Renal allograft failure in a hyperparathyroid patient following initiation of a calcimimetic.

Background: A 47-year-old man with a 6-year history of chronic dialysis for end-stage renal disease of unknown etiology presented for renal transplantation. While on dialysis, he had developed secondary hyperparathyroidism, which persisted after transplantation despite treatment with cinacalcet.

Investigations: Physical examination, serum and urine analysis, ultrasound of the renal transplant, renal biopsy, bone scintigraphy.

Diagnosis: Severe persistent hyperparathyroidism associated with mild hypercalcemia following renal transplantation. Initiation of a calcimimetic followed by fulminant graft failure. Extensive tubular calcinosis.

Management: Renal transplantation (with immunosuppressant medications: basiliximab, tacrolimus, mycophenolate mofetil, prednisolone), cinacalcet (halted on day 26 after transplantation), angiotensinconverting-enzyme inhibitor, angiotensin-receptor blocker, hydrochlorothiazide, emergency dialysis, subtotal parathyroidectomy.