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Davuluri S, Lood C, Chung L. Calcinosis in systemic sclerosis. Curr Opin Rheumatol 2023:00002281-990000000-00088. [PMID: 37830924 DOI: 10.1097/bor.0000000000000900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
PURPOSE OF REVIEW To provide updated information on the prevalence, pathogenesis, diagnostics, and therapeutics of calcinosis cutis associated with systemic sclerosis (SSc). RECENT FINDINGS Observational studies show ethnic and geographical differences in the prevalence of calcinosis. In addition to clinical and serological associations, biochemical studies and in-vivo models have attempted to explain theories behind its pathogenesis, including prolonged state of inflammation, mechanical stress, hypoxia, and dysregulation in bone and phosphate metabolism. Long-term use of proton pump inhibitors may increase the risk for calcinosis in SSc. Few single center observational studies have shown mild benefit with minocycline and topical sodium thiosulfate. SUMMARY Calcinosis cutis is the deposition of insoluble calcium in the skin and subcutaneous tissues. It affects up to 40% of SSc patients and causes significant morbidity. Long disease duration, features of vascular dysfunction, and osteoporosis have been associated with calcinosis. Altered levels of inorganic pyrophosphate and fibroblast growth factor-23 have been implicated in dysregulated phosphate metabolism that may lead to calcinosis in SSc. Plain radiography can help with diagnosis and quantifying the calcinosis burden. Surgical treatment remains the most effective therapy when feasible. At present, no medical therapies have proven efficacy in large randomized controlled trials.
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Affiliation(s)
- Srijana Davuluri
- Stanford School of Medicine, Division of Immunology &Rheumatology, Palo Alto, California
| | - Christian Lood
- University of Washington, Division of Rheumatology, Seattle, Washington
| | - Lorinda Chung
- Stanford School of Medicine & Palo Alto VA Healthcare System, Division of Immunology & Rheumatology, Palo Alto, California, USA
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Lajoie C, Ghanemi A, Bourbeau K, Sidibé A, Wang YP, Desmeules S, Mac-Way F. Multimodality approach to treat calciphylaxis in end-stage kidney disease patients. Ren Fail 2023; 45:2256413. [PMID: 37724534 PMCID: PMC10512890 DOI: 10.1080/0886022x.2023.2256413] [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: 06/26/2023] [Accepted: 09/02/2023] [Indexed: 09/21/2023] Open
Abstract
A multimodality approach has been proposed as an effective treatment for calciphylaxis in patients with end-stage kidney disease. In this retrospective study, we report the cases of 12 end-stage kidney disease patients from l'Hôtel-Dieu de Québec hospital (Canada) who were diagnosed with calciphylaxis between 2004 and 2012 and treated with a multimodality clinical approach including sodium thiosulfate (STS). Statistical analyses were performed to evaluate the impacts of patients characteristics, the different interventions as well as therapy regimen on the therapeutic response. The majority of patients (n = 9) were hemodialyzed. The patients-associated comorbidities were consistent with previously reported risk factors for calciphylaxis: Diabetes (n = 11), calcium-based phosphate binders use (n = 10), warfarin use (n = 9), obesity (n = 7), female gender (n = 8) and intravenous iron use (n = 8). STS was given for a median duration of 81 days. 75% of the patients had a response (total or partial) including a complete response in 42% of patients. One-year mortality rate was low (25%). STS was used during a mean duration of 83.33 ± 41.52 days and with a total cumulating dose of 1129.00 ± 490.58 g. The recorded mean time before a complete response was 102.20 days (51-143). Pain improvement occurred after a mean time of 8.67 ± 10.06 days. None of the studied factors was statistically associated with a complete or a partial response to the multimodality approach. Although our data have a limited statistical power, they support treating calciphylaxis with a multimodality approach including STS as its effects are independent from important clinical variables.
