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Arriaga Escamilla D, Lakhani A, Antony S, Salazar Villegas KN, Gupta M, Ramnath P, Murillo Pineda MI, Bedor A, Banegas D, Calderon Martinez E. Dermatological Manifestations in Patients With Chronic Kidney Disease: A Review. Cureus 2024; 16:e52253. [PMID: 38352109 PMCID: PMC10863542 DOI: 10.7759/cureus.52253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 02/16/2024] Open
Abstract
Chronic kidney disease (CKD) is a progressive disease and has multiple clinical manifestations; when CKD reaches the end stage, at least one cutaneous manifestation appears due to some increased toxin levels or a constant proinflammatory state. Nonspecific manifestations include pruritus, xerosis, pigmentation disorders, acquired ichthyosis, purpuric spots, and nail disorders. Some specific manifestations are bullous dermatoses, acquired perforating dermatoses (APD), eruptive xanthoma, access site infections, calcifying disorders, and nephrogenic systemic fibrosis (NSF). All these cutaneous changes negatively impact patients; early recognition and diagnosis of these dermatoses will make a difference in their quality of treatment. Exploring a patient's skin is fundamental to suspect some diseases and increased toxin levels; pruritus occurs when uremic toxins are raised, and nail disorders are associated with hypoalbuminemia. This review provides the clinician with information on the clinical manifestations that occur in CKD, including epidemiology, pathophysiology, clinical manifestations, diagnosis, histopathology, treatment, and life impact of the dermatoses in CKD.
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Affiliation(s)
| | - Alisha Lakhani
- Medicine, Research MD, Vadodara, IND
- Medicine, Shantabaa Medical College, Amreli, IND
| | - Sneha Antony
- Pharmacology, K S Hegde Medical Academy, Mangalore, IND
| | | | - Manasvi Gupta
- General Practice, Jawaharlal Nehru Medical College, Aligarh, IND
| | | | | | - Alexandra Bedor
- Internal Medicine, Instituto Salvadoreño del Seguro Social, San Salvador, SLV
| | - Douglas Banegas
- General Medicine, Universidad Nacional Autonoma de Honduras, San Pedro Sula, HND
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2
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Gossett C, Suppadungsuk S, Krisanapan P, Tangpanithandee S, Thongprayoon C, Mao MA, Cheungpasitporn W. Sodium Thiosulfate for Calciphylaxis Treatment in Patients on Peritoneal Dialysis: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1306. [PMID: 37512116 PMCID: PMC10386543 DOI: 10.3390/medicina59071306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/08/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023]
Abstract
Limited data are available on the utilization of sodium thiosulfate (STS) treatment for calciphylaxis in peritoneal dialysis (PD) patients, while it is well-studied in hemodialysis (HD) patients. A systematic literature search was conducted using Ovid MEDLINE, EBM Reviews-Cochrane Central Register of Controlled Trials, and EBM Reviews-Cochrane Database of Systematic Reviews to identify reported cases of PD patients with calciphylaxis who received STS. The search covered the inception of the databases through August 2022. Across 19 articles, this review identified 30 PD patients with calciphylaxis who received STS. These included 15 case reports, 2 case series, and 2 cohort studies. The administration routes and doses varied depending on the study. For intravenous (IV) administration (n = 18), STS doses ranged from 3.2 g twice daily to 25 g three times weekly for 5 weeks to 8 months. Outcomes included 44% of patients experiencing successful wound healing, 6% discontinuing STS due to adverse effects, 67% transitioning to HD, and 50% dying from calciphylaxis complications. For intraperitoneal (IP) administration (n = 5), STS doses ranged from 12.5 to 25 g three to four times weekly for 12 h to 3 months. Results showed 80% of patients achieving successful wound healing, 80% discontinuing STS due to adverse effects, 40% transitioning to HD, and 20% dying from IP STS-related chemical peritonitis. In cases where patients switched from IV to IP STS (n = 3), doses ranged from 12.5 to 25 g two to three times weekly for 2.5 to 5 months. Among them, 67% experienced successful wound healing, while 33% died from sepsis. Two cases utilized oral STS at a dose of 1500 mg twice daily for 6 and 11 months, resulting in successful wound healing without adverse effects or need for HD. However, one patient (50%) died due to small bowel obstruction. This systematic review provides an overview of STS treatment for PD patients with calciphylaxis. Although successful treatment cases exist, adverse effects were significant. Further research, including larger clinical studies and pharmacokinetic data, is necessary to establish the optimal route, dose, and efficacy of STS in PD patients.
