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Tan AJ, Xia J, Glennon CM, Locascio JJ, Gabel CK, Nguyen ED, Chand S, Rrapi R, Dobry AS, Garza-Mayers AC, Ko LN, Shah R, St John J, Nigwekar SU, Kroshinsky D. Assessment of diagnostic delay, morbidity, and mortality outcomes in 302 calciphylaxis patients over a 17-year period: A retrospective cohort study. J Am Acad Dermatol 2024:S0190-9622(24)00997-6. [PMID: 38972479 DOI: 10.1016/j.jaad.2024.06.058] [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: 09/24/2023] [Revised: 05/29/2024] [Accepted: 06/10/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Calciphylaxis patients historically have experienced diagnostic challenges and high morbidity; however limited data is available examining these characteristics over time. OBJECTIVE The primary goals were to a) investigate factors associated with diagnostic delay of calciphylaxis and b) assess morbidity outcomes. The secondary goal was to provide updated mortality rates. METHODS A retrospective review of 302 adult patients diagnosed with calciphylaxis between January 1, 2006 and December 31, 2022 was conducted. Univariate and multivariate statistical analyses were performed. RESULTS Nonnephrogenic calciphylaxis (P = .0004) and involvement of the fingers (P = .0001) were significantly associated with an increased diagnostic delay, whereas involvement of the arms (P = .01) and genitalia (P = .022) resulted in fewer days to diagnosis. Almost all patients with genitalia, finger, or toe involvement had nephrogenic disease. The number of complications per patient decreased with time, especially for wound infections (P = .028), increase in lesion number (P = .012), and recurrent hospitalizations (P = .020). Updated 1-year mortality rates were 36.70% and 30.77% for nephrogenic and nonnephrogenic calciphylaxis, respectively. LIMITATIONS Limitations include the retrospective nature and data from a single institution. CONCLUSION Diagnostic delay, particularly in nonnephrogenic calciphylaxis, and complications per patient decreased with time, highlighting the importance of continued awareness to expedite diagnosis. Mortality rates have continued to improve in recent years.
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Affiliation(s)
- Alice J Tan
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Joyce Xia
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Colleen M Glennon
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Joseph J Locascio
- Department of Neurology, Harvard Catalyst Biostatistics, Massachusetts General Hospital, Boston, Massachusetts
| | - Colleen K Gabel
- Department of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Emily D Nguyen
- Department of Dermatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Sidharth Chand
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Renajd Rrapi
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Allison S Dobry
- Department of Dermatology, University of California, San Francisco School of Medicine, San Francisco, California
| | | | - Lauren N Ko
- Department of Dermatology, Brigham and Women's 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; Department of Dermatology, Duke University Medical Center, Durham, North Carolina.
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Abeck F, Hansen I, Rünger A, Booken N, Schneider SW. Successful treatment of non-uremic calciphylaxis with combination therapy with sodium thiosulfate, iloprost, and heparin. Int J Dermatol 2024; 63:962-963. [PMID: 38504650 DOI: 10.1111/ijd.17131] [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: 11/19/2023] [Revised: 02/23/2024] [Accepted: 02/24/2024] [Indexed: 03/21/2024]
Affiliation(s)
- Finn Abeck
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Inga Hansen
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandra Rünger
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nina Booken
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan W Schneider
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Arriaga Escamilla D, Lakhani A, Antony S, Salazar Villegas KN, Gupta M, Ramnath P, Murillo Pineda MI, Bedor A, Banegas D, Calderon Martinez E. Dermatological Manifestations in Patients With Chronic Kidney Disease: A Review. Cureus 2024; 16:e52253. [PMID: 38352109 PMCID: PMC10863542 DOI: 10.7759/cureus.52253] [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: 01/14/2024] [Indexed: 02/16/2024] Open
Abstract
Chronic kidney disease (CKD) is a progressive disease and has multiple clinical manifestations; when CKD reaches the end stage, at least one cutaneous manifestation appears due to some increased toxin levels or a constant proinflammatory state. Nonspecific manifestations include pruritus, xerosis, pigmentation disorders, acquired ichthyosis, purpuric spots, and nail disorders. Some specific manifestations are bullous dermatoses, acquired perforating dermatoses (APD), eruptive xanthoma, access site infections, calcifying disorders, and nephrogenic systemic fibrosis (NSF). All these cutaneous changes negatively impact patients; early recognition and diagnosis of these dermatoses will make a difference in their quality of treatment. Exploring a patient's skin is fundamental to suspect some diseases and increased toxin levels; pruritus occurs when uremic toxins are raised, and nail disorders are associated with hypoalbuminemia. This review provides the clinician with information on the clinical manifestations that occur in CKD, including epidemiology, pathophysiology, clinical manifestations, diagnosis, histopathology, treatment, and life impact of the dermatoses in CKD.
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Affiliation(s)
| | - Alisha Lakhani
- Medicine, Research MD, Vadodara, IND
- Medicine, Shantabaa Medical College, Amreli, IND
| | - Sneha Antony
- Pharmacology, K S Hegde Medical Academy, Mangalore, IND
| | | | - Manasvi Gupta
- General Practice, Jawaharlal Nehru Medical College, Aligarh, IND
| | | | | | - Alexandra Bedor
- Internal Medicine, Instituto Salvadoreño del Seguro Social, San Salvador, SLV
| | - Douglas Banegas
- General Medicine, Universidad Nacional Autonoma de Honduras, San Pedro Sula, HND
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Teh YK, Renaud CJ. Clinical experience with intraperitoneal sodium thiosulphate for calciphylaxis in peritoneal dialysis: A case series. Perit Dial Int 2024; 44:66-69. [PMID: 37131321 DOI: 10.1177/08968608231163669] [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] [Indexed: 05/04/2023] Open
Abstract
Calciphylaxis is an uncommon but life-threatening syndrome in end-stage kidney disease, characterised by painful medial and intimal calcification of the arterioles in the deep dermis and subcutaneous tissues. Intravenous sodium thiosulfate serves as an off-label but effective treatment in haemodialysis patients. However, this approach confers considerable logistical challenges for affected peritoneal dialysis patients. In this case series, we demonstrate that intraperitoneal administration can be a safe, convenient and long-term alternative.
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Affiliation(s)
- Yuan Kai Teh
- Department of Medicine, Khoo Teck Puat Hospital, Singapore
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Nogueira D, Caldas IM, Dinis-Oliveira RJ. Bisphosphonates and osteonecrosis of the jaws: Clinical and forensic aspects. Arch Oral Biol 2023; 155:105792. [PMID: 37611492 DOI: 10.1016/j.archoralbio.2023.105792] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/30/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE This manuscript aims to provide a comprehensive review of the current knowledge in the pathophysiology, diagnosis, prevention, and other relevant clinical and forensic aspects of a potentially severe complication known as medication-related osteonecrosis of the jaw (MRONJ) while synthesizing state-of-the-art information on bisphosphonates and introducing a possible differential diagnosis. DESIGN An extensive search was conducted in PubMed (U.S. National Library of Medicine) without a time or language constraint, focusing on the epidemiology, pathophysiology, risk factors, site specificity, signs and symptoms, differential diagnosis, prevention, and forensic aspects of MRONJ. All types of original articles, reviews, case reports, short communications, opinion articles, guidelines, and letters to editors were considered to produce a complete review on this subject. RESULTS MRONJ prevention relies on a multidisciplinary approach and is critical since truly effective treatments are lacking. This therapeutic challenge is partly due to uncertainty regarding this condition's pathophysiology. Differential diagnosis of osteonecrosis of the jaws associated with krokodil abuse, one of the most dangerous and homemade psychoactive illicit substances, should be considered. CONCLUSIONS Further research into the etiology and site specificity of MRONJ is encouraged, aiming to develop novel treatment prospects. Indeed, comprehending this would allow for increased efficacy and therapeutic options while emphasizing the importance of prevention. In addition, we advocate for greater consensus among the various societies regarding MRONJ's treatment and management.
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Affiliation(s)
- Diana Nogueira
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; Faculty of Dental Medicine, University of Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal.
| | - Inês Morais Caldas
- Faculty of Dental Medicine, University of Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal; 1H-TOXRUN, One Health Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, 4585-116 Gandra, Portugal; Centre for Functional Ecology (CFE), Department of Life Sciences, University of Coimbra, Calçada Martim de Freitas, 3000-456 Coimbra, Portugal.
| | - Ricardo Jorge Dinis-Oliveira
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; 1H-TOXRUN, One Health Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, 4585-116 Gandra, Portugal; UCIBIO/REQUIMTE, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, R. Jorge Viterbo Ferreira, No 228, 4050-313 Porto, Portugal.
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Wipattanakitcharoen A, Takkavatakarn K, Susantitaphong P. Risk factors, treatment modalities, and clinical outcomes of penile calciphylaxis: systematic review. World J Urol 2023; 41:2959-2966. [PMID: 37782324 DOI: 10.1007/s00345-023-04611-9] [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: 05/05/2023] [Accepted: 09/01/2023] [Indexed: 10/03/2023] Open
Abstract
PURPOSE To perform a systematic review of case reports and case series to investigate risk factors, treatment modalities, and the outcome of penile calciphylaxis. METHOD We performed a systematic search of the MEDLINE and Scopus databases to identify case reports or case series of penile calciphylaxis. The patient characteristics, laboratory investigations, diagnostic modalities, treatment modalities, and outcomes were extracted. We compared clinical characteristics and treatment between patients who survived or demised and between patients with clinical improvement and those without to identify the poor prognostic risk factors. RESULTS Ninety-four articles were included from 86 case reports and 8 case series with 121 patients. Most of the patients were on hemodialysis (78.9%). The median time since starting dialysis was 48 months (24-96 months). Sodium thiosulfate was used to treat penile calciphylaxis in 23.6%. For surgical management, partial or total penectomy was performed in 45.5% of the patients. There was no association between sodium thiosulfate use, partial or total penectomy, and improvement in clinical outcomes. The mortality rate in patients with penile calciphylaxis was 47.8% and the median time to death was 3 months (0.75-9 months). The presence of extragenital involvement was significantly related to mortality (p = 0.03). CONCLUSION A calcified penile artery results in penile calciphylaxis, a rare vascular phenomenon associated with high morbidity and mortality. Management of penile calciphylaxis includes the medical management of risk factors, surgical debridement, or penectomy. Therefore, early prevention and diagnosis as well as immediate appropriate treatment are needed.
