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Herringshaw E, Kinne M, Joyce R, Nutan F. Evaluating the role of bone scan in diagnosing calciphylaxis in practice-A retrospective case series of patients who were clinically managed for calciphylaxis despite resulting negative on initial biopsy. Australas J Dermatol 2024; 65:283-286. [PMID: 38641920 DOI: 10.1111/ajd.14263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/13/2024] [Accepted: 03/25/2024] [Indexed: 04/21/2024]
Affiliation(s)
- Emilee Herringshaw
- Department of Dermatology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Maximilian Kinne
- Department of Dermatology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Renee Joyce
- Department of Dermatology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Fnu Nutan
- Department of Dermatology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, 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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3
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On the role of skin biopsy in the diagnosis of calcific uremic arteriolopathy: a case-based discussion. J Nephrol 2019; 33:859-865. [PMID: 31792896 DOI: 10.1007/s40620-019-00678-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/24/2019] [Indexed: 12/30/2022]
Abstract
Calciphylaxis is a rare disease characterized by ectopic calcification of skin arterioles resulting in ischemia, thrombosis and necrosis. Since end stage renal disease patients are those mainly affected, the term calcific uremic arteriolopathy (CUA) is also suggested. Early clinical manifestations are subtle, while overt necrotic ulcers may quickly spread and become infected so as to result in ominous outcome. Diagnosis might not be easy due to the number of other ischemic and non-ischemic skin lesions observed in uraemia. Skin biopsy, has been proposed as the diagnostic test and is often considered, but not systematically performed due to the hypothetical risk of further spreading of the lesions. Such ambiguity could be responsible for misdiagnosis or underdiagnosis. We review here five consecutive cases recorded in our Unit, all submitted to skin biopsy but with inconsistent results which generated some clinical frustration. Thus, we decided to carefully re-evaluate all of them together with pathologists and dermatologists. However, even after this ex-post discussion, we could not reach a complete agreement on the final diagnosis. In the meanwhile, papers were published in the literature that started to shed some light on the role of skin biopsy in the diagnosis of CUA.
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4
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Barbosa MM, Araújo E, Pereira MM, Mendes T. The Perfect Storm: A Case of Non-Uremic Calciphylaxis. Eur J Case Rep Intern Med 2019; 6:001078. [PMID: 31139582 PMCID: PMC6499099 DOI: 10.12890/2019_001078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 03/11/2019] [Indexed: 11/25/2022] Open
Abstract
Calciphylaxis is a severe condition associated with chronic kidney disease. We describe a rare case of non-uremic calciphylaxis in a 79-year-old woman with prosthetic aortic and mitral valves, chronic kidney disease and anaemia, who presented with painful skin lesions on her left leg. She was taking warfarin, calcium and iron supplements, and had been recently diagnosed with oligoarthritis and started on prednisolone, all factors associated with calciphylaxis. Despite treatment, the lesions rapidly progressed to large ulceration and sepsis, and pain management was challenging. Calciphylaxis was confirmed following a second skin biopsy but the patient died from septic shock and multi-organ failure. This case highlights the challenges associated with the diagnosis and treatment of calciphylaxis despite a high level of suspicion.
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Affiliation(s)
| | - Elsa Araújo
- Unidade Local Saúde Alto Minho, EPE, Ponte de Lima, Portugal
| | | | - Tiago Mendes
- Unidade Local Saúde Alto Minho, EPE, Ponte de Lima, Portugal
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5
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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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Abstract
PURPOSE OF REVIEW Calciphylaxis remains a poorly understood vascular calcification disorder with predilection for patients with end-stage renal disease (ESRD). Recent data from large patient registries and databases have begun to provide information regarding incidence, risk factors, and outcomes in patients with calciphylaxis. RECENT FINDINGS The most recent estimate places the incidence of calciphylaxis at 3.5 new cases/1000 patient-years among the patients with ESRD on chronic hemodialysis. It is possible that misdiagnosis or subclinical disease may attribute to lower than the true incidence. There is a suggestion that the incidence is higher in peritoneal dialysis patients compared with patients with hemodialysis. Recent studies have identified a number of risk factors and point to the effects of vitamin K deficiency mediated impairment in Matrix Gla Protein carboxylation as one of the likely pathogenic mechanisms. The outcomes in calciphylaxis patients remain poor with mortality approaching 30% at 6 months and 50% at 12 months. SUMMARY The present review describes recent literature in the field of calciphylaxis. Calciphylaxis registries and specimen biorepositories promise to provide insights into the pathogenesis of calciphylaxis and will pave the way for much needed clinical trials.
