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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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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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Development of the BWAT-CUA Scale to Assess Wounds in Patients with Calciphylaxis. Diagnostics (Basel) 2021; 11:diagnostics11040730. [PMID: 33924020 PMCID: PMC8073812 DOI: 10.3390/diagnostics11040730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/09/2021] [Accepted: 04/11/2021] [Indexed: 11/26/2022] Open
Abstract
Calcific uremic arteriolopathy (CUA; calciphylaxis) is a severe form of vascular calcification with no approved therapies. A standardized wound assessment tool is needed to evaluate changes in calciphylaxis wounds over time. A prospective, single-arm study of 14 patients with calciphylaxis reported improvement for the primary endpoint of wound healing using the 13-item Bates-Jensen Wound Assessment Tool (BWAT), although that tool was developed for assessment of pressure ulcers. This report describes development of BWAT-CUA, an 8-item modification of BWAT focusing on prototypical features of calciphylaxis lesions. The BWAT-CUA has a range of 8 (best) to 40 (worst) and was used ad hoc to analyze BWAT data collected in the prospective study. Using BWAT-CUA, relative improvement in calciphylaxis wounds was 30% overall (from 21.2 to 14.9; p = 0.0016) and 34% in the subset of 12 patients with ulceration at baseline (from 23.3 to 15.3; p = 0.0002). BWAT-CUA is a primary endpoint in an ongoing randomized, placebo-controlled phase 3 study of SNF472 recruiting patients with end-stage kidney disease and at least one ulcerated calciphylaxis lesion. BWAT-CUA, a newly developed tool for assessment of calciphylaxis wound severity and improvements over time, may be used in clinical research and in clinical practice.
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Calcific Uremic Arteriolopathy: A Case Series and Review from an Inner-City Tertiary University Center in End-Stage Renal Disease Patients on Renal Replacement Therapy. Int J Nephrol 2021; 2021:6661042. [PMID: 33628505 PMCID: PMC7895580 DOI: 10.1155/2021/6661042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 11/18/2022] Open
Abstract
Materials and Methods 24 patients with CUA and on RRT were evaluated at Detroit Medical Center from 2007 to 2016. Skin biopsy was used in almost all patients, along with the radiological and clinical findings. The patient's clinical and paraclinical data were retrieved from the electronic medical records. The effect of treatment modalities and the underlying hyperparathyroidism management were compared to the clinical outcomes using appropriate statistical tests. Results Twenty-one patients were on hemodialysis, two patients received renal transplants, and one patient was on peritoneal dialysis. Diabetes mellitus was the most prevalent cause of ESRD. The parathyroid hormone level (PTH) was elevated in 22 patients. Fifteen patients were diagnosed 2 weeks or more prior to skin lesion onset. Twenty-two and thirteen patients received sodium thiosulphate and cinacalcet, respectively. Patients with lower PTH and the calcium-phosphate product levels had a relatively better outcome of CUA. Conclusions A multifaceted approach may play a role in treating CUA. Referral to a nephrologist may aid in the early diagnosis and prompt management of CUA.
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Abstract
Calciphylaxis is a rare and poorly understood disease that almost exclusively occurs in end-stage renal disease (ESRD). It is characterized by the calcification of medium and small dermal arterioles with resultant gangrenous necrosis. Patients develop exquisitely painful skin ulceration and necrosis, typically in the lower extremities. Treatments are severely limited, and mortality is high, as few treatment options provide a survival benefit. Improvement in a few calciphylaxis cases affecting the extremities or abdomen have been reported using hyperbaric oxygen therapy (HBOT), however, very few have had a favorable response when it affected penile tissue. We present a case of a patient with ESRD on hemodialysis and subtotal parathyroidectomy who had biopsy-proven penile calciphylaxis with refractory pain who ultimately underwent successful HBOT.
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Adapa S, Naramala S, Gayam V, Koduri NM, Daggubati SR, Patel P, Konala VM. Calciphylaxis in a Patient on Home Hemodialysis. J Investig Med High Impact Case Rep 2020; 8:2324709620922718. [PMID: 32434389 PMCID: PMC7243381 DOI: 10.1177/2324709620922718] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Calciphylaxis is a rare and severe complication characterized by calcification of arterioles and capillaries in the dermis and subcutaneous adipose tissue that leads to ischemia, necrosis, and painful skin lesions in patients with end-stage renal disease (ESRD). It is also known as calcific uremic arteriolopathy. Calciphylaxis occurs most commonly with the ESRD with skin ulceration as a predominant presenting feature. Calcium-phosphorus dysregulation in dialysis patients are traditionally considered as a risk factor for the development of calciphylaxis. The involvement of an integrated interdisciplinary and multifaceted approach is key to the success of the calciphylaxis treatment. We present a case of a 51-year-old female with ESRD on home hemodialysis who developed calciphylaxis, which was successfully managed with increasing dialysis prescription, diligent wound care, and sodium thiosulfate infusion. Management of calciphylaxis in a patient receiving home hemodialysis has never been reported as per the review of the literature. Calciphylaxis is a sporadic disease, frequently encountered in the patients undergoing hemodialysis and carries a very grave prognosis. Current treatment is rarely effective, so preventive strategies play an important role by modifying the risk factors that promote the development of calciphylaxis.
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Affiliation(s)
- Sreedhar Adapa
- The Nephrology Group Inc, Fresno, CA, USA
- Sreedhar Adapa, Kaweah Delta Medical Center, 400 West Mineral King Avenue, Visalia, CA 93291-6263, USA.
| | | | - Vijay Gayam
- Interfaith Medical Center, New York, NY, USA
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Robert T, Lionet A, Bataille S, Seret G. Rheopheresis: A new therapeutic approach in severe calciphylaxis. Nephrology (Carlton) 2019; 25:298-304. [PMID: 31576630 DOI: 10.1111/nep.13666] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/27/2019] [Accepted: 09/03/2019] [Indexed: 01/22/2023]
Abstract
AIM Uremic calciphylaxis, also called calcific uraemic arteriolopathy (CUA), is a rare disease with a poor prognosis (mortality between 45% and 80%). Treatment is currently not standardized, and is based mainly on risk factor control, often with administration of sodium thiosulfate. We report the use of rheopheresis, a double filtration apheresis technique, specifically designed to improve blood rheology and tissue perfusion, as adjunctive therapy in eight patients with severe CUA. METHODS We retrospectively analysed eight cases of severe CUA treated by rheopheresis after failure of conventional measures, including administration of sodium thiosulfate and discontinuation of vitamin K antagonists. RESULTS Of the patients, there were 5 (63%) women, the median age was 69 (63.9-73) years. Four (50%) patients had biopsy-proven CUA. At diagnosis, the median dialysis vintage was 35 (3.9-42) months; five (63%) patients were anuric. Weekly median dialysis duration and dose were 12 (12-12.75) hours and 1.19 (1.13-1.48) Kt/V per dialysis session, respectively. Median time from CUA onset to first rheopheresis therapy was 26 (3.2-68) days. Patients started with 2-3 weekly sessions, coupled with haemodialysis. Complete remission was obtained in five patients (66%) after 25 (19-39) sessions over a duration of 119 (114-196) days. Three patients died, two of which resulted from an infectious complication related to CUA. CONCLUSION Rheopheresis is a promising approach, with a good safety profile, for the treatment of CUA. A prospective study with a larger population, would clarify its place in the therapeutic armamentarium.
