Sevelamer-induced Gastrointestinal Mucosal Injury: A Critical Review for Clinicians

Sevelamer is a non-absorbable polymer used to treat hyperphosphatemia in individuals with end-stage renal disease (ESRD) undergoing hemodialysis. The deposition of sevelamer crystals in the gastrointestinal (GI) tract, especially in the colon, can cause mucosal inflammation, pseudopolyps, ulceration, ischemia, or necrosis. Owing to its rarity and lack of physician awareness, the actual incidence and prevalence of sevelamer-induced gastrointestinal mucosal injury (SIGMI) remain unknown. The current evidence is retrospective, in the form of observational studies. This systematic review of case reports provides an overview of SIGMI, with a focus on its etiology, signs and symptoms, pathogenesis, diagnosis, and management. Electronic databases, including PubMed, Embase, and Google Scholar, were searched for published case reports, case series, and abstracts from inception to August 2023. The search yielded 1239 articles that were filtered using the study design, English language, and human subjects. After screening for duplicates and irrelevant articles, only 28 articles were included in the final review. Melena and abdominal pain were the most common complaints. Sevelamer was discontinued in all patients, and 27 (75%) experienced clinical improvement or symptom resolution. Eight patients (22%) required colectomy due to colonic perforation, malignant obstruction, or extensive necrosis. SIGMI is a unique complication of sevelamer use in patients undergoing hemodialysis. Prompt diagnosis and management are crucial to prevent life-threatening complications.