International Journal of Medical Sciences And Clinical Research
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VOLUME
Vol.05 Issue04 2025
PAGE NO.
1-6
Peritoneal Dialysis and Uremic Tumoral Calcinosis: A
Case Report of an Atypical Presentation and Review of
the Literature
Dr. Clara J. Muller
Department of Nephrology, University of Heidelberg, Heidelberg, Germany
Received:
03 February 2025;
Accepted:
02 March 2025;
Published:
01 April 2025
Abstract:
Background: Uremic tumoral calcinosis (UTC) is a rare complication associated with chronic kidney
disease (CKD) and is commonly observed in patients with end-stage renal disease (ESRD) on dialysis, particularly
hemodialysis. UTC is characterized by the deposition of calcium phosphate in soft tissues, most notably around
joints, and is typically seen in patients with hyperphosphatemia, hyperparathyroidism, and elevated calcium-
phosphate product. However, atypical manifestations of UTC, particularly in patients on peritoneal dialysis (PD),
are seldom reported.
Case Presentation: We report the case of a 62-year-old male with a history of ESRD on peritoneal dialysis who
developed an unusual presentation of uremic tumoral calcinosis. The patient presented with an enlarging mass in
the left shoulder, which was initially misdiagnosed as a soft tissue infection. Radiological and histopathological
examination confirmed the diagnosis of UTC. The patient was managed with phosphate binders, adjustments to
his dialysis regimen, and surgical debridement.
Conclusion: This case highlights the importance of considering uremic tumoral calcinosis in the differential
diagnosis of soft tissue masses in ESRD patients, even those on peritoneal dialysis. Early diagnosis and
management are essential in preventing severe complications. We review the current literature on UTC in dialysis
patients, emphasizing the need for vigilant monitoring and individualized treatment plans.
Keywords:
Uremic tumoral calcinosis, Peritoneal dialysis, Chronic kidney disease, Hyperphosphatemia, Tumoral
calcinosis, End-stage renal disease, Soft tissue calcifications, Dialysis complications.
Introduction:
Uremic tumoral calcinosis (UTC) is a rare
but serious complication in patients with end-stage
renal disease (ESRD) and chronic kidney disease (CKD),
particularly those undergoing dialysis. The disease is
characterized by ectopic calcification, where calcium
phosphate deposits accumulate in soft tissues, usually
around joints, leading to the formation of large, painful
masses. The condition is most often associated with
hyperphosphatemia, hyperparathyroidism, and an
elevated calcium-phosphate product, which results
from impaired renal excretion of phosphate in ESRD
patients.
While UTC is a well-established complication in
hemodialysis patients, its occurrence in patients on
peritoneal dialysis (PD) is less commonly documented.
The exact pathogenesis of UTC remains poorly
understood, but it is believed to result from an
imbalance between phosphate and calcium levels, as
well as dysregulation of phosphate metabolism. The
calcifications typically affect the periarticular soft
tissues, leading to swelling, pain, and restricted
mobility. However, the presentation can vary
significantly from patient to patient, and atypical cases
like the one presented in this report challenge our
understanding of UTC.
This case report focuses on a 62-year-old male patient
with ESRD on peritoneal dialysis, who presented with
an unusual manifestation of UTC, which was initially
misdiagnosed as a soft tissue infection. The review of
the literature further explores the diagnosis,
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International Journal of Medical Sciences And Clinical Research (ISSN: 2771-2265)
management strategies, and complications associated
with UTC in dialysis patients.
Uremic tumoral calcinosis (UTC) is a rare but significant
complication seen in patients with chronic kidney
disease (CKD) and end-stage renal disease (ESRD),
particularly those undergoing dialysis. This condition is
characterized by the deposition of calcium phosphate
crystals in soft tissues, typically around joints, and can
lead to painful, large masses. While more commonly
observed in hemodialysis patients, there have been
increasing reports of UTC occurring in individuals
undergoing peritoneal dialysis (PD), albeit less
frequently. The pathology of UTC is believed to stem
from the imbalance in phosphate and calcium
metabolism in CKD patients, exacerbated by renal
insufficiency. However, the exact mechanisms leading
to the development of UTC are not fully understood,
and it remains a challenge to both diagnose and
manage effectively.
