Calciphylaxis is a rare condition affecting patients suffering from end-stage renal failure, characterised by cutaneous ischaemia and necrosis. The management of calciphylaxis is challenging owing to the lack of optimal medical therapy, although parathyroidectomy has shown some benefit. We present a case of severe proximal calciphylaxis treated with a small dose of the calcimimetic 'Cinacalcet'.

Hyperphosphataemia is an inevitable consequence of end stage chronic kidney disease and is present in the majority of dialysis patients. Hyperphosphataemia is statistically associated with increased cardiovascular mortality among dialysis patients. Dietary restriction of phosphate and current dialysis modalities are not sufficiently effective to maintain serum phosphate levels within the recommended range so that the majority of dialysis patients require oral phosphate binders. However, benefits of achieving the recommended range have yet to be demonstrated prospectively. Unfortunately, conventional phosphate binders are not reliably effective and are associated with a range of limitations and side effects. Aluminium containing agents are highly efficient but no longer widely used because of well-established and proven toxicity. Calcium-based salts are inexpensive, effective and most widely used but there is now concern about their association with hypercalcaemia and vascular calcification. Sevelamer hydrochloride and lanthanum carbonate are non-aluminium, calcium-free phosphate binders. They are effective and reasonably well tolerated, but still do not control phosphate levels in all patients. Patient education programmes have been shown to be a useful and effective method of improving achievement of serum phosphate targets.

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Abstract:Hyperphosphatemia is an inevitable consequence of end stage chronic kidney disease and is present in the majority of dialysis patients. Recent observational data has associated hyperphosphatemia with increased cardiovascular mortality among dialysis patients. Dietary restriction of phosphate and current dialysis prescription practices are not enough to maintain serum phosphate levels within the recommended range so that the majority of dialysis patients require oral phosphate binders. Unfortunately, conventional phosphate binders are not reliably effective and are associated with a range of limitations and side effects. Aluminium-containing agents are highly effi cient but no longer widely used because of well established and proven toxicity. Calcium based salts are inexpensive, effective and most widely used but there is now concern about their association with hypercalcemia and vascular calcifi cation. Sevelamer hydrochloride is associated with fewer adverse effects, but a large pill burden and high cost are limiting factors to its wider use. In addition, the effi cacy of sevelamer as a monotherapy in lowering phosphate to target levels in severe hyperphosphatemia remains debatable. Lanthanum carbonate is a promising new non-aluminium, calcium-free phosphate binder. Preclinical and clinical studies have demonstrated a good safety profi le, and it appears well tolerated and effective in reducing phosphate levels in dialysis patients. Its identifi ed adverse events are apparently mild to moderate in severity and mostly GI related. It appears to be effective as a monotherapy, with a reduced pill burden, but like sevelamer, it is signifi cantly more expensive than calcium-based binders. Data on its safety profi le over 6 years of treatment are now available.