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Affiliation(s)
- Chloé Lajoie
- CHU de Québec, L’Hôtel-Dieu de Québec Hospital, Faculty and Department of Pharmacy, Université Laval, Québec, Canada
- Department of Pharmacy, CSSS de la Minganie, Québec, Canada
| | - Abdelaziz Ghanemi
- CHU de Québec Research Center, L’Hôtel-Dieu de Québec Hospital, Division of Nephrology, Faculty and Department of Medicine, Université Laval, Québec, Canada
| | - Kateri Bourbeau
- CHU de Québec, L’Hôtel-Dieu de Québec Hospital, Faculty and Department of Pharmacy, Université Laval, Québec, Canada
| | - Aboubacar Sidibé
- CHU de Québec Research Center, L’Hôtel-Dieu de Québec Hospital, Division of Nephrology, Faculty and Department of Medicine, Université Laval, Québec, Canada
| | - Yue-Pei Wang
- CHU de Québec Research Center, L’Hôtel-Dieu de Québec Hospital, Division of Nephrology, Faculty and Department of Medicine, Université Laval, Québec, Canada
| | - Simon Desmeules
- CHU de Québec Research Center, L’Hôtel-Dieu de Québec Hospital, Division of Nephrology, Faculty and Department of Medicine, Université Laval, Québec, Canada
| | - Fabrice Mac-Way
- CHU de Québec Research Center, L’Hôtel-Dieu de Québec Hospital, Division of Nephrology, Faculty and Department of Medicine, Université Laval, Québec, Canada
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Abstract
PURPOSE OF REVIEW The aim of this study was to provide updated information on the prevalence, pathogenesis, diagnostics and therapeutics of calcinosis cutis associated with systemic sclerosis (SSc). RECENT FINDINGS Observational studies show ethnic and geographical differences in the prevalence of calcinosis. In addition to clinical and serological associations, biochemical studies and in-vivo models have attempted to explain theories behind its pathogenesis, including prolonged state of inflammation, mechanical stress, hypoxia and dysregulation in bone and phosphate metabolism. Long-term use of proton pump inhibitors may increase the risk for calcinosis in SSc. Few single-centre observational studies have shown mild benefit with minocycline and topical sodium thiosulfate. SUMMARY Calcinosis cutis is the deposition of insoluble calcium in the skin and subcutaneous tissues. It affects up to 40% of SSc patients and causes significant morbidity. Long disease duration, features of vascular dysfunction and osteoporosis have been associated with calcinosis. Altered levels of inorganic pyrophosphate and fibroblast growth factor-23 have been implicated in dysregulated phosphate metabolism that may lead to calcinosis in SSc. Plain radiography can help with diagnosis and quantifying the calcinosis burden. Surgical treatment remains the most effective therapy when feasible. At present, no medical therapies have proven efficacy in large randomized controlled trials.
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Affiliation(s)
- Srijana Davuluri
- Stanford School of Medicine, Division of Immunology & Rheumatology, Palo Alto, California
| | - Christian Lood
- University of Washington, Division of Rheumatology, Seattle, Washington
| | - Lorinda Chung
- Stanford School of Medicine & Palo Alto VA Healthcare System, Division of Immunology & Rheumatology, Palo Alto, California, USA
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Davuluri S, Duvvuri B, Lood C, Faghihi-Kashani S, Chung L. Calcinosis in dermatomyositis: Origins and possible therapeutic avenues. Best Pract Res Clin Rheumatol 2022; 36:101768. [PMID: 35803868 DOI: 10.1016/j.berh.2022.101768] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Calcinosis, insoluble calcium compounds deposited in skin and other tissues, is a crippling sequela of dermatomyositis. Prolonged disease associated with ongoing inflammation, ischemia, repetitive trauma, and certain autoantibodies are associated with calcinosis. Herein, we describe potential pathogenic mechanisms including the role of mitochondrial calcification. There are no widely effective treatments for calcinosis. We review available pharmacologic therapies for calcinosis including those targeting calcium and phosphorus metabolism; immunosuppressive/anti-inflammatory therapies; and vasodilators. Mounting evidence supports the use of various formulations of sodium thiosulfate in the treatment of calcinosis. Although the early institution of aggressive immunosuppression may prevent calcinosis in juvenile dermatomyositis, only limited data support improvement once it has developed. Minocycline can be useful particularly for lesions associated with surrounding inflammation. Powerful vasodilators, such as prostacyclin analogs, may have promise in the treatment of calcinosis, but further studies are necessary. Surgical removal of lesions when amenable is our treatment of choice.