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Affiliation(s)
- Christy Gossett
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
| | - Supawadee Suppadungsuk
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10400, Thailand
| | - Pajaree Krisanapan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine Thammasat University, Pathum Thani 12120, Thailand
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10400, Thailand
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL 32224, USA
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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: 0] [Impact Index Per Article: 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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Abstract
Uremic calciphylaxis is a rare disease that affects patients with chronic end-stage renal disease. It is a pathology of the microvessels of the dermis and hypodermis which are calcified and whose thrombosis leads to skin necrosis. Calciphylaxis lesions can be distal and axial. They lead to pain, infection and are associated with denutrition and in high mortality rate (40-80% at 1 year). This general review describes the clinical and para-clinical presentations of calciphylaxis. It summarizes the current knowledge on its pathogenesis and the therapeutical options that can be proposed to improve the management and attempt to reduce the mortality of patients with uremic calciphylaxis.
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Rick J, Rrapi R, Chand S, Shinohara MM, Strowd L, Pasieka HB, Michelleti R, Kroshinsky D, Ortega-Loayza AG. Calciphylaxis: Treatment and Outlook CME Part II. J Am Acad Dermatol 2022; 86:985-992. [PMID: 35202773 DOI: 10.1016/j.jaad.2021.10.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Jonathan Rick
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Renajd Rrapi
- Harvard Medical School, Cambridge, Massachusetts, USA
| | | | | | | | - Helena B Pasieka
- Georgetown University School of Medicine, Washington, DC, USA; Uniformed Services University School of Medicine, Bethesda, MD, USA
| | - Robert Michelleti
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Yu X, Su Q, Geng J, Liu H, Liu Y, Liu J, Shi Y, Zou Y. Ginkgo biloba leaf extract prevents diabetic nephropathy through the suppression of tissue transglutaminase. Exp Ther Med 2021; 21:333. [PMID: 33732306 PMCID: PMC7903480 DOI: 10.3892/etm.2021.9764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 01/18/2021] [Indexed: 12/28/2022] Open
Abstract
The present study aimed to investigate the preventive effects of Ginkgo biloba leaf extract (GBE) against extracellular matrix (ECM) accumulation in a streptozotocin (STZ)-induced rat model of diabetic nephropathy (DN), and to determine its underlying molecular mechanism. In vivo, a rat model of DN was established by intraperitoneal injection of STZ, and the rats were subsequently administered GBE. The results demonstrated that GBE significantly decreased blood glucose, the urine protein excretion rate and ECM accumulation in DN rats. In addition, the development of DN significantly induced tissue transglutaminase (tTG) protein expression, which was detected by immunohistochemistry, western blotting and PCR analyses, while GBE administration decreased tTG expression in the diabetic kidney. In vitro, rat glomerular mesangial cells (HBZY-1 cells) cultured with high glucose were also treated with GBE. The concentrations of tTG, fibronectin, type IV collagen, transforming growth factor (TGF)-β and connective tissue growth factor (CTGF) were detected via ELISA. The results demonstrated that GBE notably decreased the concentration of these proteins, and tTG expression was positively associated with TGF-β. GBE also suppressed tTG expression of high glucose-treated HBZY-1 cells in a concentration-dependent manner. Furthermore, tTG protein expression was detected in high glucose-treated HBZY-1 cells transfected with small interfering RNA (siRNA) oligonucleotides against TGF-β and CTGF to investigate a possible mechanism of GBE-mediated inhibition of tTG. The results demonstrated that the tTG levels remained unchanged in CTGF siRNA-transfected cells, but were decreased in the GBE + CTGF siRNA group compared with the control siRNA group, suggesting that tTG may not be regulated by CTGF, and the inhibitory effect of GBE on tTG may not be associated with the direct inhibition of CTGF. However, tTG expression was decreased following the transfection with TGF-β siRNA, in which levels of tTG were similar compared with both the GBE group and GBE + TGF-β siRNA group, indicating that tTG may be regulated by TGF-β, and that the GBE-induced repression of tTG expression may be associated with the downregulation of TGF-β. Taken together, the results of the present study suggest that GBE prevented ECM accumulation by suppressing tTG expression in DN, which was predominantly mediated by TGF-β.