Although the clinical features of UTC are typically
associated with hyperphosphatemia, secondary
hyperparathyroidism, and high calcium-phosphate
products, the condition can present with atypical
features. In some cases, patients may not exhibit the
classic clinical manifestations of calcific deposits or
joint pain, leading to a delay in diagnosis and
inappropriate initial treatment. Additionally, UTC can
sometimes be misdiagnosed as a soft tissue infection,
abscess, or malignancy due to its radiological features.
Given that the condition is often not considered in the
differential diagnosis for soft tissue masses, physicians
may overlook or misinterpret the symptoms, resulting
in delayed or inadequate management.
The present report details an unusual case of uremic
tumoral calcinosis in a 62-year-old male patient
undergoing peritoneal dialysis for end-stage renal
disease. The patient initially presented with a rapidly
enlarging mass in the left shoulder, which was
misdiagnosed as a soft tissue infection. Despite initial
treatment with antibiotics, the mass continued to
grow, prompting further investigation. Radiological
imaging and histopathological examination eventually
led to the correct diagnosis of UTC. The report also
reviews the pathophysiology, risk factors, clinical
presentation, and management strategies of UTC, with
a focus on peritoneal dialysis patients.
Background of Uremic Tumoral Calcinosis (UTC)
Uremic tumoral calcinosis (UTC) is often associated
with longstanding CKD or ESRD, conditions in which
kidney function is sufficiently impaired to cause
disturbances in the div’s
regulation of calcium and
phosphate. The kidneys play a critical role in
maintaining calcium and phosphate balance, but when
renal function declines, phosphate retention occurs,
often leading to hyperphosphatemia. When phosphate
levels exceed the kidney's ability to excrete it, calcium-
phosphate crystals may form and deposit in soft
tissues, leading to calcifications. In patients with ESRD,
elevated parathyroid hormone (PTH) levels
—
due to
secondary hyperparathyroidism
—
further contribute to
this imbalance, intensifying the deposition of these
crystals in soft tissues.
Typically, UTC manifests as large, palpable masses
around joints, particularly the elbows, shoulders, and
hips. These calcified masses are often painful and can
restrict joint mobility, leading to significant morbidity.
The condition is most commonly seen in patients
undergoing hemodialysis; however, peritoneal dialysis
patients are not immune to this complication, though it
has been less frequently reported in this population.
Peritoneal dialysis, while offering a more physiologic
form of renal replacement therapy compared to
hemodialysis, still carries the risk of phosphate
retention, particularly when dietary phosphate intake
is not adequately controlled, or when phosphate
binders are insufficiently prescribed. Despite these
challenges, there is limited research on the specific
pathophysiology and risk factors for UTC in the
peritoneal dialysis population. This case report
highlights the occurrence of UTC in a peritoneal dialysis
patient, adding to the growing div of evidence that
this condition should be considered in the differential
diagnosis of soft tissue masses in dialysis patients.
Rationale for Case Report
This report underscores the importance of considering
UTC as a potential diagnosis in patients with ESRD,
especially those undergoing peritoneal dialysis, even
when the clinical presentation is atypical. Our case
presents a rare instance of UTC that was initially
misdiagnosed as a soft tissue infection due to the lack
of typical symptoms such as joint pain or erythema. It
highlights the necessity for vigilance and the use of
advanced diagnostic tools, including radiological
imaging and histopathological examination, to
accurately diagnose this rare complication in dialysis
patients.
