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Bajaj R, Courbebaisse M, Kroshinsky D, Thadhani RI, Nigwekar SU. Calciphylaxis in Patients With Normal Renal Function: A Case Series and Systematic Review. Mayo Clin Proc 2018; 93:1202-1212. [PMID: 30060958 DOI: 10.1016/j.mayocp.2018.06.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 06/02/2018] [Accepted: 06/05/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To define concomitant risk factors, treatment, and outcomes for patients with nonnephrogenic calciphylaxis (NNC). PATIENTS AND METHODS A retrospective review of Massachusetts General Hospital (MGH) medical records (January 1, 2014, through February 29, 2016) and a systematic literature review of PubMed, Google Scholar, EMBASE, MEDLINE, and CENTRAL (August 1, 1970, through July 31, 2016) were performed. Demographic characteristics and concomitant features were summarized and compared between patients with different lesion characteristics. Outcomes (lesion improvement and mortality) and their predictors were analyzed. RESULTS Nine patients (median age, 72 years [interquartile range (IQR), 44-82 years]; 78% women; 89% white race) were identified through MGH records. The literature review identified 107 patients (median age, 60 years [IQR, 49-72 years]; 77% women; 86% white race). Vitamin K antagonism and obesity were the most common concomitant factors. In the literature review, lower age (P<.001) and higher body mass index (P=.03) were associated with the central location of lesions, whereas vitamin K antagonism was associated with the peripheral location (P=.009). In the MGH series, median survival was 24.0 months (95% CI, 7.8-36.0 months), and 33% (95% CI, 14%-60%) had lesion improvement by 6 months. In the literature review, median survival was 4.2 months (95% CI, 1.9-5.9 months), median time to lesion improvement was 5.9 months (95% CI, 3.9-8.9 months), and none of the treatments were associated with lesion improvement or survival. CONCLUSION This description of concomitant traits may augment an earlier recognition of NNC. Future research is needed to investigate NNC pathogenesis and treatments.
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Affiliation(s)
- Richa Bajaj
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA; Khorana Scholar 2016, Khorana Program for Scholars, INDO-US Science and Technology Forum, New Delhi, India
| | - Marie Courbebaisse
- Division of Bone and Mineral Research, Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA; Faculty of Medicine, Paris Descartes University, Paris, France
| | | | - Ravi I Thadhani
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA; Department of Biomedical Sciences and Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sagar U Nigwekar
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA.
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[Unexplained diffuse arteriosclerosis in a 26-year-old patient]. Ann Cardiol Angeiol (Paris) 2018; 67:106-109. [PMID: 29506748 DOI: 10.1016/j.ancard.2018.01.004] [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: 01/19/2017] [Accepted: 01/30/2018] [Indexed: 11/21/2022]
Abstract
Arteriosclerosis is an alteration of the blood vessels whose walls calcify, lose their elasticity and thicken. The result is a decrease in circulating blood flow and ischemic manifestations. Calcification of the arteries is a physiological phenomenon in the elderly but young subjects may also be affected. Indeed, certain risk factors can favor the formation of plaques at the level of the vessels. These include classic cardiovascular risk factors, as well as systemic inflammatory diseases, connective tissue diseases, chronic hypercalcemia… We report the case of a 26-year-old female patient with diffuse arteriosclerosis discovered accidentally, and whose exhaustive etiological investigation remained negative.
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Isoherranen K, Bouchard L, Kluger N. Benefits of intralesional injections of sodium thiosulfate in the treatment of calciphylaxis. Int Wound J 2017; 14:955-959. [PMID: 28326673 DOI: 10.1111/iwj.12738] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/06/2017] [Accepted: 02/10/2017] [Indexed: 11/28/2022] Open
Abstract
Calciphylaxis (CPX) is a rare calcifying thrombotic vasculopathy responsible for painful necrotic ulcers, with a high mortality rate, and its management is often difficult. Recently, intravenous infusions of sodium thiosulfate (STS) have shown efficacy. The aim of this study was to assess the efficacy of intralesional STS (IL STS) in four patients. Our aim was to assess the efficacy of IL STS in a prospective mono-centric open study that included four patients with a biopsy-proven cutaneous CPX. Four women (55-84 years old, mean age: 71·2 years) with a uremic (n = 1) or non-uremic CPX (n = 3) and primary hyperparathyroidism induced by teriparatide or after the initiation of oral anti-vitamin K were treated by IL STS (250 mg/ml). The injections were performed around the ulcers, on the active borders, once or twice a week and then at 1-2 weeks intervals. The injected quantity varied from 1·5 to 15 ml. Pain usually improved after two series of injections. Clinical response was visible after 2 weeks. Three patients (75%) healed completely or almost completely. A failure was observed in the last patient who also had lower limb arteriopathy. The main side effect was the pain during injections. IL STS is an interesting alternative therapeutic option in the management of CPX necrotic ulcers with limited side effects. Larger studies are warranted to precisely define its place, its administration procedure and the patients who could benefit from it.