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Fernández M, Morales E, Gutierrez E, Polanco N, Hernández E, Mérida E, Praga M. Calcifilaxis: más allá de CKD-MBD. Nefrologia 2017; 37:501-507. [DOI: 10.1016/j.nefro.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/29/2017] [Accepted: 02/06/2017] [Indexed: 01/09/2023] Open
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Nigwekar SU, Zhao S, Wenger J, Hymes JL, Maddux FW, Thadhani RI, Chan KE. A Nationally Representative Study of Calcific Uremic Arteriolopathy Risk Factors. J Am Soc Nephrol 2016; 27:3421-3429. [PMID: 27080977 PMCID: PMC5084892 DOI: 10.1681/asn.2015091065] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 03/14/2016] [Indexed: 11/03/2022] Open
Abstract
Accurate identification of risk factors for calcific uremic arteriolopathy (CUA) is necessary to develop preventive strategies for this morbid disease. We investigated whether baseline factors recorded at hemodialysis initiation would identify patients at risk for future CUA in a matched case-control study using data from a large dialysis organization. Hemodialysis patients with newly diagnosed CUA (n=1030) between January 1, 2010, and December 31, 2014, were matched by age, sex, and race in a 1:2 ratio to hemodialysis patients without CUA (n=2060). Mean ages for patients and controls were 54 and 55 years, respectively; 67% of participants were women and 49% were white. Median duration between hemodialysis initiation and subsequent CUA development was 925 days (interquartile range, 273-2185 days). In multivariable conditional logistic regression analyses, diabetes mellitus; higher body mass index; higher levels of serum calcium, phosphorous, and parathyroid hormone; and nutritional vitamin D, cinacalcet, and warfarin treatments were associated with increased odds of subsequent CUA development. Compared with patients with diabetes receiving no insulin injections, those receiving insulin injections had a dose-response increase in the odds of CUA involving lower abdomen and/or upper thigh areas (odds ratio, 1.49; 95% confidence interval, 1.03 to 2.51 for one or two injections per day; odds ratio, 1.88; 95% confidence interval, 1.30 to 3.43 for 3 injections per day; odds ratio, 3.74; 95% confidence interval, 2.28 to 6.25 for more than three injections per day), suggesting a dose-effect relationship between recurrent skin trauma and CUA risk. The presence of risk factors months to years before CUA development observed in this study will direct the design of preventive strategies and inform CUA pathobiology.
