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On the role of skin biopsy in the diagnosis of calcific uremic arteriolopathy: a case-based discussion. J Nephrol 2019; 33:859-865. [PMID: 31792896 DOI: 10.1007/s40620-019-00678-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/24/2019] [Indexed: 12/30/2022]
Abstract
Calciphylaxis is a rare disease characterized by ectopic calcification of skin arterioles resulting in ischemia, thrombosis and necrosis. Since end stage renal disease patients are those mainly affected, the term calcific uremic arteriolopathy (CUA) is also suggested. Early clinical manifestations are subtle, while overt necrotic ulcers may quickly spread and become infected so as to result in ominous outcome. Diagnosis might not be easy due to the number of other ischemic and non-ischemic skin lesions observed in uraemia. Skin biopsy, has been proposed as the diagnostic test and is often considered, but not systematically performed due to the hypothetical risk of further spreading of the lesions. Such ambiguity could be responsible for misdiagnosis or underdiagnosis. We review here five consecutive cases recorded in our Unit, all submitted to skin biopsy but with inconsistent results which generated some clinical frustration. Thus, we decided to carefully re-evaluate all of them together with pathologists and dermatologists. However, even after this ex-post discussion, we could not reach a complete agreement on the final diagnosis. In the meanwhile, papers were published in the literature that started to shed some light on the role of skin biopsy in the diagnosis of CUA.
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Nigwekar SU, Pai AB, Mueller B, Dean MC, Costello G, Sherman CR. Impact of hemodialysis on the concentrations of sodium and potassium during infusion of sodium thiosulfate using an In Vitro hemodialysis model. PLoS One 2019; 14:e0224767. [PMID: 31721800 PMCID: PMC6853332 DOI: 10.1371/journal.pone.0224767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/21/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The purpose of this study was to evaluate the impact of hemodialysis on the concentrations of sodium and potassium in the blood when a 25 g dose of sodium thiosulfate injection is infused over 60 minutes in combination with hemodialysis. METHODS Sodium thiosulfate (25 g) was prepared by diluting 100 mL of 250 mg/mL Sodium Thiosulfate Injection with 800 mL of 5% dextrose. This was added to the circulating blood surrogate solution at a rate of 15 mL/minute using an infusion pump of an in vitro model of dialysis machine. Serial samples were collected before the administration of the sodium thiosulfate solution, after 15 minutes, 30 minutes, and 60 minutes of infusion from pre-and post-dialyzer ports in both the dialysate circuit and the extracorporeal circuit. FINDINGS The concentration of sodium thiosulfate in pre-dialyzer and post-dialyzer samples of the circulating blood surrogate solution peaked at 30 minutes and 15 minutes, respectively and then remained relatively unchanged during the remainder of the infusion. Mean sodium concentrations (mEq/L) in the circulating blood surrogate solution collected after exposure to a dialyzer were 103.2 ± 12.2, 114.2 ± 18.8, 117.2 ± 7.5, 93.5 ± 5.9 at 0, 15, 30, and 60 minutes, respectively (p = 0.248). Mean potassium concentrations (mEq/L) in the circulating blood surrogate solution collected after exposure to a dialyzer were 1.4 ± 0.3, 1.6 ± 0.3, 1.5 ± 0.1, 1.2 ± 0.1 at 0, 15, 30, and 60 minutes, respectively (p = 0.365). Sodium and potassium concentrations in dialysate increased marginally after exposure to the dialyzer. DISCUSSION Our study demonstrates that neither potassium nor sodium accumulated in circulating blood surrogate solution when a dose of sodium thiosulfate was infused in conjunction with hemodialysis.
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Affiliation(s)
- Sagar U. Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Amy Barton Pai
- University of Michigan College of Pharmacy, Ann Arbor, MI, United States of America
| | - Bruce Mueller
- University of Michigan College of Pharmacy, Ann Arbor, MI, United States of America
| | - Michael C. Dean
- University of Michigan College of Pharmacy, Ann Arbor, MI, United States of America
| | - Gabrielle Costello
- University of Michigan College of Pharmacy, Ann Arbor, MI, United States of America
| | - Craig R. Sherman
- Hope Pharmaceuticals, Scottsdale, AZ, United States of America
- * E-mail:
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Darrieurtort-Laffite C, Bertrand-Vasseur A, Garraud T, Planche L, Le Goff B. Tolerance and effect of sodium thiosulfate in calcific tendinitis of the rotator cuff. Clin Rheumatol 2019; 39:561-569. [PMID: 31673978 DOI: 10.1007/s10067-019-04793-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Calcific tendinitis of the rotator cuff is one of the most common causes of shoulder pain. Ultrasound-guided percutaneous lavage of calcific tendinopathy is performed when conservative treatments have failed. Sodium thiosulfate (STS) has recently been used with success in the treatment of tumoral calcinosis. The goal of this phase II study was to assess the tolerance and the feasibility of STS lavage of calcific tendinopathy. METHODS We included patient with type hard calcifications. Patients were treated with puncture and lavage followed by injection of STS in the calcification. VAS pain at rest and during activities, ultrasound, and X-ray were evaluated at 1 week and 1 and 3 months. RESULTS Seventeen patients were included. Baseline VAS at rest and during daily activities was a mean 40.2 ± 25.9 and 65.5 ± 21.6 respectively. All patients underwent the entire procedure with no adverse event. Calcium backflow could be obtained in 15 patients (88.2%). Five patients (30%) had more than 50% decrease of their calcific deposit size at 1 month and 8 (47%) patients at 3 months. VAS pain during activities and at rest decreased significantly at 3 months (p = 0.0004; p = 0.001). Efficacy would be demonstrated if 60% of the patients had more than 50% decrease size of their calcification CONCLUSION: Overall, STS was well tolerated with no side effect occurring during the procedure and the follow-up. However, no significant effect on calcium disappearance could be demonstrated compared with what is expected without STS. New studies using larger volume and repeated injections of STS are now needed. CLINICAL TRIAL REGISTRATION NUMBER NCT02538939Key Points• Lavage of calcific tendinopathy of the rotator cuff with sodium thiosulfate is feasible• No adverse events have been observed after or in the 3 months after the procedure• We could not demonstrate that sodium thiosulfate increases the chance of calcium disappearance• New studies using larger volume and repeated injections of STS are needed to further explore the interest of sodium thiosulfate in the treatment of calcific tendinopathy.
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Affiliation(s)
- C Darrieurtort-Laffite
- Rheumatology Department, Hôtel-Dieu, Nantes, France.,INSERM UMR1238, Bone Sarcoma and Remodeling of Calcified Tissue, Nantes, France
| | | | - T Garraud
- Rheumatology Department, Hôtel-Dieu, Nantes, France
| | - L Planche
- Biometrics and Statistic Platform, Hôtel-Dieu, Nantes, France
| | - B Le Goff
- Rheumatology Department, Hôtel-Dieu, Nantes, France. .,INSERM UMR1238, Bone Sarcoma and Remodeling of Calcified Tissue, Nantes, France.
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Robert T, Lionet A, Bataille S, Seret G. Rheopheresis: A new therapeutic approach in severe calciphylaxis. Nephrology (Carlton) 2019; 25:298-304. [PMID: 31576630 DOI: 10.1111/nep.13666] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/27/2019] [Accepted: 09/03/2019] [Indexed: 01/22/2023]
Abstract
AIM Uremic calciphylaxis, also called calcific uraemic arteriolopathy (CUA), is a rare disease with a poor prognosis (mortality between 45% and 80%). Treatment is currently not standardized, and is based mainly on risk factor control, often with administration of sodium thiosulfate. We report the use of rheopheresis, a double filtration apheresis technique, specifically designed to improve blood rheology and tissue perfusion, as adjunctive therapy in eight patients with severe CUA. METHODS We retrospectively analysed eight cases of severe CUA treated by rheopheresis after failure of conventional measures, including administration of sodium thiosulfate and discontinuation of vitamin K antagonists. RESULTS Of the patients, there were 5 (63%) women, the median age was 69 (63.9-73) years. Four (50%) patients had biopsy-proven CUA. At diagnosis, the median dialysis vintage was 35 (3.9-42) months; five (63%) patients were anuric. Weekly median dialysis duration and dose were 12 (12-12.75) hours and 1.19 (1.13-1.48) Kt/V per dialysis session, respectively. Median time from CUA onset to first rheopheresis therapy was 26 (3.2-68) days. Patients started with 2-3 weekly sessions, coupled with haemodialysis. Complete remission was obtained in five patients (66%) after 25 (19-39) sessions over a duration of 119 (114-196) days. Three patients died, two of which resulted from an infectious complication related to CUA. CONCLUSION Rheopheresis is a promising approach, with a good safety profile, for the treatment of CUA. A prospective study with a larger population, would clarify its place in the therapeutic armamentarium.
