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Becker SL, Kody S, Fett NM, Hines A, Alavi A, Ortega-Loayza AG. Approach to the Atypical Wound. Am J Clin Dermatol 2024; 25:559-584. [PMID: 38744780 DOI: 10.1007/s40257-024-00865-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
The heterogeneity of atypical wounds can present diagnostic and therapeutic challenges; however, as the prevalence of atypical wounds grows worldwide, prompt and accurate management is increasingly an essential skill for dermatologists. Addressing the underlying cause of an atypical wound is critical for successful outcomes. An integrated approach with a focus on pain management and patient engagement is recommended to facilitate enduring wound closure. Advances in treatment, in addition to further research and clinical training, are necessary to address the expanding burden of atypical wounds.
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Affiliation(s)
- Sarah L Becker
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Shannon Kody
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Nicole M Fett
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | | | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA.
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2
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Hofmann AG, Deinsberger J, Oszwald A, Weber B. The Histopathology of Leg Ulcers. Dermatopathology (Basel) 2024; 11:62-78. [PMID: 38390849 PMCID: PMC10885126 DOI: 10.3390/dermatopathology11010007] [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: 12/17/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Ulcerations of the lower extremities are a frequently encountered problem in clinical practice and are of significant interest in public health due to the high prevalence of underlying pathologies, including chronic venous disease, diabetes and peripheral arterial occlusive disease. However, leg ulcers can also present as signs and symptoms of various rare diseases and even as an adverse reaction to drugs. In such cases, correct diagnosis ultimately relies on histopathological examination. Apart from the macroscopic presentation, patient history and anatomic location, which are sometimes indicative, most ulcers have very distinct histopathological features. These features are found in different layers of the skin or even associated vessels. In this narrative review, we discuss and highlight the histopathological differences of several types of leg ulcers that can contribute to efficient and accurate diagnosis.
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Affiliation(s)
- Amun Georg Hofmann
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Julia Deinsberger
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - André Oszwald
- Department of Pathology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Benedikt Weber
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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3
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Liu Y, Zhang X. Early diagnosis strategy of calciphylaxis in dialysis patients. Ren Fail 2023; 45:2264407. [PMID: 37795796 PMCID: PMC10557543 DOI: 10.1080/0886022x.2023.2264407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 09/23/2023] [Indexed: 10/06/2023] Open
Abstract
Calciphylaxis, a rapidly progressive and potentially life-threatening vascular calcification syndrome that clinically presents with persistently painful, ulcerative, or necrotizing skin lesions in multiple parts of the body, is predominantly observed in patients treated with dialysis. Early diagnosis of calciphylaxis is a key measure for reducing high disability and mortality. At present, there is no unified diagnostic standard for calciphylaxis, and there is a lack of effective early screening strategies. This paper summarized and discussed the diagnostic accuracy of calciphylaxis based on the latest research worldwide. We propose a modified strategy for the early diagnosis of calciphylaxis, which is suitable for dialysis patients to help clinicians better identify such disease and improve prognosis.
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Affiliation(s)
- Yuqiu Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, Jiangsu, China
| | - Xiaoliang Zhang
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, Jiangsu, China
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4
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Colboc H, Moguelet P, Bazin D, Letavernier E, Sun C, Chessel A, Carvalho P, Lok C, Dillies AS, Chaby G, Maillard H, Kottler D, Goujon E, Jurus C, Panaye M, Tang E, Courville P, Boury A, Monfort JB, Chasset F, Senet P, Schanne-Klein MC. Elastic fiber alterations and calcifications in calcific uremic arteriolopathy. Sci Rep 2023; 13:15519. [PMID: 37726292 PMCID: PMC10509184 DOI: 10.1038/s41598-023-42492-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
Calcific uremic arteriolopathy (CUA) is a severely morbid disease, affecting mostly dialyzed end-stage renal disease (ESRD) patients, associated with calcium deposits in the skin. Calcifications have been identified in ESRD patients without CUA, indicating that their presence is not specific to the disease. The objective of this retrospective multicenter study was to compare elastic fiber structure and skin calcifications in ESRD patients with CUA to those without CUA using innovative structural techniques. Fourteen ESRD patients with CUA were compared to 12 ESRD patients without CUA. Analyses of elastic fiber structure and skin calcifications using multiphoton microscopy followed by machine-learning analysis and field-emission scanning electron microscopy coupled with energy dispersive X-ray were performed. Elastic fibers specifically appeared fragmented in CUA. Quantitative analyses of multiphoton images showed that they were significantly straighter in ESRD patients with CUA than without CUA. Interstitial and vascular calcifications were observed in both groups of ESRD patients, but vascular calcifications specifically appeared massive and circumferential in CUA. Unlike interstitial calcifications, massive circumferential vascular calcifications and elastic fibers straightening appeared specific to CUA. The origins of such specific elastic fiber's alteration are still to be explored and may involve relationships with ischemic vascular or inflammatory processes.
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Affiliation(s)
- Hester Colboc
- Sorbonne Université, Hôpital Rothschild, Service Plaies et Cicatrisation, UMRS_1155, 5, Rue Santerre, 75012, Paris, France.
| | - Philippe Moguelet
- Sorbonne Université, Hôpital Tenon, Anatomie et Cytologie Pathologiques, Paris, France
| | - Dominique Bazin
- Université Paris-Saclay, CNRS, Institut de Chimie Physique, 91405, Orsay, France
| | - Emmanuel Letavernier
- Sorbonne Université, Hôpital Tenon, Service des Explorations Fonctionnelles Multidisciplinaires, UMRS_1155, Paris, France
| | - Chenyu Sun
- Laboratoire d'Optique et Biosciences, CNRS, Inserm, Ecole Polytechnique, Institut Polytechnique de Paris, Palaiseau, France
| | - Anatole Chessel
- Laboratoire d'Optique et Biosciences, CNRS, Inserm, Ecole Polytechnique, Institut Polytechnique de Paris, Palaiseau, France
| | - Priscille Carvalho
- Centre Hospitalier Universitaire de Rouen, Service de Dermatologie, Rouen, France
| | - Catherine Lok
- Centre Hospitalier Universitaire d'Amiens, Service de Dermatologie, Amiens, France
| | | | - Guillaume Chaby
- Centre Hospitalier Universitaire d'Amiens, Service de Dermatologie, Amiens, France
| | - Hervé Maillard
- Centre Hospitalier du Mans, Service de Dermatologie, Le Mans, France
| | - Diane Kottler
- Centre Hospitalier Universitaire de Caen, Service de Dermatologie, Caen, France
| | - Elisa Goujon
- Centre Hospitalier de Chalon-sur-Saône, Service de Dermatologie, Chalon, France
| | - Christine Jurus
- Clinique du Tonkin, Service de Médecine Vasculaire, Villeurbanne, France
| | - Marine Panaye
- Clinique du Tonkin, Service de Médecine Vasculaire, Villeurbanne, France
| | - Ellie Tang
- Sorbonne Université, Hôpital Tenon, Service des Explorations Fonctionnelles Multidisciplinaires, UMRS_1155, Paris, France
| | - Philippe Courville
- Centre Hospitalier Universitaire de Rouen, Anatomie et Cytologie Pathologiques, Rouen, France
| | - Antoine Boury
- Université Paris-Saclay, CNRS, Institut de Chimie Physique, 91405, Orsay, France
| | - Jean-Benoit Monfort
- Sorbonne Université, Faculté de Médecine, Service de Dermatologie et Allergologie, Hôpital Tenon, Paris, France
| | - François Chasset
- Sorbonne Université, Faculté de Médecine, Service de Dermatologie 3t Allergologie, Hôpital Tenon, INSERM U1135, CIMI, Paris, France
| | - Patricia Senet
- Sorbonne Université, Faculté de Médecine, Service de Dermatologie et Allergologie, Hôpital Tenon, Paris, France
| | - Marie-Claire Schanne-Klein
- Laboratoire d'Optique et Biosciences, CNRS, Inserm, Ecole Polytechnique, Institut Polytechnique de Paris, Palaiseau, France
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5
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Jiao Y, Sun L, Xie X, Liu H, Zhao Y, Ni H, Zhang X. Clinical features and outcomes of calciphylaxis in Chinese patients with chronic kidney disease. Nephrology (Carlton) 2023; 28:305-314. [PMID: 36883928 DOI: 10.1111/nep.14156] [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: 05/22/2022] [Revised: 01/15/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023]
Abstract
AIM Calciphylaxis is a rare disease, predominantly in chronic kidney disease (CKD), characterized by high morbidity and mortality. Data from the Chinese population have been an invaluable resource for a better understanding of natural history, optimal treatments and outcomes of calciphylaxis. METHODS A retrospective study was conducted in 51 Chinese patients diagnosed with calciphylaxis at Zhong Da Hospital affiliated to Southeast University from December 2015 to September 2020. RESULTS Between 2015 and 2020, 51 cases of calciphylaxis were registered in The China Calciphylaxis Registry (http://www.calciphylaxis.com.cn), which was developed by Zhong Da Hospital. The mean age of the cohort was 52.02 ± 14.09 years, and 37.3% were female. Forty-three patients (84.3%) were on haemodialysis, with a median dialysis vintage of 88 months. Eighteen patients (35.3%) had a resolution of calciphylaxis and 20 patients (39.2%) died. Patients in later stages had higher overall mortality than those in earlier stages. Delay from skin lesions onset to diagnosis and calciphylaxis-related infections were risk factors in both early and overall mortality. Additionally, dialysis vintage and infections were significant risk factors in calciphylaxis-specific mortality. Among therapeutic strategies, only the use of sodium thiosulfate (STS) ≥3 courses (14 injections) was significantly associated with decreased hazard of death in both early and overall mortality. CONCLUSION For Chinese patients with calciphylaxis, delay from skin lesions onset to diagnosis and infections secondary to wounds are risk factors for the prognosis of patients with calciphylaxis. Additionally, patients in earlier stages have better survival and early continuous use of STS is highly suggested.
