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Calciphylaxis: A Long Road to Cure with a Multidisciplinary and Multimodal Approach. Case Rep Nephrol 2022; 2022:3818980. [PMID: 35720957 PMCID: PMC9200596 DOI: 10.1155/2022/3818980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 04/11/2022] [Indexed: 12/25/2022] Open
Abstract
Calciphylaxis is a rare yet potentially fatal condition, resulting from ectopic calcification of the small arterioles of the dermis with resulting necrotic lesions infection, sepsis, and death. In hemodialysis patients, its prevalence ranges between 1 and 4%, while mortality amounts to 30–80%. We present in here a 45-year-old female on chronic dialysis with morbid obesity, who was admitted for painful nodules in the lower abdomen and necrotic lesions at the lower extremities. Severe uremia and uncontrolled secondary hyperparathyroidism were the main characteristics in this patient, and thus, a clinical diagnosis of calciphylaxis was made. Treatment modalities included wound care plus antibiotics and analgesics, daily hemodialysis, and strategies targeting calcification with sodium thiosulfate, cinacalcet, and non-calcium-containing binders. A crucial factor for overcoming the infection-lesion vicious circle is thorough and daily care of the lesions. Nursing attention was focused on the motivation of her self-care, for the prevention of institutionalization and the psychological support of the patient and her family. The most intriguing feature was the fact that she experienced several exacerbations during the follow-up time. During the final relapse, she was prescribed hyperbaric oxygen sessions that actually put the disease under control thereafter. The good outcome for this patient was probably related to the combination of close follow-up along with a multidisciplinary approach.
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Burja S, Jovic A, Ekart R, Piko N, Miljkovic J, Breznik V. Successful treatment of extensive uremic calciphylaxis with intravenous sodium thiosulfate and its potential in treating various diseases of pathologic calcification. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2019. [DOI: 10.15570/actaapa.2019.8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Williams EA, Moy AP, Cipriani NA, Nigwekar SU, Nazarian RM. Factors associated with false-negative pathologic diagnosis of calciphylaxis. J Cutan Pathol 2018; 46:16-25. [DOI: 10.1111/cup.13364] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 08/03/2018] [Accepted: 09/19/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Erik A. Williams
- Massachusetts General Hospital; Dermatopathology Unit, Department of Pathology; Boston Massachusetts
- Harvard Medical School; Boston Massachusetts
| | - Andrea P. Moy
- Department of Dermatology; Northwell Health and Zucker School of Medicine at Hofstra/Northwell; Lake Success New York
| | - Nicole A. Cipriani
- The University of Chicago Medicine & Biological Sciences; Chicago Illinois
| | - Sagar U. Nigwekar
- Harvard Medical School; Boston Massachusetts
- Massachusetts General Hospital; Division of Nephrology, Department of Medicine; Boston Massachusetts
| | - Rosalynn M. Nazarian
- Massachusetts General Hospital; Dermatopathology Unit, Department of Pathology; Boston Massachusetts
- Harvard Medical School; Boston Massachusetts
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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: 7] [Impact Index Per Article: 1.2] [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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Abstract
PURPOSE OF REVIEW Calciphylaxis remains a poorly understood vascular calcification disorder with predilection for patients with end-stage renal disease (ESRD). Recent data from large patient registries and databases have begun to provide information regarding incidence, risk factors, and outcomes in patients with calciphylaxis. RECENT FINDINGS The most recent estimate places the incidence of calciphylaxis at 3.5 new cases/1000 patient-years among the patients with ESRD on chronic hemodialysis. It is possible that misdiagnosis or subclinical disease may attribute to lower than the true incidence. There is a suggestion that the incidence is higher in peritoneal dialysis patients compared with patients with hemodialysis. Recent studies have identified a number of risk factors and point to the effects of vitamin K deficiency mediated impairment in Matrix Gla Protein carboxylation as one of the likely pathogenic mechanisms. The outcomes in calciphylaxis patients remain poor with mortality approaching 30% at 6 months and 50% at 12 months. SUMMARY The present review describes recent literature in the field of calciphylaxis. Calciphylaxis registries and specimen biorepositories promise to provide insights into the pathogenesis of calciphylaxis and will pave the way for much needed clinical trials.