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Affiliation(s)
- Thomas Robert
- Centre de Néphrologie et Transplantation Rénale, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Arnaud Lionet
- Hopital Huriez Service de Néphrologie-dialyse et Transplantation, CHU Lille, Lille, France
| | - Stanislas Bataille
- Institut Phocéen de Néphrologie, Marseille, France.,ELSAN, Clinique Bouchard, Marseille, France
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Qiu CC, Brown AE, Lobitz GR, Shanker A, Hsu S. The color of skin: black diseases of the skin, nails, and mucosa. Clin Dermatol 2019; 37:447-467. [PMID: 31896402 DOI: 10.1016/j.clindermatol.2019.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gradations in skin color are a consequence of differing amounts of melanin and their varying distribution. Although many darkly pigmented skin lesions are melanocytic and can be attributed to melanin content, the color of a black lesion can also be due to blood, necrotic tissue, or exogenous pigment. The source, pattern, and distribution of the color in black lesions usually offer important insight into its etiology. This contribution reviews conditions that can take on a black color, discussing the cause of the hue and any additional impact sun exposure may have.
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Affiliation(s)
- Connie C Qiu
- Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA.
| | - Ashley E Brown
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Gabriella R Lobitz
- Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Akshay Shanker
- Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sylvia Hsu
- Department of Dermatology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
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Improvement in wound healing, pain, and quality of life after 12 weeks of SNF472 treatment: a phase 2 open-label study of patients with calciphylaxis. J Nephrol 2019; 32:811-821. [PMID: 31401795 DOI: 10.1007/s40620-019-00631-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 07/13/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Calciphylaxis in end-stage renal disease is characterized by painful necrotic skin ulcers and high mortality. There are no approved therapies. SNF472, an intravenous formulation of myo-inositol hexaphosphate, inhibits the formation and growth of hydroxyapatite crystals, the final common pathway in the pathogenesis of vascular calcification. METHODS In this open-label, single-arm study, calciphylaxis patients on thrice-weekly hemodialysis and standard care, received intravenous SNF472 3 times per week for 12 weeks. The primary endpoint was wound healing assessed using the quantitative Bates-Jensen Wound Assessment Tool (BWAT). Pain visual analog scale (VAS), quality of life (wound-QoL), and qualitative wound image review were secondary endpoints. Quantitative changes from baseline were analyzed by paired t-tests using multiple imputation to account for missing observations. RESULTS Fourteen patients received SNF472. Improvements from baseline to week 12 were observed for mean BWAT score (- 8.1; P < 0.001), pain VAS (- 23.6 mm; P = 0.015) and wound-QoL global score (- 0.90; P = 0.003). Of the 9 patients with ulcerated lesions at baseline who completed treatment, wound image review showed improvement for 7. SNF472 was well tolerated with no serious treatment-related adverse events. The most common adverse events were infections which occur frequently in patients on hemodialysis. None of these were considered as treatment-related. CONCLUSIONS SNF472 was well-tolerated and improvements from baseline to week 12 in wound healing, pain, and quality of life were observed. A randomized, double-blind, placebo-controlled trial is planned to evaluate SNF472 in patients with calciphylaxis.
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Abstract
The color purple can be seen in several types of eruptions including inflammatory dermatoses like lichen planus, infectious dermatoses like ecthyma gangrenosum, neoplasms like Kaposi sarcoma, and vasculitis and vasculopathy. The current review focuses on the clinical appearance, pathophysiology, and treatment of several vasculitides and vasculopathies including capillaritis, cutaneous small-vessel vasculitis, immunoglobulin A (IgA) vasculitis, cryoglobulinemia, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis, polyarteritis nodosum, warfarin-induced skin necrosis, heparin-induced thrombocytopenia, purpura fulminans, antiphospholipid antibody syndrome, calciphylaxis, levamisole-induced vasculopathy, and thrombotic thrombocytopenic purpura. Dermatologists play a central role in treating patients with cutaneous vasculitis and vasculopathy and may have the opportunity to facilitate identification of systemic disease by diagnosing cutaneous vasculitis and vasculopathy.
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Affiliation(s)
- Alexa B Steuer
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York, USA
| | - Jeffrey M Cohen
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York, USA.
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Taillé C, Debray MP, Danel C, Serhal A, Pradère P, Crestani B. Calcium-solubilizing sodium thiosulfate failed to improve pulmonary alveolar microlithiasis: Evaluation of calcium content with CT scan. Respir Med Res 2019; 75:10-12. [PMID: 31235452 DOI: 10.1016/j.resmer.2019.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/26/2019] [Accepted: 04/02/2019] [Indexed: 10/27/2022]
Affiliation(s)
- C Taillé
- Service de pneumologie et centre de référence constitutif des maladies pulmonaires rares, hôpital Bichat, Assistance publique-Hôpitaux de Paris, département hospitalo-universitaire FIRE, université Paris Diderot, Inserm UMR 1152, LabEx inflamex, Paris, 75018, France.
| | - M-P Debray
- Service de radiologie, hôpital Bichat, Assistance publique-Hôpitaux de Paris, Paris, 75018, France.
| | - C Danel
- Laboratoire de pathologie, hôpital Bichat, Assistance publique-Hôpitaux de Paris, Paris, 75018, France.
| | - A Serhal
- Service de radiologie, hôpital Bichat, Assistance publique-Hôpitaux de Paris, Paris, 75018, France.
| | - P Pradère
- Service de pneumologie et centre de référence constitutif des maladies pulmonaires rares, hôpital Bichat, Assistance publique-Hôpitaux de Paris, Paris, 75018, France.
| | - B Crestani
- Service de pneumologie et centre de référence constitutif des maladies pulmonaires rares, hôpital Bichat, Assistance publique-Hôpitaux de Paris, département hospitalo-universitaire FIRE, université Paris Diderot, Inserm UMR 1152, LabEx inflamex, Paris, 75018, France.
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Isoherranen K, O'Brien JJ, Barker J, Dissemond J, Hafner J, Jemec GBE, Kamarachev J, Läuchli S, Montero EC, Nobbe S, Sunderkötter C, Velasco ML. Atypical wounds. Best clinical practice and challenges. J Wound Care 2019; 28:S1-S92. [DOI: 10.12968/jowc.2019.28.sup6.s1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Kirsi Isoherranen
- Helsinki University Central Hospital and Helsinki University, Wound Healing Centre and Dermatology Clinic, Helsinki, Finland
| | | | - Judith Barker
- Nurse Practitioner - Wound Management, Rehabilitation, Aged and Community Care., Adjunct Associate Professor, University of Canberra, Canberra, Australia
| | - Joachim Dissemond
- University Hospital of Essen, Department of Dermatology, Venerology and Allergology, Hufelandstraße 55, Essen, Germany
| | - Jürg Hafner
- Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, Zurich, Switzerland
| | - Gregor B. E. Jemec
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark
| | - Jivko Kamarachev
- Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, Zurich, Switzerland
| | - Severin Läuchli
- Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, Zurich, Switzerland
| | | | - Stephan Nobbe
- Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, Zurich, Switzerland Department of Dermatology, Cantonal Hospital of Frauenfeld, Switzerland
| | - Cord Sunderkötter
- Chair, Department of Dermatology and Venerology, University and University Hospital of Halle, Ernst-Grube-Strasse 40, Halle, Germany
| | - Mar Llamas Velasco
- Department of Dermatology, Hospital Universitario De La Princesa, Madrid, Spain
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Affiliation(s)
- Arjun Gupta
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Snigdha Jain
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Carol Croft
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
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Udomkarnjananun S, Kongnatthasate K, Praditpornsilpa K, Eiam-Ong S, Jaber BL, Susantitaphong P. Treatment of Calciphylaxis in CKD: A Systematic Review and Meta-analysis. Kidney Int Rep 2019; 4:231-244. [PMID: 30775620 PMCID: PMC6365410 DOI: 10.1016/j.ekir.2018.10.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/20/2018] [Accepted: 10/01/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Calciphylaxis is a life-threatening complication of chronic kidney disease (CKD). To inform clinical practice, we performed a systematic review of case reports, case series, and cohort studies to synthesize the available treatment modalities and outcomes of calciphylaxis in patients with CKD. METHODS Electronic databases were searched for studies that examined the uses of sodium thiosulfate, surgical parathyroidectomy, calcimimetics, hyperbaric oxygen therapy, and bisphosphonates for calciphylaxis in patients with CKD, including end-stage renal disease. For cohort studies, the results were synthesized quantitatively by performing random-effects model meta-analyses. RESULTS A total of 147 articles met the inclusion criteria and were included in the systematic review. There were 90 case reports (90 patients), 20 case series (423 patients), and 37 cohort studies (343 patients). In the pooled cohorts, case series, and case reports, 50.3% of patients received sodium thiosulfate, 28.7% underwent surgical parathyroidectomy, 25.3% received cinacalcet, 15.3% underwent hyperbaric oxygen therapy, and 5.9% received bisphosphonates. For the subset of cohort studies, by meta-analysis, the pooled risk ratio for mortality was not significantly different among patients who received sodium thiosulfate (pooled risk ratio [RR] 0.89; 95% confidence interval [CI] 0.71-1.12), cinacalcet (pooled RR 1.04; 95% CI 0.75-1.42), hyperbaric oxygen therapy (pooled RR 0.89; 95% CI 0.71-1.12), and bisphosphonates (pooled RR 0.77; 95% CI 0.44-1.32), and those who underwent surgical parathyroidectomy (pooled RR 0.88; 95% CI 0.69-1.13). CONCLUSION This systematic review found no significant clinical benefit of the 5 most frequently used treatment modalities for calciphylaxis in patients with CKD. Randomized controlled trials are needed to test the efficacy of these therapies.
