Successful treatment of early allograft dysfunction with cinacalcet in a patient with nephrocalcinosis caused by severe hyperparathyroidism: a case report

Abstract

BackgroundHyperparathyroidism is common in patients undergoing kidney transplantation. Occasionally, this condition can cause early allograft dysfunction by inducing calcium phosphate deposition in the allograft, which results in nephrocalcinosis. Although nephrocalcinosis occurs occasionally in kidney allografts, it has only rarely been reported in the literature.Case presentationHere, we present the case of a 58-year-old Thai woman with severe hyperparathyroidism who received a living-related kidney transplant from her 35-year-old son. Our patient developed allograft dysfunction on day 2 post-transplantation despite good functioning graft on day 1. Allograft biopsy showed extensive calcium phosphate deposition in distal tubules. She was treated with cinacalcet (a calcimimetic agent) and aluminum hydroxide. Allograft function was restored to normal within 1 week after transplantation with greatly reduced intact parathyroid hormone level.ConclusionHyperparathyroidism in early functioning allograft causes elevated calcium and phosphate concentration in distal tubules resulting in nephrocalcinosis. The massive calcium phosphate precipitation obstructs tubular lumens, which leads to acute tubular dysfunction. Treatment of nephrocalcinosis with cinacalcet is safe and may improve this condition by increasing serum phosphate and reducing serum calcium and intact parathyroid hormone.

Severe hypercalcaemia early after kidney transplantation in two patients with severe secondary hyperparathyroidism previously treated with etelcalcetide

“…Hypercalcaemia usually does not exceed 2.9 mmol/L and rarely requires any acute treatment, i.e. PTX or cinacalcet re-introduction [ 7 ], the latter has even been reported as effective in the treatment of post-KT nephrocalcinosis [ 8 ]. In contrast, the hypercalcaemia observed in our two patients developed very early after KT, was severe and required urgent PTX.…”

Rocky road—an uncommon reason for kidney allograft dysfunction: Answers

“…Individual transplant outcomes are dependent on numerous factors, including the extent, rate, and duration of crystal formation as well as intact crystal clearing mechanisms which may be compromised in the setting of poor graft function. Although our patient did not have severe hyperparathyroidism or persistent hypercalcemia, there are a few single case reports that purport successful treatment of allograft calcifications with calcimimetics and/or parathyroidectomy [12,13]. Until additional pediatric data is available, we recommend fastidious attention to parathyroid hormone, calcium, and phosphorus levels before and after transplantation as well as cautious use of vitamin D analogues and phosphate supplementation especially in the setting of poor graft function.…”

Hyperparathyroidism after renal transplantation

“…However, it is not accompanied by advantages on osteopenia (12). Cinacalcet has been recommended to manage posttransplantation persisted HPT (13)(14)(15)(16)(17). Pre-transplant prescription has been recommended by others, demonstrating that pre-transplant administration of Implication for health policy/practice/research/medical education Identifying bone disorders after kidney transplantation, their risk factors and managements is a great challenge.…”