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Wang N, Angioi A, Hanset N, Ye X, Lu S, Zhu Y. Individualizing the lifesaving journey for calciphylaxis: addressing rapidly progressive attacks with multidimensional and AI research for regenerative medicine. Ren Fail 2024; 46:2392846. [PMID: 39234636 PMCID: PMC11378655 DOI: 10.1080/0886022x.2024.2392846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 08/08/2024] [Accepted: 08/09/2024] [Indexed: 09/06/2024] Open
Affiliation(s)
- Ningning Wang
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Andrea Angioi
- Department of Nephrology, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | | | - Xiaoxue Ye
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
- Putuo District Central Hospital of Shanghai, Shanghai, China
| | - Shijiu Lu
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Yi Zhu
- School of Medicine, Westlake University, Hangzhou, Zhejiang, China
- Westlake Center for Intelligent Proteomics, Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou, Zhejiang, China
- Research Center for Industries of the Future, School of Life Sciences, Westlake University, Hangzhou, Zhejiang, China
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2
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Song D, Ginsberg C, Nudleman E, Borooah S, King A, Bousquet E, Sarraf D, Goldbaum M. Catastrophic retinal vascular occlusion and vision loss due to crystal deposition in end-stage kidney disease treated with peritoneal dialysis. Am J Ophthalmol Case Rep 2024; 36:102153. [PMID: 39282596 PMCID: PMC11402114 DOI: 10.1016/j.ajoc.2024.102153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 08/14/2024] [Accepted: 08/21/2024] [Indexed: 09/19/2024] Open
Abstract
Purpose To report two cases of catastrophic retinal vascular occlusion and crystalline retinopathy due to presumed oxalosis and hyperphosphatemia. Observations We describe two unrelated patients with end-stage kidney failure (ESKD) treated with peritoneal dialysis that developed rapid bilateral vision loss due to severe retinal vascular occlusion. Multi-modal retinal imaging studies demonstrated crystalline deposits. Plasma phosphorus and oxalate levels were markedly elevated compared to persons with normal kidney function. One patient harbored a heterozygous variant of unknown significance in the Alanine--Glyoxylate Aminotransferase (AGXT) gene. Intense hemodialysis and diet modification reduced phosphorus and oxalate levels. Conclusions and importance This report serves to raise awareness of hyperphosphatemia and oxalosis in dialysis patients to alert providers so that they can act to decrease the potential risk of vision loss.
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Affiliation(s)
- Delu Song
- Shiley Eye Institute, The Viterbi Family Department of Ophthalmology, UC San Diego, La Jolla, CA, USA
- San Diego Retina Associates, San Diego, CA, USA
| | - Charles Ginsberg
- Division of Nephrology-Hypertension, UC San Diego, La Jolla, CA, USA
| | - Eric Nudleman
- Shiley Eye Institute, The Viterbi Family Department of Ophthalmology, UC San Diego, La Jolla, CA, USA
| | - Shyamanga Borooah
- Shiley Eye Institute, The Viterbi Family Department of Ophthalmology, UC San Diego, La Jolla, CA, USA
| | - Andrew King
- Department of Nephrology, Scripps Clinic, La Jolla, CA, USA
| | | | - David Sarraf
- Stein Eye Institute, UC Los Angeles, Los Angeles, CA, USA
| | - Michael Goldbaum
- Shiley Eye Institute, The Viterbi Family Department of Ophthalmology, UC San Diego, La Jolla, CA, USA
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3
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Kurniawan HI, O'Malley K, Santana R, Kowaleski J, Skarf LM. Calciphylaxis and Intractable Pain in a Veteran with Psychological Trauma History. J Palliat Med 2024; 27:1279-1283. [PMID: 38629826 DOI: 10.1089/jpm.2023.0362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2024] Open
Abstract
Guidelines are lacking for patients with calciphylaxis on renal replacement therapy, often leading to difficulty optimally treating these patients. A 60-year-old male veteran receiving hemodialysis presented with calciphylaxis of the left lower extremity and intractable pain. His condition was complicated by chronic back pain, long-term opioid therapy, and psychological trauma history. He was ultimately transferred to a calciphylaxis treatment center but was unable to tolerate further treatments due to sepsis and hemodynamic instability. He was transitioned to comfort measures and died in the hospital. Addressing complicated pain physiologies and complex trauma is challenging even in well-resourced tertiary medical centers. Despite the availability of calciphylaxis therapies and trauma-informed care, there remains a high rate of suffering and mortality in this patient population. There is much work to be done in this cohort, particularly when considering the implications of past traumatic experiences on health care engagement and pain management.
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Affiliation(s)
- Helena I Kurniawan
- VA Boston Healthcare System, Nephrology and Palliative Care, Boston, Massachusetts, USA
| | - Kelly O'Malley
- VA Boston Healthcare System, Geriatric Mental Health, Boston, Massachusetts, USA
- VA New England Geriatric Research Education and Clinical Center, Bedford, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Renée Santana
- Harvard Medical School, Boston, Massachusetts, USA
- Palliative Care Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Palliative Care VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Jeff Kowaleski
- Palliative Care and Geriatrics and Extended Care, VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lara M Skarf
- Harvard Medical School, Boston, Massachusetts, USA
- Palliative Care, VA Boston Healthcare System, Boston, Massachusetts, USA
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4
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Chaganlal PP, Kalandoor V, Jones DT, Pace C, Silver SA. Advanced Calciphylaxis in a Patient With End-Stage Renal Disease: A Case Report Highlighting Diagnostic and Therapeutic Challenges in Late-Stage Presentation. Cureus 2024; 16:e68866. [PMID: 39246637 PMCID: PMC11380459 DOI: 10.7759/cureus.68866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2024] [Indexed: 09/10/2024] Open
Abstract
Calciphylaxis, also known as calcific uremic arteriolopathy, is a rapidly progressive, rare, and severe condition characterized by vascular calcification and skin necrosis. The pathophysiology involves cutaneous arteriolar calcification followed by subsequent tissue ischemia and infarction, which eventually causes extremely painful skin lesions. The condition is associated with substantial morbidity due to severe pain, non-healing wounds, increased susceptibility to infections, and frequent hospitalizations. Calciphylaxis is a highly fatal condition with one-year mortality rates greater than 50%, most frequently due to sepsis. This report presents a case of a 63-year-old male with end-stage kidney disease (ESKD) who presented with altered mental status and was found to have notable necrotic skin ulcers on the bilateral anterior thighs, a stage IV sacral decubitus ulcer, and necrotic lesions on the scrotum and penis. This case underscores the importance of maintaining a high clinical suspicion for rare conditions like calciphylaxis in patients with multiple risk factors. Diagnosing the disease earlier in its course may improve outcomes and overall prognosis. Unfortunately, in this case, the patient presented too late into the disease course, and ultimately discussions/placement with palliative care were undertaken.
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Affiliation(s)
| | | | - Daniel T Jones
- Internal Medicine, Touro University Nevada, Henderson, USA
| | - Christopher Pace
- Internal Medicine, Valley Hospital Medical Center, Las Vegas, USA
| | - Scott A Silver
- Internal Medicine, Valley Hospital Medical Center, Las Vegas, USA
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5
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Tanaka HL, Rees JR, Zhang Z, Ptak JA, Hannigan PM, Silverman EM, Peacock JL, Buckey JC. Emerging Indications for Hyperbaric Oxygen Treatment: Registry Cohort Study. Interact J Med Res 2024; 13:e53821. [PMID: 39078624 PMCID: PMC11372337 DOI: 10.2196/53821] [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: 10/20/2023] [Revised: 02/17/2024] [Accepted: 07/30/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Hyperbaric oxygen (HBO2) treatment is used across a range of medical specialties for a variety of applications, particularly where hypoxia and inflammation are important contributors. Because of its hypoxia-relieving and anti-inflammatory effects HBO2 may be useful for new indications not currently approved by the Undersea and Hyperbaric Medical Society. Identifying these new applications for HBO2 is difficult because individual centers may only treat a few cases and not track the outcomes consistently. The web-based International Multicenter Registry for Hyperbaric Oxygen Therapy captures prospective outcome data for patients treated with HBO2 therapy. These data can then be used to identify new potential applications for HBO2, which has relevance for a range of medical specialties. OBJECTIVE Although hyperbaric medicine has established indications, new ones continue to emerge. One objective of this registry study was to identify cases where HBO2 has been used for conditions falling outside of current Undersea and Hyperbaric Medical Society-approved indications and present outcome data for them. METHODS This descriptive study used data from a web-based, multicenter, international registry of patients treated with HBO2. Participating centers agree to collect data on all patients treated using standard outcome measures, and individual centers send deidentified data to the central registry. HBO2 treatment programs in the United States, the United Kingdom, and Australia participate. Demographic, outcome, complication, and treatment data, including pre- and posttreatment quality of life questionnaires (EQ-5D-5L) were collected for individuals referred for HBO2 treatment. RESULTS Out of 9726 patient entries, 378 (3.89%) individuals were treated for 45 emerging indications. Post-COVID-19 condition (PCC; also known as postacute sequelae of COVID-19; 149/378, 39.4%), ulcerative colitis (47/378, 12.4%), and Crohn disease (40/378, 10.6%) accounted for 62.4% (n=236) of the total cases. Calciphylaxis (20/378, 5.3%), frostbite (18/378, 4.8%), and peripheral vascular disease-related wounds (12/378, 3.2%) accounted for a further 13.2% (n=50). Patients with PCC reported significant improvement on the Neurobehavioral Symptom Inventory (NSI score: pretreatment=30.6; posttreatment=14.4; P<.001). Patients with Crohn disease reported significantly improved quality of life (EQ-5D score: pretreatment=53.8; posttreatment=68.8), and 5 (13%) reported closing a fistula. Patients with ulcerative colitis and complete pre- and post-HBO2 data reported improved quality of life and lower scores on a bowel questionnaire examining frequency, blood, pain, and urgency. A subset of patients with calciphylaxis and arterial ulcers also reported improvement. CONCLUSIONS HBO2 is being used for a wide range of possible applications across various medical specialties for its hypoxia-relieving and anti-inflammatory effects. Results show statistically significant improvements in patient-reported outcomes for inflammatory bowel disease and PCC. HBO2 is also being used for frostbite, pyoderma gangrenosum, pterygium, hypospadias repair, and facial filler procedures. Other indications show evidence for improvement, and the case series for all indications is growing in the registry. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/18857.