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Affiliation(s)
- Xiaoyan Yu
- Department of Experimental Pharmacology and Toxicology, School of Pharmaceutical Sciences, Jilin University, Changchun, Jilin 130021, P.R. China
| | - Qing Su
- Department of Experimental Pharmacology and Toxicology, School of Pharmaceutical Sciences, Jilin University, Changchun, Jilin 130021, P.R. China
| | - Jianan Geng
- Department of Experimental Pharmacology and Toxicology, School of Pharmaceutical Sciences, Jilin University, Changchun, Jilin 130021, P.R. China
| | - Hui Liu
- Department of Anatomy, College of Basic Medical Science, Jilin University, Changchun, Jilin 130012, P.R. China
| | - Yumeng Liu
- Department of Experimental Pharmacology and Toxicology, School of Pharmaceutical Sciences, Jilin University, Changchun, Jilin 130021, P.R. China
| | - Jinming Liu
- Department of Experimental Pharmacology and Toxicology, School of Pharmaceutical Sciences, Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yan Shi
- Department of Experimental Pharmacology and Toxicology, School of Pharmaceutical Sciences, Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yinggang Zou
- Department of Obstetrics and Gynecology, The Second Hospital, Jilin University, Changchun, Jilin 130041, P.R. China
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Goel V, Sil A, Das A. Cutaneous Manifestations of Chronic Kidney Disease, Dialysis and Post-Renal Transplant: A Review. Indian J Dermatol 2021; 66:3-11. [PMID: 33911288 PMCID: PMC8061480 DOI: 10.4103/ijd.ijd_502_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Skin serves as the mirror of underlying systemic problems. The early diagnosis of subtle cutaneous clinical pointers often helps in identifying renal disorders, obviating the delay in diagnosis and treatment. Cutaneous changes can be observed from the beginning of renal impairment until the evolution to terminal stage, in uremia, hemodialysis, and after kidney transplantation. In the review, we have discussed the cutaneous changes, its implicated etiopathogenesis, and their treatment options, as encountered in chronic kidney disease, hemodialysis and post-renal transplantation.
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Affiliation(s)
- Vivek Goel
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Abheek Sil
- Department of Dermatology, R G Kar Medical College and Hospital, Kolkata, West Bengal, India
| | - Anupam Das
- Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
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8
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Bouchemla N, Laamani A, Chettati M, Fadili W, Laouad I. Nonuremic calciphylaxis in a patient with multiple myeloma and rheumatoid arthritis. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2020; 31:556-560. [DOI: 10.4103/1319-2442.284038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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9
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Baby D, Upadhyay M, Joseph MD, Asopa SJ, Choudhury BK, Rajguru JP, Gupta S. Calciphylaxis and its diagnosis: A review. J Family Med Prim Care 2019; 8:2763-2767. [PMID: 31681640 PMCID: PMC6820424 DOI: 10.4103/jfmpc.jfmpc_588_19] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/20/2019] [Accepted: 09/05/2019] [Indexed: 12/13/2022] Open
Abstract
Calciphylaxis also known as Calcific uremic arteriolopathy (CUA), is a rare fatal complication usually associated with end-stage renal disease (ESRD). It is characterized by skin ulceration and necrosis leading to significant pain. The disease calciphylaxis is pathological state resulting in accumulation of calcium content in medial wall of small blood vessels along with the fibrotic changes in intima. The aetiopathogenesis of this disease, small vessel vasculopathy, remains complicated, and unclear. It is believed that development of calciphylaxis depends on medial calcification, intimal fibrosis of arterioles and thrombotic occlusion. The disease is rare, life-threatening medical condition that occurs mostly in population with kidney disease or in patients on dialysis. Skin biopsy and radiographic features are helpful in the diagnosis of calciphylaxis, but negative results do not necessarily exclude the diagnosis. This article highlights steps undertaking in the diagnosis of calciphylaxis.
