Calciphylaxis, or calcific uraemic arteriolopathy (CUA), is a clinical syndrome usually associated with advanced renal disease, which is characterized by vascular calcification and the development of painful ischaemic ulcers. It is a rare disease, with an incidence of only 4.5 cases per 1000 patient-years on dialysis (Toussaint et al 2024). Diagnosis generally implies a poor prognosis, with an overall mortality of approximately 50 per cent at six months (McCarthy et al 2016). Calciphylaxis also causes significant symptom burden, with painful skin lesions requiring a specialised approach to analgaesia. Treatments are limited and can result in adverse side effects. Despite its poor prognosis and significant symptom burden, only a minority of patients diagnosed with calciphylaxis are referred for specialist palliative care (Gaster et al 2021).

We present a case of a 53-year-old female with previous renal transplant, admitted to Monash Health, Melbourne with non-uraemic calciphylaxis. She was referred to our specialist palliative care consult service for management of complex disease and treatment-related symptoms. Ischaemic wound pain in calciphylaxis is well described, and our patient required multiple analgaesic agents to achieve adequate pain relief. However, her most burdensome symptom was severe nausea and vomiting, which related to sodium thiosulfate infusions – one of few recognized treatments for the disease.

After failing first and second-line anti-emetics, a levomepromazine infusion enabled adequate tolerance of sodium thiosulphate treatment. She was transitioned from levomepromazine to intermittent doses of oral olanzapine, administered as premedication to therapy. Once she achieved a treatment response, she was discharged home, returning for maintenance therapy with intermittent sodium thiosulfate infusions administered as an outpatient, in a day-clinic infusion setting. At this time, her palliative care was transitioned to our Monash Hospital-in-the-Home Palliative Care (HITH PC) team. At the time of writing, sodium thiosulfate infusions have continued for over 6 months, with an enduring response, well tolerated with the above premedication regime.

Traditional community palliative care models were not well equipped to meet this patient’s needs. Her uncertain prognosis, and active goals of care, precluded a solely symptom-based focus. Her medical complexity and the interplay between supportive and active care (with frequent nephrology intervention) also meant that consolidating treatment teams within the one health service offered the best continuity of care. Our HITH PC service provided a transformative model to deliver specialist palliative care interventions as required.

Our case highlights the role of specialist palliative care working in novel ways, alongside nephrologists in providing optimal symptom management to manage the complex symptom burden associated with calciphylaxis and its treatments.