterol. 102 (12): 2655–63. doi:10.1111/j.1572-0241.2007.01610.x. PMID 17970832 PMID: 17970832 Check |pmid= value (help).
↑ Joo WC, Lee SW, Yang DH, Han JY, Kim MJ (2012). "A case of biopsy-proven chronic kidney disease on progression from acute phosphate nephropathy". Kidney Res Clin Pract. 31 (2): 124–7. doi:10.1016/j.krcp.2012.04.320. PMC 4715133. PMID 26889420 PMID: 26889420 Check |pmid= value (help).
↑ Markowitz GS, Nasr SH, Klein P, Anderson H, Stack JI, Alterman L; et al. (2004). "Renal failure due to acute nephrocalcinosis following oral sodium phosphate bowel cleansing". Hum Pathol. 35 (6): 675–84. doi:10.1016/j.humpath.2003.12.005. PMID 15188133 PMID 15188133 Check |pmid= value (help).
↑ "Case 514 -- Case".
↑ Wexner SD, Beck DE, Baron TH, Fanelli RD, Hyman N, Shen B; et al. (2006). "A consensus document on bowel preparation before colonoscopy: prepared by a task force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)". Gastrointest Endosc. 63 (7): 894–909. doi:10.1016/j.gie.2006.03.918. PMID 16733101 PMID: 16733101 Check |pmid= value (help).
↑ ^36.0 ^36.1 Hurst FP, Bohen EM, Osgard EM, Oliver DK, Das NP, Gao SW; et al. (2007). "Association of oral sodium phosphate purgative use with acute kidney injury". J Am Soc Nephrol. 18 (12): 3192–8. doi:10.1681/ASN.2007030349. PMID 17978311 PMID: 17978311 Check |pmid= value (help).
↑ ^37.0 ^37.1 Moon W (2013). "Optimal and safe bowel preparation for colonoscopy". Clin Endosc. 46 (3): 219–23. doi:10.5946/ce.2013.46.3.219. PMC 3678056. PMID 23767029 PMID: 23767029 Check |pmid= value (help).
↑ Hookey LC, Vanner S (2004). "Recognizing the clinical contraindications to the use of oral sodium phosphate for colon cleansing: a case study". Can J Gastroenterol. 18 (7): 455–8. doi:10.1155/2004/787515. PMID 15229748 PMID: 15229748 Check |pmid= value (help).
↑ Frizelle FA, Colls BM (2005). "Hyponatremia and seizures after bowel preparation: report of three cases". Dis Colon Rectum. 48 (2): 393–6. doi:10.1007/s10350-004-0778-6. PMID 15812590 PMID: 15812590 Check |pmid= value (help).

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Template:WikiDoc Sources

[pmidPMID:_2183591-1] Vanner SJ, MacDonald PH, Paterson WG, Prentice RS, Da Costa LR, Beck IT (1990). "A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy". Am J Gastroenterol. 85 (4): 422–7. PMID 2183591 PMID: 2183591 Check |pmid= value (help).

[pmidPMID:_19675530-2] 2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 Markowitz GS, Perazella MA (2009). "Acute phosphate nephropathy". Kidney Int. 76 (10): 1027–34. doi:10.1038/ki.2009.308. PMID 19675530 PMID: 19675530 Check |pmid= value (help).

[pmidPMID:_30182391-3] Davies MRP, Williams D, Niewiadomski OD (2018). "Phosphate nephropathy: an avoidable complication of bowel preparation for colonoscopy". Intern Med J. 48 (9): 1141–1144. doi:10.1111/imj.14015. PMID 30182391 PMID: 30182391 Check |pmid= value (help).

[pmidPMID:_2886377-4] "International colloquy on the management of intrauterine fetal death". Int J Gynaecol Obstet. 25 (3): 185–97. 1987. PMID 2886377 PMID: 2886377 Check |pmid= value (help).

[pmidPMID_8726759-5] Lieberman DA, Ghormley J, Flora K (1996). "Effect of oral sodium phosphate [[colon]] preparation on [[serum]] [[electrolytes]] in patients with normal serum [[creatinine]]". Gastrointest Endosc. 43 (5): 467–9. doi:10.1016/s0016-5107(96)70287-0. PMID 8726759 PMID 8726759 Check |pmid= value (help). URL–wikilink conflict (help)

[pmidPMID_11396609-6] Murer H, Hernando N, Forster L, Biber J (2001). "Molecular mechanisms in proximal tubular and small intestinal phosphate reabsorption (plenary lecture)". Mol Membr Biol. 18 (1): 3–11. doi:10.1080/09687680010019357. PMID 11396609 PMID 11396609 Check |pmid= value (help).

[pmidPMID_18596115-7] 7.0 ^7.1 Heher EC, Thier SO, Rennke H, Humphreys BD (2008). "Adverse renal and metabolic effects associated with oral sodium phosphate bowel preparation". Clin J Am Soc Nephrol. 3 (5): 1494–503. doi:10.2215/CJN.02040408. PMC 4571150. PMID 18596115 PMID 18596115 Check |pmid= value (help).

[pmidPMID_5953818-8] Hebert LA, Lemann J, Petersen JR, Lennon EJ (1966). "Studies of the mechanism by which phosphate infusion lowers serum calcium concentration". J Clin Invest. 45 (12): 1886–94. doi:10.1172/JCI105493. PMC 292874. PMID 5953818 PMID 5953818 Check |pmid= value (help).