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Affiliation(s)
- Thomas Robert
- Centre de Néphrologie et Transplantation Rénale, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Arnaud Lionet
- Hopital Huriez Service de Néphrologie-dialyse et Transplantation, CHU Lille, Lille, France
| | - Stanislas Bataille
- Institut Phocéen de Néphrologie, Marseille, France.,ELSAN, Clinique Bouchard, Marseille, France
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Calciphylaxis: Successful Management of a Rare Complication of Chronic Kidney Disease in Two Patients. Case Rep Nephrol 2019; 2019:1630613. [PMID: 31316845 PMCID: PMC6601500 DOI: 10.1155/2019/1630613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 05/02/2019] [Accepted: 05/30/2019] [Indexed: 01/13/2023] Open
Abstract
Calciphylaxis, or calcification uremic arteriolopathy, is a rare disease thought to occur due to arteriolar calcifications of the dermis and is responsible for ischemia with cutaneous necrosis and painful panniculitis. Its mechanism remains poorly understood which makes its management challenging and difficult to standardize. We report our management of two patients diagnosed with calciphylaxis. In one patient, calciphylaxis was mentioned upon admission given the context of preexisting secondary hyperparathyroidism and the existence of multiple risk factors. In both patients, the diagnosis was confirmed histologically. Our two observations highlight the difficulty of the diagnosis and the complexity of the therapeutic management that has been personalized according to patient characteristics and clinical evolution. Several therapeutic means can be implemented once the diagnosis is made; nevertheless, its prognosis remains pejorative despite the therapeutic advances. Broad debridement, good phosphocalcic balance control, and the correction of the risk factors top the list of any therapeutic strategy. One of the major challenges of the therapy is normalizing the calcium-phosphate balance. Thus, Cinacalcet and sodium thiosulfate appear to be promising treatments.
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Udomkarnjananun S, Kongnatthasate K, Praditpornsilpa K, Eiam-Ong S, Jaber BL, Susantitaphong P. Treatment of Calciphylaxis in CKD: A Systematic Review and Meta-analysis. Kidney Int Rep 2019; 4:231-244. [PMID: 30775620 PMCID: PMC6365410 DOI: 10.1016/j.ekir.2018.10.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/20/2018] [Accepted: 10/01/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Calciphylaxis is a life-threatening complication of chronic kidney disease (CKD). To inform clinical practice, we performed a systematic review of case reports, case series, and cohort studies to synthesize the available treatment modalities and outcomes of calciphylaxis in patients with CKD. METHODS Electronic databases were searched for studies that examined the uses of sodium thiosulfate, surgical parathyroidectomy, calcimimetics, hyperbaric oxygen therapy, and bisphosphonates for calciphylaxis in patients with CKD, including end-stage renal disease. For cohort studies, the results were synthesized quantitatively by performing random-effects model meta-analyses. RESULTS A total of 147 articles met the inclusion criteria and were included in the systematic review. There were 90 case reports (90 patients), 20 case series (423 patients), and 37 cohort studies (343 patients). In the pooled cohorts, case series, and case reports, 50.3% of patients received sodium thiosulfate, 28.7% underwent surgical parathyroidectomy, 25.3% received cinacalcet, 15.3% underwent hyperbaric oxygen therapy, and 5.9% received bisphosphonates. For the subset of cohort studies, by meta-analysis, the pooled risk ratio for mortality was not significantly different among patients who received sodium thiosulfate (pooled risk ratio [RR] 0.89; 95% confidence interval [CI] 0.71-1.12), cinacalcet (pooled RR 1.04; 95% CI 0.75-1.42), hyperbaric oxygen therapy (pooled RR 0.89; 95% CI 0.71-1.12), and bisphosphonates (pooled RR 0.77; 95% CI 0.44-1.32), and those who underwent surgical parathyroidectomy (pooled RR 0.88; 95% CI 0.69-1.13). CONCLUSION This systematic review found no significant clinical benefit of the 5 most frequently used treatment modalities for calciphylaxis in patients with CKD. Randomized controlled trials are needed to test the efficacy of these therapies.
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Affiliation(s)
- Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kitravee Kongnatthasate
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Bertrand L. Jaber
- Department of Medicine, St. Elizabeth’s Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Hepschke JL, Masselos K, Sandbach J, Fraser CL. Seeing the difference—Painless progressive vision loss in a vasculopath. Surv Ophthalmol 2019; 64:123-131. [DOI: 10.1016/j.survophthal.2017.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/11/2017] [Indexed: 02/01/2023]
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Abstract
Calciphylaxis is a rare disease that typically presents in patients with end-stage renal disease on dialysis or those who have received a renal transplant. Nonuremic calciphylaxis leads to ischemia and subsequent necrosis of subcutaneous tissue. Diseases associated with nonuremic calciphylaxis include primary hyperparathyroidism, connective tissue disease, malignancy, and alcoholic liver disease. Due to its high mortality, early identification and an aggressive multidisciplinary treatment approach is necessary to improve patient outcomes.
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Truong DH, Riedhammer MM, Zinszer K. Non-uraemic calciphylaxis successfully treated with pamidronate infusion. Int Wound J 2018; 16:250-255. [PMID: 30393969 DOI: 10.1111/iwj.13019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 09/26/2018] [Accepted: 10/05/2018] [Indexed: 01/11/2023] Open
Abstract
Calciphylaxis is a rare and potentially fatal disease that affects the subcutaneous layer of the skin. It is a calcific vasculopathy induced by a systemic process that causes occlusion of small blood vessels. The mortality rate for individuals diagnosed with calciphylaxis is estimated between 52% and 81% with sepsis being the leading cause of death. Uraemic calciphylaxis and its known effective treatments are well documented in the literature. Unfortunately, there is no known effective treatment for non-uraemic calciphylaxis. Most of the current treatments for non-uraemic calciphylaxis are derived from uraemic calciphylaxis treatment protocols. We report a case of a 75-year-old female with calciphylaxis on the right lower extremity who was successfully treated with four pamidronate infusions in addition to local wound care. This case represents a non-uraemic calciphylaxis wound successfully treated with pamidronate infusions and standard wound care, and suggests that IV pamidronate can be an effective treatment option.