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Affiliation(s)
- Deepak Baby
- Department of Conservative Dentistry and Endodontics, P.S.M Dental College and Research Centre, Akkikavu, Thrissur, Kerala, India
| | - Meenakshi Upadhyay
- Department of Pediatric and Preventive Dentistry, Saraswati Dental College, Lucknow, Uttar Pradesh, India
| | - M Derick Joseph
- Department of Conservative Dentistry and Endodontics, P.S.M Dental College and Research Centre, Akkikavu, Thrissur, Kerala, India
| | - Swati Joshi Asopa
- Department of Prosthodontics, Rajasthan Dental College and Hospital, Jaipur, Rajasthan, India
| | - Basanta Kumar Choudhury
- Department of Oral Medicine and Radiology, Institute of Dental Sciences, Siksha 'O' Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India
| | - Jagadish Prasad Rajguru
- Department of Oral and Maxillofacial Pathology, Hi-Tech Dental College and Hospital, Bhubaneswar, Odisha, India
| | - Shivangi Gupta
- Department of Periodontics, Private Practitioner, Chandigarh, India
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10
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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: 60] [Impact Index Per Article: 12.0] [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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Fernández Cañabate S, Alvarez CL, Ortega Valin L, Estifan Ksabji J. Sodium thiosulfate and pamidronate for treatment of calciphylaxis: case report. Colomb Med (Cali) 2018; 49:288-291. [PMID: 30700922 PMCID: PMC6342083 DOI: 10.25100/cm.v49i3.4134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/29/2018] [Accepted: 12/10/2018] [Indexed: 06/09/2023] Open
Abstract
INTRODUCTION Calciphylaxis is an infrequent disease that almost exclusively affects patients with chronic kidney disease, although cases have been observed in patients without renal function impairment. The diagnosis is mainly made by clinical manifestations and subsequently confirmed by radiological and histological study. The optimal treatment is not known, although there is a consensus that a multifactorial approach is required. CLINICAL CASE A 68-year-old woman on hemodialysis for 2 years, who presented a painful nodular lesion in the left thigh, a skin biopsy was performed resulting in a diagnosis of calciphylaxis. TREATMENT AND OUTCOME Treatment was started with intravenous sodium thiosulfate. Pamidronate is added intravenously, three months later, due to an unfavorable evolution. After 6 months of treatment, improvement in nodular lesions and healing of the ulcerated lesion was observed to be generally well tolerated treatment. CONCLUSION The combined treatment of sodium thiosulfate, pamidronate and calcitomimetics has been effectiveand safe for the treatment of calciphylaxis, inducing complete remission.
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Affiliation(s)
| | | | - Luis Ortega Valin
- Complejo Asistencial Universitario de León, Servicio de Farmacia, León, España
| | - Jorge Estifan Ksabji
- Complejo Asistencial Universitario de León, Servicio de Nefrología, León, España
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12
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Dado DN, Huang B, Foster DV, Nielsen JS, Gurney JM, Morrow BD, Sharma K, Chung KK, Ainsworth CR. Management of calciphylaxis in a burn center: A case series and review of the literature. Burns 2018; 45:241-246. [PMID: 30322738 DOI: 10.1016/j.burns.2018.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/07/2018] [Accepted: 09/10/2018] [Indexed: 11/28/2022]
Abstract
Calciphylaxis is a rare, necrotizing skin disorder usually associated with kidney disease, but also caused by many other systemic illnesses. This disease is associated with mortality rates as high as 80% at 1year. We present the demographic and clinical data of nine patients with calciphylaxis treated at our burn center over a 10year period. We review the literature on the clinical presentation, pathophysiology, diagnosis and treatment of this rare disease. We propose that these patients be treated similar to patients with thermal burn injury; meaning intensive wound care, surgical management, critical care and physical therapy. Burn centers are uniquely capable of caring for these incredibly complex patients due to their experience in managing patients with extensive skin and soft tissue defects, wounds and diseases.
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Affiliation(s)
- David N Dado
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States
| | - Benjamin Huang
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States
| | - Daniel V Foster
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States
| | - Jamison S Nielsen
- Burn Center, US Army Institute of Surgical Research, Fort Sam Houston, TX, United States
| | - Jennifer M Gurney
- Burn Center, US Army Institute of Surgical Research, Fort Sam Houston, TX, United States
| | - Benjamin D Morrow
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Kumar Sharma
- Division of Nephrology, University of Texas Health Sciences Center, San Antonio, TX, United States
| | - Kevin K Chung
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Craig R Ainsworth
- Burn Center, US Army Institute of Surgical Research, Fort Sam Houston, TX, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States.