[pmidPMID:_18596115-9] 9.0 ^9.1 ^9.2 ^9.3 Heher EC, Thier SO, Rennke H, Humphreys BD (2008). "Adverse renal and metabolic effects associated with oral sodium phosphate bowel preparation". Clin J Am Soc Nephrol. 3 (5): 1494–503. doi:10.2215/CJN.02040408. PMC 4571150. PMID 18596115 PMID: 18596115 Check |pmid= value (help).

[pmidPMID:_25548470-10] Parra-Blanco A, Ruiz A, Alvarez-Lobos M, Amorós A, Gana JC, Ibáñez P; et al. (2014). "Achieving the best bowel preparation for colonoscopy". World J Gastroenterol. 20 (47): 17709–26. doi:10.3748/wjg.v20.i47.17709. PMC 4273122. PMID 25548470 PMID: 25548470 Check |pmid= value (help).

[pmidPMID_8967338-11] Asplin JR, Mandel NS, Coe FL (1996). "Evidence of calcium phosphate supersaturation in the loop of Henle". Am J Physiol. 270 (4 Pt 2): F604–13. doi:10.1152/ajprenal.1996.270.4.F604. PMID 8967338 PMID 8967338 Check |pmid= value (help).

[pmidPMID_16164641-12] Verhulst A, Asselman M, De Naeyer S, Vervaet BA, Mengel M, Gwinner W; et al. (2005). "Preconditioning of the distal tubular epithelium of the human kidney precedes nephrocalcinosis". Kidney Int. 68 (4): 1643–7. doi:10.1111/j.1523-1755.2005.00584.x. PMID 16164641 PMID 16164641 Check |pmid= value (help).

[pmidPMID:_16192415-13] 13.0 ^13.1 ^13.2 ^13.3 ^13.4 ^13.5 ^13.6 ^13.7 Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD (2005). "Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure". J Am Soc Nephrol. 16 (11): 3389–96. doi:10.1681/ASN.2005050496. PMID 16192415 PMID: 16192415 Check |pmid= value (help).

[pmidPMID:_1317418-14] Alon U, Donaldson DL, Hellerstein S, Warady BA, Harris DJ (1992). "Metabolic and histologic investigation of the nature of nephrocalcinosis in children with hypophosphatemic rickets and in the Hyp mouse". J Pediatr. 120 (6): 899–905. doi:10.1016/s0022-3476(05)81957-2. PMID 1317418 PMID: 1317418 Check |pmid= value (help).

[pmidPMID_16192415-15] 15.0 ^15.1 ^15.2 ^15.3 Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD (2005). "Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure". J Am Soc Nephrol. 16 (11): 3389–96. doi:10.1681/ASN.2005050496. PMID 16192415 PMID 16192415 Check |pmid= value (help).

[pmidPMID:_20740089-16] 16.0 ^16.1 ^16.2 ^16.3 Abcar A, Hever A, Momi JS, Sim JJ (2009). "Acute phosphate nephropathy". Perm J. 13 (3): 48–50. doi:10.7812/tpp/08-069. PMC 2911810. PMID 20740089 PMID: 20740089 Check |pmid= value (help).

[pmidPMID:_30466393-17] Fenton A, Montgomery E, Nightingale P, Peters AM, Sheerin N, Wroe AC; et al. (2018). "Glomerular filtration rate: new age- and gender- specific reference ranges and thresholds for living kidney donation". BMC Nephrol. 19 (1): 336. doi:10.1186/s12882-018-1126-8. PMC 6249883. PMID 30466393 PMID: 30466393 Check |pmid= value (help).

[pmidPMID_17978311-18] Hurst FP, Bohen EM, Osgard EM, Oliver DK, Das NP, Gao SW; et al. (2007). "Association of oral sodium phosphate purgative use with acute kidney injury". J Am Soc Nephrol. 18 (12): 3192–8. doi:10.1681/ASN.2007030349. PMID 17978311 PMID 17978311 Check |pmid= value (help).

[pmidPMID_2183591-19] Vanner SJ, MacDonald PH, Paterson WG, Prentice RS, Da Costa LR, Beck IT (1990). "A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy". Am J Gastroenterol. 85 (4): 422–7. PMID 2183591 PMID 2183591 Check |pmid= value (help).

[pmidPMID_18945285-20] Russmann S, Lamerato L, Motsko SP, Pezzullo JC, Faber MD, Jones JK (2008). "Risk of further decline in renal function after the use of oral sodium phosphate or polyethylene glycol in patients with a preexisting glomerular filtration rate below 60 ml/min". Am J Gastroenterol. 103 (11): 2707–16. doi:10.1111/j.1572-0241.2008.02201.x. PMID 18945285 PMID 18945285 Check |pmid= value (help).

[pmidPMID_17970832-21] Russmann S, Lamerato L, Marfatia A, Motsko SP, Pezzullo JC, Olds G; et al. (2007). "Risk of impaired renal function after colonoscopy: a cohort study in patients receiving either oral sodium phosphate or polyethylene glycol". Am J Gastroenterol. 102 (12): 2655–63. doi:10.1111/j.1572-0241.2007.01610.x. PMID 17970832 PMID 17970832 Check |pmid= value (help).

[pmidPMID:_18362251-22] Khurana A, McLean L, Atkinson S, Foulks CJ (2008). "The effect of oral sodium phosphate drug products on renal function in adults undergoing bowel endoscopy". Arch Intern Med. 168 (6): 593–7. doi:10.1001/archinte.168.6.593. PMID 18362251 PMID: 18362251 Check |pmid= value (help).