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Affiliation(s)
- Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts;
| | - Sophia Zhao
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Julia Wenger
- Division of Nephrology, University of North Carolina Kidney Center, Chapel Hill, North Carolina; and
| | - Jeffrey L Hymes
- Medical office, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Franklin W Maddux
- Medical office, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Ravi I Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kevin E Chan
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Medical office, Fresenius Medical Care North America, Waltham, Massachusetts
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McCarthy JT, El-Azhary RA, Patzelt MT, Weaver AL, Albright RC, Bridges AD, Claus PL, Davis MDP, Dillon JJ, El-Zoghby ZM, Hickson LJ, Kumar R, McBane RD, McCarthy-Fruin KAM, McEvoy MT, Pittelkow MR, Wetter DA, Williams AW. Survival, Risk Factors, and Effect of Treatment in 101 Patients With Calciphylaxis. Mayo Clin Proc 2016; 91:1384-1394. [PMID: 27712637 DOI: 10.1016/j.mayocp.2016.06.025] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/18/2016] [Accepted: 06/21/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To report on the survival and the associations of treatments upon survival of patients with calciphylaxis seen at a single center. PATIENTS AND METHODS Using the International Classification of Diseases, Ninth Revision diagnosis code of 275.49 and the keyword "calciphylaxis" in the dismissal narrative, we retrospectively identified 101 patients with calciphylaxis seen at our institution between January 1, 1999, through September 20, 2014, using a predefined, consensus-developed classification scheme. RESULTS The average age of patients was 60 years: 81 (80.2%) were women; 68 (68.0%) were obese; 19 (18.8%) had stage 0 to 2 chronic kidney disease (CKD), 19 (18.9%) had stage 3 or 4 CKD; 63 (62.4%) had stage 5 or 5D (dialysis) CKD. Seventy-five patients died during follow-up. Six-month survival was 57%. Lack of surgical debridement was associated with insignificantly lower 6-month survival (hazard ratio [HR]=1.99; 95% CI, 0.96-4.15; P=.07) and significantly poorer survival for the entire duration of follow-up (HR=1.98; 95% CI, 1.15-3.41; P=.01), which was most pronounced in stage 5 or 5D CKD (HR=1.91; 95% CI, 1.03-3.56; P=.04). Among patients with stage 5/5D CKD, subtotal parathyroidectomy (performed only in patients with hyperparathyroidism) was associated with better 6-month (HR=0.12; 95% CI, 0.02-0.90; P=.04) and overall survival (HR= 0.37; 95% CI, 0.15-0.87; P=.02). CONCLUSION Calciphylaxis is associated with a high mortality rate. Significantly effective treatments included surgical debridement and subtotal parathyroidectomy in patients with stage 5/5D CKD with hyperparathyroidism. Treatments with tissue-plasminogen activator, sodium thiosulfate, and hyperbaric oxygen therapy were not associated with higher mortality.
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Affiliation(s)
- James T McCarthy
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
| | | | - Michelle T Patzelt
- Mayo Medical School, Mayo Graduate School of Medicine, Mayo Clinic, Rochester, MN
| | - Amy L Weaver
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Robert C Albright
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - Paul L Claus
- Department of Medicine, Division of Hyperbaric Medicine in Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | | | - John J Dillon
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Ziad M El-Zoghby
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - LaTonya J Hickson
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Rajiv Kumar
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Robert D McBane
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Amy W Williams
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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El-Azhary RA, Patzelt MT, McBane RD, Weaver AL, Albright RC, Bridges AD, Claus PL, Davis MDP, Dillon JJ, El-Zoghby ZM, Hickson LJ, Kumar R, McCarthy-Fruin KAM, McEvoy MT, Pittelkow MR, Wetter DA, Williams AW, McCarthy JT. Calciphylaxis: A Disease of Pannicular Thrombosis. Mayo Clin Proc 2016; 91:1395-1402. [PMID: 27712638 DOI: 10.1016/j.mayocp.2016.06.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/18/2016] [Accepted: 06/21/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To identify coagulation risk factors in patients with calciphylaxis and the relationship between anticoagulation use and overall survival. PATIENTS AND METHODS Study subjects were 101 patients with calciphylaxis seen at Mayo Clinic from 1999 to September 2014. Data including thrombophilia profiles were extracted from the medical records of each patient. Survival status was determined using patient registration data and the Social Security Death Index. Survival was estimated using the Kaplan-Meier method, and associations were evaluated using Cox proportional hazards models. RESULTS Sixty-four of the 101 patients underwent thrombophilia testing. Of these, a complete test panel was performed in 55 and a partial panel in 9. Severe thrombophilias observed in 60% (33 of 55) of the patients included antiphospholipid antibody syndrome protein C, protein S, or antithrombin deficiencies or combined thrombophilias. Of the 55 patients, severe thrombophilia (85%, 23 of 27) was noted in patients who were not on warfarin at the time of testing (27). Nonsevere thrombophilias included heterozygous factor V Leiden (n=2) and plasminogen deficiency (n=1). For the comparison of survival, patients were divided into 3 treatment categories: Warfarin (n=63), other anticoagulants (n=20), and no anticoagulants (n=18). There was no statistically significant survival difference between treatment groups. CONCLUSION Laboratory testing reveals a strikingly high prevalence of severe thrombophilias in patients with calciphylaxis, underscoring the importance of congenital and acquired thrombotic propensity potentially contributing to the pathogenesis of this disease. These findings may have therapeutic implications; however, to date, survival differences did not vary by therapeutic choice.
