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Volpini K, Kinonen C. Abdominal Catastrophe in a 43-Year-Old Female with End Stage Renal Disease. Semin Dial 2011; 24:79-82. [DOI: 10.1111/j.1525-139x.2010.00813.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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52
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Abstract
Skin ulceration is a major source of morbidity and is often difficult to manage. Ulcers caused by an inflammatory cause or microvascular occlusion are particularly challenging in terms of diagnosis and treatment. The management of such ulcers requires careful assessment of associated systemic conditions and a thorough analysis of the ulcer's clinical and histologic findings. In this article, the authors discuss several examples of inflammatory ulcers and the approach to the diagnosis and treatment of these ulcers.
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Affiliation(s)
- Jaymie Panuncialman
- Department of Dermatology, Roger Williams Medical Center, 50 Maude Street, Providence, RI 02908, USA
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53
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Funabiki M, Tanioka M, Miyachi Y, Utani A. Sudden onset of calciphylaxis: painful violaceous livedo in a patient with peritoneal dialysis. Clin Exp Dermatol 2009; 34:622-4. [DOI: 10.1111/j.1365-2230.2008.02999.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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54
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Amuluru L, High W, Hiatt KM, Ranville J, Shah SV, Malik B, Swaminathan S. Metal deposition in calcific uremic arteriolopathy. J Am Acad Dermatol 2009; 61:73-9. [PMID: 19406504 PMCID: PMC3622256 DOI: 10.1016/j.jaad.2009.01.042] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Revised: 01/26/2009] [Accepted: 01/29/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND Calcific uremic arteriolopathy (CUA) is an often fatal disease that affects patients with end-stage renal disease. Although animal studies support a role for metals in the pathogenesis of CUA, metal accumulation in human tissue has not been previously evaluated. OBJECTIVE We sought to evaluate metal deposition in CUA. METHODS Twelve histologically proven cases of CUA were identified from our dermatopathology database. Five skin biopsy specimens from patients with chronic kidney disease exposed to gadolinium contrast but without CUA were used as controls. Quantification of metals including iron, aluminum, and gadolinium in the lesional skin was performed using inductively coupled mass spectrometry. RESULTS Seven patients had documented exposure to gadolinium-based contrast in the 2 years before CUA. Three of them had concurrent nephrogenic systemic fibrosis. Highly significant quantities of iron (P = .03) and aluminum (P = .0002) were detected in CUA specimens compared with controls. Significant amounts of gadolinium were present in several CUA biopsy specimens. LIMITATIONS Observational, retrospective study design and small sample size are limitations. CONCLUSION Tissue iron and aluminum content is increased in CUA. A significant amount of gadolinium is also present in some CUA specimens. Based on animal studies that strongly implicate metals in the pathogenesis of CUA, our data suggest that metal deposition should be considered in the pathogenesis of human CUA.
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Affiliation(s)
- Lavanya Amuluru
- Division of Nephrology, University of Arkansas for Medical Sciences, 4301 W.Markham St. #501, Little Rock, AR 72205, USA.
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55
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Hussein MRA, Ali HO, Abdulwahed SR, Argoby Y, Tobeigei FH. Calciphylaxis cutis: a case report and review of literature. Exp Mol Pathol 2009; 86:134-5. [PMID: 19348063 DOI: 10.1016/j.yexmp.2009.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Calciphylaxis is a poorly understood syndrome of vascular calcification and skin necrosis. It affects 1-4% of the population with end stage renal disease (ESRD). Disorders implicated in the pathogenesis of calciphylaxis include chronic renal failure, hypercalcemia, hyperphosphatemia, an elevated calcium-phosphate product, and secondary hyperparathyroidism (Essary, L.R. and Wick, M.R. (2000) Cutaneous calciphylaxis. An underrecognized clinicopathologic entity. Am. J. Clin. Pathol. 113, 280-287, Beitz, J.M. (2004) Calciphylaxis:an uncommon but potentially deadly form of skin necrosis. Am. J. Nurs. 104, 36-37.). Although these abnormalities are extremely common in-patients with ESRD, calciphylaxis is relatively rare. The mortality rate of calciphylaxis is about 60-80%. The leading cause of death is sepsis from necrotic skin lesions (Hitti,W.A., Papadimitriou, J.C., Bartlett, S. and Wali, R.K. (2007) Spontaneous cutaneous ulcers in a patient with a moderate degree of chronic kidney disease: a different spectrum of calciphylaxis. Scand. J. Urol. Nephrol.1-3.). Here, we report a case of calciphylaxis in a 23-year-old female with past history of chronic renal failure, renal transplantation and intake of immunosuppressive drug. The relevant literature was discussed.