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Affiliation(s)
- David H Truong
- Podiatric Medicine and Surgery Residency, Geisinger Community Medical Center, Scranton, Pennsylvania
| | | | - Kathya Zinszer
- Department of Orthopaedics, Geisinger Medical Center, Danville, Pennsylvania
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Delma S, Isnard-Bagnis C, Deray G, Barthelemy RN, Mercadal L, Desbuissons G. [Hyperthyroidism-induced calciphylaxis: A case report]. Nephrol Ther 2018; 14:548-553. [PMID: 30385137 DOI: 10.1016/j.nephro.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 07/28/2018] [Accepted: 08/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Calciphylaxis or calcific uremic arteriolopathy (CUA) is a cutaneous disease with ulcerations secondary to calcification of cutaneous and subcutaneous small arteries and arterioles. It is a rare but severe disease with significant morbidity and mortality affecting 1 to 4% of dialysis patients. The circumstances of occurrence are multiple. CASE We report the case of a severe bilateral lower limb calciphylaxis in a 69-year-old, obese, hemodialysis patient with a recent diagnosis of Graves' disease complicated with hypercalcemia and cardiac arrhythmia requiring the use of vitamin K antagonist. Complex and multidisciplinary therapeutic management (daily hemodialysis, sodium thiosulfate therapy, treatment of hypercalcemia by denosumab, hyperbaric oxygen therapy, meshed skin autograft) allowed complete healing of the lesions. CONCLUSION This is the first description of AUC secondary to hyperthyroidism in a dialysis patient. Multidisciplinary care is essential to achieve clinical improvement in those critical situations.
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Affiliation(s)
- Samuel Delma
- Service de néphrologie, groupe hospitalier La Pitié-Salpêtrière, 75013 Paris, France
| | - Corinne Isnard-Bagnis
- Service de néphrologie, groupe hospitalier La Pitié-Salpêtrière, 75013 Paris, France
| | - Gilbert Deray
- Service de néphrologie, groupe hospitalier La Pitié-Salpêtrière, 75013 Paris, France
| | | | - Lucile Mercadal
- Service de néphrologie, groupe hospitalier La Pitié-Salpêtrière, 75013 Paris, France
| | - Geoffroy Desbuissons
- Service de néphrologie, groupe hospitalier La Pitié-Salpêtrière, 75013 Paris, France.
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Abdalla AO, Al-Khafaji J, Taha M, Malik S. A Fatal Case of Non-Uremic Calciphylaxis: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:804-807. [PMID: 29983410 PMCID: PMC6066970 DOI: 10.12659/ajcr.909546] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Patient: Female, 61 Final Diagnosis: Non-uremic calciphylaxis Symptoms: Pain • skin ulcers Medication: — Clinical Procedure: — Specialty: General and Internal Medicine
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Affiliation(s)
- Abubaker O Abdalla
- Department of Internal Medicine, School of Medicine, University of Nevada, Reno, NV, USA
| | - Jaafar Al-Khafaji
- Department of Internal Medicine, School of Medicine, University of Nevada, Reno, NV, USA
| | - Mohamed Taha
- Department of Internal Medicine, University of Nevada, School of Medicine, Reno, NV, USA
| | - Samira Malik
- Department of Internal Medicine, University of Nevada, School of Medicine, Reno, NV, USA
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15
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Hemdani R, Rajput GR, Sridhar J, Chatterjee M, Rathod D. Calciphylaxis as cutaneous marker of hyperparathyroidism and successful outcome with parathyroidectomy followed by hyperbaric oxygen therapy. Indian J Dermatol Venereol Leprol 2018; 84:209-211. [PMID: 29451194 DOI: 10.4103/ijdvl.ijdvl_252_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Ruchi Hemdani
- Department of Dermatology, INHS Asvini, Mumbai, Maharashtra, India
| | - G R Rajput
- Department of Dermatology, INHS Asvini, Mumbai, Maharashtra, India
| | - J Sridhar
- Department of Dermatology, INHS Asvini, Mumbai, Maharashtra, India
| | - Manas Chatterjee
- Department of Dermatology, INHS Asvini, Mumbai, Maharashtra, India
| | - Dipali Rathod
- Department of Dermatology, INHS Asvini, Mumbai, Maharashtra, India
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Fernández M, Morales E, Gutierrez E, Polanco N, Hernández E, Mérida E, Praga M. Calcifilaxis: más allá de CKD-MBD. Nefrologia 2017; 37:501-507. [DOI: 10.1016/j.nefro.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/29/2017] [Accepted: 02/06/2017] [Indexed: 01/09/2023] Open
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McCulloch N, Wojcik SM, Heyboer M. Patient Outcomes and Factors Associated with Healing in Calciphylaxis Patients Undergoing Adjunctive Hyperbaric Oxygen Therapy. J Am Coll Clin Wound Spec 2016; 7:8-12. [PMID: 28053862 DOI: 10.1016/j.jccw.2016.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Calcific uremic arteriolopathy, also known as calciphylaxis, is a rare syndrome of small vessel calcification of unknown etiology causing painful, violaceous skin lesions that progress to form chronic non-healing ulcers and gangrene. Hyperbaric oxygen therapy (HBOT) can be used as adjunctive therapy in the treatment of these ulcers. However, due to paucity of cases, there is limited data on the clinical benefit of HBOT and identifying factors associated with healing. The purpose of this study was to determine patient outcomes and factors associated with healing in patients with calciphylaxis undergoing HBOT. A retrospective chart review was completed on patients who were diagnosed with calciphylaxis and had hyperbaric medicine consultation between May 2012 and January 2016. Clinical outcomes, demographics, risk factors, laboratory values, wound distribution, and HBOT profiles were collected and analyzed. We identified 8 patients. Out of 8 patients consulted for calciphylaxis, five were consented and underwent HBOT (2 males and 3 females). All had coexisting ESRD and Diabetes. All males were able to tolerate being in the chamber and received therapeutic treatments (at least 20 HBOT) with complete resolution of ulcers. HBOT was discontinued in one female due to an inconsistent biopsy report and two others due to death secondary to septic shock or respiratory arrest and severe uremia. Calciphylaxis is a devastating disease with a high mortality rate. Our results demonstrated a positive response to HBOT especially when receiving at least 20 treatments. A majority of calciphylaxis cases are females and indeed female gender has been cited as a risk factor for this disease. However, current literature has not conferred a relationship between gender nor the number of HBOT received and outcomes. Our results showed that males had a more favorable outcome provided they received at least twenty HBOT. Further prospective studies are needed to elucidate these outcomes.
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Affiliation(s)
- Norman McCulloch
- Fellowship in Undersea & Hyperbaric Medicine, Department of Emergency Medicine, Division of Hyperbaric Medicine and Wound Care, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Susan M Wojcik
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Marvin Heyboer
- Department of Emergency Medicine, Division of Hyperbaric Medicine and Wound Care, SUNY Upstate Medical University, 550 East Genesee Street, Suite 103, Syracuse, NY 13202, USA
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Abstract
PURPOSE OF REVIEW Calcific uremic arteriolopathy (CUA), as known as calciphylaxis, is a rare and poorly understood disease seen predominantly in end stage renal disease patients. A collaborative multidisciplinary approach to develop and implement treatment and prevention methods is described. RECENT FINDINGS Overall, the scientific literature on CUA is largely restricted to case reports and case series. Recent reports indicate that the incidence of CUA may be on the rise and emphasize an association with vitamin K antagonist therapy, obesity, and diabetes mellitus. Serum calcium, phosphorous, and parathyroid hormone levels have been reported to be quite variable in patients with CUA and may reflect the heterogeneity of study designs. A multidisciplinary and multimodal approach that incorporates wound and pain management, sodium thiosulfate, optimization of mineral bone parameters, bisphosphonates, and avoidance of risk factors such as vitamin K antagonist has been advocated in the latest reports. Sodium thiosulfate although used frequently to treat CUA has unclear efficacy requiring further examination. SUMMARY This review describes the recent literature in the field of CUA including its limitations. It provides a summary of a multidisciplinary approach to CUA management.