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Affiliation(s)
- Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kitravee Kongnatthasate
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Bertrand L. Jaber
- Department of Medicine, St. Elizabeth’s Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Darres A, Delaval R, Fournier A, Tournier E, Cointault O, Moussion F, Chauveau D, Seigneuric B, Lumbroso C, Kamar N, Ribes D, Leou S, Huart A, Testevuide P, Faguer S. The Effectiveness of Topical Cerium Nitrate-Silver Sulfadiazine Application on Overall Outcome in Patients with Calciphylaxis. Dermatology 2019; 235:120-129. [DOI: 10.1159/000493975] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/24/2018] [Indexed: 11/19/2022] Open
Abstract
Background: Calciphylaxis (CPX) is a rare and life-threatening disease characterized by vascular calcification and development of painful and necrotizing skin lesions with a challenging management. Mechanisms of CPX are complex and include an imbalance between vascular calcification promoters and inhibitors, and frequently vitamin K deficiency. Objectives: To describe the various presentations and identify predictive factors of death in patients with CPX. Methods: In this multicenter retrospective study, we included 71 CPX patients followed in South-West France (n = 26) and in French Polynesia (n = 45), and who all received sodium thiosulfate (25 g thrice weekly for a median of 61 days). Results: Characteristics at presentation significantly differed between metropolitan and Polynesian French patients. Polynesians were less frequently on regular dialysis at the onset of CPX, had a higher incidence of diabetes mellitus and obesity, more disturbances of calcium-phosphorus metabolism, and received vitamin K antagonists less frequently than patients from South-West France. Despite intensive management, the 1-year mortality rate was 66% and median time to death was 200 days (IQR, 40; 514). The number of body areas involved (i.e., three: OR 2.70 [1.09; 6.65], p = 0.031; four: OR 8.79 [1.54; 50.29], p = 0.015) was the only predictive factor for death, whereas application of topical cerium nitrate-silver sulfadiazine was protective (OR 0.44 [0.20; 0.99], p = 0.046). Surgical debridement, hyperbaric oxygenation therapy, and geographical origin were not associated with overall outcomes. Conclusions: Cerium nitrate may lead to vascular decalcification and chelation of reactive oxygen species, and prevent infection. Cerium nitrate-silver sulfadiazine was associated with better outcomes and should be tested in a prospective comparative trial in CPX patients.
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Peng T, Zhuo L, Wang Y, Jun M, Li G, Wang L, Hong D. Systematic review of sodium thiosulfate in treating calciphylaxis in chronic kidney disease patients. Nephrology (Carlton) 2018; 23:669-675. [PMID: 28603903 DOI: 10.1111/nep.13081] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 12/21/2022]
Abstract
AIM Calciphylaxis is a severe complication of advanced chronic kidney disease (CKD). Sodium thiosulphate (STS), an antioxidant and calcium chelating agent, has been used for the treatment of calciphylaxis. However, its efficacy and safety have not been systematically analysed and evaluated. METHODS MEDLINE, EMBASE, and the Cochrane Library database were systematically searched for case report or cases series on use of STS for calciphylaxis published between July 1974 and October 2016. We extracted data on clinical characteristics, laboratory tests result and medication use. The effective treatment was defined as improvement in skin lesion cicatrisation or pain relief without death. Non-responding effects were defined as stable skin lesions without remission or exacerbation of the disease in patients who remained alive. All-cause mortality after STS treatment was defined as death due to exacerbations of calciphylaxis or other complications of advanced CKD. We compared the baseline parameters of the patients as well as the efficacy and mortality of the STS therapy between case report and multi-case reports. Statistical analyses were performed using SPSS 19. RESULTS A total of 83 papers were screened, 45 of them (n = 358) met the inclusion criteria, including 36 case reports (n = 64) and nine multi-case reports (n = 294). The mean age of the patients with calciphylaxis was 58 ± 14 years (range 26-91 years). They were female predominant, accounting for 74.1%. Among the patients with calciphylaxis, 96.1% patients were on dialysis with median dialysis vintage of 44.5 months (range 24-84 months). STS was effective in 70.1% of patients, 37.6% patients died. The proportion of patients with sepsis was higher among those who received intravenous STS. There was no significant difference in efficacy between the different STS administration methods (P = 0.19). CONCLUSION Although the study was unable to assess the efficacy of sodium thiosulphate alone in the treatment of calciphylaxis, it still reveals a promising role of STS as an effective therapy for calciphylaxis. Further prospective studies to define the optimal therapy for calciphylaxis are needed.
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Affiliation(s)
- Ting Peng
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Ling Zhuo
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Ying Wang
- The George Institute for Global Health, University of Sydney, Australia
| | - Min Jun
- The George Institute for Global Health, University of Sydney, Australia
| | - Guisen Li
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Li Wang
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Daqing Hong
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,The George Institute for Global Health, University of Sydney, Australia
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Cucchiari D, Torregrosa JV. Calciphylaxis in patients with chronic kidney disease: A disease which is still bewildering and potentially fatal. Nefrologia 2018; 38:579-586. [PMID: 30415999 DOI: 10.1016/j.nefro.2018.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/11/2018] [Accepted: 05/09/2018] [Indexed: 11/30/2022] Open
Abstract
Calciphylaxis, also known as calcific uraemic arteriolopathy, is a rare syndrome that typically causes skin necrosis and usually affects dialysis patients. Its pathogenesis is multifactorial and is the consequence of many factors causing ectopic calcifications in patients with chronic kidney disease, such as calcium-phosphate metabolism disorders, hyper- or hypo-parathyroidism, diabetes, obesity, systemic inflammation and the use of vitamin K antagonists, among others. From a clinical point of view, calciphylaxis may progress from painful purpura to extensive areas of skin necrosis that can potentially lead to superinfection and the death of the patient due to sepsis. Treatment is primarily based on managing the wounds, eliminating all the possible precipitating factors of ectopic calcification and administering agents which are capable of inhibiting the process of calcification.
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Affiliation(s)
- David Cucchiari
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, España; Nephrology and Dialysis Unit, Humanitas Clinical Research Center, Rozzano, Italia
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In Vitro Analysis of the Degradation of Calcium Hydroxylapatite Dermal Filler: A Proof-of-Concept Study. Dermatol Surg 2018; 44 Suppl 1:S5-S9. [DOI: 10.1097/dss.0000000000001683] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Delma S, Isnard-Bagnis C, Deray G, Barthelemy RN, Mercadal L, Desbuissons G. [Hyperthyroidism-induced calciphylaxis: A case report]. Nephrol Ther 2018; 14:548-553. [PMID: 30385137 DOI: 10.1016/j.nephro.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 07/28/2018] [Accepted: 08/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Calciphylaxis or calcific uremic arteriolopathy (CUA) is a cutaneous disease with ulcerations secondary to calcification of cutaneous and subcutaneous small arteries and arterioles. It is a rare but severe disease with significant morbidity and mortality affecting 1 to 4% of dialysis patients. The circumstances of occurrence are multiple. CASE We report the case of a severe bilateral lower limb calciphylaxis in a 69-year-old, obese, hemodialysis patient with a recent diagnosis of Graves' disease complicated with hypercalcemia and cardiac arrhythmia requiring the use of vitamin K antagonist. Complex and multidisciplinary therapeutic management (daily hemodialysis, sodium thiosulfate therapy, treatment of hypercalcemia by denosumab, hyperbaric oxygen therapy, meshed skin autograft) allowed complete healing of the lesions. CONCLUSION This is the first description of AUC secondary to hyperthyroidism in a dialysis patient. Multidisciplinary care is essential to achieve clinical improvement in those critical situations.
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Affiliation(s)
- Samuel Delma
- Service de néphrologie, groupe hospitalier La Pitié-Salpêtrière, 75013 Paris, France
| | - Corinne Isnard-Bagnis
- Service de néphrologie, groupe hospitalier La Pitié-Salpêtrière, 75013 Paris, France
| | - Gilbert Deray
- Service de néphrologie, groupe hospitalier La Pitié-Salpêtrière, 75013 Paris, France
| | | | - Lucile Mercadal
- Service de néphrologie, groupe hospitalier La Pitié-Salpêtrière, 75013 Paris, France
| | - Geoffroy Desbuissons
- Service de néphrologie, groupe hospitalier La Pitié-Salpêtrière, 75013 Paris, France.