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56
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Skin problems in chronic kidney disease. Nat Rev Nephrol 2009; 5:157-70. [PMID: 19190625 DOI: 10.1038/ncpneph1040] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Accepted: 12/16/2008] [Indexed: 12/14/2022]
Abstract
Skin disorders associated with chronic kidney disease (CKD) can markedly affect a patient's quality of life and can negatively impact their mental and physical health. Uremic pruritus, which is frequently encountered in patients with CKD, is considered to be an inflammatory systemic disease rather than a local skin disorder. Biomarkers of inflammation are increased in patients with uremic pruritus and an imbalance of the endogenous opioidergic system might be involved in the complex pathogenesis of the disease. Treatment options for uremic pruritus include emollients, topical capsaicin cream, ultraviolet B phototherapy, gabapentin, oral activated charcoal and nalfurafine, a kappa-opioid-receptor agonist. Calcific uremic arteriolopathy is triggered by an imbalance of promoters and inhibitors of vascular calcification, caused by the inflammatory changes that occur in uremia. Promising therapeutic strategies for calcific uremic arteriolopathy include bisphosphonates and intravenous sodium thiosulfate. Nephrogenic systemic fibrosis is a devastating condition associated with the use of gadolinium-based contrast agents in patients with CKD. At present, no therapies are available for this complication. Preventive measures include use of iodine-based contrast agents, particularly in patients with CKD stage 4 and 5. If gadolinium contrast is necessary, administration of low volumes of the more stable macrocyclic ionic types of gadolinium-based contrast agent is advocated. Hemodialysis following gadolinium exposure might offer benefits but evidence is lacking.
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57
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A fatal case of iatrogenic hypercalcemia after calcium channel blocker overdose. J Med Toxicol 2009; 4:25-9. [PMID: 18338308 DOI: 10.1007/bf03160947] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We report a case of a 61-year-old woman treated for a suspected verapamil overdose with continuous calcium chloride infusion, resulting in severe hypercalcemia of 32.3 mg/dL (8.07 mmol/L) with a normal range of 8.6-10.5 mg/dL (2.15-2.63 mmol/L). Treatment with acute hemodialysis rapidly normalized the serum calcium level, but the patient later died of vasoconstrictive complications of hypercalcemia.
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58
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Hirschmann JV, Raugi GJ. Blue (or purple) toe syndrome. J Am Acad Dermatol 2009; 60:1-20; quiz 21-2. [DOI: 10.1016/j.jaad.2008.09.038] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 08/26/2008] [Accepted: 09/03/2008] [Indexed: 01/19/2023]
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59
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Abstract
Calciphylaxis is defined by the presence of calcium deposits within the wall of small and medium-sized vessels. It is classically considered a life-threatening disease in patients with end-stage renal disease under dialysis. Clinically, it is characterized by the presence of painful plaques surrounded by a reticulate purpura that progresses to nonhealing ulcers, predominately in the lower limbs. It is associated with elevated parathyroid hormone levels and a dysregulation of the calcium/phosphate metabolism. In the absence of renal disease, normal parathyroid hormone levels, and calcium/phosphorus product, a good prognosis and the observation of similar calcium deposits associated with different conditions or even an epiphenomenon in diseases with well-known diagnosis leads one to consider the term calciphylaxis controversial.
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Affiliation(s)
- Esteban Daudén
- Department of Dermatology, Servicio de Dermatología, Hospital Universitario de la Princesa, Diego de León, 62, 28006 Madrid, Spain.
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60
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Breast necrosis following left internal mammary artery harvest: a case series and a comprehensive review of the literature. Ann Plast Surg 2008; 61:368-74. [PMID: 18812704 DOI: 10.1097/sap.0b013e3181640851] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Breast necrosis is a rare complication following coronary artery bypass grafting, as the blood supply to the breast is abundant. Internal mammary artery (IMA) harvest has been cited as a risk factor for breast necrosis following cardiac procedures. We retrospectively reviewed 3 cases of breast necrosis following IMA harvest, performed a comprehensive literature review, and noted risk factors. Obesity, macromastia, diabetes, hypertension, and end-stage renal disease were present in all cases. Two of 3 patients had pathology suggestive of calciphylaxis. Despite a rich blood supply, breast necrosis following use of the IMA for cardiac revascularization may occur in a subset of patients. Our review suggests that obese patients with macromastia and end-stage renal disease may be at increased risk for breast necrosis following IMA harvest. As the prevalence of obesity increases, we may see an increase in this previously uncommon complication.
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62
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Abstract
Retiform purpura (RPP) is a livedoid pattern of cutaneous haemorrhage that may result from vasculitis, occlusion or altered coagulation. When this pattern presents as palpable plaques, vascular inflammation is present, and the differential diagnosis includes calciphylaxis, warfarin-induced skin necrosis, antiphospholipid antibody syndrome and heparin-induced skin necrosis. These diseases are clinically aggressive and may result in significant morbidity and mortality. Early recognition is essential to make the necessary medication changes and to begin intervention. Our morphological approach to diagnosis differs from traditional methods and can expedite management. Biopsy results and laboratory findings are then used to verify the diagnosis and determine the specific cause. This approach may allow the development of a treatment plan prior to availability of all ancillary data. Clinical and histological cases are presented for these four syndromes presenting as RPP.
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Affiliation(s)
- A Jones
- Department of Dermatology, University of Iowa, Iowa City, IA 50266, USA
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63
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Meissner M, Kaufmann R, Gille J. Sodium Thiosulphate: A New Way of Treatment for Calciphylaxis? Dermatology 2007; 214:278-82. [PMID: 17460397 DOI: 10.1159/000100877] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Accepted: 12/08/2006] [Indexed: 12/15/2022] Open
Abstract
Sodium thiosulphate has been used in medicine for almost 100 years. There are some very important areas of application such as cyanide intoxications or the treatment of cisplatin toxicity. Till this day, this compound is almost unknown to most physicians. This is astonishing, especially because there are some promising reports in the literature describing a possibly wider area of application in different domains of medicine such as urology, nephrology or dermatology. Perhaps one of the most exciting and recent domains of sodium thiosulphate use is the treatment of calciphylaxis, providing new options dealing with this severe and mostly lethal illness. The goal of this article is to review the new application possibility of this compound.