[pmidPMID_16047480-23] Ainley EJ, Winwood PJ, Begley JP (2005). "Measurement of serum electrolytes and phosphate after sodium phosphate colonoscopy bowel preparation: an evaluation". Dig Dis Sci. 50 (7): 1319–23. doi:10.1007/s10620-005-2780-9. PMID 16047480 PMID 16047480 Check |pmid= value (help).

[pmidPMID:_21113224_.-24] Santos P, Branco A, Silva S, Paiva A, Baldaia J, Maximino J; et al. (2010). "Acute phosphate nephropathy after bowel cleansing: still a menace". Nefrologia. 30 (6): 702–4. doi:10.3265/Nefrologia.pre2010.Jul.10544. PMID 21113224 . PMID: 21113224 . Check |pmid= value (help).

[pmidPMID_29939592-25] 25.0 ^25.1 "StatPearls". 2020. PMID 29939592 PMID 29939592 Check |pmid= value (help).

[pmidPMID:_16630226-26] Tan JJ, Tjandra JJ (2006). "Which is the optimal bowel preparation for colonoscopy - a meta-analysis". Colorectal Dis. 8 (4): 247–58. doi:10.1111/j.1463-1318.2006.00970.x. PMID 16630226 PMID: 16630226 Check |pmid= value (help).

[pmidPMID:_15772276-27] Markowitz GS, Whelan J, D'Agati VD (2005). "Renal failure following bowel cleansing with a sodium phosphate purgative". Nephrol Dial Transplant. 20 (4): 850–1. doi:10.1093/ndt/gfh718. PMID 15772276 PMID: 15772276 Check |pmid= value (help).

[pmidPMID:_21113224-28] 28.0 ^28.1 ^28.2 ^28.3 Santos P, Branco A, Silva S, Paiva A, Baldaia J, Maximino J; et al. (2010). "Acute phosphate nephropathy after bowel cleansing: still a menace". Nefrologia. 30 (6): 702–4. doi:10.3265/Nefrologia.pre2010.Jul.10544. PMID 21113224 PMID: 21113224 Check |pmid= value (help).

[pmidPMID:_20976065-29] 29.0 ^29.1 Pálmadóttir VK, Gudmundsson H, Hardarson S, Arnadóttir M, Magnússon T, Andrésdóttir MB (2010). "Incidence and outcome of acute phosphate nephropathy in Iceland". PLoS One. 5 (10): e13484. doi:10.1371/journal.pone.0013484. PMC 2957439. PMID 20976065 PMID: 20976065 Check |pmid= value (help).

[pmidPMID:_18854672-30] Ori Y, Herman M, Tobar A, Chernin G, Gafter U, Chagnac A; et al. (2008). "Acute phosphate nephropathy-an emerging threat". Am J Med Sci. 336 (4): 309–14. doi:10.1097/MAJ.0b013e318167410c. PMID 18854672 PMID: 18854672 Check |pmid= value (help).

[pmidPMID:_17970832-31] Russmann S, Lamerato L, Marfatia A, Motsko SP, Pezzullo JC, Olds G; et al. (2007). "Risk of impaired renal function after colonoscopy: a cohort study in patients receiving either oral sodium phosphate or polyethylene glycol". Am J Gastroenterol. 102 (12): 2655–63. doi:10.1111/j.1572-0241.2007.01610.x. PMID 17970832 PMID: 17970832 Check |pmid= value (help).

[pmidPMID:_26889420-32] Joo WC, Lee SW, Yang DH, Han JY, Kim MJ (2012). "A case of biopsy-proven chronic kidney disease on progression from acute phosphate nephropathy". Kidney Res Clin Pract. 31 (2): 124–7. doi:10.1016/j.krcp.2012.04.320. PMC 4715133. PMID 26889420 PMID: 26889420 Check |pmid= value (help).

[pmidPMID_15188133-33] Markowitz GS, Nasr SH, Klein P, Anderson H, Stack JI, Alterman L; et al. (2004). "Renal failure due to acute nephrocalcinosis following oral sodium phosphate bowel cleansing". Hum Pathol. 35 (6): 675–84. doi:10.1016/j.humpath.2003.12.005. PMID 15188133 PMID 15188133 Check |pmid= value (help).

[34] "Case 514 -- Case".

[pmidPMID:_16733101-35] Wexner SD, Beck DE, Baron TH, Fanelli RD, Hyman N, Shen B; et al. (2006). "A consensus document on bowel preparation before colonoscopy: prepared by a task force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)". Gastrointest Endosc. 63 (7): 894–909. doi:10.1016/j.gie.2006.03.918. PMID 16733101 PMID: 16733101 Check |pmid= value (help).

[pmidPMID:_17978311-36] 36.0 ^36.1 Hurst FP, Bohen EM, Osgard EM, Oliver DK, Das NP, Gao SW; et al. (2007). "Association of oral sodium phosphate purgative use with acute kidney injury". J Am Soc Nephrol. 18 (12): 3192–8. doi:10.1681/ASN.2007030349. PMID 17978311 PMID: 17978311 Check |pmid= value (help).

[pmidPMID:_23767029-37] 37.0 ^37.1 Moon W (2013). "Optimal and safe bowel preparation for colonoscopy". Clin Endosc. 46 (3): 219–23. doi:10.5946/ce.2013.46.3.219. PMC 3678056. PMID 23767029 PMID: 23767029 Check |pmid= value (help).

[pmidPMID:_15229748-38] Hookey LC, Vanner S (2004). "Recognizing the clinical contraindications to the use of oral sodium phosphate for colon cleansing: a case study". Can J Gastroenterol. 18 (7): 455–8. doi:10.1155/2004/787515. PMID 15229748 PMID: 15229748 Check |pmid= value (help).

