Abstract | March 24, 2024

Gangrenous Calciphylaxis in a Peritoneal Dialysis Patient: Case Report

Maryam Ahmad, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA

Aldin Malkoc, MD, MS, PGY3, General Surgery, Arrowhead Regional Medical Center / Kaiser Permanente Fontana Medical Center, Fontana, CA; and Majid Tayyarah, MD, Attending, Vascular Surgery, Kaiser Permanente Fontana Medical Center, Fontana, CA

Learning Objectives

  1. Identify the clinical manifestations of calciphylaxis in peritoneal dialysis patients, and discuss the therapeutic role of angioplasty in treating concomitant gangrenous calciphylaxis and peripheral arterial disease

Introduction: Calciphylaxis, a rare condition primarily associated with end-stage renal disease (ESRD), manifests as painful cutaneous ulcerations, microvascular calcification, and tissue necrosis. While frequently studied in hemodialysis patients, its presentation and management in peritoneal dialysis (PD) patients remain underexplored. This case describes a patient on PD who developed gangrenous calciphylaxis in the setting of pre-existing peripheral arterial disease, eventually requiring multi-limb amputation despite aggressive, multimodal treatment.

Case Presentation: A 63-year-old male with a history of hypertension, diabetes mellitus type II, ESRD, hyperparathyroidism, and hyperphosphatemia on PD presented with bilateral calf ulcers and penile and toe gangrene. The patient had noticed tender erythematous nodules on his lower legs three months prior, with later development of ulceration and necrosis on the penile glans and toes. Physical exam revealed black necrotic skin on the penile glans, toes, and multiple subcutaneous, firm, erythematous nodules with central necrosis on the legs. His right extremity exhibited weak dorsalis pedis and popliteal pulses. Calciphylaxis was strongly suspected due to the clinical features, ESRD history, hyperparathyroidism, and hyperphosphatemia. Other differential diagnoses were initially considered, such as cellulitis and peripheral arterial disease. Punch biopsy of a subcutaneous nodule confirmed the diagnosis of calciphylaxis, and a right leg angiogram additionally revealed severe peripheral arterial disease at the ankle and below.

Final/Working Diagnosis: Calciphylaxis with co-existing peripheral arterial disease

Management/Outcome: The patient was transitioned to hemodialysis for improved serum phosphorus control and to facilitate treatment with sodium thiosulfate. He received angioplasty of the right posterior tibial artery for treatment of his co-existing peripheral arterial disease. Despite this multimodal treatment, he eventually required multi-limb amputation, including a right and left transmetatarsal amputation.

This case presentation underscores the distinctive clinical presentation of calciphylaxis with co-existing peripheral arterial disease in PD patients. The significance of angioplasty in patients with concomitant calciphylaxis and peripheral arterial disease remains an area requiring further investigation. Further research is essential to optimize the management of this condition in PD populations.

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