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Warfarin-Induced Pulmonary Metastatic Calcification and Calciphylaxis in a Patient With End-stage Renal Disease

Juan C. Cadavid, MD; Matthew L. DiVietro, DO; Elio A. Torres, MD; Peter Fumo, MD; Glenn Eiger, MD, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Drs Cadavid and Eiger), the Department of Medicine (Dr DiVietro), and the Division of Nephrology (Drs Torres and Fumo), Albert Einstein Medical Center, Philadelphia, PA.

Correspondence to: Juan C. Cadavid, MD, Division of Pulmonary and Critical Care Medicine, Albert Einstein Medical Center, 5401 Old York Rd, Philadelphia, PA 19141; email: cadavid75@gmail.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(6):1503-1506. doi:10.1378/chest.10-1322
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Patients with end-stage renal disease (ESRD) receiving hemodialysis (HD) suffer from a number of metabolic derangements. Ectopic deposition of calcium in the skin, soft tissues, blood vessels, and viscera is a potentially devastating consequence of disorders of calcium and phosphorus homeostasis. We report the case of a patient with ESRD and secondary hyperparathyroidism receiving HD who developed metastatic pulmonary calcification and calciphylaxis following initiation of warfarin therapy after mechanical valve replacement. Because not all patients with ESRD receiving HD develop ectopic calcification, there appears to be a complex cascade of metabolic interactions that predispose patients to this process. Warfarin is a vitamin K antagonist with inhibitory effects not only on proteins of the coagulation cascade, but also on other important protein systems. Its role in ectopic calcium deposition has been the subject of theories and has been reported in the literature, but no link with metastatic pulmonary calcification has been made. Patients receiving HD have an increased incidence of conditions that require chronic anticoagulation with warfarin, such as VTE, atrial fibrillation, and valvular heart disease requiring valve replacement surgery. Bioprosthetic valves should be considered in these patients because of the potential risk of metastatic calcification when warfarin is used in the setting of mechanical valve replacement.

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