Challenges of ongoing VKA use in calciphylaxis: The potential of multimodal treatment including rheopheresis, — a...

We report two cases of complete remission of uremic calciphylaxis in hemodialysis patients despite continued use of vitamin K antagonists (VKAs). These cases highlight the potential of a multimodal treatment approach including rheopheresis as a promising therapy when VKA discontinuation is not feasible. Both patients presented with severe calciphylaxis while on VKAs for mechanical mitral valve replacement. They received intensive multimodal treatment, including daily hemodialysis, intravenous sodium thiosulfate, calcimimetics, phosphate binders, opioid analgesics, and plastic surgery evaluation. In addition, rheopheresis was initiated twice weekly for four months, during which VKAs were maintained. Rheopheresis frequency was then gradually reduced. Complete wound healing was achieved within seven months. Both patients subsequently underwent parathyroidectomy for tertiary hyperparathyroidism. To our knowledge, these are the first reported cases of full remission of calciphylaxis without VKA discontinuation. A multimodal, multidisciplinary treatment strategy may represent an effective approach for high-risk anticoagulated patients.