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Affiliation(s)
- M Meissner
- Department of Dermatology and Venerology, Johann Wolfgang Goethe University, Frankfurt, Germany.
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64
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65
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Jacobs-Kosmin D, Dehoratius RJ. Calciphylaxis: An important imitator of cutaneous vasculitis. ACTA ACUST UNITED AC 2007; 57:533-7. [PMID: 17394184 DOI: 10.1002/art.22616] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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66
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Meissner M, Gille J, Kaufmann R. Calciphylaxis: no therapeutic concepts for a poorly understood syndrome? J Dtsch Dermatol Ges 2006; 4:1037-44. [PMID: 17176411 DOI: 10.1111/j.1610-0387.2006.06127.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Calciphylaxis is a very uncommon and severe disease which mainly appears in patients with chronic renal insufficiency. It presents with ischemia and necrosis of the skin, subcutaneous adipose tissue, muscles and rarely viscera. The pathogenetic mechanisms inducing calciphylaxis are for the most part unknown. The mortality rate of 80% in the first year is very high. Patients experience marked pain, recurrent infections and the constant risk of secondary sepsis. Even multidisciplinary therapeutic strategies are limited, although there are recent case reports providing promising new therapeutic options including sodium thiosulfate and cinacalcet. This review summarizes the important aspects of diagnosis, pathogenesis, prevention and the possible therapeutic strategies of this intriguing, rare and often fatal disease.
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Affiliation(s)
- Markus Meissner
- Dept. of Dermatology, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
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67
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Korzets A, Ori Y, Zevin D, Chagnac A, Herman M, Rozen-Zvi B, Gafter U. A worrying thought—could there be a connection between encapsulating peritoneal sclerosis, tamoxifen and calciphylaxis? Nephrol Dial Transplant 2006; 21:2975-8. [PMID: 16861730 DOI: 10.1093/ndt/gfl372] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Asher Korzets
- Department of Nephrology, Hasharon Hospital-Rabin Medical Center, Petach Tikva 49372, Israel
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68
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Araya CE, Fennell RS, Neiberger RE, Dharnidharka VR. Sodium thiosulfate treatment for calcific uremic arteriolopathy in children and young adults. Clin J Am Soc Nephrol 2006; 1:1161-6. [PMID: 17699342 DOI: 10.2215/cjn.01520506] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In adult patients with ESRD, calcific uremic arteriolopathy (CUA) is an uncommon but life-threatening complication. No effective therapy exists, although anecdotal case reports highlight the use of sodium thiosulfate (STS), a calcium-chelating agent with antioxidant properties. CUA is rare in children, and STS use has not been reported. The objective of this study was to determine the influence of STS treatment on three patients with CUA in a pediatric chronic dialysis unit. The patients were between 12 and 21 yr of age; two were male; and primary diagnoses were obstructive uropathy, renal dysplasia, and calcineurin nephrotoxicity. Time from ESRD to CUA diagnosis was 1, 9, and 20 yr. Diagnosis was made by tissue biopsy and three-phase bone scan. Pain was the presenting symptom. Initial treatment included discontinuation of calcitriol and use of non-calcium-based phosphate binders and low-calcium dialysate concentration. STS dosage was 25 g/1.73 m(2) per dose intravenously after each hemodialysis session. For optimization of removal of calcium deposits, patient three received a combination of STS and continuous venovenous hemofiltration for the first 10 d. All patients demonstrated rapid pain relief. Within weeks, skin induration and joint mobility of the extremities improved. Radiographic evidence of reduction in the calcium deposits occurred within 3 mo of initiation of STS. The only complication was prolonged QT interval in one patient as a result of hypocalcemia, who was resolved by use of a higher dialysate calcium concentration. STS seems well tolerated in children and young adults with CUA and has mild adverse effects. For determination of its efficacy, optimum dosage, duration of therapy, and dialysis modality, controlled trials are needed.
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Affiliation(s)
- Carlos E Araya
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida Health Science Center, Gainesville, FL 32610-0296, USA
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69
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Abstract
Renal osteodystrophy (ROD) develops as the early stages of chronic renal failure (CRF) and covers a spectrum of bone changes observed in the uraemic patient, which extend from high remodelling bone disease (frequently known as osteitis fibrosa) to low turnover, or adynamic disease. Between these two extremes there are also cases of bone mineralization compromised in variable degrees, as is the case of 'mixed bone disease' and osteomalacia. The dynamic process of bone remodelling is compromised in CRF, and a positive or negative bone balance can be observed in uraemic patients. In addition to the classic modulators of bone remodelling, like parathyroid hormone, calcitriol and calcitonin, other factors were recently identified as significant modulators of osteoblast and osteoclast activation in uraemic patients. In fact, different cytokines and growth factors, acting at an autocrine or paracrine level, seem to play a relevant role in the bone and mineral changes observed in uraemia. Recently, observations have been made of the development of more sensitive and specific techniques to assay different biochemical markers of bone turnover and mineral metabolism. Analogously, new contributions of conventional bone histology, bone immunocytochemistry and molecular biology, which enabled the understanding of some etiopathogenic mechanisms of ROD, were observed.