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13
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Fernández Cañabate S, Lucas Alvarez C, Ortega Valin L, Estifan Ksabji J. Sodium thiosulfate and pamidronate for treatment of calciphylaxis: case report. Colomb Med (Cali) 2018. [DOI: 10.25100/cm.v49i4.4134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction:
Calciphylaxis is an infrequent disease that almost exclusively affects patients with chronic kidney disease, although cases have been observed in patients without renal function impairment. The diagnosis is mainly made by clinical manifestations and subsequently confirmed by radiological and histological study. The optimal treatment is not known, although there is a consensus that a multifactorial approach is required.
Clinical Case:
A 68-year-old woman on hemodialysis for 2 years, who presented a painful nodular lesion in the left thigh, a skin biopsy was performed resulting in a diagnosis of calciphylaxis.
Treatment and Outcome:
Treatment was started with intravenous sodium thiosulfate. Pamidronate is added intravenously, three months later, due to an unfavorable evolution. After 6 months of treatment, improvement in nodular lesions and healing of the ulcerated lesion was observed to be generally well tolerated treatment.
Conclusion:
The combined treatment of sodium thiosulfate, pamidronate and calcitomimetics has been effectiveand safe for the treatment of calciphylaxis, inducing complete remission.
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14
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García-Lozano JA, Ocampo-Candiani J, Martínez-Cabriales SA, Garza-Rodríguez V. An Update on Calciphylaxis. Am J Clin Dermatol 2018; 19:599-608. [PMID: 29808451 DOI: 10.1007/s40257-018-0361-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Calciphylaxis, also known as calcific uremic arteriolopathy and uremic small artery disease with medial wall calcification and intimal hyperplasia, is a multifactorial cutaneous vascular disease characterized by chronic, painful, non-healing wounds that occur frequently in patients with chronic kidney disease, predominantly in those with end-stage renal disease. The pathogenesis remains unclear, and the development of calciphylaxis lesions depends on medial calcification, intimal fibrosis of arterioles and thrombotic occlusion. Despite an increase in reports of calciphylaxis in the literature and clinical recognition of demographic characteristics and risk factors associated with calciphylaxis, it remains a poorly understood disease with high morbidity and mortality. In this review, we analyze and summarize the clinical manifestations, pathogenesis and pathophysiology, histopathology, differential diagnosis, diagnostic workup and treatment modalities for calciphylaxis. Because of the lack of consensus regarding the optimal approach to and treatment of this disorder, a high degree of clinical suspicion, early diagnosis, and multimodal and multidisciplinary treatment in collaboration with dermatology, nephrology, wound care, nutrition and pain management specialties may improve survival in patients with calciphylaxis.
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Couri T, Stier M, Mikolajczyk A, Aronsohn A. Calciphylaxis in end-stage liver and renal disease patients before and after transplant. Clin Transplant 2018; 32:e13272. [PMID: 29714030 DOI: 10.1111/ctr.13272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2018] [Indexed: 11/29/2022]
Abstract
Calciphylaxis is a rare vascular disorder characterized by calcification of arterioles which causes tissue inflammation and necrosis. It is associated with the metabolic disturbances seen in end-stage renal disease (ESRD) and has also been described in patients with cirrhosis with preserved kidney function. Characteristic calciphylaxis lesions are black eschars surrounded by retiform purpura, and the gold standard for diagnosis is skin biopsy. Reported 1-year mortality rates range between 45% and 80%. No treatment modality has been evaluated in a prospective randomized trial, and reports of treatment efficacy vary. Kidney transplant has been reported as a successful therapy for calciphylaxis; however, cases exist of the initial onset of calciphylaxis following kidney transplant as well as simultaneous liver-kidney (SLK) transplant. The decision to maintain a patient with end-stage renal and liver disease on the waiting list for SLK transplant following the onset of calciphylaxis must consider the high 1-year mortality associated with this condition. More research is necessary to understand how to allocate donor allografts to manage patients with calciphylaxis and ESRD and/or cirrhosis effectively.