[pmidPMID:_15812590-39] Frizelle FA, Colls BM (2005). "Hyponatremia and seizures after bowel preparation: report of three cases". Dis Colon Rectum. 48 (2): 393–6. doi:10.1007/s10350-004-0778-6. PMID 15812590 PMID: 15812590 Check |pmid= value (help).

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@@ Line 10: / Line 10: @@
 ==[[Phosphate nephropathy historical perspective|Historical Perspective]]==
-* In 1990, [[Oral]] [[sodium phosphate]] [[purgative]] got acceptance as a  [[bowel]] preparation agent prior to [[colonoscopy]].<ref name="pmidPMID: 2183591">{{cite journal| author=Vanner SJ, MacDonald PH, Paterson WG, Prentice RS, Da Costa LR, Beck IT| title=A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy. | journal=Am J Gastroenterol | year= 1990 | volume= 85 | issue= 4 | pages= 422-7 | pmid=PMID: 2183591 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2183591  }} </ref> This was due to the reason that less [[amount]] of [[drug]] was required leading to increased [[patient]]'s [[compliance]], less discomfort and improved [[bowel]] cleansing as compared to other available [[bowel]] [[purgatives]] including [[polyethylene glycol]].<ref name="pmidPMID: 19675530">{{cite journal| author=Markowitz GS, Perazella MA| title=Acute phosphate nephropathy. | journal=Kidney Int | year= 2009 | volume= 76 | issue= 10 | pages= 1027-34 | pmid=PMID: 19675530 | doi=10.1038/ki.2009.308 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19675530  }} </ref>  *The first case of [[acute kidney injury]] followed by [[chronic kidney disease]] due to [[oral]] [[sodium phosphate]] [[consumption]] was reported in 1975. In 2003, deposition of [[calcium phosphate]]  was observed in the [[renal tubules]] after the consumption of the [[drug]].<ref name="pmidPMID: 30182391">{{cite journal| author=Davies MRP, Williams D, Niewiadomski OD| title=Phosphate nephropathy: an avoidable complication of bowel preparation for colonoscopy. | journal=Intern Med J | year= 2018 | volume= 48 | issue= 9 | pages= 1141-1144 | pmid=PMID: 30182391 | doi=10.1111/imj.14015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30182391  }} </ref>
+* In 1990, [[Oral]] [[sodium phosphate]] [[purgative]] got acceptance as a  [[bowel]] preparation agent prior to [[colonoscopy]].<ref name="pmidPMID: 2183591">{{cite journal| author=Vanner SJ, MacDonald PH, Paterson WG, Prentice RS, Da Costa LR, Beck IT| title=A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy. | journal=Am J Gastroenterol | year= 1990 | volume= 85 | issue= 4 | pages= 422-7 | pmid=PMID: 2183591 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2183591  }} </ref>
+*This was due to the reason that less [[amount]] of [[drug]] was required leading to increased [[patient]]'s [[compliance]], less discomfort and improved [[bowel]] cleansing as compared to other available [[bowel]] [[purgatives]] including [[polyethylene glycol]].<ref name="pmidPMID: 19675530">{{cite journal| author=Markowitz GS, Perazella MA| title=Acute phosphate nephropathy. | journal=Kidney Int | year= 2009 | volume= 76 | issue= 10 | pages= 1027-34 | pmid=PMID: 19675530 | doi=10.1038/ki.2009.308 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19675530  }} </ref>
+*The first case of [[acute kidney injury]] followed by [[chronic kidney disease]] due to [[oral]] [[sodium phosphate]] [[consumption]] was reported in 1975. In 2003, deposition of [[calcium phosphate]]  was observed in the [[renal tubules]] after the consumption of the [[drug]].<ref name="pmidPMID: 30182391">{{cite journal| author=Davies MRP, Williams D, Niewiadomski OD| title=Phosphate nephropathy: an avoidable complication of bowel preparation for colonoscopy. | journal=Intern Med J | year= 2018 | volume= 48 | issue= 9 | pages= 1141-1144 | pmid=PMID: 30182391 | doi=10.1111/imj.14015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30182391  }} </ref>
 *Due to repeated acute phosphate nephropathy cases after the [[oral]] [[sodium phosphate]] [[ingestion]], on 11 December 2008, [[United States]] [[Food and Drug Administration]] prohibited its [[over-the-counter]] purchase of and limited its purchase to [[prescription]] only. Soon this product was withdrawn from the market and now it is no longer available as an option for [[bowel]] preparation before a [[colonoscopy]] or any other [[procedure]].<ref name="pmidPMID: 2886377">{{cite journal| author=| title=International colloquy on the management of intrauterine fetal death. | journal=Int J Gynaecol Obstet | year= 1987 | volume= 25 | issue= 3 | pages= 185-97 | pmid=PMID: 2886377 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2886377  }} </ref>
@@ Line 16: / Line 18: @@
 ===Hyperphosphatemia===