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An J, Devaney B, Ooi KY, Ford S, Frawley G, Menahem S. Hyperbaric oxygen in the treatment of calciphylaxis: A case series and literature review. Nephrology (Carlton) 2016; 20:444-50. [PMID: 25707425 DOI: 10.1111/nep.12433] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2015] [Indexed: 11/28/2022]
Abstract
AIMS Calcific uraemic arteriolopathy (CUA) or calciphylaxis is most commonly seen in end-stage renal disease and is associated with significant morbidity and mortality. The aim of this study was to determine whether hyperbaric oxygen therapy (HBOT) is effective in healing calciphylaxis lesions and to determine if there are any patient factors that can predict wound healing and patient survival. METHODS We identified by retrospective review all cases of CUA referred to our institution for treatment with HBOT. We documented the clinical and biochemical parameters of this patient population, the size and distribution of the lesions as well as wound outcomes and patient survival following treatment. RESULTS A total 46 patients were identified with CUA associated with renal failure. Of the 46 patients, only 34 received a full course of HBOT. The balance was deemed unsuitable for treatment or was unable to tolerate treatment and was palliated. Of the 34 patients that received a full course of HBOT, 58% showed improvement in their wound scores, with more than half of these patients having complete healing of their wounds. The balance did not benefit from the therapy and had a very poor prognosis. Those that benefited from HBOT survived on average for more than 3 years. The only factor significantly associated with improved wound healing and survival was diabetes. CONCLUSION This retrospective analysis suggests a role for HBOT in the treatment of CUA with more than half of the treated patients benefiting and surviving for an average of more than 3 years.
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Affiliation(s)
- Jennifer An
- Department Renal Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Bridget Devaney
- Department Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Khai Yang Ooi
- Department Renal Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Sharon Ford
- Department Renal Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Geoff Frawley
- Department Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Solomon Menahem
- Department Renal Medicine, Alfred Hospital, Melbourne, Victoria, Australia
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20
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Nigwekar SU, Kroshinsky D, Nazarian RM, Goverman J, Malhotra R, Jackson VA, Kamdar MM, Steele DJR, Thadhani RI. Calciphylaxis: risk factors, diagnosis, and treatment. Am J Kidney Dis 2015; 66:133-46. [PMID: 25960299 DOI: 10.1053/j.ajkd.2015.01.034] [Citation(s) in RCA: 251] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/22/2015] [Indexed: 02/07/2023]
Abstract
Calciphylaxis is a rare but devastating condition that has continued to challenge the medical community since its early descriptions in the scientific literature many decades ago. It is predominantly seen in patients with chronic kidney failure treated with dialysis (uremic calciphylaxis) but is also described in patients with earlier stages of chronic kidney disease and with normal kidney function. In this review, we discuss the available medical literature regarding risk factors, diagnosis, and treatment of both uremic and nonuremic calciphylaxis. High-quality evidence for the evaluation and management of calciphylaxis is lacking at this time due to its rare incidence and poorly understood pathogenesis and the relative paucity of collaborative research efforts. We hereby provide a summary of recommendations developed by a multidisciplinary team for patients with calciphylaxis.
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Affiliation(s)
- Sagar U Nigwekar
- Division of Nephrology, Massachusetts General Hospital, Boston, MA.
| | | | - Rosalynn M Nazarian
- Pathology Service, Dermatopathology Unit, Massachusetts General Hospital, Boston, MA
| | - Jeremy Goverman
- Burn Service, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Rajeev Malhotra
- Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Vicki Ann Jackson
- Palliative Care Division, Massachusetts General Hospital, Boston, MA
| | - Mihir M Kamdar
- Palliative Care Division, Massachusetts General Hospital, Boston, MA
| | - David J R Steele
- Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Ravi I Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, MA
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21
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Chan SQ, Wagner I, Vittor GS. Calciphylaxis in the absence of renal failure and hyperparathyroidism in a nonagenarian. BMJ Case Rep 2015; 2015:bcr-2014-205483. [PMID: 25878225 DOI: 10.1136/bcr-2014-205483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Calciphylaxis is a rare, potentially life-threatening syndrome of progressive cutaneous necrosis from calcium deposition. It is well described in uraemic diseases. However, its mechanism is poorly understood and information on non-uraemic causes is lacking. This is the first report of a biopsy-proven non-uraemic calciphylaxis in a nonagenarian.
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Affiliation(s)
- Shuang Quan Chan
- Department of Geriatrics, Monash Health, Dandenong, Victoria, Australia
| | - Irene Wagner
- Department of Geriatrics, Monash Health, Dandenong, Victoria, Australia
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Bohorquez HE, Chamorro N, Garces J, Cohen AJ, Reichman TW, Davis NK, Vincent B, Bruce DA, Carmody IC, Moiz A, Staffeld C, Loss GE. Calciphylaxis in simultaneous liver-kidney transplantation. Am J Transplant 2015; 15:1105-9. [PMID: 25716643 DOI: 10.1111/ajt.13082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/21/2014] [Accepted: 10/21/2014] [Indexed: 01/25/2023]
Affiliation(s)
- H E Bohorquez
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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23
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Bennis Y, Becquart C, Aljudaibi N, Patenotre P, Guerreschi P, Delaporte E, Duquennoy-Martinot V. [Massive panniculectomy and bilateral subtotal mastectomy in a case of calciphylaxis: A case report and up date]. ANN CHIR PLAST ESTH 2015; 60:527-32. [PMID: 25799428 DOI: 10.1016/j.anplas.2015.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 02/18/2015] [Indexed: 12/17/2022]
Abstract
Calciphylaxis or calcific arteriolopathy is a rare, life-threatening obstructive pathology of the small cutaneous and subcutaneous vessels. It mainly affects patients with chronic renal failure but it also has been described in patients with normal renal function. The principal risks factors apart from renal failure and phosphocalcic metabolism imbalance are: the female sex, obesity, peripheral vascular disease, diabetes and oral anti-coagulation. We present a very rare case of abdominal, mammarian and upper thighs calciphylaxis in a patient with normal renal function. She presented a severe obesity with a recent important loss of weight and had been treated by oral anticoagulants for a long time. She benefited of a multidisciplinary approach with dermatologists, plastic surgeons and anesthesists permitting a recovery in fourteen weeks. Multidisciplinary approach is necessary but the place of the surgery is not well defined. We report a case in which early and wide surgical approach permitted to obtain a favourable evolution of the pathology. Then, we propose a therapeutic strategy after review of the literature.