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Affiliation(s)
- Thomas Couri
- Department of Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Matthew Stier
- Department of Internal Medicine Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | - Adam Mikolajczyk
- Department of Internal Medicine Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | - Andrew Aronsohn
- Department of Internal Medicine Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
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Campbell RA, Alzweri LM, Sopko NA, Macura KJ, Burnett AL. Penile Calciphylaxis: The Use of Radiological Investigations in the Management of a Rare and Challenging Condition. Urol Case Rep 2017; 13:113-116. [PMID: 28507910 PMCID: PMC5429139 DOI: 10.1016/j.eucr.2017.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/08/2017] [Indexed: 11/30/2022] Open
Abstract
Penile calciphylaxis is a rare phenomenon of penile necrosis observed in patients with hemodialysis-dependent end-stage renal failure. Multiple treatments have been proposed including conservative management, surgical debridement and penectomy; yet, the prognosis remains extremely poor. Here, we describe a patient with protracted resolution of dry gangrene of the glans, which failed conservative management of wound care and pain management. Radiological studies revealed extensive calcification of abdominal aorta and branching vessels including the penile arteries. Due to intolerable pain, the patient required total penectomy. Earlier surgical intervention guided by findings on radiological studies may improve quality of life in this population.
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Affiliation(s)
- Rebecca A Campbell
- Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106, USA
| | - Laith M Alzweri
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Nikolai A Sopko
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Katarzyna J Macura
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA.,Department of Radiology and Radiological Sciences, The Johns Hopkins School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Arthur L Burnett
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
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Seminars in Dialysis: The 100 Most Highly Cited Papers. Semin Dial 2016; 29:518-520. [PMID: 27774673 DOI: 10.1111/sdi.12536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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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Storan ER, O'Gorman SM, Murphy A, Laing M. Case Report of Calciphylaxis Secondary to Calcium and Vitamin D 3 Supplementation. J Cutan Med Surg 2016; 21:162-163. [PMID: 27566435 DOI: 10.1177/1203475416668162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Calciphylaxis is a rare disorder that is very unusual outside the setting of end-stage kidney disease. CASE SUMMARY A 64-year-old woman with normal renal function presented with painful leg ulcers. She had previously received 300 000 IU of vitamin D3 followed by daily calcium and vitamin D3 supplementation. A skin biopsy was consistent with calciphylaxis, and she was treated with sodium thiosulphate infusions and wound debridement. CONCLUSION Calcium and vitamin D3 supplements are widely prescribed. We report a case of calciphylaxis triggered by calcium and vitamin D3 supplementation in a patient with none of the typical risk factors. Our patient had an excellent response to treatment with sodium thiosulphate.
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Affiliation(s)
- Eoin R Storan
- 1 Department of Dermatology, University College Hospital, Galway, Ireland
| | - Susan M O'Gorman
- 1 Department of Dermatology, University College Hospital, Galway, Ireland
| | - Annette Murphy
- 1 Department of Dermatology, University College Hospital, Galway, Ireland
| | - Mary Laing
- 1 Department of Dermatology, University College Hospital, Galway, Ireland
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20
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Jeong HS, Dominguez AR. Calciphylaxis: Controversies in Pathogenesis, Diagnosis and Treatment. Am J Med Sci 2016; 351:217-27. [DOI: 10.1016/j.amjms.2015.11.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 09/22/2015] [Indexed: 10/22/2022]
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Malbos S, Ureña-Torres P, Bardin T, Ea HK. Sodium thiosulfate is effective in calcific uremic arteriolopathy complicating chronic hemodialysis. Joint Bone Spine 2015; 83:89-92. [PMID: 26494591 DOI: 10.1016/j.jbspin.2015.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 03/09/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Calcific uremic arteriolopathy (CUA) or calciphylaxis is a severe complication of advanced chronic kidney disease (CKD) and dialysis. Few effective treatments are available and the mortality rate is high. We report 4 cases in which sodium thiosulfate therapy was rapidly effective. CASES Sodium thiosulfate therapy was given to 4 Caucasian patients (3 females and 1 male aged 49 to 91 years) with CUA. The causes of end-stage CKD were nephroangiosclerosis (n=2) and diabetic nephropathy (n=2). The lesions developed 1 to 6.5 years after the initiation of hemodialysis and involved the lower limbs in 2 patients, the fingers in 1 patient, and a breast in the remaining patient. They were responsible for pain and skin necrosis in all 4 patients. Local superinfection occurred in 3 patients. Intravenous sodium thiosulfate was given in a dosage of 12.5 to 25g after each hemodialysis session, for 12 to 24 weeks. The pain and trophic disorders resolved fully in all 4 patients. The side effects consisted of nausea and vomiting (n=2) and a moderate blood pressure decrease (n=1). No recurrences were noted during the follow-up of 5 to 17 months after treatment discontinuation. CONCLUSION The findings from this small case-series suggest that sodium thiosulfate may hold promise for the treatment of CUA.
