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Wickens O, Rengarajan S, Chinnadurai R, Ford I, Macdougall IC, Kalra PA, Sinha S. The Role of Iron in Calciphylaxis—A Current Review. J Clin Med 2022; 11:jcm11195779. [PMID: 36233647 PMCID: PMC9570530 DOI: 10.3390/jcm11195779] [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: 09/05/2022] [Revised: 09/20/2022] [Accepted: 09/26/2022] [Indexed: 11/25/2022] Open
Abstract
Calcific uraemic arteriolopathy (CUA), also known as calciphylaxis, is a rare and often fatal condition, frequently diagnosed in end-stage renal disease (ESRD) patients. Although exact pathogenesis remains unclear, iron supplementation is suggested as a potential risk factor. Iron and erythropoietin are the main stay of treatment for anaemia in ESRD patients. Few observational studies support the role of iron in the pathogenesis of calciphylaxis although data from the pivotal trial was not strongly supportive of this argument, i.e., no difference in incidence of calciphylaxis between the low-dose and high-dose iron treatment arms. Elevated levels of vascular cell adhesion molecules in association with iron excess were postulated to the pathogenesis of CUA by causing inflammation and calcification within the microvasculature. In-addition, oxidative stress generated because of iron deposition in cases of systemic inflammation, such as those seen in ESRD, may play a role in vascular calcification. Despite these arguments, a direct correlation between cumulative iron exposure with CUA incidence is not clearly demonstrated in the literature. Consequently, we do not have evidence to recommend iron reduction or cessation in ESRD patients that develop CUA.
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Affiliation(s)
- Olivia Wickens
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
| | - Sharmilee Rengarajan
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
| | - Rajkumar Chinnadurai
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow G12 8QQ, UK
| | - Iain C. Macdougall
- Department of Renal Medicine, King’s College Hospital, London SE5 9RS, UK
| | - Philip A. Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Smeeta Sinha
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
- Correspondence:
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Podestà MA, Ciceri P, Galassi A, Cozzolino M. Calciphylaxis after kidney transplantation: a rare but life-threatening disorder. Clin Kidney J 2022; 15:611-614. [PMID: 35371446 PMCID: PMC8967658 DOI: 10.1093/ckj/sfab247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Indexed: 11/20/2022] Open
Abstract
Calciphylaxis is a rare disorder characterized by vascular calcification and thrombosis of the subcutaneous microcirculation, leading to painful necrotic skin lesions and bearing a dreadfully high mortality rate. This syndrome is frequently also termed uraemic calcific arteriolopathy, since most cases are observed in patients with kidney failure. However, it is increasingly clear that calciphylaxis may also affect patients with normal or only slightly impaired renal function, including kidney transplant recipients. A precise definition of the characteristics and risk factors of calciphylaxis developing after kidney transplantation has been hindered by the extreme rarity of this condition, which also hampered the development of effective therapeutic strategies. In the present issue of CKJ, Guillén and colleagues report the largest case series of calciphylaxis in kidney transplant recipients to date, outlining several features that are apparently specific to this population. In this editorial, we briefly present the epidemiology and pathogenesis of calciphylaxis in different patient populations and discuss recent findings for its therapeutic management.
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Affiliation(s)
- Manuel Alfredo Podestà
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Paola Ciceri
- Department of Nephrology, Dialysis and Renal Transplant, Renal Research Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
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Rostoker G, Senet P, Lepeytre F, Griuncelli M, Loridon C, Rabaté C, Cohen Y. Analysis of liver iron concentration in an elderly female undergoing hemodialysis with calcific uremic arteriolopathy does not support the role of iron overload in calciphylaxis: lesson for the clinical nephrologist. J Nephrol 2021; 34:1547-1551. [PMID: 33484427 PMCID: PMC8494698 DOI: 10.1007/s40620-020-00904-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/04/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Guy Rostoker
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France.
- Collège de Médecine des Hôpitaux de Paris, 10 Rue des Fossés Saint-Marcel, 75005, Paris, France.