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Affiliation(s)
- Yongyi Jiao
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Li Sun
- Department of Nephrology, Xuyi People's Hospital, Huaian, China
| | - Xiaotong Xie
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Hong Liu
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Yu Zhao
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Haifeng Ni
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Xiaoliang Zhang
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
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6
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Nakai K, Mihara Y, Kado H, Hosokawa Y, Hatta T. Hemodialysis Patient with Streptococcal Toxic Shock Syndrome and Penile Necrosis. Intern Med 2023; 62:135-138. [PMID: 35650128 PMCID: PMC9876726 DOI: 10.2169/internalmedicine.9467-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A 72-year-old man on hemodialysis due to diabetic nephropathy presented with a fever and penile pain. Although his physical examination was unremarkable, his general condition deteriorated. Penile necrosis was observed by evening on the same day of presentation, and the patient died the next morning. Blood cultures revealed the presence of Group G Streptococcus, leading to a diagnosis of streptococcal toxic shock syndrome (STSS). Autopsy suggested penile necrosis due to septic shock. STSS in hemodialysis patients with vascular calcification, even in the absence of calciphylaxis, can lead to severe organ damage due to ischemia.
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Affiliation(s)
- Kunihiro Nakai
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Yu Mihara
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Hiroshi Kado
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Yohei Hosokawa
- Department of Pathology, Omihachiman Community Medical Center, Japan
| | - Tsuguru Hatta
- Department of Nephrology, Omihachiman Community Medical Center, Japan
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7
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Tamagake M, Nagao M, Miura C, Imai Y. Surgical treatment of nonuremic calciphylaxis: a case report and review of literature. Case Reports Plast Surg Hand Surg 2022; 10:1-6. [PMID: 38229696 PMCID: PMC10790797 DOI: 10.1080/23320885.2022.2145962] [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: 02/07/2022] [Accepted: 11/04/2022] [Indexed: 12/23/2022]
Abstract
Calciphylaxis is characterized by extremely painful skin ulcers and develops in patients with or without severe kidney diseases. Herein, a female patient without renal dysfunction developed calciphylaxis in the right lower extremity and underwent successful surgical debridement and split-thickness skin grafting. Nevertheless, prompt wound evaluation and proper surgical approaches are essential.
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Affiliation(s)
- Minami Tamagake
- Department of Plastic and Reconstructive Surgery, School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Munetomo Nagao
- Department of Plastic and Reconstructive Surgery, School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Chieko Miura
- Department of Plastic and Reconstructive Surgery, School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Yoshimichi Imai
- Department of Plastic and Reconstructive Surgery, School of Medicine, Tohoku University, Sendai, Miyagi, Japan
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8
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Yang X, Liu Y, Xie X, Shi W, Si J, Li X, Zhang X, Liu B. Use of the optimized sodium thiosulfate regimen for the treatment of calciphylaxis in Chinese patients. Ren Fail 2022; 44:914-922. [PMID: 35634730 PMCID: PMC9154757 DOI: 10.1080/0886022x.2022.2081179] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Sodium thiosulfate (STS) can be used to treat patients diagnosed with calciphylaxis, which is a rare life-threatening syndrome. However, our patients treated with the recommended STS regimen presented with serious adverse events, resulting in treatment withdrawal. Then an optimized STS regimen was used to increase the tolerance of patients to STS and improve treatment continuation. The curative effect of the new regimen is not yet definite. Therefore, this study aimed to evaluate the response to the use of the optimized STS regimen for the treatment of calciphylaxis in Chinese patients during the first three courses of treatment. METHODS Demographic, clinical, and laboratory data were retrospectively collected on 31 calciphylaxis patients with chronic kidney disease (CKD) or end-stage kidney disease (ESKD) treated with the optimized STS regimen. The primary outcome was a clinical improvement. The secondary outcomes included survival rate and adverse events. RESULTS Twenty-five patients (over 80%) achieved clinical improvement considering improvement or nonspecific changes of skin lesions (80.65%) and pain relief (100%). Furthermore, 54.84% of patients did not experience any adverse events and none died from complications. During a median follow-up of 9 months (interquartile range 4‒19), 27 patients (87.10%) survived; additionally, 13 patients (41.94%) survived after a one-year follow-up period. CONCLUSION The optimized STS regimen is relatively safe, associated with satisfactory outcomes, and well tolerated by patients for short to medium treatment duration. Hence, it is a promising approach for the treatment of patients diagnosed with calciphylaxis.
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Affiliation(s)
- Xin Yang
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Yuqiu Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Xiaotong Xie
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Wen Shi
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Jiyi Si
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Xiaomin Li
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Xiaoliang Zhang
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China,CONTACT Xiaoliang Zhang Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Dingjiaqiao Road, 87th, Nanjing, 210009, China
| | - Bicheng Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
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Wickens O, Rengarajan S, Chinnadurai R, Ford I, Macdougall IC, Kalra PA, Sinha S. The Role of Iron in Calciphylaxis—A Current Review. J Clin Med 2022; 11:jcm11195779. [PMID: 36233647 PMCID: PMC9570530 DOI: 10.3390/jcm11195779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/20/2022] [Accepted: 09/26/2022] [Indexed: 11/25/2022] Open
Abstract
Calcific uraemic arteriolopathy (CUA), also known as calciphylaxis, is a rare and often fatal condition, frequently diagnosed in end-stage renal disease (ESRD) patients. Although exact pathogenesis remains unclear, iron supplementation is suggested as a potential risk factor. Iron and erythropoietin are the main stay of treatment for anaemia in ESRD patients. Few observational studies support the role of iron in the pathogenesis of calciphylaxis although data from the pivotal trial was not strongly supportive of this argument, i.e., no difference in incidence of calciphylaxis between the low-dose and high-dose iron treatment arms. Elevated levels of vascular cell adhesion molecules in association with iron excess were postulated to the pathogenesis of CUA by causing inflammation and calcification within the microvasculature. In-addition, oxidative stress generated because of iron deposition in cases of systemic inflammation, such as those seen in ESRD, may play a role in vascular calcification. Despite these arguments, a direct correlation between cumulative iron exposure with CUA incidence is not clearly demonstrated in the literature. Consequently, we do not have evidence to recommend iron reduction or cessation in ESRD patients that develop CUA.