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Affiliation(s)
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Paweena Susantitaphong
- Research Unit for Metabolic Bone Disease in CKD patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Bahar P, Mancuso J, Ramani K, Wasylyshyn A, Wasylyshyn G, George A. Scrotal calciphylaxis in a fifty-one-year-old man with end-stage renal disease and prior bacteremia. Urol Case Rep 2023; 51:102564. [PMID: 37818408 PMCID: PMC10561032 DOI: 10.1016/j.eucr.2023.102564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 09/10/2023] [Indexed: 10/12/2023] Open
Abstract
Isolated, ischemic scrotal lesions are an uncommon manifestation of systemic calciphylaxis. This highly morbid disease seen in patients with end-stage renal disease and other risk factors for small vessel calcification results in tissue necrosis and ulceration. Scrotal calciphylaxis is uncommon and difficult to diagnose in patients with comorbid conditions that cause isolated genital skin lesions, including prior systemic infections. We describe a 51-year-old male with end-stage renal disease on hemodialysis and recent history of bacteremia who developed isolated penile and scrotal ulceration due to calciphylaxis. The patient died two months after presentation despite multidisciplinary care.
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van Heeswijk I, Ugur A, Havill L, Kinton R, Hughes D. Calciphylaxis in a patient with hypoparathyroidism and MEN-1 syndrome. Endocrinol Diabetes Metab Case Rep 2023; 2023:23-0009. [PMID: 38064896 PMCID: PMC10762544 DOI: 10.1530/edm-23-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 11/08/2023] [Indexed: 01/05/2024] Open
Abstract
Summary Calciphylaxis is a rare disorder characterised by the development of painful necrotic skin lesions. Occlusion of cutaneous arterioles due to ectopic calcification leads to potentially life-threatening widespread skin loss. Most cases occur in patients with chronic renal disease, which leads to dysregulation of calcium and phosphate homeostasis. Only a handful of case reports exist describing calciphylaxis occurring in patients without chronic renal disease but with hypoparathyroidism. We report on a unique case of a 53-year-old man with multiple endocrine neoplasia type 1 syndrome and acquired hypoparathyroidism due to total parathyroidectomy who went on to develop calciphylaxis following cardiac surgery. Learning points Calciphylaxis most commonly occurs in the context of chronic renal disease but can rarely occur in its absence as a consequence of calcium and phosphate dysregulation. Patients who develop necrotic skin lesions in the presence of hypoparathyroidism require an urgent dermatological opinion. Mortality from calciphylaxis is high, with the majority of deaths occurring secondary to sepsis. Management of calciphylaxis requires a multidisciplinary team approach to manage wound healing, infections and pain. Recovery with full rehabilitation from calciphylaxis can take months to years.
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Affiliation(s)
- Isabelle van Heeswijk
- Department of Endocrinology, University Hospitals Derby & Burton NHS Trust, Derby, UK
| | - Antonia Ugur
- Department of Endocrinology, University Hospitals Derby & Burton NHS Trust, Derby, UK
| | - Lynsey Havill
- Department of Endocrinology, University Hospitals Derby & Burton NHS Trust, Derby, UK
| | - Rebecca Kinton
- Department of Endocrinology, University Hospitals Derby & Burton NHS Trust, Derby, UK
| | - David Hughes
- Department of Endocrinology, University Hospitals Derby & Burton NHS Trust, Derby, UK
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9
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Huang C, Duan Z, Xu C, Chen Y. Influence of sodium thiosulfate on coronary artery calcification of patients on dialysis: a meta-analysis. Ren Fail 2023; 45:2254569. [PMID: 37755153 PMCID: PMC10538455 DOI: 10.1080/0886022x.2023.2254569] [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: 05/18/2023] [Accepted: 08/29/2023] [Indexed: 09/28/2023] Open
Abstract
Coronary artery calcification (CAC) is common in dialysis patients and is associated with a higher risk of future cardiovascular events. Sodium thiosulfate (STS) is effective for calciphylaxis in dialysis patients; however, the influence of STS on CAC in dialysis patients remains unclear. This systematic review and meta-analysis were conducted to evaluate the effects of STS on CAC in patients undergoing dialysis. PubMed, Embase, Cochrane Library, CNKI, and Wanfang databases were searched from inception to 22 March 2023 for controlled studies comparing the influence of STS versus usual care without STS on CAC scores in dialysis patients. A random effects model incorporating the potential influence of heterogeneity was used to pool the results. Nine studies, including two non-randomized studies and seven randomized controlled trials, were included in the meta-analysis. Among these, 365 patients on dialysis were included in the study. Compared with usual care without STS, intravenous STS for 3-6 months was associated with significantly reduced CAC scores (mean difference [MD] = -180.17, 95% confidence interval [CI]: -276.64 to -83.70, p < 0.001, I2 = 0%). Sensitivity analysis limited to studies of patients on hemodialysis showed similar results (MD: -167.33, 95% CI: -266.57 to -68.09, p = 0.001; I2 = 0%). Subgroup analyses according to study design, sample size, mean age, sex, dialysis vintage of the patients, and treatment duration of STS also showed consistent results (p for subgroup differences all > 0.05). In conclusion, intravenous STS may be effective in attenuating CAC in dialysis patients.
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Affiliation(s)
- Chong Huang
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhibing Duan
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chengyun Xu
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yan Chen
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
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Khudair AD, Khudair AD, Awadh M, Pérez Romano NS, Darwish A. Calciphylaxis: A Rare Complication With a Fatal Outcome in End-Stage Renal Disease. Cureus 2023; 15:e45557. [PMID: 37868583 PMCID: PMC10586526 DOI: 10.7759/cureus.45557] [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: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Calciphylaxis, or calcific uremic arteriolopathy, is a rare and deadly disease that affects patients with end-stage renal disease (ESRD). It typically manifests in the abdomen and lower extremities. We present a case of a 59-year-old female patient on dialysis due to ESRD who complained of a three-week history of hemorrhagic and painful bilateral lower limb lesions. The predominant clinical suspicion was warfarin-induced skin necrosis (WISN); however, the persistence of unresolved skin lesions post-warfarin cessation generated the impression of calciphylaxis. A skin biopsy confirmed the classical histological findings associated with calciphylaxis. This paper highlights the possible importance of warfarin being an inciting event, as well as the early differentiation between the presentations of WISN and calciphylaxis.
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Affiliation(s)
- Ahmed D Khudair
- Department of Pathology and Laboratory Medicine, Royal College of Surgeons in Ireland - Bahrain, Muharraq, BHR
| | - Aiman D Khudair
- Department of Pathology and Laboratory Medicine, Royal College of Surgeons in Ireland - Bahrain, Muharraq, BHR
| | - Mohamed Awadh
- Department of Pathology and Laboratory Medicine, Bahrain Defense Force Hospital - Royal Medical Services, Riffa, BHR
| | - Nuria S Pérez Romano
- Department of Nephrology, Bahrain Defense Force Hospital - Royal Medical Services, Riffa, BHR
| | - Abdulla Darwish
- Department of Pathology and Laboratory Medicine, Bahrain Defense Force Hospital - Royal Medical Services, Riffa, BHR
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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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Makowicz C. Skin lesions in a man with end-stage renal disease. JAAPA 2023; 36:24-27. [PMID: 37097778 DOI: 10.1097/01.jaa.0000911192.01231.c5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
ABSTRACT Calciphylaxis is an uncommon condition most often seen in patients with end-stage renal disease. It is easily mistaken for other more common conditions and requires a high level of suspicion to make a timely diagnosis. Although various treatments such as IV sodium thiosulfate and bisphosphonates have been used for management, calciphylaxis remains a condition with a high mortality that requires an interdisciplinary approach for optimal management.
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Affiliation(s)
- Chelsea Makowicz
- Chelsea Makowicz is a lieutenant commander in the US Public Health Service and practices at Federal Medical Center Devens, part of the Federal Bureau of Prisons, in Ayer, Mass. The author has disclosed no potential conflicts of interest, financial or otherwise. Opinions expressed in this article are those of the author and do not necessarily represent the opinions of the Federal Bureau of Prisons or the Department of Justice
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13
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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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Chinnappan J, Aguirre J, Marcus H, Azher Q, Bachuwa G. A Fatal Case of Systemic Calciphylaxis in the Gastrointestinal Tract: A Case Report and Literature Review. Cureus 2023; 15:e36641. [PMID: 37101995 PMCID: PMC10123329 DOI: 10.7759/cureus.36641] [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: 03/24/2023] [Indexed: 04/28/2023] Open
Abstract
Calciphylaxis is an infrequent yet lethal disease often associated with end-stage kidney disease (ESKD). The most common sites include proximal and distal extremities and the trunk, with few reported in the penis and very few as gastrointestinal (GI) disease. We report a case of systemic calciphylaxis in a middle-aged male, presenting with a colostomy leak and parastomal abscess. Workup revealed severe calcification of the intestinal arteries and ischemic colon necrosis. The patient underwent colectomy, antibiotic therapy, regular hemodialysis (HD), and sodium thiosulphate infusion with clinical stability. Histopathology of the colon revealed ischemic necrosis and pericolonic vessel calcification suggestive of calciphylaxis. It is an important differential to be considered in patients with risk factors presenting with symptoms of gastrointestinal hemorrhage and necrosis with perforation.