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Bouderlique E, Provot F, Lionet A. Rheopheresis for Adjuvant Treatment in Resistant Calciphylaxis. Ther Apher Dial 2018; 22:413-414. [DOI: 10.1111/1744-9987.12666] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 12/09/2017] [Accepted: 12/12/2017] [Indexed: 11/29/2022]
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Fenves AZ, Kroshinsky D. Invited Commentary: Calcinosis cutis and renal disease: an evolving story. Proc AMIA Symp 2017; 30:370-371. [PMID: 28670092 DOI: 10.1080/08998280.2017.11929653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Andrew Z Fenves
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, E-mail:
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Optimal management of bone mineral disorders in chronic kidney disease and end stage renal disease. Curr Opin Nephrol Hypertens 2016; 25:120-6. [PMID: 26785065 DOI: 10.1097/mnh.0000000000000203] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW The review summarizes recent studies on chronic kidney disease-mineral bone disorders, with a focus on new developments in disease management. RECENT FINDINGS The term chronic kidney disease-mineral bone disorder has come to describe an increasingly complex network of alterations in minerals and skeletal disorders that contribute to the significant cardiovascular morbidity and mortality seen in patients with chronic kidney disease and end stage renal disease. Clinical studies continue to suggest associations with clinical outcomes, yet current clinical trials have failed to support causality. Variability in practice exists as current guidelines for management of mineral bone disorders are often based on weak evidence. Recent studies implicate novel pathways for therapeutic intervention in clinical trials. SUMMARY Mineral bone disorders in chronic kidney disease arise from alterations in a number of molecules in an increasingly complex physiological network interconnecting bone and the cardiovascular system. Despite extensive associations with improved outcomes in a number of molecules, clinical trials have yet to prove causality and there is an absence of new therapies available to improve patient outcomes. Additional clinical trials that can incorporate the complexity of mineral bone disorders, and with the ability to intervene on more than one pathway, are needed to advance patient care.
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Resolution of Calciphylaxis After Urgent Kidney Transplantation in 3 Patients With End-Stage Kidney Failure. Transplant Direct 2016; 2:e113. [PMID: 27826606 PMCID: PMC5096440 DOI: 10.1097/txd.0000000000000627] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 09/19/2016] [Indexed: 11/25/2022] Open
Abstract
Background Calcific uremic arteriolopathy (CUA), also referred to as calciphylaxis, is a rare and serious complication of kidney failure with limited treatment options. Kidney transplantation (KTX) restores kidney function and is hence a potential treatment option for CUA. We present 3 patients who had their CUA lesions successfully healed after urgent KTX. Methods Data were retrospectively retrieved from hospital records at our national transplant center. Results All 3 patients had previously been kidney transplanted and had experienced graft loss and were in stage 5 kidney failure when CUA developed. One patient was on warfarin treatment for pulmonary embolism. Skin lesions developed in the lower limbs in all 3 patients. Multidisciplinary care including intensified hemodialysis did not induce any clinically relevant improvement of the lesions. The recipients were enlisted on a clinically urgent waitlist for KTX and received a deceased donor kidney after 2 to 4 weeks. All recipients experienced good graft function. The lesions healed completely within 6 weeks in 2 patients. In the third patient, partial healing occurred after 2 months and complete healing was achieved 4 months after transplantation. Conclusions These cases indicate that urgent KTX may contribute to an efficient treatment for end-stage renal disease patients with CUA.
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Zhang Y, Corapi KM, Luongo M, Thadhani R, Nigwekar SU. Calciphylaxis in peritoneal dialysis patients: a single center cohort study. Int J Nephrol Renovasc Dis 2016; 9:235-241. [PMID: 27698566 PMCID: PMC5034913 DOI: 10.2147/ijnrd.s115701] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Calciphylaxis is a rare but devastating condition in end-stage renal disease (ESRD) patients. Most research in the field of calciphylaxis is focused on hemodialysis (HD) patients; however, data on calciphylaxis incidence, risk factors, and mortality in peritoneal dialysis (PD) patients are limited. METHODS In this cohort study, we examined data from adult patients who initiated PD for ESRD management at our institute's PD unit from January 2001 to December 2015. Associations with the development of calciphylaxis were examined for clinical, laboratory, and medication exposures. Incidence of calciphylaxis and mortality in PD patients who developed calciphylaxis were analyzed. Treatments administered to treat calciphylaxis in PD patients were summarized. RESULTS In this cohort of 63 patients, 7 patients developed calciphylaxis (incidence rate: 9.0 per 1,000 patient-years). Median age of PD patients who developed calciphylaxis was 50 years, 57% were white, 71% females, and 71% were previously on HD. Female sex, obesity, HD as a prior dialysis modality, recurrent hypotension, elevated time-averaged serum phosphorous levels, reduced time-averaged serum albumin levels, and warfarin therapy were associated with increased calciphylaxis risk in univariate logistic regression analyses. Intravenous sodium thiosulfate was administered in 57% of PD patients who developed calciphylaxis. One-year mortality in PD patients who developed calciphylaxis was 71% despite multimodal treatment including sodium thiosulfate, hyperbaric oxygen, cinacalcet, and wound debridement. CONCLUSION Calciphylaxis is a rare but frequently fatal condition in PD patients. Our study provides critical early insights into calciphylaxis incidence, risk factors, and prognosis in PD patients. Sample size and characteristics of patients included in our study limit generalizability to overall PD population and warrant examination in larger independent studies.
