Frequent Involvement of the Duodenum with Lanthanum Deposition: A Retrospective Observational Study

Drug-induced mucosal alterations observed during esophagogastroduodenoscopy

Several features of drug-induced mucosal alterations have been observed in the upper gastrointestinal tract, i.e., the esophagus, stomach, and duodenum. These include pill-induced esophagitis, desquamative esophagitis, worsening of gastroesophageal reflux, chemotherapy-induced esophagitis, proton pump inhibitor-induced gastric mucosal changes, medication-induced gastric erosions and ulcers, pseudomelanosis of the stomach, olmesartan-related gastric mucosal inflammation, lanthanum deposition in the stomach, zinc acetate hydrate tablet-induced gastric ulcer, immune-related adverse event gastritis, olmesartan-asso-ciated sprue-like enteropathy, pseudomelanosis of the duodenum, and lanthanum deposition in the duodenum. For endoscopists, acquiring accurate knowledge regarding these diverse drug-induced mucosal alterations is crucial not only for the correct diagnosis of these lesions but also for differential diag-nosis of other conditions. This minireview aims to provide essential information on drug-induced mucosal alterations observed on esophagogastroduodenoscopy, along with representative endoscopic images.

Long-term safety of lanthanum carbonate in the real word: a 19-year disproportionality analysis from the FDA Adverse Event Reporting System

BACKGROUND

Lanthanum carbonate is widely used to manage serum phosphate and calcium levels in end-stage kidney disease (ESKD) patients, yet comprehensive long-term safety data are lacking. This study leverages the FDA Adverse Event Reporting System (FAERS) to assess the extended safety profile of lanthanum carbonate.

RESEARCH DESIGN AND METHODS

We analyzed FAERS data (2004-2022) to study the association between lanthanum carbonate and adverse events (AEs). Using MedDRA v25.0, we identified risk signals through System Organ Classes (SOCs) and Preferred Terms (PTs). Disproportionality analyzes quantified lanthanum carbonate-associated AE signals.

RESULTS

Among 3,284 reports, 2,466 were primary suspected AEs linked to lanthanum carbonate. Males reported AEs more frequently than females. Patients aged over 64 represented the majority. Median onset time for lanthanum carbonate-related AEs was 146 days. Gastrointestinal disorders were prevalent. We identified 16 new signals, including stress, abnormal hepatic function, cholelithiasis, bile duct stone, gastric cancer, and adenocarcinoma gastric. Stress was notable, particularly in male patients over 65 and those with lower weight.

CONCLUSIONS

This study affirms lanthanum carbonate's long-term safety for reducing elevated blood phosphorus levels. While gastrointestinal disorders were common, attention must focus on emerging AEs, particularly stress, especially in elderly patients.

An update on phosphate binders for the treatment of hyperphosphatemia in chronic kidney disease patients on dialysis: a review of safety profiles

INTRODUCTION

Hyperphosphatemia is an inevitable complication for patients undergoing dialysis, as is the resulting need for treatment with phosphate binders. Currently, various phosphate binders are clinically available. In addition to their phosphate-lowering activity, individual phosphate binders have differing safety profiles and off-target actions.

AREAS COVERED

This paper reviews the safety of phosphate binders and issues to be resolved.

EXPERT OPINION

Calcium-based phosphate binders are well tolerated but may increase calcium overload risk. Sevelamer reduces serum cholesterol levels and exerts anti-inflammatory effects. Compared to sevelamer, bixalomer is associated with fewer gastrointestinal symptoms. Aluminum-containing binders, lanthanum carbonate, and sucroferric oxyhydroxide exhibit strong phosphate-lowering activity. Although ferric citrate reduces erythropoiesis-stimulating agents and intravenous iron doses, its use requires monitoring of iron metabolic markers to avoid overload. Occasionally, combined use of multiple phosphate binders can offer the advantages of each phosphate binder while minimizing their drawbacks; thus, this may be desirable according to individual patients' conditions and comorbidities. However, increased pill burden and nonadherence to phosphate binders emerge as new problems. We expect that novel therapeutic strategies will be developed to resolve these issues.