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Affiliation(s)
- Hideaki L Tanaka
- Division of Undersea and Hyperbaric Medicine, Department of Emergency Medicine, University of California at San Diego, San Diego, CA, United States
| | - Judy R Rees
- Geisel School of Medicine, Dartmouth College, Lebanon, NH, United States
| | - Ziyin Zhang
- Geisel School of Medicine, Dartmouth College, Lebanon, NH, United States
| | - Judy A Ptak
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | | | | | - Janet L Peacock
- Geisel School of Medicine, Dartmouth College, Lebanon, NH, United States
| | - Jay C Buckey
- Geisel School of Medicine, Dartmouth College, Lebanon, NH, United States
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6
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Tan AJ, Xia J, Glennon CM, Locascio JJ, Gabel CK, Nguyen ED, Chand S, Rrapi R, Dobry AS, Garza-Mayers AC, Ko LN, Shah R, St John J, Nigwekar SU, Kroshinsky D. Assessment of diagnostic delay, morbidity, and mortality outcomes in 302 calciphylaxis patients over a 17-year period: A retrospective cohort study. J Am Acad Dermatol 2024:S0190-9622(24)00997-6. [PMID: 38972479 DOI: 10.1016/j.jaad.2024.06.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 05/29/2024] [Accepted: 06/10/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Calciphylaxis patients historically have experienced diagnostic challenges and high morbidity; however limited data is available examining these characteristics over time. OBJECTIVE The primary goals were to a) investigate factors associated with diagnostic delay of calciphylaxis and b) assess morbidity outcomes. The secondary goal was to provide updated mortality rates. METHODS A retrospective review of 302 adult patients diagnosed with calciphylaxis between January 1, 2006 and December 31, 2022 was conducted. Univariate and multivariate statistical analyses were performed. RESULTS Nonnephrogenic calciphylaxis (P = .0004) and involvement of the fingers (P = .0001) were significantly associated with an increased diagnostic delay, whereas involvement of the arms (P = .01) and genitalia (P = .022) resulted in fewer days to diagnosis. Almost all patients with genitalia, finger, or toe involvement had nephrogenic disease. The number of complications per patient decreased with time, especially for wound infections (P = .028), increase in lesion number (P = .012), and recurrent hospitalizations (P = .020). Updated 1-year mortality rates were 36.70% and 30.77% for nephrogenic and nonnephrogenic calciphylaxis, respectively. LIMITATIONS Limitations include the retrospective nature and data from a single institution. CONCLUSION Diagnostic delay, particularly in nonnephrogenic calciphylaxis, and complications per patient decreased with time, highlighting the importance of continued awareness to expedite diagnosis. Mortality rates have continued to improve in recent years.
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Affiliation(s)
- Alice J Tan
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Joyce Xia
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Colleen M Glennon
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Joseph J Locascio
- Department of Neurology, Harvard Catalyst Biostatistics, Massachusetts General Hospital, Boston, Massachusetts
| | - Colleen K Gabel
- Department of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Emily D Nguyen
- Department of Dermatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Sidharth Chand
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Renajd Rrapi
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Allison S Dobry
- Department of Dermatology, University of California, San Francisco School of Medicine, San Francisco, California
| | | | - Lauren N Ko
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Radhika Shah
- Department of Dermatology, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jessica St John
- Department of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sagar U Nigwekar
- Department of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Department of Dermatology, Duke University Medical Center, Durham, North Carolina.
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7
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Toker M, Forelli N, Wind O, Khanna U, Jaller JA, Fischer S, Mardakhaev E, Wu B. Histopathology and radiologic imaging for the confirmation of calciphylaxis in a diverse population: A retrospective cohort study. J Am Acad Dermatol 2024; 91:148-151. [PMID: 38513831 DOI: 10.1016/j.jaad.2024.03.012] [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: 09/25/2023] [Revised: 02/22/2024] [Accepted: 03/11/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Michelle Toker
- Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
| | - Nicholas Forelli
- Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Olivia Wind
- Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Urmi Khanna
- Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Jose A Jaller
- Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Sarah Fischer
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Edward Mardakhaev
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Benedict Wu
- Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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8
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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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Grittani A, Kouzounis K, Zarry S, Suarez JH. The Accelerated Onset of Calciphylaxis in a 72-Year-Old Female Hemodialysis Patient. Cureus 2024; 16:e58492. [PMID: 38765385 PMCID: PMC11101609 DOI: 10.7759/cureus.58492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
Calciphylaxis is a unique medical condition characterized by calcification of the medial layer of arterioles and soft tissues in a patient's skin at the level of the dermis and subcutaneous adipose tissue. The rate of progression of calciphylaxis is rapid, starting with a reduction of blood flow that leads to ischemic changes in the skin that can manifest as painful cutaneous erythematous nodules or plaques and later as skin ulceration. The majority of patients affected by calciphylaxis have predisposing comorbidities such as end-stage renal disease with a long history of hemodialysis and electrolyte abnormalities in calcium, phosphate, and parathyroid hormone levels. This report presents the case of a 72-year-old female patient on hemodialysis who developed calciphylaxis. The methods for early prognosis (the methods of early diagnosis), including clinical presentation, risk factors, imaging techniques, and laboratory investigations, are discussed. The presented case is particularly noteworthy given the onset of calciphylaxis within a mere three months of initiating hemodialysis, a timeline significantly shorter than the typically observed period in most patients. (The case detailed in this report outlines the rapid onset of calciphylaxis in a patient who was receiving hemodialysis for only three months.) This patient with early-onset calciphylaxis highlights the unpredictable nature of calciphylaxis and the need for increased clinical vigilance even in the initial stages of hemodialysis.
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Affiliation(s)
| | | | - Samantha Zarry
- Internal Medicine, The University of Western Ontario, Toronto, CAN
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10
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Toussaint ND, Davies CE, Bongetti E, Ruderman I, Elder GJ, Hawley CM, Krishnasamy R, Roberts MA, Jardine MJ, De Zoysa JR, McDonald SP. Calciphylaxis Episodes in the Australia and New Zealand Dialysis and Transplant Registry. Kidney Int Rep 2024; 9:951-959. [PMID: 38765561 PMCID: PMC11101771 DOI: 10.1016/j.ekir.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/06/2024] [Accepted: 01/11/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Calciphylaxis is a rare disorder associated with significant morbidity and mortality. Data registries are an invaluable source of information for rare diseases. We reviewed cases of calciphylaxis recorded in the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and evaluated associations and outcomes of this condition. Methods Data was obtained on all cases of calciphylaxis reported between 2019 and 2022 in Australian and New Zealand patients on kidney replacement therapy (KRT). This cohort was compared to all patients in the registry who received KRT from 2019 to 2022 without an episode of calciphylaxis. Cox proportional hazards regression including a time-varying covariate for calciphylaxis episode was conducted for mortality with models restricted to patients on dialysis only. Results From 2019 to 2022, 333 patients had calciphylaxis episodes reported. Overall incidence rate for patients on dialysis was 4.5 (4.1-5.1) episodes per 1000 patient-years on dialysis. Median age was 63 (interquartile range [IQR]: 55-73) years, 54% were female, 66% had diabetes, 59% were obese (body mass index [BMI] ≥ 30 kg/m2) and 77% were receiving hemodialysis (HD) treatment. Compared to patients without calciphylaxis (n = 46,526), patients with calciphylaxis were more likely to be older, female, and have diabetes, greater BMI, coronary artery, and peripheral vascular disease. The median time to calciphylaxis was 3.2 (IQR: 0.9-6.7) years after KRT commencement. Half of the patients with calciphylaxis died by 12 months from diagnosis. Adjusted hazard ratio (HR) of mortality for patients on dialysis with calciphylaxis <1 year and 1 to 4 years after an episode was 5.8 (4.9-6.9) and 1.5 (1.0-2.1), respectively compared to patients on dialysis without calciphylaxis. Conclusion Calciphylaxis is a rare but life-threatening condition in people on KRT with the greatest mortality burden within 12 months of diagnosis.
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Affiliation(s)
- Nigel D. Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Christopher E. Davies
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Elisa Bongetti
- Department of Nephrology, Monash Medical Centre, Clayton, Australia
| | - Irene Ruderman
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Grahame J. Elder
- School of Medicine, University of Notre Dame, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Skeletal Biology Program, Garvan Institute of Medical Research, Darlinghurst, Australia
- Department of Nephrology, Westmead Hospital, Sydney, Australia
| | - Carmel M. Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Rathika Krishnasamy
- Department of Nephrology, Sunshine Coast Hospital University Hospital, Birtinya, Australia
| | | | - Meg J. Jardine
- NHMRC Clinical Trials Centre, University of Sydney New South Wales, Australia
- Department of Nephrology, Concord Repatriation General Hospital, Sydney, Australia
- The George Institute for Global Health, UNSW, Sydney Australia
| | - Janak R. De Zoysa
- Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
- Te Whatu Ora Waitemata, Auckland, New Zealand
| | - Stephen P. McDonald
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
- Central and Northern Adelaide Renal and Transplantation Services, Royal Adelaide Hospital, Adelaide, Australia
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11
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Gupta K, Suthar PP, Bhave N, Singh JS, Venkatraman SMK, Jadhav RB. Potential Role of Bone Scintigraphy in the Diagnosis of Calciphylaxis. World J Nucl Med 2024; 23:3-9. [PMID: 38595840 PMCID: PMC11001438 DOI: 10.1055/s-0043-1760760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Nonosseous abnormalities are often seen on bone scans and can be related to a wide variety of pathology ranging across vascular, infection, and inflammatory etiology. Diffuse soft tissue radiotracer uptake on bone scans is typically attributed to renal or metabolic derangements. Calciphylaxis is the deposition of calcium in small blood vessels, skin, and other organs leading to vascular obstruction and skin necrosis. It is a rare disorder with unknown pathophysiology. Diagnosis of calciphylaxis is challenging and requires an interdisciplinary approach including clinical findings, laboratory results, medical imaging, and skin biopsy. An early diagnosis is important as the disease is associated with high morbidity and mortality. The purpose of this review article is to highlight the role of bone scintigraphy in the evaluation of calciphylaxis and to correlate the findings with other imaging modalities and histopathology.