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Affiliation(s)
- Stéphanie Malbos
- Service de rhumatologie, pôle appareil locomoteur, centre Viggo-Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Pablo Ureña-Torres
- Clinique du Landy, 93400 Saint-Ouen, France; Service des explorations fonctionnelles rénales, hôpital Necker, 75015 Paris, France
| | - Thomas Bardin
- Service de rhumatologie, pôle appareil locomoteur, centre Viggo-Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; UFR de médecine, université Paris Diderot, Sorbonne Paris Cité, 75205 Paris, France
| | - Hang-Korng Ea
- Service de rhumatologie, pôle appareil locomoteur, centre Viggo-Petersen, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; UFR de médecine, université Paris Diderot, Sorbonne Paris Cité, 75205 Paris, France; Inserm, UMR-1132, hôpital Lariboisière, 75010 Paris, France.
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22
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Multiple Ectopic Calcification in Subcutaneous Tissues Detected by Bone Scintigraphy in a Patient With Chronic Renal Failure. Clin Nucl Med 2015; 40:512-4. [DOI: 10.1097/rlu.0000000000000685] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Abstract
Calciphylaxis, or calcific uremic arteriolopathy, is a vascular ossification-calcification disease involving cutaneous or visceral arterioles, with ischemic damage of the surrounding tissues, usually in the setting of chronic kidney disease. Pathogenesis is still unclear and probably comprises the participation of vascular smooth muscle cells, endothelial cells and macrophages surrounded by a uremic and/or pro-calcifying environment. According to the original concept of calcific uremic arteriolopathy coined by Hans Selye, risk factors may be divided into sensitizers and challengers and their knowledge is useful in clinical practice to pre-emptively identify both uremic and non-uremic 'at risk' patients and guide treatment. Systemic calcific uremic arteriolopathy is a rarity. Cutaneous calcific uremic arteriolopathy is more frequent and clinically presents as a first phase of cutaneous hardening and erythema, followed by a second phase of ulcerations and scars; these two phases are probably associated with the initial development of arteriolar lesion and tissue ischemic damage, respectively. Clinical history, physical examination, laboratory analysis, histology and imaging are the main tools to exclude important differential diagnoses and obtain a definitive diagnosis. Treatment is generally unrewarding and consists of rigorous control of comorbid conditions, anti-oxidant, anti-inflammatory and antithrombotic strategies, avoidance of iatrogeny and wound and pain management. Prognosis remains poor in terms of morbidity and mortality. Efforts should be made towards a greater awareness of calcific uremic arteriolopathy, development of better therapies and improvement of clinical outcomes.
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25
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Tamayo-Isla RA, Cuba de la Cruz M. Calciphylaxis in end-stage renal disease prior to dialytic treatment: a case report and literature review. Int J Nephrol Renovasc Dis 2015; 8:13-8. [PMID: 25709494 PMCID: PMC4334332 DOI: 10.2147/ijnrd.s78310] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Introduction Calciphylaxis is a rare medical condition that is usually diagnosed in patients suffering from end-stage renal disease who are already receiving renal replacement therapy and in those post-transplantation. The pathogenesis still remains to be fully elucidated; hence, the treatment is not uniform. The prognosis is generally poor. The ulcerative stage exhibits a worse prognosis than the nonulcerative one. Calciphylaxis presenting in terminal kidney disease prior to dialytic treatment has only rarely been reported. Case presentation A 32-year-old female Caucasian clerk sought medical attention for increasing tiredness and lower limb skin ulcers. Polycystic kidney disease was diagnosed in her late father and two of her siblings. At the first nephrology consultation, obesity, pallor, bilateral flank masses with ballottement, and two ulcers with a dark necrotic center on the distal left leg were noted. In addition, another indurated light bluish lesion of 5 cm just above the right knee with intact skin was observed. All lesions were very tender and warm on touch. Laboratory results yielded hypercalcemia, hyperphosphatemia, anemia, and parathyroid hormone levels that were more than ten times the normal values in the patient, and with a glomerular filtration rate of 4 mL/minute. Skin biopsy confirmed the suspicion of calciphylaxis. The patient was placed on peritoneal dialysis with low Ca concentration baths, cinacalcet, and aluminum hydroxide. The results included correction of hypercalcemia, improvement of phosphate levels, and the product of both Ca and phosphate, but only a transitory decrease in serum parathyroid hormone levels. The ulcerations were completely healed after 2 months of treatment. Cinacalcet was discontinued after 18 months, but multiple large-size, nonulcerative indurated areas appeared 3 months later in the lower limbs after discontinuation of the drug. A parathyroidectomy performed 17 months later revealed a four-gland hyperplastic disease. The patient experienced relief of skin symptoms soon after the procedure and remains in a very satisfactory condition. Conclusion Calciphylaxis is a very complex clinical entity. Calciphylaxis presenting prior to dialytic treatment in end-stage renal disease is rare in the absence of a trigger. Cinacalcet and parathyroidectomy should be considered in selected patients.