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Affiliation(s)
| | - Michelle T Patzelt
- Mayo Medical School, Mayo Graduate School of Medicine, Mayo Clinic, Rochester, MN
| | - Robert D McBane
- Department of Medicine, Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | - Amy L Weaver
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Robert C Albright
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - Paul L Claus
- Department of Medicine, Division of Hyperbaric Medicine in Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | | | - John J Dillon
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Ziad M El-Zoghby
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - LaTonya J Hickson
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Rajiv Kumar
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Amy W Williams
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - James T McCarthy
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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11
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Zhang Y, Corapi KM, Luongo M, Thadhani R, Nigwekar SU. Calciphylaxis in peritoneal dialysis patients: a single center cohort study. Int J Nephrol Renovasc Dis 2016; 9:235-241. [PMID: 27698566 PMCID: PMC5034913 DOI: 10.2147/ijnrd.s115701] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Calciphylaxis is a rare but devastating condition in end-stage renal disease (ESRD) patients. Most research in the field of calciphylaxis is focused on hemodialysis (HD) patients; however, data on calciphylaxis incidence, risk factors, and mortality in peritoneal dialysis (PD) patients are limited. METHODS In this cohort study, we examined data from adult patients who initiated PD for ESRD management at our institute's PD unit from January 2001 to December 2015. Associations with the development of calciphylaxis were examined for clinical, laboratory, and medication exposures. Incidence of calciphylaxis and mortality in PD patients who developed calciphylaxis were analyzed. Treatments administered to treat calciphylaxis in PD patients were summarized. RESULTS In this cohort of 63 patients, 7 patients developed calciphylaxis (incidence rate: 9.0 per 1,000 patient-years). Median age of PD patients who developed calciphylaxis was 50 years, 57% were white, 71% females, and 71% were previously on HD. Female sex, obesity, HD as a prior dialysis modality, recurrent hypotension, elevated time-averaged serum phosphorous levels, reduced time-averaged serum albumin levels, and warfarin therapy were associated with increased calciphylaxis risk in univariate logistic regression analyses. Intravenous sodium thiosulfate was administered in 57% of PD patients who developed calciphylaxis. One-year mortality in PD patients who developed calciphylaxis was 71% despite multimodal treatment including sodium thiosulfate, hyperbaric oxygen, cinacalcet, and wound debridement. CONCLUSION Calciphylaxis is a rare but frequently fatal condition in PD patients. Our study provides critical early insights into calciphylaxis incidence, risk factors, and prognosis in PD patients. Sample size and characteristics of patients included in our study limit generalizability to overall PD population and warrant examination in larger independent studies.
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Affiliation(s)
- Yanchen Zhang
- Harvard Summer Research Program in Kidney Medicine, Boston, MA, USA
| | - Kristin M Corapi
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Maria Luongo
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Ravi Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Sagar U Nigwekar
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
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12
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Brandenburg VM, Evenepoel P, Floege J, Goldsmith D, Kramann R, Massy Z, Mazzaferro S, Schurgers LJ, Sinha S, Torregrosa V, Ureña-Torres P, Vervloet M, Cozzolino M. Lack of evidence does not justify neglect: how can we address unmet medical needs in calciphylaxis? Nephrol Dial Transplant 2016; 31:1211-9. [PMID: 27005994 DOI: 10.1093/ndt/gfw025] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 01/27/2016] [Indexed: 12/20/2022] Open
Abstract
Calcific uraemic arteriolopathy (CUA), or calciphylaxis, is a rare disease predominantly occurring in comorbidity with dialysis. Due to the very low frequency of CUA, prospective studies on its management are lacking and even anecdotal reports on treatment remain scarce. Therefore, calciphylaxis is still a challenging disease with dismal prognosis urgently requiring adequate strategies for diagnosis and treatment.In an attempt to fill some of the current gaps in evidence on various, highly debated and controversial aspects of dialysis-associated calciphylaxis, 13 international experts joined the 1st Consensus Conference on CUA, held in Leuven, Belgium on 21 September 2015. The conference was supported by the European Calciphylaxis Network (EuCalNet), which is a task force of the ERA-EDTA scientific working group on Chronic Kidney Disease-Mineral and Bone Disorders (CKD-MBD). After an intense discussion, a 9-point Likert scale questionnaire regarding 20 items on calciphylaxis was anonymously answered by each participant. These 20 items addressed unsolved issues in terms of diagnosis and management of calciphylaxis. On the one hand, the analysis of the expert opinions identified areas of general consensus, which might be a valuable aid for physicians treating such a disease with less experience in the field. On the other hand, some topics such as the pertinence of skin biopsy and administration of certain treatments revealed divergent opinions. The aim of the present summary report is to provide some guidance for clinicians who face patients with calciphylaxis in the current setting of absence of evidence-based medicine.