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Affiliation(s)
- Y Bennis
- Service de chirurgie plastique reconstructrice et esthétique, hôpital Roger-Salengro, CHRU, 59037 Lille, France.
| | - C Becquart
- Clinique dermatologique, hôpital Claude-Huriez, CHRU, 59037 Lille, France; Faculté de médecine Henri Warembourg, université de Lille, 59045 Lille, France
| | - N Aljudaibi
- Service de chirurgie plastique reconstructrice et esthétique, hôpital Roger-Salengro, CHRU, 59037 Lille, France
| | - P Patenotre
- Chirurgie générale et vasculaire, hôpital Claude-Huriez, CHRU, 59037 Lille, France; Faculté de médecine Henri Warembourg, université de Lille, 59045 Lille, France
| | - P Guerreschi
- Service de chirurgie plastique reconstructrice et esthétique, hôpital Roger-Salengro, CHRU, 59037 Lille, France; Faculté de médecine Henri Warembourg, université de Lille, 59045 Lille, France
| | - E Delaporte
- Clinique dermatologique, hôpital Claude-Huriez, CHRU, 59037 Lille, France; Faculté de médecine Henri Warembourg, université de Lille, 59045 Lille, France
| | - V Duquennoy-Martinot
- Service de chirurgie plastique reconstructrice et esthétique, hôpital Roger-Salengro, CHRU, 59037 Lille, France; Faculté de médecine Henri Warembourg, université de Lille, 59045 Lille, France
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24
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Borges L, Rosa P, Dias E, Cássio I. Successful treatment of calciphylaxis by a multidisciplinary approach. BMJ Case Rep 2014; 2014:bcr-2014-204354. [PMID: 25035446 DOI: 10.1136/bcr-2014-204354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A 48-year-old woman performing peritoneal dialysis for end-stage renal disease presented with a painful leg ulcer. The investigation revealed an elevated parathyroid hormone level and the histological examination of the biopsy tissue from the ulcer revealed medial calcification of the arterioles, consistent with calciphylaxis. The patient developed additional ulcers in the lower limbs and treatment with antibiotics, cinacalcet, sevelamer, sodium thiosulfate, low calcium dialysate and hyperbaric oxygen therapy was instituted. The patient had a favourable outcome and after 9 months the ulcers had healed and the parathyroid hormone level reached the normal range. Calciphylaxis is a rare and life-threatening disorder associated with a mortality of 60-80%. Its pathogenesis is not fully understood hence there is no consensus in the treatment of this pathology.
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Affiliation(s)
- Lisa Borges
- Department of Vascular Surgery, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
| | - Pedro Rosa
- Hyperbaric Medicine Department, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
| | - Emanuel Dias
- Department of Angiology and Vascular Surgery, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
| | - Isabel Cássio
- Department of Angiology and Vascular Surgery, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
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25
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Gil-Gascón JM, Guerrero-Cauqui R, de la Prada-Alvarez F, García-Fuentes F, Fraga GR, Wetmore JB. Bosentan for the treatment of a clinical syndrome closely resembling calcific uremic arteriolopathy: a case report. Nephrology (Carlton) 2014; 19:366-7. [PMID: 24842789 DOI: 10.1111/nep.12218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- José M Gil-Gascón
- Department of Internal Medicine, Hospital SAS Punta de Europa, Algeciras, Spain
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26
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Gallimore GG, Curtis B, Smith A, Benca M. Curious case of calciphylaxis leading to acute mitral regurgitation. BMJ Case Rep 2014; 2014:bcr-2013-201803. [PMID: 24789150 DOI: 10.1136/bcr-2013-201803] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Calciphylaxis is uncommon and typically seen in patients with end-stage renal disease. It has been defined as a vasculopathic disorder characterised by cutaneous ischaemia and necrosis due to calcification, intimal fibroplasia and thrombosis of pannicular arterioles. We present the case of a 74-year-old woman with chronic kidney disease stage III who developed calciphylaxis leading to mitral valve calcification, chordae tendineae rupture and acute mitral regurgitation. Although an alternative explanation can typically be found for non-uraemic calciphylaxis, her evaluation did not reveal any usual non-uraemic causes including elevated calcium-phosphorus product, hyperparathyroidism, or evidence of connective tissue disease. Her wounds improved with sodium thiosulfate, pamidronate, penicillin and hyperbaric oxygen therapies but she ultimately decompensated with the onset of acute mitral regurgitation attributed to rupture of a previously calcified chordae tendineae. This case highlights an unusual case of calciphylaxis without clear precipitant as well as a novel manifestation of the disease.
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27
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Maroz N, Mohandes S, Field H, Kabakov Z, Simman R. Calciphylaxis in Patients With Preserved Kidney Function. J Am Coll Clin Wound Spec 2014; 6:24-8. [PMID: 26442208 PMCID: PMC4566866 DOI: 10.1016/j.jccw.2015.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Calcific uremic arteriolopathy (CUA), also known as calciphylaxis, is a devastating disease typically seen in patients with end stage renal disease. It manifests as extremely painful symmetrical wounds resistant to surgical and medical interventions. The prevalence of CUA among hemodialysis dependent patients was found to be as high as 4.1%. The management of patients with CUA requires a multidisciplinary approach by the medical team, yet often results in a low rate of successful outcomes. Recently, non-uremic calciphylaxis (NUC) has been described in the absence of kidney disease. Limited knowledge exists on the management of NUC and the outcomes of this condition. Herein we describe three clinical scenarios of patients diagnosed with NUC in the absence of permanent or prolonged acute renal pathology. The reporting of successful and fruitless therapeutic interventions for wound management in NUC is important for compiling the evidence of effective therapeutic strategies.
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Affiliation(s)
- Natallia Maroz
- Renal Physicians Inc., Dayton, OH, USA
- Department of Medicine, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
| | - Samer Mohandes
- Department of Medicine, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
- Miamy Valley Hospital, Dayton, OH, USA
| | - Halle Field
- Department of Medicine, Kettering Medical Center, Dayton, OH, USA
| | | | - Richard Simman
- Division of Plastic and Reconstructive Surgery, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
- Department of Pharmacology and Toxicology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
- Department of Dermatology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
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28
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Abstract
Calciphylaxis, also referred to as calcific uremic arteriolopathy, is a relatively rare but well described syndrome that occurs most commonly in patients with late stage CKD. It is characterized by very painful placques or subcutaneous nodules and violaceous, mottled skin lesions that may progress to nonhealing ulcers, tissue necrosis, and gangrene with a 1-year mortality rate >50%. The pathogenesis of calciphylaxis is poorly understood. Risk factors include female sex, obesity, hyperphosphatemia, hypercalcemia, hyperparathyroidism, longer dialysis vintage, hypercoagulable states, and use of calcium-containing phosphate binders and warfarin. Treatment strategies for calciphylaxis are limited by inadequate understanding of its pathophysiology. Therapy is generally focused on correcting disturbances of calcium, phosphorus, and parathyroid hormone metabolism. Additional therapy focuses on decreasing inflammation and on dissolution of tissue calcium deposits with sodium thiosulfate and/or bisphosphonates. Successful treatment generally results in improvement of pain and healing of the lesions within 2-4 weeks, but the disorder generally takes many months to completely resolve.