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Affiliation(s)
- A Ferreira
- Hospital Curry Cabral, Universidade Nova de Lisboa, Lisbon, Portugal.
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70
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Cardús A, Parisi E, Gallego C, Aldea M, Fernández E, Valdivielso JM. 1,25-Dihydroxyvitamin D3 stimulates vascular smooth muscle cell proliferation through a VEGF-mediated pathway. Kidney Int 2006; 69:1377-84. [PMID: 16557229 DOI: 10.1038/sj.ki.5000304] [Citation(s) in RCA: 137] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Atherosclerosis is a complex process characterized by an increase in the wall thickness owing to the accumulation of cells and extracellular matrix between the endothelium and the smooth muscle cell wall. This process is associated with different pathologies and it is accelerated in patients with chronic renal failure. In these patients, decreased synthesis of 1,25-dihydroxyvitamin D(3) (1,25(OH)(2)D(3)) leads to secondary complications, like hyperparathyroidism, and treatment with 1,25(OH)(2)D(3) is a common practice. The effect of 1,25(OH)(2)D(3) on vascular smooth muscle cells (VSMCs) calcification has been widely studied, but the role of 1,25(OH)(2)D(3) on VSMC proliferation remains obscure. We have analyzed the effects of 1,25(OH)(2)D(3) in the proliferation of VSMC. We found that 1,25(OH)(2)D(3) (5-100 nM) induces a dose-dependent increase in VSMC proliferation in quiescent cells and in cells stimulated to grow. This increase in proliferation is achieved by shortening the G1 phase. The effect of 1,25(OH)(2)D(3) on VSMC proliferation is mediated by an increase of the expression of vascular endothelial growth factor A (VEGF), as the inhibition of VEGF activity totally blunted the 1,25(OH)(2) D(3)-induced VSMC proliferation. We found this increase in proliferation in vitro, ex vivo in aortic rings incubated with 1,25(OH)(2)D(3), and in vivo in animals with a model of chronic renal failure (5/6 nephrectomy) treated with 1,25(OH)(2)D(3) (1 mug/kg three times a week for 8 weeks). Thus, we conclude that 1,25(OH)(2)D(3) induces increases in VSMC proliferation through an increase on VEGF expression.
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Affiliation(s)
- A Cardús
- Department of Medicine, University of Lleida, Lleida, Spain
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71
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Meissner M, Bauer R, Beier C, Betz C, Wolter M, Kaufmann R, Gille J. Sodium Thiosulphate as a Promising Therapeutic Option to Treat Calciphylaxis. Dermatology 2006; 212:373-6. [PMID: 16707889 DOI: 10.1159/000092290] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Accepted: 11/13/2005] [Indexed: 01/02/2023] Open
Abstract
A 35-year-old haemodialysis-dependent woman with chronic renal failure developed large, very painful necrotic ulcers and necrosis on the thighs, buttocks and the abdomen with signs of fast progression. The skin biopsy specimens showed a broad necrosis of the epidermis and thrombosed dermal vessels with focal calcium deposits within the wall. In addition, laboratory findings presented an increased product of serum calcium and phosphate concentrations. Thus, we diagnosed calciphylaxis on the basis of clinical, biochemical and histopathological criteria. We initiated a therapy in which our patient was treated with intravenous sodium thiosulphate 3 times weekly. Already after 2 weeks of treatment, no new lesions were detectable and there was a dramatic pain relief. In the following 4 weeks, a successive decline of the ulcers and the healing of individual tissue defects could be seen. Four months after the start of the therapy, the patient underwent successful renal transplantation. Thus, the intravenous therapy of calciphylaxis with sodium thiosulphate might be a new effective alternative in the treatment of this life-threatening disease.
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Affiliation(s)
- M Meissner
- Department of Dermatology, Johann Wolfgang Goethe University, Frankfurt, Germany.
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72
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Abstract
Calciphylaxis is a rare but highly morbid disorder of vascular calcification and skin necrosis, affecting 1% to 4% of adults with end-stage renal disease. Only three affected children have previously been described. We report an unusual instance of fatal calciphylaxis involving a 10-year-old boy, in the setting of sarcoidosis-induced end-stage renal disease. A review of pediatric calciphylaxis cases suggests: (a) increased risk in boys with end-stage renal disease and secondary hyperparathyroidism; (b) frequent distal extremity and visceral organ involvement, (c) worse prognosis with acral necrosis, and (d) possible increased resistance to medical treatment compared to adult patients. Hyperesthetic pain is a common sentinel symptom, and soft tissue x-rays or xeroradiography or both may aid in the diagnosis of pediatric calciphylaxis. Parathyroidectomy in combination with supportive medical management may be the best treatment option in stopping the progression of disease in the pediatric population.