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Affiliation(s)
| | - Pieter Evenepoel
- Department of Internal Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Jürgen Floege
- Department of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - David Goldsmith
- Renal and Transplantation Department, Guy's and St Thomas' Hospitals, London, UK
| | - Rafael Kramann
- Department of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Ziad Massy
- Division of Nephrology, Ambroise Paré University Hospital, APHP, University of Paris Ouest-Versailles-St-Quentin-en-Yvelines (UVSQ), Boulogne-Billancourt, Paris INSERM U1018, Research Centre in Epidemiology and Population Health (CESP) Team 5, Villejuif, France F-CRIN-INI-CRCT, Nancy, France
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic, Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Leon J Schurgers
- Department of Biochemistry, Faculty of Medicine, Health and Life Science, Maastricht, The Netherlands
| | - Smeeta Sinha
- Department of Renal Medicine, Manchester Academic Health Sciences Centre, Salford Royal NHS Foundation Trust, Salford, UK
| | - Vicens Torregrosa
- Nephrology and Renal Transplantation Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Pablo Ureña-Torres
- Department of Nephrology and Dialysis, Clinique du Landy, Saint-Ouen, France Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Marc Vervloet
- Department of Nephrology, VU University Medical Center, Amsterdam, The Netherlands
| | - Mario Cozzolino
- Department of Health Sciences, University of Milan, Renal Division, San Paolo Hospital, Milan, Italy
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13
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Russo D, Capuano A, Cozzolino M, Napolitano P, Mosella F, Russo L, Saviano C, Zoccali C. Multimodal treatment of calcific uraemic arteriolopathy (calciphylaxis): a case series. Clin Kidney J 2015; 9:108-12. [PMID: 26798470 PMCID: PMC4720199 DOI: 10.1093/ckj/sfv120] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 10/20/2015] [Indexed: 12/27/2022] Open
Abstract
Background This is an incident series of five dialysis patients with late-diagnosed calcific uraemic arteriolophathy (CUA), severe uncontrolled hyperparathyroidism and infected skin ulcerations. Methods A multimodal intervention was based on wound care, antibiotics, surgical debridement, sodium thiosulphate and cinacalcet and associated with regression of skin disease in four cases after varying treatment time periods ranging from 4 to 33 months. Results Multimodal treatment including sodium thiosulphate and cinacalcet was associated with very favourable local outcomes and survival. This series further confirms that the diagnosis of CUA is rarely made at the nodular, non-ulcerative phase of the disease. Conclusions This series contributes to the build-up of case series reporting on the treatment of CUA, and will hopefully serve as a basis of well-conceived comparative effectiveness studies investigating the value of the combined interventions applied so far in this severe condition.