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Affiliation(s)
- Kirsi Isoherranen
- Department of Dermatology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Laura Bouchard
- Department of Dermatology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Nicolas Kluger
- Department of Dermatology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
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Abstract
Wound management imposes a defined approach to each phase of healing and thereby the need for in-depth knowledge of the various medical devices available: primary and secondary dressings. Secondary dressings are essential as they have an impact on the efficacy of the primary dressing. Their role is to protect, reinforce and cover the primary dressing. In practice, it is usually nurses who have the responsibility of selecting and prescribing the most suitable dressing for the wound.
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Affiliation(s)
- Anne Philippe
- Direction des Soins, hôpital Saint-Antoine - GH Est Parisien, AP-HP, 184, rue du Faubourg Saint-Antoine, 75571 Paris Cedex 12, France.
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Perceau G. [Uraemic and non-uraemic calcific arteriopathy: The need for rapid diagnosis and therapy]. Ann Dermatol Venereol 2015; 142:506-12. [PMID: 26253008 DOI: 10.1016/j.annder.2015.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Calcific arteriopathy (CA), also commonly known as calciphylaxis, is a disease carrying a poor prognosis. It is seen primarily in patients with chronic renal insufficiency (CRI), particularly those on haemodialysis (HD), where it is referred to as uraemic calcific arteriopathy (UCA), but it also occurs outside this setting, in which case it is known as non-uraemic calcific arteriopathy (NUCA). It is caused by thrombotic cutaneous arteriolar microangiopathy associated with fine calcium deposits in the media associated with hyperplasia of the intima of the dermal and hypodermal arterioles. Its course comprises two phases: a silent phase in which the arteriolar abnormalities begin, followed by a symptomatic phase, frequently triggered by specific factors, with sudden appearance of necrotic ischaemic plaques on the skin. Several clinical forms exist, proximal, distal and mixed, depending on the main site of the lesions. The prognosis is poor due to septic complications and the involvement of other organs. Diagnosis is based on the patient's history, clinical examination, laboratory examinations and skin biopsy with Von Kossa staining. The physiopathology, which is complex and is becoming increasingly well understood, involves high phosphorous and calcium levels and hyperparathyroidism, as well as other factors (inflammation, factors promoting or inhibiting calcification, coagulation disorders and traumatisms). Treatment involves a multidisciplinary and medical-surgical approach.
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Affiliation(s)
- G Perceau
- Service de dermatologie, hôpital Robert-Debré, CHU de Reims, avenue du Général-Koenig, 51092 Reims cedex, France.
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Bennis Y, Becquart C, Aljudaibi N, Patenotre P, Guerreschi P, Delaporte E, Duquennoy-Martinot V. [Massive panniculectomy and bilateral subtotal mastectomy in a case of calciphylaxis: A case report and up date]. ANN CHIR PLAST ESTH 2015; 60:527-32. [PMID: 25799428 DOI: 10.1016/j.anplas.2015.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 02/18/2015] [Indexed: 12/17/2022]
Abstract
Calciphylaxis or calcific arteriolopathy is a rare, life-threatening obstructive pathology of the small cutaneous and subcutaneous vessels. It mainly affects patients with chronic renal failure but it also has been described in patients with normal renal function. The principal risks factors apart from renal failure and phosphocalcic metabolism imbalance are: the female sex, obesity, peripheral vascular disease, diabetes and oral anti-coagulation. We present a very rare case of abdominal, mammarian and upper thighs calciphylaxis in a patient with normal renal function. She presented a severe obesity with a recent important loss of weight and had been treated by oral anticoagulants for a long time. She benefited of a multidisciplinary approach with dermatologists, plastic surgeons and anesthesists permitting a recovery in fourteen weeks. Multidisciplinary approach is necessary but the place of the surgery is not well defined. We report a case in which early and wide surgical approach permitted to obtain a favourable evolution of the pathology. Then, we propose a therapeutic strategy after review of the literature.
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Affiliation(s)
- Y Bennis
- Service de chirurgie plastique reconstructrice et esthétique, hôpital Roger-Salengro, CHRU, 59037 Lille, France.