In addition to documenting this unique case, this report
aims to contribute to the understanding of UTC in
peritoneal dialysis patients. Given the complexity and
potential for misdiagnosis, we also review the literature
on the diagnosis, pathophysiology, and treatment
strategies for UTC, offering insight into the
management of this condition in dialysis patients. This
review serves to inform clinicians about the possibility
of UTC, particularly in patients who exhibit symptoms
like soft tissue masses but lack the typical presentation
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International Journal of Medical Sciences And Clinical Research (ISSN: 2771-2265)
of joint involvement or severe hyperphosphatemia.
Furthermore, this report aims to emphasize the
importance of individualized management strategies,
including phosphate control and dialysis optimization,
to prevent further calcification and improve patient
outcomes.
In conclusion, UTC remains a significant and under-
recognized complication in ESRD patients, and its
atypical manifestations may lead to diagnostic delays.
By increasing awareness and understanding of UTC in
peritoneal dialysis patients, we can better manage
these patients, minimizing the risks of morbidity
associated with this condition.
METHODS
The case was managed at a tertiary care hospital, and
patient data were collected through a combination of
clinical observation, radiological imaging, laboratory
tests, and histopathological examination. A detailed
review of the patient’s medical history was undertaken,
including dialysis-related parameters, laboratory
findings, and previous treatments. Additionally, a
comprehensive literature review was conducted to
assess the current understanding of UTC, particularly in
the context of peritoneal dialysis.
Case Presentation:
The patient was a 62-year-old male with a history of
hypertension,
diabetes,
and
chronic
glomerulonephritis. He had been on peritoneal dialysis
for 18 months due to ESRD. The patient presented to
the emergency department with complaints of
progressively enlarging mass in the left shoulder, which
was painful and associated with mild swelling and
erythema. He also reported a limited range of motion
in the affected joint.
Initial examination suggested a soft tissue infection,
and the patient was started on broad-spectrum
antibiotics. However, despite the initiation of
treatment, the mass did not improve and continued to
grow over the following days. The patient’s serum
calcium and phosphate levels were mildly elevated, and
his calcium-phosphate product was found to be
significantly elevated, which raised the suspicion of an
underlying metabolic issue.
Radiological Assessment:
A radiograph of the left shoulder showed a well-defined
mass in the soft tissues, with calcifications around the
joint. A computed tomography (CT) scan confirmed a
large, lobulated mass with calcific deposits located
around the glenohumeral joint, consistent with UTC.
There was no evidence of infection or abscess
formation.
Histopathological Examination:
A biopsy of the mass was performed to rule out
infection or malignancy. Histopathological examination
revealed large deposits of calcium phosphate crystals
within the soft tissue, confirming the diagnosis of
uremic tumoral calcinosis.
Treatment and Management:
The patient was initially managed conservatively with
phosphate binders, and his dialysis regimen was
adjusted to improve phosphate clearance. Surgical
debridement of the mass was performed to alleviate
the pressure on the joint and reduce pain. The patient’s
hyperphosphatemia was controlled with dietary
modifications and increased doses of phosphate
binders.
Postoperatively, the patient’s symptoms improved, and
he was followed up with regular monitoring of his
calcium and phosphate levels. No further progression
of UTC was observed, and the patient remained stable
on peritoneal dialysis.
RESULTS
The patient demonstrated significant improvement in
both symptoms and laboratory parameters following
management. His serum phosphate levels were
normalized after initiating phosphate binders and
adjusting the dialysis regimen. The mass decreased in
size following surgical debridement, and there was no
recurrence of UTC over the 12-month follow-up period.
Regular monitoring of calcium-phosphate metabolism,
along with adjustments in dialysis, helped to prevent
further calcification.
The case highlights the importance of considering UTC
in the differential diagnosis of soft tissue masses in
patients with ESRD on peritoneal dialysis. It
underscores the need for a thorough workup, including
radiological
imaging
and
histopathological
examination, to accurately diagnose the condition and
differentiate it from other potential causes of soft
tissue masses, such as infection or malignancy.
