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J Nephropathol. 2017;6(4): 349-351.
doi: 10.15171/jnp.2017.56

Scopus ID: 85036567642
  Abstract View: 2844
  PDF Download: 1382

Case Report

“Fish-scales” and graft nephrectomy: unexpected findings at
an unusual site

Smiley Annie George*, Issam Francis

1 Department of Histopathology, Mubarak Al-Kabir Hospital, Jabriya, Kuwait
*Corresponding Author: *Corresponding author: Smiley Annie George, Email: , Email: annsmiley78@gmail.com

Abstract

Background: Kayexalate and sevelamer are resin medications commonly used in the
setting of chronic renal failure for the treatment of hyperkalemia and hyperphosphatemia
respectively, are known to cause bowel ischemia, ulcerations, necrosis, pseudotumors
and perforations and the incidence is higher after post-transplant. Herein we report its
presence on the surface of a graft nephrectomy following a masked intestinal perforation.

Case Presentation: A 30-year-old male, a renal transplant recipient for dysplastic kidney
underwent graft nephrectomy due to wound infection, peri-graft collection and risk of
hemorrhage from the vascular anastomotic site. Histological evaluation showed extensive
acute tubular necrosis and peri-renal abscess with vegetable matter and numerous colored
crystals morphologically consistent with kayexalate and sevelamer. The possibility of an
underlying resin induced intestinal perforation was rendered.

Conclusions: Kayexalate or sevelamer induced mucosal injury in the gastrointestinal tract
could be a clinical emergency and a high index of suspicion particularly in a post-transplant
setting may allow prompt recognition and surgical cure. From the pathologists’ view
familiarity with the morphological appearances of these non-systemic resin medications
and its histologic mimics enables accurate diagnosis and timely clinical intervention.


Implication for health policy/practice/research/medical education:

Resin medications (Kayexalate and sevelamer), commonly used in the setting of chronic renal failure are known to cause
gastrointestinal mucosal damage. The incidence of which is higher in a post-transplant setting. A high level of clinical suspicion
allows prompt recognition of these complications. From the pathologists’ view, familiarity with the different morphological
appearances of these non-systemic resin medications and its histologic mimics enables proper identification in biopsy samples
and timely clinical intervention. Correlation with patient history is mandatory.


Please cite this paper as:
George SA, Francis I. “Fish-scales” and graft nephrectomy: unexpected findings at an unusual site. J
Nephropathol. 2017;6(4):349-351. DOI: 10.15171/jnp.2017.56.

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Submitted: 17 Feb 2017
Accepted: 23 Jun 2017
ePublished: 05 Jul 2017
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