| | - C Becquart
- Clinique dermatologique, hôpital Claude-Huriez, CHRU, 59037 Lille, France; Faculté de médecine Henri Warembourg, université de Lille, 59045 Lille, France
| | - N Aljudaibi
- Service de chirurgie plastique reconstructrice et esthétique, hôpital Roger-Salengro, CHRU, 59037 Lille, France
| | - P Patenotre
- Chirurgie générale et vasculaire, hôpital Claude-Huriez, CHRU, 59037 Lille, France; Faculté de médecine Henri Warembourg, université de Lille, 59045 Lille, France
| | - P Guerreschi
- Service de chirurgie plastique reconstructrice et esthétique, hôpital Roger-Salengro, CHRU, 59037 Lille, France; Faculté de médecine Henri Warembourg, université de Lille, 59045 Lille, France
| | - E Delaporte
- Clinique dermatologique, hôpital Claude-Huriez, CHRU, 59037 Lille, France; Faculté de médecine Henri Warembourg, université de Lille, 59045 Lille, France
| | - V Duquennoy-Martinot
- Service de chirurgie plastique reconstructrice et esthétique, hôpital Roger-Salengro, CHRU, 59037 Lille, France; Faculté de médecine Henri Warembourg, université de Lille, 59045 Lille, France
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Aoun A, Baubion E, Banydeen R, Djiconkpode I, Ekindi N, Ureña-Torres P, Riaux A, Sadreux T, Dueymes JM, Quist D, Derancourt C. Incidence et caractéristiques de la calciphylaxie en Martinique (2006–2012). Ann Dermatol Venereol 2014; 141:743-9. [DOI: 10.1016/j.annder.2014.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 03/22/2014] [Accepted: 06/19/2014] [Indexed: 01/26/2023]
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Hacard F, Grézard O, El Khoury N, Maître F, Delaplace M, Estève E. [Diffuse calcinosis in terminal renal failure]. Ann Dermatol Venereol 2010; 137:759-60. [PMID: 21074668 DOI: 10.1016/j.annder.2010.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 07/20/2010] [Accepted: 08/04/2010] [Indexed: 10/19/2022]
Affiliation(s)
- F Hacard
- Hôpital Porte-Madeleine, CHR d'Orléans, France
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Prey S, Sparsa A, Durox H, Allot V, Pommepuy I, Salem A, Roux C, Labrousse F, Bonnetblanc JM. Le traitement de la calciphylaxie par cinacalcet : une alternative médicale à la parathyroïdectomie. Rev Med Interne 2009; 30:186-9. [DOI: 10.1016/j.revmed.2008.04.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2008] [Revised: 04/13/2008] [Accepted: 04/25/2008] [Indexed: 11/30/2022]
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[Livedo: from pathophysiology to diagnosis]. Rev Med Interne 2008; 29:380-92. [PMID: 18374456 DOI: 10.1016/j.revmed.2007.11.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Revised: 10/18/2007] [Accepted: 11/05/2007] [Indexed: 11/20/2022]
Abstract
PURPOSE We propose a diagnostic approach when facing a livedo. First, the pathophysiology of the livedo is reviewed using key articles barely quoted in the literature. Then the topic is handled in two ways. Figures and tables allow a rapid reading convenient "at the patient's bedside". The subject is also reviewed thoroughly, and we emphasize the intricacy of the various pathophysiological mechanisms involved for each livedo's related disease. Diseases associated with livedo are then briefly described with emphasis on the key diagnostic features and prevalence. Usefulness of the main diagnostic procedures is discussed. CURRENT KNOWLEDGE AND KEY POINTS A livedo is a usually purplish-blue erythema, reticulated (small and complete meshes) or racemosa (large broken circular segments) which is related to a slowdown of the blood flow in the dermic venules. These venules form adjacent circles communicating with each other, parallel to the skin surface. The blood flow slowdown may be due to a local vasoconstriction (vasomotor livedo) or to an arteriolar occlusion. Arteriolar occlusion may be related to blood abnormalities (thrombosis, high viscosity, embolus) or to increased parietal thickness (vasculitis, calcic deposition, intimal hyperplasia). It is not always possible to clinically distinguish a vasomotor livedo from those associated with diseases. Diagnostic procedures should be oriented by the medical history, the features of the livedo, and associated symptoms. Usefulness of the skin biopsy is usually limited to the situations where the livedo is infiltrated or necrotic. FUTURE PROSPECTS AND PROJECTS To raise controversy about their importance and implications, some pathophysiological data are presented: intimal pseudohyperplasia in Sneddon's syndrome and antiphospholipid syndrome, and white cell activation in essential thrombocythemia.
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Ferrando F, Ricart J, Vayá A, Mira Y. Actitud ante un paciente con calcifilaxia que precisa anticoagulación. ACTAS DERMO-SIFILIOGRAFICAS 2007; 98:721-2. [DOI: 10.1016/s0001-7310(07)70171-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Management of a Patient With Calciphylaxis and Requiring Anticoagulant Therapy. ACTAS DERMO-SIFILIOGRAFICAS 2007. [DOI: 10.1016/s1578-2190(07)70551-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Bura-Rivière A. Artériolopathie calcifiante urémique ou calciphylaxie : un facteur de risque vasculaire indépendant ? Rev Med Interne 2006; 27:181-3. [PMID: 16364506 DOI: 10.1016/j.revmed.2005.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2005] [Accepted: 11/10/2005] [Indexed: 12/21/2022]
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