Critical Care Medicine-Renal, Electrolyte and Acid Base Disorders>>>>>Calcium, Phosphate, and Magnesium
Question 4#

A 65-year-old male with a history of end-stage renal disease on hemodialysis presents to the emergency room with history of fever for the last few days. Vitals are as follows:

Lap values are notable for parathyroid hormone (PTH) 350 pg/mL and calcium 12 mg/dL.

Physical examination reveals the following skin lesions:

Which of the following is the most appropriate first-line pharmacological therapy for this patient?

A. Antibiotics
B. Sodium thiosulphate infusion
C. Sodium thiosulphate infusion and cinacalcet
D. Treat with analgesics till surgical parathyroidectomy

Correct Answer is C


Correct Answer: C

This patient has calciphylaxis. Sodium thiosulfate is an agent with antioxidant and vasodilatory properties that also inhibits adipocyte calcification and blocks the ability of adipocytes to induce calcification of vascular smooth muscle cells. Two studies have shown effectiveness of sodium thiosulphate in treatment of calciphylaxis. Also, in addition to sodium thiosulphate, patients who have elevated serum PTH levels (>300 pg/mL) are treated with cinacalcet. Several case reports have suggested cinacalcet can be effective in the management of this condition.


  1. Nigwekar SU, Thadhani R, Brandenburg VM. Calciphylaxis. N Engl J Med. 2018;378:1704-1714.
  2. Nigwekar SU, Brunelli SM, Meade D, et al. Sodium thiosulfate therapy for calcific uremic arteriolopathy. Clin J Am Soc Nephrol. 2013;8:1162- 1170.
  3. Zitt E, König M, Vychytil A, et al. Use of sodium thiosulphate in a multiinterventional setting for the treatment of calciphylaxis in dialysis patients. Nephrol Dial Transplant. 2013;28:1232-1240.
  4. Velasco N, MacGregor MS, Innes A, et al. Successful treatment of calciphylaxis with cinacalcet-an alternative to parathyroidectomy? Nephrol Dial Transplant. 2006;21:1999.
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  6. . Sharma A, Burkitt-Wright E, Rustom R. Cinacalcet as an adjunct in the successful treatment of calciphylaxis. Br J Dermatol. 2006;155:1295.