Gastric lanthanosis (lanthanum deposition) in an immunosuppressed patient that discontinued lanthanum carbonate seven years ago

A 72-year-old female patient used the oral phosphate binder lanthanum carbonate for 6 years, before discontinuing it after receiving a pancreas and kidney transplant. Now, 7 years after discontinuation, the patient developed bilious emesis. An upper gastrointestinal endoscopy showed an unspecific gastritis. Biopsies showed subepithelial crystalline deposits consistent with gastric lanthanosis.

[Unexpected deposits in the upper gastrointestinal tract : When medical history matters]

In order to regulate their phosphate uptake, patients with end-stage renal disease rely on phosphate binders such as lanthanum carbonate (LC). The earliest histopathological reports of this rare entity in the gastrointestinal mucosa were described and published in 2015.We present a case of an 80-year-old patient with LC gastro-enteropathy. Histopathologically it can mimic other drug-induced depositions and even infectious or neoplastic entities. Evaluation of the patient's medical and especially drug history is essential to obtain the appropriate diagnosis. We present an overview of the clinical presentation and histological differential diagnosis of LC.

Gastropathy associated with lanthanum phosphate deposition that was endoscopically tracked for 3 years. A case report

Background

With the recent increased use of lanthanum carbonate, several cases of lanthanum phosphate deposition to gastric mucosa in dialysis patients have been reported. However, the endoscopic appearance of the early-stage lesion and the over-time alterations of endoscopic findings due to the progression of lanthanum phosphate deposition remain unclear.

Case presentation

An 80-year-old man receiving dialysis and taking lanthanum carbonate as a phosphate binder over a 4-year period underwent upper gastrointestinal endoscopy four times beginning 1 year after initiation of treatment. The first endoscopic examination (after 1 year of exposure to lanthanum carbonate) revealed rough mucosa with a few areas of white granular mucosa. Over the 3 years of endoscopic follow-up, the white granular mucosa spread and multiple erosions appeared. Histopathological findings of biopsy specimens from an erosion showed extensive infiltration by histiocytes containing deposits. Scanning electron microscopy-energy dispersive X-ray spectroscopy (SEM-EDX) revealed that the presence of the deposits containing phosphorus and lanthanum in the gastric mucosa.

On the basis of these results, the patient was diagnosed with gastropathy associated with lanthanum phosphate deposition.

Conclusions

Over a 3-year period, endoscopic findings associated with lanthanum deposition gradually changed and expanded from the early stage.

Review of the diagnosis of gastrointestinal lanthanum deposition

Lanthanum carbonate is used for treatment of hyperphosphatemia mostly in patients with chronic renal failure. Although lanthanum carbonate is safe, recently, lanthanum deposition in the gastrointestinal mucosa of patients has been reported in the literature. This review provides an overview of gastroduodenal lanthanum deposition and focuses on disease’s endoscopic, radiological, and histological features, prevalence, and outcome, by reviewing relevant clinical studies, case reports, and basic research findings, to better understand the endoscopic manifestation of gastrointestinal lanthanum deposition. The possible relationship between gastric lanthanum deposition pattern and gastric mucosal atrophy is also illustrated; in patients without gastric mucosal atrophy, gastric lanthanum deposition appears as diffuse white lesions in the posterior wall and lesser curvature of the gastric body. In the gastric mucosa with atrophy, lanthanum-related lesions likely appear as annular or granular whitish lesions. Moreover, these white lesions are probably more frequently observed in the lower part of the stomach, where intestinal metaplasia begins.

Phosphate binders in chronic kidney disease: an updated narrative review of recent data

Chronic kidney disease (CKD) is frequently accompanied by hyperphosphatemia. High serum phosphate usually requires dietary measures, adequate dialysis prescription and/or phosphate binders. For this narrative review a PubMed searched was undertaken to identify new publications on phosphate binders that had been published between January 2015 and July 2019. The present review summarizes this most recent information on dietary measures and their problems in treating hyperphosphatemia in CKD patients, overall effects of phosphate binders on cardiovascular mortality and morbidity, adherence to phosphate binder therapy as well as new data on specific aspects of the various phosphate binders on the market: calcium-containing phosphate binders, polymeric phosphate binders (sevelamer, bixalomer, colestilan), magnesium-containing phosphate binders, lanthanum carbonate, ferric citrate, sucroferric oxyhydroxide, and new compounds in development, in particular drugs targeting intestinal phosphate transporters.