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Al-Khazraji Y, Al-Khazraji M, Oluaderounmu O, Quintanilla B. Progression of Skin Ulcer Secondary to Calciphylaxis in a Patient With End-Stage Renal Disease (ESRD) on Hemodialysis and the Therapeutic Approach. Cureus 2024; 16:e55161. [PMID: 38558589 PMCID: PMC10980508 DOI: 10.7759/cureus.55161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
Calciphylaxis is a rare and severe medical condition characterized by the calcification of small blood vessels and soft tissues, leading to tissue damage, skin ulcers, and intense pain. It most commonly affects individuals with underlying health conditions such as kidney disease, particularly end-stage renal disease (ESRD), and is associated with high mortality rates. Understanding the diagnosis and management of calciphylaxis is crucial for improving patient outcomes. Diagnosing calciphylaxis can be challenging due to its rarity and overlapping symptoms with other skin conditions. Healthcare professionals typically use a combination of clinical evaluation and diagnostic tests to reach a conclusive diagnosis. The management of calciphylaxis is multifaceted and typically involves a collaborative effort between various healthcare specialists, including nephrologists, dermatologists, and wound care experts. The primary goals of treatment are to alleviate pain, promote wound healing, address underlying causes, and prevent further complications.
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Gossett C, Suppadungsuk S, Krisanapan P, Tangpanithandee S, Thongprayoon C, Mao MA, Cheungpasitporn W. Sodium Thiosulfate for Calciphylaxis Treatment in Patients on Peritoneal Dialysis: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1306. [PMID: 37512116 PMCID: PMC10386543 DOI: 10.3390/medicina59071306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/08/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023]
Abstract
Limited data are available on the utilization of sodium thiosulfate (STS) treatment for calciphylaxis in peritoneal dialysis (PD) patients, while it is well-studied in hemodialysis (HD) patients. A systematic literature search was conducted using Ovid MEDLINE, EBM Reviews-Cochrane Central Register of Controlled Trials, and EBM Reviews-Cochrane Database of Systematic Reviews to identify reported cases of PD patients with calciphylaxis who received STS. The search covered the inception of the databases through August 2022. Across 19 articles, this review identified 30 PD patients with calciphylaxis who received STS. These included 15 case reports, 2 case series, and 2 cohort studies. The administration routes and doses varied depending on the study. For intravenous (IV) administration (n = 18), STS doses ranged from 3.2 g twice daily to 25 g three times weekly for 5 weeks to 8 months. Outcomes included 44% of patients experiencing successful wound healing, 6% discontinuing STS due to adverse effects, 67% transitioning to HD, and 50% dying from calciphylaxis complications. For intraperitoneal (IP) administration (n = 5), STS doses ranged from 12.5 to 25 g three to four times weekly for 12 h to 3 months. Results showed 80% of patients achieving successful wound healing, 80% discontinuing STS due to adverse effects, 40% transitioning to HD, and 20% dying from IP STS-related chemical peritonitis. In cases where patients switched from IV to IP STS (n = 3), doses ranged from 12.5 to 25 g two to three times weekly for 2.5 to 5 months. Among them, 67% experienced successful wound healing, while 33% died from sepsis. Two cases utilized oral STS at a dose of 1500 mg twice daily for 6 and 11 months, resulting in successful wound healing without adverse effects or need for HD. However, one patient (50%) died due to small bowel obstruction. This systematic review provides an overview of STS treatment for PD patients with calciphylaxis. Although successful treatment cases exist, adverse effects were significant. Further research, including larger clinical studies and pharmacokinetic data, is necessary to establish the optimal route, dose, and efficacy of STS in PD patients.
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Affiliation(s)
- Christy Gossett
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
| | - Supawadee Suppadungsuk
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10400, Thailand
| | - Pajaree Krisanapan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine Thammasat University, Pathum Thani 12120, Thailand
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10400, Thailand
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL 32224, USA
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Assessment of outcomes of calciphylaxis. J Am Acad Dermatol 2020; 85:1057-1064. [PMID: 33130181 DOI: 10.1016/j.jaad.2020.10.067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Calciphylaxis is a rare thrombotic vasculopathy characterized by high morbidity and mortality. There is a paucity of studies examining longitudinal outcomes. OBJECTIVE To assess mortality, days spent in the hospital, and amputations in patients with calciphylaxis. METHODS A retrospective medical record review was conducted in 145 patients diagnosed with calciphylaxis at an urban tertiary care hospital from January 2006 to December 2018. RESULTS Six-month mortality was 37.2%, and 1-year mortality was 44.1%. Patients with nephrogenic calciphylaxis had worse survival than those with nonnephrogenic calciphylaxis (P = .007). This difference in survival disappeared when limiting mortality to deaths due to calciphylaxis. Age (P = .003) and end-stage renal disease (P = .01) were risk factors associated with 1-year mortality. Diabetes mellitus was associated with greater total hospitalization days (coefficient, 1.1; 95% confidence interval, 1.01-1.4); bedside debridement was associated with fewer hospitalization days (coefficient, 0.8; 95% confidence interval, 0.7-0.9). Amputations were not associated with any of the examined risk factors. The use of warfarin followed by a transition to nonwarfarin anticoagulation was associated with decreased hazard of death (P = .01). LIMITATIONS Retrospective nature. CONCLUSIONS Calciphylaxis remains a complex, heterogeneous disease. Mortality is lower in patients with nonnephrogenic disease. These findings may be incorporated during discussions regarding the goals of care to facilitate informed shared decision making.
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Calciphylaxis: Diagnostic and Treatment Advances for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00316-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Liu S, Zhang R, Lu X. The Impact of Individuals' Attitudes Toward Health Websites on Their Perceived Quality of Health Information: An Empirical Study. Telemed J E Health 2018; 25:1099-1107. [PMID: 30585763 DOI: 10.1089/tmj.2018.0217] [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: 11/13/2022] Open
Abstract
Background: A growing number of patients have increasingly used health websites to search and gather health information. Nevertheless, few studies have focused on the driving factors of internet health information quality from the perspective of psychology. Accordingly, this study explores how the attitudes of individuals toward health websites affect their perceived quality of internet health information through the mediation of seeking behavior on treatment information by employing regulatory focus theory. Materials and Methods: We defined six hypotheses that both trust in health websites and expectancy of health websites have a positive impact on emerging and conservative treatment-related online health information seeking; emerging treatment seeking has a negative impact on internet health information quality; and conservative treatment seeking has a positive impact on internet health information quality. Emerging treatment refers to some therapies based on new technologies or research, which is barely used, whereas conservative treatment is more common among the medical field. An online survey involving 336 valid participants was conducted in China. In the research model, all variables were measured using multiple-item scales, and structural equation modeling was employed for testing the hypotheses. Results: The expectancy of health websites significantly affects conservative and emerging treatment-related online health information seeking, but trust in health websites does not. Moreover, trust in health websites strongly affects the expectancy of health websites, and attitudes toward health websites have a strong effect on conservative treatment-related online information seeking. The effect of conservative treatment-related online health information seeking was considerably larger than that of emerging treatment-related online health information seeking on perceived quality of internet health information. Conclusions: From the perspective of health websites operators and public hospitals, conservative treatment and online service might be worth providing and improving. Cooperation between health websites and hospitals might be a good choice.