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Affiliation(s)
- Khushboo Gupta
- Department of Radiology, Nuclear Medicine Division, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | | | - Neetal Bhave
- Department of Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, Illinois, United States
| | - Jagadeesh S. Singh
- Department of Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, Illinois, United States
| | | | - Rahul B. Jadhav
- Department of Radiology, Neurointervention Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
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12
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Ballegaard ELF, Lindhard K, Lindhardt M, Peters CD, Thomsen Nielsen F, Tietze IN, Borg R, Boesby L, Bertelsen MC, Brøsen JMB, Cibulskyte-Ninkovic D, Rantanen JM, Mose FH, Kampmann JD, Nielsen AS, Breinholt JK, Kofod DH, Bressendorff I, Clausen PV, Lange T, Køber L, Kamper AL, Bang CNF, Torp-Pedersen C, Hansen D, Grove EL, Gislason G, Dam Jensen J, Olesen JB, Hornum M, Rix M, Schou M, Carlson N. Protocol for a randomised controlled trial comparing warfarin with no oral anticoagulation in patients with atrial fibrillation on chronic dialysis: the Danish Warfarin-Dialysis (DANWARD) trial. BMJ Open 2024; 14:e081961. [PMID: 38413147 PMCID: PMC10900386 DOI: 10.1136/bmjopen-2023-081961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/12/2024] [Indexed: 02/29/2024] Open
Abstract
INTRODUCTION Atrial fibrillation is highly prevalent in patients on chronic dialysis. It is unclear whether anticoagulant therapy for stroke prevention is beneficial in these patients. Vitamin K-antagonists (VKA) remain the predominant anticoagulant choice. Importantly, anticoagulation remains inconsistently used and a possible benefit remains untested in randomised clinical trials comparing oral anticoagulation with no treatment in patients on chronic dialysis. The Danish Warfarin-Dialysis (DANWARD) trial aims to investigate the safety and efficacy of VKAs in patients with atrial fibrillation on chronic dialysis. The hypothesis is that VKA treatment compared with no treatment is associated with stroke risk reduction and overall benefit. METHODS AND ANALYSIS The DANWARD trial is an investigator-initiated trial at 13 Danish dialysis centres. In an open-label randomised clinical trial study design, a total of 718 patients with atrial fibrillation on chronic dialysis will be randomised in a 1:1 ratio to receive either standard dose VKA targeting an international normalised ratio of 2.0-3.0 or no oral anticoagulation. Principal analyses will compare the risk of a primary efficacy endpoint, stroke or transient ischaemic attack and a primary safety endpoint, major bleeding, in patients allocated to VKA treatment and no treatment, respectively. The first patient was randomised in October 2019. Patients will be followed until 1 year after the inclusion of the last patient. ETHICS AND DISSEMINATION The study protocol was approved by the Regional Research Ethics Committee (journal number H-18050839) and the Danish Medicines Agency (case number 2018101877). The trial is conducted in accordance with the Helsinki declaration and standards of Good Clinical Practice. Study results will be disseminated to participating sites, at research conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBERS NCT03862859, EUDRA-CT 2018-000484-86 and CTIS ID 2022-502500-75-00.
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Affiliation(s)
- Ellen Linnea Freese Ballegaard
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kristine Lindhard
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Morten Lindhardt
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Internal Medicine 1, Holbæk Hospital, Holbæk, Denmark
| | - Christian Daugaard Peters
- Dept. of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Finn Thomsen Nielsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Bornholms Hospital, Ronne, Denmark
| | | | - Rikke Borg
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Lene Boesby
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Marianne Camilla Bertelsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Julie Maria Bøggild Brøsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | | | | | - Frank Holden Mose
- Department of Nephrology, Gødstrup Regional Hospital, Herning, Denmark
| | - Jan Dominik Kampmann
- Internal medicine, Hospital of Southern Jutland Sonderborg Branch, Sonderborg, Denmark
| | - Alice Skovhede Nielsen
- Department of Medicine, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Johanne Kodal Breinholt
- Department of Clinical Biochemistry, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Dea Haagensen Kofod
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Iain Bressendorff
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Peter Vilhelm Clausen
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Kobenhavns, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne-Lise Kamper
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Casper Niels Furbo Bang
- Department of Cardiology, Copenhagen University Hospital - Frederiksberg and Bispebjerg, Copenhagen, Denmark
| | | | - Ditte Hansen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Faculty of Health, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
| | - Jens Dam Jensen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Mads Hornum
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Schou
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Abdalla M, Faris ME, Saad E, Meng Q, Friedman H, Soifer N. Profound metabolic acidosis in association with sodium thiosulfate therapy in a patient with calcific uremic arteriolopathy: a case report and literature review. CEN Case Rep 2024; 13:59-65. [PMID: 37273129 PMCID: PMC10834920 DOI: 10.1007/s13730-023-00801-x] [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: 03/01/2023] [Accepted: 05/15/2023] [Indexed: 06/06/2023] Open
Abstract
Calciphylaxis, also known as Calcific uremic arteriolopathy (CUA), is a serious disorder that presents with skin necrosis due to calcification of dermal and subcutaneous adipose tissue capillaries and arterioles. The condition occurs primarily in patients with end-stage renal disease (ESRD) on dialysis, and it carries high morbidity and mortality, primarily due to sepsis, with an estimated six-month survival of approximately 50%. Although there are no high-quality studies to guide the optimal treatment approach for patients with calciphylaxis, many retrospective studies and case series support treatment with sodium thiosulfate (STS). Despite the frequent use of STS as an off-label treatment, data regarding its safety and efficacy are limited. STS has generally been considered a safe drug with mild side effects. However, severe metabolic acidosis associated with STS is a rare and life-threatening complication of STS treatment and is often unpredictable. Herein, we report a 64-year-old female with ESRD on peritoneal dialysis (PD) who presented with a profound high anion gap metabolic acidosis and severe hyperkalemia while on STS treatment for CUA. No other etiology for her severe metabolic acidosis other than STS was identified. ESRD patients receiving STS should be monitored closely for this side effect. Dose reduction, increasing the duration of infusion, or even discontinuing STS treatment should be considered if severe metabolic acidosis develops.
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Affiliation(s)
- Mohammed Abdalla
- Medical Residents, Department of Internal Medicine, Ascension Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA.
| | - Mohammed Elamin Faris
- Medical Residents, Department of Internal Medicine, Ascension Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Eltaib Saad
- Medical Residents, Department of Internal Medicine, Ascension Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Qingqing Meng
- Medical Residents, Department of Internal Medicine, Ascension Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Harvey Friedman
- Pulmonary and Critical Care Attending, Department of Critical Care and Pulmonology, Ascension Saint Francis Hospital, Evanston, IL, USA
| | - Neil Soifer
- Lakeside Nephrology, Ascension Saint Francis Hospital, Evanston, IL, USA
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14
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Al-Khazraji Y, Al-Khazraji M, Oluaderounmu O, Quintanilla B. Progression of Skin Ulcer Secondary to Calciphylaxis in a Patient With End-Stage Renal Disease (ESRD) on Hemodialysis and the Therapeutic Approach. Cureus 2024; 16:e55161. [PMID: 38558589 PMCID: PMC10980508 DOI: 10.7759/cureus.55161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
Calciphylaxis is a rare and severe medical condition characterized by the calcification of small blood vessels and soft tissues, leading to tissue damage, skin ulcers, and intense pain. It most commonly affects individuals with underlying health conditions such as kidney disease, particularly end-stage renal disease (ESRD), and is associated with high mortality rates. Understanding the diagnosis and management of calciphylaxis is crucial for improving patient outcomes. Diagnosing calciphylaxis can be challenging due to its rarity and overlapping symptoms with other skin conditions. Healthcare professionals typically use a combination of clinical evaluation and diagnostic tests to reach a conclusive diagnosis. The management of calciphylaxis is multifaceted and typically involves a collaborative effort between various healthcare specialists, including nephrologists, dermatologists, and wound care experts. The primary goals of treatment are to alleviate pain, promote wound healing, address underlying causes, and prevent further complications.
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15
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Teh YK, Renaud CJ. Clinical experience with intraperitoneal sodium thiosulphate for calciphylaxis in peritoneal dialysis: A case series. Perit Dial Int 2024; 44:66-69. [PMID: 37131321 DOI: 10.1177/08968608231163669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
Calciphylaxis is an uncommon but life-threatening syndrome in end-stage kidney disease, characterised by painful medial and intimal calcification of the arterioles in the deep dermis and subcutaneous tissues. Intravenous sodium thiosulfate serves as an off-label but effective treatment in haemodialysis patients. However, this approach confers considerable logistical challenges for affected peritoneal dialysis patients. In this case series, we demonstrate that intraperitoneal administration can be a safe, convenient and long-term alternative.
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Affiliation(s)
- Yuan Kai Teh
- Department of Medicine, Khoo Teck Puat Hospital, Singapore
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16
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Jang A, Mark Ho MH, Yan L. Characterization of Risk Factors for Calciphylaxis in Hemodialysis Patients in the Fraser Health Renal Program - A Matched Case-Control Retrospective Review. J Pharm Pract 2023; 36:1424-1437. [PMID: 36036088 DOI: 10.1177/08971900221118444] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Introduction: Calciphylaxis is a lethal and rare disease characterized by ischemic and necrotic skin lesions caused by vascular calcification of adipose tissue. There have been many risk factors analyzed in the literature; however, the pathogenesis of calciphylaxis is still not well understood and treatment options are limited due to the lack of interventional studies. Our objectives were to describe risk factors, prevalence, incidence, and outcomes for calciphylaxis in hemodialysis patients within the Fraser Health Renal Program. Methods: This was a retrospective matched case-control study of hemodialysis patients within the Fraser Health Renal Program. Hemodialysis patients with calciphylaxis were matched to hemodialysis patients without calciphylaxis in a 1:2 ratio for age and sex from September 2, 2017 to July 3, 2020. Findings: There was a total of 40 calciphylaxis cases matched to 80 controls. In the univariate analysis, peritoneal dialysis, higher body mass index, lower serum iron, lower transferrin saturation, sevelamer, cinacalcet, warfarin, iron (PO), and insulin were associated with increased risk of calciphylaxis. In the multivariate analysis, only peritoneal dialysis, serum iron, sevelamer, and warfarin were identified as significant and strong risk factors associated with calciphylaxis. A low prevalence of 1.9% and high mortality rate of 57.5% at 12 months was found for calciphylaxis cases. Discussion: Significant risk factors associated with calciphylaxis were peritoneal dialysis, serum iron, sevelamer, and warfarin. Future studies should further investigate the impact of minimizing exposure to these risk factors to reduce calciphylaxis development.