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Affiliation(s)
- Srijana Davuluri
- Stanford School of Medicine, Division of Immunology &Rheumatology, 1000 Welch Road, Suite 204, Palo Alto, 94304, California, USA.
| | - Bhargavi Duvvuri
- University of Washington, Department of Medicine, Division of Rheumatology, 750 Republican Street, Seattle, WA, 98109, USA.
| | - Christian Lood
- University of Washington, Division of Rheumatology, 750 Republican Street, Room E-545, Seattle, WA, 98109, USA.
| | - Sara Faghihi-Kashani
- Stanford School of Medicine, Division of Immunology &Rheumatology, 1000 Welch Road, Suite 204, Palo Alto, 94304, California, USA.
| | - Lorinda Chung
- Stanford School of Medicine & Palo Alto VA Health Care System, Division of Immunology &Rheumatology, 1000 Welch Road, Suite 203, Palo Alto, 94304, California, USA.
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Therapy of Pseudoxanthoma Elasticum: Current Knowledge and Future Perspectives. Biomedicines 2021; 9:biomedicines9121895. [PMID: 34944710 PMCID: PMC8698611 DOI: 10.3390/biomedicines9121895] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 12/24/2022] Open
Abstract
Pseudoxanthoma elasticum (PXE) is a rare, genetic, metabolic disease with an estimated prevalence of between 1 per 25,000 and 56,000. Its main hallmarks are characteristic skin lesions, development of choroidal neovascularization, and early-onset arterial calcification accompanied by a severe reduction in quality-of-life. Underlying the pathology are recessively transmitted pathogenic variants of the ABCC6 gene, which results in a deficiency of ABCC6 protein. This results in reduced levels of peripheral pyrophosphate, a strong inhibitor of peripheral calcification, but also dysregulation of blood lipids. Although various treatment options have emerged during the last 20 years, many are either already outdated or not yet ready to be applied generally. Clinical physicians often are left stranded while patients suffer from the consequences of outdated therapies, or feel unrecognized by their attending doctors who may feel uncertain about using new therapeutic approaches or not even know about them. In this review, we summarize the broad spectrum of treatment options for PXE, focusing on currently available clinical options, the latest research and development, and future perspectives.
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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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Djuric P, Dimkovic N, Schlieper G, Djuric Z, Pantelic M, Mitrovic M, Jankovic A, Milanov M, Kuzmanovic Pficer J, Floege J. Sodium thiosulphate and progression of vascular calcification in end-stage renal disease patients: a double-blind, randomized, placebo-controlled study. Nephrol Dial Transplant 2020; 35:162-169. [PMID: 31764989 DOI: 10.1093/ndt/gfz204] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 07/18/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Sodium thiosulphate (NaTS) is mostly used in haemodialysis (HD) patients with calcific uraemic arteriolopathy. This double-blind, randomized, placebo-controlled study assessed the effect of NaTS on progression of cardiovascular calcifications in HD patients. METHODS From 65 screened patients, we recruited 60 patients with an abdominal aorta Agatston calcification score ≥100. Thirty patients were randomized to receive NaTS 25 g/1.73 m2 and 30 patients to receive 100 mL of 0.9% sodium chloride intravenously during the last 15 min of HD over a period of 6 months. The primary endpoint was the absolute change of the abdominal aortic calcification score. RESULTS The abdominal aortic calcification score and calcification volume of the abdominal aorta increased similarly in both treatment groups during the trial. As compared with the saline group, patients receiving NaTS exhibited a reduction of their iliac artery calcification score (-137 ± 641 versus 245 ± 755; P = 0.049), reduced pulse wave velocity (9.6 ± 2.7 versus 11.4 ± 3.6; P = 0.000) and a lower carotid intima-media thickness (0.77 ± 0.1 versus 0.83 ± 00.17; P = 0.033) and had better preservation of echocardiographic parameters of left ventricular hypertrophy. No patient of the NaTS group developed new cardiac valve calcifications during the trial as compared with 8 of 29 patients in the saline group. By univariate analysis, NaTS therapy was the only predictor of not developing new valvular calcifications. No adverse events possibly related to NaTS infusion were noted. CONCLUSIONS While NaTS failed to retard abdominal aortic calcification progress, it positively affected calcification progress in iliac arteries and heart valves as well as several other cardiovascular functional parameters.
