Sevelamer-associated gastrointestinal mucosal injury with bleeding and Enterococcus faecalis peritonitis in a peritoneal dialysis patient: a case report

Background Sevelamer is a noncalcium-containing phosphate binder widely used in patients with end-stage kidney disease (ESKD). Although sevelamer is generally well tolerated, sevelamer crystals have rarely been associated with gastrointestinal (GI) mucosal injury, including colitis, ulceration, and bleeding. In patients undergoing peritoneal dialysis (PD), GI mucosal injury may coexist with or contribute to peritonitis caused by enteric organisms. Case presentation A 24-year-old woman with ESKD on PD presented with abdominal pain, dark stool, cloudy peritoneal dialysis fluid, and inability to perform PD. Laboratory testing showed severe anemia and a positive fecal occult blood test, and abdominal computed tomography revealed colonic wall thickening from the cecum to the transverse colon. Sevelamer was discontinued on the day of admission. Colonoscopy demonstrated multiple shallow ulcers in the cecum. Biopsy showed focal neutrophilic inflammation with characteristic sevelamer crystals. PD fluid culture grew Enterococcus faecalis , and she was treated with intraperitoneal vancomycin. She was switched from sevelamer to ferric citrate and discharged while continuing PD. Conclusions This case highlights an important diagnostic pitfall in patients undergoing PD who are receiving sevelamer. Abdominal pain and cloudy dialysate should not be attributed solely to peritoneal dialysis-related peritonitis when signs of GI bleeding or colitis are present. Early evaluation of both the peritoneal cavity and GI tract may allow timely discontinuation of sevelamer and appropriate treatment of peritonitis before progression to severe complications.