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Affiliation(s)
- Siying Liu
- Department of Information Management, School of Economics and Management, Beijing Jiaotong University, Beijing, China
| | - Runtong Zhang
- Department of Information Management, School of Economics and Management, Beijing Jiaotong University, Beijing, China
| | - Xinyi Lu
- Department of Information Management, School of Economics and Management, Beijing Jiaotong University, Beijing, China
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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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Dado DN, Huang B, Foster DV, Nielsen JS, Gurney JM, Morrow BD, Sharma K, Chung KK, Ainsworth CR. Management of calciphylaxis in a burn center: A case series and review of the literature. Burns 2018; 45:241-246. [PMID: 30322738 DOI: 10.1016/j.burns.2018.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/07/2018] [Accepted: 09/10/2018] [Indexed: 11/28/2022]
Abstract
Calciphylaxis is a rare, necrotizing skin disorder usually associated with kidney disease, but also caused by many other systemic illnesses. This disease is associated with mortality rates as high as 80% at 1year. We present the demographic and clinical data of nine patients with calciphylaxis treated at our burn center over a 10year period. We review the literature on the clinical presentation, pathophysiology, diagnosis and treatment of this rare disease. We propose that these patients be treated similar to patients with thermal burn injury; meaning intensive wound care, surgical management, critical care and physical therapy. Burn centers are uniquely capable of caring for these incredibly complex patients due to their experience in managing patients with extensive skin and soft tissue defects, wounds and diseases.
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Affiliation(s)
- David N Dado
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States
| | - Benjamin Huang
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States
| | - Daniel V Foster
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States
| | - Jamison S Nielsen
- Burn Center, US Army Institute of Surgical Research, Fort Sam Houston, TX, United States
| | - Jennifer M Gurney
- Burn Center, US Army Institute of Surgical Research, Fort Sam Houston, TX, United States
| | - Benjamin D Morrow
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Kumar Sharma
- Division of Nephrology, University of Texas Health Sciences Center, San Antonio, TX, United States
| | - Kevin K Chung
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Craig R Ainsworth
- Burn Center, US Army Institute of Surgical Research, Fort Sam Houston, TX, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States.
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García-Lozano JA, Ocampo-Candiani J, Martínez-Cabriales SA, Garza-Rodríguez V. An Update on Calciphylaxis. Am J Clin Dermatol 2018; 19:599-608. [PMID: 29808451 DOI: 10.1007/s40257-018-0361-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Calciphylaxis, also known as calcific uremic arteriolopathy and uremic small artery disease with medial wall calcification and intimal hyperplasia, is a multifactorial cutaneous vascular disease characterized by chronic, painful, non-healing wounds that occur frequently in patients with chronic kidney disease, predominantly in those with end-stage renal disease. The pathogenesis remains unclear, and the development of calciphylaxis lesions depends on medial calcification, intimal fibrosis of arterioles and thrombotic occlusion. Despite an increase in reports of calciphylaxis in the literature and clinical recognition of demographic characteristics and risk factors associated with calciphylaxis, it remains a poorly understood disease with high morbidity and mortality. In this review, we analyze and summarize the clinical manifestations, pathogenesis and pathophysiology, histopathology, differential diagnosis, diagnostic workup and treatment modalities for calciphylaxis. Because of the lack of consensus regarding the optimal approach to and treatment of this disorder, a high degree of clinical suspicion, early diagnosis, and multimodal and multidisciplinary treatment in collaboration with dermatology, nephrology, wound care, nutrition and pain management specialties may improve survival in patients with calciphylaxis.
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Kramer ON, Garden BC, Altman I, Braniecki M, Aronson IK. The Signs Aligned: Nonuremic Calciphylaxis. Am J Med 2017; 130:1051-1054. [PMID: 28601542 DOI: 10.1016/j.amjmed.2017.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 05/17/2017] [Accepted: 05/21/2017] [Indexed: 01/15/2023]
Affiliation(s)
- Owen N Kramer
- College of Medicine, University of Illinois at Chicago
| | | | - Igor Altman
- Department of Surgery, University of Illinois at Chicago
| | | | - Iris K Aronson
- Department of Dermatology, University of Illinois at Chicago
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10
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Acero G, Nava Catorce M, González-Mendoza R, Meraz-Rodríguez MA, Hernández-Zimbron LF, González-Salinas R, Gevorkian G. Sodium thiosulphate attenuates brain inflammation induced by systemic lipopolysaccharide administration in C57BL/6J mice. Inflammopharmacology 2017; 25:10.1007/s10787-017-0355-y. [PMID: 28526927 DOI: 10.1007/s10787-017-0355-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/26/2017] [Indexed: 02/03/2023]
Abstract
It has been demonstrated that peripheral infections accompanied by neuroinflammation may modify brain development or affect normal brain aging and represent major risk factors for the development of neurological disorders. A wide range of synthetic and natural compounds with anti-inflammatory properties have been evaluated in animal models of neuroinflammation and neurodegeneration as an adjuvant therapeutic strategy. In the present study we have demonstrated for the first time that sodium thiosulphate (STS), a known antidote approved for treatment of certain medical conditions, is capable of reducing brain inflammation caused by systemic LPS administration. STS reduced brain levels of pro-inflammatory cytokine interleukin-1β (IL-1β), cyclooxygenase-2 (COX-2), ionized calcium binding adaptor molecule 1 (Iba-1) and 18 kDa translocator protein (TSPO) in an animal model of systemic LPS-induced neuroinflammation. In addition, we demonstrated for the first time elevated TSPO expression in retinal ganglion cells layer after peripheral LPS challenge and inhibition of ocular TSPO expression after treatment with STS. We think that STS may be used as an adjuvant anti-inflammatory therapy for many pathological conditions associated with inflammation in the brain.
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Affiliation(s)
- Gonzalo Acero
- Instituto de Investigaciones Biomedicas, Universidad Nacional Autonoma de Mexico (UNAM), Apartado Postal 70228, Cuidad Universitaria, Mexico DF, CP 04510, Mexico
| | - Miryam Nava Catorce
- Instituto de Investigaciones Biomedicas, Universidad Nacional Autonoma de Mexico (UNAM), Apartado Postal 70228, Cuidad Universitaria, Mexico DF, CP 04510, Mexico
| | - Ricardo González-Mendoza
- Instituto de Investigaciones Biomedicas, Universidad Nacional Autonoma de Mexico (UNAM), Apartado Postal 70228, Cuidad Universitaria, Mexico DF, CP 04510, Mexico
| | - Marco Antonio Meraz-Rodríguez
- Instituto de Investigaciones Biomedicas, Universidad Nacional Autonoma de Mexico (UNAM), Apartado Postal 70228, Cuidad Universitaria, Mexico DF, CP 04510, Mexico
| | | | | | - Goar Gevorkian
- Instituto de Investigaciones Biomedicas, Universidad Nacional Autonoma de Mexico (UNAM), Apartado Postal 70228, Cuidad Universitaria, Mexico DF, CP 04510, Mexico.
