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Acute calciphylaxis precipitated by the initiation of hemodialysis

Gagangeet Sandhu, Pablo Casares, Aditi Ranade

    Clinical Nephrology
    |July 6, 2012
    PubMed

    Insights

    Calciphylaxis (CUA) can acutely develop after starting hemodialysis (HD) due to calcium-phosphate imbalances. Careful management of calcium levels and dialysate composition during initial HD is crucial for prevention.

    Area of Science:

    • Nephrology
    • Vascular Medicine
    • Dermatology

    Background:

    • Calciphylaxis (calcific uremic arteriopathy) involves calcification of small arteries, leading to skin necrosis, often in end-stage renal disease (ESRD) patients.
    • Elevated serum calcium × phosphorus (Ca × P) product is a key risk factor, and its normalization is critical for CUA management.

    Observation:

    • A novel case of acute calciphylaxis (CUA) is presented in a Stage-5 chronic kidney disease (CKD) patient immediately following the initiation of hemodialysis (HD).
    • This iatrogenic CUA is hypothesized to result from rapid calcium influx from dialysate and acidosis correction, creating a favorable environment for Ca-P complex formation during the first HD session.

    Findings:

    • This is the first reported instance of hemodialysis-associated acute iatrogenic calciphylaxis (CUA).
    • The study highlights the potential for rapid CUA development in CKD patients with high Ca × P product upon commencing HD.

    Implications:

    • Initiating HD in high Ca × P product patients requires strategies to prevent CUA, including adequate hydration, lower calcium dialysate, and avoidance of vitamin D analogues and calcium-based medications.
    • Empiric use of sodium thiosulfate during initial HD sessions may be a promising strategy to prevent Ca-P precipitation and mitigate the risk of potentially fatal CUA.

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