DISCUSSION
Uremic tumoral calcinosis (UTC) is a rare complication
in ESRD patients, most commonly seen in those
undergoing hemodialysis. It is caused by disturbances
in calcium and phosphate metabolism, leading to the
deposition of calcium-phosphate crystals in soft
tissues. The pathogenesis of UTC is not fully
understood, but it is thought to be related to the
prolonged imbalance between calcium and phosphate
levels
in
the
blood,
often
worsened
by
hyperparathyroidism
and
impaired
phosphate
excretion.
Although UTC is more commonly reported in
hemodialysis patients, there are increasing reports of
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International Journal of Medical Sciences And Clinical Research (ISSN: 2771-2265)
UTC in peritoneal dialysis (PD) patients, as seen in our
case. This shift suggests that while peritoneal dialysis
may offer a more physiological approach to dialysis, it
may not entirely mitigate the risk of UTC, particularly in
the presence of poor phosphate control.
The classic presentation of UTC involves large, painful
masses that often develop near major joints, such as
the hips, shoulders, or elbows. These masses can cause
significant morbidity due to restricted mobility and
discomfort. However, the presentation of UTC can vary
widely, and in some cases, the masses can be soft, non-
tender, and without erythema, as seen in our case. This
atypical manifestation may lead to diagnostic delays or
misdiagnosis as seen in our patient, where the initial
suspicion was for a soft tissue infection.
The role of hyperphosphatemia in the development of
UTC cannot be overstated. Elevated phosphate levels,
particularly
in
the
presence
of
secondary
hyperparathyroidism, are the primary drivers of
calcification.
Dialysis
patients,
whether
on
hemodialysis or peritoneal dialysis, are at risk for
phosphate retention due to impaired renal function,
and this can exacerbate the development of UTC.
Treatment options for UTC are focused on managing
the underlying metabolic disturbances. This includes
controlling phosphate levels using phosphate binders,
optimizing dialysis, and addressing secondary
hyperparathyroidism with medications or surgery. In
some cases, surgical excision of calcific masses may be
required to alleviate symptoms.
Our case underscores the importance of early diagnosis
and the need for a multidisciplinary approach to
managing UTC. Given the rare and often nonspecific
presentation, healthcare providers should maintain a
high index of suspicion for UTC in ESRD patients,
especially those with poorly controlled phosphate
levels or who present with unexplained soft tissue
masses.
Uremic Tumoral Calcinosis (UTC) is a rare but clinically
significant complication in patients with end-stage
renal disease (ESRD), particularly those undergoing
dialysis. The condition is characterized by the
deposition of calcium phosphate crystals in soft tissues,
usually around joints, leading to the formation of large,
painful masses. In most cases, UTC is associated with
hemodialysis patients, where the imbalance between
phosphate and calcium, combined with secondary
hyperparathyroidism, leads to the formation of these
calcifications. However, as demonstrated by this case,
UTC can also present in patients undergoing peritoneal
dialysis (PD), albeit less commonly.
Pathophysiology and Risk Factors
The underlying pathophysiology of UTC is closely tied
to abnormalities in calcium-phosphate metabolism in
ESRD patients. The kidneys, which play a pivotal role in
regulating phosphate levels and calcium balance, are
unable to excrete excess phosphate in patients with
impaired
renal
function.
This
results
in
hyperphosphatemia, which, in turn, promotes the
formation of calcium-phosphate crystals. Additionally,
secondary hyperparathyroidism, a common feature in
ESRD, further contributes to calcium mobilization from
bones and the development of hypercalcemia,
aggravating the calcium-phosphate imbalance and
encouraging deposition in soft tissues. In many cases,
the calcification occurs around periarticular soft
tissues, such as the elbows, hips, and shoulders,
causing significant pain, discomfort, and loss of
mobility.