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Affiliation(s)
- Petar Djuric
- Clinical Department for Nephrology, Zvezdara University Medical Center, Belgrade, Serbia
| | - Nada Dimkovic
- Clinical Department for Nephrology, Zvezdara University Medical Center, Belgrade, Serbia.,Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Georg Schlieper
- Division of Nephrology and Immunology, Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany.,Center for Nephrology, Hypertension, and Metabolic Diseases, Hannover, Germany
| | - Zivka Djuric
- Clinical Department for Nephrology, Zvezdara University Medical Center, Belgrade, Serbia
| | - Milan Pantelic
- Center for Radiology, Zvezdara University Medical Center, Belgrade, Serbia
| | - Milica Mitrovic
- Center for Radiology and Magnetic Resonance Imaging, Clinical Center of Serbia, Beograd, Serbia
| | - Aleksandar Jankovic
- Clinical Department for Nephrology, Zvezdara University Medical Center, Belgrade, Serbia
| | - Marko Milanov
- Clinical Department for Cardiology, Zvezdara University Medical Center, Belgrade, Serbia
| | - Jovana Kuzmanovic Pficer
- Department for Medical Statistics and Informatics, School of Dental Medicine, University of Belgrade, Belgrade, Serbia
| | - Jürgen Floege
- Division of Nephrology and Immunology, Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
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Udomkarnjananun S, Kongnatthasate K, Praditpornsilpa K, Eiam-Ong S, Jaber BL, Susantitaphong P. Treatment of Calciphylaxis in CKD: A Systematic Review and Meta-analysis. Kidney Int Rep 2019; 4:231-244. [PMID: 30775620 PMCID: PMC6365410 DOI: 10.1016/j.ekir.2018.10.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/20/2018] [Accepted: 10/01/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Calciphylaxis is a life-threatening complication of chronic kidney disease (CKD). To inform clinical practice, we performed a systematic review of case reports, case series, and cohort studies to synthesize the available treatment modalities and outcomes of calciphylaxis in patients with CKD. METHODS Electronic databases were searched for studies that examined the uses of sodium thiosulfate, surgical parathyroidectomy, calcimimetics, hyperbaric oxygen therapy, and bisphosphonates for calciphylaxis in patients with CKD, including end-stage renal disease. For cohort studies, the results were synthesized quantitatively by performing random-effects model meta-analyses. RESULTS A total of 147 articles met the inclusion criteria and were included in the systematic review. There were 90 case reports (90 patients), 20 case series (423 patients), and 37 cohort studies (343 patients). In the pooled cohorts, case series, and case reports, 50.3% of patients received sodium thiosulfate, 28.7% underwent surgical parathyroidectomy, 25.3% received cinacalcet, 15.3% underwent hyperbaric oxygen therapy, and 5.9% received bisphosphonates. For the subset of cohort studies, by meta-analysis, the pooled risk ratio for mortality was not significantly different among patients who received sodium thiosulfate (pooled risk ratio [RR] 0.89; 95% confidence interval [CI] 0.71-1.12), cinacalcet (pooled RR 1.04; 95% CI 0.75-1.42), hyperbaric oxygen therapy (pooled RR 0.89; 95% CI 0.71-1.12), and bisphosphonates (pooled RR 0.77; 95% CI 0.44-1.32), and those who underwent surgical parathyroidectomy (pooled RR 0.88; 95% CI 0.69-1.13). CONCLUSION This systematic review found no significant clinical benefit of the 5 most frequently used treatment modalities for calciphylaxis in patients with CKD. Randomized controlled trials are needed to test the efficacy of these therapies.