-[[Oral]] [[sodium phosphate]] consumption leads to [[hyperphosphatemia]]. Particularly, those patients who have to consume a large amount of Oral [[Sodium Phosphate]] as a [[bowel purgative]] before an elective [[colonoscopy]] have markedly elevated [[phosphate]] levels in the [[blood]].<ref name="pmidPMID 8726759">{{cite journal| author=Lieberman DA, Ghormley J, Flora K| title=Effect of oral sodium phosphate [[colon]] preparation on [[serum]] [[electrolytes]] in patients with normal serum [[creatinine]]. | journal=Gastrointest Endosc | year= 1996 | volume= 43 | issue= 5 | pages= 467-9 | pmid=PMID 8726759 | doi=10.1016/s0016-5107(96)70287-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8726759  }} </ref> This is due to increase [[phosphate]] [[absorption]] from the [[small intestine]] and lack of [[downregulation]] of [[sodium-phosphate]] [[cotransporters]] in the [[small intestine]] even when a large amount of [[phosphate]] has already been absorbed.<ref name="pmidPMID 11396609">{{cite journal| author=Murer H, Hernando N, Forster L, Biber J| title=Molecular mechanisms in proximal tubular and small intestinal phosphate reabsorption (plenary lecture). | journal=Mol Membr Biol | year= 2001 | volume= 18 | issue= 1 | pages= 3-11 | pmid=PMID 11396609 | doi=10.1080/09687680010019357 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11396609  }} </ref> Hyperphosphatemia affects the kidneys by increasing the intratubular [[phosphate]] [[concentration]], resulting in the [[deposition]] of [[calcium phosphate]] in the [[distal tubule]] and [[collecting duct]]. It directly damages the tubular [[epithelial cells]] and leads to luminal [[obstruction]]. The [[calcium phosphate]] crystals activate the innate immune system due to recognition by the epithelial TLRs leading to to tubular injury.<ref name="pmidPMID 18596115">{{cite journal| author=Heher EC, Thier SO, Rennke H, Humphreys BD| title=Adverse renal and metabolic effects associated with oral sodium phosphate bowel preparation. | journal=Clin J Am Soc Nephrol | year= 2008 | volume= 3 | issue= 5 | pages= 1494-503 | pmid=PMID 18596115 | doi=10.2215/CJN.02040408 | pmc=4571150 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18596115  }} </ref> <ref name="pmidPMID 5953818">{{cite journal| author=Hebert LA, Lemann J, Petersen JR, Lennon EJ| title=Studies of the mechanism by which phosphate infusion lowers serum calcium concentration. | journal=J Clin Invest | year= 1966 | volume= 45 | issue= 12 | pages= 1886-94 | pmid=PMID 5953818 | doi=10.1172/JCI105493 | pmc=292874 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5953818  }} </ref> <ref name="pmidPMID: 18596115">{{cite journal| author=Heher EC, Thier SO, Rennke H, Humphreys BD| title=Adverse renal and metabolic effects associated with oral sodium phosphate bowel preparation. | journal=Clin J Am Soc Nephrol | year= 2008 | volume= 3 | issue= 5 | pages= 1494-503 | pmid=PMID: 18596115 | doi=10.2215/CJN.02040408 | pmc=4571150 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18596115  }} </ref>
+[[Oral]] [[sodium phosphate]] consumption leads to [[hyperphosphatemia]]. Particularly, those patients who have to consume a large amount of Oral [[Sodium Phosphate]] as a [[bowel purgative]] before an elective [[colonoscopy]] have markedly elevated [[phosphate]] levels in the [[blood]].<ref name="pmidPMID 8726759">{{cite journal| author=Lieberman DA, Ghormley J, Flora K| title=Effect of oral sodium phosphate [[colon]] preparation on [[serum]] [[electrolytes]] in patients with normal serum [[creatinine]]. | journal=Gastrointest Endosc | year= 1996 | volume= 43 | issue= 5 | pages= 467-9 | pmid=PMID 8726759 | doi=10.1016/s0016-5107(96)70287-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8726759  }} </ref> This is due to increase [[phosphate]] [[absorption]] from the [[small intestine]] and lack of [[downregulation]] of [[sodium-phosphate]] [[cotransporters]] in the [[small intestine]] even when a large amount of [[phosphate]] has already been absorbed.<ref name="pmidPMID 11396609">{{cite journal| author=Murer H, Hernando N, Forster L, Biber J| title=Molecular mechanisms in proximal tubular and small intestinal phosphate reabsorption (plenary lecture). | journal=Mol Membr Biol | year= 2001 | volume= 18 | issue= 1 | pages= 3-11 | pmid=PMID 11396609 | doi=10.1080/09687680010019357 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11396609  }} </ref>
-===Activation of Innate Immune system===
+Hyperphosphatemia affects the kidneys by increasing the intratubular [[phosphate]] [[concentration]], resulting in the [[deposition]] of [[calcium phosphate]] in the [[distal tubule]] and [[collecting duct]]. It directly damages the tubular [[epithelial cells]] and leads to luminal [[obstruction]]. The [[calcium phosphate]] crystals activate the innate immune system due to recognition by the epithelial TLRs leading to to tubular injury.<ref name="pmidPMID 18596115">{{cite journal| author=Heher EC, Thier SO, Rennke H, Humphreys BD| title=Adverse renal and metabolic effects associated with oral sodium phosphate bowel preparation. | journal=Clin J Am Soc Nephrol | year= 2008 | volume= 3 | issue= 5 | pages= 1494-503 | pmid=PMID 18596115 | doi=10.2215/CJN.02040408 | pmc=4571150 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18596115  }} </ref> <ref name="pmidPMID 5953818">{{cite journal| author=Hebert LA, Lemann J, Petersen JR, Lennon EJ| title=Studies of the mechanism by which phosphate infusion lowers serum calcium concentration. | journal=J Clin Invest | year= 1966 | volume= 45 | issue= 12 | pages= 1886-94 | pmid=PMID 5953818 | doi=10.1172/JCI105493 | pmc=292874 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5953818  }} </ref> <ref name="pmidPMID: 18596115">{{cite journal| author=Heher EC, Thier SO, Rennke H, Humphreys BD| title=Adverse renal and metabolic effects associated with oral sodium phosphate bowel preparation. | journal=Clin J Am Soc Nephrol | year= 2008 | volume= 3 | issue= 5 | pages= 1494-503 | pmid=PMID: 18596115 | doi=10.2215/CJN.02040408 | pmc=4571150 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18596115  }} </ref>