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Affiliation(s)
- Domenico Russo
- Department of Nephrology , University of Naples , Napoli , Italy
| | - Alfredo Capuano
- Department of Nephrology , University of Naples , Napoli , Italy
| | | | - Paola Napolitano
- Department of Nephrology , University of Naples , Napoli , Italy
| | | | - Luigi Russo
- Department of Nephrology , Second University of Naples , Napoli , Italy
| | - Caterina Saviano
- Department of Internal Medicine , 'San Sebastiano' Hospital , Caserta , Italy
| | - Carmine Zoccali
- Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria Unit of CNR-IFC (National Research Council of Italy and Institute of Clinical Physiology), Reggio Calabria, Italy
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14
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Gupta N, Haq KF, Mahajan S, Nagpal P, Doshi B. Gastrointestinal Bleeding Secondary to Calciphylaxis. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:818-22. [PMID: 26572938 PMCID: PMC4654591 DOI: 10.12659/ajcr.895164] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Female, 66 Final Diagnosis: Calciphylaxis Symptoms: Gastrointesinal haemorrhage Medication: None Clinical Procedure: Hemodialysis • blood transfusions Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Nancy Gupta
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Khwaja F Haq
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | | | - Prashant Nagpal
- Department of Radiology, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Bijal Doshi
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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15
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Brandenburg V, Adragao T, van Dam B, Evenepoel P, Frazão JM, Ketteler M, Mazzaferro S, Urena Torres P, Ramos R, Torregrosa JV, Cozzolino M. Blueprint for a European calciphylaxis registry initiative: the European Calciphylaxis Network (EuCalNet). Clin Kidney J 2015; 8:567-71. [PMID: 26413282 PMCID: PMC4581376 DOI: 10.1093/ckj/sfv056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 06/14/2015] [Indexed: 02/03/2023] Open
Abstract
Calcific uraemic arteriolopathy (CUA) is a rare disease and continues to be a clinical challenge. The typical course of CUA is characterized by painful skin discolouration and induration evolving to necrotic ulcerations. Medial calcification of cutaneous arterioles and extensive extracellular matrix remodelling are the hallmarks of CUA. The epidemiology and risk factors associated with this disease are still not fully understood. Moreover, CUA treatment strategies vary significantly among centres and expert recommendations are heterogeneous. Registries may provide important insights and information to increase our knowledge about epidemiology and clinical aspects of CUA and may help to optimize its therapeutic management. In 2006, we established an internet-based registry in Germany (www.calciphylaxie.de) to allow online notification of patients with established or suspected CUA. The registry includes a comprehensive database with questions covering >70 parameters and items regarding patient-related and laboratory data, clinical background and presentation as well as therapeutic strategies. The next phase will be to allow international patient registration via www.calciphylaxis.net as part of the multinational EuCalNet (European Calciphylaxis Network) initiative, which is supported by the ERA-EDTA scientific working group ‘CKD-MBD’. Based on the valuable experience with the previous German CUA registry, EuCalNet will be a useful tool to collect data on the rare disease CUA and may become a basis for prospective controlled trials in the near future.
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Affiliation(s)
- Vincent Brandenburg
- Department of Cardiology , University Hospital RWTH Aachen , Aachen , Germany; on behalf of the ERA-EDTA scientific working group 'CKD-MBD'
| | | | - Bastiaan van Dam
- Department of Internal Medicine, Medisch Centrum Alkmaar, Alkmaar, The Netherlands
| | - Pieter Evenepoel
- Department of Internal Medicine, Division of Nephrology , University Hospitals Leuven , Leuven , Belgium
| | - João M Frazão
- Medical School and Nephrology Research and Development Unit , Hospital de S. João, University of Porto , Porto , Portugal
| | - Markus Ketteler
- Department of Nephrology , Klinikum Coburg , Coburg , Germany
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic, Geriatric Sciences , Sapienza University of Rome , Rome , Italy
| | - Pablo Urena Torres
- Department of Nephrology and Dialysis, Clinique du Landy, Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris , France ; Department of Renal Physiology, Necker Hospital , University of Paris V. René Descartes , Paris , France
| | - Rosa Ramos
- Departamento de Dirección Médica , Fresenius Medical Care España , Madrid , Spain
| | - Jose-Vicente Torregrosa
- Nephrology and Renal Transplantation Department, Hospital Clinic , University of Barcelona , Barcelona , Spain
| | - Mario Cozzolino
- Renal Division , DMCO, University of Milan, San Paolo Hospital , Milan , Italy
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