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Affiliation(s)
- Olivia Wickens
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
| | - Sharmilee Rengarajan
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
| | - Rajkumar Chinnadurai
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow G12 8QQ, UK
| | - Iain C. Macdougall
- Department of Renal Medicine, King’s College Hospital, London SE5 9RS, UK
| | - Philip A. Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Smeeta Sinha
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
- Correspondence:
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Osonoi S, Hamaura K, Murakami H. A diabetic patient with finger gangrene. Eur J Intern Med 2022; 103:100-101. [PMID: 35606289 DOI: 10.1016/j.ejim.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/09/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Sho Osonoi
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan; Department of Diabetes and Endocrinology, Mutsu General Hospital, Aomori 035-0071, Japan.
| | - Kiho Hamaura
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Hiroshi Murakami
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan; Department of Diabetes and Endocrinology, Mutsu General Hospital, Aomori 035-0071, Japan
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11
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Liu Y, Yang C, Yang X, Xie X, Liu H, Zhang L, Ye J, Jiang D, Zhang X, Liu B. Prevalence and Clinical Characteristics of Calciphylaxis in Chinese Hemodialysis Patients. Front Med (Lausanne) 2022; 9:902171. [PMID: 35755071 PMCID: PMC9226545 DOI: 10.3389/fmed.2022.902171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background Calciphylaxis is a grievous life-threatening vascular disease that commonly affects dialysis population. This is the first epidemiological survey of calciphylaxis initiated in China. Methods In the cross-sectional survey, a stratified sampling method was used to select 24 dialysis centers in Jiangsu Province. The participants were all adult patients in each center who had been on hemodialysis for more than 6 months. Calciphylaxis patients were uniformly diagnosed based on characteristic skin lesions and histopathological features. Results A total of 3,867 hemodialysis patients (average age of 55.33 ± 13.89 years; 61.81% of males) were included. Forty eight cases were diagnosed with calciphylaxis, and prevalence was 1.24%. Among calciphylaxis patients, 33 cases were male, and the average age and median dialysis duration were 53.85 ± 15.17 years and 84.00 (48.00, 138.75) months, respectively. Skin biopsy was performed in 70.83% of calciphylaxis patients, and positive rate was 64.71%. Meanwhile, the positive rate of bone scintigraphy in the diagnosis of calciphylaxis was 62.5%. The prevalence of hyperparathyroidism in case group was as high as 72.92% with longer duration, and 42.86% had undergone parathyroidectomy. Multivariate analysis indicated that increased BMI, prolonged dialysis duration, warfarin therapy, hyperparathyroidism, diabetes, tumors, low serum albumin and high serum alkaline phosphatase levels were high-risk factors for calciphylaxis. Conclusions The prevalence of calciphylaxis in Chinese hemodialysis patients was 1.24% according to regional epidemiological survey, but its actual prevalence would be presumably far beyond present data. It's urgent to improve clinical understanding of calciphylaxis, and multifaceted diagnostic methods should be applied for early screening.
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Affiliation(s)
- Yuqiu Liu
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Canlin Yang
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xin Yang
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xiaotong Xie
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Hong Liu
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Liuping Zhang
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jianming Ye
- Department of Nephrology, The First People's Hospital of Kunshan, Suzhou, China
| | - Dongsheng Jiang
- Department of Nephrology, Taizhou People's Hospital, Taizhou, China
| | - Xiaoliang Zhang
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Bicheng Liu
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
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Rick J, Rrapi R, Chand S, Shinohara MM, Strowd L, Pasieka HB, Michelleti R, Kroshinsky D, Ortega-Loayza AG. Calciphylaxis: Treatment and Outlook CME Part II. J Am Acad Dermatol 2022; 86:985-992. [PMID: 35202773 DOI: 10.1016/j.jaad.2021.10.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Jonathan Rick
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Renajd Rrapi
- Harvard Medical School, Cambridge, Massachusetts, USA
| | | | | | | | - Helena B Pasieka
- Georgetown University School of Medicine, Washington, DC, USA; Uniformed Services University School of Medicine, Bethesda, MD, USA
| | - Robert Michelleti
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Gabel CK, Blum AE, François J, Chakrala T, Dobry AS, Garza-Mayers AC, Ko LN, Nguyen ED, Shah R, John JS, Nigwekar SU, Kroshinsky D. Clinical mimickers of calciphylaxis: A retrospective study. J Am Acad Dermatol 2021; 85:1520-1527. [PMID: 33744358 DOI: 10.1016/j.jaad.2021.03.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/25/2021] [Accepted: 03/06/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Calciphylaxis is an ischemic vasculopathy with high morbidity and mortality. Early and accurate diagnosis is critical to management of calciphylaxis. Clinical mimickers may contribute to delayed or misdiagnosis. OBJECTIVE To assess the rate and risk factors for misdiagnosis and to identify clinical mimickers of calciphylaxis. METHODS A retrospective medical record review was conducted of patients with calciphylaxis at a large urban tertiary care hospital between 2006 and 2018. RESULTS Of 119 patients diagnosed with calciphylaxis, 73.1% were initially misdiagnosed. Of patients not initially misdiagnosed, median time to diagnosis from initial presentation was 4.5 days (interquartile range, 1.0-23.3), compared to 33 days (interquartile range, 13.0-68.8) in patients who were initially misdiagnosed (P = .0002). The most common misdiagnoses were cellulitis (31.0%), unspecified skin infection (8.0%), and peripheral vascular disease (6.9%). Patients who were misdiagnosed frequently received at least 1 course of antibiotics. Patients with end-stage renal disease were less likely to be misdiagnosed than those without this disease (P = .001). LIMITATIONS Single-center, retrospective study. CONCLUSIONS Understanding the risk factors for misdiagnosis of calciphylaxis is an opportunity for further education concerning this rare disease.
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Affiliation(s)
- Colleen K Gabel
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Amy E Blum
- Harvard Medical School, Boston, Massachusetts
| | | | - Teja Chakrala
- Narayana Medical College and Hospital, Nellore, India
| | - Allison S Dobry
- Department of Dermatology, University of California, Irvine School of Medicine, Irvine, California
| | | | - Lauren N Ko
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Emily D Nguyen
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Radhika Shah
- Department of Dermatology, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jessica St John
- Department of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sagar U Nigwekar
- Department of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts.
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14
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Sánchez-Pujol M, Docampo Simón A, Illán Gambín F, Niveiro de Jaime M, Blanes Martínez M. Calciphylaxis: Risk Factors and Histologic Findings in a Case Series From a Tertiary Care Referral Hospital. ACTAS DERMO-SIFILIOGRAFICAS 2021. [DOI: 10.1016/j.adengl.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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15
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Sánchez-Pujol MJ, Docampo Simón A, Illán Gambín F, Niveiro de Jaime M, Blanes Martínez M. Calciphylaxis: Risk Factors and Histologic Findings in a Case Series From a Tertiary Care Referral Hospital. ACTAS DERMO-SIFILIOGRAFICAS 2021; 112:S0001-7310(21)00164-2. [PMID: 33939992 DOI: 10.1016/j.ad.2020.08.014] [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: 06/01/2020] [Revised: 08/19/2020] [Accepted: 08/22/2020] [Indexed: 11/29/2022] Open
Abstract
Recent years have seen important advances in our understanding of calciphylaxis, especially regarding newly identified risk factors and histologic findings that may aid diagnosis. This retrospective study of cases of calciphylaxis treated in our hospital in the last 13 years focuses on newly revealed aspects of this disease. We describe 16 patients (62.5% women; mean age, 67.9 years). In addition to advanced kidney disease (in 75% of our patients), other factors associated with the presence of calciphylaxis were a history of treatments related to phosphorus and calcium metabolism (75%) and anticoagulation (62.5%), usually with vitamin-K antagonists. Histology showed alterations in elastic fibers in only 25% of the biopsy specimens. Eleven of the patients died: sepsis was most often the cause.
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Affiliation(s)
- M J Sánchez-Pujol
- Servicio de Dermatología, Hospital General Universitario de Alicante. Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España.
| | - A Docampo Simón
- Servicio de Dermatología, Hospital General Universitario de Alicante. Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
| | - F Illán Gambín
- Servicio de Anatomía Patológica, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
| | - M Niveiro de Jaime
- Servicio de Anatomía Patológica, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
| | - M Blanes Martínez
- Servicio de Dermatología, Hospital General Universitario de Alicante. Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
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16
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Gonzalez DE, Foresto RD, Maldonado ALS, Padilha WSC, Roberto FB, Pereira MEVDC, Durão Junior MDS, Carvalho AB. Multiple extremity necrosis in fatal calciphylaxis: Case report. J Bras Nefrol 2021; 43:274-278. [PMID: 32645129 PMCID: PMC8257280 DOI: 10.1590/2175-8239-jbn-2020-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/04/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The clinical impact of vascular calcification is well established in the context of cardiovascular morbidity and mortality, but other clinical syndromes, such as calciphylaxis, although less frequent, have a significant impact on chronic kidney disease. METHODS Case report of a 27-year-old woman, who had complained of bilateral pain in her toes for 3 days, with the presence of small necrotic areas in the referred sites. She had a history of type 1 diabetes (25 years ago), with chronic kidney disease, on peritoneal dialysis, in addition to rheumatoid arthritis. She was admitted to the hospital, which preceded the current condition, due to exacerbation of rheumatoid arthritis, evolving with intracardiac thrombus due to venous catheter complications, when she started using warfarin. Ischemia progressed to her feet, causing the need for bilateral amputations. Her chirodactyls were also affected. Thrombophilia, vasculitis, endocarditis or other embolic sources were investigated and discarded. Her pathology report evidenced skin necrosis and superficial soft parts with recent arterial thrombosis, and Monckeberg's medial calcification. We started treatment with bisphosphonate and sodium thiosulfate, conversion to hemodialysis and replacement of warfarin with unfractionated heparin. Despite all the therapy, the patient died after four months of evolution. DISCUSSION Calciphylaxis is a rare microvasculature calcification syndrome that results in severe ischemic injuries. It has pathogenesis related to the mineral and bone disorder of chronic kidney disease combined with the imbalance between promoters and inhibitors of vascular calcification, with particular importance to vitamin K antagonism. CONCLUSION The preventive strategy is fundamental, since the therapy is complex with poorly validated effectiveness.
