Successful Simultaneous Liver-Kidney Transplantation in a Patient with Nonuremic Calciphylaxis (NUC) Secondary to Alcoholic Cirrhosis

Introduction: Calciphylaxis is a rare condition characterized by painful, non-healing skin lesions due to arterial calcification and thrombosis. While typically associated with end-stage renal disease (ESRD), calciphylaxis can also occur in the absence of renal dysfunction, known as non-uremic calciphylaxis (NUC). Common causes include primary hyperparathyroidism, alcoholic liver disease, and malignancy. Case Description: A 45-year-old male with end-stage liver disease secondary to alcohol (EtOH) cirrhosis presented with worsening bilateral lower extremity necrotic wounds over 6 months. He was initially diagnosed with livedo reticularis. At the time of lesion appearance, renal function was normal (GFR 123 mL/min), but as liver failure progressed, renal dysfunction ensued, necessitating dialysis. Skin biopsy confirmed calciphylaxis, prompting treatment with vitamin K and sodium thiosulfate (STS), along with wound care and prophylactic antibiotics. Significant labs revealed PTH of 68 pg/ml, 25 OH Vit D of 22 ng/ml, calcium of 8.3 mg/dl, PO4 of 5 mg/ml, and albumin of 1.8 g/dl. The patient underwent simultaneous liver and kidney transplantation attaining a baseline creatinine of 0.9 mg/dl. Maintenance Immunosuppression included tacrolimus and mycophenolate. Continuation of STS therapy for 6 weeks post-transplantation led to complete resolution of lesions. Discussion: We present a case of successful simultaneous liver and kidney transplantation in a patient with active NUC. Although NUC complicates pre-transplant evaluation due to associated high mortality and infection risks, aggressive medical management and continued STS therapy can yield favorable outcomes. While the literature on NUC and transplantation is limited, existing reports suggest favorable outcomes with STS post-transplantation. This case emphasizes that a diagnosis of NUC may not preclude transplantation or immunosuppression.