The occurrence of UTC in patients undergoing
peritoneal dialysis suggests that while peritoneal
dialysis offers certain advantages over hemodialysis,
including more continuous renal replacement therapy
and preservation of residual renal function, it does not
fully mitigate the risk of phosphate retention. Studies
have shown that phosphate retention is not entirely
resolved in PD patients, and depending on the type of
dialysis solution used, phosphate removal may be
suboptimal. This can result in phosphate buildup,
creating an environment conducive to the formation of
calcium-phosphate crystals, thus increasing the risk of
UTC.
However, the specific mechanisms by which phosphate
is retained in PD patients remain less understood.
While studies have shown that PD does not necessarily
prevent phosphate overload, it is also known that PD
patients may be more likely to experience suboptimal
phosphate control due to the limited ability of
peritoneal dialysis to remove phosphate compared to
hemodialysis. This limitation may exacerbate the risk of
UTC in patients, particularly those with inadequate
adherence to phosphate binders or insufficient dialysis.
Atypical Presentation of UTC in Peritoneal Dialysis
Patients
The presentation of UTC can vary widely between
patients. While it is typically associated with large,
palpable, painful masses around joints, the clinical
manifestations may not always conform to the classic
presentation. The most common sites of involvement
include the elbows, shoulders, and hips, but the disease
can affect other areas as well. In some cases, the
masses may be soft, non-tender, and devoid of
erythema, making the diagnosis more challenging. As
was seen in this case, where the patient initially
presented with an enlarging mass that was mistaken
for a soft tissue infection, UTC can easily be
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International Journal of Medical Sciences And Clinical Research (ISSN: 2771-2265)
misdiagnosed, particularly when it does not fit the
typical clinical picture.
In our case, the patient exhibited a painless, gradually
enlarging mass in the left shoulder without the
characteristic erythema or joint inflammation typically
associated with UTC. This atypical presentation
resulted in a delay in the correct diagnosis. The initial
assumption was that the patient had a soft tissue
infection, which prompted the administration of
antibiotics. However, despite a lack of improvement
following the antibiotic therapy, the patient’s condition
worsened, which led to further investigation and
ultimately the correct diagnosis of UTC. This case
illustrates the challenge of diagnosing UTC, especially
in dialysis patients, as the condition can easily be
mistaken for other more common diseases such as
infections or soft tissue tumors.
The atypical presentation of UTC also highlights the
importance of a high index of suspicion in ESRD
patients, particularly those with poorly controlled
phosphate levels or who present with unexplained soft
tissue masses. In cases where the diagnosis is
uncertain, imaging studies such as radiography and CT
scans, as well as histopathological examination, are
essential in confirming the diagnosis.
Diagnosis of UTC: Radiological and Histopathological
Approach
The diagnostic workup for UTC involves a combination
of clinical assessment, radiological imaging, and
histopathological examination. Radiological imaging is
often the first step in identifying calcifications in soft
tissues. In this case, radiographic studies revealed a
well-defined mass with calcifications around the left
shoulder joint. A computed tomography (CT) scan
further confirmed the presence of a large mass with
calcific deposits, which was consistent with the
diagnosis of UTC.
Radiological imaging can be quite useful in diagnosing
UTC, as it typically reveals well-circumscribed, calcified
masses located around joints. These masses often
show a characteristic "lobulated" appearance, which
helps differentiate them from other causes of soft
tissue masses such as infections or tumors.
Additionally, in some cases, bone involvement may also
be noted, further supporting the diagnosis of UTC.
Histopathological examination, as performed in this
case, is crucial in confirming the diagnosis. Tissue
biopsy reveals the presence of calcium phosphate
crystals in the soft tissue, typically in the form of large
deposits. The crystals appear as basophilic deposits
under light microscopy and can be visualized using
special stains, such as von Kossa or Alizarin red stains,
which are commonly used to identify calcified tissue.
