Tumoral Calcinosis in Dialysis-Dependent Kidney Failure

A 42-year-old man, who was diagnosed with stage 5 chronic kidney disease (CKD) and was undergoing maintenance hemodialysis for the last 7 years via left brachio-cephalic fistula, presented with a growing, painless lump on his left forearm. The fistula had remained functional without any history of significant access-related complications such as extravasation, major hematoma, thrombosis, or infection. His medical history included hypertension, anemia, and tertiary hyperparathyroidism.¹ Laboratory results indicated significantly elevated intact parathyroid hormone levels (4991 ng/L), increased alkaline phosphatase (2229 U/L), hyperphosphatemia (5.4 mg/dL), hypercalcemia (11.1 mg/dL), and low vitamin D levels (10 ng/mL), which are indicative of tertiary hyperparathyroidism. Imaging studies of the forearm displayed a large, lobulated, heterogeneous calcified mass (arrow-marked) in a peri-diaphyseal location, suggestive of tumoral calcinosis linked to CKD and mineral and bone disorder [Figure 1].² Ultrasound imaging and Doppler were done, which showed a normal radial artery; there is no vascular calcification [Supplementary Material]. Tertiary hyperparathyroidism in individuals with CKD on dialysis can lead to significant extra-skeletal calcification and may necessitate surgical intervention. X-rays of the contralateral forearm, chest, shoulders, and hips showed no evidence of additional lesions

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Figure 1: Radiographic images (a) antero-posterior and (b) lateral view of the forearm of the left hand, showing a large, lobulated, heterogeneous calcified mass (arrow-marked) in a peri-diaphyseal location, suggestive of tumoral calcinosis linked to chronic kidney disease and mineral and bone disorder.

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This patient was managed with phosphate binders, vitamin D, cinacalcet and calcitriol. However, the swelling did not resolve and had to be removed surgically. Parathyroidectomy is also planned.