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Frunza-Stefan S, Poola-Kella S, Silver K. Non-uraemic calciphylaxis (NUC) postliver transplantation. BMJ Case Rep 2018; 2018:bcr-2018-226537. [PMID: 30361453 DOI: 10.1136/bcr-2018-226537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Calciphylaxis is a rare and life-threatening disease characterized by cutaneous arteriolar stenosis and vascular thrombosis leading to skin ischaemia and necrosis. While calciphylaxis occurs mostly in patients with end-stage renal disease, the disorder has been described in patients with normal renal function, namely non-uraemic calciphylaxis (NUC). A 41-year-old African-American woman presented with a painful ulcerative rash on her thighs and right buttock 2 months after undergoing an orthotopic liver transplantation. She underwent debridement of the lesions and an excisional biopsy of one of the lesions, which revealed calciphylaxis. She was treated with sodium thiosulfate, cinacalcet and hyperbaric oxygen with complete resolution of the lesions 4-5 months after presentation. While she was treated with a course of high-dose glucocorticoids after the transplant, she did not have other risk factors for calciphylaxis. NUC should be considered in the differential diagnosis of necrotic skin lesions in postliver transplant patients.
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Affiliation(s)
- Simona Frunza-Stefan
- Medicine; Endocrinology, Diabetes and Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
| | | | - Kristi Silver
- Medicine; Endocrinology, Diabetes and Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
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Affiliation(s)
- Natallia Maroz
- Renal Physicians Inc., Dayton, OH, USA.,Department of Medicine, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
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Ahmed MM, Zakir A, Ahsraf MF, Ejaz A, Ashraf A, Namburu L, Farooqi MS, Ahmed M, Raza I. Chronic Kidney Disease and Calciphylaxis: A Literature Review. Cureus 2018; 10:e3334. [PMID: 30473967 PMCID: PMC6248774 DOI: 10.7759/cureus.3334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Calcific uremic arteriolopathy (CUA), also known as calciphylaxis, is a rare complication of chronic kidney disease (CKD). Its incidence is increasing due to a better understanding and diagnosis by physicians. Calciphylaxis is a fatal complication of many metabolic disorders. If not managed properly, it can lead to death within a year. This review is an effort to highlight the importance of research on prompt diagnosis and treatment guidelines for calciphylaxis, as it poses a challenge due to its diverse clinical presentation and high mortality rate.
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Affiliation(s)
- Munis M Ahmed
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | - Asma Zakir
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | | | - Amna Ejaz
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | - Aqsa Ashraf
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | - Lalith Namburu
- Internal Medicine, Siddhartha Medical College, Vijayawada, IND
| | - Muhammad S Farooqi
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | - Moeed Ahmed
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | - Ibrahim Raza
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
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Berry A, Degheim G, Saba S. Arteriolar vs. valvular thrombosis: Pick your evil! Thromb J 2018; 16:23. [PMID: 30181717 PMCID: PMC6114737 DOI: 10.1186/s12959-018-0175-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 06/14/2018] [Indexed: 11/13/2022] Open
Abstract
Background Anticoagulation therapy for mechanical prosthetic valves is limited to vitamin K antagonists, unfractionated heparin and low-molecular-weight-heparin. Other forms of anticoagulation are either contraindicated or have not been well studied. Hence, anticoagulation for preexisting mechanical valves is controversial if vitamin K antagonists are contraindicated. We present a case involving an end-stage-renal disease patient with both mitral and aortic mechanical valves who developed warfarin-induced calciphylaxis. Case presentation A 72-year-old male with history of end-stage renal disease, chronic atrial fibrillation and rheumatic heart disease status post mitral and aortic valve replacements presented with complaints of left thigh erythema with skin induration. Despite multiple antibiotic regimens for presumed cellulitis, the skin lesions progressed to necrotic ulcers. A biopsy revealed evidence of calciphylaxis; a lethal condition typically associated with renal disease. The patient was on warfarin for anticoagulation of his mechanical heart valves as well as prophylactically for atrial fibrillation. Warfarin contributes to the development of calciphylaxis and needed to be exchanged to avoid progression of the ulceration. The only other acceptable option for long-term anticoagulation was subcutaneous unfractionated heparin but this approach was not taken. The patient suffered from further sequelae of calciphylaxis and eventually expired. Conclusion Calciphylaxis is a rare, serious disorder that presents with skin ischemia and necrosis mainly in end-stage renal disease patients. The pathogenesis and treatment are poorly understood and the prognosis remains grave. It is proposed that certain medications, including warfarin, contribute to its evolution. The optimal anticoagulation therapy in those with concomitant warfarin-induced calciphylaxis and mechanical valves is undetermined. Further studies are essential to establish new anticoagulation regimens in these devastating circumstances.
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Affiliation(s)
- Abeer Berry
- St John Providence-Providence Park Hospitals, 19001 W. 9 Mile Rd, Southfield, MI 48075 USA
| | - George Degheim
- St John Providence-Providence Park Hospitals, 19001 W. 9 Mile Rd, Southfield, MI 48075 USA
| | - Souheil Saba
- St John Providence-Providence Park Hospitals, 19001 W. 9 Mile Rd, Southfield, MI 48075 USA
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Abdalla AO, Al-Khafaji J, Taha M, Malik S. A Fatal Case of Non-Uremic Calciphylaxis: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:804-807. [PMID: 29983410 PMCID: PMC6066970 DOI: 10.12659/ajcr.909546] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Patient: Female, 61 Final Diagnosis: Non-uremic calciphylaxis Symptoms: Pain • skin ulcers Medication: — Clinical Procedure: — Specialty: General and Internal Medicine
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Affiliation(s)
- Abubaker O Abdalla
- Department of Internal Medicine, School of Medicine, University of Nevada, Reno, NV, USA
| | - Jaafar Al-Khafaji
- Department of Internal Medicine, School of Medicine, University of Nevada, Reno, NV, USA
| | - Mohamed Taha
- Department of Internal Medicine, University of Nevada, School of Medicine, Reno, NV, USA
| | - Samira Malik
- Department of Internal Medicine, University of Nevada, School of Medicine, Reno, NV, USA
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Non-uraemic calciphylaxis: a diagnostic and management challenge for the burns team. EUROPEAN JOURNAL OF PLASTIC SURGERY 2018. [DOI: 10.1007/s00238-017-1358-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Verstappen EMJ, Maaskant-Braat AJG, Scheltinga MR. Bilateral breast calciphylaxis in a patient who survived earlier extensive tissue necrosis 5 years previously: A case report. Int J Surg Case Rep 2018; 48:22-25. [PMID: 29775967 PMCID: PMC6043165 DOI: 10.1016/j.ijscr.2018.04.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/06/2018] [Accepted: 04/28/2018] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Calciphylaxis is a rare condition including patchy dermal necrosis that mostly affects chronic hemodialysis patients. The syndrome usually heralds impending death although patients may survive following a set of measures including an adapted dialysis regimen. The present case is a unique patient who recovered from an earlier episode of upper leg calciphylaxis 5 years previously but developed fatal bilateral breast necrosis. PRESENTATION OF CASE A 69 year old Caucasian woman with a history of atrial fibrillation, hypertension, CVA, hyperparathyroidectomy for secondary hyperparathyroidism and end stage renal disease with hemodialysis recovered in 2012 from extensive symptomatic left upper leg necrosis due to calciphylaxis. In 2017, she developed painful, necrotic ulcers on both breasts, again due to calciphylaxis. She had no history of anticoagulants use but she did use prednisolone 5mg/day. She received adequate wound care, pain medication, antibiotics and dialysis frequency was increased with an addition of sodium thiosulfate. A bilateral ablation was discussed but she decided to stop all treatment following pulmonary aspiration and passed away one week later. DISCUSSION Calciphylaxis is a rare diagnosis that should be considered in patients with renal insufficiency developing painful patches of skin necrosis. CONCLUSION A multidisciplinary treatment approach including hyperparathyroidectomy, modified hemodialysis and wound treatment is recommended. There is limited evidence for surgical intervention.
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Affiliation(s)
- E M J Verstappen
- Departement of general surgery. Máxima Medisch Centrum, De Run 4600, 5504 DB Veldhoven, The Netherlands.
| | - A J G Maaskant-Braat
- Departement of general surgery. Máxima Medisch Centrum, De Run 4600, 5504 DB Veldhoven, The Netherlands.
| | - M R Scheltinga
- Departement of general surgery. Máxima Medisch Centrum, De Run 4600, 5504 DB Veldhoven, The Netherlands.