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Affiliation(s)
- Stuart M Sprague
- Division of Nephrology and Hypertension, NorthShore University Health System, Evanston, Illinois
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29
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Tsolakidis S, Grieb G, Piatkowski A, Alharbi Z, Demir E, Simons D, Pallua N. Calciphylaxis - a challenging & solvable task for plastic surgery? A case report. BMC DERMATOLOGY 2013; 13:1. [PMID: 23311951 PMCID: PMC3566927 DOI: 10.1186/1471-5945-13-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 01/07/2013] [Indexed: 11/25/2022]
Abstract
Background Calciphylaxis (calcific uremic arteriolopathy) is rare and its pathogenesis is not fully understood. Indeed, Calciphylaxis presents a challenge through the course of its management which involve different specialities but unfortunately this disease so far has a poor prognosis. We herein present, in this case report, a multidisciplinary approach involving plastic surgeons with special regards to reconstructive approach after debridement procedures. Case presentation We present a 21 years old male with a BMI of 38,2, who was transferred to our department from another hospital. Calciphylaxis has been diagnosed after receiving anticoagulation with phenprocoumon after a single event of pulmonary embolism. The INR on admission was 1,79. He had necrotic spots on both sides of the abdominal wall and on both thighs medially. During this time he underwent several reconstructive procedures in our department. Conclusion It can be suggested that this agonizing disease needs indeed a multidisciplinary approach involving Nephrologists, Dermatologists, Intensive Care Physicians and Plastic Surgeons, taking into consideration that surgical correction can achieve further improvement in a specialized centre. Notwithstanding, further cohort studies should be approached clinically to insight the light on this disease with special regard to the prognosis after this approach.
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Affiliation(s)
- Savas Tsolakidis
- Department of Plastic Surgery and Hand Surgery, Burn Center, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany.
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Yalin AS, Altiparmak MR, Trabulus S, Yalin SF, Yalin GY, Melikoglu M. Calciphylaxis: a report of six cases and review of literature. Ren Fail 2012; 35:163-9. [PMID: 23151146 DOI: 10.3109/0886022x.2012.741426] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Calciphylaxis is usually a fatal condition that develops in a few chronic renal failure patients, and it is characterized by calcifications in subcutaneous arteries, infarcts in skin, and the neighboring subcutis. Calciphylaxis, once considered as a rare condition, has been reported to have an annual incidence of 1% and a prevalence of 4% in dialysis patients. We describe our clinical experience in six end-stage renal disease patients on dialysis that presented with calciphylaxis and died due to sepsis, and review the pathogenesis, epidemiology, clinical and histopathologic features, and treatment of calciphylaxis. Physicians should initially consider the possibility of calciphylaxis in case of development of skin lesions in chronic renal failure patients with impaired calcium, phosphorus, and parathyroid hormone levels. The most important cause of mortality in this condition is infection. Therefore, differential diagnosis of these lesions from systemic vasculitis in their early stages and withdrawal of immunosuppressive therapy that increases the tendency to infections are essential.
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Affiliation(s)
- Ayse Serap Yalin
- Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Brucculeri M, Haydon AH. Calciphylaxis presenting in early chronic kidney disease with mixed hyperparathyroidism. Int J Nephrol Renovasc Dis 2011; 4:157-60. [PMID: 22259253 PMCID: PMC3259692 DOI: 10.2147/ijnrd.s27607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Calciphylaxis is a disabling and life-threatening complication that primarily affects patients who are dialysis dependent. Reports have grown in the literature of cases occurring in those who have advanced chronic kidney disease (pre-end-stage renal disease) or in the setting of transplantation. There are also a few reports of cases occurring in those without any form of chronic kidney disease but with primary hyperparathyroidism. This disease entity is characterized by calcification, intimal hypertrophy, and thrombosis of small vessels that result in necrotizing, nonhealing ulcers – many of which are life threatening. Although several strategies aimed at treating and preventing this affliction have been reported in the literature, the outcome for most patients with calciphylaxis remains quite poor. We describe a patient with comparatively early stage-3 chronic kidney disease who developed calciphylaxis in the setting of both primary and secondary hyperparathyroidism. Predictably, after subtotal parathyroidectomy, her wounds did not completely heal and her biochemical markers of hyperparathyroidism did not completely normalize until her underlying secondary hyperparathyroidism was treated medically. It was only after initiating cinacalcet that the patient experienced complete wound healing and resolution of her calciphylaxis. It also supports other authors’ findings that cinacalcet may be an important adjunct in the treatment of calciphylaxis.
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Baldwin C, Farah M, Leung M, Taylor P, Werb R, Kiaii M, Levin A. Multi-intervention Management of Calciphylaxis: A Report of 7 Cases. Am J Kidney Dis 2011; 58:988-91. [DOI: 10.1053/j.ajkd.2011.06.022] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 06/02/2011] [Indexed: 11/11/2022]
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Reiter N, El-Shabrawi L, Leinweber B, Berghold A, Aberer E. Calcinosis cutis: part I. Diagnostic pathway. J Am Acad Dermatol 2011; 65:1-12; quiz 13-4. [PMID: 21679810 DOI: 10.1016/j.jaad.2010.08.038] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 08/06/2010] [Accepted: 08/06/2010] [Indexed: 11/17/2022]
Abstract
Calcinosis cutis is characterized by the deposition of insoluble calcium salts in the skin and subcutaneous tissue. The syndrome is separated into five subtypes: dystrophic calcification, metastatic calcification, idiopathic calcification, iatrogenic calcification, and calciphylaxis. Dystrophic calcification appears as a result of local tissue damage with normal calcium and phosphate levels in serum. Metastatic calcification is characterized by an abnormal calcium and/or phosphate metabolism, leading to the precipitation of calcium in cutaneous and subcutaneous tissue. Idiopathic calcification occurs without any underlying tissue damage or metabolic disorder. Skin calcification in iatrogenic calcinosis cutis is a side effect of therapy. Calciphylaxis presents with small vessel calcification mainly affecting blood vessels of the dermis or subcutaneous fat. Disturbances in calcium and phosphate metabolism and hyperparathyroidism can be observed.
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Affiliation(s)
- Nadine Reiter
- Department of Dermatology, Medical University of Graz, Graz, Austria
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34
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Vedvyas C, Winterfield LS, Vleugels RA. Calciphylaxis: a systematic review of existing and emerging therapies. J Am Acad Dermatol 2011; 67:e253-60. [PMID: 21821309 DOI: 10.1016/j.jaad.2011.06.009] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 05/20/2011] [Accepted: 06/10/2011] [Indexed: 10/17/2022]
Abstract
Calciphylaxis, also known as calcific uremic arteriolopathy, is a cutaneous ischemic small vessel vasculopathy seen in 1 to 4% of patients with chronic kidney disease on hemodialysis. It is associated with extreme pain and a 60 to 80% mortality rate in the setting of few and frequently ineffective therapeutic options, although this may be changing based on reports of success with newer therapies.
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Affiliation(s)
- Chetan Vedvyas
- Harvard Medical School, Boston, Massachusetts 02115, USA.