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Affiliation(s)
- Ashley Jang
- Department of Pharmacy, Burnaby Hospital, Burnaby, BC, Canada
| | - Man Hon Mark Ho
- Department of Pharmacy, Royal Columbian Hospital, New Westminster, BC, Canada
| | - Luzhi Yan
- Department of Pharmacy, Surrey Memorial Hospital, Surrey, BC, Canada
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17
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Pan Y, Wang H, Ye Y, Lv M, Zhu Y, Wang N, Zhao J, Shi J, Lv X. The application of MDT model for calciphylaxis management in patients with end-stage renal disease. Int Wound J 2023; 20:3717-3723. [PMID: 37309083 PMCID: PMC10588363 DOI: 10.1111/iwj.14265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/20/2023] [Indexed: 06/14/2023] Open
Abstract
This study focuses on the application of nurse-led multidisciplinary collaborative therapy (MDT) management model for calciphylaxis prevention of patients with terminal renal disease. Through the establishment of a multidisciplinary management team spanning nephrology department, blood purification center, dermatology department, burn and plastic surgery department, infection department, stem cell platform, nutrition department, pain department, cardiology department, hydrotherapy group, dermatology group, and outpatient treatment room, the distribution of duties among team members were clarified to bring out the best advantages of a multidisciplinary teamwork during treatment and nursing. For patients with calciphylaxis symptoms in terminal renal disease, a case-by-case management model was carried out with the focus on personalised problem. We emphasised on personalised wound care, precise medication care, active pain management, psychological intervention and palliative care, the amelioration of calcium and phosphorus metabolism disorder, nutritional supplementation, and the therapeutic intervention based on human amniotic mesenchymal stem cell regeneration. The MDT model effectively compensates for traditional nursing mode and could serve as a novel clinical management modality for calciphylaxis prevention in patients with terminal renal disease.
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Affiliation(s)
- Yanyan Pan
- Department of NephrologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Hui Wang
- Department of NephrologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Yajun Ye
- Department of NephrologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Manman Lv
- Department of NephrologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Yamei Zhu
- Blood Purification CenterThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Ningning Wang
- Department of NephrologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Jing Zhao
- Outpatient Treatment RoomThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Jingping Shi
- Department of Plastic and BurnThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Xiaolin Lv
- Department of NephrologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
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18
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Bahar P, Mancuso J, Ramani K, Wasylyshyn A, Wasylyshyn G, George A. Scrotal calciphylaxis in a fifty-one-year-old man with end-stage renal disease and prior bacteremia. Urol Case Rep 2023; 51:102564. [PMID: 37818408 PMCID: PMC10561032 DOI: 10.1016/j.eucr.2023.102564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 09/10/2023] [Indexed: 10/12/2023] Open
Abstract
Isolated, ischemic scrotal lesions are an uncommon manifestation of systemic calciphylaxis. This highly morbid disease seen in patients with end-stage renal disease and other risk factors for small vessel calcification results in tissue necrosis and ulceration. Scrotal calciphylaxis is uncommon and difficult to diagnose in patients with comorbid conditions that cause isolated genital skin lesions, including prior systemic infections. We describe a 51-year-old male with end-stage renal disease on hemodialysis and recent history of bacteremia who developed isolated penile and scrotal ulceration due to calciphylaxis. The patient died two months after presentation despite multidisciplinary care.
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19
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Yu Y, Chen Y, Yang F, Song Q. Black necrosis of the glans penis associated with calciphylaxis: A case report. Medicine (Baltimore) 2023; 102:e35609. [PMID: 37861559 PMCID: PMC10589551 DOI: 10.1097/md.0000000000035609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/21/2023] [Indexed: 10/21/2023] Open
Abstract
RATIONALE Calciphylaxis, known as calcific uremic arteriolopathy, is a rare cause of dry gangrene. Despite an increase in the clinical recognition of demographic characteristics and risk factors associated with calciphylaxis, it remains a poorly understood disease with high mortality. PATIENT CONCERNS AND DIAGNOSES We present a 45-year-old man, who was diagnosed with calciphylaxis disease, with a history of diabetes mellitus, end-stage renal disease and cirrhosis with a half-month evolution of painful dry gangrene on his glans penis and scrotum. The patient also presented with gangrene of fingers. INTERVENTIONS AND OUTCOMES The patient and his family opted for palliative care. However, he died eventually. LESSONS This case contributed to the current understanding of calciphylaxis. Since no standard treatment is available and the prognosis remained poor, early, and accurate diagnosis of calciphylaxis is important. We here report the current case and provide data for the diagnosis and treatment of this kind of disease.
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Affiliation(s)
- Youwei Yu
- Department of Emergency Medicine, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Yangxi Chen
- Department of Emergency Medicine, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Fan Yang
- Department of Emergency Medicine, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Qitai Song
- Department of Emergency Medicine, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
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20
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Liu Y, Zhang X. Early diagnosis strategy of calciphylaxis in dialysis patients. Ren Fail 2023; 45:2264407. [PMID: 37795796 PMCID: PMC10557543 DOI: 10.1080/0886022x.2023.2264407] [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: 04/25/2023] [Accepted: 09/23/2023] [Indexed: 10/06/2023] Open
Abstract
Calciphylaxis, a rapidly progressive and potentially life-threatening vascular calcification syndrome that clinically presents with persistently painful, ulcerative, or necrotizing skin lesions in multiple parts of the body, is predominantly observed in patients treated with dialysis. Early diagnosis of calciphylaxis is a key measure for reducing high disability and mortality. At present, there is no unified diagnostic standard for calciphylaxis, and there is a lack of effective early screening strategies. This paper summarized and discussed the diagnostic accuracy of calciphylaxis based on the latest research worldwide. We propose a modified strategy for the early diagnosis of calciphylaxis, which is suitable for dialysis patients to help clinicians better identify such disease and improve prognosis.
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Affiliation(s)
- Yuqiu Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, Jiangsu, China
| | - Xiaoliang Zhang
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, Jiangsu, China
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21
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Diaz-Churion F, Yu Lee-Mateus A, Mirzan H, Khoor A, Abia-Trujillo D, Fernandez-Bussy S. Patient With Metastatic Airway Calcification and Hypercalcemia Due to Secondary Hyperparathyroidism. J Bronchology Interv Pulmonol 2023; 30:387-390. [PMID: 37055879 DOI: 10.1097/lbr.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Affiliation(s)
| | | | - Haares Mirzan
- Division of Pulmonary, Allergy, and Sleep Medicine Mayo Clinic, Jacksonvile, FL
| | - Andras Khoor
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine Mayo Clinic, Jacksonvile, FL
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22
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Okan T, Ghuman K, Chaudhary F, Doshi K, Shoaib U. Calcific Uremic Arteriolopathy in End-Stage Renal Disease: A Rare Life-Threatening Condition. Cureus 2023; 15:e48002. [PMID: 38034199 PMCID: PMC10687493 DOI: 10.7759/cureus.48002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/29/2023] [Indexed: 12/02/2023] Open
Abstract
Calcific uremic arteriolopathy, or calciphylaxis, is a highly morbid, life-threatening syndrome of microvascular calcification leading to progressive skin necrosis. It affects 1-4% of the population with end-stage renal disease (ESRD) and is rarely seen in other conditions. The one-year mortality rate is 80% for patients with ulcerations. There is no evidence-based treatment, and the response to therapy is poor; thus, it creates a serious therapeutic challenge for clinicians. Our aim is to discuss a diagnostic approach and management of calciphylaxis and to raise awareness about this condition among the medical community. We are describing a case of calciphylaxis in a 68-year-old female with a past medical history of ESRD on hemodialysis, who presented with altered mental status and painful ulcers on her feet and thighs. The patient was admitted for acute encephalopathy due to sepsis secondary to a urinary tract infection (UTI) versus permacath-related bacteremia versus wound infection of pressure ulcers on the lower extremities. Broad-spectrum antibiotics were started. Computed tomography (CT) of bilateral thighs with contrast showed extensive arterial calcifications, characteristic of calciphylaxis. Nephrology recommended sodium thiosulfate with each hemodialysis session. Vitamin D and iron were discontinued. Despite therapy, the wound significantly progressed within the next eight weeks, leading to mortality due to sepsis. In conclusion, calcific uremic arteriolopathy is a challenging disease with a poor prognosis. Early diagnosis is crucial, so aggressive therapy can be started immediately. A multidisciplinary approach may improve survival in cases of calciphylaxis. More studies are needed to improve the diagnostic approach and medical management of the disease.
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Affiliation(s)
- Tetyana Okan
- Department of Internal Medicine, Jamaica Hospital Medical Center, New York, USA
| | - Kulbir Ghuman
- Department of Internal Medicine, Jamaica Hospital Medical Center, New York, USA
| | - Faiza Chaudhary
- Department of Internal Medicine, Jamaica Hospital Medical Center, New York, USA
| | - Kaushik Doshi
- Department of Internal Medicine, Jamaica Hospital Medical Center, New York, USA
| | - Usman Shoaib
- Department of Internal Medicine, Jamaica Hospital Medical Center, New York, USA
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23
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Khalayli N, Hodifa Y, Hodaifa A, Alsamarrai O, Kudsi M. Calciphylaxis during the course of psoriatic arthritis patient. Is it coincidence? A case report. Ann Med Surg (Lond) 2023; 85:5263-5266. [PMID: 37811033 PMCID: PMC10552990 DOI: 10.1097/ms9.0000000000001281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/27/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction and importance Calciphylaxis manifests clinically by skin ischemia and necrosis and histologically by calcification of dermal arterioles. Usually, it occurs in patients with end-stage renal disease on dialysis or in patients who had a kidney transplant. Here, the authors present a case of calciphylaxis occurring in a patient with psoriasis and psoriatic arthritis. Case presentation A 66-year-old Syrian male with a history of psoriatic arthritis presented for evaluation of 2-month nonpainful ulcers on his feet and hands that were treated with warfarin. Biopsies confirmed the diagnosis of calciphylaxis. The patient received sodium thiosulfate, zoledronic acid, intralesional sodium thiosulfate injections, and an intravenous infusion of vitamin K with dramatic improvement. At the 3-month follow-up, his wounds had been completely remitted. Discussion Nonuremic calciphylaxis occurs in many cases, like vitamin D administration, vitamin K antagonists' administration, chronic inflammation, and others. The association between calciphylaxis and psoriasis was reported only in four cases in the literature; meanwhile, this was the first case that described calciphylaxis in the setting of psoriatic arthritis. Conclusion A suspicion of calciphylaxis should be maintained in patients with underlying inflammatory mechanism diseases.