 ===Volume depletion===
@@ Line 27: / Line 29: @@
 ==Differentiating Acute Phosphate Nephropathy from other Diseases==
 * Acute Phosphate Nephropathy needs to be differentiated from other causes of [[nephrocalcinosis]] which are associated with [[hypercalcemia]] such as;
 :*[[Hyperparathyroidism]]
 :*[[Hypervitaminosis D]]
@@ Line 32: / Line 35: @@
 :*[[Sarcoidosis]]
 :*[[Distal]] [[renal tubular acidosis]]<ref name="pmidPMID: 16192415">{{cite journal| author=Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD| title=Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. | journal=J Am Soc Nephrol | year= 2005 | volume= 16 | issue= 11 | pages= 3389-96 | pmid=PMID: 16192415 | doi=10.1681/ASN.2005050496 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16192415  }} </ref>
-* and, a rare case of [[nephrocalcinosis]] is associated with [[hyperphosphatemia]] due to [[Phosphate]] supplements for the treatment of [[hypophosphatemic]] [[rickets]]PMID: 1317418 <ref name="pmidPMID: 16192415">{{cite journal| author=Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD| title=Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. | journal=J Am Soc Nephrol | year= 2005 | volume= 16 | issue= 11 | pages= 3389-96 | pmid=PMID: 16192415 | doi=10.1681/ASN.2005050496 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16192415  }} </ref>
+* It should also be differenitated from a rare case of [[nephrocalcinosis]] associated with [[hyperphosphatemia]] due to [[Phosphate]] [[supplements]] for the [[treatment]] of [[hypophosphatemic]] [[rickets]]<ref name="pmidPMID: 1317418">{{cite journal| author=Alon U, Donaldson DL, Hellerstein S, Warady BA, Harris DJ| title=Metabolic and histologic investigation of the nature of nephrocalcinosis in children with hypophosphatemic rickets and in the Hyp mouse. | journal=J Pediatr | year= 1992 | volume= 120 | issue= 6 | pages= 899-905 | pmid=PMID: 1317418 | doi=10.1016/s0022-3476(05)81957-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1317418  }} </ref><ref name="pmidPMID: 16192415">{{cite journal| author=Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD| title=Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. | journal=J Am Soc Nephrol | year= 2005 | volume= 16 | issue= 11 | pages= 3389-96 | pmid=PMID: 16192415 | doi=10.1681/ASN.2005050496 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16192415  }} </ref>
 ==[[Phosphate nephropathy epidemiology and demographics|Epidemiology and Demographics]]==
 ===Gender===
-Several studies report a higher [[incidence]] among [[females]] as compared to [[males]].<ref name="pmidPMID: 19675530">{{cite journal| author=Markowitz GS, Perazella MA| title=Acute phosphate nephropathy. | journal=Kidney Int | year= 2009 | volume= 76 | issue= 10 | pages= 1027-34 | pmid=PMID: 19675530 | doi=10.1038/ki.2009.308 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19675530  }} </ref> <ref name="pmidPMID 16192415">{{cite journal| author=Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD| title=Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. | journal=J Am Soc Nephrol | year= 2005 | volume= 16 | issue= 11 | pages= 3389-96 | pmid=PMID 16192415 | doi=10.1681/ASN.2005050496 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16192415  }} </ref> <ref name="pmidPMID: 18596115">{{cite journal| author=Heher EC, Thier SO, Rennke H, Humphreys BD| title=Adverse renal and [[metabolic]] [[effects]] associated with [[oral]] [[sodium phosphate]] [[bowel]] preparation. | journal=Clin J Am Soc Nephrol | year= 2008 | volume= 3 | issue= 5 | pages= 1494-503 | pmid=PMID: 18596115 | doi=10.2215/CJN.02040408 | pmc=4571150 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18596115  }} </ref> <ref name="pmidPMID: 20740089">{{cite journal| author=Abcar A, Hever A, Momi JS, Sim JJ| title=Acute phosphate nephropathy. | journal=Perm J | year= 2009 | volume= 13 | issue= 3 | pages= 48-50 | pmid=PMID: 20740089 | doi=10.7812/tpp/08-069 | pmc=2911810 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20740089  }} </ref> It could be related to their smaller heights and subsequently lower [[GFR]] as compared to men. Hence the same amount of [[Oral]] [[sodium phosphate]] could be more harmful to the women than men.<ref name="pmidPMID: 30466393">{{cite journal| author=Fenton A, Montgomery E, Nightingale P, Peters AM, Sheerin N, Wroe AC | display-authors=etal| title=Glomerular filtration rate: new age- and gender- specific reference ranges and thresholds for living kidney donation. | journal=BMC Nephrol | year= 2018 | volume= 19 | issue= 1 | pages= 336 | pmid=PMID: 30466393 | doi=10.1186/s12882-018-1126-8 | pmc=6249883 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30466393  }} </ref>