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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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12
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Kubalczyk P, Chwatko G, Głowacki R. Fast and simple MEKC sweeping method for determination of thiosulfate in urine. Electrophoresis 2015; 37:1155-60. [DOI: 10.1002/elps.201500411] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 10/05/2015] [Accepted: 10/08/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Paweł Kubalczyk
- Department of Environmental Chemistry, Faculty of Chemistry; University of Łódź; Poland
| | - Grażyna Chwatko
- Department of Environmental Chemistry, Faculty of Chemistry; University of Łódź; Poland
| | - Rafał Głowacki
- Department of Environmental Chemistry, Faculty of Chemistry; University of Łódź; Poland
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Floege J, Kubo Y, Floege A, Chertow GM, Parfrey PS. The Effect of Cinacalcet on Calcific Uremic Arteriolopathy Events in Patients Receiving Hemodialysis: The EVOLVE Trial. Clin J Am Soc Nephrol 2015; 10:800-7. [PMID: 25887067 DOI: 10.2215/cjn.10221014] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/07/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Uncontrolled secondary hyperparathyroidism (sHPT) in patients with ESRD is a risk factor for calcific uremic arteriolopathy (CUA; calciphylaxis). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Adverse event reports collected during the Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events trial were used to determine the frequency of CUA in patients receiving hemodialysis who had moderate to severe sHPT, as well as the effects of cinacalcet versus placebo. CUA events were collected while patients were receiving the study drug. RESULTS Among the 3861 trial patients who received at least one dose of the study drug, 18 patients randomly assigned to placebo and six assigned to cinacalcet developed CUA (unadjusted relative hazard, 0.31; 95% confidence interval [95% CI], 0.13 to 0.79; P=0.014). Corresponding cumulative event rates (95% CI) at year 4 were 0.011% (0.006% to 0.018%) and 0.005% (0.002% to 0.010%). By multivariable analysis, other factors associated with CUA included female sex, higher body mass index, higher diastolic BP, and history of dyslipidemia or parathyroidectomy. Median (10%, 90% percentile) plasma parathyroid hormone concentrations proximal to the report of CUA were 796 (225, 2093) pg/ml and 410 (71, 4957) pg/ml in patients randomly assigned to placebo and cinacalcet, respectively. Active use of vitamin K antagonists was recorded in 11 of 24 patients with CUA, nine randomly assigned to placebo, and two to cinacalcet, in contrast to 5%-7% at any one time point in patients in whom CUA was not reported. CONCLUSION Cinacalcet appeared to reduce the incidence of CUA in hemodialysis recipients who have moderate to severe sHPT.
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Affiliation(s)
- Jürgen Floege
- Division of Nephrology, RWTH University of Aachen, Aachen, Germany;
| | - Yumi Kubo
- Amgen Inc., Thousand Oaks, California
| | - Anna Floege
- Division of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California; and
| | - Patrick S Parfrey
- Department of Medicine, Memorial University, St. John's, Newfoundland, Canada
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Morrison M, Merati M, Ramirez J, Cha H, LaFond A. Penile calciphylaxis diagnosed with computed tomography. J Eur Acad Dermatol Venereol 2014; 30:352-3. [DOI: 10.1111/jdv.12764] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- M. Morrison
- Department of Dermatology; St. Joseph Mercy Hospital; Ypsilanti MI USA
| | - M. Merati
- Michigan State University; East Lansing MI USA
| | - J. Ramirez
- Department of Dermatopathology; St. Joseph Mercy Hospital; Ypsilanti MI USA
| | - H.C. Cha
- Department of Dermatology; St. Joseph Mercy Hospital; Ypsilanti MI USA
| | - A. LaFond
- Department of Dermatology; St. Joseph Mercy Hospital; Ypsilanti MI USA
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Marques SA, Kakuda AC, Mendaçolli TJ, Abbade LPF, Marques MEA. Calciphylaxis: a rare but potentially fatal event of chronic kidney disease. Case report. An Bras Dermatol 2014; 88:44-7. [PMID: 24346877 PMCID: PMC3875989 DOI: 10.1590/abd1806-4841.20132280] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 12/06/2012] [Indexed: 11/22/2022] Open
Abstract
Calciphylaxis or calcific uremic arteriolopathy is a rare cutaneous-systemic disease
occurring in patients with advanced chronic kidney disease. The classical clinical
picture is that of a necrotic and progressive skin ulcer of reticular pattern, mostly
in the lower legs and susceptible to local infection. It is a product of mural
calcification and occlusion of cutaneous and sub-cutaneous arteries and arterioles.
The authors report the case of a 73-year-old male patient in his late stage of renal
disease presenting severe necrotic cutaneous ulcers on lower legs followed by local
and systemic infection and death due to sepse after parathyroidectomy.
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Affiliation(s)
- Silvio Alencar Marques
- São Paulo State University "Júlio de Mesquita Filho", Botucatu Medical School, Department of Dermatology and Radiotherapy, BotucatuSP, Brazil
| | | | | | - Luciana P Fernandes Abbade
- São Paulo State University "Júlio de Mesquita Filho", Botucatu Medical School, Department of Dermatology and Radiotherapy, BotucatuSP, Brazil
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Leonard O, Spaak J, Goldsmith D. Regression of vascular calcification in chronic kidney disease - feasible or fantasy? a review of the clinical evidence. Br J Clin Pharmacol 2014; 76:560-72. [PMID: 23110527 DOI: 10.1111/bcp.12014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 10/23/2012] [Indexed: 12/19/2022] Open
Abstract
The complex relationships between cardiovascular, renal, and bone disease are increasingly recognized but not yet clearly understood. Vascular calcification (VC) represents a common end point between these interlinked systems. It is highly prevalent in chronic kidney disease (CKD) and may be responsible for some of the excess cardiovascular events seen in this condition. There is much interest in developing therapeutic agents to stop its development or reverse its progression. Traditionally considered to be due to abnormalities in calcium and phosphate metabolism alone, VC is now known to be the product of active, dynamic processes within the vessel wall. Primary prevention of VC is possible through successful prevention or reversal of progressive renal dysfunction, hypertension and hyperlipidaemia, but is challenging given the increasing global prevalence of these risk factors. Secondary prevention of VC through tight control of calcium and phosphate, can be achieved by dietary or pharmacological means. Both the modification of haemodialysis duration or methods and the use of renal transplantation have an effect. Novel drugs such as cinacalcet were hoped to halt calcification but results have been mixed, and no intervention has yet been shown to reverse calcification reliably. A new range of experimental targets involved in the putative mediatory pathways between bone and vascular disease has emerged. Aiming to manipulate the active mechanisms involved in calcium deposition, these hold hope for reversal of calcification, but are still theoretical or in early animal or human experimentation.