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Affiliation(s)
- Sagar U Nigwekar
- From the Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston (S.U.N., R.T.); the Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Los Angeles (R.T.); and the Department of Cardiology, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen University Hospital, Aachen (V.M.B.), and the Department of Cardiology, Rhein-Maas Klinikum, Würselen (V.M.B.) - both in Germany
| | - Ravi Thadhani
- From the Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston (S.U.N., R.T.); the Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Los Angeles (R.T.); and the Department of Cardiology, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen University Hospital, Aachen (V.M.B.), and the Department of Cardiology, Rhein-Maas Klinikum, Würselen (V.M.B.) - both in Germany
| | - Vincent M Brandenburg
- From the Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston (S.U.N., R.T.); the Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Los Angeles (R.T.); and the Department of Cardiology, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen University Hospital, Aachen (V.M.B.), and the Department of Cardiology, Rhein-Maas Klinikum, Würselen (V.M.B.) - both in Germany
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Abstract
PURPOSE OF REVIEW Calciphylaxis remains a poorly understood vascular calcification disorder with predilection for patients with end-stage renal disease (ESRD). Recent data from large patient registries and databases have begun to provide information regarding incidence, risk factors, and outcomes in patients with calciphylaxis. RECENT FINDINGS The most recent estimate places the incidence of calciphylaxis at 3.5 new cases/1000 patient-years among the patients with ESRD on chronic hemodialysis. It is possible that misdiagnosis or subclinical disease may attribute to lower than the true incidence. There is a suggestion that the incidence is higher in peritoneal dialysis patients compared with patients with hemodialysis. Recent studies have identified a number of risk factors and point to the effects of vitamin K deficiency mediated impairment in Matrix Gla Protein carboxylation as one of the likely pathogenic mechanisms. The outcomes in calciphylaxis patients remain poor with mortality approaching 30% at 6 months and 50% at 12 months. SUMMARY The present review describes recent literature in the field of calciphylaxis. Calciphylaxis registries and specimen biorepositories promise to provide insights into the pathogenesis of calciphylaxis and will pave the way for much needed clinical trials.
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Harris C, Kiaii M, Lau W, Farah M. Multi-intervention management of calcific uremic arteriolopathy in 24 patients. Clin Kidney J 2018; 11:704-709. [PMID: 30288266 PMCID: PMC6165754 DOI: 10.1093/ckj/sfy007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/12/2018] [Indexed: 12/20/2022] Open
Abstract
Background Calcific uremic arteriolopathy (CUA), also known as calciphylaxis, is a rare but life-threatening condition predominately occurring in patients with end-stage renal disease on dialysis. In the absence of randomized clinical trials to guide management, clinicians must rely on observational data. We have previously reported the outcomes of our multi-intervention management in seven patients and now present a larger series of patients with extended follow-up. Methods We performed a retrospective analysis of all patients diagnosed with CUA at a single academic center between 2008 and 2017. We identified 24 patients including 13 hemodialysis, 8 peritoneal dialysis and 3 predialysis Stage 5 chronic kidney disease patients. Results Mean age at diagnosis was 60.5 years (range 35–83) and mean follow-up 30.5 months (range <1–99). Patients were predominately female (71%) and Caucasian (83%) with diabetes mellitus diagnosed in 16 of 24 patients. Fifteen of 24 patients had ulcerating lesions suggestive of advanced disease and 20 of 24 had extensive involvement (bilateral disease or lesion size >5 cm). Treatment consisted of intensive hemodialysis (>20 h per week), sodium thiosulfate, wound care, analgesics and discontinuation of trigger medications including warfarin. Hyperbaric oxygen, cinacalcet, bisphosphonates and vitamin K were used in some cases. Overall 1 year mortality was 41% (9/22) and overall mortality at the end of follow-up was 64% (14/24). Cause of death was felt to be attributable to CUA in only four cases (16.7%). Complete or partial resolution of lesions occurred in 17 of 24 patients. One patient had recurrence of CUA 20 months after initial diagnosis. Conclusions Although mortality remains high in this group, direct CUA-attributable mortality is lower than historic reports. We conclude that a multi-intervention approach can be successful in treating a group of patients with severe CUA lesions.
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Affiliation(s)
- Claire Harris
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
| | - Mercedeh Kiaii
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
| | - Wynnie Lau
- St Paul's Hospital, Vancouver, BC, Canada
| | - Myriam Farah
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
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De Flammineis E, Mulvaney PM, Kraft S, Mihm MC, Das S, Kroshinsky D. A 71-Year-Old Female with Myocardial Infarction and Long-Standing Ulcers on the Thigh. Dermatopathology (Basel) 2018; 4:18-23. [PMID: 29456997 PMCID: PMC5803738 DOI: 10.1159/000481727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Calciphylaxis is most commonly encountered in patients with end-stage renal disease; however, it is increasingly observed in nonuremic patients as well. It is important to consider and diagnose nonuremic calciphylaxis early, as prompt treatment and mitigation of associated risk factors is essential to improve long-term outcomes for these patients. Here, we present the case of a 71-year-old woman with atrial fibrillation on warfarin, but without renal disease, who presented with two long-standing ulcers on her thigh and was diagnosed with the aid of biopsy with calciphylaxis. We review the existing literature on the subject and offer this case as a representative report of a clinicopathologic correlation for this disorder.
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Affiliation(s)
| | - Patrick M Mulvaney
- Harvard Combined Dermatology Residency Program, Massachusetts General Hospital, Boston, MA, USA
| | - Stefan Kraft
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Martin C Mihm
- Department of Dermatology and Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Shinjita Das
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
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Clinical characteristics and risk factors associated with mortality in calcific uremic arteriolopathy. Int Urol Nephrol 2017; 49:2247-2256. [DOI: 10.1007/s11255-017-1721-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 10/06/2017] [Indexed: 12/17/2022]
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81
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Dugbartey GJ. The smell of renal protection against chronic kidney disease: Hydrogen sulfide offers a potential stinky remedy. Pharmacol Rep 2017; 70:196-205. [PMID: 29471067 DOI: 10.1016/j.pharep.2017.10.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/28/2017] [Accepted: 10/17/2017] [Indexed: 12/20/2022]
Abstract
Chronic kidney disease (CKD) is a common global health challenge characterized by irreversible pathological processes that reduce kidney function and culminates in development of end-stage renal disease. It is associated with increased morbidity and mortality in addition to increased caregiver burden and higher financial cost. A central player in CKD pathogenesis and progression is renal hypoxia. Renal hypoxia stimulates induction of oxidative and endoplasmic reticulum stress, inflammation and tubulointerstitial fibrosis, which in turn, promote cellular susceptibility and further aggravate hypoxia, thus forming a pathological vicious cycle in CKD progression. Although the importance of CKD is widely appreciated, including improvements in the quality of existing therapies such as dialysis and transplantation, new therapeutic options are limited, as there is still increased morbidity, mortality and poor quality of life among CKD patients. Growing evidence indicates that hydrogen sulfide (H2S), a small gaseous signaling molecule with an obnoxious smell, accumulates in the renal medulla under hypoxic conditions, and functions as an oxygen sensor that restores oxygen balance and increases medullary flow. Moreover, plasma H2S level has been recently reported to be markedly reduced in CKD patients and animal models. Also, H2S has been established to possess potent antioxidant, anti-inflammatory, and anti-fibrotic properties in several experimental models of kidney diseases, suggesting that its supplementation could protect against CKD and retard its progression. The purpose of this review is to discuss current clinical and experimental developments regarding CKD, its pathophysiology, and potential cellular and molecular mechanisms of protection by H2S in experimental models of CKD.
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Affiliation(s)
- George J Dugbartey
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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82
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Olaoye OA, Koratala A. Patient with ESRD with vascular calcifications and ischaemic complications. BMJ Case Rep 2017; 2017:bcr-2017-222674. [PMID: 28978613 DOI: 10.1136/bcr-2017-222674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Olanrewaju A Olaoye
- Department of Nephrology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Abhilash Koratala
- Department of Nephrology, College of Medicine, University of Florida, Gainesville, Florida, USA
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Vascular Damage and Kidney Transplant Outcomes: An Unfriendly and Harmful Link. Am J Med Sci 2017; 354:7-16. [DOI: 10.1016/j.amjms.2017.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/20/2016] [Accepted: 01/09/2017] [Indexed: 12/31/2022]
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Goossens J, Courbebaisse M, Caudron E, Bahans C, Vacquerie V, Melchior J, Salle PV, Moesch C, Daudon M, Frocht V, Richette P, Ea HK, Guigonis V. Efficacy of intralesional sodium thiosulfate injections for disabling tumoral calcinosis: Two cases. Semin Arthritis Rheum 2017; 47:451-455. [PMID: 28779847 DOI: 10.1016/j.semarthrit.2017.05.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 05/10/2017] [Accepted: 05/30/2017] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Tumoral calcinosis (TC) is a difficult-to-treat complication that can occur during several diseases such as dermatomyositis or genetic hyperphosphatemia. It is a painful and disabling condition that can lead to local complications including joint mobility reduction, cutaneous ulceration and superinfection. For the largest lesions, the treatment relies essentially on surgery. Intravenous sodium thiosulfate (STS) is efficient to treat calciphylaxis in patients undergoing hemodialysis. Local injections of STS seem efficient in superficial calcifications. OBJECTIVE To report the efficacy and safety of intra-lesional injections of STS in tumoral calcinosis. RESULTS We report two cases of successful intra-lesional injections of STS. A 44-year-old woman, with a history of dermatomyositis, presenting large subcutaneous calcifications in the right elbow, and a 42-year-old man, with a history of familial tumoral calcinosis, presenting large intramuscular calcifications in the right buttock, received weekly intra-lesional of 1-3g STS injections for 12 and 21 months, respectively. In both cases, the treatment relieved pain and greatly reduced the tumoral calcinosis with a very significant functional improvement without specific adverse effects. In case 1, TC size decreased from 28.7*56.0mm at baseline to 21.5*30.6mm at M12 treatment (59% reduction). In case 2, TC reduced from 167.5*204.3mm at baseline to 86.2*85.2mm at M21 treatment (79% reduction). CONCLUSION Local injection of STS could be a promising therapeutic strategy for large and deep TC lesions and could therefore be an alternative to surgery.