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Affiliation(s)
- Diego Ennes Gonzalez
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Hospital do Rim, São Paulo, SP, Brasil
| | - Renato Demarchi Foresto
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Hospital do Rim, São Paulo, SP, Brasil
| | - Ana Luiza Santos Maldonado
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Hospital do Rim, São Paulo, SP, Brasil
| | | | - Fernanda Badiani Roberto
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Hospital do Rim, São Paulo, SP, Brasil
| | | | - Marcelino de Souza Durão Junior
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Departamento de Medicina, São Paulo, SP, Brasil
| | - Aluizio Barbosa Carvalho
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Departamento de Medicina, São Paulo, SP, Brasil
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17
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López Martínez JA, Rodríguez Valiente M, Fuente-Mora C, García-Hernández AM, Cánovas Sanchís S, Fernández Pascual CJ. Use of cryopreserved human amniotic membrane in the treatment of skin ulcers secondary to calciphylaxis. Dermatol Ther 2021; 34:e14769. [PMID: 33421241 DOI: 10.1111/dth.14769] [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: 09/24/2020] [Revised: 11/29/2020] [Accepted: 12/30/2020] [Indexed: 11/29/2022]
Abstract
Calciphylaxis is a rare condition characterized by skin ulceration and necrosis as a result of vascular calcification of the small and medium blood vessels of skin and subcutaneous tissues. It mainly occurs in patients with advanced chronic kidney disease and sometimes leads to complications with a fatal outcome. In this report, we describe the case of a 67-year-old male patient with end stage renal disease presenting painful skin ulcers on his lower limbs. The lesions had progressively grown and were associated to severe pain and decreased quality of life. The ulcers did not respond to conventional treatments and the patient underwent skin biopsy of these lesions obtaining anatomopathological findings compatible with calciphylaxis. In this report, we present an innovative treatment for skin ulcers secondary to calciphylaxis using cryopreserved amniotic membrane (AM) as a dressing in order to promote epithelialization of the wounds. After four applications, healing of the main ulcer and reduction in pain was achieved. In summary, applying cryopreserved AM probed to be a promising strategy to reduce pain and to enhance epithelialization and healing of chronic non-responsive ulcers in calciphylaxis.
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Affiliation(s)
- José Antonio López Martínez
- Department of Plastic Surgery and Burns Unit, Clinical University Hospital "Virgen de la Arrixaca", Biomedical Research Institute of Murcia ("Instituto Murciano de Investigación Biosanitaria", IMIB), Murcia, Spain
| | - Mónica Rodríguez Valiente
- Department of General Surgery, Complex wounds and Diabetic Foot Unit, Clinical University "Hospital Virgen de la Arrixaca", Biomedical Research Institute of Murcia ("Instituto Murciano de Investigación Biosanitaria", IMIB), Murcia, Spain
| | - Cristina Fuente-Mora
- Biomedical Research Institute of Murcia ("Instituto Murciano de Investigación Biosanitaria", IMIB), Clinical University Hospital "Virgen de la Arrixaca", Murcia, Spain
| | - Ana María García-Hernández
- Cell Therapy Unit, Clinical University Hospital "Virgen de la Arrixaca", Biomedical Research Institute of Murcia ("Instituto Murciano de Investigación Biosanitaria", IMIB), Murcia, Spain
| | - Sergio Cánovas Sanchís
- Department of Plastic Surgery and Burns Unit, Clinical University Hospital "Virgen de la Arrixaca", Biomedical Research Institute of Murcia ("Instituto Murciano de Investigación Biosanitaria", IMIB), Murcia, Spain
| | - Clemente José Fernández Pascual
- Department of Plastic Surgery and Burns Unit, Clinical University Hospital "Virgen de la Arrixaca", Biomedical Research Institute of Murcia ("Instituto Murciano de Investigación Biosanitaria", IMIB), Murcia, Spain
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18
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Macklis P, Chung C, Kaffenberger B. Calciphylaxis associated with the fibroblast growth factor receptor inhibitor erdafitinib. JAAD Case Rep 2020; 7:125-127. [PMID: 33426250 PMCID: PMC7777177 DOI: 10.1016/j.jdcr.2020.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Paul Macklis
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Catherine Chung
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Department of Internal Medicine, Division of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Benjamin Kaffenberger
- Department of Internal Medicine, Division of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
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19
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Tanaka Y, Ooike M, Watanabe K, Horiuchi N, Kobayashi Y. Severe calcification of systemic blood vessel walls caused by continuous hypercalcemia in a cat with congenital hypothyroidism. J Vet Med Sci 2020; 82:1506-1510. [PMID: 32879233 PMCID: PMC7653323 DOI: 10.1292/jvms.20-0391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
A 97-day-old male Japanese domestic cat was diagnosed as congenital hypothyroidism.
During the treatment, continuous hypercalcemia was detected. Although fluid therapy was
performed, the cat died at the age of 1785 days. At autopsy, both parathyroid glands were
enlarged, and elastic arterial walls were increased in thickness and hardness.
Histopathological examination revealed hyperplasia of both parathyroid glands and
interstitial fibrosis of bilateral kidneys. Severe calcification of the tunica media and
tunica externa in systemic elastic and muscular arteries were also observed. These
calcifications were considered to be due to renal secondary hyperparathyroidism. In the
present case, hypothyroidism might have caused hyperparathyroidism through renal failure.
In veterinary medicine, this is the first reported case of hypothyroidism accompanied with
hyperparathyroidism.
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Affiliation(s)
- Yusuke Tanaka
- Department of Veterinary Medicine, Obihiro University of Agriculture and Veterinary Medicine, Nishi 2-11, Inada-cho, Obihiro, Hokkaido 080-8555, Japan
| | - Michio Ooike
- Ooike Animal Hospital, Minami 5-46-21, Nishi 19, Obihiro, Hokkaido 080-8555, Japan
| | - Kenichi Watanabe
- Department of Veterinary Medicine, Obihiro University of Agriculture and Veterinary Medicine, Nishi 2-11, Inada-cho, Obihiro, Hokkaido 080-8555, Japan
| | - Noriyuki Horiuchi
- Department of Veterinary Medicine, Obihiro University of Agriculture and Veterinary Medicine, Nishi 2-11, Inada-cho, Obihiro, Hokkaido 080-8555, Japan
| | - Yoshiyasu Kobayashi
- Department of Veterinary Medicine, Obihiro University of Agriculture and Veterinary Medicine, Nishi 2-11, Inada-cho, Obihiro, Hokkaido 080-8555, Japan
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20
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Tezuka M, Mizusawa H, Tsukada M, Mimura Y, Shimizu T, Kobayashi A, Takahashi Y, Maejima T. Severe necrosis of the glans penis associated with calciphylaxis treated by partial penectomy. IJU Case Rep 2020; 3:133-136. [PMID: 33392472 PMCID: PMC7770588 DOI: 10.1002/iju5.12166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/23/2020] [Accepted: 04/28/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Calciphylaxis is characterized by marked vascular calcification and painful skin ulcers, and it has a poor prognosis. CASE PRESENTATION The patient was a 72-year-old male. He was referred for penile pain. He had a 4-year history of dialysis therapy under a diagnosis of diabetic nephropathy. Black and yellow necrosis was observed involving the entire glans, accompanying severe pain. Computed tomography revealed marked calcification involving the thoracoabdominal aorta to iliac arteries, the dorsal artery of the penis and the corpus cavernosum, leading to a diagnosis of calciphylaxis. Penile pain gradually exacerbated and partial penectomy was performed. After surgery, penile pain promptly subsided. Pathological examination confirmed marked calcification of the microvascular wall and narrowing of the lumen. CONCLUSION We reviewed 15 Japanese patients with calciphylaxis who had undergone penile surgery. Surgical treatment was considered to be effective at relieving penile pain, but the prognosis remained poor.
