Abstract: PO0393
Complete Resolution of Calciphylaxis in a Renal Transplant Patient with Calcifediol
Session Information
- Calcified Tissues in Kidney Diseases
October 22, 2020 | Location: On-Demand
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 402 Bone and Mineral Metabolism: Clinical
Authors
- Doraiswamy, Mohankumar, Comprehensive Transplant Center, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
- Singh, Priyamvada, Comprehensive Transplant Center, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
- Meng, Shumei, Division of Endocrinology, The Ohio State University Medical Center, Columbus, Ohio, United States
- Pesavento, Todd E., Comprehensive Transplant Center, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
Introduction
Calciphylaxis is a rare but lethal disorder (mortality 60-80%) characterized by occlusion of microvasculature in the subcutaneous adipose tissue and dermis, resulting in excruciating painful, ischemic skin lesions. It commonly occurs in dialysis patients but only few cases in transplants reported. Treatment options are meager, and a multidisciplinary approach (dermatology, nephrology, nutrition, pain, palliative medicine, plastic surgery, and wound care), with surgical debridement, antimicrobial therapy, optimization of calcium-phosphorus product, dialysis adequacy, sodium thiosulfate, and hyperbaric oxygen been suggested.
Case Description
A 62-year-old female with a LDKT (2008) complicated with CKD III, lupus nephritis, hypothyroidism, presented with painful, bilateral, medial calf ischemic ulcerations, which on punch biopsy revealed calciphylaxis. Her baseline iPTH, calcium, phosphorus, and 25-hydroxy-vitamin D, was 372 pg/mL, 9.4 mg/dL, 3.8 mg/dL, and 17.4 ng/mL, respectively. She was on calcitriol 0.75 mg/daily, ergocalciferol 50,000 units weekly and cinacalcet 30 mcg every other day. We started her on Calcifediol 30 mg, which increased to 60 mg daily. Her calcitriol and ergocalciferol doses were reduced slowly, while cinacalcet remained the same. This led to gradual increase in 25-hydroxyvitamin D and reduction in iPTH levels without effect on the calcium-phosphorus product. Over 1-year follow-up, her ulcers completely resolved as shown in the images with marked improvement in the pain.
Discussion
Treatment of hyperparathyroidism is limited as calcitriol and ergocalciferol worsen the calcium-phosphorus product while calcimimetics cause hypocalcemia, which hinders the attempt to lower calcitriol. Calcifediol is well tolerated and causes a progressive increase in serum 1,25-dihydroxy vitamin D and reductions in plasma iPTH without a significant effect of serum calcium and phosphorus levels. This led to remarkable clinical improvement with resolution of calciphylaxis in this case. Large clinical trials mandated to test these findings
Image 1 & 2: Calciphylaxis wound in the Lower Extremity
Image 3: Resolution of wound after Calcefediol