Endocrine Abstracts

Introduction: The calcific uremic arteriolopathy (CUA) is one of the several types of extra-osseous calcification that may occur in patients with end-stage renal disease (ESRD). CUA is a serious disorder characterized by calcification of the arterioles that leads to ischemia and subcutaneous necrosis. The pathogenesis is poorly understood, and the optimal treatment is not known.

Case report: We present the case of a 64-year-old female with ESRD on hemodialysis since 2010, is hypertensive, had a heart attack in 2006. She was referred to our hospital with extensive two ulcers on the left leg with necrotic eschars.

Laboratory investigations showed elevated levels of phosphorus 2.46 mmol/l, calcium 2.73 mmol/l, [Ca]×[P] 6.7 mmol/l, iPTH 2529 pg/ml. Ultrasound revealed multiple enlarged parathyroid glands, DEXA revealed osteopenia. The clinical diagnosis was severe secondary hyperparathyroidism and CUA.

Considering the severity of CUA, was recommended a total parathyroidectomy. However, due to the patient’s cardiovascular status, there were certain contraindications. Initially, we cancelled the warfarin, recommended a hypophosphatic diet, analgesics, intravenous antibiotics, assessment by surgeons for wound care. She started intensive dialysis on a daily: 3-h-sessions with low calcium (1.25 mmol/l) dialysate for 2 weeks, later three times a week, followed by 24 mg of sodium thiosulfate intravenous administration at the end of every session. She was also started on phosphate binders (sevelamer 2400 mg/day) and calcimimetics (cinacalcet 30–60 mg/day) for better control.

Laboratory investigations were done during the treatment – phosphorus 2.14 mmol/l, calcium 2.13 mmol/l, [Ca]×[P] 4.55 mmol/l, iPTH 2086 pg/ml. We added other phosphate binders Almagel for a short period. Six months later, the first CUA lesion was healed, a year later – the second one.

Conclusion: Our case study shows that only a multi-interventional strategy is likely to be more effective in treating CUA in patients on hemodialysis and with several secondary hyperparathyroidisms.