Analysis of liver iron concentration in an elderly female undergoing hemodialysis with calcific uremic arteriolopathy does not support the role of iron overload in calciphylaxis: lesson for the clinical nephrologist

Abstract

An 88-year-old female patient started hemodialysis in August 2016 using a tunneled catheter due to end-stage kidney disease (ESKD) related to idiopathic membranous nephropathy combined with diabetic nephropathy (Table 1). She had suffered from type 2 diabetes mellitus since the age of 54 years (complicated by mild diabetic retinopathy and mild sensitive polyneuritis of the lower limbs), had a long history of diastolic cardiac insufficiency and had suffered from atrial fibrillation since 2016 with high risk of thromboembolic events, requiring long-term anticoagulation with fluindione (a vitamin K antagonist) (VKA). She was considered to have very good physiologic and psychological adaptation to hemodialysis despite her old age. Apart from the failure of vascular access surgery, she had no dialysis or general complications until June 2019, when extensive painful ulcers appeared on both legs without any evidence of peripheral arterial disease on imaging (vascular computerized axial tomography coupled with ultrasound scans); the ulcers were preceded by erysipelas-like lesions. The patient was referred for a dermatology consultation to the Tenon hospital, Paris, where calciphylaxis was clinically suspected and formally diagnosed on a deep dermal biopsy (16th July, 2020) (Fig.1). Serum calcium, phosphorus, and aluminum were within the normal range, whereas parathyroid hormone and bone alkaline phosphatase levels were slightly low for a dialysis patient (Table 2). Serum iron biomarkers were close to the target of the European statement for anemia management [1] (Table 2). The patient underwent multidisciplinary management with hospitalization in a geriatric unit (from 23rd August, 2019 to 25th March, 2020) with pain relief by opioids and pregabalin, daily wound cleaning by specialized nurses, together with intensification of dialysis by Expanded Hemodialysis (HDx therapy with high cut-off dialyzer Theranova®) 3-times a week for 4 h (because of the patient’s refusal of daily dialysis) with administration of sodium thiosulfate (25 g infused during the last hour of each dialysis session until 13th December, 2019, without any side-effects during the whole duration of therapy). The disappearance of lower limb pain occurred in November 2019 and opioids and pregabalin were therefore stopped, respectively, 12th November and 18th November, 2019. Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s4062 0-020-00904 -z) contains supplementary material, which is available to authorized users.