This patient had a high phosphorus level with an increased PTH and alkaline phosphatase level, suggesting high-turnover disease. He was started on a phosphate binder (calcium acetate), activated vitamin D (doxercalciferol), and calcimimetics.
The patient had calciphylaxis (calcific uremic arteriolopathy). This is characterized by systemic medial calcification of the arteries. It occurs more commonly among patients on dialysis but can be present in individuals with CKD who are not on dialysis. Risk factors include hyperphosphatemia; obesity; female sex; hypercoagulable states; hypoalbuminemia; and use of warfarin, calcium-based phosphate binders, and vitamin D analogues. Lesions classically develop on areas with the greatest adiposity, including the abdomen, buttocks, and thighs.
No specific diagnostic tests for calciphylaxis are available. Skin biopsy reveals arterial occlusion and calcification in the absence of vasculitic change. Treatment includes aggressive wound care, oxygen therapy, phosphorus control, better clearance, sodium thiosulfate, and calcimimetics (or parathyroidectomy).
Dialysis education should be provided if the eGFR is < 20 mL/min. At this time, placement of an arteriovenous fistula in the arm is recommended in case the patient chooses to begin hemodialysis in the future. Usual indications for dialysis in CKD include uremia-related pericarditis, coagulopathy, anorexia, unexplained weight loss, encephalopathy, volume overload or hypertension that is unresponsive to diuretic therapy, and resistant hyperkalemia. However, the aim of management is avoidance of these complications; dialysis should therefore be initiated when patients are relatively asymptomatic, with an eGFR of 5-9 mL/min. Early dialysis does not improve survival.
When the patient's eGFR fell to 20 mL/min, he was advised to undergo placement of an arteriovenous fistula in his arm. The fistula developed nicely, and the patient was started on dialysis while relatively asymptomatic when his eGFR reached 6 mL/min.
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Cite this: Pradeep Arora, Karen Convay. A 65-Year-Old Man With Hypertension and Proteinuria - Medscape - Oct 12, 2015.