+* Several studies report a higher [[incidence]] among [[females]] as compared to [[males]].<ref name="pmidPMID: 19675530">{{cite journal| author=Markowitz GS, Perazella MA| title=Acute phosphate nephropathy. | journal=Kidney Int | year= 2009 | volume= 76 | issue= 10 | pages= 1027-34 | pmid=PMID: 19675530 | doi=10.1038/ki.2009.308 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19675530  }} </ref> <ref name="pmidPMID 16192415">{{cite journal| author=Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD| title=Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. | journal=J Am Soc Nephrol | year= 2005 | volume= 16 | issue= 11 | pages= 3389-96 | pmid=PMID 16192415 | doi=10.1681/ASN.2005050496 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16192415  }} </ref> <ref name="pmidPMID: 18596115">{{cite journal| author=Heher EC, Thier SO, Rennke H, Humphreys BD| title=Adverse renal and [[metabolic]] [[effects]] associated with [[oral]] [[sodium phosphate]] [[bowel]] preparation. | journal=Clin J Am Soc Nephrol | year= 2008 | volume= 3 | issue= 5 | pages= 1494-503 | pmid=PMID: 18596115 | doi=10.2215/CJN.02040408 | pmc=4571150 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18596115  }} </ref> <ref name="pmidPMID: 20740089">{{cite journal| author=Abcar A, Hever A, Momi JS, Sim JJ| title=Acute phosphate nephropathy. | journal=Perm J | year= 2009 | volume= 13 | issue= 3 | pages= 48-50 | pmid=PMID: 20740089 | doi=10.7812/tpp/08-069 | pmc=2911810 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20740089  }} </ref>
+* It could be related to their smaller heights and subsequently lower [[GFR]] as compared to men. Hence the same amount of [[Oral]] [[sodium phosphate]] could be more harmful to the women than men.<ref name="pmidPMID: 30466393">{{cite journal| author=Fenton A, Montgomery E, Nightingale P, Peters AM, Sheerin N, Wroe AC | display-authors=etal| title=Glomerular filtration rate: new age- and gender- specific reference ranges and thresholds for living kidney donation. | journal=BMC Nephrol | year= 2018 | volume= 19 | issue= 1 | pages= 336 | pmid=PMID: 30466393 | doi=10.1186/s12882-018-1126-8 | pmc=6249883 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30466393  }} </ref>
 ===Age===
@@ Line 67: / Line 72: @@
 ==[[Phosphate nephropathy natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
-The majority of patients with [disease name] remain asymptomatic for [duration/years].
+*The [[patient]] with acute phosphate nephropathy present with the [[clinical features]] of [[acute kidney injury]] such as [[oliguria]]/or [[anuria]], and [[volume]] depletion such as [[hypotension]], cold [[extremities]], dry [[mucous membran]]e and increased [[skin]] [[turgidity]], following the consumption of [[oral]] [[sodium phosphate]] [[bowel]] [[purgative]] for the purpose of [[bowel]] cleansing prior to [[colonoscopy]].<ref name="pmidPMID: 21113224 .">{{cite journal| author=Santos P, Branco A, Silva S, Paiva A, Baldaia J, Maximino J | display-authors=etal| title=Acute phosphate nephropathy after bowel cleansing: still a menace. | journal=Nefrologia | year= 2010 | volume= 30 | issue= 6 | pages= 702-4 | pmid=PMID: 21113224 . | doi=10.3265/Nefrologia.pre2010.Jul.10544 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21113224  }} </ref> <ref name="pmidPMID 29939592">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID 29939592 | doi= | pmc= | url= }} </ref>
-Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
+*If left untreated, acute phosphate nephropathy can progress to [[chronic kidney disease]] and a [[patient]] can die of progressive [[renal failure]].<ref name="pmidPMID: 16630226">{{cite journal| author=Tan JJ, Tjandra JJ| title=Which is the optimal bowel preparation for colonoscopy - a meta-analysis. | journal=Colorectal Dis | year= 2006 | volume= 8 | issue= 4 | pages= 247-58 | pmid=PMID: 16630226 | doi=10.1111/j.1463-1318.2006.00970.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16630226  }} </ref>
-If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
-Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
+* Acute phosphate nephropathy leads to [[irreversible]] [[kidney]] damage hence [[renal replacement therapies]], such as [[hemodialysis]] and [[peritoneal dialysis]], and [[renal transplantation]] is important.<ref name="pmidPMID: 16192415">{{cite journal| author=Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD| title=Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. | journal=J Am Soc Nephrol | year= 2005 | volume= 16 | issue= 11 | pages= 3389-96 | pmid=PMID: 16192415 | doi=10.1681/ASN.2005050496 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16192415  }} </ref> <ref name="pmidPMID 16192415">{{cite journal| author=Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD| title=Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. | journal=J Am Soc Nephrol | year= 2005 | volume= 16 | issue= 11 | pages= 3389-96 | pmid=PMID 16192415 | doi=10.1681/ASN.2005050496 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16192415  }} </ref>
-Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
-Despite aggressive fluid replacement and resuscitation our patient died. Some patients with this presentation survive and show renal function recovery.<ref name="pmidPMID: 16630226">{{cite journal| author=Tan JJ, Tjandra JJ| title=Which is the optimal bowel preparation for colonoscopy - a meta-analysis. | journal=Colorectal Dis | year= 2006 | volume= 8 | issue= 4 | pages= 247-58 | pmid=PMID: 16630226 | doi=10.1111/j.1463-1318.2006.00970.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16630226  }} </ref>