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35
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Abstract
Retiform purpura consists of branching purpuric lesions caused by a complete blockage of blood flow in the dermal and subcutaneous vasculature. The differential diagnosis for retiform purpura is broad, including vasculitides of the small and medium vessels as well as microvascular occlusion due to thrombotic, infectious, and embolic phenomena. Determining the etiology of this important dermatologic sign can be a diagnostic challenge; however, an organized approach can improve the speed and accuracy of diagnosis and identify an effective treatment. This review focuses on early recognition, evaluation, and treatment of hospitalized patients with retiform purpura. Specifically, vasculitis, protein C and S deficiencies, heparin necrosis, warfarin necrosis, antiphospholipid antibody syndrome, disseminated intravascular coagulation, cryoglobulinemia, calciphylaxis, and cholesterol embolization syndrome will be discussed in detail. These conditions are commonly seen in consultative dermatology and can have multiorgan involvement, complicated laboratory evaluation, and long-term therapeutic implications.
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Affiliation(s)
- Ashley Wysong
- Department of Dermatology, Stanford University, Stanford, CA, USA
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36
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New N, Mohandas J, John GT, Ratanjee S, Healy H, Francis L, Ranganathan D. Calcific uremic arteriolopathy in peritoneal dialysis populations. Int J Nephrol 2011; 2011:982854. [PMID: 21748002 PMCID: PMC3124933 DOI: 10.4061/2011/982854] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 04/11/2011] [Accepted: 04/14/2011] [Indexed: 11/30/2022] Open
Abstract
Calciphylaxis or calcific uremic arteriolopathy is an infrequent complication of end stage kidney disease. It is characterized by arteriolar medial calcification, thrombotic cutaneous ischemia, tissue necrosis often leading to ulceration, secondary infection and increased mortality rates. Current, multimodality treatment involves local wound care, well-controlled calcium, phosphate and parathyroid hormone levels and combination therapy with sodium thiosulfate and hyperbaric oxygen therapy. This combination therapy may be changing the historically poor prognosis of calcific uremic arteriolopathy reported in the literature. Peritoneal dialysis is considered a risk factor based on limited publications, however this remains to be proven. Clinical presentation, diagnosis, pathogenesis and treatment of calcific uremic arteriolopathy in these patients are no different from other patients manifesting with this condition.
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Affiliation(s)
- Nicholas New
- Department of Nephrology, Royal Brisbane and Women's Hospital, Queensland Health, Butterfield Street, Herston, QLD 4029, Australia
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38
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Poels M, Joppich R, Gerbershagen K, Wappler F. [Analgesic therapy of calciphylaxis with levomethadone : a case study]. Schmerz 2011; 24:621-4. [PMID: 20963612 DOI: 10.1007/s00482-010-0984-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Calciphylaxis, or calcific uremic arteriopathy, is a rare complication of end-stage renal impairment. It is characterized by calcification of arterioles and development of intensely painful subcutaneous ischemic ulcerations. While symptomatic management is the mainstay of treatment, particular emphasis is placed on adequate analgesia. Conventional analgesic concepts have mostly proved to be insufficient which increases the extreme suffering of patients. This case report describes the successful analgesic treatment of calciphylaxis with levomethadone.
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Affiliation(s)
- M Poels
- Klinik für Anästhesiologie und Operative Intensivmedizin, Krankenhaus Merheim, Klinikum der Privaten Universität Witten/Herdecke, Ostmerheimerstr. 200, 51109 Köln, Deutschland.
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Mason D, Best SD. Calcific uremic arteriolopathy: contemporary pharmacotherapy. Adv Chronic Kidney Dis 2010; 17:428-38. [PMID: 20727513 DOI: 10.1053/j.ackd.2010.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Revised: 05/11/2010] [Accepted: 05/17/2010] [Indexed: 12/26/2022]
Abstract
Calcific uremic arteriolopathy (CUA) is a poorly understood disease affecting 4% to 5% of the patients with end-stage renal disease. Strategies aimed at prompt identification and diagnosis, such as use of plain radiographs, bone scans, and transcutaneous oxygen saturation tension, may lead to earlier initiation of treatment. Early treatment should focus on preventing progression into overt ulceration, which significantly raises the likelihood of infection, amputation, and death. Several agents, including sodium thiosulfate, bisphosphonates, cinacalcet, and tissue plasminogen activator, have been used in the treatment of CUA with varying effects; however, there has been no consensus on an optimal treatment option. The lack of randomized trials comparing treatment options and a potential bias with respect to publication of case reports hinders the ability to choose the most effective agent in the treatment of CUA. Future insights into the molecular basis of vascular calcification may help determine new therapeutic targets.
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Banerjee C, Woller SC, Holm JR, Stevens SM, Lahey MJ. Atypical calciphylaxis in a patient receiving warfarin then resolving with cessation of warfarin and application of hyperbaric oxygen therapy. Clin Appl Thromb Hemost 2010; 16:345-50. [PMID: 20019019 DOI: 10.1177/1076029609355588] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
UNLABELLED Calciphylaxis is a rare, usually fatal vasculopathic disorder characterized by cutaneous ischemia and necrosis due to calcification of arterioles. Although calciphylaxis is most frequently associated with end-stage renal disease (ESRD) and secondary hyperparathyroidism, it has been reported infrequently among patients on warfarin. No standard treatment has been established for atypical calciphylaxis; however, a potentially beneficial treatment is hyperbaric oxygen therapy (HBOT). A high degree of clinical suspicion, early diagnosis, and understanding the pathophysiology of this disease promotes the optimal management of this extremely morbid and often fatal condition. CASE REPORT We present a 63-year-old Polynesian woman with biopsy-proven calciphylaxis in the absence of ESRD or elevated serum calcium levels while taking warfarin. Therapeutic dose enoxaparin was substituted for warfarin and she received 40 sessions of HBOT during which lower extremity ulcers resolved. DISCUSSION Warfarin has been implicated when calciphylaxis presents in an atypical fashion. No guidelines exist for treatment of atypical calciphylaxis in the setting of concomitant warfarin therapy. Up to 80% of calciphylaxis patients die within 1 year of diagnosis. Our patient was changed to low-molecular-weight heparin and received HBOT. CONCLUSION We present what we believe is the first case of atypical calciphylaxis thought to be attributable to warfarin treated with a therapeutic substitution of anticoagulant and HBOT leading to resolution of cutaneous lesions.
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Amin N, Gonzalez E, Lieber M, Salusky IB, Zaritsky JJ. Successful treatment of calcific uremic arteriolopathy in a pediatric dialysis patient. Pediatr Nephrol 2010; 25:357-62. [PMID: 19885686 PMCID: PMC7811521 DOI: 10.1007/s00467-009-1313-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Revised: 08/14/2009] [Accepted: 08/19/2009] [Indexed: 11/26/2022]
Abstract
Calcific uremic arteriolopathy (CUA) is a rare, life-threatening disease, typically affecting patients with end-stage renal disease. It is characterized by widespread vascular calcification, endothelial fibrosis and end-organ ischemia. The mortality rate is high with infection and sepsis being the most common causes of death. Common therapies include restoration of calcium and phosphorous homeostasis, wound care and pain control. Although soft tissue calcification is a known complication in children with advanced renal disease, the incidence of CUA in pediatrics remains unknown. Additionally, current literature regarding its management in pediatric patients is lacking. We report the case of a 17-year-old African-American male patient with end-stage renal disease secondary to Wegener's granulomatosis who developed CUA after 3 years on peritoneal dialysis. Treatment with sodium thiosulfate (STS) and hyperbaric oxygen (HBO) therapy alone was ineffective, forcing the patient to undergo bilateral below the-knee-amputation (BKA) 5 months after presentation. It was not until peritoneal dialysis had been changed to daily hemodialysis, while continuing STS and HBO therapy, that the patient demonstrated complete resolution of CUA on repeat bone scan. Based on these findings, and the extremely high mortality rate associated with this disease, CUA management requires early and aggressive intervention with multi-faceted therapy, including prompt conversion from peritoneal dialysis to hemodialysis, STS infusions and hyperbaric oxygen therapy.