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Affiliation(s)
- J Goossens
- Service de rhumatologie, hôpital Lariboisière, centre Viggo Petersen, Paris, France
| | - M Courbebaisse
- AP-HP, Georges Pompidou European Hospital, Physiology Department, Paris Descartes University, and INSERM, Unit 1151, Paris, France
| | - E Caudron
- AP-HP, Hôpital Européen Georges Pompidou, Department of Pharmacy, Paris, France; Lip(Sys), Chimie analytique pharmaceutique EA 4041, Univ. Paris Sud, Université Paris-Saclay, Chatenay Malabry, France
| | - C Bahans
- Service de pédiatrie, Hopital de la Mère et de l'Enfant, Limoges, France
| | - V Vacquerie
- Service de chirurgie pédiatrique, Hopital de la Mère et de l'Enfant, Limoges, France
| | - J Melchior
- Service de Rhumatologie, Hopitaux de Brabois, Vandoeuvre les Nancy, France
| | - P Vergne Salle
- Service de Rhumatologie, Hôpital Dupuytren, Limoges, France
| | - C Moesch
- Service de Pharmacologie-toxicologie, Hôpital Dupuytren, Limoges, France
| | - M Daudon
- Service des explorations fonctionnelles, Hôpital Tenon, Paris, France
| | - V Frocht
- Service des explorations fonctionnelles, Hôpital Tenon, Paris, France
| | - P Richette
- Service de rhumatologie, hôpital Lariboisière, centre Viggo Petersen, Paris, France
| | - Hang-Korng Ea
- Service de rhumatologie, hôpital Lariboisière, centre Viggo Petersen, Paris, France.
| | - V Guigonis
- Service de pédiatrie, Hopital de la Mère et de l'Enfant, Limoges, France.
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Dobry A, Ko L, Kroshinsky D. Fractures in calciphylaxis patients following intravenous sodium thiosulfate therapy. J Eur Acad Dermatol Venereol 2017; 31:e445-e446. [DOI: 10.1111/jdv.14255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- A.S. Dobry
- Department of Dermatology, Massachusetts General Hospital; Harvard Medical School; 50 Staniford Street 2nd Floor Boston MA USA
| | - L.N. Ko
- Department of Dermatology, Massachusetts General Hospital; Harvard Medical School; 50 Staniford Street 2nd Floor Boston MA USA
| | - D. Kroshinsky
- Department of Dermatology, Massachusetts General Hospital; Harvard Medical School; 50 Staniford Street 2nd Floor Boston MA USA
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86
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Ohtake T, Kobayashi S. Impact of vascular calcification on cardiovascular mortality in hemodialysis patients: clinical significance, mechanisms and possible strategies for treatment. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0094-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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87
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Chen NC, Hsu CY, Chen CL. The Strategy to Prevent and Regress the Vascular Calcification in Dialysis Patients. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9035193. [PMID: 28286773 PMCID: PMC5329685 DOI: 10.1155/2017/9035193] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/17/2017] [Indexed: 12/31/2022]
Abstract
The high prevalence of arterial calcification in end-stage renal disease (ESRD) is far beyond the explanation by common cardiovascular risk factors such as aging, diabetes, hypertension, and dyslipidemia. The finding relies on the fact that vascular and valvular calcifications are predictors of cardiovascular diseases and mortality in persons with chronic renal failure. In addition to traditional cardiovascular risk factors such as diabetes mellitus and blood pressure control, other ESRD-related risks such as phosphate retention, excess calcium, and prolonged dialysis time also contribute to the development of vascular calcification. The strategies are to reverse "calcium paradox" and lower vascular calcification by decreasing procalcific factors including minimization of inflammation (through adequate dialysis and by avoiding malnutrition, intravenous labile iron, and positive calcium and phosphate balance), correction of high and low bone turnover, and restoration of anticalcification factor balance such as correction of vitamin D and K deficiency; parathyroid intervention is reserved for severe hyperparathyroidism. The role of bone antiresorption therapy such as bisphosphonates and denosumab in vascular calcification in high-bone-turnover disease remains unclear. The limited data on sodium thiosulfate are promising. However, if calcification is to be targeted, ensure that bone health is not compromised by the treatments.
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Affiliation(s)
- Nai-Ching Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung City, Taiwan
| | - Chih-Yang Hsu
- Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chien-Liang Chen
- Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
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88
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H 2S as a possible therapeutic alternative for the treatment of hypertensive kidney injury. Nitric Oxide 2017; 64:52-60. [PMID: 28069557 DOI: 10.1016/j.niox.2017.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/22/2016] [Accepted: 01/04/2017] [Indexed: 12/12/2022]
Abstract
Hypertension is the most common cause of cardiovascular morbidities and mortalities, and a major risk factor for renal dysfunction. It is considered one of the causes of chronic kidney disease, which progresses into end-stage renal disease and eventually loss of renal function. Yet, the mechanism underlying the pathogenesis of hypertension and its associated kidney injury is still poorly understood. Moreover, despite existing antihypertensive therapies, achievement of blood pressure control and preservation of renal function still remain a worldwide public health challenge in a subset of hypertensive patients. Therefore, novel modes of intervention are in demand. Hydrogen sulfide (H2S), a gaseous signaling molecule, has been established to possess antihypertensive and renoprotective properties, which may represent an important therapeutic alternative for the treatment of hypertension and kidney injury. This review discusses recent findings about H2S in hypertension and kidney injury from both experimental and clinical studies. It also addresses future direction regarding therapeutic use of H2S.
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89
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Mageau A, Guigonis V, Ratzimbasafy V, Bardin T, Richette P, Urena P, Ea HK. Intravenous sodium thiosulfate for treating tumoral calcinosis associated with systemic disorders: Report of four cases. Joint Bone Spine 2016; 84:341-344. [PMID: 27955821 DOI: 10.1016/j.jbspin.2016.10.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/26/2016] [Indexed: 01/01/2023]
Abstract
Intravenous sodium thiosulfate (ivSTS) is a promising new therapeutic option for calciphylaxis related to end-stage renal disease. However, its effect on tumoral calcinosis (TC) complicating autoimmune connective-tissue diseases has been scarcely described. We report here 4 cases (3 adults and 1 child) of TC treated with ivSTS. TC was secondary to CREST syndrome, dermatomyositis (1 adult and 1 child) and systemic erythematous lupus and involved multiple sites in all cases. In all 4 patients, TC was responsible for joint pain, reduced mobility, inflammatory flares and skin fistulations. One patient experienced difficulty sitting due to the pain induced by calcified lesions on the buttock; another patient had major disability, moved only with wheelchair and was under opioid treatment for pain. For all patients, treatment with several medications before STS was unsuccessful. The 3 adults received at least 6 cycles of ivSTS (20g/d, 5 days/month) and the child received a daily infusion of 17g STS during 1 month then a 9-g/d infusion during 3 months. Two adults and the child showed clinical improvement with STS treatment and the third adult felt disappointed and stopped STS treatment after 6 months. The child also stopped STS after 6 months due to vomiting. In one patient, an intensive regimen of ivSTS (20g every 2 days) controlled recurrent flares and fistulations. Unfortunately, TC remained unchanged. Further studies are needed to decipher how STS modulates ectopic calcification, the optimal regimen and posology.
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Affiliation(s)
- Arthur Mageau
- Pôle locomoteur, service de rhumatologie, centre Viggo Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Vincent Guigonis
- Service de pédiatrie, hôpital de la Mère et de l'Enfant, 8, avenue Dominique-Larrey, 87000 Limoges, France
| | - Voa Ratzimbasafy
- Service de pharmacie, hôpital de la Mère et de l'Enfant, 8, avenue Dominique-Larrey, 87000 Limoges, France
| | - Thomas Bardin
- Pôle locomoteur, service de rhumatologie, centre Viggo Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; UFR de médecine, université Paris 7 Denis Diderot, Paris Cité Sorbonne, 16, rue Henri-Huchard, 75018 Paris, France
| | - Pascal Richette
- Pôle locomoteur, service de rhumatologie, centre Viggo Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; UFR de médecine, université Paris 7 Denis Diderot, Paris Cité Sorbonne, 16, rue Henri-Huchard, 75018 Paris, France
| | - Pablo Urena
- Service de néphrologie et dialyse, Ramsay-Générale de Santé, clinique du Landy, 23, rue de Landy, 93400 Saint-Ouen, France
| | - Hang-Korng Ea
- Pôle locomoteur, service de rhumatologie, centre Viggo Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; UFR de médecine, université Paris 7 Denis Diderot, Paris Cité Sorbonne, 16, rue Henri-Huchard, 75018 Paris, France.