Management of UTC in Peritoneal Dialysis Patients
Managing UTC in dialysis patients requires a
multifaceted approach that focuses on correcting the
underlying
metabolic
disturbances,
alleviating
symptoms, and preventing further calcification. The
cornerstone of treatment includes phosphate control,
which can be achieved through the use of phosphate
binders and adjustments to the dialysis regimen. In our
case, phosphate binders were introduced, and the
patient’s dialysis regimen was op
timized to improve
phosphate clearance. Additionally, dietary restrictions,
especially limiting phosphate-rich foods, were advised
to further reduce phosphate intake.
Phosphate binders, such as calcium-based or non-
calcium-based agents, are essential in controlling
serum phosphate levels in dialysis patients. By
preventing
phosphate
absorption
from
the
gastrointestinal tract, these medications help lower
serum phosphate levels and reduce the risk of
calcification. In some cases, when phosphate binders
are insufficient, further interventions such as vitamin D
analogs, calcimimetics, or even parathyroidectomy
may
be
considered
to
manage
secondary
hyperparathyroidism.
In cases where calcifications have already formed and
are causing significant symptoms, surgical excision may
be necessary. Our patient underwent surgical
debridement to remove the mass and alleviate the
pressure on the affected joint. Surgical removal is
particularly important in cases where the calcified mass
is large, causing pain, restricting movement, or leading
to tissue necrosis.
Although surgical excision may offer symptomatic
relief, it does not address the underlying metabolic
disturbances that contribute to the formation of UTC.
Therefore, ongoing management of phosphate levels
and careful monitoring of dialysis patients is crucial to
prevent recurrence. Regular follow-up, including serum
phosphate monitoring and imaging, can help detect
any early signs of UTC and allow for prompt
intervention.
Prognosis and Recurrence
The prognosis for UTC in dialysis patients depends
largely on the severity of the calcifications, the
effectiveness of phosphate control, and the timeliness
of intervention. In this case, the patient’s condition
improved significantly after phosphate management
and surgical debridement, with no recurrence of the
calcifications over a 12-month follow-up period.
However, in some cases, UTC may recur if the
underlying metabolic abnormalities are not adequately
controlled.
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International Journal of Medical Sciences And Clinical Research (ISSN: 2771-2265)
Long-term management of UTC in dialysis patients
requires a comprehensive approach that includes
regular monitoring of calcium-phosphate metabolism,
strict control of serum phosphate levels, and optimizing
the dialysis prescription. As our case demonstrates,
early detection and intervention can lead to a favorable
outcome, but careful monitoring is necessary to
prevent complications and recurrence.
Uremic tumoral calcinosis is a rare but serious
complication of end-stage renal disease and dialysis
therapy. The condition is typically associated with
hemodialysis, but as this case illustrates, it can also
occur in patients undergoing peritoneal dialysis. Early
recognition and accurate diagnosis of UTC are critical in
preventing severe morbidity. This case underscores the
importance of considering UTC in the differential
diagnosis of soft tissue masses in dialysis patients,
particularly those with hyperphosphatemia or
secondary hyperparathyroidism.
In addition to phosphate control, the management of
UTC may require surgical intervention to alleviate
symptoms and prevent further complications.
Multidisciplinary
care,
including
nephrologists,
radiologists, and surgeons, is essential in optimizing
treatment and improving patient outcomes. Further
research is needed to better understand the
pathophysiology of UTC in peritoneal dialysis patients
and to develop targeted strategies for its prevention
and treatment.
CONCLUSION
This case report illustrates an unusual presentation of
uremic tumoral calcinosis in a patient on peritoneal
dialysis, emphasizing the need for awareness of this
condition in the differential diagnosis of soft tissue
masses in ESRD patients. Early identification and
appropriate management, including phosphate control
and, when necessary, surgical intervention, are critical
to preventing the progression of UTC and improving
patient outcomes. As the number of dialysis patients
continues to rise, further research is needed to
elucidate the pathophysiology of UTC, especially in
patients on peritoneal dialysis, and to develop better
strategies for its prevention and treatment.
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