Pulmonary metastatic calcification with respiratory insufficiency in patients on maintenance haemodialysis.

Abstract

A uraemic patient undergoing chronic haemodialysis developed diffuse metastatic pulmonary calcification and died from acute respiratory insufficiency after renal transplantation. Thirteen similar cases previously published are reviewed, with emphasis on the clinical and anatomical features of such calcinosis. The pathogenesis of this calcification in patients on maintenance haemodialysis and some rules for its prevention are discussed.Metastatic calcification in chronic renal failure has been well known since Virchow's first work in 1855. Such pathological calcification is either visceral or non-visceral. The former affects the muscles, the myocardium, and the lungs, whereas the latter is arterial, subcutaneous, or paraarticular.With the advent of haemodialysis the manifestations of metastatic calcification have become prominent. Davidson and Pendras (1967), McLachlan et al (1968), Smith et al (1969), Mootz et al (1973), andGiacobetti et al (1977) have reported several cases of pulmonary metastatic calcification in patients undergoing chronic haemodialysis. We describe the case of a uraemic patient treated by chronic haemodialysis then renal transplantation who developed diffuse pulmonary micronodular calcification responsible for death from pulmonary insufficiency. Case reportIn 1955 urinalysis showed proteinuria in a 15-yearold boy. In 1969 gout occurred in the big toe, the knees and the ankles (serum urate was 112 mg/l).

FVC, FEV1, FEV1/FVC ratio and FEF25-75% in End-stage renal disease (ESRD) patients undergoing maintenance haemodialysis

“…Research evidences suggested that restrictive and obstructive lung disease in these patients may attributed to pulmonary hypertension, pulmonary edema, pulmonary fibrosis and calcification, pleural effusion and pleural fibrosis 12,18,19 .…”

“…Metastatic pulmonary calcification occurs in 50% or more of renal patients with metastatic soft tissue calcification 11 . This lesion predominantly affects alveolar septa with varying degrees of fibrosis, calcification & macrophagic giant cells and causes septal thickening 11,12 .…”

Calcificaciones pulmonares metastásicas en un trasplantado renal con un injerto con función renal adecuada: Caso clínico

“…Se ha postulado que ello es favorecido por el ambiente alcalino de las áreas altas del pulmón, al tener un cociente ventilación/perfusión elevado, que reduciría la solubilidad del calcio y fósforo circulante promoviendo la calcificación 5,14 . También se ha pensado que la acidosis metabólica contribuye a la salida de calcio desde los huesos y que la alcalinidad del período post-diálisis, que aumenta la actividad de las fosfatasas alcalinas favoreciendo la liberación de fosfatos, favorecería el depósito de esos iones en los tejidos blandos 31 .…”

“…Otras veces existe tos no productiva y disnea de esfuerzo, ocasionalmente puede seguir un curso fulminante y fatal 9,14,17 o asociarse a calcifilaxis y necrosis pulmonar 18 . Las CPM se han observado también en pacientes con hiperparatiroidismo primario y secundario, hipercalcemias de otras causas, terapia endovenosa con calcio, mieloma múltiple, leucemias, sarcoidosis, intoxicación por vitamina D, osteolisis masiva por metástasis, síndrome de leche-alcalinos, enfermedad de Paget , neoplasia endocrina múltiple 9,19-21 y en trasplantados renales (TxR) con injertos disfuncionantes 4,7,14,16,17,22,23 . Rara vez se ha observado CPM en pacientes con trasplantes exitosos 8,24,25 .…”

Diffuse Calcification of the Airways

“…Whereas the former composition is found in visceral calcification, the latter is generally demonstrated in nonvisceral extraosseous calcification (3, 4); both are well described as a consequence of chronic renal disease (3)(4)(5)(6). Nonvisceral calcification is generally found in the arteries and veins, in the subcutaneous tissues, and around tendons and joints.…”