Severe Hyperphosphatemia in a Newborn With Renal Insufficiency Because of an Erroneous Medical Prescription

We report on an 8-day-old boy with renal failure attributable to bilateral vesicoureteral reflux and dysplastic kidneys. He developed hyperphosphatemia because of his oral phosphate intake. Because he had mild metabolic acidosis, alkaline therapy was planned, but through a medical prescription error he was given a phosphate instead of an alkaline solution. He developed carpopedal spasm, with calcium and phosphate at 5.3mg/dL and 26.0mg/dL, respectively. His phosphate levels gradually decreased via diuretic and calcium gluconate therapy, without dialysis.