FRI699 Hyperphosphatemia In The Setting Of Sodium Hypochlorite Use

Abstract

Abstract Disclosure: K. Champagne: None. A.D. Mooradian: None. N. Gupta: None. M.J. Haas: None. G.Y. Gandhi: None. M.M. Jurado-Flores: None. Introduction: Acute elevation of serum phosphorous occurs for various reasons, including cellular injury (hemolysis, rhabdomyolysis, tumor lysis syndrome), decreased excretion (acute renal injury), or increased absorption/intake. Case Description: A 20-year-old woman presented as a pedestrian struck by a car after a motor vehicle accident. She sustained significant injury to the left leg, including degloving injury, femur, and tibia fracture requiring intramedullary nailing, skin graft, and multiple debridements. A review of systems was positive for chronic constipation. Physical exam was remarkable for several large, deep wounds on the left leg with a wound vac. Her wound was treated with sodium hypochlorite 0.25% solution. Laboratory results revealed that serum CK was 2,903 U/L on admission, and serum phosphorous level was normal and only started to rise one month after admission. She was transfused for blood loss and received IV fluids intermittently. Serum ionized calcium was low on admission at 0.90 mmol/L, calcium supplement was started, and hypocalcemia resolved. GFR dropped twice (at 46 and 62 mL/min/1.73M2) during admission but recovered to normal within a day. Serum phosphorous was elevated and ranged from 4.7-8.0 mg/dL, magnesium level fluctuated between 1.5-2.5 mg/dL, the parathyroid hormone was low at 7.0 pg/ml, 25-hydroxy vitamin D was low at <5.0 ng/ml, 1,25-dihydroxy vitamin D was low at <5.0pg/ml, FGF-23 was high at 616 RU/ml. Sevelamer was given for 9 days and discontinued. Sodium hypochlorite 0.25% solution and calcium supplement were discontinued, and vitamin D supplementation was initiated. The fractional excretion of phosphorous calculated from spot urine phosphorous and creatinine was low at 3.03%. Seven days later, plasma phosphorous levels normalized. Discussion: Sodium hypochlorite is a strong alkali (pH ∼11) and is the active ingredient of bleach. When exposed to water, it forms hypochlorous acid that generates superoxide radicals, leading to oxidative injury and cell death. This solution is bactericidal and may cause some tissue injury as well. It is used in healthcare settings to disinfect dialysis machines and tunneled catheters, surgical equipment, wound cleaning, hand hygiene, and root canal sterilization. It may increase the risk of hyperphosphatemia when used in a patient with immobilization, bone fractures, hypoparathyroidism, low vitamin D, multiple blood transfusions, and wound debridements. There have been rare reports of acute kidney injury with an intravenous bleach injection. Presentation: Friday, June 16, 2023