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Affiliation(s)
- Jing Feng
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut 06520-8059, USA
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73
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Duffy A, Schurr M, Warner T, Chen H. Long-Term Outcomes in Patients With Calciphylaxis From Hyperparathyroidism. Ann Surg Oncol 2006; 13:96-102. [PMID: 16378160 DOI: 10.1245/aso.2006.03.042] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2005] [Accepted: 09/08/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Calciphylaxis is a rare condition associated with chronic renal failure and entails a very poor prognosis. Pathogenesis is poorly understood but involves abnormalities in calcium and phosphorus metabolism that lead to vascular and extravascular calcification. Patients present with painful ulcerating plaques that progress to gangrenous wounds. Parathyroidectomy has been advanced as a life-saving intervention in these patients, but long-term results with wound healing and survival after parathyroidectomy are not well described. METHODS Between January 1987 and October 2003, 15 patients with biopsy-confirmed calciphylaxis were treated at the University of Wisconsin. Of these 15 patients, 9 were treated with medical therapy (bisphosphonates and phosphate binders), whereas 6 underwent parathyroidectomy. The medical records were reviewed, and patients or relatives were interviewed. Survival was determined by Kaplan-Meier analysis. RESULTS Four patients underwent subtotal parathyroidectomy, and two patients underwent total parathyroidectomy. All had reductions in the intact parathyroid hormone level (mean +/- SD, 25.2 +/- 4.5 pg/mL). Whereas all six patients treated with parathyroidectomy had partial/complete wound healing, only two of nine in the medical group had any improvements in the skin lesions (P = .006). With up to 80 months of follow-up, patients who underwent parathyroidectomy had a longer median survival compared with those who did not have surgery (39 vs. 3 months; P = .017). CONCLUSIONS On the basis of our long-term follow-up of this patient population, subtotal or total parathyroidectomy was associated with long-term survival and was more likely to promote healing if performed earlier in the course of disease. Therefore, patients with calciphylaxis from secondary hyperparathyroidism should be referred promptly for potential parathyroidectomy.
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Affiliation(s)
- Allison Duffy
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin 53792-7375, USA
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74
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Garini G, Galletti E, Ricci R, Vaglio A, Buzio C. Calciphylaxis: evolving concepts. Intern Emerg Med 2006; 1:320-2. [PMID: 17217159 DOI: 10.1007/bf02934772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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75
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Abstract
Calciphylaxis is a rare but significant condition. It is associated with a high degree of morbidity and is fatal in between 60% and 80% of patients. It occurs most commonly in patients with endstage renal failure and is associated with hypercalcaemia or hyperphosphataemia or both (elevated calcium-phosphate product). Secondary hyperparathyroidism is also common. Clinically, patients develop rapidly progressive, necrotic skin ulcers that are extremely painful. They, universally, respond poorly to usual ulcer therapies. Some surgeons advocate parathyroidectomy for patients with calciphylaxis. Evidence is inconclusive regarding this treatment; however, some trials have shown improved rates of ulcer healing and overall survival in patients treated with parathyroidectomy.
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76
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Reis ND, Zinman C, Misselevich I, Boss JH. The fasciitis-panniculitis syndrome presenting as complex regional pain syndrome type 1: report of a case. Clin J Pain 2005; 21:185-9. [PMID: 15722813 DOI: 10.1097/00002508-200503000-00011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 28-year-old man presented with a clinical picture suggestive of complex regional pain syndrome type I following a blow to the thenar eminence and thumb. Symptoms, including swelling of the hand and distal forearm, progressed until an amputation was carried out to rid the patient of an unendurable painful and nonfunctioning wrist and hand. The histologic evaluation of the amputation specimen showed: 1) dermal edema, perivascular dermatitis, and epidermal hyperkeratosis; 2) subcutaneous chronic inflammation with subtotal replacement of the adipose lobules by fibrous tissue associated with thickening of the muscular fascia, implying the fasciitis-panniculitis reaction pattern; 3) atrophy, degeneration, necrosis, and focal calcifications of the skeletal muscles; 4) phlebosclerosis, phlebectasias and lymphocytic arteritis; and 5) increased cortical porosity of the bones. It seems that the pathogenetic process underlying the fasciitis-panniculitis syndrome may rarely manifest as a complex regional pain syndrome-like disorder.
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Affiliation(s)
- N D Reis
- Department of Orthopaedic Surgery B, Rambam Medical Center, Haifa, Israel
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77
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Payasli C, Hosnuter M, Babuccu O, Kargi E, Kocak E, Isikdemir A. Spotting the signs: a case of late diagnosed painful calciphylaxis. J Wound Care 2005; 14:12-3. [PMID: 15656457 DOI: 10.12968/jowc.2005.14.1.26728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although the number of cases of calciphylaxis is increasing, it is often not diagnosed until a late stage, increasing the risk of mortality. A characteristic is purple, mottled and painful lesions, which have a tendency to become necrotic.
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Affiliation(s)
- C Payasli
- Zonguldak Karaelmas University, Zonguldak, Turkey.
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de Francisco ALM. Secondary hyperparathyroidism: Review of the disease and its treatment. Clin Ther 2004; 26:1976-93. [PMID: 15823762 DOI: 10.1016/j.clinthera.2004.12.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND Most patients with chronic kidney disease (CKD) stage 5 develop secondary hyperparathyroidism (SHPT). SHPT is an adaptive response to CKD and its associated disruptions in the homeostatic control of serum phosphorus, calcium, and vitamin D. The poor control of mineral and parathyroid hormone (PTH) levels characteristic of SHPT is associated with serious clinical consequences. OBJECTIVE This review discusses the pathophysiology and consequences of SHPT, as well as the efficacy and limitations of current treatment modalities. METHODS Literature searches were conducted using the MEDLINE, EMBASE, and BIOSIS databases. Additional information was obtained from Internet web sites, textbooks, and nephrology congress abstracts. RESULTS Patients with uncontrolled SHPT are at higher risk for cardiovascular morbidity and mortality, hospitalization, bone disease, vascular and soft-tissue calcification, and vascular access failure than patients whose mineral and PTH levels are well managed. New National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) targets for calcium, phosphorus, calcium-phosphorus product, and PTH control have recently been published with the aim of improving the management of mineral metabolism in CKD patients. Data from observational studies suggest that the majority of patients currently have PTH and mineral levels outside these target ranges. CONCLUSIONS Given the inadequacies of current therapies, novel agents are being developed that may help improve the management of SHPT.