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Affiliation(s)
| | - Yara Hodifa
- Faculty of Medicine, Damascus University, Damascus, Syria
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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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25
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Caudill J, Chrisman T, Chen J, Zajac K, Simman R. Differential diagnosis of stage 2, 3 and 4 pressure injuries of the pelvis and lower extremity: a case series. J Wound Care 2023; 32:S22-S36. [PMID: 37682800 DOI: 10.12968/jowc.2023.32.sup9.s22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Constant, unrelieved pressure of local tissue, particularly over bony prominences, may provoke damage that progresses to necrosis and pressure injury (PI). Differentiating PIs from conditions of similar appearance is imperative to minimising complications and implementing prompt treatment. This case series describes several conditions that may be mistaken for a PI. Outlined are the key differences in patient history, presentation and clinical cues that assist in correctly identifying the true pathology behind these conditions. Conditions reviewed included: pyoderma gangrenosum; necrotising fasciitis; genital herpes; Marjolin ulcer, Rosai-Dorfman disease; vascular disease; coagulopathies; calciphylaxis; trauma and surgical wounds; pilonidal cysts; graft-versus-host disease; hidradenitis suppurativa; Stevens-Johnson syndrome; epidermolysis bullosa; radiation wounds; spider bites; and end-of-life skin failure pressure ulcers (also known as Kennedy ulcers). Although commonly recognised and diagnosed, stage 2, 3 and 4 PIs occasionally prove to be difficult to pinpoint, with undefined characteristics and similarities in presentation to several other conditions. Therefore, it is clinically vital to be aware of their appearance, risk factors and aetiology in order to make an appropriate patient assessment and avoid misdiagnosis.
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Affiliation(s)
- Jennifer Caudill
- University of Toledo, College of Medicine and Life Science, Department of Surgery, Toledo, Ohio, US
| | - Tim Chrisman
- University of Toledo, College of Medicine and Life Science, Department of Surgery, Toledo, Ohio, US
| | - Joanna Chen
- University of Toledo, College of Medicine and Life Science, Department of Surgery, Toledo, Ohio, US
| | - Kelsee Zajac
- University of Toledo, College of Medicine and Life Science, Department of Surgery, Toledo, Ohio, US
| | - Richard Simman
- University of Toledo, College of Medicine and Life Science, Department of Surgery, Toledo, Ohio, US
- Jobst Vascular Institute, ProMedica Health Network, Toledo, Ohio, US
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26
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Costa E Silva J, Ramos JN. Calciphylaxis Secondary to Vitamin D Supplementation. Cureus 2023; 15:e44778. [PMID: 37809218 PMCID: PMC10556987 DOI: 10.7759/cureus.44778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Calciphylaxis is a rare cutaneous disease consisting of purpuric and necrotic lesions, and it affects mostly patients with renal failure. More rarely, it can be observed in patients with preserved renal function, acquiring the name of non-uremic calciphylaxis (NUC). Although its pathophysiology is under uncertainty, many etiological factors have been implicated. This report describes a patient who developed NUC, possibly triggered by vitamin D supplementation.
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Affiliation(s)
- Joana Costa E Silva
- Plastic Reconstructive and Maxilofacial Surgery, Centro Hospitalar de Lisboa Ocidental, Lisbon, PRT
| | - José N Ramos
- Plastic Reconstructive and Maxilofacial Surgery, Centro Hospitalar de Lisboa Ocidental, Lisbon, PRT
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27
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Luo S, Feng Y, Zhou Y. Calciphylaxis causing skin gangrene in an old woman with end-stage renal disease. Indian J Dermatol Venereol Leprol 2023; 89:792. [PMID: 37436012 DOI: 10.25259/ijdvl_525_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 05/02/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Shuaihantian Luo
- Department of Dermatology, The second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yu Feng
- Department of Dermatology, The second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ying Zhou
- Department of Dermatology, The second Xiangya Hospital of Central South University, Changsha, Hunan, China
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28
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Khudair AD, Khudair AD, Awadh M, Pérez Romano NS, Darwish A. Calciphylaxis: A Rare Complication With a Fatal Outcome in End-Stage Renal Disease. Cureus 2023; 15:e45557. [PMID: 37868583 PMCID: PMC10586526 DOI: 10.7759/cureus.45557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Calciphylaxis, or calcific uremic arteriolopathy, is a rare and deadly disease that affects patients with end-stage renal disease (ESRD). It typically manifests in the abdomen and lower extremities. We present a case of a 59-year-old female patient on dialysis due to ESRD who complained of a three-week history of hemorrhagic and painful bilateral lower limb lesions. The predominant clinical suspicion was warfarin-induced skin necrosis (WISN); however, the persistence of unresolved skin lesions post-warfarin cessation generated the impression of calciphylaxis. A skin biopsy confirmed the classical histological findings associated with calciphylaxis. This paper highlights the possible importance of warfarin being an inciting event, as well as the early differentiation between the presentations of WISN and calciphylaxis.
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Affiliation(s)
- Ahmed D Khudair
- Department of Pathology and Laboratory Medicine, Royal College of Surgeons in Ireland - Bahrain, Muharraq, BHR
| | - Aiman D Khudair
- Department of Pathology and Laboratory Medicine, Royal College of Surgeons in Ireland - Bahrain, Muharraq, BHR
| | - Mohamed Awadh
- Department of Pathology and Laboratory Medicine, Bahrain Defense Force Hospital - Royal Medical Services, Riffa, BHR
| | - Nuria S Pérez Romano
- Department of Nephrology, Bahrain Defense Force Hospital - Royal Medical Services, Riffa, BHR
| | - Abdulla Darwish
- Department of Pathology and Laboratory Medicine, Bahrain Defense Force Hospital - Royal Medical Services, Riffa, BHR
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29
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Al Yacoub R, Jamalifard F, Ladna M, Walker A. Non-uremic Calciphylaxis With Possible Initial Misdiagnosis as Erythema Multiforme/Toxic Epidermal Necrolysis Successfully Treated as Inpatient. Cureus 2023; 15:e43618. [PMID: 37719563 PMCID: PMC10504681 DOI: 10.7759/cureus.43618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/19/2023] Open
Abstract
Non-uremic calciphylaxis (NUC) is a rare, high-mortality disease, and it can be easily misdiagnosed as other ulcerative dermatologic conditions. A female in her late 30s with a medical history of alcoholic liver cirrhosis and obesity who previously underwent gastric bypass surgery presented with an 11-month history of worsening bilateral lower extremity wounds following the initiation of spironolactone. A wound biopsy at the time of initial presentation favored erythema multiforme/toxic epidermal necrolysis (EM/TEN). She initially responded to systemic steroids, but her wounds later worsened, prompting her to seek representation a few months later. The initial suspicion was for a superimposed bacterial infection; however, her wounds did not improve following antibiotics. A repeat skin biopsy revealed calciphylaxis, for which she had multiple risk factors, including severe vitamin D deficiency causing secondary hyperparathyroidism. A multidisciplinary approach was successful in achieving a satisfactory response with pain control, wound care, skin grafting, and mitigation of risk factors in addition to the use of sodium thiosulfate. Upon our review, the initial biopsy did not demonstrate features of EM/TEN but did demonstrate features suspicious for calciphylaxis. The exposure to systemic corticosteroids due to the presumed diagnosis of EM/TEN may have worsened her condition since this is a known risk factor for calciphylaxis. Our case highlights the importance of clinicopathologic correlation as well as the place for calciphylaxis in the clinical and histopathologic differential diagnosis of ulcerated, necrotic lesions on the lower extremities in the absence of renal disease.
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Affiliation(s)
- Raed Al Yacoub
- Internal Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Faread Jamalifard
- Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Michael Ladna
- Internal Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Addie Walker
- Dermatopathology, University of Florida College of Medicine, Gainesville, USA
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30
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Sanha V, Vidori L, Pachi BC, Marchezi LV, Meinerz G. A Rare Case of Post-parathyroidectomy Calciphylaxis in a Young Patient With End-Stage Renal Disease: A Case Report and Literature Review. Cureus 2023; 15:e42937. [PMID: 37667695 PMCID: PMC10475163 DOI: 10.7759/cureus.42937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/06/2023] Open
Abstract
Calciphylaxis is a serious complication in chronic kidney disease (CKD) patients and requires a multidisciplinary approach. Dialysis patients are the most affected, especially those who are obese and diabetic, have liver diseases and autoimmune diseases, or are on systemic glucocorticoids. Parathyroidectomy (PTx) is curative for secondary hyperparathyroidism (SHPT) and calciphylaxis in most cases. Calciphylaxis after parathyroidectomy is a rare presentation. We present a case of a young patient who developed calciphylaxis after parathyroidectomy, an uncommon presentation.
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Affiliation(s)
- Valberto Sanha
- General Surgery, Federal University of Health Science of Porto Alegre, Porto Alegre, BRA
| | - Lennon Vidori
- Internal Medicine, Federal University of Health Science of Porto Alegre, Porto Alegre, BRA
| | - Beatriz C Pachi
- Internal Medicine, Federal University of Health Science of Porto Alegre, Porto Alegre, BRA
| | - Liana V Marchezi
- Internal Medicine, Federal University of Health Science of Porto Alegre, Porto Alegre, BRA
| | - Gisele Meinerz
- Nephrology, Federal University of Health Science of Porto Alegre, Porto Alegre, BRA
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31
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Springer JM, Villa-Forte A. Vasculitis Mimics and Other Related Conditions. Rheum Dis Clin North Am 2023; 49:617-631. [PMID: 37331736 DOI: 10.1016/j.rdc.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
The approach to diagnosis of primary systemic vasculitis can be challenging, often requiring consideration of important secondary causes of vasculitis and non-inflammatory mimics. An atypical pattern of vascular involvement and/or atypical features of primary vasculitis (eg, cytopenia, lymphadenopathy) should prompt a more thorough investigation into other diseases. Herein, we review selected mimics organized by the size of blood vessels typically affected.
