Strategies to stop calcification of blood vessels

Correct Hyperphosphatemia

- More and longer dialysis sessions (4 - 5 times/wk)

- Dietary phosphate restriction: avoid colas and processed food; seek nutrition consult

- Non Ca++ phosphate binder

Correct Hypercalcemia

- Reduce Ca++ concentration in dialysis bath to 1.5 or 2 mEq/l; ovoid 2.5 mEq/l

- Stop Ca++ based phosphate binder (Ca++ acetate)

Correct Hyperparathyroidism

- Cinacalcet (medical parathyroidectomy)

- Surgical parathyroidectomy in medically refractory cases

Stop Vitamin D

- E.g. calcitriol

Stop Warfarin

- Evaluate need for alternate anticoagulant

- No data to justify anticoagulation for stroke prevention in atrial fibrillation in dialysis patients

- Apixaban 2.5 mg bid in pulmonary embolism, deep vein thrombosis, mechanical valve (limited safety data)

Convert to Hemodialysis from Peritoneal Dialysis

Strategies to promote decalcification of blood vessels

Sodium Thiosulfate

- Route and dose

- Intravenous (standard): 25 gm if weight > 60 kg; 12.5 gm if weight < 60 kg: infusion in the last hour of dialysis

- Subcutaneous (non standard) 0.25 to 0.75 gm (1 to 3 ml of 250 mg/ml); at the periphery and center of the lesion

- Duration of iv infusion: minimum of 2 - 3 mos.; typical total duration of 6 mos. or until lesions completely heal

Vitamin K

- Route and dose: 10 mg per so three times a week (normal daily vitamin k intake: 0.10 - 0.15 mg)

Wound care and pain control


- Surgical debridement for infected and wounds with exudates

- Nonsurgical debridement for noninfected and dry wounds

Hyperbaric Oxygen Therapy

- Delivery of 100% oxygen at 2.5 times the atmospheric pressure in a sealed chamber for 90 min

- Aim for 20 - 30 sessions (optimal number unknown)

- Reserved for refractory wounds

Pain Control

- Fentanyl and methadone preferred in renal failure. Avoid morphine and hydromorphone because accumulating active metabolite can cause respiratory depression.