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Allegretti AS, Nazarian RM, Goverman J, Nigwekar SU. Calciphylaxis: a rare but fatal delayed complication of Roux-en-Y gastric bypass surgery. Am J Kidney Dis 2014; 64:274-7. [PMID: 24787764 DOI: 10.1053/j.ajkd.2014.02.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 02/27/2014] [Indexed: 01/15/2023]
Abstract
Gastric bypass is a commonly used surgical procedure that has shown impressive health benefits for patients with morbid obesity. However, mineral bone abnormalities (hypocalcemia, hypovitaminosis D, and secondary hyperparathyroidism) and micronutrient (e.g., iron) deficiencies are common complications after gastric bypass surgery due to alterations in the digestive anatomy. These abnormalities, their treatments, and a number of other factors associated with obesity can set up a perfect storm to induce calciphylaxis, a rare but highly fatal condition with severe comorbid conditions. We present a fatal case of nonuremic calciphylaxis coincident with symptomatic hypocalcemia in a morbidly obese man with a history of Roux-en-Y gastric bypass surgery.
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Affiliation(s)
| | - Rosalynn M Nazarian
- Dermatopathology Unit, Pathology Service, Massachusetts General Hospital, Boston, MA
| | - Jeremy Goverman
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Sagar U Nigwekar
- Division of Nephrology, Massachusetts General Hospital, Boston, MA.
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Christie M, Roscoe J, Chee J, Inparajah M, Vaughn-Neil T, Nagai G, Ng P, Fung J, Ting R, Tam P, Sikaneta T. Treatment of a hemodialysis patient with pulmonary calcification-associated progressive respiratory failure with sodium thiosulfate. Transplantation 2013; 96:e1-2. [PMID: 23807461 DOI: 10.1097/tp.0b013e3182958502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Calciphylaxis is a devastating disorder with a mortality rate of 80% due to sepsis and organ failure. Hallmarks of this rare disease are arteriolar media calcification, thrombotic cutaneous ischemia, and necrotic ulcerations. Different mechanisms of vascular calcification can lead to calciphylaxis. Early diagnosis by deep cutaneous ulcer biopsy is most important for prognosis. Here, dermatologists play a significant role although treatment usually needs an interdisciplinary approach. Surgical procedures had been the cornerstone of treatment in the past including parathyroidectomy, but recently new medical treatments emerged aiming to normalize disturbances of minerals to reduce the serum concentration of sodium phosphate and to prevent precipitation and calcification. Multimodal therapy is warranted but only aggressive surgical debridement of cutaneous ulcers has shown significant outcome improvement.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, 01067 Dresden, Germany
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Nigwekar SU, Brunelli SM, Meade D, Wang W, Hymes J, Lacson E. Sodium thiosulfate therapy for calcific uremic arteriolopathy. Clin J Am Soc Nephrol 2013; 8:1162-70. [PMID: 23520041 DOI: 10.2215/cjn.09880912] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Calcific uremic arteriolopathy (CUA) is an often fatal condition with no effective treatment. Multiple case reports and case series have described intravenous sodium thiosulfate (STS) administration in CUA, but no studies have systematically evaluated this treatment. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study included 172 patients undergoing maintenance hemodialysis who had CUA and were treated with STS between August 2006 and June 2009 at Fresenius Medical Care North America. Of these, 85% completed STS therapy. Clinical, laboratory, and mortality data were abstracted from clinical information systems. Responses to survey questionnaires sent to treating physicians regarding patient-level outcomes were available for 53 patients. Effect on CUA lesions and mortality were summarized as CUA outcomes. Relevant laboratory measures, weight (using pairwise comparisons of values before, during, and after STS), and adverse events were summarized as safety parameters. RESULTS Mean age of the cohort was 55 years, and 74% of patients were women. Median STS dose was 25 g, and median number of doses was 38. Among surveyed patients, CUA completely resolved in 26.4%, markedly improved in 18.9%, improved in 28.3%, and did not improve in 5.7%; in the remaining patients (20.8%), the response was unknown. One-year mortality in patients treated with STS was 35%. Adverse events, laboratory abnormalities, and weight-related changes were mild. Significant reductions in serum phosphorous (P=0.02) and parathyroid hormone (P=0.01) were noted during STS treatment in patients who completed the therapy. CONCLUSIONS Although conclusive evidence regarding its efficacy is lacking, a majority of patients who received STS demonstrated clinical improvement in this study.
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Affiliation(s)
- Sagar U Nigwekar
- Renal Division, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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Zitt E, König M, Vychytil A, Auinger M, Wallner M, Lingenhel G, Schilcher G, Rudnicki M, Salmhofer H, Lhotta K. Use of sodium thiosulphate in a multi-interventional setting for the treatment of calciphylaxis in dialysis patients. Nephrol Dial Transplant 2013; 28:1232-40. [PMID: 23291368 DOI: 10.1093/ndt/gfs548] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Calciphylaxis is a life-threatening complication in patients with end-stage renal disease (ESRD). No established therapy exists so far. The aim of the present study was to determine the therapeutic response to a multi-interventional treatment regimen with consistent use of sodium thiosulphate (STS) in an Austrian cohort of calciphylaxis patients. METHODS We retrospectively collected demographic, clinical and laboratory data on 27 calciphylaxis patients treated with STS at seven Austrian dialysis centres between June 2004 and November 2010. RESULTS Twenty-seven dialysis patients (68 ± 12 years) were treated with STS for a median (25th, 75th percentile) of 96 (54, 133) days. Seven patients (26%) suffered from proximal-type, and 20 patients (74%) from distal-type calciphylaxis. Fourteen patients (52%) showed a complete remission, five patients (19%) a partial remission and eight patients (30%) progression that resulted in amputation in four patients. During a median follow-up of 101 (79, 273) days, 14 patients died (52%). Non-survivors were older (P = 0.04), showed higher CRP values (P = 0.04), presented more frequently with proximal-type calciphylaxis (P = 0.03), had a higher disease severity score at diagnosis (P = 0.01), were treated more often with antibiotics (P = 0.01) and cinacalcet (P = 0.03) and had a lower remission rate during treatment (P = 0.004) than did survivors. The use of antibiotics and cinacalcet, disease severity at diagnosis and remission rates were found to be significant survival predictors in logistic regression analysis. CONCLUSIONS Calciphylaxis remains a serious complication with high mortality. Early and consistent therapy including STS may help to improve the disease outcome.
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Affiliation(s)
- Emanuel Zitt
- Department of Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria.
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22
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Kramann R, Brandenburg VM, Schurgers LJ, Ketteler M, Westphal S, Leisten I, Bovi M, Jahnen-Dechent W, Knüchel R, Floege J, Schneider RK. Novel insights into osteogenesis and matrix remodelling associated with calcific uraemic arteriolopathy. Nephrol Dial Transplant 2012; 28:856-68. [PMID: 23223222 DOI: 10.1093/ndt/gfs466] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Calcific uraemic arteriolopathy (CUA) or calciphylaxis is a rare, life-threatening disease predominantly occurring in patients with end-stage renal disease. Its pathogenesis has been suggested to include ectopic osteogenesis in soft tissue and the vasculature associated with extracellular matrix (ECM) remodelling. METHODS To gain further insights into the pathogenesis of CUA, we performed systematic analyses of skin specimens obtained from seven CUA patients including histology, immunohistochemistry, electron microscopy, electron dispersive X-ray analysis (EDX) and quantitative real-time RT-PCR. Skin specimens of (i) seven patients without chronic kidney disease and without CUA and (ii) seven dialysis patients without CUA served as controls. RESULTS In the CUA skin lesions, we observed a significant upregulation of bone morphogenic protein 2 (BMP-2), its target gene Runx2 and its indirect antagonist sclerostin. Furthermore, we detected an increased expression of inactive uncarboxylated matrix Gla protein (Glu-MGP). The upregulation of osteogenesis-associated markers was accompanied by an increased expression of osteopontin, fibronectin, laminin and collagen I indicating an extensive remodelling of the subcutaneous ECM. EDX analysis revealed calcium/phosphate accumulations in the subcutis of all CUA patients with a molar ratio of 1.68 ± 0.06 matching that of hydroxyapatite mineral. Widespread media calcification in cutaneous arterioles was associated with destruction of the endothelial layer and partial exfoliation of the endothelial cells (ECs). CD31 immunostaining revealed aggregates of ECs contributing to intraluminal obstruction and consecutive malperfusion resulting in the clinical picture of ulcerative necrosis in all seven patients. CONCLUSIONS Our data indicate that CUA is an active osteogenic process including the upregulation of BMP-2 signalling, hydroxyapatite deposition and extensive matrix remodelling of the subcutis.