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Affiliation(s)
- Jason M Springer
- Vanderbilt University Medical Center, 1161 21st Avenue South, T-3113 Medical Center North, Nashville, TN 37232-2681, USA.
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32
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Raja A, Karch J, Shih AF, De La Garza H, De Zepeda Diaz AJ, Maymone MBC, Phillips TJ, Secemsky E, Vashi N. Part II: Cutaneous manifestations of peripheral vascular disease. J Am Acad Dermatol 2023; 89:211-226. [PMID: 35504485 DOI: 10.1016/j.jaad.2021.05.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/29/2021] [Accepted: 05/19/2021] [Indexed: 10/18/2022]
Abstract
In this Part 2 of a 2-part continuing medical education series, we review the epidemiology of peripheral vascular disease, its association with cutaneous symptoms, and the diagnosis and evaluation of cutaneous features of vascular disorders. As peripheral vascular disease becomes more prevalent globally, it is essential for dermatologists to become competent at accurately recognizing and diagnosing cutaneous manifestations and directing individuals to receive appropriate care and treatment.
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Affiliation(s)
- Aishwarya Raja
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jamie Karch
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Allen F Shih
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Henriette De La Garza
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | | | - Mayra B C Maymone
- Department of Dermatology, The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Tania J Phillips
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Eric Secemsky
- Smith Center for Outcomes Research, Departments of Cardiology and Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Neelam Vashi
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts; Department of Dermatology, US Department of Veteran Affairs, Boston Health Care System, Boston, Massachusetts.
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33
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Xia J, Tan AJ, Biglione B, Cucka B, Ko L, Nguyen ED, Khoury CC, Robinson MK, Nigwekar SU, Kroshinsky D. Nephrogenic Calciphylaxis Arising after Bariatric Surgery: A Case Series. Am J Nephrol 2023; 55:196-201. [PMID: 37487472 DOI: 10.1159/000531784] [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: 04/05/2023] [Accepted: 06/22/2023] [Indexed: 07/26/2023]
Abstract
Nephrogenic calciphylaxis is associated with multiple risk factors including long-term dialysis dependence, hyperphosphatemia, hypercalcemia, parathyroid hormone derangements, vitamin K deficiency, obesity, diabetes mellitus, warfarin use, and female sex. Bariatric surgery is known to cause altered absorption, leading to mineral and hormonal abnormalities in addition to nutritional deficiency. Prior case reports on calciphylaxis development following bariatric surgery have been published, though are limited in number. We report a case series of five bariatric patients from a single institution who developed nephrogenic calciphylaxis between 2012 and 2018. These patients had a history of bariatric surgery, and at the time of calciphylaxis diagnosis, demonstrated laboratory abnormalities associated with surgery including hypercalcemia (n = 3), hyperparathyroidism (n = 2), hypoalbuminemia (n = 5), and vitamin D deficiency (n = 5), in addition to other medication exposures such as vitamin D supplementation (n = 2), calcium supplementation (n = 4), warfarin (n = 2), and intravenous iron (n = 1). Despite the multifactorial etiology of calciphylaxis and the many risk factors present in the subjects of this case series, we submit that bariatric surgery represents an additional potential risk factor for calciphylaxis directly stemming from the adverse impact of malabsorption and overuse of therapeutic supplementation. We draw attention to this phenomenon to encourage early consideration of calciphylaxis in the differential for painful skin lesions arising after bariatric surgery as swift intervention is essential for these high-risk patients.
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Affiliation(s)
- Joyce Xia
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA,
| | - Alice J Tan
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bianca Biglione
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bethany Cucka
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lauren Ko
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily D Nguyen
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Dermatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Charbel C Khoury
- Department of Nephrology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Malcolm K Robinson
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Metabolic and Bariatric Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sagar U Nigwekar
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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34
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Gossett C, Suppadungsuk S, Krisanapan P, Tangpanithandee S, Thongprayoon C, Mao MA, Cheungpasitporn W. Sodium Thiosulfate for Calciphylaxis Treatment in Patients on Peritoneal Dialysis: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1306. [PMID: 37512116 PMCID: PMC10386543 DOI: 10.3390/medicina59071306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/08/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023]
Abstract
Limited data are available on the utilization of sodium thiosulfate (STS) treatment for calciphylaxis in peritoneal dialysis (PD) patients, while it is well-studied in hemodialysis (HD) patients. A systematic literature search was conducted using Ovid MEDLINE, EBM Reviews-Cochrane Central Register of Controlled Trials, and EBM Reviews-Cochrane Database of Systematic Reviews to identify reported cases of PD patients with calciphylaxis who received STS. The search covered the inception of the databases through August 2022. Across 19 articles, this review identified 30 PD patients with calciphylaxis who received STS. These included 15 case reports, 2 case series, and 2 cohort studies. The administration routes and doses varied depending on the study. For intravenous (IV) administration (n = 18), STS doses ranged from 3.2 g twice daily to 25 g three times weekly for 5 weeks to 8 months. Outcomes included 44% of patients experiencing successful wound healing, 6% discontinuing STS due to adverse effects, 67% transitioning to HD, and 50% dying from calciphylaxis complications. For intraperitoneal (IP) administration (n = 5), STS doses ranged from 12.5 to 25 g three to four times weekly for 12 h to 3 months. Results showed 80% of patients achieving successful wound healing, 80% discontinuing STS due to adverse effects, 40% transitioning to HD, and 20% dying from IP STS-related chemical peritonitis. In cases where patients switched from IV to IP STS (n = 3), doses ranged from 12.5 to 25 g two to three times weekly for 2.5 to 5 months. Among them, 67% experienced successful wound healing, while 33% died from sepsis. Two cases utilized oral STS at a dose of 1500 mg twice daily for 6 and 11 months, resulting in successful wound healing without adverse effects or need for HD. However, one patient (50%) died due to small bowel obstruction. This systematic review provides an overview of STS treatment for PD patients with calciphylaxis. Although successful treatment cases exist, adverse effects were significant. Further research, including larger clinical studies and pharmacokinetic data, is necessary to establish the optimal route, dose, and efficacy of STS in PD patients.
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Affiliation(s)
- Christy Gossett
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
| | - Supawadee Suppadungsuk
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10400, Thailand
| | - Pajaree Krisanapan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine Thammasat University, Pathum Thani 12120, Thailand
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10400, Thailand
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL 32224, USA
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Shahriari S, Ensign E, Huang S, Harrison J, Whisonant C, Aubin-Lemay C. Successful Treatment of Wounds from Nonuremic Calciphylaxis with Acellular Piscine Dermis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5120. [PMID: 37448761 PMCID: PMC10337706 DOI: 10.1097/gox.0000000000005120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/01/2023] [Indexed: 07/15/2023]
Abstract
In this report, we present a 57-year-old man with chronic bilateral lower extremity wounds from nonuremic calciphylaxis, which were successfully reconstructed using a piscine-derived acellular dermal matrix. The acellular dermal matrix incorporated quickly, providing a wound bed that was amenable to skin grafting. We demonstrate that this is an effective off-the-shelf solution for these chronic wounds, resulting in pain reduction and complete closure of the wounds, allowing the patient to return to his previous baseline activities, and improving his quality of life.
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Affiliation(s)
- Shawhin Shahriari
- From the Department of Surgery, Division of Plastic, Reconstructive, Hand and Burn Surgery, University of New Mexico, Albuquerque, N.M
| | - Eric Ensign
- School of Medicine, University of New Mexico, Albuquerque, N.M
| | - Samantha Huang
- From the Department of Surgery, Division of Plastic, Reconstructive, Hand and Burn Surgery, University of New Mexico, Albuquerque, N.M
| | - Joshua Harrison
- From the Department of Surgery, Division of Plastic, Reconstructive, Hand and Burn Surgery, University of New Mexico, Albuquerque, N.M
| | - Cees Whisonant
- Department of Surgery, Creighton University – Phoenix, Phoenix, Ariz
| | - Camille Aubin-Lemay
- From the Department of Surgery, Division of Plastic, Reconstructive, Hand and Burn Surgery, University of New Mexico, Albuquerque, N.M
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36
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Makowicz C. Skin lesions in a man with end-stage renal disease. JAAPA 2023; 36:24-27. [PMID: 37097778 DOI: 10.1097/01.jaa.0000911192.01231.c5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
ABSTRACT Calciphylaxis is an uncommon condition most often seen in patients with end-stage renal disease. It is easily mistaken for other more common conditions and requires a high level of suspicion to make a timely diagnosis. Although various treatments such as IV sodium thiosulfate and bisphosphonates have been used for management, calciphylaxis remains a condition with a high mortality that requires an interdisciplinary approach for optimal management.
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Affiliation(s)
- Chelsea Makowicz
- Chelsea Makowicz is a lieutenant commander in the US Public Health Service and practices at Federal Medical Center Devens, part of the Federal Bureau of Prisons, in Ayer, Mass. The author has disclosed no potential conflicts of interest, financial or otherwise. Opinions expressed in this article are those of the author and do not necessarily represent the opinions of the Federal Bureau of Prisons or the Department of Justice
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37
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Zhou Y, Chen Y, Yin G, Xie Q. Calciphylaxis and its co-occurrence with connective tissue diseases. Int Wound J 2023; 20:1316-1327. [PMID: 36274216 PMCID: PMC10031236 DOI: 10.1111/iwj.13972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/23/2022] [Accepted: 09/27/2022] [Indexed: 03/23/2023] Open
Abstract
Calciphylaxis, also known as calcific uremic arteriopathy, is a rare calcification syndrome that presents as ischemic skin necrosis and severe pain. It has a high mortality rate and is characterised by calcification of the small and medium arteries and micro-thrombosis. Calciphylaxis mainly occurs in patients with end-stage renal disease. In recent years, there have been an increasing number of cases of calciphylaxis associated with connective tissue diseases. Given the absence of clear diagnostic criteria for calciphylaxis thus far, an early diagnosis is crucial for designing an effective multidisciplinary treatment plan. In this article, we review the research progress on calciphylaxis and describe its characteristics in the context of connective tissue diseases.