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Affiliation(s)
- Nimisha Amin
- Division of Pediatric Nephrology, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA.
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Alikadic N, Kovac D, Krasna M, Lindic J, Sabovic M, Tomazic J, Jeras M, Smrke D. Review of calciphylaxis and treatment of a severe case after kidney transplantation with iloprost in combination with hyperbaric oxygen and cultured autologous fibrin-based skin substitutes. Clin Transplant 2009; 23:968-74. [DOI: 10.1111/j.1399-0012.2009.01062.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yeh SM, Hwang SJ, Chen HC. Treatment of severe metastatic calcification in hemodialysis patients. Hemodial Int 2009; 13:163-7. [PMID: 19432688 DOI: 10.1111/j.1542-4758.2009.00353.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Soft tissue and vascular calcifications are commonly present in uremic patients secondary to disturbances in calcium and phosphate balance and secondary to hyperparathyroidism. We report a uremic patient who developed uncontrolled hyperparathyroidism rapidly within 6 months after commencing hemodialysis (HD) therapy, with clinical presentations of tumoral calcinosis, calciphylaxis, and myocardial calcifications. After treatment with a low-calcium dialysate, non-calcium-containing phosphate binders, and parathyroidectomy, a dramatic resolution of soft tissue calcification was achieved. However, there was relatively little change in the vascular and other visceral calcifications over the 3-month observation period. This case highlights an unusual and rapid development of tertiary hyperparathyroidism, the importance of tight calcium/phosphate control in uremic patients, the potential hazards of a high calcium concentration dialysate, and the dangers of the overzealous use of active vitamin D therapy in HD patients with uncontrolled hyperparathyroidism.
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Affiliation(s)
- Shih-Mong Yeh
- Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University, Kaohsiung, Taiwan
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Kalisiak M, Courtney M, Lin A, Brassard A. Calcific uremic arteriolopathy (calciphylaxis): successful treatment with sodium thiosulfate in spite of elevated serum phosphate. J Cutan Med Surg 2009; 13 Suppl 1:S29-34. [PMID: 19480749 DOI: 10.2310/7750.2009.00007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Michal Kalisiak
- Division of Dermatology and Cutaneous Sciences, Department of Medicine, University of Alberta, Edmonton, AB
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Abstract
Calciphylaxis is defined by the presence of calcium deposits within the wall of small and medium-sized vessels. It is classically considered a life-threatening disease in patients with end-stage renal disease under dialysis. Clinically, it is characterized by the presence of painful plaques surrounded by a reticulate purpura that progresses to nonhealing ulcers, predominately in the lower limbs. It is associated with elevated parathyroid hormone levels and a dysregulation of the calcium/phosphate metabolism. In the absence of renal disease, normal parathyroid hormone levels, and calcium/phosphorus product, a good prognosis and the observation of similar calcium deposits associated with different conditions or even an epiphenomenon in diseases with well-known diagnosis leads one to consider the term calciphylaxis controversial.
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Affiliation(s)
- Esteban Daudén
- Department of Dermatology, Servicio de Dermatología, Hospital Universitario de la Princesa, Diego de León, 62, 28006 Madrid, Spain.
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Abstract
Severe peripheral artery disease (PAD) is the predominant cause of ischemic ulcerations involving the lower extremities. PAD-associated ulcerations are typically distally located involving the feet, toes, and sometimes the calves. In contradistinction, atypical ischemic ulcerations of the lower extremity are often non-atherosclerotic in etiology, involve the proximal leg (thigh/buttocks), can evolve despite palpable distal pulses, and may coexist with other cutaneous aberrations (e.g. macules, purpura, nodules, and livedo reticularis). A differential diagnosis of atypical ischemic ulcerations involving the legs is presented.
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Affiliation(s)
- Steven M Dean
- Department of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio 43210, USA.
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Akalin A, Kilincal H, Kiper H. Unusual case of calciphylaxis associated with primary hyperparathyroidism without coexistent renal failure. Endocr Pract 2008; 14:368-72. [PMID: 18463046 DOI: 10.4158/ep.14.3.368] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report a case of calciphylaxis in a patient with primary hyperparathyroidism without coexistent renal failure. METHODS The clinical, laboratory, and radiographic details of this case are reviewed, and the pathogenesis of calciphylaxis and the associated prognosis are discussed. RESULTS A 52-year-old woman had progressive fatigue, cachexia, severe osteoporosis, and necrotizing skin lesions. Her serum calcium level was 16 mg/dL, serum phosphorus level was 2.13 mg/dL, and parathyroid hormone level was 2,257 pg/mL (reference range, 15 to 65). On physical examination, gangrenous skin lesions with black crusts were noted on her legs, abdomen, and gluteal region. A mass lesion was detected in the parathyroid region by both ultrasonography and a parathyroid scan. The patient underwent a bilateral neck exploration, and a parathyroid adenoma measuring 3.5 by 1.5 by 1.2 cm was found on pathologic examination. After the operation, biochemical findings normalized, and the skin lesions progressively improved. CONCLUSION Severe primary hyperparathyroidism may be a factor leading to calciphylaxis, even in the absence of renal failure and a high calcium-phosphate product. This potentially life-threatening condition should not be left untreated if the levels of serum calcium and parathyroid hormone are severely elevated.
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Affiliation(s)
- Aysen Akalin
- Department of Endocrinology, Eskisehir Osmangazi University, School of Medicine, Eskisehir, Turkey
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Rogers NM, Chang SH, Teubner DJO, Coates PTH. Hyperbaric oxygen as effective adjuvant therapy in the treatmentof distal calcific uraemic arteriolopathy. NDT Plus 2008; 1:244-9. [PMID: 25983894 PMCID: PMC4421205 DOI: 10.1093/ndtplus/sfn036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Accepted: 03/14/2008] [Indexed: 01/06/2023] Open
Affiliation(s)
- Natasha M Rogers
- Department of Nephrology and Transplantation Services, The Queen Elizabeth Hospital , University of Adelaide , Adelaide, South Australia 5011
| | - Sean H Chang
- ANZDATA Registry, The Queen Elizabeth Hospital , University of Adelaide , Adelaide, South Australia 5011
| | - David J O Teubner
- Hyperbaric Unit , The Royal Adelaide Hospital , Adelaide, South Australia 5000 , Australia
| | - Patrick T H Coates
- Department of Nephrology and Transplantation Services, The Queen Elizabeth Hospital , University of Adelaide , Adelaide, South Australia 5011
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