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Affiliation(s)
- Justine Chinnappan
- Internal Medicine, Hurley Medical Center - Michigan State University, Flint, USA
| | - Jesus Aguirre
- Internal Medicine, Hurley Medical Center - Michigan State University, Flint, USA
| | - Huda Marcus
- Internal Medicine, Hurley Medical Center - Michigan State University, Flint, USA
| | - Qazi Azher
- Pathology, Hurley Medical Center - Michigan State University, Flint, USA
| | - Ghassan Bachuwa
- Internal Medicine, Hurley Medical Center - Michigan State University, Flint, USA
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15
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Wen W, Portales-Castillo I, Seethapathy R, Krinsky S, Kroshinsky D, Kalim S, Goverman J, Nazarian RM, Chitalia V, Malhotra R, Kramann R, Malhotra CK, Nigwekar SU. Intravenous sodium thiosulphate for vascular calcification of hemodialysis patients-a systematic review and meta-analysis. Nephrol Dial Transplant 2023; 38:733-745. [PMID: 35521751 PMCID: PMC10111152 DOI: 10.1093/ndt/gfac171] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Vascular calcification (VC) is a common comorbidity among patients with chronic kidney disease (CKD), indicating major cardiovascular events. This study aimed to evaluate the effects and safety of intravenous sodium thiosulphate (STS) for VC in CKD patients. METHODS Electronic databases were searched for clinical trials that provided data comparing outcomes among patients treated with and without STS. The PRISMA guidelines were followed. Efficacy was assessed using calcification scores and arterial stiffness. Safety was examined by analyzing adverse symptoms, electrolytes and bone mineral density (BMD). Random-effects models were performed. Meta-regression and sensitivity analysis were done. The risk of bias was assessed using the Cochrane tools. RESULTS Among the 5601 publications, 6 studies involving 305 participants (mean age: 56 years, male: 56.6%) with all participants on maintenance hemodialysis met eligibility criteria. For efficacy, the progression in Agatston scores in the coronary arteries [107 patients, mean difference (MD): -241.27, 95% confidence interval (95% CI): -421.50 to -61.03] and iliac arteries (55 patients, MD: -382.00, 95% CI: -751.07 to -12.93) was lower in the STS treated group compared with controls. The increase in pulse wave velocity was lower in the STS group (104 patients, MD: -1.29 m/s, 95% CI: -2.24 to -0.34 m/s). No association was found between the change in calcification scores and STS regimen. For safety, gastrointestinal symptoms (e.g. nausea) and increased anion gap acidosis were noted. No reduction in BMD by STS was observed. CONCLUSIONS Intravenous STS may attenuate the progression of VC and arterial stiffness in hemodialysis patients. Large and well-designed randomized controlled trials are warranted.
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Affiliation(s)
- Wen Wen
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.,Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Scott Krinsky
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
| | - Sahir Kalim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeremy Goverman
- Sumner Redstone Burn Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Vipul Chitalia
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA, USA
| | - Rajeev Malhotra
- Cardiovascular Research Center and the Cardiology Division of the Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Rafael Kramann
- Division of Nephrology and Clinical Immunology, Medical Faculty RWTH Aachen University, Aachen, Germany.,Institute of Experimental Medicine and Systems Biology, Medical Faculty RWTH Aachen University, Aachen, Germany.,Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Cindy K Malhotra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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16
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Wen W, Krinsky S, Kroshinsky D, Durant O, He J, Seethapathy R, Hillien SAS, Mengesha B, Malhotra R, Chitalia V, Nazarian RM, Goverman J, Lyons KS, Nigwekar SU. Patient-Reported and Clinical Outcomes Among Patients With Calciphylaxis. Mayo Clin Proc Innov Qual Outcomes 2023; 7:81-92. [PMID: 36712824 PMCID: PMC9880339 DOI: 10.1016/j.mayocpiqo.2022.12.006] [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: 01/26/2023] Open
Abstract
Objective To describe the pain intensity among hospitalized patients with calciphylaxis, elucidate the factors associated with pain improvement, and examine the link between pain improvement and clinical outcomes. Patients and Methods Patients were identified from the Partners Research Patient Data Registry and the Partners Calciphylaxis Registry and Biorepository (Clinicaltrials.gov ID: NCT03032835). Those with calciphylaxis requiring hospitalization for at least 14 consecutive days during the study period from May 2016 through December 2021 were included. Pain intensity was assessed using patient-reported pain scores on numerical rating scales from 0 to 10. Associations between pain improvement and clinical outcomes, including lesion improvement, amputation, and mortality, were examined using univariate and multivariate regression models. Results Our analysis included 111 patients (age, 58±14 years; men, 40%; on maintenance dialysis, 79%). No significant improvement of pain intensity was observed over the 14 days of hospitalization (mean difference, -0.71; P=.08). However, among 49 (44.1%) patients who showed at least 1-point improvement in the pain score, there was an association with surgical debridement during hospitalization (odds ratio, 3.37; 95% CI, 1.17-9.67; P=.02). Hyperbaric oxygen therapy was associated with pain improvement (odds ratio, 5.38; 95% CI, 1.14-25.50; P=.03) in patients on maintenance dialysis. Pain improvement was associated with lower rates of subsequent amputation at 6 months of follow up (6% vs 13%; P<.05) but did not predict lesion improvement or survival. Conclusion Pain control remains a challenge among hospitalized patients with calciphylaxis. Surgical debridement and hyperbaric oxygen therapy may improve pain intensity. Pain improvement predicted a lower risk of future amputation.
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Affiliation(s)
- Wen Wen
- Division of Nephrology, Massachusetts General Hospital, Boston, MA,Correspondence: Address to Wen Wen, MD, MMSc, Division of Nephrology, Massachusetts General Hospital, 165 Cambridge St, Suite 302, Boston, MA 02114.
| | - Scott Krinsky
- Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | | | - Olivia Durant
- Bouvé College of Health Sciences, Northeastern University, Boston, MA
| | | | | | | | - Beza Mengesha
- Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Rajeev Malhotra
- Cardiovascular Research Center and the Cardiology Division of the Department of Medicine, Massachusetts General Hospital, Boston, MA,Cardiovascular Research Center and the Cardiology Division of the Department of Medicine, Harvard Medical School, Boston, MA
| | - Vipul Chitalia
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA,Veterans Affairs Boston Healthcare System, Boston, MA,Institute of Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA
| | | | - Jeremy Goverman
- Sumner Redstone Burn Center, Massachusetts General Hospital, Boston, MA
| | - Karen S. Lyons
- William F. Connell School of Nursing, Boston College, Chestnut Hill, MA
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17
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Alasmari MM, Alsheikh MY, Metwali HH. Successful Treatment Using Apixaban in a Patient on Hemodialysis with Uremic Calciphylaxis. Clin Cosmet Investig Dermatol 2022; 15:2329-2333. [PMID: 36330317 PMCID: PMC9626249 DOI: 10.2147/ccid.s382503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/26/2022] [Indexed: 12/03/2022]
Abstract
Calciphylaxis is a rare but serious condition in which microvessel occlusion occurs within the subcutaneous adipose tissue and dermis, leading to painful lesions. End-stage renal disease requiring hemodialysis and warfarin therapy can increase the risk of calciphylaxis. In this report, we describe the evaluation and treatment of a 75-year-old female patient with warfarin-induced calciphylaxis who presented unique symptoms. The patient required intensive care unit admission due to hemodynamic instability, which was treated with inotropes and broad-spectrum intravenous antibiotics. This description of the patient's unusual symptoms has the potential to provide insights needed to improve the diagnosis of future patients. Due to the unavailability of FDA-approved treatment for calciphylaxis, its management is based on data from observational studies and clinical experience.
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Affiliation(s)
- Moudi M Alasmari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia,King Abdullah International Medical Research Centre, Jeddah, Saudi Arabia,Correspondence: Moudi M Alasmari, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Centre, P. O. Box. 9515, Jeddah, 6656, Saudi Arabia, Tel +966-12-2245000, Email
| | | | - Hend H Metwali
- King Abdullah International Medical Research Centre, Jeddah, Saudi Arabia,Pharmaceutical Care Department, King Abdulaziz Medical City, Ministry of National Guard - Health Affairs, Jeddah, Saudi Arabia
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18
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Wiltfang L, Booken N, Schneider SW. Successful Novel Treatment of Nonuremic Calciphylaxis with Sodium Thiosulfate and Iloprost: A Case Report. Case Rep Dermatol 2022; 14:269-274. [PMID: 36824154 PMCID: PMC9941758 DOI: 10.1159/000525712] [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: 06/03/2022] [Accepted: 06/19/2022] [Indexed: 11/19/2022] Open
Abstract
Calciphylaxis is a rare and potentially life-threatening disease which occurs most frequently in end-stage renal disease. Here, we describe a 69-year-old male patient who presented to the clinic with extremely painful necrotic ulcers of the right lower extremity. His risk factors included hypertension, diabetes mellitus type II, steatosis hepatis, and chronic hepatitis B. Laboratory studies revealed no signs for uremia, hyperparathyroidism, and normal phosphorus as well as calcium levels. A diagnosis of nonuremic calciphylaxis was made in correlation with clinical and histological features. A novel therapeutic approach combining sodium thiosulfate and iloprost showed remarkable improvement of the wound-associated pain and healing of the ulcers within 3 months. Due to its high mortality rate, an early diagnosis and initiation of treatment are crucial to be beneficial for patient outcomes.
