Gastric Lanthanum Deposition in Advanced CKD: An Underrecognized Diagnostic Pitfall in Refractory Anemia and Mucosal Injury
Abstract
Lanthanum carbonate is a noncalcium phosphate binder used in advanced chronic kidney disease (CKD), especially in dialysis populations. Gastroduodenal lanthanum deposition is now a recognized histopathologic finding, but its clinical importance is heterogeneous. The central clinical question is not whether lanthanum can be found in the mucosa but when deposition should be interpreted as a possible contributor to mucosal injury and, otherwise, unexplained bleeding-anemia phenotypes. Available evidence supports a spectrum from incidental histologic deposition to a smaller clinically meaningful subset associated with melena, occult or chronic upper gastrointestinal blood loss, iron deficiency, recurrent transfusion requirement, or erythropoiesis-stimulating agent (ESA) hyporesponsiveness. Characteristic whitish lesions are useful endoscopic clues, but deposition can also occur in nonwhitish or minimally abnormal mucosa. Histopathology typically shows histiocyte-rich accumulation of granular eosinophilic or light-brown material, sometimes with a foreign-body-type reaction. A plausible subset-specific pathway links mucosal deposition and macrophage activation to epithelial injury, chronic microbleeding, iron-restricted erythropoiesis, and increased ESA requirements. Clinically meaningful disease is most plausible when exposure history, phenotype, mucosal context, biopsy findings, and-when observed-improvement after lanthanum withdrawal converge. Deposition alone does not…
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