Radiographically Progressive Metastatic Pulmonary Calcification in a Three-Time Liver Transplant Recipient Requiring Intraoperative Resuscitation

A 51-year-old woman with primary biliary cirrhosis requiring two previous liver transplants, current chronic liver rejection, and progressive chronic kidney disease underwent combined liver-kidney transplantation. The surgery was complicated by hemorrhagic shock and cardiopulmonary arrest of 8 minutes, requring transfusion of 40 U of red blood cells and 59 U of plasma. The patient remained asymptomatic from a pulmonary perspective, but 6 months postoperatively, a routine CT scan showed radiographically progressive calcification in the prior areas of ground-glass opacity. Even though her calcium, vitamin D, and parathyroid hormone were normal, technetiurn-99m bone scan confirmed clinical suspicion of metastatic pulmonary calcification, which can occur after liver transplantation secondary to intraoperative transfusion of a significant amount of elemental calcium and of citrate-containing plasma.