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Affiliation(s)
| | - Nina Booken
- Clinic of Dermatology and Venerology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan W. Schneider
- Clinic of Dermatology and Venerology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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19
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Strand N, Maloney J, Wu S, Kraus M, Schneider R, Gomez D, Char S. Perioperative Management of Calciphylaxis: Literature Review and Treatment Recommendations. Orthop Rev (Pavia) 2022; 14:37573. [DOI: 10.52965/001c.37573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Calciphylaxis is a serious and rare medical condition that leads to substantial clinical manifestations including pain, creating perioperative and treatment challenges. No standard treatment protocol exists nor are comprehensive guidelines available for perioperative management of patients with calciphylaxis. In this review, we evaluate existing literature (January 2000 to May 2021) with the aim to offer guidance for treating patients with this challenging disease through the perioperative period. Although no therapies are currently considered standard for treating calciphylaxis, multiple interventions are available for improving symptoms. Preoperative and intraoperative management involves monitoring and optimizing patient comorbid conditions and any possible electrolyte imbalances. Postoperative management can be challenging when potential calciphylaxis triggers are indicated, such as warfarin and corticosteroids. In addition, poor wound healing and difficult pain control are common. Therefore, a multifactorial approach to controlling postoperative pain is recommended that includes the use of nerve blocks, renal-sparing opioids, benzodiazepines, and/or ketamine. We present preoperative, intraoperative, and postoperative recommendations for treating calciphylaxis with levels of evidence when appropriate.
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20
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Cao Y, Dominic W, Knezevich S, Kochubey M. Multiple Leg Wounds in an Obese Female with Normal Renal Function. Am J Med 2022; 135:e159-e161. [PMID: 35367179 DOI: 10.1016/j.amjmed.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Yangming Cao
- Division of Nephrology, Department of Internal Medicine, UCSF Fresno Center for Medical Education and Research, Fresno, Calif; The Nephrology Group, Fresno, Calif.
| | - William Dominic
- Burn Service, Department of Surgery, UCSF Fresno Center for Medical Education and Research, Fresno, Calif
| | | | - Mariya Kochubey
- Burn Service, Department of Surgery, UCSF Fresno Center for Medical Education and Research, Fresno, Calif
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21
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Calciphylaxis: A Long Road to Cure with a Multidisciplinary and Multimodal Approach. Case Rep Nephrol 2022; 2022:3818980. [PMID: 35720957 PMCID: PMC9200596 DOI: 10.1155/2022/3818980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 04/11/2022] [Indexed: 12/25/2022] Open
Abstract
Calciphylaxis is a rare yet potentially fatal condition, resulting from ectopic calcification of the small arterioles of the dermis with resulting necrotic lesions infection, sepsis, and death. In hemodialysis patients, its prevalence ranges between 1 and 4%, while mortality amounts to 30–80%. We present in here a 45-year-old female on chronic dialysis with morbid obesity, who was admitted for painful nodules in the lower abdomen and necrotic lesions at the lower extremities. Severe uremia and uncontrolled secondary hyperparathyroidism were the main characteristics in this patient, and thus, a clinical diagnosis of calciphylaxis was made. Treatment modalities included wound care plus antibiotics and analgesics, daily hemodialysis, and strategies targeting calcification with sodium thiosulfate, cinacalcet, and non-calcium-containing binders. A crucial factor for overcoming the infection-lesion vicious circle is thorough and daily care of the lesions. Nursing attention was focused on the motivation of her self-care, for the prevention of institutionalization and the psychological support of the patient and her family. The most intriguing feature was the fact that she experienced several exacerbations during the follow-up time. During the final relapse, she was prescribed hyperbaric oxygen sessions that actually put the disease under control thereafter. The good outcome for this patient was probably related to the combination of close follow-up along with a multidisciplinary approach.
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22
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Abstract
Uremic calciphylaxis is a rare disease that affects patients with chronic end-stage renal disease. It is a pathology of the microvessels of the dermis and hypodermis which are calcified and whose thrombosis leads to skin necrosis. Calciphylaxis lesions can be distal and axial. They lead to pain, infection and are associated with denutrition and in high mortality rate (40-80% at 1 year). This general review describes the clinical and para-clinical presentations of calciphylaxis. It summarizes the current knowledge on its pathogenesis and the therapeutical options that can be proposed to improve the management and attempt to reduce the mortality of patients with uremic calciphylaxis.
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23
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Gröger M, Hogg M, Abdelsalam E, Kress S, Hoffmann A, Stahl B, Calzia E, Wachter U, Vogt JA, Wang R, Merz T, Radermacher P, McCook O. Effects of Sodium Thiosulfate During Resuscitation From Trauma-and-Hemorrhage in Cystathionine-γ-Lyase Knockout Mice With Diabetes Type 1. Front Med (Lausanne) 2022; 9:878823. [PMID: 35572988 PMCID: PMC9106371 DOI: 10.3389/fmed.2022.878823] [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: 02/18/2022] [Accepted: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background Sodium thiosulfate (STS) is a recognized drug with antioxidant and H2S releasing properties. We recently showed that STS attenuated organ dysfunction and injury during resuscitation from trauma-and-hemorrhage in CSE-ko mice, confirming its previously described organ-protective and anti-inflammatory properties. The role of H2S in diabetes mellitus type 1 (DMT1) is controversial: genetic DMT1 impairs H2S biosynthesis, which has been referred to contribute to endothelial dysfunction and cardiomyopathy. In contrast, development and severity of hyperglycemia in streptozotocin(STZ)-induced DMT1 was attenuated in CSE-ko mice. Therefore, we tested the hypothesis whether STS would also exert organ-protective effects in CSE-ko mice with STZ-induced DMT1, similar to our findings in animals without underlying co-morbidity. Methods Under short-term anesthesia with sevoflurane and analgesia with buprenorphine CSE-ko mice underwent DMT1-induction by single STZ injection (100 μg⋅g-1). Seven days later, animals underwent blast wave-induced blunt chest trauma and surgical instrumentation followed by 1 h of hemorrhagic shock (MAP 35 ± 5 mmHg). Resuscitation comprised re-transfusion of shed blood, lung-protective mechanical ventilation, fluid resuscitation and continuous i.v. norepinephrine together with either i.v. STS (0.45 mg⋅g-1) or vehicle (n = 9 in each group). Lung mechanics, hemodynamics, gas exchange, acid-base status, stable isotope-based metabolism, and visceral organ function were assessed. Blood and organs were collected for analysis of cytokines, chemokines, and immunoblotting. Results Diabetes mellitus type 1 was associated with more severe circulatory shock when compared to our previous study using the same experimental design in CSE-ko mice without co-morbidity. STS did not exert any beneficial therapeutic effect. Most of the parameters measured of the inflammatory response nor the tissue expression of marker proteins of the stress response were affected either. Conclusion In contrast to our previous findings in CSE-ko mice without underlying co-morbidity, STS did not exert any beneficial therapeutic effect in mice with STZ-induced DMT1, possibly due to DMT1-related more severe circulatory shock. This result highlights the translational importance of both integrating standard ICU procedures and investigating underlying co-morbidity in animal models of shock research.
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Affiliation(s)
- Michael Gröger
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Melanie Hogg
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Essam Abdelsalam
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Sandra Kress
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Andrea Hoffmann
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Bettina Stahl
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Enrico Calzia
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Ulrich Wachter
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Josef A. Vogt
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Rui Wang
- Faculty of Science, York University, Toronto, ON, Canada
| | - Tamara Merz
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Ulm, Germany
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Oscar McCook
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
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24
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Byers A, Herrera N, Owoyemi I. Chronic inflammation and calciphylaxis. BMJ Case Rep 2022; 15:e248668. [PMID: 35487645 PMCID: PMC9058681 DOI: 10.1136/bcr-2021-248668] [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] [Accepted: 04/01/2022] [Indexed: 11/04/2022] Open
Abstract
Calciphylaxis also known as calcific uraemic arteriolopathy is a rare condition mostly seen in patients with end-stage kidney disease. We report a case of a simultaneous-kidney-pancreas transplant patient with functioning grafts developing biopsy-proven calciphylaxis in the setting of chronic inflammation. Despite several modalities of management, the patient developed progression of her disease leading to multiple amputations. This case illustrates chronic inflammation driven by persistent infection as a probable contributing factor to the development and progression of calciphylaxis in a simultaneous kidney-pancreas recipient. Calciphylaxis should be considered in the differential for a painful, non-healing ulcer even in the absence of common risk factors.