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Affiliation(s)
- Masato Tezuka
- Department ofUrologyNational Hospital Organization Shinshu Ueda Medical CenterUedaNaganoJapan
| | - Hiroya Mizusawa
- Department ofUrologyNational Hospital Organization Shinshu Ueda Medical CenterUedaNaganoJapan
| | - Manabu Tsukada
- Department ofUrologyNational Hospital Organization Shinshu Ueda Medical CenterUedaNaganoJapan
| | - Yuji Mimura
- Department ofUrologyNational Hospital Organization Shinshu Ueda Medical CenterUedaNaganoJapan
| | - Takaaki Shimizu
- Department ofUrologyNational Hospital Organization Shinshu Ueda Medical CenterUedaNaganoJapan
| | - Aya Kobayashi
- Department ofDermatologyNational Hospital Organization Shinshu Ueda Medical CenterUedaNaganoJapan
| | - Yasufumi Takahashi
- Department ofNephrologyNational Hospital Organization Shinshu Ueda Medical CenterUedaNaganoJapan
| | - Toshitaka Maejima
- Department ofPathology and Laboratory MedicineNational Hospital Organization Shinshu Ueda Medical CenterUedaNaganoJapan
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21
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Colboc H, Moguelet P, Bazin D, Carvalho P, Dillies AS, Chaby G, Maillard H, Kottler D, Goujon E, Jurus C, Panaye M, Frochot V, Letavernier E, Daudon M, Lucas I, Weil R, Courville P, Monfort JB, Chasset F, Senet P. Localization, Morphologic Features, and Chemical Composition of Calciphylaxis-Related Skin Deposits in Patients With Calcific Uremic Arteriolopathy. JAMA Dermatol 2020; 155:789-796. [PMID: 31116362 DOI: 10.1001/jamadermatol.2019.0381] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Calcific uremic arteriolopathy (CUA), a rare, potentially fatal, disease with calcium deposits in skin, mostly affects patients with end-stage renal disease who are receiving dialysis. Chemical composition and structure of CUA calcifications have been poorly described. Objectives To describe the localization and morphologic features and determine the precise chemical composition of CUA-related calcium deposits in skin, and identify any mortality-associated factors. Design, Setting, and Participants A retrospective, multicenter cohort study was conducted at 7 French hospitals including consecutive adults diagnosed with CUA between January 1, 2006, and January 1, 2017, confirmed according to Hayashi clinical and histologic criteria. Patients with normal renal function were excluded. For comparison, 5 skin samples from patients with arteriolosclerosis and 5 others from the negative margins of skin-carcinoma resection specimens were also analyzed. Main Outcomes and Measures Localization and morphologic features of the CUA-related cutaneous calcium deposits were assessed with optical microscopy and field-emission-scanning electron microscopy, and the chemical compositions of those deposits were evaluated with μ Fourier transform infrared spectroscopy, Raman spectroscopy, and energy dispersive radiographs. Results Thirty-six patients (median [range] age, 64 [33-89] years; 26 [72%] female) were included, and 29 cutaneous biopsies were analyzed. Calcific uremic arteriolopathy and arteriolosclerosis skin calcifications were composed of pure calcium-phosphate apatite. Calcific uremic arteriolopathy vascular calcifications were always circumferential, found in small to medium-sized vessels, with interstitial deposits in 22 (76%) of the samples. A thrombosis, most often in noncalcified capillary lumens in the superficial dermis, was seen in 5 samples from patients with CUA. Except for calcium deposits, the vessel structure of patients with CUA appeared normal, unlike thickened arteriolosclerotic vessel walls. Twelve (33%) patients died of CUA. Conclusions and Relevance Calcific uremic arteriolopathy-related skin calcifications were exclusively composed of pure calcium-phosphate apatite, localized circumferentially in small to medium-sized vessels and often associated with interstitial deposits, suggesting its pathogenesis differs from that of arteriolosclerosis. Although the chemical compositions of CUA and arteriolosclerosis calcifications were similar, the vessels' appearances and deposit localizations differed, suggesting different pathogenetic mechanisms.
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Affiliation(s)
- Hester Colboc
- Service Plaies et Cicatrisation, Sorbonne Université, Hôpital Rothschild, Paris, France.,Institut National de la Santé et de la Recherche Médicale (INSERM), Unité Mixte de Recherche (UMR) S 1155, Paris, France
| | - Philippe Moguelet
- Anatomie et Cytologie Pathologiques, Sorbonne Université, Hôpital Tenon, Paris, France
| | - Dominique Bazin
- Centre National de la Recherche Scientifique (CNRS), Laboratoire de Chimie Physique, Ba340, Université Paris XI, Orsay, France
| | - Priscille Carvalho
- Service de Dermatologie, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Anne-Sophie Dillies
- Service de Dermatologie, Centre Hospitalier Universitaire d'Amiens, Amiens, France
| | - Guillaume Chaby
- Service de Dermatologie, Centre Hospitalier Universitaire d'Amiens, Amiens, France
| | - Hervé Maillard
- Service de Dermatologie, Centre Hospitalier du Mans, Le Mans, France
| | - Diane Kottler
- Service de Dermatologie, Hôpital Bichat, Paris, France
| | - Elisa Goujon
- Service de Dermatologie, Centre Hospitalier de Chalon-sur-Saône, Chalon-sur-Saône, France
| | - Christine Jurus
- Service de Médecine Vasculaire, Clinique du Tonkin, Villeurbanne, France
| | - Marine Panaye
- Service de Médecine Vasculaire, Clinique du Tonkin, Villeurbanne, France
| | - Vincent Frochot
- Service des Explorations Fonctionnelles Multidisciplinaires, Sorbonne Université, Hôpital Tenon, Paris, France
| | - Emmanuel Letavernier
- Institut National de la Santé et de la Recherche Médicale (INSERM), Unité Mixte de Recherche (UMR) S 1155, Paris, France.,Sorbonne Université, Hôpital Tenon, Service des Explorations Fonctionnelles Multidisciplinaires, Paris
| | - Michel Daudon
- Service des Explorations Fonctionnelles Multidisciplinaires, Sorbonne Université, Hôpital Tenon, Paris, France
| | - Ivan Lucas
- Sorbonne Universités, Unité Mixte de Recherche (UMR) 8235, Paris, France
| | - Raphaël Weil
- Centre National de la Recherche Scientifique (CNRS), Laboratoire de Physique des Solides, Ba510, Université Paris XI, Orsay, France
| | - Philippe Courville
- Centre Hospitalier Universitaire de Rouen, Anatomie et Cytologie Pathologiques, Rouen, France
| | | | - François Chasset
- Service de Dermatologie, Sorbonne Université, Hôpital Tenon, Paris, France
| | - Patricia Senet
- Service de Dermatologie, Sorbonne Université, Hôpital Tenon, Paris, France
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Abstract
Over the last decades, the association between vascular calcification (VC) and all-cause/cardiovascular mortality, especially in patients with high atherogenic status, such as those with diabetes and/or chronic kidney disease, has been repeatedly highlighted. For over a century, VC has been noted as a passive, degenerative, aging process without any treatment options. However, during the past decades, studies confirmed that mineralization of the arteries is an active, complex process, similar to bone genesis and formation. The main purpose of this review is to provide an update of the existing biomarkers of VC in serum and develop the various pathogenetic mechanisms underlying the calcification process, including the pivotal roles of matrix Gla protein, osteoprotegerin, bone morphogenetic proteins, fetuin-a, fibroblast growth-factor-23, osteocalcin, osteopontin, osteonectin, sclerostin, pyrophosphate, Smads, fibrillin-1 and carbonic anhydrase II.
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23
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Gaisne R, Péré M, Menoyo V, Hourmant M, Larmet-Burgeot D. Calciphylaxis epidemiology, risk factors, treatment and survival among French chronic kidney disease patients: a case-control study. BMC Nephrol 2020; 21:63. [PMID: 32101140 PMCID: PMC7045437 DOI: 10.1186/s12882-020-01722-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 02/11/2020] [Indexed: 11/10/2022] Open
Abstract
Background Calcific Uremic Arteriolopathy (CUA) is a rare disease, causing painful skin ulcers in patients with end stage renal disease. Recommendations for CUA management and treatment are lacking. Methods We conducted a retrospective cohort study on CUA cases identified in western France, in order to describe its management and outcome in average clinical practices. Selection was based on the Hayashi diagnosis criteria (2013) extended to patients with eGFR < 30 mL/min/1.73m2. Dialyzed CUA cases were compared with 2 controls, matched for age, gender, region of treatment and time period. Results Eighty-nine CUA cases were identified between 2006 and 2016, including 19 non dialyzed and 70 dialyzed patients. Females with obesity (55.1%) were predominant. Bone mineral disease abnormalities, inflammation and malnutrition (weight loss, serum albumin decrease) preceded CUA onset for 6 months. The multimodal treatment strategy included wound care (98.9%), antibiotherapy (77.5%), discontinuation of Vitamin K antagonists (VKA) (70.8%) and intravenous sodium thiosulfate (65.2%). 40.4% of the patients died within the year after lesion onset, mainly under palliative care. Surgical debridement, distal CUA, localization to the lower limbs and non calcium-based phosphate binders were associated with better survival. Risks factors of developing CUA among dialysis patients were obesity, VKA, weight loss, serum albumin decrease or high serum phosphate in the 6 months before lesion onset. Conclusion CUA involved mainly obese patients under VKA. Malnutrition and inflammation preceded the onset of skin lesions and could be warning signs among dialysis patients at risk. Trial registration ClinicalTrials.gov identifier NCT02854046, registered August 3, 2016.
