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Calciphylaxis (first report with calcitriol) in an elderly patient with renal failure: case report A 65-year-old male liver transplant recipient, with renal failure on haemodialysis, developed severe calciphylaxis while receiving immunosuppressants, acenocoumarol, calcium carbonate and calcitriol; he subsequently died. The man received a liver transplant in 1996 and started receiving prednisone, mycophenolate* and ciclosporin; he later received pulses of methylprednisolone for early graft rejection [dosages not stated]. He developed acute renal failure secondary to ciclosporin-induced nephrotoxicity and required haemodialysis from July 2002. He also had a history of type 2 diabetes mellitus, dilated cardiomyopathy and atrial fibrillation, and was receiving acenocoumarol [dosage not stated]. Calcium carbonate up to 12 g/day and oral calcitriol 1 µg/day were started for severe hypocalcaemia, maintaining intact parathyroid hormone (iPTH) levels of 100–250 pg/mL and a calcium × phosphorus product levels of < 50. He presented with bilateral small and painful skin lesions on his legs in December 2002 [duration of treatments to reaction onset not stated]. Some lesions appeared ecchymotic while others had violaceous borders, were eroded and overlaid by a necrotic ulcer. The man received opiates and topical antibacterials. In January 2003, he developed haemodynamic instability during a haemodialysis session and was hospitalised. He had fever and anaemia, and his skin lesions showed increasing necrosis and infection. Laboratory investigations revealed the following levels and values: WBC count 1900/mm3, haemoglobin 6.7 g/dL, calcium 7 mg/dL, phosphate 3.5 mg/dL, iPTH 72.5 pg/mL, CRP 13.9 mg/L and albumin 2.6 g/dL. Blood cultures and antigenaemia were positive for Cryptococcus neoformans. Multiple vascular calcifications were noted on abdominal x-ray, and a skin biopsy revealed calcifications in the dermal arteries and arterioles, thromboses and adipose tissue necrosis; findings were compatible with calciphylaxis. He received wide-spectrum antibacterials and IV fluconazole, and underwent surgical debridement; his mycophenolate dosage was decreased. However, he subsequently died of septic shock. Author comment: Calciphylaxis is associated with "chronic renal insufficiency, dialysis and kidney transplant. Other risk factors were identified: hyperparathyroidism, elevated calcium-phosphorus product, hyperphosphatemia . . . prolonged treatment with vitamin D supplements, calciumbased phosphorus chelating agents, oral anticoagulants, steroids, intravenous iron load [and] diabetes mellitus." * It was not clear if the patient was receiving mycophenolate mofetil or mycophenolate sodium. Caride MC, et al. Severe calciphylaxis in a patient on dialysis, with a liver transplant and long evolution hypocalcaemia. Nefrologia 28: 226-227, No. 2, 2008 801111446 - Spain

» Editorial comment: A search of AdisBase, Medline and Embase did not reveal any previous case reports of calciphylaxis associated with calcitriol. The WHO Adverse Drug