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Affiliation(s)
- Aaron Byers
- Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nicholas Herrera
- Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Itunu Owoyemi
- Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
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25
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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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26
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Udomkarnjananun S, Phannajit J, Takkavatakarn K, Tumkosit M, Kingpetch K, Avihingsanon Y, Praditpornsilpa K, Eiam-Ong S, Susantitaphong P. Effects of Phosphate Binders on Bone Biomarkers and Bone Density in Hemodialysis Patients. Nephrology (Carlton) 2022; 27:441-449. [PMID: 35044029 DOI: 10.1111/nep.14022] [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: 11/12/2021] [Revised: 01/04/2022] [Accepted: 01/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUNDS The incidences of osteoporosis, fracture, and vascular calcification increase concordantly with the progression of chronic kidney disease (CKD). CKD-mineral bone disease (CKD-MBD) induced by hyperphosphatemia is a major pathophysiologic mechanism. The effects of phosphate binders on bone turnover biomarkers and bone mineral density (BMD) in hemodialysis patients are still inconclusive. Our aim is to demonstrate the effects of these phosphate binders on different aspects of CKD-MBD. METHODS We conducted a prospective cohort of 65 hemodialysis patients to investigate the effect of 12-month monotherapy of phosphate binders composing calcium-based phosphate binders (CPB) or non-calcium-based phosphate binders (NCPB), including sevelamer and lanthanum, on bone turnover biomarkers and BMD changes. The performance of bone turnover biomarkers to predict low BMD was attentively determined. RESULTS When compared with CPB, NCPB use was associated with higher levels of bone turnover biomarkers. NCPB was also associated with lower BMD at lumbar and distal radius. Total procollagen type 1 N-terminal propeptide (P1NP), bone-specific alkaline phosphatase (BALP), and tartrate-resistant acid phosphatase 5b (TRAP5b) provided the best performance for diagnosing low BMD in hemodialysis patients. CONCLUSIONS Switching from CPB to NCPB might increase bone biomarkers and prevent the development of adynamic bone disease. On the contrary, NCPB should be cautiously used in hemodialysis patients who already had low BMD. P1NP, BALP, and TRAP5b could be used to guide the appropriate management, including anti-resorptive and anabolic medications, and predict low BMD in hemodialysis patients treated with phosphate binders. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jeerath Phannajit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Research Unit for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Monravee Tumkosit
- Department of Radiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kanaungnit Kingpetch
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Yingyos Avihingsanon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Research Unit for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Smilnak G, Jiang M, Jain B. Calciphylaxis of the penis and distal digits: a case report. J Med Case Rep 2022; 16:18. [PMID: 35039083 PMCID: PMC8764786 DOI: 10.1186/s13256-021-03231-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022] Open
Abstract
Background Calciphylaxis is a rare, often fatal disease resulting from calcification of dermal arterioles and capillaries. Usually diagnosed in patients with end-stage renal disease, this disorder typically presents as necrotic, nonhealing ulcers in acral or adipose areas. Here we report the case of an elderly man who was found to have calciphylaxis of the distal digits and penis, the latter of which is an uncommon site of disease that carries a particularly poor prognosis. Case presentation A 73-year-old African American man with multiple medical comorbidities including dialysis-dependent end-stage renal disease presented with worsening painful, necrotic lesions on his glans penis and several distal digits over the last 2 months. The wound on the glans was foul smelling with overlying purulence and had been unsuccessfully treated with amoxicillin–clavulanic acid. Discovery of diffuse intravascular calcification on computed tomography, in addition to a markedly elevated calcium–phosphate product immediately prior to the onset of his ulcers, led to the diagnosis of calciphylaxis. The patient was initiated on sodium thiosulfate without improvement in his lesions, and he died 3 months later after another prolonged hospitalization. Conclusions While calciphylaxis is a rare disease, involvement of the distal digits and especially the penis is even more uncommon and portends a particularly poor prognosis: 6-month mortality rates are reportedly as high as 70%. This suggests that prompt recognition and management of the disease is required; however, despite receiving standard therapy, our patient failed to experience improvement in his disease and instead developed several more fingertip ulcers at blood glucose sample points during his hospitalization. A corollary of the case presented here is the need for more effective management of calciphylaxis, especially for patients in whom uncommon sites, such as the penis, are involved.
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Affiliation(s)
- Gordon Smilnak
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael Jiang
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Hospital Medicine at Jesse Brown VAMC, Northwestern University Feinberg School of Medicine, 820 S Damen Ave, Suite 7566, Chicago, IL, 60612, USA
| | - Bijal Jain
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Division of Hospital Medicine at Jesse Brown VAMC, Northwestern University Feinberg School of Medicine, 820 S Damen Ave, Suite 7566, Chicago, IL, 60612, USA.
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Lu Y, Shen L, Zhou L, Xu D. Success of small-dose fractionated sodium thiosulfate in the treatment of calciphylaxis in a peritoneal dialysis patient. BMC Nephrol 2022; 23:4. [PMID: 34979980 PMCID: PMC8722146 DOI: 10.1186/s12882-021-02648-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 12/21/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Calciphylaxis, or calcific uremic arteriolopathy (CUA), is a rare, fatal disorder of microvascular calcification and thrombosis that typically affects patients with end-stage renal disease (ESRD) receiving long-term dialysis. Fewer reports describe calciphylaxis in peritoneal dialysis patients than hemodialysis patients as per a literature review. To date, there are no clear guidelines for CUA diagnosis and treatment. While sodium thiosulfate (STS) has been increasingly used for treatment in recent years, there have also been reports of severe side effects. There is no uniform standard for its usage and dosage, especially for peritoneal dialysis patients. CASE PRESENTATION We present a case of a 40-year-old Chinese male patient with ESRD on peritoneal dialysis who developed calciphylaxis with severe painful cutaneous ulcers on the fingers and toes that were managed successfully for 6 months with comprehensive treatment composed mainly of small-dose fractionated sodium thiosulfate. CONCLUSIONS Our experience suggests that the treatment of calciphylaxis requires timely and multi-angle intervention. Treatment with small-dose fractionated sodium thiosulfate has proven effective and tolerated in this patient.
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Affiliation(s)
- Yuan Lu
- Department of Nephrology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215008, Jiangsu, China
| | - Lei Shen
- Department of Nephrology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215008, Jiangsu, China.
| | - Ling Zhou
- Department of Nephrology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215008, Jiangsu, China
| | - Deyu Xu
- Department of Nephrology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215008, Jiangsu, China
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Podestà MA, Ciceri P, Galassi A, Cozzolino M. Calciphylaxis after Kidney Transplantation: a rare but life-threatening disorder. Clin Kidney J 2021; 15:611-614. [PMID: 35371446 PMCID: PMC8967658 DOI: 10.1093/ckj/sfab247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Indexed: 11/20/2022] Open
Abstract
Calciphylaxis is a rare disorder characterized by vascular calcification and thrombosis of the subcutaneous microcirculation, leading to painful necrotic skin lesions and bearing a dreadfully high mortality rate. This syndrome is frequently also termed uraemic calcific arteriolopathy, since most cases are observed in patients with kidney failure. However, it is increasingly clear that calciphylaxis may also affect patients with normal or only slightly impaired renal function, including kidney transplant recipients. A precise definition of the characteristics and risk factors of calciphylaxis developing after kidney transplantation has been hindered by the extreme rarity of this condition, which also hampered the development of effective therapeutic strategies. In the present issue of CKJ, Guillén and colleagues report the largest case series of calciphylaxis in kidney transplant recipients to date, outlining several features that are apparently specific to this population. In this editorial, we briefly present the epidemiology and pathogenesis of calciphylaxis in different patient populations and discuss recent findings for its therapeutic management.
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Affiliation(s)
- Manuel Alfredo Podestà
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
| | - Paola Ciceri
- Department of Nephrology, Dialysis and Renal Transplant, Renal Research Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
| | - Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
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Roy S, Reddy SN, Garcha AS, Vantipalli P, Patel SS, Ur Rahman E, Adapa S. Successful Treatment of Calciphylaxis in a Young Female With End-Stage Renal Disease on Peritoneal Dialysis With Parathyroidectomy, Intensification of Dialysis, and Sodium Thiosulphate-A Case Report and Literature Review. J Investig Med High Impact Case Rep 2021; 9:23247096211060580. [PMID: 34845938 PMCID: PMC8637396 DOI: 10.1177/23247096211060580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Calcific uremic arteriolopathy, commonly referred to as “calciphylaxis,” is a rare life-threatening condition observed in patients with chronic kidney disease and end-stage renal disease on dialysis. This results in necrotic, ischemic, tender dermal lesions anywhere in the body, but mainly on the abdominal wall and lower extremities, where subcutaneous tissue is abundant. Histologically, it is defined by calcification in dermal capillaries, arterioles, and subcutaneous adipose tissues. It can occur in all advanced stages of chronic kidney disease as well as end-stage renal disease patients on hemodialysis or peritoneal dialysis. Our case highlights a successful case of calciphylaxis in a young female patient who underwent parathyroidectomy and intensification of peritoneal dialysis regimen along with the infusion of sodium thiosulphate injection resulting in complete resolution of the lesion in 3 months. With limited evidence of treatment options and increased frequency of this condition in a dialysis patient, our case highlights the key aspects of calciphylaxis management in a young end-stage renal disease patient who didn’t need a change of dialysis modality. We also review the risk factors and current practiced management options of this condition in our article.
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Affiliation(s)
- Sasmit Roy
- University of Virginia, Charlottesville, USA
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Clinical Efficacy and Safety of Sodium Thiosulfate in the Treatment of Uremic Pruritus: A Meta-Analysis of Randomized Controlled Trials. Toxins (Basel) 2021; 13:toxins13110769. [PMID: 34822553 PMCID: PMC8624535 DOI: 10.3390/toxins13110769] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 10/24/2021] [Accepted: 10/27/2021] [Indexed: 11/17/2022] Open
Abstract
Uremic pruritus is a distressful complication of chronic kidney disease and results in impaired quality of life and higher mortality rates. Intravenous sodium thiosulfate has been reported to alleviate pruritus in hemodialysis patients. We performed a systematic review and meta-analysis to estimate the efficacy of intravenous sodium thiosulfate in patients with uremic pruritus. A systematic search of electronic databases up to June 2021 was conducted for randomized controlled trials that evaluated the clinical effects of sodium thiosulfate in the management of patients with uremic pruritus. Two reviewers selected eligible articles and evaluated the risk of bias; the results of pruritus assessment and uremic pruritus-related laboratory parameters in selected studies were analyzed. There are four trials published between 2018 and 2021, which include 222 participants. The sodium thiosulfate group displayed significant decrease in the pruritus score (standardized mean difference = -3.52, 95% confidence interval = -5.63 to -1.41, p = 0.001), without a significant increase in the adverse effects (risk ratio = 2.44, 95% confidence interval = 0.37 to 15.99, p = 0.35) compared to the control group. Administration of sodium thiosulfate is found to be a safe and efficacious complementary therapy in improving uremic pruritus in patients with chronic kidney disease.