- Service de Néphrologie et de Dialyse, Ramsay Santé, HP Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France.
| | - Patricia Senet
- Division of Dermatology and Allergology, Assistance Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 Rue de la Chine, 75020, Paris, France
| | - Fanny Lepeytre
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France
| | - Mireille Griuncelli
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France
| | - Christelle Loridon
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France
| | - Clémentine Rabaté
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France
| | - Yves Cohen
- Division of Radiology, Ramsay Santé, Hôpital Privé Claude Galien, 20 Route de Boussy-Saint-Antoine, 91480, Quincy-Sous-Sénart, France
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AlQattan AS, Ghulam WZ, Aldaoud N, Algheryafi L, Aleisa N, Aldulaijan FA. Breast fat necrosis secondary to warfarin-induced calciphylaxis, a rare mimicker of breast cancer: A case report and a review of literature. Breast J 2021; 27:258-263. [PMID: 33480097 DOI: 10.1111/tbj.14160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/05/2021] [Indexed: 11/26/2022]
Abstract
Breast fat necrosis (BFN) is usually a benign inflammatory response to breast trauma. However, an extremely rare cause of fat necrosis is calciphylaxis, a calcification of small- and medium-sized arteries causing thrombosis and ischemia. It is classified into (A) uremic (B) nonuremic-induced calciphylaxis. Calciphylaxis has been reported to be encountered in different parts of the body. However, to the best of our knowledge there is only one case in the English literature of BFN 2ry to warfarin-induced calciphylaxis. We report a 65-year-old female, known case of atrial fibrillation on warfarin, presented with a left breast mass of 4-month duration. The mass was painful and progressively enlarging. Examination of the left breast showed 7 × 4 cm mass, spanning from 10-2 o'clock, free from surrounding structures, with preserved overlying skin. However, the mass was not visualized on mammogram. Ultrasound showed a left breast lobulated hypoechoic mass containing a hyperechoic component. Biopsy showed fat necrosis. After 1 month, she presented with ulceration of the overlying skin. After wide local excision, histopathology demonstrated a calciphylaxis-induced fat necrosis. Considering the patient's background, the diagnosis was BFN secondary to warfarin-induced calciphylaxis. Hence, the warfarin was shifted to Rivaroxaban, 6 months follow-up showed no evidence of recurrence. In conclusion, the rarity of nonuremic calciphylaxis is reflected on the delay of diagnosis in some of the reported cases and the lack of grading system used to guide the management of such difficult wounds. However, keeping a high index of suspicion is important whenever such wounds are encountered with presence of risk factors other than end-stage kidney disease.
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Affiliation(s)
- Abdullah Saleh AlQattan
- Department of Surgery, Breast and Endocrine Surgery Section, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Weaam Zohier Ghulam
- Imam Abdulrahman Bin Faisal University, King Fahad University Hospital, Dammam, Saudi Arabia
| | - Najla Aldaoud
- Department of Pathology and Microbiology, Jordan University of Science and Technology, Irbid, Jordan.,Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Lama Algheryafi
- Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Nadia Aleisa
- Department of Radiology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Fozan A Aldulaijan
- Department of Surgery, Breast and Endocrine Surgery Section, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
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El-Saygeh S, Roese D, Moe SM. Calciphylaxis or vascular oxalosis? Clin Kidney J 2020; 14:435-438. [PMID: 33564451 PMCID: PMC7857799 DOI: 10.1093/ckj/sfz190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/09/2019] [Indexed: 11/13/2022] Open
Abstract
We report the case of a 31-year-old female with primary hyperoxaluria type 1 with end-stage kidney disease who developed severe peripheral vascular disease leading to limb amputation initially thought to be secondary to calciphylaxis. However, polarized review of the pathologic specimen revealed calcium oxalate deposition in the lumen of blood vessels. This unusual presentation of systemic oxalosis demonstrates the adverse consequences of elevations of serum oxalate in patients with hyperoxaluria and that levels can acutely worsen with abrupt onset of kidney failure.
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Affiliation(s)
- Skye El-Saygeh
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Douglas Roese
- Department of Surgery, Columbus Regional Hospital, Columbus, IN, USA
| | - Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
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