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79
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Affiliation(s)
- Janice M Beitz
- School of Nursing, La Salle University, Philadelphia, USA.
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80
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Abstract
Calciphylaxis-induced chronic wounds are difficult to heal. The value of vacuum-assisted closure (VAC) was assessed in two patients with calciphylaxis. Two middle-aged females with type 2 diabetes were transferred to the burn unit with a clinical diagnosis of necrotizing fasciitis, although the pathologic diagnosis was calciphylaxis. With extensive debridement, antibiotics, and meticulous wound care, one patient had progressive necrosis of her skin from 18 to 48% TBSA, whereas the other progressed from 5 to 10% TBSA only. The patient with the smaller chronic wound healed well and left the hospital at 72 days after admission. Although there was some success with the use of VAC, the patient with the extensive progressive wounds developed a fungal wound infection that did not respond to treatment; she died 78 days after initiation of burn center treatment. Some disadvantages to the usefulness would be extensive contiguous wounds and the lack of an intact skin surface. The VAC system was of value in healing wounds resulting from calciphylaxis.
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Affiliation(s)
- Osa Emohare
- Imperial College, Faculty of Medicine, London, United Kingdom
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81
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Eich D, Scharffetter-Kochanek K, Weihrauch J, Krieg T, Hunzelmann N. Calcinosis of the cutis and subcutis: an unusual nonimmunologic adverse reaction to subcutaneous injections of low-molecular-weight calcium-containing heparins. J Am Acad Dermatol 2004; 50:210-4. [PMID: 14726874 DOI: 10.1016/j.jaad.2003.07.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Local side effects at the injection sites of low-molecular-weight heparins are rare and can be of immunologic or nonimmunologic origin. Calcinosis cutis is a rare disorder and occurs in various circumstances. In patients with chronic renal failure the risk of pathologic calcifications is raised due to elevated calcium-phosphorus products. OBJECTIVE Five patients suffering from renal failure developed remarkable cutaneous and subcutaneous nodules or plaques following subcutaneous nadroparin-calcium injections. Our aim was to evaluate the morphology and precipitation factors of these calcifications and to discuss immunological and nonimmunological differential diagnoses. METHODS Histological examination, spectroscopic analysis, ultrasonography, allergy testing and reexposition testing including non-calcium heparins were performed. RESULTS Histology using the van Kossa staining technique revealed calcinosis of the dermis and subcutis. Ultrasonography showed focal subcutaneous calcifications. In all patients the calcium-phosphorus products were elevated. CONCLUSION Clinicians should be aware that patients with renal failure and elevated calcium-phosphorus products may be at risk of developing calcinosis cutis at calcium-containing heparin injection sites. As a consequence, we propose the use of non-calcium heparins in these patients.
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Affiliation(s)
- Dorothee Eich
- Department of Dermatology, University of Cologne, Cologne, Germany.
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82
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Oikawa S, Osajima A, Tamura M, Murata K, Yasuda H, Anai H, Kabashima N, Matsushima Y, Nakamoto M, Nakashima Y. Development of proximal calciphylaxis with penile involvement after parathyroidectomy in a patient on hemodialysis. Intern Med 2004; 43:63-8. [PMID: 14964582 DOI: 10.2169/internalmedicine.43.63] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Elevated parathyroid hormone (PTH) levels and hyperphosphatemia are thought to be associated with the development of calciphylaxis. We report a patient on hemodialysis who developed proximal calciphylaxis with consistently low PTH levels after parathyroidectomy. A 31-year-old man was admitted to our hospital because of abdominal skin ulcerations. Calciphylaxis spread to the penis, and simultaneous progressive lung calcification was evident on chest X-ray, suggestive of pulmonary calciphylaxis on 99mTc-methylene disphosphonate scintigraphy. The patient died of respiratory failure despite intensive treatment including hyperbaric oxygen therapy. This is the first report of a patient on hemodialysis who developed calciphylaxis involving the penis after parathyroidectomy.
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Affiliation(s)
- Shigeru Oikawa
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu
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83
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Goldman RJ, Brewley BI, Cohen R, Rudnick M. Use of Electrotherapy to Reverse Expanding Cutaneous Gangrene in End-Stage Renal Disease. Adv Skin Wound Care 2003; 16:363-6. [PMID: 14688644 DOI: 10.1097/00129334-200312000-00013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Robert J Goldman
- Department of Rehabilitation Medicine, University of Pennsylvania School of Medicine, USA
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84
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Abdelbaqi-Salhab M, Shalhub S, Morgan MB. A current review of the cutaneous manifestations of renal disease. J Cutan Pathol 2003; 30:527-38. [PMID: 14507400 DOI: 10.1034/j.1600-0560.2003.00109.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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85
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Bertazzolo W, Toscani L, Calcaterra S, Crippa L, Caniatti M, Bonfanti U. Clinicopathological findings in five cats with paw calcification. J Feline Med Surg 2003; 5:11-7. [PMID: 12547618 PMCID: PMC10822659 DOI: 10.1053/jfms.2002.0195] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2002] [Indexed: 11/11/2022]
Abstract
This retrospective study describes the clinicopathological findings in five cats with soft tissue mineralisation of interdigital spaces and footpads. Paw disease was the reason for veterinary consultation in three out of five cats. All cats had laboratory findings suggestive of renal failure and high solubility product [calciumxphosphorus]. In all cases, cytological examination of paw lesions was suggestive of calcinosis. The results of our study agree with two previous case reports of paw calcification in the cat, suggesting a metastatic pathogenesis and a correlation between paw mineralisation and renal failure.