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Tangkijngamvong N, Susantitaphong P, Numkarunarunrote N, Jearnsujitwimol O, Asawanonda P, Rerknimitr P. Sodium Thiosulfate as a Treatment for Calciphylaxis. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2021; 14:48-51. [PMID: 34976291 PMCID: PMC8711617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The use of sodium thiosulfate has emerged as a promising treatment for calciphylaxis, albeit inconclusively in terms of efficacy and variable outcomes. Research in this field has been limited by a paucity of samples due to the rarity of the disease. We herein discuss eight calciphylaxis patients' responses to STS, the potential predictive factors affecting outcomes and compare our results with previously published literature. We are able to show that lesion severity, concomitant drugs, and dialysis duration may be predictive factors of outcomes. Further, improvement of the wound site may be a clinically relevant prognostic determinant.
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Affiliation(s)
- Natsinee Tangkijngamvong
- Tangkijngamvong, Asawanonda, and Dr. Rerknimitr are with the Division of Dermatology, Department of Medicine, Faculty of Medicine, Skin and Allergy Research Unit, Chulalongkorn University in Bangkok, Thailand
- Susantitaphong is with the Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand
- Numkarunarunrote is with the Department of Radiology, Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand
- Jearnsujitwimol is with the Division of Nephrology, Department of Medicine, Prapokklao Hospital in Chantaburi, Thailand
| | - Paweena Susantitaphong
- Tangkijngamvong, Asawanonda, and Dr. Rerknimitr are with the Division of Dermatology, Department of Medicine, Faculty of Medicine, Skin and Allergy Research Unit, Chulalongkorn University in Bangkok, Thailand
- Susantitaphong is with the Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand
- Numkarunarunrote is with the Department of Radiology, Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand
- Jearnsujitwimol is with the Division of Nephrology, Department of Medicine, Prapokklao Hospital in Chantaburi, Thailand
| | - Numphung Numkarunarunrote
- Tangkijngamvong, Asawanonda, and Dr. Rerknimitr are with the Division of Dermatology, Department of Medicine, Faculty of Medicine, Skin and Allergy Research Unit, Chulalongkorn University in Bangkok, Thailand
- Susantitaphong is with the Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand
- Numkarunarunrote is with the Department of Radiology, Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand
- Jearnsujitwimol is with the Division of Nephrology, Department of Medicine, Prapokklao Hospital in Chantaburi, Thailand
| | - Onanong Jearnsujitwimol
- Tangkijngamvong, Asawanonda, and Dr. Rerknimitr are with the Division of Dermatology, Department of Medicine, Faculty of Medicine, Skin and Allergy Research Unit, Chulalongkorn University in Bangkok, Thailand
- Susantitaphong is with the Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand
- Numkarunarunrote is with the Department of Radiology, Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand
- Jearnsujitwimol is with the Division of Nephrology, Department of Medicine, Prapokklao Hospital in Chantaburi, Thailand
| | - Pravit Asawanonda
- Tangkijngamvong, Asawanonda, and Dr. Rerknimitr are with the Division of Dermatology, Department of Medicine, Faculty of Medicine, Skin and Allergy Research Unit, Chulalongkorn University in Bangkok, Thailand
- Susantitaphong is with the Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand
- Numkarunarunrote is with the Department of Radiology, Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand
- Jearnsujitwimol is with the Division of Nephrology, Department of Medicine, Prapokklao Hospital in Chantaburi, Thailand
| | - Pawinee Rerknimitr
- Tangkijngamvong, Asawanonda, and Dr. Rerknimitr are with the Division of Dermatology, Department of Medicine, Faculty of Medicine, Skin and Allergy Research Unit, Chulalongkorn University in Bangkok, Thailand
- Susantitaphong is with the Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand
- Numkarunarunrote is with the Department of Radiology, Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand
- Jearnsujitwimol is with the Division of Nephrology, Department of Medicine, Prapokklao Hospital in Chantaburi, Thailand
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Castiñeiras González J, Eiris Salvado N, Rodríguez Prieto MÁ. Usefulness of plain radiography in monitoring the treatment of calciphylaxis. Med Clin (Barc) 2021; 157:304-305. [PMID: 32819771 DOI: 10.1016/j.medcli.2020.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Jose Castiñeiras González
- Servicio de Dermatología y Venereología Médico-Quirúrgica, Complejo Asistencial Universitario de León, León, España.
| | - Noemí Eiris Salvado
- Servicio de Dermatología y Venereología Médico-Quirúrgica, Complejo Asistencial Universitario de León, León, España
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Helmeczi W, Pitre T, Hudson E, Mondhe S, Burns K. Isolated Penile Calciphylaxis Diagnosed by Ultrasound Imaging in a New Dialysis Patient: A Case Report. Can J Kidney Health Dis 2021; 8:20543581211025846. [PMID: 34367646 PMCID: PMC8317242 DOI: 10.1177/20543581211025846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/12/2021] [Indexed: 11/15/2022] Open
Abstract
RATIONALE The recognition of calciphylaxis often eludes practitioners because of its multiple ambiguous presentations. It classically targets areas of the body dense with adipose tissue. A heightened suspicion for the disorder is therefore required in the case of penile calciphylaxis, given its unconventional location. The diagnosis of calciphylaxis is also challenging as the gold standard for diagnosis is biopsy which can often yield equivocal results. Unfortunately, in penile calciphylaxis, the utility of biopsies is further debated due to their potential to precipitate new lesions and their decreased sensitivity due to the limited depth of tissue that can be sampled. For these reasons, it is important that practitioners recognize other accessible and accurate investigative tools which can aid in their diagnosis. PRESENTING CONCERNS OF THE PATIENT We present the case of a 49-year-old man who presented to the emergency room with penile pain in the context of known chronic kidney disease secondary to diabetic nephropathy. The pain had been present for about a week, was exquisitely tender, and was initially associated with a faint violaceous lesion. This gentleman had just recently initiated peritoneal dialysis and had no other lesions on his body. DIAGNOSIS His pain was determined by ultrasound and plain radiograph to be secondary to calciphylaxis after two biopsies were nondiagnostic. INTERVENTIONS The patient had already made changes to his diet to reduce phosphate and calcium intake, and had been on phosphate-lowering therapy with both calcium and phosphate being within their respective target range. Following his diagnosis, this patient was promptly converted from peritoneal dialysis to hemodialysis with sodium thiosulphate and initiated hyperbaric oxygen therapy. This patient continues to be followed by nephrology and urology specialists.
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Affiliation(s)
- Wryan Helmeczi
- Department of Internal Medicine, University of Ottawa, ON, Canada
| | - Tyler Pitre
- Department of Internal Medicine, McMaster University, Hamilton, ON, Canada
| | - Emma Hudson
- Department of Family Medicine, Queen’s University, Kingston, ON, Canada
| | - Suhas Mondhe
- Department of Nephrology, University of Ottawa, ON, Canada
| | - Kevin Burns
- Department of Nephrology, University of Ottawa, ON, Canada
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Abstract
Introduction Calciphylaxis is a rare, but serious, kidney complication. Calciphylaxia is a vasculopathy of small blood vessels characterized by the deposition of calcium deposits in intimal arterioles with the consequent proliferation of intima, fibrosis and thrombosis. Aim The aim was to show the significance of recognition of calciphylaxis relies on heightened clinical awareness of the presence of atypical skin nodules or ulcers that occur in patients with hemodialysis dependence and to characterize features of calciphylaxis or components of treatment that may lead to improved outcome. Case report We present the case of 84-year-old woman with chronic kidney disease and diabetes mellitus as well as severely painful, firm, indurated plaques on the lower extremities. The plaques progressed to involve larger areas with associated local ulceration and necrosis. Laboratory testing revealed hyperparathyroidism and incisional skin biopsy confirmed calciphylaxis. Wound microbiology confirmed Staphylococcus aureus. Conclusion The diagnosis can be based on clinical grounds, supported by histological analysis if possible. The laboratory workout must cover all the possible implications of chronic kidney disease with special attention to Ca+ and P+ values and evidence of skin or systemic infection. Calciphylaxis must be known by dermatologist as early diagnosis and proper management can be decisive for better prognosis.
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Affiliation(s)
- Nejra Prohic
- Clinic for Hemodialysis, Clinical Centre University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Fahrudin Masnic
- Clinic for Hemodialysis, Clinical Centre University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Mersiha Krupalija Fazlic
- Department of Dermatology, Clinical Centre University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Aida Coric
- Clinic for Hemodialysis, Clinical Centre University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Selma Ajanovic
- Clinic for Hemodialysis, Clinical Centre University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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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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Ghanavatian S, James DL, Sadolf JS. The role of short-term, low dose intravenous ketamine infusion in Calciphylaxis. CEN Case Rep 2021; 10:422-425. [PMID: 33606191 DOI: 10.1007/s13730-020-00557-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 11/13/2020] [Indexed: 11/25/2022] Open
Abstract
Calciphylaxis is a small vessel vasculopathy causing subcutaneous ischemic necrosis. This condition is a recognized complication of end stage renal disease and is associated with severe pain. The mechanism of the pain generated by calciphylaxis is thought to be partly related to tissue ischemia, with a significant neuropathic component associated with neuronal hypoxic injury. The pain can be further exacerbated by the inflammatory process ensuing as a result of calciphylactic lesion infections which are commonly associated with this condition. Obtaining adequate pain relief is a challenging aspect of symptom control in calciphylaxis, and historically, patients suffering from calciphylaxis required high dose opioid medications to achieve satisfactory analgesia.This case report presents a multimodal pain management approach utilizing low dose ketamine infusion in an opioid-tolerant patient suffering from severe calciphylaxis-related pain. Ketamine is an anesthetic agent well established for its efficacy in the management of neuropathic pain in opioid-tolerant patients, and has been shown to prevent opioid-induced hyperalgesia and decrease opioid requirements. Prior published data studying pain control in calciphylaxis have mainly focused on subcutaneous ketamine administration which as noted in the literature, can be associated with infusion site complications. To the best of our knowledge, this report is first of its kind to describe successful use of ketamine infusion in treatment of acute calciphylaxis-related pain.Dose modification of ketamine is not required for patients with impaired renal function, and low dose intravenous ketamine infusion was associated with no reported adverse effects in our patient.
