Tumoral calcinosis in kidney failure

We report images from two patients living with kidney failure and refractory hyperparathyroidism who developed tumoral calcinosis. This uncommon complication of kidney failure typically occurs in patients undergoing long-term dialysis and is characterized by periarticular calcium–phosphate deposition in soft tissues. Although now rare due to improved management of chronic kidney disease–mineral and bone disorder, it remains clinically relevant in patients with refractory disease and poor adherence to therapy. The upper images depict a 36-year-old man with kidney failure secondary to chronic pyelonephritis due to spina bifida, on hemodialysis for 6.5 years, who presented with a painful right shoulder mass that developed over four weeks (Panel A). Imaging revealed extensive periarticular calcified deposits consistent with tumoral calcinosis (Panels B–C). Laboratory evaluation demonstrated severe mineral metabolism derangement, including hypercalcemia (11.8 mg/dL), hyperphosphatemia (10.1 mg/dL), and elevated parathyroid hormone (PTH 616 pg/mL). The patient reported long-standing nonadherence to phosphate binders and vitamin D analogs; as well as denial of urologic evaluation and management for possible kidney transplantation. Treatment included intensified dialysis, low-calcium dialysate, discontinuation of calcium-containing medications, and initiation of calcium-free phosphate binders, resulting in biochemical improvement and reduction of lesion size. Persistent hyperparathyroidism led to surgical parathyroidectomy, with subsequent normalization of PTH levels.