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Evaluation and treatment of penile gangrene in a chronic dialysis patient.

Sir, With great interest, we have read the article by Liao et al. [1] entitled ‘Penile gangrene in a chronic dialysis patient’ in a recent issue of Nephrology Dialysis Transplantation. They reported a case of penile gangrene in a 66-year-old man with diabetic nephropathy in end-stage renal disease (ESRD) on regular haemodialysis for 1 year. The patient received partial penile resection to stem the progression of gangrene, but he died of overwhelming sepsis 5 days after the operation. The authors attributed the penile gangrene to calcification of the bilateral penile artery (documented by non-contrast computed tomography), associated with high serum calcium phosphate production (65mg/dl), and Foley catheter retention, which might have further decreased blood flow to the penile artery and subsequently facilitated distal penile gangrene. However, the status of secondary hyperparathyroidism (i.e. serum parathyroid hormone level) and the definite pathological diagnosis were not clarified. In our opinion, the probability of calciphylaxis (calcific uraemic arteriolopathy) associated with diabetes, ESRD and secondary hyperparathyroidism is high. A pathological review to identify the evidence of calciphylaxis (e.g. medial calcification and intimal hyperplasia of medium and small arteries) is crucial. Further, emergent parathyroidectomy should be considered because the study of Karpman et al. [2] has revealed that the survival was better in patients who underwent parathyroidectomy (75%) than those treated with local debridement or penectomy alone (28%). In addition, recent studies have supported a role of hyperbaric oxygen therapy in the treatment of some patients with calciphylaxis, particularly as in the absence of uncontrolled secondary hyperparathyroidism there are few therapeutic options [3,4].