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Affiliation(s)
- W Bertazzolo
- Clinica Veterinaria Alto Lambro, Via Molini taverna 1, 20050, Gerno di Lesmo, (MI), Italy.
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86
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Abstract
Calciphylaxis is a condition with a high mortality rate that is often found in patients with renal failure. It is characterized by soft tissue calcification and painful skin ulceration. A serum calcium-phosphorus product of more than 60 mg2/dl2 indicates great risk for calciphylaxis. The diagnosis is made on the basis of an incisional biopsy showing calcification of the small, subcutaneous arteries.
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Affiliation(s)
- Robert W Parker
- Division of Community Geriatrics, Department of Family and Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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87
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Daudén Tello E, Ruiz Genao D, Fraga Fernández J. Calcificación vascular cutánea. Correlación clínico-patológica y proposición de una nueva clasificación de las calcinosis cutáneas. ACTAS DERMO-SIFILIOGRAFICAS 2002. [DOI: 10.1016/s0001-7310(02)79166-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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88
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Au S, Crawford RI. Three-dimensional analysis of a calciphylaxis plaque: clues to pathogenesis. J Am Acad Dermatol 2002; 47:53-7. [PMID: 12077581 DOI: 10.1067/mjd.2002.120927] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Calciphylaxis is a rare, life-threatening disorder associated with chronic renal failure, presenting with ulcerating plaques leading to death by sepsis in 60% of patients. Calcification of subcutaneous arterioles, thromboses, and extravascular calcification have been demonstrated in incisional biopsy specimens. However, the sequence of these pathologic events is unknown. OBJECTIVE We examined a calciphylaxis plaque to document the wave of pathologic change from its center to its periphery. METHODS A calciphylaxis plaque was excised postmortem from a female patient. It was examined histologically along 12 radii from the center of the lesion to its periphery. RESULTS Calcification of small subcutaneous vessels was present in all histologically abnormal sections and extended further peripherally than extravascular calcification by up to 3.0 cm and further than subcutaneous thrombosis by up to 1.5 cm. CONCLUSION Vascular mural calcification is an early and essential process in the development of a calciphylaxis plaque.
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Affiliation(s)
- Sheila Au
- Division of Dermatology, Department of Pathology, University of British Columbia, Vancouver, BC, Canada V6Z 1Y6
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89
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Abstract
Calciphylaxis is a small vessel vasculopathy involving mural calcification with intimal proliferation, fibrosis, and thrombosis. This syndrome occurs predominantly in individuals with renal failure and results in ischemia and necrosis of skin, subcutaneous fat, visceral organs, and skeletal muscle. The syndrome causes significant morbidity in the form of infection, organ failure, and pain. Mortality rates are high. In individuals with renal failure, risk factors for the development of calciphylaxis include female sex, Caucasian race, obesity, and diabetes mellitus. Many cases occur within the first year of dialysis treatment. Several recent reports demonstrate that prolonged hyperphosphatemia and/or elevated calcium x phosphorus products are associated with the syndrome. Protein malnutrition increases the likelihood of calciphylaxis, as does warfarin use and hypercoagulable states, such as protein C and/or protein S deficiency. Recent advances in diagnostic tools and therapeutic strategies have helped in the management of patients with calciphylaxis.
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Affiliation(s)
- William A Wilmer
- Division of Nephrology, Department of Internal Medicine, Ohio State University College of Medicine and Public Health, Columbus, Ohio, USA.
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90
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Rivera-Nieves J, Bamias G, Alfert J, Bickston SJ, Moskaluk CA, Cominelli F. Intestinal ischemia and peripheral gangrene in a patient with chronic renal failure. Gastroenterology 2002; 122:495-9. [PMID: 11832463 DOI: 10.1053/gast.2002.31387] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Gastrointestinal complications are common in patients with renal failure and result in significant morbidity and mortality. Systemic calciphylaxis is an uncommon complication of renal failure, characterized by disseminated intravascular calcification and associated with progressive vascular compromise. We describe the case of a 63-year-old woman who presented with abdominal pain, elevated transaminases, and skin manifestations consistent with a vasculitic process. Hand films and skin biopsies showed extensive vascular calcification, and a computerized tomography scan confirmed colonic perforation and disseminated visceral vascular calcification. Histologic analysis of the resected skin and colonic tissues revealed extensive ischemic damage and mural calcification of medium to large vessels. Gastrointestinal involvement has been reported in only 3 prior cases of calciphylaxis; consequently, gastroenterologists are often unaware of this disease entity and may fail to recognize it, even in patients with the classical presentation. Prompt diagnosis is crucial, as parathyroidectomy may result in clinical improvement in up to two thirds of patients who present with elevated parathyroid hormone levels.
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Affiliation(s)
- Jesús Rivera-Nieves
- Digestive Health Center of Excellence, University of Virginia, Charlottesville, Virginia, USA.