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Affiliation(s)
- Shirin Ghanavatian
- Department of Anesthesiology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC, 27514, USA.
| | - Dominika Lipowska James
- Department of Anesthesiology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC, 27514, USA
| | - Joshua Simon Sadolf
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Calcific Uremic Arteriolopathy: A Case Series and Review from an Inner-City Tertiary University Center in End-Stage Renal Disease Patients on Renal Replacement Therapy. Int J Nephrol 2021; 2021:6661042. [PMID: 33628505 PMCID: PMC7895580 DOI: 10.1155/2021/6661042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 11/18/2022] Open
Abstract
Materials and Methods 24 patients with CUA and on RRT were evaluated at Detroit Medical Center from 2007 to 2016. Skin biopsy was used in almost all patients, along with the radiological and clinical findings. The patient's clinical and paraclinical data were retrieved from the electronic medical records. The effect of treatment modalities and the underlying hyperparathyroidism management were compared to the clinical outcomes using appropriate statistical tests. Results Twenty-one patients were on hemodialysis, two patients received renal transplants, and one patient was on peritoneal dialysis. Diabetes mellitus was the most prevalent cause of ESRD. The parathyroid hormone level (PTH) was elevated in 22 patients. Fifteen patients were diagnosed 2 weeks or more prior to skin lesion onset. Twenty-two and thirteen patients received sodium thiosulphate and cinacalcet, respectively. Patients with lower PTH and the calcium-phosphate product levels had a relatively better outcome of CUA. Conclusions A multifaceted approach may play a role in treating CUA. Referral to a nephrologist may aid in the early diagnosis and prompt management of CUA.
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Steinl GK, Kuo JH. Surgical Management of Secondary Hyperparathyroidism. Kidney Int Rep 2021; 6:254-264. [PMID: 33615051 PMCID: PMC7879113 DOI: 10.1016/j.ekir.2020.11.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/08/2020] [Accepted: 11/17/2020] [Indexed: 12/12/2022] Open
Abstract
Secondary hyperparathyroidism (SHPT) affects a majority of patients with chronic kidney disease (CKD) of stage 3 or worse. Despite the development of calcimimetics and their effectiveness in treating SHPT, many patients continue to fail medical management and should be referred to a parathyroid surgeon. In this narrative review, we summarize the indications for surgical referral, preoperative planning, intraoperative strategies to guide resection, and postoperative management. In the absence of universal guidelines, it can be difficult to determine when it is appropriate to make this referral. The majority of studies evaluating parathyroidectomy (PTX) for SHPT use the criteria of parathyroid hormone level (PTH) >800 pg/ml with hypercalcemia and/or hyperphosphatemia, which may be accompanied by symptoms such as bone pain and pruritis that can improve after surgery. Although the reported utility of the various imaging modalities (i.e., 99m-technetium-sestamibi scintigraphy with computed tomography [SPECT/CT], CT, or ultrasound) is highly variable in SHPT, SPECT/CT appears to be the most sensitive. Intraoperatively, PTH monitoring is effective in predicting long-term cure of SHPT but not in predicting hypoparathyroidism. Ectopic and supernumerary parathyroid glands are common in these patients and are often implicated in persistent or recurrent disease. Postoperatively, patients are at risk of severe hypocalcemia and hungry bone syndrome requiring close monitoring and replenishment.
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Affiliation(s)
- Gabrielle K. Steinl
- Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
| | - Jennifer H. Kuo
- Department of Surgery, Division of Gastrointestinal/Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
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40
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Zaayman M, Silfvast-Kaiser A, Rodriguez E, DeCrescenzo AJ, Menter A. Penile calciphylaxis with extragenital gangrene. Proc AMIA Symp 2021; 34:416-418. [PMID: 33953484 DOI: 10.1080/08998280.2020.1868280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Penile calciphylaxis is a rare cause of penile gangrene and is typically associated with multiple comorbidities, most commonly diabetes mellitus and hyperparathyroidism. It demonstrates a high mortality rate of 64% and is seen almost exclusively in patients with end-stage renal disease on hemodialysis. Underreporting of this disease likely occurs, contributing to a paucity of data and lack of formal therapeutic guidelines and approved treatments. Conflicting guidance exists regarding effective treatment strategies, with most formal literature existing in the form of case reports. Herein, we describe a 44-year-old man with end-stage renal disease on hemodialysis who presented with a 2-month history of nonhealing wounds on his penis and lower extremities.
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Affiliation(s)
- Marcus Zaayman
- Division of Dermatology, Baylor University Medical Center, Dallas, Texas
| | | | - Edgar Rodriguez
- Division of Dermatology, Baylor University Medical Center, Dallas, Texas
| | | | - Alan Menter
- Division of Dermatology, Baylor University Medical Center, Dallas, Texas.,Division of Dermatology, Texas A&M University College of Medicine, Dallas, Texas
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41
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Goel V, Sil A, Das A. Cutaneous Manifestations of Chronic Kidney Disease, Dialysis and Post-Renal Transplant: A Review. Indian J Dermatol 2021; 66:3-11. [PMID: 33911288 PMCID: PMC8061480 DOI: 10.4103/ijd.ijd_502_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Skin serves as the mirror of underlying systemic problems. The early diagnosis of subtle cutaneous clinical pointers often helps in identifying renal disorders, obviating the delay in diagnosis and treatment. Cutaneous changes can be observed from the beginning of renal impairment until the evolution to terminal stage, in uremia, hemodialysis, and after kidney transplantation. In the review, we have discussed the cutaneous changes, its implicated etiopathogenesis, and their treatment options, as encountered in chronic kidney disease, hemodialysis and post-renal transplantation.
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Affiliation(s)
- Vivek Goel
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Abheek Sil
- Department of Dermatology, R G Kar Medical College and Hospital, Kolkata, West Bengal, India
| | - Anupam Das
- Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
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42
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Bhamidipati T, Doan HL, Hossein-Javaheri N, Tang HT, Soliman M. Beneficial Effects of Amnion-Chorion Stem Cell Grafting in the Long Term Management of Nonuremic Calciphylaxis Wounds. Cureus 2020; 12:e12170. [PMID: 33489581 PMCID: PMC7813429 DOI: 10.7759/cureus.12170] [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: 12/04/2022] Open
Abstract
Calciphylaxis is a poorly understood disease with high morbidity and mortality. The current primary literature on treatment is lacking; however, disease management often involves a multifaceted approach with a primary focus on consistent wound care. This report describes a case outlining the long-term management of nonuremic calciphylaxis wounds in a patient with severe malnutrition with the use of human amniotic membrane grafts, aggressive surgical debridement, nutritional therapy, and advanced wound healing techniques. A 38-year-old African American female with a history of non-uremic calciphylaxis presented from a transitional facility with numerous non-healing wounds in the setting of severe malnutrition secondary to bariatric surgery. Biweekly wound debridement was initiated utilizing an amniotic stem cell skin graft, dry applicable absorbent dressing, high-frequency ultrasonic ablation, and wound vacuum-assisted closure (VAC) over the course of approximately nine months. Nutritional supplementation was given in the form of jejunostomy tube feed due to a gastric bypass and a perforated viscus. At the current date, the patient demonstrates significant improvement in pain and wound healing. The patient is also able to ambulate with care and has begun steps towards independent management of wounds. Future goals of care include independent bedside wound management, placement of allograft, and discharge to a long-term care facility. Most patients with refractory pain, widespread necrotic wounds, and dangerous comorbidities will inevitably be referred to palliative care. This case creates a framework for the long term management of medically complex patients with nonuremic calciphylaxis using human amniotic membrane stem cell grafts and appropriate advanced wound care techniques.
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Affiliation(s)
- Theja Bhamidipati
- General Surgery, Menorah Medical Center/Kansas City University, Overland Park, USA
| | - Huy L Doan
- General Surgery, Menorah Medical Center/Kansas City University, Overland Park, USA
| | | | - Hao T Tang
- General Surgery, Menorah Medical Center/Kansas City University, Overland Park, USA
| | - Mohsin Soliman
- General and Bariatric Surgery, Menorah Medical Center, Overland Park, USA
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43
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Kodumudi V, Jeha GM, Mydlo N, Kaye AD. Management of Cutaneous Calciphylaxis. Adv Ther 2020; 37:4797-4807. [PMID: 32997277 PMCID: PMC7595979 DOI: 10.1007/s12325-020-01504-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/11/2020] [Indexed: 12/21/2022]
Abstract
Calciphylaxis is a deadly, painful disease with a 1-year mortality of up to 50%. The disease is commonly associated with patients with end-stage kidney disease (ESKD), but it can manifest in non-uremic patients as well. In patients who are undergoing dialysis, the incidence of calciphylaxis can range from 0.04% to 4%. The progressive arterial calcification seen in calciphylaxis can affect multiple body organs, including the skin, brain, lungs, and muscle. In cutaneous calciphylaxis, painful and non-healing nodules, plaques, and ulcers may appear, increasing morbidity for patients. Diagnosis can be difficult, and the condition can clinically appear similar to other dermatological diseases, especially in non-uremic patients. Currently, skin biopsy with histological analysis is the most reliable method to help diagnose the condition. In certain cases, the use of medical imaging may be helpful. Treatment of pain in this condition can be difficult and should be multimodal and include wound care as well as modification of risk factors. Analgesic options include opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), as well as analgesic options that are targeted for specific patients. There are currently multiple clinical trials underway that are studying targeted therapies for this condition.