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Affiliation(s)
- Rafael Kramann
- Department of Pathology, Haartman Institute, University of Helsinki, Helsinki, Finland.
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Irazabal MP, Marques Martin L, Idoate Gastearena MÁ, Labiano Miravalles T, García Fernández N. Necrotic ulcerations on the back of the hands in a patient with chronic renal failure: an uncommon presentation of calciphylaxis. J Am Acad Dermatol 2012; 67:e152-4. [PMID: 22980276 DOI: 10.1016/j.jaad.2011.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 12/14/2011] [Accepted: 12/16/2011] [Indexed: 11/24/2022]
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Firstenberg MS, Tripathi RS, Grose NA, Abel E, Peters SB, Papadimos TJ. Calciphylaxis following coronary artery bypass surgery: an underappreciated cause of wound complications? Heart Surg Forum 2012; 15:E218-20. [PMID: 22917828 DOI: 10.1532/hsf98.20121024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Wound complications following cardiac surgery are typically infectious and associated with a high morbidity and mortality. Calciphylaxis, vascular calcification of small and medium sized vessels, often associated with end-stage renal disease, can result in extensive tissue necrosis. We hypothesize that calciphylaxis is an under-recognized and under-reported precipitating wound and breast complication following coronary artery bypass surgery and thereby necessitates further study.
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Gupta DR, Sangha H, Khanna R. Chemical peritonitis after intraperitoneal sodium thiosulfate. Perit Dial Int 2012; 32:220-2. [PMID: 22383725 DOI: 10.3747/pdi.2011.00088] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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26
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McManus DD, Saczynski JS, Ward JA, Jaggi K, Bourrell P, Darling C, Goldberg RJ. The Relationship Between Atrial Fibrillation and Chronic Kidney Disease : Epidemiologic and Pathophysiologic Considerations for a Dual Epidemic. J Atr Fibrillation 2012; 5:442. [PMID: 28496745 DOI: 10.4022/jafib.442] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Revised: 03/23/2012] [Accepted: 04/17/2012] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) presently affects over 2 million Americans, and the magnitude and population burden from AF continues to increase concomitant with the aging of the U.S. POPULATION Chronic kidney disease (CKD) is present in 13% of individuals in the U.S., and the prevalence of CKD is also rapidly increasing. The increasing population burden of CKD and AF will profoundly affect the clinical and public health, since CKD and AF are both associated with lower quality of life, increased hospitalization rates, and a greater risk of heart failure, stroke, and total mortality. AF and CKD often co-exist, each condition predisposes to the other, and the co-occurrence of these disorders worsens prognosis relative to either disease alone. The shared epidemiology of CKD and AF may be explained by the strong pathophysiologic connections between these diseases. In order to promote a better understanding of CKD and AF, we have reviewed their shared epidemiology and pathophysiology and described the natural history of patients affected by both diseases.
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Affiliation(s)
- David D McManus
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, University of Massachusetts Medical Center, Worcester, MA, USA.,Department of Quantitative Health Sciences, University of Massachusetts Medical School
| | - Jane S Saczynski
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, University of Massachusetts Medical Center, Worcester, MA, USA.,Department of Quantitative Health Sciences, University of Massachusetts Medical School
| | - Jeanine A Ward
- Department of Emergency Medicine, University of Massachusetts Medical Center
| | - Khushleen Jaggi
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Peter Bourrell
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Chad Darling
- Department of Emergency Medicine, University of Massachusetts Medical Center
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School
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Nichols B, Saadat P, Vadmal MS. Fatal systemic nonuremic calciphylaxis in a patient with primary autoimmune myelofibrosis. Int J Dermatol 2011; 50:870-4. [PMID: 21699526 DOI: 10.1111/j.1365-4632.2010.04595.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Benjamin Nichols
- Department of Dermatology, University of Southern California Medical Center, Los Angeles County, Los Angeles, CA 90033, USA
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28
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Auriemma M, Carbone A, Di Liberato L, Cupaiolo A, Caponio C, De Simone C, Tulli A, Bonomini M, Amerio P. Treatment of cutaneous calciphylaxis with sodium thiosulfate: two case reports and a review of the literature. Am J Clin Dermatol 2011; 12:339-46. [PMID: 21834598 DOI: 10.2165/11587060-000000000-00000] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Cutaneous calciphylaxis is a potentially fatal condition characterized by calcium deposition in dermal arterioles and the subsequent development of livedo reticularis, plaques, and extremely painful ulcers. This condition may be present in up to 4% of end-stage renal disease patients. Several treatments, which mainly attempt to control calcium phosphate metabolism, are available for this condition. We describe two patients treated with sodium thiosulfate with good results. Moreover, we also performed a PubMed literature search of sodium thiosulfate treatment for calciphylaxis. We found 41 cases of which most (> 90%) presented a rapid and sustained resolution, indicating this drug is a very good candidate for the treatment of this condition.
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Affiliation(s)
- Matteo Auriemma
- Department of Dermatology, University of Chieti-Pescara, Chieti, Italy.
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29
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Vedvyas C, Winterfield LS, Vleugels RA. Calciphylaxis: a systematic review of existing and emerging therapies. J Am Acad Dermatol 2011; 67:e253-60. [PMID: 21821309 DOI: 10.1016/j.jaad.2011.06.009] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 05/20/2011] [Accepted: 06/10/2011] [Indexed: 10/17/2022]
Abstract
Calciphylaxis, also known as calcific uremic arteriolopathy, is a cutaneous ischemic small vessel vasculopathy seen in 1 to 4% of patients with chronic kidney disease on hemodialysis. It is associated with extreme pain and a 60 to 80% mortality rate in the setting of few and frequently ineffective therapeutic options, although this may be changing based on reports of success with newer therapies.
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Affiliation(s)
- Chetan Vedvyas
- Harvard Medical School, Boston, Massachusetts 02115, USA.