 ==Diagnosis==
 ===Diagnostic Criteria===
-*The diagnosis of acute phosphate nephropathy is made when the following diagnostic criteria is met:<ref name="pmidPMID: 16192415">{{cite journal| author=Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD| title=Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. | journal=J Am Soc Nephrol | year= 2005 | volume= 16 | issue= 11 | pages= 3389-96 | pmid=PMID: 16192415 | doi=10.1681/ASN.2005050496 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16192415  }} </ref>
+*The diagnosis of acute phosphate nephropathy is made when the following diagnostic criteria is met:<ref name="pmidPMID: 16192415">{{cite journal| author=Markowitz GS, Stokes MB, Radhakrishnan J, D'Agati VD| title=Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. | journal=J Am Soc Nephrol | year= 2005 | volume= 16 | issue= 11 | pages= 3389-96 | pmid=PMID: 16192415 | doi=10.1681/ASN.2005050496 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16192415  }} </ref> <ref name="pmidPMID: 15772276">{{cite journal| author=Markowitz GS, Whelan J, D'Agati VD| title=Renal failure following bowel cleansing with a sodium phosphate purgative. | journal=Nephrol Dial Transplant | year= 2005 | volume= 20 | issue= 4 | pages= 850-1 | pmid=PMID: 15772276 | doi=10.1093/ndt/gfh718 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15772276  }} </ref>
 :*[[acute kidney injury]] or [[chronic renal failure]]
 :*[[Histopathological]] findings of [[acute]] or [[chronic]] [[tubular injury]] and deposition of [[calcium phosphate]] in the [[tubules]]
 :*History of recent consumption of [[oral]] [[sodium phosphate]] [[bowel]] [[purgative]].
-:*Absence of [[hypercalcemia]]
 === Symptoms ===
 *Acute phosphate nephropathy could be asymptomatic due to which it can be undiagnosed until [[chronic kidney failure]] occurs.
 *The following symptoms can occur after consumption of [[oral]] [[sodium phosphate]] which gives a strong suspicion of acute phosphate nephropathy:
 :*[[Abdominal]] [[pain]]
 :*[[Oliguria]],[[Anuria]]
@@ Line 94: / Line 97: @@
 *Patients with [disease name] usually appear [general appearance].
 *Physical examination may be remarkable for:
 :*[[Hypotension]]/[[hypertension]]
 :*[[Pedal]] and [[orbital]] [[edema]]
@@ Line 105: / Line 109: @@
 ====Electrolyte disturbances====
 Following [[electrolyte abnormalities]] are diagnostic of acute phosphate nephropathy after the consumption of [[oral]] [[sodium phosphate]] [[bowel]] [[purgative]].
 :*[[Hyperphosphataemia]]
 :*[[Hypocalcemia]]
@@ Line 113: / Line 118: @@
 ====Urinanalysis====
-:*0 to 1+ [[proteinuria]]
+:*0 to 1+ [[proteinuria]]
 :*[[Hematuria]]
 :*[[Pyuria]]
@@ Line 119: / Line 125: @@
 ====Renal function test====
 :*Elevated [[creatinine]]
 :*Reduced [[GFR]]<ref name="pmidPMID: 19675530">{{cite journal| author=Markowitz GS, Perazella MA| title=Acute phosphate nephropathy. | journal=Kidney Int | year= 2009 | volume= 76 | issue= 10 | pages= 1027-34 | pmid=PMID: 19675530 | doi=10.1038/ki.2009.308 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19675530  }} </ref> <ref name="pmidPMID: 17970832">{{cite journal| author=Russmann S, Lamerato L, Marfatia A, Motsko SP, Pezzullo JC, Olds G | display-authors=etal| title=Risk of impaired renal function after colonoscopy: a cohort study in patients receiving either oral sodium phosphate or polyethylene glycol. | journal=Am J Gastroenterol | year= 2007 | volume= 102 | issue= 12 | pages= 2655-63 | pmid=PMID: 17970832 | doi=10.1111/j.1572-0241.2007.01610.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17970832  }} </ref>
@@ Line 158: / Line 165: @@
 :*[[Drugs]] which decrease renal perfusion and function, including [[diuretics]], [[angiotensin-converting enzyme inhibitors (ACEI)]], [[angiotensin receptor blockers (ARB)]], and [[nonsteroidal anti-inflammatory drugs]] ([[NSAIDs]])
 * [[Oral]] [[sodium phosphate]] are absolutely contrandicated in these patients:
 :*[[Pregnancy]]
 :*[[Age]] <18 years
@@ Line 167: / Line 175: @@
 :*recent (within <6 months) [[symptomatic]] [[ischemic heart disease]] ([[unstable angina]] or [[myocardial infarction]]).<ref name="pmidPMID: 17978311">{{cite journal| author=Hurst FP, Bohen EM, Osgard EM, Oliver DK, Das NP, Gao SW | display-authors=etal| title=Association of oral sodium phosphate purgative use with acute kidney injury. | journal=J Am Soc Nephrol | year= 2007 | volume= 18 | issue= 12 | pages= 3192-8 | pmid=PMID: 17978311 | doi=10.1681/ASN.2007030349 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17978311  }} </ref> <ref name="pmidPMID: 23767029">{{cite journal| author=Moon W| title=Optimal and safe bowel preparation for colonoscopy. | journal=Clin Endosc | year= 2013 | volume= 46 | issue= 3 | pages= 219-23 | pmid=PMID: 23767029 | doi=10.5946/ce.2013.46.3.219 | pmc=3678056 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23767029  }} </ref>
 *The relative [[contraindications]] include,
 :*Active [[inflammatory bowel disease]]
 :*Delayed [[bowel]] transit
@@ Line 173: / Line 182: @@
 *Increase the time gap between the doses.
 *Ask [[patient]] to avoid the following drugs on the day before and the day after the [[colonoscopy]] procedure:
 :*[[ACE-I]] and [[ARB]]
 :*[[Diuretics]]