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44
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Maida V, Shi RB, Fazzari FGT, Zomparelli L. Promoting wound healing of uremic calciphylaxis leg ulcers using topical
cannabis‐based
medicines. Dermatol Ther 2020; 33:e14419. [DOI: 10.1111/dth.14419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/08/2020] [Accepted: 10/10/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Vincent Maida
- Faculty of Medicine University of Toronto Ontario Canada
- Division of Supportive and Palliative Care William Osler Health System Toronto Ontario Canada
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Cherayil NR, Scoles D, Moran AM, Elder DE, Tamhankar MA. Gazing Into the Crystal Ball: Calciphylaxis Causing Striking Retinal Vascular Calcification, Ocular Ischemic Syndrome, Crystalline Retinopathy, and Ischemic Optic Neuropathy. J Neuroophthalmol 2020; 41:e212-e214. [PMID: 33105406 DOI: 10.1097/wno.0000000000001090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT A 72-year-old woman with membranous glomerulonephritis and failed renal transplant on peritoneal dialysis presented with bilateral vision loss. She reported several months of diminishing right eye vision that worsened after cataract extraction. On presentation, visual acuity was hand motion in the right and 20/100 in the left eye with a right afferent pupillary defect. Confrontation visual fields were constricted bilaterally. Intraocular pressure was 23 in the right eye, and there was diffuse right eye central corneal opacity with iris neovascularization. Fundus examination revealed bilateral pale optic nerves with cotton wool spot inferior to the left optic disc and diffuse arteriolar whitening with crystalline deposits in the left macula. Given fundus appearance, concurrent ischemic optic neuropathy, and ocular ischemic syndrome, ocular calciphylaxis was suspected. The patient reported development of painful gluteal nodules a month prior, and biopsy revealed calcinosis cutis, a dermatopathologic finding on the spectrum of calcific vasculitides. Her vision continued to decline in both eyes with left eye vision of 20/400. Intravenous sodium thiosulfate through hemodialysis was started with initial improvement in left eye vision to 20/125, but subsequently declined despite treatment. Pathogenesis of systemic calciphylaxis is poorly understood but believed to result from upregulation of osteogenesis and decreased inhibition of vascular calcification in parathyroid axis dyscrasias due to end-stage renal disease. Excess serum calcium-phosphate deposits in blood vessels causing tissue infarction, most commonly in the skin. Prior case reports have described ischemic optic neuropathy mimicking giant cell arteritis and crystalline retinopathy with ocular ischemic syndrome separately. Treatment with empiric intravenous sodium thiosulfate and calcium chelation may preserve vision in some patients.
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Affiliation(s)
- Neena R Cherayil
- Department of Neurology (NRC, MAT), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Ophthalmology (NRC, DS, MAT), Scheie Eye Institute, Philadelphia, Pennsylvania; and Department of Pathology (AMM, DEE), University of Pennsylvania, Philadelphia, Pennsylvania
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46
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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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47
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Maida V, Shi RB, Fazzari FGT, Zomparelli L. Topical cannabis-based medicines - A novel paradigm and treatment for non-uremic calciphylaxis leg ulcers: An open label trial. Int Wound J 2020; 17:1508-1516. [PMID: 32875692 PMCID: PMC7540661 DOI: 10.1111/iwj.13484] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 11/30/2022] Open
Abstract
Non-Uremic Calciphylaxis (NUC) is a rare condition that often manifests as intractable and painful integumentary wounds, afflicting patients with a high burden of co-morbidity. The Endocannabinoid System (ECS) is a ubiquitous signalling system that is theorised to be dysregulated within wound beds and associated peri-wound tissues. Preclinical research has shown that the dominant chemical classes derived from the cannabis plant, cannabinoids, terpenes, and flavonoids, interact with the integumentary ECS to promote wound closure and analgesia. This is a prospective open label cohort study involving two elderly Caucasian females with recalcitrant NUC leg ulcers of greater than 6 months duration. Topical Cannabis-Based Medicines (TCBM) composed of cannabinoids, terpenes, and flavonoids were applied daily to both the wound bed and peri-wound tissues until complete wound closure was achieved. Wounds were photographed regularly, and the digital images were subjected to planimetric analysis to objectively quantify the degree of granulation and epithelization. Analgesic utilisation, as a surrogate/proxy for pain scores, was also tracked. The cohort had a mean M3 multimorbidity index score of 3.31. Complete wound closure was achieved in a mean of 76.3 days. Additionally, no analgesics were required after a mean of 63 days. The treatments were well tolerated with no adverse reactions. The positive results demonstrated in very challenging wounds such as NUC, among highly complex patients, suggest that TCBM may have an even broader role within integumentary and wound management. This treatment paradigm warrants being trialled in other wound types and classes, and ultimately should be subjected to randomised controlled trials.
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Affiliation(s)
- Vincent Maida
- Division of Palliative CareUniversity of TorontoTorontoOntarioCanada
- Division of Supportive & Palliative CareWilliam Osler Health SystemTorontoOntarioCanada
| | - Runjie B. Shi
- Division of Palliative CareUniversity of TorontoTorontoOntarioCanada
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48
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Cabrera Fermin CM, Singh S, Koratala A. Penile Pain in a Hemodialysis Patient. KIDNEY360 2020; 1:1032-1033. [PMID: 35369553 PMCID: PMC8815606 DOI: 10.34067/kid.0001472020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/30/2020] [Indexed: 06/14/2023]
Affiliation(s)
| | - Shashank Singh
- Division of Nephrology, University of Texas at San Antonio, San Antonio, Texas
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Safety and Tolerability of Sodium Thiosulfate in Patients with an Acute Coronary Syndrome Undergoing Coronary Angiography: A Dose-Escalation Safety Pilot Study (SAFE-ACS). J Interv Cardiol 2020; 2020:6014915. [PMID: 33041696 PMCID: PMC7532357 DOI: 10.1155/2020/6014915] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/26/2020] [Accepted: 09/07/2020] [Indexed: 12/14/2022] Open
Abstract
Background In animal studies, hydrogen sulfide (H2S) has been shown to protect the heart from ischemia-reperfusion injury. This study evaluates the safety and tolerability of the H2S donor sodium thiosulfate (STS) in patients with acute coronary syndrome (ACS). Methods Eighteen patients, undergoing coronary angiography for ACS, received STS intravenously immediately after arrival at the catheterization laboratory according to a “3 + 3 dose-escalation design” with fixed dosing endpoint (0, 2.5, 5, 10, 12.5, and 15 grams). This first dose STS was combined with verapamil and nitroglycerin required for transradial procedures. A second dose STS was administered 6 hours later. Primary endpoint was dose-limiting toxicity, defined as significant hemodynamic instability or death up to 24 hours or before discharge from the coronary care unit. Secondary outcomes included the occurrence of anaphylaxis, nausea, vomiting, and systolic blood pressure (SBP) course. Results Sixteen patients received two dosages of STS and two patients one dosage. None of the patients reached the primary endpoint, nor experienced a serious adverse event. We observed a clinically well-tolerated decline in SBP 1 hour after administration of the first STS dose and concomitant verapamil/nitroglycerin. SBP for all patients together reduced 16.8 (8.1–25.5) mmHg (P = 0.0008). No significant decline in SBP occurred after the second dose. Mild nausea was observed in one patient. Conclusion This is the first report on sodium thiosulfate administration in patients with acute coronary syndromes. Our data suggest that sodium thiosulfate was well tolerated in this setting. The potential benefit of this intervention has to be examined in larger studies.
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50
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Chinnadurai R, Sinha S, Lowney AC, Miller M. Pain management in patients with end-stage renal disease and calciphylaxis- a survey of clinical practices among physicians. BMC Nephrol 2020; 21:403. [PMID: 32948131 PMCID: PMC7501607 DOI: 10.1186/s12882-020-02067-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/15/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Calciphylaxis is a rare condition usually seen in patients with end-stage renal disease. Pain is a hallmark of this condition and can be extremely difficult to control. Anecdotal data suggests that pain management in calciphylaxis is challenging with variable approaches across the United Kingdom (UK) and internationally. A knowledge and practice survey was conducted to establish current practice in the management of pain in patients with calciphylaxis, in the UK. Based on the results and clinical experience the authors suggest a clinical practice guideline. METHODS An online questionnaire was circulated among physicians (renal and palliative care) involved in the management of pain in calciphylaxis. The questionnaire included a mix of open-ended questions and questions with drop down options. RESULTS One hundred and six clinicians responded to the survey of which 60 (57%) respondents were from palliative medicine; the remaining 46 (43%) were from renal medicine. 31 (30%) respondents across both specialties had not encountered any patients with a diagnosis of calciphylaxis (renal-2, palliative care-29). A referral to the palliative care team was undertaken by 18% of renal physicians, 32% referred to the pain team and 50% referred to both. Only 3% of the palliative medicine respondents indicated that they had received a referral from the renal team at the time of diagnosis. Opioids were the preferred initial drug of choice for the management of all types of pain. Paracetamol was universally selected as the preferred first-choice adjuvant agent for management of all types of pain. The importance of advance care planning was highlighted with 72% undertaking advanced care planning discussions often or most of the time. CONCLUSION There was wide variation in the current practice of pain management in patients with calciphylaxis, with variation between renal specialists and palliative care specialists. Referral to specialists in pain management is not universal despite the severe nature of the pain experienced by patients with calciphylaxis. The data generated has facilitated the development of a clinical practice guideline to support complex pain management in a group of patients with multiple comorbidities.
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Affiliation(s)
- Rajkumar Chinnadurai
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK.
| | - Smeeta Sinha
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Aoife C Lowney
- Palliative Medicine, Sir Michael Sobell House Hospice, Oxford, UK.,Palliative Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Miller
- Palliative Medicine, Sir Michael Sobell House Hospice, Oxford, UK.,Palliative Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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