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30
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Selk N, Rodby RA. Unexpectedly severe metabolic acidosis associated with sodium thiosulfate therapy in a patient with calcific uremic arteriolopathy. Semin Dial 2011; 24:85-8. [PMID: 21338397 DOI: 10.1111/j.1525-139x.2011.00848.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Calcific uremic arteriolopathy, formerly known as calciphylaxis is a devastating condition that primarily affects patients with end-stage renal disease. The lesions can progress to massive ulcerations of the subcutaneous tissue that are associated with a high degree of morbidity and mortality, usually related to sepsis. Although the pathophysiology of this condition is poorly understood, it appears to be related to a derangement in calcium-phosphate metabolism. Thus, treatments have focused on the treatment of hyperparathyroidism albeit with poor results. More recently, sodium thiosulfate (STS) has emerged as a promising therapy following multiple case reports of marked disease regression following its use. As STS is a strong acid, metabolic acidosis has been described following its administration, although relatively mild in degree. We report a case of a patient with calciphylaxis who repeatedly developed a severe anion gap metabolic acidosis following each dose of STS requiring a significant reduction in the dose.
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Affiliation(s)
- Natalie Selk
- Section of Nephrology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA.
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Abstract
Retiform purpura consists of branching purpuric lesions caused by a complete blockage of blood flow in the dermal and subcutaneous vasculature. The differential diagnosis for retiform purpura is broad, including vasculitides of the small and medium vessels as well as microvascular occlusion due to thrombotic, infectious, and embolic phenomena. Determining the etiology of this important dermatologic sign can be a diagnostic challenge; however, an organized approach can improve the speed and accuracy of diagnosis and identify an effective treatment. This review focuses on early recognition, evaluation, and treatment of hospitalized patients with retiform purpura. Specifically, vasculitis, protein C and S deficiencies, heparin necrosis, warfarin necrosis, antiphospholipid antibody syndrome, disseminated intravascular coagulation, cryoglobulinemia, calciphylaxis, and cholesterol embolization syndrome will be discussed in detail. These conditions are commonly seen in consultative dermatology and can have multiorgan involvement, complicated laboratory evaluation, and long-term therapeutic implications.
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Affiliation(s)
- Ashley Wysong
- Department of Dermatology, Stanford University, Stanford, CA, USA
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Miceli S, Milio G, La Placa S, Di Raimondo D, Tuttolomondo A, Li Vecchi M, Licata G, Pinto A. Sodium thiosulfate not always resolves calciphylaxis: an ambiguous response. Ren Fail 2011; 33:84-7. [PMID: 21219211 DOI: 10.3109/0886022x.2010.536288] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Calciphylaxis is a severe "vascular ossification-calcification," associated with a very high mortality rate that involves arterial wall, venular wall, and nerves resulting in ischemia and necrosis of skin, subcutaneous fat, visceral organs, and skeletal muscles. Sodium thiosulfate has recently been used as a novel treatment option for calciphylaxis because of its dual role as an antioxidant and a chelator. Multiple case reports demonstrated that such therapy has resulted in pain relief and healing of skin ulceration. We report a case of calciphylaxis of large severity that had an ambiguous response to sodium thiosulfate treatment (improvement of symptomatology and skin lesions, improvement of blood parameters, worsening of general conditions, and consciousness until death).
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Affiliation(s)
- Salvatore Miceli
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
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Calciphylaxis: no longer rare; no longer calciphylaxis? A paradigm shift for wound, ostomy and continence nursing. J Wound Ostomy Continence Nurs 2011; 38:379-84. [PMID: 21606862 DOI: 10.1097/won.0b013e31821e5807] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article challenges conventional wisdom that calciphylaxis is a rare condition. Rather, emerging evidence suggests that calciphylaxis is neither rare nor uncommon. In addition, the term calciphylaxis is questioned because misrepresents the underlying etiology of the condition. Multiple researchers and clinicians advocate abandoning the use of the term, but nursing literature has not yet followed suit. This article reviews the epidemiology, clinical manifestations, diagnosis, prevention, and treatment of this condition and associated wounds, and suggests areas for future research. The WOC nurse's role as an educator, leader, researcher, clinical expert, and patient advocate is summarized.
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Abstract
Calciphylaxis represents a dermatological emergency with a mortality of up to 80%. The disease is characterized by a triad of arteriolar medial calcification, thrombotic cutaneous ischemia and necrotic ulcerations. Recently several mechanisms of vascular calcification have been identified. This may led to preventive measures in the future. Early diagnosis is important to avoid complications such as sepsis. The dermatologist plays an important role in early diagnosis based on the recognition of clinical presentation and histopathology. Patients with end-stage renal disease are most commonly affected by calciphylaxis. The most frequent non-uremic predisposing conditions are primary hyperparathyroidism, malignancies, alcohol-induced liver disease, and autoimmune connective tissue diseases. Medical treatment aims to normalize mineral metabolism to reduce the serum concentration of sodium phosphate and thus to prevent precipitation and calcification. Newer compounds are bisphosphonates, non-sodium/non-aluminium phosphate binders, cinacalcet, paricalcitrol, and sodium thiosulfate. Among the surgical procedures parathyroidectomy did not result in a significant survival benefit. An aggressive surgical debridement of necrotic ulcerations, on the other hand, improved survival. Early diagnosis and a multidisciplinary treatment approach including re-vascularization by the vascular surgeon, repeated surgical debridement and split skin transplantation support wound healing and insure limb conservation.
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Affiliation(s)
- U Wollina
- Klinik für Dermatologie und Allergologie, Krankenhaus Dresden-Friedrichstadt, Städtisches Klinikum, Akademisches Lehrkrankenhaus der Technischen Universität Dresden, Friedrichstr. 41, 01067, Dresden.
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Singh RP, Derendorf H, Ross EA. Simulation-based sodium thiosulfate dosing strategies for the treatment of calciphylaxis. Clin J Am Soc Nephrol 2011; 6:1155-9. [PMID: 21441129 DOI: 10.2215/cjn.09671010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Calciphylaxis remains a poorly understood life-threatening disorder with limited therapeutic options. Sodium thiosulfate (STS) has reported efficacy, thought to be because solubilizing calcium deposits promote clearance by hemodialysis (HD). Lack of rigorous pharmacokinetic studies makes it problematic for determining proper STS dosing given the expanding range of dialysis prescriptions and intensities. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The purpose of this study was to determine the dosing strategies for STS during different dialysis regimens. Given reported successes using an empiric 25 g, intravenous, 3 times per week after HD, simulations were performed to predict dosing guidelines for alternative, more or less intense dialysis to produce equivalent area under the curve drug exposure. The modeled prescriptions varied HD time from 12 to 40 h/wk over three to six sessions (Q(b) 200 to 400 ml/min, Q(d) 500 to 800 ml/min), and continuous venovenous hemodialysis at low flow rates (Q(b) 100 to 200 ml/min, Q(d) 35 to 50 ml/min), using high-flux polysulfone hemofilters. RESULTS Simulations showed a marked variation in STS doses depending on HD frequency and duration. Blood and dialysate flows have a less prominent effect. Assuming no residual renal function, HD prescription permutations caused the dose to vary from 72 to 245 g/wk (70-kg adult), and the simulations provide specific guidelines for clinicians. CONCLUSIONS Based on the success reported for one STS dosing regimen and assuming area under the curve exposure of STS is proportional to its effect, pharmacokinetic simulations can be used to calculate the dose for alternative, higher or lower intensity dialysis regimens. These strategies are imperative to assure adequate treatment for this mortal disease, as well as to avoid toxicity from excess dosing.
