History: A 48-year-old woman was hospitalized because of the presence of asymptomatic bilateral pulmonary infiltrates in the conventional chest radiograph. An antibiotic treatment administered 3 months before had been without any effect on the radiological aspect. The patient had had an end-stage renal disease of unknown cause and was on hemodialysis since 1993. 1997 she received a cadaveric renal transplant.
Investigations: Computed tomography scan detected the infiltrates as diffuse calcifications mainly at the lung bases. Extended arterial vascular calcifications were also found. Since approximately 4 years calcium-phosphorus product and parathyroid hormone had been increased.
Treatment and course: Because of the long-term increased calcium-phosphorus product and the high parathyroid hormone levels we interpreted the pulmonary calcifications as a result of the tertiary hyperparathyroidism. After parathyroidectomy calcium-phosphorus product and PTH levels normalized, but our patient suffered from increasing disturbances of the peripheral blood circulation induced by the vascular calcifications, necessitating amputation of finger and toe tips.
Conclusion: Patients with renal failure should undergo regular controls of calcium, phosphorus and parathyroid hormone when creatinine clearance is below 50 ml/min/1.73 m2. Only an early medical treatment can prevent the various complications induced by the secondary or tertiary hyperparathyroidism. If medical therapy fails, parathyroidectomy has to be done. Especially before renal transplantation the extent of hyperparathyroidism has to be carefully analyzed and treated aggressively, if necessary by surgery before the date of transplantation.