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Affiliation(s)
- Raphaël Gaisne
- Department of Nephrology and Immunology, Institute of Transplantation Urology and Nephrology, Centre Hospitalier Universitaire de Nantes, Nantes, France. .,Service de Néphrologie et Immunologie Clinique, Centre Hospitalier Universitaire de Nantes, 30, bd Jean Monnet 44093, Nantes, Cedex 01, France.
| | - Morgane Péré
- Biostatistician, Direction de la Recherche, Plateforme de Méthodologie et Biostatistiques, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | | | - Maryvonne Hourmant
- Department of Nephrology and Immunology, Institute of Transplantation Urology and Nephrology, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - David Larmet-Burgeot
- Department of Nephrology and Immunology, Institute of Transplantation Urology and Nephrology, Centre Hospitalier Universitaire de Nantes, Nantes, France.,Department of Nephrology, Centre Hospitalier de Saint Nazaire, St Nazaire, France
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24
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Róbert L, Kiss N, Medvecz M, Kuroli E, Sárdy M, Hidvégi B. Epidemiology and Treatment of Calcinosis Cutis: 13 Years of Experience. Indian J Dermatol 2020; 65:105-111. [PMID: 32180595 PMCID: PMC7059479 DOI: 10.4103/ijd.ijd_527_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Calcinosis cutis is a rare condition associated with different diseases, which is difficult to manage. Aims and Objectives: In this retrospective study, the epidemiology of calcinosis cutis and the effectiveness of various treatment regimens in its management were assessed in a single center. Materials and Methods: The data of 34 patients suffering from calcinosis cutis (male:female = 12:22; mean age = 48.6 ± 18.6 years) treated at our department between 2003 and 2016 were analyzed retrospectively. Results: Dystrophic, idiopathic, metastatic subtype, and calciphylaxis occurred in 70.6%, 11.8%, 5.9%, and 11.8% of the cases, respectively. Underlying diseases of dystrophic calcinosis included autoimmune connective tissue disease, skin trauma, cutaneous neoplasm, and inherited disorder in 58.3%, 20.8%, 12.5%, and 8.3% of the cases, respectively. Extremities were most frequently affected (n = 18). In the management, diltiazem was most frequently used in monotherapy with partial response in five of eight cases. Other drugs in monotherapy or in combination were administered in single cases. Surgical treatment resulted in least partial response in all of the cases followed (n = 7). Conclusion: Dystrophic was the most common subtype and autoimmune connective tissue disease was the most frequent underlying disease. We conclude that lower doses of diltiazem have only partial efficiency, and surgical therapy is at least partially effective in localized calcinosis.
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Affiliation(s)
- Lili Róbert
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Norbert Kiss
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Márta Medvecz
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Enikő Kuroli
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Miklós Sárdy
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Bernadett Hidvégi
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
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25
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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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26
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Mima Y, Wada Y, Shikida Y, Hamada T, Kanazawa N, Iida A, Sugiyama M, Shibata T. Rapid regression of calciphylaxis in a hemodialysis patient after intensive management of disturbance of calcium and phosphate metabolism: a case report with literature review. RENAL REPLACEMENT THERAPY 2019. [DOI: 10.1186/s41100-019-0216-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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27
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Kang SJW, Madhan K. Gastrointestinal Manifestations in a Patient with Calciphylaxis: A Case Report. Case Rep Nephrol Dial 2019; 9:119-125. [PMID: 31616672 PMCID: PMC6787423 DOI: 10.1159/000502436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/29/2019] [Indexed: 11/19/2022] Open
Abstract
Calciphylaxis is a rare condition usually seen in patients with significant renal disease, affecting 1-4' of patients undergoing haemodialysis. Although the disease usually manifests as lesions in the subcutaneous tissue, there have been rare occurrences of calciphylaxis presenting as lesions in the gastrointestinal tract, leading to complications of bowel necrosis and haemorrhage. In view of this, we report the case of suspected gastrointestinal tract calciphylaxis in a 63-year-old patient with end-stage kidney disease (ESKD) who presented with painful swelling in the medial and lateral aspect of both thighs. Physical examination revealed extensive tender subcutaneous tissue nodules suggestive of calciphylaxis. During her hospital admission, the patient developed an episode of gastrointestinal bleeding requiring multiple blood transfusions. A computed tomography scan of the abdomen showed widespread vascular calcification within the aorta and its somatic and visceral branches as well as a splenic infarct. Oesophagogastroduodenoscopy revealed a large gastric ulcer, while flexible sigmoidoscopy revealed necrosis of the rectal mucosa. She was started on vitamin D supplementation and intravenous sodium thiosulphate during each dialysis session. She clinically improved with no further gastrointestinal haemorrhage and partial resolution of her rectal necrosis and was transferred to a rehabilitation facility for further care and discharge planning.
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Affiliation(s)
- Shaun Jia Wei Kang
- Department of Internal Medicine, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Krishan Madhan
- Department of Renal Medicine, Wide Bay Hospital and Health Service, Bundaberg, Queensland, Australia
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28
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Kumakura S, Nakamichi T, Suzuki N, Yamakage S, Ishikawa A, Fujikura E, Sato S, Aoki T, Musha H, Kikuchi K, Nagasawa T, Sato H, Ito S, Miyazaki M. A Catastrophic Case of Idiopathic Cholesterol Crystal Embolism with Multiple Lethal Complications: A Labyrinth Underneath the Diagnosis of Skin Ulcers in Chronic Kidney Disease Patients. Intern Med 2019; 58:1753-1758. [PMID: 30713332 PMCID: PMC6630139 DOI: 10.2169/internalmedicine.2378-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 66-year-old man was admitted to our hospital because of multiple refractory skin ulcers. Based on his severe systemic arterial calcification and severe calcium-phosphate imbalance due to severe kidney dysfunction, we initially considered calciphylaxis. However, a skin biopsy provided a diagnosis of cholesterol crystal embolization. Although we initiated hemodialysis, steroid treatment, and low-density lipoprotein-cholesterol apheresis, he died of multiple intestinal perforation. An autopsy showed cholesterol crystals occluding multiple organ arterioles. This case suggests that skin ulcers in patients with chronic kidney disease may be an important diagnostic hallmark and may be associated with several serious diseases.
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Affiliation(s)
- Satoshi Kumakura
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
- Division of Blood Purification, Tohoku University Hospital, Japan
| | - Takashi Nakamichi
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Nonoka Suzuki
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Shu Yamakage
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Ayako Ishikawa
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Emi Fujikura
- Division of Blood Purification, Tohoku University Hospital, Japan
| | - Satoko Sato
- Department of Pathology, Tohoku University Hospital, Japan
| | - Takeshi Aoki
- Department of Surgery, Tohoku University Graduate School of Medicine, Japan
| | - Hiroaki Musha
- Department of Surgery, Tohoku University Graduate School of Medicine, Japan
| | - Katsuko Kikuchi
- Department of Dermatology, Tohoku University Graduate School of Medicine, Japan
| | - Tasuku Nagasawa
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroshi Sato
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Mariko Miyazaki
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
- Division of Blood Purification, Tohoku University Hospital, Japan
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29
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Chiriac A, Grosu OM, Terinte C, Perţea M. Calcific uremic arteriolopathy (calciphylaxis) calls into question the validity of guidelines of diagnosis and treatment. J DERMATOL TREAT 2019; 31:545-548. [PMID: 31075991 DOI: 10.1080/09546634.2019.1618435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Calciphylaxis is associated with end-stage renal failure or kidney transplant, although, cases of non-uremic calciphylaxis have been reported. It is a rare disorder, with high mortality, characterized by vascular calcification within cutaneous vessels; vascular calcification can occur in other organs, besides skin, like heart, lung, or pancreas, which is named visceral calciphylaxis.Objective: The purpose was to review current knowledge regarding diagnosis and therapeutic approach to cutaneous calciphylaxis.Methods: A literature review has been conducted associated to word "calciphylaxis".Results: The diagnosis is based mainly on clinical features and histologic findings. Therapeutic options are still controversial.Conclusions: Cutaneous calciphylaxis is a puzzling disease, with a challenging diagnosis, and a complex treatment, which requires a multidisciplinary team and expertise.
