Fluindione

Abstract

Calciphylaxis: case reportAn 88-year-old woman developed calciphylaxis during treatment with long-term anticoagulant fluindione [duration of treatment to reaction onset not stated].The woman, who had end stage kidney disease related to diabetic nephropathy with idiopathic membranous nephropathy, initiated on haemodialysis in August 2016. Her medical history included type 2 diabetes mellitus since the age of 54 years, which was complicated due to mild sensitive polyneuritis of the lower limbs and mild diabetic retinopathy. Additional medical history included diastolic cardiac insufficiency and atrial fibrillation since 2016 with high risk of thromboembolic events for which she was on long-term anticoagulation with a vitamin-K antagonist fluindione [fuindione; route and dosage not stated]. She had no general or dialysis complications, except for vascular access surgery failure until June 2019, when she developed extensive painful ulcers on both the legs. Her ulcers were further preceded by erysipelas-like lesions.The woman underwent multidisciplinary management with hospitalisation in a geriatric unit (from 23 rd August 2019 to 25 th March 2020) with pain relief by unspecified opioids and pregabalin, daily wound cleaning and intensification of dialysis by Expanded Hemodialysis with sodium thiosulfate. On 24 th July 2019, fluindione therapy was stopped as it was considered to be responsible for calciphylaxis as a drug-related adverse event. Calcium dialysate levels 1.5 mmol remained unchanged. On 14 October 2019, she underwent successful split-thickness skin graft; and subsequently, on 14 October 2019, second successful split-thickness skin graft was performed in the hospital. Liver iron concentration were slightly elevated observed on signal intensity ratio MRI and R2 relaxometry. In November 2019, her lower limb pain disappeared, and unspecified opioids discontinued on 12 November 2019 and pregabalin was discontinued on 18 November 2019. On 10 December 2019, dermatology consultation suggested 90% healing of leg ulcers, and sodium thiosulfate was discontinued. Then, complete healing of the leg ulcers was confirmed on subsequent dermatology consultation on 10 March 2020, and she was discharged home at the end of March 2020. She started receiving anticoagulation with danaparoid [danaparoid-sodium], which was later replaced with rivaroxaban and heparin during dialysis sessions 28 January 2020. On 16 July 2020, she was referred for a dermatology consultation, where calciphylaxis was confirmed based on deep dermal biopsy. Laboratory investigation of biochemical marker showed decrease levels of serum calcium and serum bone alkaline phosphatase and elevated levels of serum phosphate, serum parathyroid hormone, serum ferritin and serum c-reactive protein. Serum iron biomarkers levels were closed to anaemia as per European statement for anaemia management.Rostoker G, et al. Analysis of liver iron concentration in an elderly female undergoing hemodialysis with calcific uremic arteriolopathy does not support the role of iron ...