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Affiliation(s)
- Yanchen Zhang
- Harvard Summer Research Program in Kidney Medicine, Boston, MA, USA
| | - Kristin M Corapi
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Maria Luongo
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Ravi Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Sagar U Nigwekar
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
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Kingi L, Grech R, Lam M, Dissanayake A, Otter S. Calciphylaxis - A case study in a patient with Maori heritage. J Tissue Viability 2016; 25:216-219. [PMID: 27443245 DOI: 10.1016/j.jtv.2016.07.001] [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: 12/11/2015] [Revised: 03/09/2016] [Accepted: 07/03/2016] [Indexed: 10/21/2022]
Abstract
This case history describes a rare complaint - Calciphylaxis, seen in a New Zealand Maori patient undergoing renal dialysis. This condition causes non-healing tissue ulceration, typically with sepsis and is associated with a very high mortality rate. The need for vigilance among health professionals is highlighted, including the risk factors that may faciliate an early diagnosis; together with the value associated with a multi-disciplinary team approach to management.
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Affiliation(s)
- Lawrence Kingi
- Counties Manukau District Health Board, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand
| | - Roger Grech
- Counties Manukau District Health Board, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand
| | - Michael Lam
- Counties Manukau District Health Board, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand
| | - Ajith Dissanayake
- Counties Manukau District Health Board, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand
| | - Simon Otter
- School of Podiatry, Health & Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland 1142, New Zealand; School of Health Science, University of Brighton, 49 Darley Rd, Eastbourne BN20 7UR, UK.
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Brandenburg VM, Evenepoel P, Floege J, Goldsmith D, Kramann R, Massy Z, Mazzaferro S, Schurgers LJ, Sinha S, Torregrosa V, Ureña-Torres P, Vervloet M, Cozzolino M. Lack of evidence does not justify neglect: how can we address unmet medical needs in calciphylaxis? Nephrol Dial Transplant 2016; 31:1211-9. [PMID: 27005994 DOI: 10.1093/ndt/gfw025] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 01/27/2016] [Indexed: 12/20/2022] Open
Abstract
Calcific uraemic arteriolopathy (CUA), or calciphylaxis, is a rare disease predominantly occurring in comorbidity with dialysis. Due to the very low frequency of CUA, prospective studies on its management are lacking and even anecdotal reports on treatment remain scarce. Therefore, calciphylaxis is still a challenging disease with dismal prognosis urgently requiring adequate strategies for diagnosis and treatment.In an attempt to fill some of the current gaps in evidence on various, highly debated and controversial aspects of dialysis-associated calciphylaxis, 13 international experts joined the 1st Consensus Conference on CUA, held in Leuven, Belgium on 21 September 2015. The conference was supported by the European Calciphylaxis Network (EuCalNet), which is a task force of the ERA-EDTA scientific working group on Chronic Kidney Disease-Mineral and Bone Disorders (CKD-MBD). After an intense discussion, a 9-point Likert scale questionnaire regarding 20 items on calciphylaxis was anonymously answered by each participant. These 20 items addressed unsolved issues in terms of diagnosis and management of calciphylaxis. On the one hand, the analysis of the expert opinions identified areas of general consensus, which might be a valuable aid for physicians treating such a disease with less experience in the field. On the other hand, some topics such as the pertinence of skin biopsy and administration of certain treatments revealed divergent opinions. The aim of the present summary report is to provide some guidance for clinicians who face patients with calciphylaxis in the current setting of absence of evidence-based medicine.
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Affiliation(s)
| | - Pieter Evenepoel
- Department of Internal Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Jürgen Floege
- Department of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - David Goldsmith
- Renal and Transplantation Department, Guy's and St Thomas' Hospitals, London, UK
| | - Rafael Kramann
- Department of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Ziad Massy
- Division of Nephrology, Ambroise Paré University Hospital, APHP, University of Paris Ouest-Versailles-St-Quentin-en-Yvelines (UVSQ), Boulogne-Billancourt, Paris INSERM U1018, Research Centre in Epidemiology and Population Health (CESP) Team 5, Villejuif, France F-CRIN-INI-CRCT, Nancy, France
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic, Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Leon J Schurgers
- Department of Biochemistry, Faculty of Medicine, Health and Life Science, Maastricht, The Netherlands
| | - Smeeta Sinha
- Department of Renal Medicine, Manchester Academic Health Sciences Centre, Salford Royal NHS Foundation Trust, Salford, UK
| | - Vicens Torregrosa
- Nephrology and Renal Transplantation Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Pablo Ureña-Torres
- Department of Nephrology and Dialysis, Clinique du Landy, Saint-Ouen, France Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Marc Vervloet
- Department of Nephrology, VU University Medical Center, Amsterdam, The Netherlands
| | - Mario Cozzolino
- Department of Health Sciences, University of Milan, Renal Division, San Paolo Hospital, Milan, Italy
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