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Affiliation(s)
- Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kitravee Kongnatthasate
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Bertrand L. Jaber
- Department of Medicine, St. Elizabeth’s Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Peng T, Zhuo L, Wang Y, Jun M, Li G, Wang L, Hong D. Systematic review of sodium thiosulfate in treating calciphylaxis in chronic kidney disease patients. Nephrology (Carlton) 2018; 23:669-675. [PMID: 28603903 DOI: 10.1111/nep.13081] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 12/21/2022]
Abstract
AIM Calciphylaxis is a severe complication of advanced chronic kidney disease (CKD). Sodium thiosulphate (STS), an antioxidant and calcium chelating agent, has been used for the treatment of calciphylaxis. However, its efficacy and safety have not been systematically analysed and evaluated. METHODS MEDLINE, EMBASE, and the Cochrane Library database were systematically searched for case report or cases series on use of STS for calciphylaxis published between July 1974 and October 2016. We extracted data on clinical characteristics, laboratory tests result and medication use. The effective treatment was defined as improvement in skin lesion cicatrisation or pain relief without death. Non-responding effects were defined as stable skin lesions without remission or exacerbation of the disease in patients who remained alive. All-cause mortality after STS treatment was defined as death due to exacerbations of calciphylaxis or other complications of advanced CKD. We compared the baseline parameters of the patients as well as the efficacy and mortality of the STS therapy between case report and multi-case reports. Statistical analyses were performed using SPSS 19. RESULTS A total of 83 papers were screened, 45 of them (n = 358) met the inclusion criteria, including 36 case reports (n = 64) and nine multi-case reports (n = 294). The mean age of the patients with calciphylaxis was 58 ± 14 years (range 26-91 years). They were female predominant, accounting for 74.1%. Among the patients with calciphylaxis, 96.1% patients were on dialysis with median dialysis vintage of 44.5 months (range 24-84 months). STS was effective in 70.1% of patients, 37.6% patients died. The proportion of patients with sepsis was higher among those who received intravenous STS. There was no significant difference in efficacy between the different STS administration methods (P = 0.19). CONCLUSION Although the study was unable to assess the efficacy of sodium thiosulphate alone in the treatment of calciphylaxis, it still reveals a promising role of STS as an effective therapy for calciphylaxis. Further prospective studies to define the optimal therapy for calciphylaxis are needed.
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Affiliation(s)
- Ting Peng
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Ling Zhuo
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Ying Wang
- The George Institute for Global Health, University of Sydney, Australia
| | - Min Jun
- The George Institute for Global Health, University of Sydney, Australia
| | - Guisen Li
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Li Wang
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Daqing Hong
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,The George Institute for Global Health, University of Sydney, Australia
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Vasculitic and autoimmune wounds. J Vasc Surg Venous Lymphat Disord 2016; 5:280-292. [PMID: 28214498 DOI: 10.1016/j.jvsv.2016.09.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 09/01/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Chronic wounds are a major cause of morbidity and mortality. Approximately 20% to 23% of nonhealing wounds that are refractory to vascular intervention have other causes, including vasculitis, pyoderma gangrenosum, and other autoimmune diseases. The purpose of this article was to review the literature across medical and surgical specialties with regard to refractory chronic wounds associated with vasculitis and autoimmune diseases and to delineate clinical outcomes of these wounds in response to vascular and other interventions. METHODS An electronic search encompassing MEDLINE, PubMed, Cochrane Library, and Scopus was completed using the following search terms: rheumatoid arthritis; systemic sclerosis; systemic lupus erythematosus; antineutrophil cytoplasmic antibody-associated vasculitis; mixed connective tissue disease; antiphospholipid syndrome; pyoderma gangrenosum; thromboangiitis obliterans; cryoglobulinemia; hydroxyurea; sickle cell; atrophie blanche; livedoid vasculitis; cholesterol emboli; calciphylaxis; antiphospholipid antibodies; prothrombotic; combined with the terms: chronic wound and leg ulcer. Full-text articles published in English up to March 1, 2016, that investigated the clinical outcomes of chronic wounds associated with autoimmune diseases were included. Review articles and evaluations of management of chronic wounds were also reviewed. Primary outcomes included in the review were amputation, ulcer healing, reduction in wound size, overall survival, and freedom from reintervention. Owing to the heterogeneity of data reporting among articles, qualitative analysis is also reported. RESULTS Vasculitis and autoimmune diseases play a role in 20% to 23% of patients with chronic lower extremity ulcers. Furthermore, patients with autoimmune disease have a significantly high rate of split thickness skin graft failure (50% compared to 97% in patients without autoimmune disease; P = .0002). The management of leg ulcers associated with autoimmune diseases is discussed. CONCLUSIONS Autoimmune and vasculitic causes should be considered in patients with chronic wounds who do not respond to appropriate vascular intervention and standard local wound care. A multidisciplinary approach with the involvement of rheumatologists allows investigation for underlying systemic disease and improves clinical outcomes for many of these challenging patients.