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91
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Block GA. Control of serum phosphorus: implications for coronary artery calcification and calcific uremic arteriolopathy (calciphylaxis). Curr Opin Nephrol Hypertens 2001; 10:741-7. [PMID: 11706300 DOI: 10.1097/00041552-200111000-00003] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
There is mounting evidence that elevated serum phosphorus is an important cardiovascular risk factor in patients with end stage renal disease. Recent work has shown that vascular smooth muscle cells have the ability to undergo osteoblastic differentiation and produce an environment conducive to mineralization. Serum phosphorus is an important stimulator of this process and the adverse cardiovascular effects of hyperphosphatemia are most likely mediated via its ability to enhance the development of vascular calcification. Arterial calcification, whether it is intimal or medial in location, is a strong independent risk factor for cardiovascular morbidity and mortality. Both coronary artery calcification and calciphylaxis are prototypical examples of arterial calcification that have been associated with poor phosphate control. Furthermore, several investigators have recently suggested that the prescription of large doses of calcium to achieve phosphate control may augment, rather than diminish, the risk of vascular calcification. This is more likely to be true in the presence of low turnover bone disease, a diagnosis difficult to make with routine laboratory testing. A brief review of the molecular biology of vascular calcification supports the concept that warfarin administration may exacerbate the calcific process, particularly in the setting of hyperphosphatemia, as has been reported in patients with calciphylaxis. Recognizing the consequences of poor phosphate control, it is time to adopt strict target levels that aim to normalize serum phosphorus levels. The available evidence supports that this control should not be achieved through the use of supraphysiologic doses of supplemental calcium.
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Affiliation(s)
- G A Block
- Denver Nephrologists, PC, Denver, Colorado, USA.
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92
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Girotto JA, Harmon JW, Ratner LE, Nicol TL, Wong L, Chen H. Parathyroidectomy promotes wound healing and prolongs survival in patients with calciphylaxis from secondary hyperparathyroidism. Surgery 2001; 130:645-50; discussion 650-1. [PMID: 11602895 DOI: 10.1067/msy.2001.117101] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Calciphylaxis is a rare but life-threatening condition occasionally affecting patients with secondary hyperparathyroidism. Parathyroidectomy has been advocated as the only potentially curative intervention. METHODS Between January 1989 and May 2000, 13 patients with pathologic/clinical criteria of calciphylaxis were treated at our institution. Of these 13 patients, 7 were managed with medical therapy alone, and 6 were referred for parathyroidectomy. The medical records were reviewed, and patients/relatives were interviewed. RESULTS All patients had cutaneous wounds requiring local debridement predominantly located on the lower extremities or abdominal wall. Six patients underwent subtotal (3.5 gland) parathyroidectomy without morbidity. All 6 had significant reductions in parathyroid hormone levels after surgery (mean decrease, 94% +/- 0%), and all reported resolution of pain and healing of cutaneous wounds. Of the remaining 7 patients who had medical management alone, 5 eventually died of complications related to calciphylaxis. In comparing the 2 groups, patients who underwent parathyroidectomy had a significantly longer median survival than those who did not have surgery (36 vs 3 months, P =.021). CONCLUSIONS Calciphylaxis frequently causes gangrene, sepsis, and eventual death. Parathyroidectomy can be performed with minimal morbidity and is associated with resolution of pain, wound healing, and a significantly longer median survival. Therefore, patients with secondary hyperparathyroidism and signs/symptoms of calciphylaxis should be referred promptly for consideration of parathyroidectomy.
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Affiliation(s)
- J A Girotto
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md, USA
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93
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Mirza I, Chaubay D, Gunderia H, Shih W, El-Fanek H. An unusual presentation of calciphylaxis due to primary hyperparathyroidism. Arch Pathol Lab Med 2001; 125:1351-3. [PMID: 11570914 DOI: 10.5858/2001-125-1351-aupocd] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We present the case of a 69-year-old woman with calciphylaxis due to primary hyperparathyroidism. A 0.5-g parathyroid adenoma was surgically removed, which resulted in complete recovery of the patient. Review of the literature revealed 7 other cases of calciphylaxis due to primary hyperparathyroidism and showed that prompt surgical removal of the autonomous parathyroid gland lesion results in clinical recovery of calciphylactic skin lesions.
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Affiliation(s)
- I Mirza
- Department of Pathology, Danbury Hospital, Danbury, CT 06810, USA
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94
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Alawi F, Freedman PD. Metastatic calcification of the nasal septum presenting as an intraoral mass: a case report with a review of the literature. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 2001; 91:693-9. [PMID: 11402285 DOI: 10.1067/moe.2001.115468] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Metastatic calcification is a pathologic condition characterized by deposition of calcified product in otherwise normal tissues as a result of hyperphosphatemia with or without concurrent hypercalcemia. Metastatic calcification presenting clinically as an oral lesion is extremely rare. To date, only 7 cases of metastatic calcification involving the oral soft tissues have been described. This report describes a case of metastatic calcification of the nasal septum presenting as a mass of the anterior maxillary vestibule in a patient with end-stage renal disease. The case reported is only the second example with nasal septum involvement. A brief review of the clinical and histopathologic features of previously reported intraoral cases is also presented.
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Affiliation(s)
- F Alawi
- Oral and Maxillofacial Pathology, Flushing, NY, USA
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