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90
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Dugbartey GJ. Diabetic nephropathy: A potential savior with 'rotten-egg' smell. Pharmacol Rep 2016; 69:331-339. [PMID: 28183033 DOI: 10.1016/j.pharep.2016.11.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 10/20/2016] [Accepted: 11/09/2016] [Indexed: 02/06/2023]
Abstract
Diabetic nephropathy (DN) is currently the leading cause of end-stage renal disease. Despite optimal management, DN is still a major contributor to morbidity and mortality of diabetic patients worldwide. The major pathological alterations in DN include excessive accumulation and deposition of extracellular matrix, leading to expansion of mesangial matrix, thickening of glomerular basement membrane and tubulointerstitial fibrosis. At the molecular level, accumulating evidence suggests that hyperglycemia or high glucose mediates renal injury in DN via multiple molecular mechanisms such as induction of oxidative stress, upregulation of renal transforming growth factor beta-1 expression, production of proinflammatory cytokines, activation of fibroblasts and renin angiotensin system, and depletion of adenosine triphosphate. Also worrying is the fact that existing therapies only retard the disease progression but do not prevent it. Therefore, there is urgent need to identify novel therapies to target additional disease mechanisms. Hydrogen sulfide (H2S), the third member of the gasotransmitter family, has recently been identified and demonstrated to possess important therapeutic characteristics that prevent the development and progression of DN in experimental animals by targeting several important molecular pathways, and therefore may represent an alternative or additional therapeutic approach for DN. This review discusses recent experimental findings on the molecular mechanisms underlying the therapeutic effects of H2S against the development and progression of DN and its clinical application in the future.
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Affiliation(s)
- George J Dugbartey
- Department of Medicine, Aab Cardiovascular Research Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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91
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Nigwekar SU, Zhao S, Wenger J, Hymes JL, Maddux FW, Thadhani RI, Chan KE. A Nationally Representative Study of Calcific Uremic Arteriolopathy Risk Factors. J Am Soc Nephrol 2016; 27:3421-3429. [PMID: 27080977 PMCID: PMC5084892 DOI: 10.1681/asn.2015091065] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 03/14/2016] [Indexed: 11/03/2022] Open
Abstract
Accurate identification of risk factors for calcific uremic arteriolopathy (CUA) is necessary to develop preventive strategies for this morbid disease. We investigated whether baseline factors recorded at hemodialysis initiation would identify patients at risk for future CUA in a matched case-control study using data from a large dialysis organization. Hemodialysis patients with newly diagnosed CUA (n=1030) between January 1, 2010, and December 31, 2014, were matched by age, sex, and race in a 1:2 ratio to hemodialysis patients without CUA (n=2060). Mean ages for patients and controls were 54 and 55 years, respectively; 67% of participants were women and 49% were white. Median duration between hemodialysis initiation and subsequent CUA development was 925 days (interquartile range, 273-2185 days). In multivariable conditional logistic regression analyses, diabetes mellitus; higher body mass index; higher levels of serum calcium, phosphorous, and parathyroid hormone; and nutritional vitamin D, cinacalcet, and warfarin treatments were associated with increased odds of subsequent CUA development. Compared with patients with diabetes receiving no insulin injections, those receiving insulin injections had a dose-response increase in the odds of CUA involving lower abdomen and/or upper thigh areas (odds ratio, 1.49; 95% confidence interval, 1.03 to 2.51 for one or two injections per day; odds ratio, 1.88; 95% confidence interval, 1.30 to 3.43 for 3 injections per day; odds ratio, 3.74; 95% confidence interval, 2.28 to 6.25 for more than three injections per day), suggesting a dose-effect relationship between recurrent skin trauma and CUA risk. The presence of risk factors months to years before CUA development observed in this study will direct the design of preventive strategies and inform CUA pathobiology.
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Affiliation(s)
- Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts;
| | - Sophia Zhao
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Julia Wenger
- Division of Nephrology, University of North Carolina Kidney Center, Chapel Hill, North Carolina; and
| | - Jeffrey L Hymes
- Medical office, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Franklin W Maddux
- Medical office, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Ravi I Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kevin E Chan
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Medical office, Fresenius Medical Care North America, Waltham, Massachusetts
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92
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McCarthy JT, El-Azhary RA, Patzelt MT, Weaver AL, Albright RC, Bridges AD, Claus PL, Davis MDP, Dillon JJ, El-Zoghby ZM, Hickson LJ, Kumar R, McBane RD, McCarthy-Fruin KAM, McEvoy MT, Pittelkow MR, Wetter DA, Williams AW. Survival, Risk Factors, and Effect of Treatment in 101 Patients With Calciphylaxis. Mayo Clin Proc 2016; 91:1384-1394. [PMID: 27712637 DOI: 10.1016/j.mayocp.2016.06.025] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/18/2016] [Accepted: 06/21/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To report on the survival and the associations of treatments upon survival of patients with calciphylaxis seen at a single center. PATIENTS AND METHODS Using the International Classification of Diseases, Ninth Revision diagnosis code of 275.49 and the keyword "calciphylaxis" in the dismissal narrative, we retrospectively identified 101 patients with calciphylaxis seen at our institution between January 1, 1999, through September 20, 2014, using a predefined, consensus-developed classification scheme. RESULTS The average age of patients was 60 years: 81 (80.2%) were women; 68 (68.0%) were obese; 19 (18.8%) had stage 0 to 2 chronic kidney disease (CKD), 19 (18.9%) had stage 3 or 4 CKD; 63 (62.4%) had stage 5 or 5D (dialysis) CKD. Seventy-five patients died during follow-up. Six-month survival was 57%. Lack of surgical debridement was associated with insignificantly lower 6-month survival (hazard ratio [HR]=1.99; 95% CI, 0.96-4.15; P=.07) and significantly poorer survival for the entire duration of follow-up (HR=1.98; 95% CI, 1.15-3.41; P=.01), which was most pronounced in stage 5 or 5D CKD (HR=1.91; 95% CI, 1.03-3.56; P=.04). Among patients with stage 5/5D CKD, subtotal parathyroidectomy (performed only in patients with hyperparathyroidism) was associated with better 6-month (HR=0.12; 95% CI, 0.02-0.90; P=.04) and overall survival (HR= 0.37; 95% CI, 0.15-0.87; P=.02). CONCLUSION Calciphylaxis is associated with a high mortality rate. Significantly effective treatments included surgical debridement and subtotal parathyroidectomy in patients with stage 5/5D CKD with hyperparathyroidism. Treatments with tissue-plasminogen activator, sodium thiosulfate, and hyperbaric oxygen therapy were not associated with higher mortality.
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Affiliation(s)
- James T McCarthy
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
| | | | - Michelle T Patzelt
- Mayo Medical School, Mayo Graduate School of Medicine, Mayo Clinic, Rochester, MN
| | - Amy L Weaver
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Robert C Albright
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - Paul L Claus
- Department of Medicine, Division of Hyperbaric Medicine in Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | | | - John J Dillon
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Ziad M El-Zoghby
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - LaTonya J Hickson
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Rajiv Kumar
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Robert D McBane
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Amy W Williams
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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93
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El-Azhary RA, Patzelt MT, McBane RD, Weaver AL, Albright RC, Bridges AD, Claus PL, Davis MDP, Dillon JJ, El-Zoghby ZM, Hickson LJ, Kumar R, McCarthy-Fruin KAM, McEvoy MT, Pittelkow MR, Wetter DA, Williams AW, McCarthy JT. Calciphylaxis: A Disease of Pannicular Thrombosis. Mayo Clin Proc 2016; 91:1395-1402. [PMID: 27712638 DOI: 10.1016/j.mayocp.2016.06.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/18/2016] [Accepted: 06/21/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To identify coagulation risk factors in patients with calciphylaxis and the relationship between anticoagulation use and overall survival. PATIENTS AND METHODS Study subjects were 101 patients with calciphylaxis seen at Mayo Clinic from 1999 to September 2014. Data including thrombophilia profiles were extracted from the medical records of each patient. Survival status was determined using patient registration data and the Social Security Death Index. Survival was estimated using the Kaplan-Meier method, and associations were evaluated using Cox proportional hazards models. RESULTS Sixty-four of the 101 patients underwent thrombophilia testing. Of these, a complete test panel was performed in 55 and a partial panel in 9. Severe thrombophilias observed in 60% (33 of 55) of the patients included antiphospholipid antibody syndrome protein C, protein S, or antithrombin deficiencies or combined thrombophilias. Of the 55 patients, severe thrombophilia (85%, 23 of 27) was noted in patients who were not on warfarin at the time of testing (27). Nonsevere thrombophilias included heterozygous factor V Leiden (n=2) and plasminogen deficiency (n=1). For the comparison of survival, patients were divided into 3 treatment categories: Warfarin (n=63), other anticoagulants (n=20), and no anticoagulants (n=18). There was no statistically significant survival difference between treatment groups. CONCLUSION Laboratory testing reveals a strikingly high prevalence of severe thrombophilias in patients with calciphylaxis, underscoring the importance of congenital and acquired thrombotic propensity potentially contributing to the pathogenesis of this disease. These findings may have therapeutic implications; however, to date, survival differences did not vary by therapeutic choice.
