Images in Clinical Urology Early Allograft Calcifications After Kidney Transplantation Pasquale Esposito, Giulia Bedino, Anna Gallotti, Marilena Gregorini, Teresa Rampino, and Antonio Dal Canton Early allograft calcifications after kidney transplantation (KT) have already been reported, but the clinical implications of this finding are not clear thus far. Patient-related factors such as age, gender, underlying renal disease, and dialytic modality, seem to be irrelevant. It has been postulated that factors promoting the development of metastatic calcifications, including elevated calcium phosphate product and severe secondary hyperparathyroidism, could play a causal role. Here we report a case of a KT patient who developed early kidney calcifications which were associated with severe allograft dysfunction. UROLOGY 79: e44, 2012. © 2012 Elsevier Inc. A 47-year-old woman underwent non– heart-beating donor kidney transplantation (KT) with a long ischemia time. The patient was discharged receiv- ing tacrolimus as an immunosuppressive agent. One week later the patient presented with acute abdominal pain; a computed tomography (CT) scan showed a strangulated paraumbilical hernia, but the transplanted kidney appeared normal (Fig. 1). The patient was operated and then dis- charged; blood examinations showed: serum creatinine 3.2 mg/dL, phosphorus 4 mg/dL, and parathyroid hormone (PTH) 653 pg/mL. One month later the patient became febrile and asthenic; serum creatinine was 10.3 mg/dL, as- sociated with increased phosphorus and PTH levels (11.3 mg/dL and 689 pg/mL, respectively). Abdominal ultra- sonography and CT scan showed the presence of diffuse pyramidal calcifications in the transplanted kidney, sugges- tive for nephrocalcinosis (Fig. 2). Because of persistent graft dysfunction, fever, and positive urine culture, the kidney was explanted. The pathologic examinations confirmed the presence of pyramidal calcifications associated with diffuse papillary necrosis. Our patient presented several possible causes of renal calcifications, including long ischemia time, uncontrolled hyperparathyroidism and hyperphosphatemia, infections, and the use of tacrolimus, already associated with calcifications. 1,2 This case emphasizes that it is necessary to give prominence to factors related to KT calcifications, which have a great impact on graft function and survival. 3 References 1. Evenepoel P, Lerut E, Naesens M, et al. Localization, etiology and impact of calcium phosphate deposits in renal allografts. Am J Transplant. 2009;9:2470-2478. 2. Iguchi S, Nishi S, Shinbo J, et al. Intratubular calcification in a post-renal transplanted patient with secondary hyperparathyroidism. Clin Transpl. 2001;15:51-54. 3. Pinheiro HS, Câmara NO, Osaki KS, et al. Early presence of calcium oxalate deposition in kidney graft biopsies is associated with poor long-term graft survival. Am J Transplant. 2005;5:323-329. From the Department of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy; and Department of Radiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy Reprint requests: Pasquale Esposito Dept. of Nephrology, Dialysis and Transplan- tation Fondazione, Policlinico S.Matteo, Pavia, Italy; and Piazzale Golgi 2, 27100, Pavia-Italy. E-mail: pasqualeesposito@hotmail.com Figure 1. Unenhanced CT image shows a normal transplanted kidney. There are no calcifications or hydronephrosis. Figure 2. Unenhanced CT image shows multiple pyramidal calcifications in the transplanted kidney (arrows). This im- age was recorded one month after that showed in Figure 1. e44 © 2012 Elsevier Inc. 0090-4295/12/$36.00 All Rights Reserved doi:10.1016/j.urology.2011.10.049