Calciphylaxis in peritoneal dialysis patients: a single center cohort study

Abstract

Background: Calciphylaxis is a rare but devastating condition in end-stage renal disease (ESRD) patients. Most research in the field of calciphylaxis is focused on hemodialysis (HD) patients; however, data on calciphylaxis incidence, risk factors, and mortality in peritoneal dialysis (PD) patients are limited. Methods: In this cohort study, we examined data from adult patients who initiated PD for ESRD management at our institute's PD unit from January 2001 to December 2015. Associations with the development of calciphylaxis were examined for clinical, laboratory, and medication exposures. Incidence of calciphylaxis and mortality in PD patients who developed calciphylaxis were analyzed. Treatments administered to treat calciphylaxis in PD patients were summarized. Results: In this cohort of 63 patients, 7 patients developed calciphylaxis (incidence rate: 9.0 per 1,000 patient-years). Median age of PD patients who developed calciphylaxis was 50 years, 57% were white, 71% females, and 71% were previously on HD. Female sex, obesity, HD as a prior dialysis modality, recurrent hypotension, elevated time-averaged serum phosphorous levels, reduced time-averaged serum albumin levels, and warfarin therapy were associated with increased calciphylaxis risk in univariate logistic regression analyses. Intravenous sodium thiosulfate was administered in 57% of PD patients who developed calciphylaxis. One-year mortality in PD patients who developed calciphylaxis was 71% despite multimodal treatment including sodium thiosulfate, hyperbaric oxygen, cinacalcet, and wound debridement. Conclusion: Calciphylaxis is a rare but frequently fatal condition in PD patients. Our study provides critical early insights into calciphylaxis incidence, risk factors, and prognosis in PD patients. Sample size and characteristics of patients included in our study limit generalizability to overall PD population and warrant examination in larger independent studies.

A Case Report: Calciphylaxis Presenting as Digital Ischemia in Patient with End Stage Kidney Disease on Peritoneal Dialysis

“…Bearing in mind that this was a study on a limited number of patients and in a single center it was difficult to conclude weather PD carries higher risk for developing CUA compared to HD [7]. Furthermore, many of the studied patients were on HD before transitioning to PD, this alone implies worse outcomes and higher mortality which make it more challenging to generalize this study finding [7].…”

“…Bearing in mind that this was a study on a limited number of patients and in a single center it was difficult to conclude weather PD carries higher risk for developing CUA compared to HD [7]. Furthermore, many of the studied patients were on HD before transitioning to PD, this alone implies worse outcomes and higher mortality which make it more challenging to generalize this study finding [7]. Another single-center study of seven peritoneal dialysis patients who developed CUA noted that five of these patients were previously on hemodialysis and were transitioned to peritoneal dialysis for access failure or inability to tolerate hemodialysis [7].…”

“…Furthermore, many of the studied patients were on HD before transitioning to PD, this alone implies worse outcomes and higher mortality which make it more challenging to generalize this study finding [7]. Another single-center study of seven peritoneal dialysis patients who developed CUA noted that five of these patients were previously on hemodialysis and were transitioned to peritoneal dialysis for access failure or inability to tolerate hemodialysis [7]. In this case report, our patient was on HD for years before transition to PD.…”

“…The exact mechanism of presumed increased incidence of CUA in PD patients is not well described and in one report was attributed to the use of calcium containing phosphate binders [9] [10]. Other reports indicate that PD is associated with more abnormalities in phosphorus and albumin than HD, especially once residual renal function has deteriorated in HD [7] [11] [12].…”

Calciphylaxis

“…However, specific calciphylaxis incidence rates in patients with peritoneal dialysis and renal transplant were not reported. In a small single center cohort study of 63 patients with ESRD treated with peritoneal dialysis, seven patients developed calciphylaxis during the study period that extended from January 2001 to December 2015 tendering the incidence rate of 9.0 per 1000 patient-years [9 ■ ]. However, a larger study to investigate calciphylaxis incidence in the patients with ESRD treated with renal replacement modalities other than hemodialysis is needed.…”