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Affiliation(s)
- Rajendra Pratap Singh
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL 32610-0224, USA
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Ea HK, Nguyen C, Bazin D, Bianchi A, Guicheux J, Reboul P, Daudon M, Lioté F. Articular cartilage calcification in osteoarthritis: insights into crystal-induced stress. ACTA ACUST UNITED AC 2011; 63:10-8. [PMID: 20862682 DOI: 10.1002/art.27761] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Hang-Korng Ea
- INSERM UMR-S 606, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, PRES Sorbonne Paris-Cité, and Université Paris Denis Diderot, Paris, France.
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Sowers KM, Hayden MR. Calcific uremic arteriolopathy: pathophysiology, reactive oxygen species and therapeutic approaches. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2010. [PMID: 20716935 PMCID: PMC2952095 DOI: 10.4161/oxim.3.2.5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Calcific uremic arteriolopathy (CUA)/calciphylaxis is an important cause of morbidity and mortality in patients with chronic kidney disease requiring renal replacement. Once thought to be rare, it is being increasingly recognized and reported on a global scale. The uremic milieu predisposes to multiple metabolic toxicities including increased levels of reactive oxygen species and inflammation. Increased oxidative stress and inflammation promote this arteriolopathy by adversely affecting endothelial function resulting in a prothrombotic milieu and significant remodeling effects on vascular smooth muscle cells. These arteriolar pathological effects include intimal hyperplasia, inflammation, endovascular fibrosis and vascular smooth muscle cell apoptosis and differentiation into bone forming osteoblast-like cells resulting in medial calcification. Systemic factors promoting this vascular condition include elevated calcium, parathyroid hormone and hyperphosphatemia with consequent increases in the calcium × phosphate product. The uremic milieu contributes to a marked increased in upstream reactive oxygen species—oxidative stress and subsequent downstream increased inflammation, in part, via activation of the nuclear transcription factor NFκB and associated downstream cytokine pathways. Consitutive anti-calcification proteins such as Fetuin-A and matrix GLA proteins and their signaling pathways may be decreased, which further contributes to medial vascular calcification. The resulting clinical entity is painful, debilitating and contributes to the excess morbidity and mortality associated with chronic kidney disease and end stage renal disease. These same histopathologic conditions also occur in patients without uremia and therefore, the term calcific obliterative arteriolopathy could be utilized in these conditions.
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Abstract
Calciphylaxis/calcific uremic arteriolopathy is rare but an important cause of morbidity and mortality in patients with chronic and end-stage kidney disease with increasing prevalence. Intravenous sodium thiosulfate (STS) has rapidly emerged from a seldom used therapy for the treatment of calciphylaxis/calcific uremic arteriolopathy to a treatment that is being increasingly utilized globally due to multiple positive outcomes shared in the form of case reports and reviews during the past 6 years. Its role as a rather potent antioxidant has uniquely been associated with a prompt decrease in pain and its slower chelating properties are associated with regression of subcutaneous calcifications. Excessive reactive oxygen species (ROS) activate nuclear transcription factor, NF(kappa)B and downstream cytokines resulting in inflammation, which may result in dysregulated hepatic protein synthesis. Indeed, inflammation activates acute-phase reactant synthesis, while concurrently inhibiting synthesis of fetuin-A (an inhibitor of extraosseous calcification) and the antioxidant albumin. Additionally, ROS may decrease locally synthesized matrix GLA proteins and this combination may contribute to increased vascular and subcutaneous calcification. STS used alone or in combination with other novel emerging therapies may result in the improved clinical outcomes in this challenging clinical condition.
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Affiliation(s)
- Melvin R Hayden
- Department of Internal Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA.
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Sulková SD, Válek M. Skin wounds associated with calciphylaxis in end-stage renal disease patients on dialysis. Nutrition 2010; 26:910-4. [PMID: 20692603 DOI: 10.1016/j.nut.2010.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 01/23/2010] [Indexed: 11/19/2022]
Affiliation(s)
- Sylvie Dusilová Sulková
- Division of Nephrology, Department of Gerontology and Metabolism, Medical Faculty of Charles University and Faculty Hospital, Hradec Králové, Czech Republic
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[Calciphylaxis in dialysis patients: To recognize and treat it as soon as possible]. Nephrol Ther 2010; 6:499-504. [PMID: 20627839 DOI: 10.1016/j.nephro.2010.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 04/12/2010] [Accepted: 04/12/2010] [Indexed: 12/11/2022]
Abstract
Calciphylaxis (CPX) or calcific uraemic arteriolopathy is a rare life-threatening complication, affecting mainly dialysis patients. The condition is characterized by calcifications and thrombosis of the small cutaneous vessels and small vessels in the fat tissue, resulting in the development of necrotizing and non-healing ulcers. The development of these lesions leads to poor outcomes owing to infectious complications and some frequently associated unfavourable medical conditions: obesity, diabetes, and peripheral vascular disease. We report the case of six patients with different clinical forms of CPX in the past 10 years with favourable outcomes observed in five of the six patients. The diagnosis was based on clinical presentation: bilateral and hyperalgesic necrotic lesions along with a history of mineral metabolism disorder or warfarin use. The therapeutic strategy included the following: daily dialysis, hyperbaric oxygen therapy, treatment of limb artery stenosis, maintenance of the optimal haemodynamic stability, delivery of cutaneous care, administration of analgesics and antibiotics, warfarin and calcium cessation, and additional therapy with cinacalcet or parathyroidectomy and therapy with bisphosphonates or sodium thiosulphate. Healing was observed in five out of six CPX patients by using this strategy that should be rapidly employed in order to decrease the necrotizing areas that result in poor outcomes. Prevention includes identification of at-risk patients in order to optimize the treatment of the identified risk factors for CPX.
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Shao JS, Cheng SL, Sadhu J, Towler DA. Inflammation and the osteogenic regulation of vascular calcification: a review and perspective. Hypertension 2010; 55:579-92. [PMID: 20101002 PMCID: PMC2853014 DOI: 10.1161/hypertensionaha.109.134205] [Citation(s) in RCA: 178] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jian-Su Shao
- Department of Medicine, Washington University in St. Louis, Center for Cardiovascular Research, IM-B Campus Box 8301, 660 South Euclid Ave, St. Louis, MO 63110, USA
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Sowers KM, Hayden MR. Calcific Uremic Arteriolopathy: Pathophysiology, Reactive Oxygen Species and Therapeutic Approaches. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2010; 3:109-21. [DOI: 10.4161/oxim.3.2.11354] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Calcific uremic arteriolopathy (CUA)/calciphylaxis is an important cause of morbidity and mortality in patients with chronic kidney disease requiring renal replacement. Once thought to be rare, it is being increasingly recognized and reported on a global scale. The uremic milieu predisposes to multiple metabolic toxicities including increased levels of reactive oxygen species and inflammation. Increased oxidative stress and inflammation promote this arteriolopathy by adversely affecting endothelial function resulting in a prothrombotic milieu and significant remodeling effects on vascular smooth muscle cells. These arteriolar pathological effects include intimal hyperplasia, inflammation, endovascular fibrosis and vascular smooth muscle cell apoptosis and differentiation into bone forming osteoblast-like cells resulting in medial calcification. Systemic factors promoting this vascular condition include elevated calcium, parathyroid hormone and hyperphosphatemia with consequent increases in the calcium × phosphate product. The uremic milieu contributes to a marked increased in upstream reactive oxygen species—oxidative stress and subsequent downstream increased inflammation, in part, via activation of the nuclear transcription factor NFκB and associated downstream cytokine pathways. Consitutive anti-calcification proteins such as Fetuin-A and matrix GLA proteins and their signaling pathways may be decreased, which further contributes to medial vascular calcification. The resulting clinical entity is painful, debilitating and contributes to the excess morbidity and mortality associated with chronic kidney disease and end stage renal disease. These same histopathologic conditions also occur in patients without uremia and therefore, the term calcific obliterative arteriolopathy could be utilized in these conditions.
