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Complete resolution of calciphylaxis in a renal transplant patient with Calcifediol

© Author(s) (or their employer(s)) 2021. No commercial reuse. See rights and permissions. Published by BMJ. Presentation: A 62yearold woman with a Living Donor Kidney transplant in 2008 complicated with chronic kidney disease III, lupus nephritis, hypothyroidism (but no history of diabetes) presented with painful, bilateral, medial calf ischaemic ulcerations (figure 1), which on punch biopsy revealed calciphylaxis (figure 2). Her weight was 66.3 kg, height 1.6 m and body mass index of 25.9 kg/m. She was on hydroxychloroquine, mycophenolate and prednisone for lupus/transplant and levothyroxine 125 mcg daily for hypothyroidism. Her baseline intact parathyroid harmone (iPTH), calcium, phosphorus and 25hydroxyvitamin D was 372 pg/mL, 9.4 mg/dL, 3.8 mg/dL and 17.4 ng/mL, respectively (table 1depicting laboratories and medication changes over time). She was on calcitriol (0.75 mcg/daily), ergocalciferol (50 000 units weekly) and cinacalcet 30 mcg every other day. We started her on calcifediol 30 mg, which was later increased to 60 mg daily. Her calcitriol and ergocalciferol doses were reduced slowly, while cinacalcet remained the same. This led to a gradual increase in 25hydroxyvitamin D and reduction in iPTH levels without effect on the calciumphosphorus product. Calcifediol is well tolerated and causes a progressive increase in serum 1,25dihydroxy vitamin D and reductions in plasma iPTH without a significant effect of serum calcium and phosphorus levels. This led to remarkable clinical improvement with the resolution of calciphylaxis in this case. Over the 1year followup, her calciphylaxis ulcers completely resolved (figure 3) with marked improvement in the pain. The mean age at the time of diagnosis is 50–70 years and approximately 60%– 70% of patients with calciphylaxis are women. 2 Risk factors for calciphylaxis include obesity, diabetes mellitus, female sex and dependence on dialysis for more than 2 years. 4 Obesity and diabetes mellitus are also risk factors for calciphylaxis in patients without End stage renal disease.5 Figure 1 Bilateral deep, very painful lumps which ulcerate creating open nonhealing sores with black– brown crust that fails to heal in medial calves. Figure 2 Medial calcification of deep dermal/ subcutaneous vessel walls consistent with calciphylaxis.