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Affiliation(s)
- Anca Chiriac
- Department of Dermatology, Nicolina Medical Center, Apollonia University, Iaşi, Romania.,Department of Dermato-Physiology, Apollonia University, Iaşi, Romania
| | - Oxana-Madalina Grosu
- University of Medicine and Pharmacy "Grigore T. Popa", Iaşi, Romania.,Clinic of Plastic Surgery, Emergency Hospital "Sf. Spiridon", Iaşi, Romania
| | - Cristina Terinte
- Department of Pathology, Regional Institute of Oncology, Iaşi, Romania
| | - Mihaela Perţea
- University of Medicine and Pharmacy "Grigore T. Popa", Iaşi, Romania.,Clinic of Plastic Surgery, Emergency Hospital "Sf. Spiridon", Iaşi, Romania
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30
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Hepschke JL, Masselos K, Sandbach J, Fraser CL. Seeing the difference—Painless progressive vision loss in a vasculopath. Surv Ophthalmol 2019; 64:123-131. [DOI: 10.1016/j.survophthal.2017.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/11/2017] [Indexed: 02/01/2023]
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31
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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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32
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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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33
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Kawaji Q, Eller EB, Yee J, Lin JC. Digital gangrene and pneumatosis intestinalis associated with calciphylaxis. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2018; 4:133-135. [PMID: 29942902 PMCID: PMC6013295 DOI: 10.1016/j.jvscit.2018.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 02/11/2018] [Indexed: 12/04/2022]
Abstract
Reports of calciphylaxis or calcific uremic arteriolopathy associated with acral and gastrointestinal involvement are rare. We describe a 36-year-old white woman with end-stage renal disease on hemodialysis after failed kidney and pancreas transplantation who developed dry gangrene of bilateral digits, osteomyelitis, and small bowel ischemia within several months of each presentation. She had multiple débridements of a septic right ankle. Computed tomography angiography showed severe vascular calcification and pneumatosis intestinalis. She underwent intestinal resection for gangrenous small bowel. A multidisciplinary approach with aggressive medical and surgical management may improve survival. Our case and the literature confirm the high morbidity of patients with calciphylaxis and vascular complications. Careful follow-up remains necessary for diagnosis and management to prevent complication, infection, and death.
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Affiliation(s)
- Qingwen Kawaji
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, Mich
| | - Erik Brian Eller
- Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Mich
| | - Jerry Yee
- Division of Nephrology, Henry Ford Hospital, Detroit, Mich
| | - Judith C Lin
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, Mich
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34
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Ellis CL, O'Neill WC. Questionable specificity of histologic findings in calcific uremic arteriolopathy. Kidney Int 2018; 94:390-395. [PMID: 29885932 DOI: 10.1016/j.kint.2018.03.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 03/14/2018] [Accepted: 03/22/2018] [Indexed: 10/14/2022]
Abstract
A variety of criteria exist for histopathologic diagnosis of calciphylaxis, also known as calcific uremic arteriolopathy but data on their specificity are limited. To assess this, histologic findings of 38 skin biopsies performed for a suspicion of calcific uremic arteriolopathy were compared with histologic findings in skin obtained from healthy margins of 43 amputations in patients with end-stage renal disease (ESRD) without evidence of calcific uremic arteriolopathy. Abnormalities in small arteries or arterioles were present in 35% of amputation specimens and 55% of skin biopsies, and among these only thrombosis but not calcification was significantly more prevalent in skin biopsies. The prevalence of extravascular calcification did not differ. Vascular lesions were more common in skin biopsies from patients with high clinical suspicion of calcific uremic arteriolopathy (81%), significantly driven by increases in both calcification and thrombosis, compared to amputations (35%). The combination of medial calcification and thrombosis was six-fold more prevalent in high-suspicion skin biopsies than in amputation specimens. The location of affected vessels did not differ. In two autopsy cases, some but not all findings of involved skin were also present in uninvolved skin. Thus, histopathologic findings historically associated with calcific uremic arteriolopathy can also occur in viable tissue from unaffected patients with ESRD, calling into question the specificity of individual histologic findings for calcific uremic arteriolopathy. However, the combination of medial calcification and thrombosis was rare in unaffected patients and may provide a higher degree of specificity.
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Affiliation(s)
- Carla L Ellis
- Department of Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - W Charles O'Neill
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.
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35
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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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36
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Penn LA, Brinster N. Calciphylaxis with pseudoxanthoma elasticum-like changes: A case series. J Cutan Pathol 2017; 45:118-121. [DOI: 10.1111/cup.13075] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 10/21/2017] [Accepted: 10/26/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Lauren A. Penn
- The Ronald O. Perelman Department of Dermatology, Section of Dermatopathology; New York University; New York New York
| | - Nooshin Brinster
- The Ronald O. Perelman Department of Dermatology, Section of Dermatopathology; New York University; New York New York
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37
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Theodoropoulos KC, Papachristidis A, Papitsas M, Byrne J, Monaghan MJ. 3DTEE imaging of a descending aorta floating thrombus in a patient with calciphylaxis. Echocardiography 2017; 35:132-134. [PMID: 29226430 DOI: 10.1111/echo.13769] [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] [Indexed: 11/28/2022] Open
Abstract
We present a case of a 68-year-old man with calciphylaxis, who was found to have a floating thrombus in the descending aorta on a transesophageal echocardiogram. The use of 3D echocardiography demonstrated nicely the free motion of the thrombus, emerging from an atherosclerotic plaque in the descending aorta. Anticoagulation was started for thromboembolism prevention.
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Affiliation(s)
| | - Alexandros Papachristidis
- Department of Cardiology, King's College Hospital NHS Foundation Trust, King's College London, London, UK
| | - Michael Papitsas
- Department of Cardiology, King's College Hospital NHS Foundation Trust, King's College London, London, UK
| | - Jonathan Byrne
- Department of Cardiology, King's College Hospital NHS Foundation Trust, King's College London, London, UK
| | - Mark J Monaghan
- Department of Cardiology, King's College Hospital NHS Foundation Trust, King's College London, London, UK
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38
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Cassius C, Moguelet P, Monfort J, Fessi H, Michel P, Boulahia G, Cury K, Frances C, Senet P. Calciphylaxis in haemodialysed patients: diagnostic value of calcifications in cutaneous biopsy. Br J Dermatol 2017; 178:292-293. [DOI: 10.1111/bjd.15655] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- C. Cassius
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - P. Moguelet
- Department of Pathology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - J.B. Monfort
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - H. Fessi
- Department of Nephrology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - P.A. Michel
- Department of Nephrology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - G. Boulahia
- Department of Nephrology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - K. Cury
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - C. Frances
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - P. Senet
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
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39
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Hasegawa H. Clinical Assessment of Warfarin Therapy in Patients with Maintenance Dialysis-Clinical Efficacy, Risks and Development of Calciphylaxis. Ann Vasc Dis 2017; 10. [PMID: 29147170 PMCID: PMC5684169 DOI: 10.3400/avd.ra.17-00062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Recent years, multiple studies regarding clinical efficacy and risks of Warfarin therapy in dialysis patients have been reported, and not a few reports conclude that clinical advantage of Warfarin is questionable in dialysis patients. Conversely, its hemorrhagic risk might be a little more serious in dialysis patients comparing to non-dialysis patients. Basically, it is assumed that long-term administration of Warfarin accelerates the development of vascular athelosclerosis because of the abolished anti-calcification effect of Gla-protein activation by decreased vitamin K activity. This assumption is recently confirmed by multiple reports, suggesting that the Warfarin administration might be worse harmful than ever expected in dialysis patients who are essentially considered to have higher risk of calcification comparing to non-dialysis patients. In addition, it is recently well considered that the Warfarin administration would be a risk factor to cause Warfarin skin necrosis or calciphylaxis, therapy resistant ulcerative skin lesions, which are considered to be highly related to the Warfarin-induced transient hypercoagulable state or acceleration of calcification. Therefore, it is considered that the indication of Warfarin administration to dialysis patients should be carefully assessed. (This is a translation of Jpn J Vasc Surg 2017; 26: 83–90.)
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Affiliation(s)
- Hajime Hasegawa
- Department of Nephrology and Hypertension, and Blood Purification Center, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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40
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Campbell RA, Alzweri LM, Sopko NA, Macura KJ, Burnett AL. Penile Calciphylaxis: The Use of Radiological Investigations in the Management of a Rare and Challenging Condition. Urol Case Rep 2017; 13:113-116. [PMID: 28507910 PMCID: PMC5429139 DOI: 10.1016/j.eucr.2017.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/08/2017] [Indexed: 11/30/2022] Open
Abstract
Penile calciphylaxis is a rare phenomenon of penile necrosis observed in patients with hemodialysis-dependent end-stage renal failure. Multiple treatments have been proposed including conservative management, surgical debridement and penectomy; yet, the prognosis remains extremely poor. Here, we describe a patient with protracted resolution of dry gangrene of the glans, which failed conservative management of wound care and pain management. Radiological studies revealed extensive calcification of abdominal aorta and branching vessels including the penile arteries. Due to intolerable pain, the patient required total penectomy. Earlier surgical intervention guided by findings on radiological studies may improve quality of life in this population.