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Affiliation(s)
- Yueyuan Zhou
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuehong Chen
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Geng Yin
- Department of General Practice, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qibing Xie
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
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38
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Wu J, Chen L, Dang F, Zha P, Li R, Ran X. Refractory wounds induced by normal-renal calciphylaxis: An under-recognised calcific arteriolopathy. Int Wound J 2023; 20:1262-1275. [PMID: 36068658 PMCID: PMC10031205 DOI: 10.1111/iwj.13951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/21/2022] [Accepted: 08/22/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Normal-renal calciphylaxis (NRC) is a devastating calcific vasculopathy characterised by refractory wounds. It is more likely to be misdiagnosed because of the absence of renal insufficiency. Failure to effectively control may lead to rapid deterioration and ultimately death. However, current knowledge of it is still inadequate. OBJECTIVES To provide a relatively comprehensive review of NRC. METHODS Nine electronic medical databases including PubMed, Web of Science, Embase, the Cochrane Library and so on were searched from inception to April 1, 2022. Articles in which calciphylaxis was diagnosed in patients with normal renal function were included. RESULTS Totally 140 articles were retrieved with 187 patients (median age, 62 years [IQR, 49.63 ~ 75.70 years]; 83.42% female; 84.5% Caucasian). Vitamin K antagonism (43.32%) and diabetes (39.57%) accounted for most of the concomitant factors. Cutaneous presentations were the most common. Pathological confirmation was made in 97.86% of patients with an accuracy of 99.45%. Multidisciplinary therapeutic strategies were usually implemented while the final prognosis was not ideal, with a 6-month mortality rate of 21.10% and a 1-year mortality rate of 27.52%. CONCLUSION NRC is an under-recognised disease caused by a variety of factors; meanwhile, multidisciplinary efforts are required to inform diagnostic and therapeutic decisions.
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Affiliation(s)
- Jing Wu
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Lihong Chen
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Fangping Dang
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing/Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Panpan Zha
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Rao Li
- West China School of Nursing/Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Xingwu Ran
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing/Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
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Jiao Y, Sun L, Xie X, Liu H, Zhao Y, Ni H, Zhang X. Clinical features and outcomes of calciphylaxis in Chinese patients with chronic kidney disease. Nephrology (Carlton) 2023; 28:305-314. [PMID: 36883928 DOI: 10.1111/nep.14156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 01/15/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023]
Abstract
AIM Calciphylaxis is a rare disease, predominantly in chronic kidney disease (CKD), characterized by high morbidity and mortality. Data from the Chinese population have been an invaluable resource for a better understanding of natural history, optimal treatments and outcomes of calciphylaxis. METHODS A retrospective study was conducted in 51 Chinese patients diagnosed with calciphylaxis at Zhong Da Hospital affiliated to Southeast University from December 2015 to September 2020. RESULTS Between 2015 and 2020, 51 cases of calciphylaxis were registered in The China Calciphylaxis Registry (http://www.calciphylaxis.com.cn), which was developed by Zhong Da Hospital. The mean age of the cohort was 52.02 ± 14.09 years, and 37.3% were female. Forty-three patients (84.3%) were on haemodialysis, with a median dialysis vintage of 88 months. Eighteen patients (35.3%) had a resolution of calciphylaxis and 20 patients (39.2%) died. Patients in later stages had higher overall mortality than those in earlier stages. Delay from skin lesions onset to diagnosis and calciphylaxis-related infections were risk factors in both early and overall mortality. Additionally, dialysis vintage and infections were significant risk factors in calciphylaxis-specific mortality. Among therapeutic strategies, only the use of sodium thiosulfate (STS) ≥3 courses (14 injections) was significantly associated with decreased hazard of death in both early and overall mortality. CONCLUSION For Chinese patients with calciphylaxis, delay from skin lesions onset to diagnosis and infections secondary to wounds are risk factors for the prognosis of patients with calciphylaxis. Additionally, patients in earlier stages have better survival and early continuous use of STS is highly suggested.
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Affiliation(s)
- Yongyi Jiao
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Li Sun
- Department of Nephrology, Xuyi People's Hospital, Huaian, China
| | - Xiaotong Xie
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Hong Liu
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Yu Zhao
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Haifeng Ni
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Xiaoliang Zhang
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
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40
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Shabani J, Shah V, Jaiswal V, Sharma A, Song D. Chronic skin ulcers in hemodialysis patient: A fatal case of calciphylaxis. Radiol Case Rep 2023; 18:1522-1526. [PMID: 36824989 PMCID: PMC9941061 DOI: 10.1016/j.radcr.2023.01.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 02/10/2023] Open
Abstract
Calciphylaxis is a rare and deadly vascular disease with poorly understood pathophysiology and without definitive treatment. Early presentations include skin ulcers with risk factors including end stage renal disease on hemodialysis, hypertension, hyperlipidemia, and diabetes mellitus. In our case, we present an 80-year-old female with multiple risk factors including hemodialysis and clinical features of necrotic and gangrenous skin lesions diagnostic of calciphylaxis who became hemodynamically unstable and ultimately expired secondary to toxic sequelae. We illustrate this case to explore early clinical presentation, limitations of current disease management and treatments, and the role for further studies to improve diagnosis and reduce mortality.
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Affiliation(s)
- Jawad Shabani
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center, Queens, NY, USA
| | - Vaibhav Shah
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center, Queens, NY, USA
| | - Vikash Jaiswal
- Larkin Community Hospital, South Miami, FL, 33143, USA,Corresponding author at: Larkin Community Hospital, South Miami, FL, 33143, USA.
| | - Akanksha Sharma
- Department of Internal Medicine, UPMC Mercy, Pittsburg, PA, USA
| | - David Song
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center, Queens, NY, USA
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41
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Roberson JL, Butt Z, Florez-Pollack S, Morgan E, Rosenbach M, Braslow BM, Yelon JA. An Intensive Multidisciplinary Approach in Management of Extensive Nonuremic Calciphylaxis of the Bilateral Lower Extremities with Angioinvasive Fungus and Mold. J Burn Care Res 2023; 44:218-221. [PMID: 36269818 DOI: 10.1093/jbcr/irac158] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Indexed: 01/11/2023]
Abstract
Management of infected wounds related to calciphylaxis poses a significant clinical challenge with high morbidity and mortality. Given no definitive management guidelines exist specific to nonuremic calciphylaxis, multiple modalities including sodium thiosulfate, antibiotics, hyperbaric oxygen therapy, and surgical debridement with wound care must be considered. When occurring over a large surface area, standard daily dressing changes are especially labor intensive, inefficient, and ineffective. Negative pressure wound therapy with instillation and dwell time offers broad wound coverage with ongoing therapeutic benefit. We present the case of a previously healthy 19-year-old woman who was transferred for tertiary level care of extensive nonuremic calciphylaxis wounds of the bilateral lower extremities complicated by angioinvasive coinfection with fungus and mold that was managed with a multidisciplinary approach of intensive medical management, aggressive surgical debridement, and negative pressure wound therapy with instillation of hypochlorous acid solution. Ultimately, she achieved full granulation and wound coverage with skin grafting. Large area, infected wounds related to nonuremic calciphylaxis can be successfully managed with multidisciplinary medical management, aggressive surgical debridement, and negative pressure wound therapy that can instill and dwell hypochlorous acid solution.
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Affiliation(s)
- Jeffrey L Roberson
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zoya Butt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie Florez-Pollack
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Morgan
- Department of Pathology & Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Misha Rosenbach
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin M Braslow
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jay A Yelon
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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42
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Tan R, Ou S, Kang T, Wu W, Xiong L, Zhu T, Zhang L. Altered serum metabolome associated with vascular calcification developed from CKD and the critical pathways. Front Cardiovasc Med 2023; 10:1114528. [PMID: 37113701 PMCID: PMC10126378 DOI: 10.3389/fcvm.2023.1114528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/14/2023] [Indexed: 04/29/2023] Open
Abstract
Introduction Vascular calcification (VC) is more likely to be detected in the chronic kidney disease (CKD) population. The mechanism of VC development from CKD is different from that for simple VC and has always been a major research area. The aim of this study was to detect alterations in the metabolome during development of VC in CKD and to identify the critical metabolic pathways and metabolites involved in its pathogenesis. Methods Rats in the model group were given an adenine gavage combined with a high-phosphorus diet to imitate VC in CKD. The aorta calcium content was measured and used to divide the model group into a VC group and non-vascular calcification group (non-VC group). The control group was fed a normal rat diet and given a saline gavage. Ultra-high-performance liquid chromatography-mass spectrometry (UHPLC-MS) was used to determine the altered serum metabolome in the control, VC, and non-VC groups. The identified metabolites were mapped into the Kyoto Encyclopedia of Genes and Genomes (KEGG) database (https://www.genome.jp/kegg/) for pathway and network analyses. Result There were 14 metabolites that changed significantly in the VC group, with three metabolic pathways playing critical roles in the pathogenesis of VC in CKD: steroid hormone biosynthesis; valine, leucine and isoleucine biosynthesis; and pantothenate and CoA biosynthesis. Conclusion Our results indicated changes in the expression of steroid sulfatase and estrogen sulfotransferase, and down-regulation of the in situ synthesis of estrogens in the VC group. In conclusion, the serum metabolome alters significantly during the pathogenesis of VC in CKD. The key pathways, metabolites, and enzymes we identified are worth further study and may become a promising therapeutic target for the treatment of VC in CKD.