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Affiliation(s)
- Kurt M. Sowers
- University of Maryland, Division of Nephrology, Columbia, MI, USA
- University of Maryland, Division of Physiology, Columbia, MI, USA
| | - Melvin R. Hayden
- University of Missouri School of Medicine, Department of Internal Medicine, Columbia, MI, USA
- University of Missouri School of Medicine, Department of Endocrinology Diabetes and Metabolism, Columbia, MI, USA
- Diabetes and Cardiovascular Disease Research Center, University of Missouri School of Medicine, Columbia, MI, USA
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Amin N, Gonzalez E, Lieber M, Salusky IB, Zaritsky JJ. Successful treatment of calcific uremic arteriolopathy in a pediatric dialysis patient. Pediatr Nephrol 2010; 25:357-62. [PMID: 19885686 PMCID: PMC7811521 DOI: 10.1007/s00467-009-1313-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Revised: 08/14/2009] [Accepted: 08/19/2009] [Indexed: 11/26/2022]
Abstract
Calcific uremic arteriolopathy (CUA) is a rare, life-threatening disease, typically affecting patients with end-stage renal disease. It is characterized by widespread vascular calcification, endothelial fibrosis and end-organ ischemia. The mortality rate is high with infection and sepsis being the most common causes of death. Common therapies include restoration of calcium and phosphorous homeostasis, wound care and pain control. Although soft tissue calcification is a known complication in children with advanced renal disease, the incidence of CUA in pediatrics remains unknown. Additionally, current literature regarding its management in pediatric patients is lacking. We report the case of a 17-year-old African-American male patient with end-stage renal disease secondary to Wegener's granulomatosis who developed CUA after 3 years on peritoneal dialysis. Treatment with sodium thiosulfate (STS) and hyperbaric oxygen (HBO) therapy alone was ineffective, forcing the patient to undergo bilateral below the-knee-amputation (BKA) 5 months after presentation. It was not until peritoneal dialysis had been changed to daily hemodialysis, while continuing STS and HBO therapy, that the patient demonstrated complete resolution of CUA on repeat bone scan. Based on these findings, and the extremely high mortality rate associated with this disease, CUA management requires early and aggressive intervention with multi-faceted therapy, including prompt conversion from peritoneal dialysis to hemodialysis, STS infusions and hyperbaric oxygen therapy.
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Affiliation(s)
- Nimisha Amin
- Division of Pediatric Nephrology, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA.
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Hanvesakul R, Silva MA, Hejmadi R, Mellor S, Ready AR, Cockwell P, Inston N. Calciphylaxis following kidney transplantation: a case report. J Med Case Rep 2009; 3:9297. [PMID: 20062786 PMCID: PMC2803820 DOI: 10.1186/1752-1947-3-9297] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Accepted: 11/24/2009] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Calciphylaxis occurring after kidney transplantation is rare and rarely reported. It results in chronic non-healing wounds and is associated with a poor prognosis and is often fatal. We present a case of proximal lower limb calciphylaxis that occurred early after kidney transplantation. The patient had no classic associated risk factors. He had previously had a total parathyroidectomy but had normal serum calcium-phosphate product and parathyroid hormone levels. The clinical outcome of this case was favorable and highlights some fundamental issues relating to management. CASE PRESENTATION A 70-year-old British Caucasian man with end-stage renal failure secondary to IgA nephropathy presented six months post kidney transplantation with cutaneous calciphylaxis lesions involving the medial aspect of the thigh bilaterally. CONCLUSION To the best of our knowledge, this is the first reported case of rapid onset cutaneous calciphylaxis occurring soon after kidney transplantation that was associated with a favorable outcome. Cutaneous calciphylaxis lesions should be promptly managed with meticulous wound care, antimicrobial therapy and the correction of calcium-phosphate product where indicated.
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Affiliation(s)
- Rajesh Hanvesakul
- Department of Nephrology, University Hospital Birmingham, Birmingham B15 2TH, UK
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Schlieper G, Brandenburg V, Ketteler M, Floege J. Sodium thiosulfate in the treatment of calcific uremic arteriolopathy. Nat Rev Nephrol 2009; 5:539-43. [DOI: 10.1038/nrneph.2009.99] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kalisiak M, Courtney M, Lin A, Brassard A. Calcific uremic arteriolopathy (calciphylaxis): successful treatment with sodium thiosulfate in spite of elevated serum phosphate. J Cutan Med Surg 2009; 13 Suppl 1:S29-34. [PMID: 19480749 DOI: 10.2310/7750.2009.00007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Michal Kalisiak
- Division of Dermatology and Cutaneous Sciences, Department of Medicine, University of Alberta, Edmonton, AB
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Vargemezis V, Liakopoulos V, Kriki P, Panagoutsos S, Leontsini M, Passadakis P, Thodis E. Pivotal role of paricalcitol in the treatment of calcific uremic arteriolopathy in the presence of a parathyroid adenoma. Am J Kidney Dis 2009; 55:144-7. [PMID: 19481317 DOI: 10.1053/j.ajkd.2009.03.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Accepted: 03/27/2009] [Indexed: 11/11/2022]
Abstract
Calcific uremic arteriolopathy, or calciphylaxis, is a serious and life-threatening complication of end-stage renal disease. Its pathogenesis is not yet fully elucidated and treatment is controversial. In the presence of severe hyperparathyroidism, parathyroidectomy should be considered. We report a case of a woman on maintenance hemodialysis therapy with calciphylaxis and parathyroid adenoma who refused to undergo parathyroidectomy. She was treated successfully with a combination of noncalcium phosphate binders, cinacalcet, and paricalcitol. Subcutaneous plaques disappeared, and the necrotic lesion was healed. Discontinuation of paricalcitol led to an increase in serum parathyroid hormone levels and reappearance of the patient's symptoms, whereas its reintroduction resulted in complete remission of the clinical picture. Paricalcitol, a less calcemic vitamin D analogue, is also a selective vitamin D receptor activator with a number of nonclassic actions (such as inhibition of inflammation and ossification-calcification) that could prove beneficial in cases of calciphylaxis.
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Affiliation(s)
- Vassilis Vargemezis
- Department of Nephrology, Medical School, Democritus University of Thrace, Alexandroupolis, 68100, Greece.
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