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  Table of Contents  
IMAGES IN NEPHROLOGY
Year : 2016  |  Volume : 26  |  Issue : 3  |  Page : 225-226
 

Whole body calcification in a hemodialysis patient


1 Department of Internal Medicine, School of Medicine, Sakarya University, Sakarya, Turkey
2 Department of Dermatology, School of Medicine, Sakarya University, Sakarya, Turkey
3 Department of Internal Medicine, Division of Nephrology, School of Medicine, Sakarya University, Sakarya, Turkey

Date of Web Publication27-Apr-2016

Correspondence Address:
B Solak
Department of Dermatology, School of Medicine, Sakarya University, Sakarya
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-4065.160340

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How to cite this article:
Yildirim M, Acikgoz S B, Solak B, Sipahi S, Solak Y. Whole body calcification in a hemodialysis patient. Indian J Nephrol 2016;26:225-6

How to cite this URL:
Yildirim M, Acikgoz S B, Solak B, Sipahi S, Solak Y. Whole body calcification in a hemodialysis patient. Indian J Nephrol [serial online] 2016 [cited 2020 Apr 4];26:225-6. Available from: http://www.indianjnephrol.org/text.asp?2016/26/3/225/160340




A 38-year-old male presented with necrotic lesions on both feet. He has had chronic kidney disease (CKD) for 21 years and been receiving hemodialysis treatment for the last 10 years. He had undergone parathyroidectomy for severe secondary hyperparathyroidism. The parathormone (PTH) level had reduced to 1200 pg/ml after surgery from a pre-op value of 3500 pg/ml but gradually started to increase again. The patient underwent a second surgery for recurrent parathyroid adenoma. Since then he was managed with active Vitamin D until current presentation. The patient had thick black necrotic lesions on the toes compatible with nephrocalcinosis [Figure 1]a. Admission laboratory values were as follows: creatinine 4.9 mg/dl, calcium 8.1 mg/dl, phosphate: 4.3 mg/dl and PTH 5542 pg/ml. The patient was started on broad spectrum antibiotic therapy along with hyperbaric oxygen treatment. Lower extremity computed tomographic (CT) angiography, and thoracoabdominal CT showed widespread dystrophic paranchymal calcifications as well as extensive atherosclerotic lesions and vessel wall calcifications. Severe destructive osteoporosis was also notable in all scanned areas [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e.
Figure 1: (a) Deep ulcer with a diameter of 6 cm on dorsal aspect of the right foot, necrotic appearance in 2nd, 3rd, 4th and 5th fingers. (b) Extensive calcifications in mesenteric veins (arrows), calcium deposits compatible with nephrocalcinosis in both kidneys (ellipses) and severe osteopotic changes in the vertebrae (asterix). (c) Expansil growth due to Brown tumor and severe osteoporosis in bilateral femur and tibias seen in coronal reformatted images. (d) Pleural dystrophic calcifications in right pleural space (red arrows), compression fractures owing to severe osteoporosis and resultant scoliosis (green arrows). (e) Pleural dystrophic calcifications in right pleura in axial computed tomographic images (red arrows), widespread calcifications in coronary sinuses (veins) (ellipses)

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Secondary hyperparathyroidism and bone and cardiac complications are now named as CKD-mineral and bone disorder (CKD-MBD).[1] When left untreated, CKD-MBD may have serious health consequences.[2] As in our case, sky-high serum PTH levels led to calcifications, osteoporosis and Brown tumors in the whole skeletal system, but more importantly in the vascular system and parenchymal organs throughout the body. Both surgical and medical treatment options were attempted in our patient, including surgery, active Vitamin D, oral phosphorus binders, efficient hemodialysis and cinacalcet. Unfortunately, some cases may be resistant to all these treatments.

This case illustrates dramatic changes secondary to severe and resistant secondary hyperparathyroidism and fortunately rarely encountered in this modern age of secondary hyperparathyroidism management.

 
  References Top

1.
London G, Coyne D, Hruska K, Malluche HH, Martin KJ. The new kidney disease: Improving global outcomes (KDIGO) guidelines – Expert clinical focus on bone and vascular calcification. Clin Nephrol 2010;74:423-32. [Erratum in: Clin Nephrol 2013;80:80].  Back to cited text no. 1
    
2.
Kalantar-Zadeh K, Shah A, Duong U, Hechter RC, Dukkipati R, Kovesdy CP. Kidney bone disease and mortality in CKD: Revisiting the role of Vitamin D, calcimimetics, alkaline phosphatase, and minerals. Kidney Int Suppl 2010;117:S10-21.  Back to cited text no. 2
    


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