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Affiliation(s)
- Ruyu Tan
- Department of Nephrology, Affiliated Hospital of Southwest Medical University, Luzhou, China
- Department of Nephrology, The Fifth Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Santao Ou
- Department of Nephrology, Affiliated Hospital of Southwest Medical University, Luzhou, China
- Sichuan Clinical Research Center for Nephropathy, China
- Correspondence: Santao Ou
| | - Ting Kang
- Department of Nephrology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Weihua Wu
- Department of Nephrology, Affiliated Hospital of Southwest Medical University, Luzhou, China
- Sichuan Clinical Research Center for Nephropathy, China
| | - Lin Xiong
- Department of Nephrology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Tingting Zhu
- Department of Nephrology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Liling Zhang
- Department of Nephrology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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43
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Gholizadeh Ghozloujeh Z, Rajasekaran A, Abdipour A, Norouzi S. Calciphylaxis in a Patient With Lupus Nephritis and Acute Kidney Injury: A Rare Case Report and Literature Review. J Investig Med High Impact Case Rep 2023; 11:23247096231215705. [PMID: 38097351 PMCID: PMC10725146 DOI: 10.1177/23247096231215705] [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: 08/24/2023] [Revised: 10/19/2023] [Accepted: 11/03/2023] [Indexed: 12/18/2023] Open
Abstract
Calciphylaxis is a rare and severe disease characterized by calcification, fibrosis, and thrombosis of small blood vessels. Although it primarily affects patients with end-stage renal disease (ESRD) on dialysis, limited cases have been reported of calciphylaxis in patients with acute kidney injury (AKI) and lupus. This case report describes the occurrence of calciphylaxis in a 35-year-old female recently diagnosed with lupus nephritis class IV and AKI requiring dialysis.
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44
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Ramrattan A, Mohammed EP, Cumberbatch A, Reemaul J. Calciphylaxis Case Series: A Late Presentation of Chronic Kidney Disease From the Eastern Caribbean. Cureus 2023; 15:e34082. [PMID: 36699107 PMCID: PMC9869808 DOI: 10.7759/cureus.34082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 01/25/2023] Open
Abstract
Calcific uremic arteriolopathy (CUA) or calciphylaxis is a rare condition that predominantly affects the dialysis population and is characterized by calcification of cutaneous arterioles accompanied by painful necrotic skin ulcers. At the hemodialysis unit of the Port-of-Spain General Hospital, there have been eight cases between the years 2015-2019 with an incidence of 121 cases per 10,000 patients undergoing renal replacement therapy, quite possibly one of the highest in the world along with an 87.5% mortality when diagnosed with this condition. Risk factors identified in this case series include female gender, obesity, and late presentation of end-stage renal disease. This case series highlights limitations in the diagnosis and management of the disease in a resource-limited setting and intends to raise awareness of this condition in the Caribbean.
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Affiliation(s)
- Amit Ramrattan
- Internal Medicine, Port-of-Spain General Hospital, Port-of-Spain, TTO
| | - Emile P Mohammed
- Internal Medicine and Nephrology, Port-of-Spain General Hospital, Port-of-Spain, TTO
| | | | - Jeanine Reemaul
- Internal Medicine and Dermatology, Port-of-Spain General Hospital, Port-of-Spain, TTO
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45
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Tamagake M, Nagao M, Miura C, Imai Y. Surgical treatment of nonuremic calciphylaxis: a case report and review of literature. Case Reports Plast Surg Hand Surg 2022; 10:1-6. [PMID: 38229696 PMCID: PMC10790797 DOI: 10.1080/23320885.2022.2145962] [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: 02/07/2022] [Accepted: 11/04/2022] [Indexed: 12/23/2022]
Abstract
Calciphylaxis is characterized by extremely painful skin ulcers and develops in patients with or without severe kidney diseases. Herein, a female patient without renal dysfunction developed calciphylaxis in the right lower extremity and underwent successful surgical debridement and split-thickness skin grafting. Nevertheless, prompt wound evaluation and proper surgical approaches are essential.
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Affiliation(s)
- Minami Tamagake
- Department of Plastic and Reconstructive Surgery, School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Munetomo Nagao
- Department of Plastic and Reconstructive Surgery, School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Chieko Miura
- Department of Plastic and Reconstructive Surgery, School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Yoshimichi Imai
- Department of Plastic and Reconstructive Surgery, School of Medicine, Tohoku University, Sendai, Miyagi, Japan
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46
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Eswaran H, Googe P, Vedak P, Marston WA, Moll S. Livedoid vasculopathy: A review with focus on terminology and pathogenesis. Vasc Med 2022; 27:593-603. [PMID: 36285834 PMCID: PMC9732787 DOI: 10.1177/1358863x221130380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Livedoid vasculopathy (LV) is a rare thrombotic vasculopathy of the dermis characterized by painful, relapsing ulcers over the lower extremities. Diagnosis is challenging due to the overlap in clinical appearance and nomenclature with other skin disorders. Treatment selection is complicated by poor understanding of the pathogenesis of LV and lack of robust clinical trials evaluating therapy efficacy. The terminology and pathophysiology of LV are reviewed here, along with its epidemiology, clinical and histologic features, and treatment options. A diagnostic pathway is suggested to guide providers in evaluating for comorbidities, referring to appropriate specialists, and choosing from the available classes of therapy.
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Affiliation(s)
- Harish Eswaran
- Department of Medicine, Division of
Hematology, University of North Carolina School of Medicine, Chapel Hill, NC,
USA
| | - Paul Googe
- Department of Dermatology, University
of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Priyanka Vedak
- Department of Dermatology, University
of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - William A Marston
- Department of Surgery, University of
North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Stephan Moll
- Department of Medicine, Division of
Hematology, University of North Carolina School of Medicine, Chapel Hill, NC,
USA
- Blood Research Center, University of
North Carolina School of Medicine, Chapel Hill, NC, USA
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47
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Nagy E, Sobh MM, Abdalbary M, Elnagar S, Elrefaey R, Shabaka S, Elshabrawy N, Shemies R, Tawfik M, Santos CGS, Barreto FC, El-Husseini A. Is Adynamic Bone Always a Disease? Lessons from Patients with Chronic Kidney Disease. J Clin Med 2022; 11:jcm11237130. [PMID: 36498703 PMCID: PMC9736225 DOI: 10.3390/jcm11237130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022] Open
Abstract
Renal osteodystrophy (ROD) is a common complication of end-stage kidney disease that often starts early with loss of kidney function, and it is considered an integral part in management of patients with chronic kidney disease (CKD). Adynamic bone (ADB) is characterized by suppressed bone formation, low cellularity, and thin osteoid seams. There is accumulating evidence supporting increasing prevalence of ADB, particularly in early CKD. Contemporarily, it is not very clear whether it represents a true disease, an adaptive mechanism to prevent bone resorption, or just a transitional stage. Several co-players are incriminated in its pathogenesis, such as age, diabetes mellitus, malnutrition, uremic milieu, and iatrogenic factors. In the present review, we will discuss the up-to-date knowledge of the ADB and focus on its impact on bone health, fracture risk, vascular calcification, and long-term survival. Moreover, we will emphasize the proper preventive and management strategies of ADB that are pivotal issues in managing patients with CKD. It is still unclear whether ADB is always a pathologic condition or whether it can represent an adaptive process to suppress bone resorption and further bone loss. In this article, we tried to discuss this hard topic based on the available limited information in patients with CKD. More studies are needed to be able to clearly address this frequent ROD finding.
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Affiliation(s)
- Eman Nagy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mahmoud M. Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Sherouk Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Rabab Elrefaey
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Shimaa Shabaka
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Nehal Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Rasha Shemies
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mona Tawfik
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Cássia Gomes S. Santos
- Department of Internal Medicine, Division of Nephrology, Federal University of Paraná, Curitiba 80060-00, PR, Brazil
| | - Fellype C. Barreto
- Department of Internal Medicine, Division of Nephrology, Federal University of Paraná, Curitiba 80060-00, PR, Brazil
| | - Amr El-Husseini
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40536-0298, USA
- Correspondence: ; Tel.: +1-859-218-0934; Fax: +1-859-323-0232
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48
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Swatesutipun V, Benyakorn T. Challenges management in penile calciphylaxis. Urol Case Rep 2022; 45:102219. [PMID: 36131716 PMCID: PMC9483792 DOI: 10.1016/j.eucr.2022.102219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/05/2022] [Accepted: 09/11/2022] [Indexed: 11/26/2022] Open
Abstract
Calciphylaxis is a rare, life-threatening vascular disease, which predominantly affects patients with chronic renal failure treated by dialysis. Penile calciphylaxis is an extremely rare condition, a severe manifestation of calciphylaxis, which is associated with poor prognosis and high mortality rate. Diagnosis and management are challenging and still debatable. We present a case with penile calciphylaxis on whom an arterial bypass to the deep dorsal penile vein was performed. Although, in this case, the method was not permanently successful, the histology showed a cluster of neovascularization after the operation. Deep dorsal arterialization might be a proper technique in well-selected patients.
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49
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Cucka B, Biglione B, Ko L, Nguyen ED, Khoury CC, Nigwekar SU, Robinson MK, Kroshinsky D. Calciphylaxis arising following bariatric surgery: A case series. JAAD Case Rep 2022; 28:4-7. [PMID: 36090194 PMCID: PMC9450058 DOI: 10.1016/j.jdcr.2022.07.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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50
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Zulauf EE, Connors JC, Hardy MA. Manifestation of Nonuremic Calciphylaxis in the Extremities: Case Report and Review. J Foot Ankle Surg 2022; 61:e41-e47. [PMID: 34876341 DOI: 10.1053/j.jfas.2021.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 02/16/2021] [Accepted: 10/12/2021] [Indexed: 02/03/2023]
Abstract
Nonuremic calciphylaxis is a rare condition presenting with peripheral ischemic ulcerations. Calciphylaxis is the deposition of calcium and phosphate into arteriolar walls caused by exceeding their solubility range in the blood. It is most commonly seen in patients with end-stage renal disease; however, nonuremic calciphylaxis occurs in patients with normal or mildly impaired renal function. Risk factors for nonuremic calciphylaxis include Coumadin therapy, obesity, and diabetes mellitus. Histopathologic examination of deep skin biopsy containing subcutaneous adipose tissue reveals medial calcification of dermal and subcutaneous arterioles. This diagnosis must be managed locally with wound care and systemically by control of blood calcium solubility. Avoidance of infection is critical to survival. Here we report a case of calciphylaxis in a patient with normal renal function and serum levels of calcium and phosphorus who presented with gangrene of the extremities. Increased awareness of this debilitating disease will lead to earlier diagnosis, proper treatment and improved patient outcomes.
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Affiliation(s)
- Emily E Zulauf
- Grant Medical Center Foot & Ankle Surgery Resident, Columbus, OH.
| | - James C Connors
- Kent State University College of Podiatric Medicine, Independence, OH
| | - Mark A Hardy
- Kent State University College of Podiatric Medicine, Independence, OH
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