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Affiliation(s)
- Rebecca A Campbell
- Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106, USA
| | - Laith M Alzweri
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Nikolai A Sopko
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Katarzyna J Macura
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA.,Department of Radiology and Radiological Sciences, The Johns Hopkins School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Arthur L Burnett
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
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41
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Renner R, Dissemond J, Goerge T, Hoff N, Kröger K, Erfurt-Berge C. Analysis of the German DRG data for livedoid vasculopathy and calciphylaxis. J Eur Acad Dermatol Venereol 2017; 31:1884-1889. [DOI: 10.1111/jdv.14190] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/09/2017] [Indexed: 12/11/2022]
Affiliation(s)
- R. Renner
- Department of Dermatology; Universitätsklinikum Erlangen; Erlangen Germany
| | - J. Dissemond
- Department of Dermatology; University Hospital Essen; Essen Germany
| | - T. Goerge
- Department of Dermatology; University Hospital Münster; Münster Germany
| | - N. Hoff
- Department of Dermatology; University of Düsseldorf; Düsseldorf Germany
| | - K. Kröger
- Department of Vascular Medicine, Angiology; HELIOS Medical Center Krefeld LLC; Krefeld Germany
| | - C. Erfurt-Berge
- Department of Dermatology; Universitätsklinikum Erlangen; Erlangen Germany
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Oda T, Sawada Y, Yamaguchi T, Ohmori S, Omoto D, Haruyama S, Yoshioka M, Okada E, Nakamura M. Calciphylaxis following acute renal injury: a case and literature review. SPRINGERPLUS 2016; 5:1043. [PMID: 27462491 PMCID: PMC4940327 DOI: 10.1186/s40064-016-2740-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 07/01/2016] [Indexed: 12/04/2022]
Abstract
Background Calciphylaxis following acute renal failure is rare. Findings We report A 57-year-old male with an acute renal failure associated with necrotizing fasciitis. We also review the cases of calciphylaxis due to acute renal disorder further. Conclusions It should be kept in mind that calciphylaxis is observed in patient with not only chronic renal disease but also acute renal failure.
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Monegal A, Peris P, Alsina M, Colmenero J, Guañabens N. Development of multiorganic calciphylaxis during teriparatide, vitamin D, and calcium treatment. Osteoporos Int 2016; 27:2631-4. [PMID: 27010647 DOI: 10.1007/s00198-016-3571-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 03/14/2016] [Indexed: 12/13/2022]
Abstract
Non-uremic calciphylaxis is a severe rare disorder characterized by ischemic necrosis. Recently, three cases of cutaneous calciphylaxis have been described in the context of teriparatide treatment. We present a 51-year-old woman with alcoholic cirrhosis who developed multiorganic calciphylaxis shortly after starting teriparatide treatment associated with calcium and 25-hydroxyvitamin D supplements for severe osteoporosis. After lengthy care of the infectious complications and treatment with bisphosphonates and sodium thiosulfate progressive improvement was observed over a 3-year period. The time between the initiation of teriparatide and the development of calciphylaxis suggests that this agent may have been the triggering factor of this process. Nevertheless, other non-negligible risk factors for calciphylaxis such as alcoholic liver disease, obesity, and vitamin D treatment must also be considered in this patient. Considering the severity of this extremely rare clinical condition, better knowledge of the risk factors related to calciphylaxis development is mandatory.
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Affiliation(s)
- A Monegal
- Department of Rheumatology, Hospital Clínic. CIBERehd, University of Barcelona, C/Villarroel 170, Barcelona, 08036, Spain.
| | - P Peris
- Department of Rheumatology, Hospital Clínic. CIBERehd, University of Barcelona, C/Villarroel 170, Barcelona, 08036, Spain
| | - M Alsina
- Department Dermatology, Hospital Clínic. CIBERehd, University of Barcelona, Barcelona, Spain
| | - J Colmenero
- Department of Hepatology Unit, Hospital Clínic. CIBERehd, University of Barcelona, Barcelona, Spain
| | - N Guañabens
- Department of Rheumatology, Hospital Clínic. CIBERehd, University of Barcelona, C/Villarroel 170, Barcelona, 08036, Spain
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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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45
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Huilaja L, Turpeinen M, Tokola H, Kauma H, Tasanen K, Ikäheimo R. Warfarin-induced calciphylaxis in patients with normal renal function. J Clin Pharm Ther 2016; 41:449-452. [DOI: 10.1111/jcpt.12411] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 05/25/2016] [Indexed: 12/22/2022]
Affiliation(s)
- L. Huilaja
- Department of Dermatology; Oulu University Hospital; Oulu Finland
- PEDEGO Research Unit and MRC Oulu; University of Oulu; Oulu Finland
| | - M. Turpeinen
- Research Unit of Biomedicine and MRC Oulu; University of Oulu; Oulu Finland
- Administration Center; Oulu University Hospital; Oulu Finland
| | - H. Tokola
- Department of Pathology; Oulu University Hospital; Oulu Finland
- Department of Pathology; Cancer and Translational Medicine Research Unit; University of Oulu; Oulu Finland
| | - H. Kauma
- Department of Internal Medicine; Oulu University Hospital; Oulu Finland
| | - K. Tasanen
- Department of Dermatology; Oulu University Hospital; Oulu Finland
- PEDEGO Research Unit and MRC Oulu; University of Oulu; Oulu Finland
| | - R. Ikäheimo
- Department of Internal Medicine; Oulu University Hospital; Oulu Finland
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46
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Bover J, Ureña-Torres P, Lloret MJ, Ruiz C, DaSilva I, Diaz-Encarnacion MM, Mercado C, Mateu S, Fernández E, Ballarin J. Integral pharmacological management of bone mineral disorders in chronic kidney disease (part II): from treatment of phosphate imbalance to control of PTH and prevention of progression of cardiovascular calcification. Expert Opin Pharmacother 2016; 17:1363-73. [DOI: 10.1080/14656566.2016.1182985] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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47
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Ossorio-García L, Jiménez-Gallo D, Arjona-Aguilera C, Linares-Barrios M. Intralesional Sodium Thiosulfate to Treat Calciphylaxis. ACTAS DERMO-SIFILIOGRAFICAS 2016. [DOI: 10.1016/j.adengl.2016.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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48
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Morton LM, Phillips TJ. Wound healing and treating wounds. J Am Acad Dermatol 2016; 74:589-605; quiz 605-6. [DOI: 10.1016/j.jaad.2015.08.068] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/03/2015] [Accepted: 08/14/2015] [Indexed: 11/26/2022]
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49
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Sato R, Akimoto T, Imai T, Nakagawa S, Okada M, Miki A, Takeda S, Yamamoto H, Saito O, Muto S, Kusano E, Nagata D. Minimal Change Nephrotic Syndrome Sequentially Complicated by Acute Kidney Injury and Painful Skin Ulcers due to Calciphylaxis. Intern Med 2016; 55:3315-3320. [PMID: 27853075 PMCID: PMC5173500 DOI: 10.2169/internalmedicine.55.7180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Calciphylaxis is rare cutaneous manifestation associated with painful skin ulceration and necrosis. It primarily occurs in patients with end-stage chronic kidney disease. In this report, we would like to show our experience with a male patient presenting with minimal change nephrotic syndrome that was sequentially complicated by acute kidney injury and painful ulcerative cutaneous lesions due to calciphylaxis. There seemed to be several contributing factors, including a disturbance of the patient's mineral metabolism and the systemic use of glucocorticoids and warfarin. Various concerns regarding the diagnostic and therapeutic conundrums that were encountered in the present case are also discussed.
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Affiliation(s)
- Ryuta Sato
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Japan
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50
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Ossorio-García L, Jiménez-Gallo D, Arjona-Aguilera C, Linares-Barrios M. Intralesional Sodium Thiosulfate to Treat Calciphylaxis. ACTAS DERMO-SIFILIOGRAFICAS 2015; 107:359-62. [PMID: 26739119 DOI: 10.1016/j.ad.2015.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 09/27/2015] [Accepted: 10/04/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- L Ossorio-García
- Unidad de Gestión Clínica de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario Puerta del Mar, Cádiz, España.
| | - D Jiménez-Gallo
- Unidad de Gestión Clínica de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario Puerta del Mar, Cádiz, España
| | - C Arjona-Aguilera
- Unidad de Gestión Clínica de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario Puerta del Mar, Cádiz, España
| | - M Linares-Barrios
- Unidad de Gestión Clínica de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario Puerta del Mar, Cádiz, España
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