Review

Extraosseous calcification in kidney disease

Korey Bartolomeo, DO, Xin Yee Tan, MD and Richard Fatica, MD
Cleveland Clinic Journal of Medicine February 2022, 89 (2) 81-90; DOI: https://doi.org/10.3949/ccjm.89a.21073

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Calcium and phosphate metabolism in chronic kidney disease. Decreased glomerular filtration rate (GFR) leads to changes in serum calcium and phosphate, triggering release of parathyroid hormone (PTH) from the parathyroid glands and fibroblast growth factor 23 (FGF-23) from osteoblasts and osteocytes. These hormones have complex downstream effects on the kidney, gut, and bone, both from direct effects on the tissue and from indirect effects through modulation of enzyme activity in vitamin D conversion.

    aMinimally increased.

    25(OH) vitamin D = 25-hydroxycholecalciferol; 1,25(OH)2 vitamin D = 1,25-dihydroxycholecalciferol

  • Figure 2
    Figure 2

    Calciphylaxis in a 51-year-old man with end-stage kidney disease.

    From reference 27.

  • Figure 3
    Figure 3

    Radiography shows calcified masses (arrows) in a 47-year-old woman with tumoral calcinosis.

    From reference 30.

Tables

  • TABLE 1

    Common terms used to describe calcification

    Soft tissue calcification
    Dystrophic calcification: occurring in damaged or degenerated tissue in the setting of normal metabolic factors
    Metastatic calcification: occurring in otherwise normal tissue, secondary to deranged metabolic factors, as in hypercalcemia
    Calciphylaxis (calcific uremic arteriopathy): ischemic skin lesions characterized by calcium deposition and thrombosis in the dermis and subcutaneous adipose tissue, most commonly associated with advanced kidney disease
    Calcinosis cutis universalis: diffuse involvement of subcutaneous and fibrous structures, most commonly in association with autoimmune disorders
    Tumoral calcinosis: massive deposition of calcium-phosphorus crystals in periarticular areas
    Calcinosis circumscripta: localized or isolated calcification; term sometimes used if calciphylaxis involvement is limited to an extremity
    Vascular calcification
    Atherosclerotic (intimal) calcification: inflammatory vaso-occlusive calcification of intima as a result of endothelial dysfunction
    Monckeberg arterial calcification: medial calcification deposition in small and medium arteries without luminal narrowing
    Infantile calcification: extensive calcification of medium and large arteries due to ENPP1 gene mutation
  • TABLE 2

    Risk factors associated with vascular calcification

    Traditional risk factors
    Hypertension
    Diabetes mellitus
    Old age
    Smoking
    Dyslipidemia
    Family history of premature coronary artery disease
    Male sex
    Increased levels of C-reactive protein or other
    inflammatory markers
    Kidney disease-related risk factors
    Longer hemodialysis duration
    Persistent hyperphosphatemia
    Increased calcium-phosphate product
    Calcium-containing phosphate binders
    Secondary hyperparathyroidism
    Adynamic bone disease
    Vitamin D deficiency and excessive vitamin D administration
    High dialysate calcium
    Hypomagnesemia
    Low fetuin-A
    Low albumin
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