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Mageau A, Guigonis V, Ratzimbasafy V, Bardin T, Richette P, Urena P, Ea HK. Intravenous sodium thiosulfate for treating tumoral calcinosis associated with systemic disorders: Report of four cases. Joint Bone Spine 2016; 84:341-344. [PMID: 27955821 DOI: 10.1016/j.jbspin.2016.10.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/26/2016] [Indexed: 01/01/2023]
Abstract
Intravenous sodium thiosulfate (ivSTS) is a promising new therapeutic option for calciphylaxis related to end-stage renal disease. However, its effect on tumoral calcinosis (TC) complicating autoimmune connective-tissue diseases has been scarcely described. We report here 4 cases (3 adults and 1 child) of TC treated with ivSTS. TC was secondary to CREST syndrome, dermatomyositis (1 adult and 1 child) and systemic erythematous lupus and involved multiple sites in all cases. In all 4 patients, TC was responsible for joint pain, reduced mobility, inflammatory flares and skin fistulations. One patient experienced difficulty sitting due to the pain induced by calcified lesions on the buttock; another patient had major disability, moved only with wheelchair and was under opioid treatment for pain. For all patients, treatment with several medications before STS was unsuccessful. The 3 adults received at least 6 cycles of ivSTS (20g/d, 5 days/month) and the child received a daily infusion of 17g STS during 1 month then a 9-g/d infusion during 3 months. Two adults and the child showed clinical improvement with STS treatment and the third adult felt disappointed and stopped STS treatment after 6 months. The child also stopped STS after 6 months due to vomiting. In one patient, an intensive regimen of ivSTS (20g every 2 days) controlled recurrent flares and fistulations. Unfortunately, TC remained unchanged. Further studies are needed to decipher how STS modulates ectopic calcification, the optimal regimen and posology.
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Affiliation(s)
- Arthur Mageau
- Pôle locomoteur, service de rhumatologie, centre Viggo Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Vincent Guigonis
- Service de pédiatrie, hôpital de la Mère et de l'Enfant, 8, avenue Dominique-Larrey, 87000 Limoges, France
| | - Voa Ratzimbasafy
- Service de pharmacie, hôpital de la Mère et de l'Enfant, 8, avenue Dominique-Larrey, 87000 Limoges, France
| | - Thomas Bardin
- Pôle locomoteur, service de rhumatologie, centre Viggo Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; UFR de médecine, université Paris 7 Denis Diderot, Paris Cité Sorbonne, 16, rue Henri-Huchard, 75018 Paris, France
| | - Pascal Richette
- Pôle locomoteur, service de rhumatologie, centre Viggo Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; UFR de médecine, université Paris 7 Denis Diderot, Paris Cité Sorbonne, 16, rue Henri-Huchard, 75018 Paris, France
| | - Pablo Urena
- Service de néphrologie et dialyse, Ramsay-Générale de Santé, clinique du Landy, 23, rue de Landy, 93400 Saint-Ouen, France
| | - Hang-Korng Ea
- Pôle locomoteur, service de rhumatologie, centre Viggo Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; UFR de médecine, université Paris 7 Denis Diderot, Paris Cité Sorbonne, 16, rue Henri-Huchard, 75018 Paris, France.
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Shanmugam VK. Vasculitic Diseases and Prothrombotic States Contributing to Delayed Healing In Chronic Wounds. CURRENT DERMATOLOGY REPORTS 2016; 5:270-277. [PMID: 27833788 DOI: 10.1007/s13671-016-0157-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE Autoimmune diseases are a common cause of delayed wound healing and should be considered in patients with chronic wounds who do not respond to local wound care or who fail skin grafting in the absence of infection. RECENT FINDINGS Epidemiologic studies have shown that, of patients with chronic wounds evaluated in specialized wound healing clinics, 20-23% have autoimmune etiologies for their wounds including vasculitis, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, pyoderma gangrenosum and other autoimmune diseases. SUMMARY In this article autoimmune diseases known to be associated with chronic wounds and delayed wound healing are reviewed and the importance of a multidisciplinary approach for patients with chronic wounds, with involvement of rheumatology and dermatology is highlighted. This approach allows for investigation of underlying systemic disease and improves clinical outcomes for many of these challenging patients.
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Affiliation(s)
- Victoria K Shanmugam
- Division of Rheumatology, The George Washington University, School of Medicine and Health Sciences, 701 Ross Hall, 2300 Eye Street, NW, Washington, DC 20037
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