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Affiliation(s)
| | - Michelle T Patzelt
- Mayo Medical School, Mayo Graduate School of Medicine, Mayo Clinic, Rochester, MN
| | - Robert D McBane
- Department of Medicine, Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | - Amy L Weaver
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Robert C Albright
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - Paul L Claus
- Department of Medicine, Division of Hyperbaric Medicine in Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | | | - John J Dillon
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Ziad M El-Zoghby
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - LaTonya J Hickson
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Rajiv Kumar
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Amy W Williams
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - James T McCarthy
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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Zhang Y, Corapi KM, Luongo M, Thadhani R, Nigwekar SU. Calciphylaxis in peritoneal dialysis patients: a single center cohort study. Int J Nephrol Renovasc Dis 2016; 9:235-241. [PMID: 27698566 PMCID: PMC5034913 DOI: 10.2147/ijnrd.s115701] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Calciphylaxis is a rare but devastating condition in end-stage renal disease (ESRD) patients. Most research in the field of calciphylaxis is focused on hemodialysis (HD) patients; however, data on calciphylaxis incidence, risk factors, and mortality in peritoneal dialysis (PD) patients are limited. METHODS In this cohort study, we examined data from adult patients who initiated PD for ESRD management at our institute's PD unit from January 2001 to December 2015. Associations with the development of calciphylaxis were examined for clinical, laboratory, and medication exposures. Incidence of calciphylaxis and mortality in PD patients who developed calciphylaxis were analyzed. Treatments administered to treat calciphylaxis in PD patients were summarized. RESULTS In this cohort of 63 patients, 7 patients developed calciphylaxis (incidence rate: 9.0 per 1,000 patient-years). Median age of PD patients who developed calciphylaxis was 50 years, 57% were white, 71% females, and 71% were previously on HD. Female sex, obesity, HD as a prior dialysis modality, recurrent hypotension, elevated time-averaged serum phosphorous levels, reduced time-averaged serum albumin levels, and warfarin therapy were associated with increased calciphylaxis risk in univariate logistic regression analyses. Intravenous sodium thiosulfate was administered in 57% of PD patients who developed calciphylaxis. One-year mortality in PD patients who developed calciphylaxis was 71% despite multimodal treatment including sodium thiosulfate, hyperbaric oxygen, cinacalcet, and wound debridement. CONCLUSION Calciphylaxis is a rare but frequently fatal condition in PD patients. Our study provides critical early insights into calciphylaxis incidence, risk factors, and prognosis in PD patients. Sample size and characteristics of patients included in our study limit generalizability to overall PD population and warrant examination in larger independent studies.
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Affiliation(s)
- Yanchen Zhang
- Harvard Summer Research Program in Kidney Medicine, Boston, MA, USA
| | - Kristin M Corapi
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Maria Luongo
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Ravi Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Sagar U Nigwekar
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
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95
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Hundemer GL, Fenves AZ, Phillips KM, Emmett M. Sodium Thiosulfate and the Anion Gap in Patients Treated by Hemodialysis. Am J Kidney Dis 2016; 68:499-500. [DOI: 10.1053/j.ajkd.2016.02.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 02/05/2016] [Indexed: 11/11/2022]
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96
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Alternate release of different target species based on the same gold nanorods and monitored by cell imaging. Colloids Surf B Biointerfaces 2016; 145:671-678. [DOI: 10.1016/j.colsurfb.2016.05.087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 05/25/2016] [Accepted: 05/28/2016] [Indexed: 12/25/2022]
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97
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Bover J, Ureña-Torres P, Górriz JL, Lloret MJ, da Silva I, Ruiz-García C, Chang P, Rodríguez M, Ballarín J. Cardiovascular calcifications in chronic kidney disease: Potential therapeutic implications. Nefrologia 2016; 36:597-608. [PMID: 27595517 DOI: 10.1016/j.nefro.2016.05.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/19/2016] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular (CV) calcification is a highly prevalent condition at all stages of chronic kidney disease (CKD) and is directly associated with increased CV and global morbidity and mortality. In the first part of this review, we have shown that CV calcifications represent an important part of the CKD-MBD complex and are a superior predictor of clinical outcomes in our patients. However, it is also necessary to demonstrate that CV calcification is a modifiable risk factor including the possibility of decreasing (or at least not aggravating) its progression with iatrogenic manoeuvres. Although, strictly speaking, only circumstantial evidence is available, it is known that certain drugs may modify the progression of CV calcifications, even though a direct causal link with improved survival has not been demonstrated. For example, non-calcium-based phosphate binders demonstrated the ability to attenuate the progression of CV calcification compared with the liberal use of calcium-based phosphate binders in several randomised clinical trials. Moreover, although only in experimental conditions, selective activators of the vitamin D receptor seem to have a wider therapeutic margin against CV calcification. Finally, calcimimetics seem to attenuate the progression of CV calcification in dialysis patients. While new therapeutic strategies are being developed (i.e. vitamin K, SNF472, etc.), we suggest that the evaluation of CV calcifications could be a diagnostic tool used by nephrologists to personalise their therapeutic decisions.
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Affiliation(s)
- Jordi Bover
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España.
| | - Pablo Ureña-Torres
- Departamento de Nefrología y Diálisis, Clinique du Landy, París, Francia; Departamento de Fisiología Renal, Hospital Necker, Universidad de París Descartes, París, Francia
| | - José Luis Górriz
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Valencia, España
| | - María Jesús Lloret
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
| | - Iara da Silva
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
| | - César Ruiz-García
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
| | - Pamela Chang
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
| | - Mariano Rodríguez
- Servicio de Nefrología, Hospital Universitario Reina Sofía, IMIBIC, Universidad de Córdoba, Córdoba, España
| | - José Ballarín
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
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Abstract
PURPOSE OF REVIEW Calcific uremic arteriolopathy (CUA), as known as calciphylaxis, is a rare and poorly understood disease seen predominantly in end stage renal disease patients. A collaborative multidisciplinary approach to develop and implement treatment and prevention methods is described. RECENT FINDINGS Overall, the scientific literature on CUA is largely restricted to case reports and case series. Recent reports indicate that the incidence of CUA may be on the rise and emphasize an association with vitamin K antagonist therapy, obesity, and diabetes mellitus. Serum calcium, phosphorous, and parathyroid hormone levels have been reported to be quite variable in patients with CUA and may reflect the heterogeneity of study designs. A multidisciplinary and multimodal approach that incorporates wound and pain management, sodium thiosulfate, optimization of mineral bone parameters, bisphosphonates, and avoidance of risk factors such as vitamin K antagonist has been advocated in the latest reports. Sodium thiosulfate although used frequently to treat CUA has unclear efficacy requiring further examination. SUMMARY This review describes the recent literature in the field of CUA including its limitations. It provides a summary of a multidisciplinary approach to CUA management.
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Koratala A, Ejaz AA, Mohandas R. Calciphylaxis of the breast: a rare metabolic complication of kidney disease. BMJ Case Rep 2016; 2016:bcr-2016-216665. [PMID: 27507694 DOI: 10.1136/bcr-2016-216665] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Abhilash Koratala
- Department of Nephrology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Abutaleb A Ejaz
- Department of Nephrology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Rajesh Mohandas
- Department of Nephrology, University of Florida College of Medicine, Gainesville, Florida, USA
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Kingi L, Grech R, Lam M, Dissanayake A, Otter S. Calciphylaxis - A case study in a patient with Maori heritage. J Tissue Viability 2016; 25:216-219. [PMID: 27443245 DOI: 10.1016/j.jtv.2016.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 03/09/2016] [Accepted: 07/03/2016] [Indexed: 10/21/2022]
Abstract
This case history describes a rare complaint - Calciphylaxis, seen in a New Zealand Maori patient undergoing renal dialysis. This condition causes non-healing tissue ulceration, typically with sepsis and is associated with a very high mortality rate. The need for vigilance among health professionals is highlighted, including the risk factors that may faciliate an early diagnosis; together with the value associated with a multi-disciplinary team approach to management.
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Affiliation(s)
- Lawrence Kingi
- Counties Manukau District Health Board, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand
| | - Roger Grech
- Counties Manukau District Health Board, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand
| | - Michael Lam
- Counties Manukau District Health Board, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand
| | - Ajith Dissanayake
- Counties Manukau District Health Board, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand
| | - Simon Otter
- School of Podiatry, Health & Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland 1142, New Zealand; School of Health Science, University of Brighton, 49 Darley Rd, Eastbourne BN20 7UR, UK.
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