Penile Necrosis in a Patient With End-Stage Kidney Disease: Suspected Uremic Calciphylaxis in the Setting of Severe Peripheral Arterial Disease

Uremic calciphylaxis, also known as calcific uremic arteriolopathy, is a rare and potentially fatal complication of advanced kidney disease.Penile involvement is uncommon and may result in progressive tissue necrosis.In patients with end-stage kidney disease, penile necrosis may have multiple contributing etiologies, including calciphylaxis, severe peripheral arterial disease, diabetic vasculopathy, and infection.A 68-year-old man with end-stage kidney disease receiving continuous ambulatory peritoneal dialysis, longstanding diabetes mellitus, severe peripheral arterial disease, profound hypoalbuminemia, and abnormalities in mineral metabolism presented with extensive necrosis involving the penis, left hemiscrotum, and lower extremities.Laboratory evaluation demonstrated severe hypoalbuminemia, hyperphosphatemia, hypocalcemia, anemia, and leukocytosis.A sputum culture grew extended-spectrum βlactamase (ESBL)-producing Klebsiella pneumoniae, while a urine culture grew ESBL-producing Escherichia coli.These microbiological findings documented respiratory and urinary isolates, respectively, but did not establish infection of the necrotic genital or lower-extremity tissues.The patient underwent right aboveknee amputation and total penectomy with perineal urethrostomy.Despite surgical removal of grossly necrotic tissue, ischemic changes persisted, followed by amputation stump wound dehiscence, hemodynamic deterioration, septic shock, acute respiratory failure, and death.The coexistence of end-stage kidney disease requiring peritoneal dialysis, longstanding diabetes mellitus, severe peripheral arterial disease, profound hypoalbuminemia, mineral abnormalities, and multisite tissue necrosis raised substantial clinical suspicion for uremic calciphylaxis.However, the absence of histopathological confirmation, documented radiological evidence of vascular calcification, and intact parathyroid hormone measurement precluded a definitive diagnosis.The tissue necrosis was considered multifactorial, with severe peripheral arterial disease, diabetic vasculopathy, infection, and suspected uremic calciphylaxis representing potential contributors.