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Affiliation(s)
- Ramón Alberto Tamayo-Isla
- Internal Medicine Department, Pietersburg Provincial Hospital, Polokwane Kidney and Dialysis Centre, Limpopo Province, South Africa
| | - Mauro Cuba de la Cruz
- Internal Medicine Department, Pietersburg Provincial Hospital, Polokwane Kidney and Dialysis Centre, Limpopo Province, South Africa
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26
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Spanakis EK, Sellmeyer DE. Nonuremic calciphylaxis precipitated by teriparatide [rhPTH(1-34)] therapy in the setting of chronic warfarin and glucocorticoid treatment. Osteoporos Int 2014; 25:1411-4. [PMID: 24292108 PMCID: PMC4096496 DOI: 10.1007/s00198-013-2580-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 11/12/2013] [Indexed: 10/26/2022]
Abstract
Calciphylaxis occurs rarely in the absence of end stage renal disease. Predisposing factors for nonuremic calciphylaxis (NUC) include hyperparathyroidism, coagulopathies, connective tissue disease, liver disease, glucocorticoid use, and malignancy. Warfarin can facilitate vascular calcification by reducing vitamin K-dependent carboxylation of matrix-Gla proteins. An 86-year-old Caucasian woman with a history of polymyalgia rheumatica, two spontaneous deep venous thromboses (DVTs) and multiple fractures was treated with calcium, vitamin D, prednisone, and warfarin. The patient's low bone density was treated initially with estrogen, then oral bisphosphonate, which was discontinued due to upper gastrointestinal symptoms. Nasal calcitonin was initiated. After 10 years of calcitonin treatment, she was changed to teriparatide. Two months after initiating teriparatide, she developed lower extremity edema and painful erythematous nodular lesions on her calves bilaterally, that progressed to necrotic ulcers despite antibiotic therapy. Biopsy of the lesions showed calcification in the media of small blood vessels and subcutaneous fat with fat necrosis, consistent with calciphylaxis. Teriparatide was discontinued. Aggressive wound care, antibiotics, and intravenous zoledronic acid were initiated. With cessation of teriparatide therapy and intensive wound care, the patient's lesions resolved over 8 months. We report the first case of NUC precipitated by teriparatide therapy. Our patient had multiple underlying predisposing factors including a connective tissue disorder, glucocorticoid therapy, warfarin use, and possible underlying coagulopathy given her history of multiple DVTs. In such patients, alternative osteoporosis therapies may be preferred.
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Affiliation(s)
- E. K. Spanakis
- Division of Endocrinology, Johns Hopkins Hospital, Johns Hopkins University, Baltimore, MD, USA
| | - D. E. Sellmeyer
- Division of Endocrinology, Johns Hopkins Bayview Hospital, Johns Hopkins University, 5200 Eastern Ave, Mason F Lord Center Tower, Suite 4300, Baltimore, MD 21224, USA
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Burnie R, Smail S, Javaid MM. Calciphylaxis and sodium thiosulphate: a glimmer of hope in desperate situation. J Ren Care 2013; 39:71-6. [PMID: 23551819 DOI: 10.1111/j.1755-6686.2013.12008.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Calciphylaxis is an uncommon and often under diagnosed condition affecting patients undergoing chronic dialysis. Its pathogenesis is poorly understood. The abnormalities of calcium, phosphate and parathyroid hormone homeostasis leading to vascular calcification and ischaemic skin necrosis are thought to be the central problem. Meticulous wound care and aggressive metabolic control remain the cornerstone of the treatment; however, the overall benefit of these treatment options remains low and mortality and morbidity remain very high. Sodium thiosulphate is an inorganic salt, which is used for treating acute cyanide poisoning, recurrent calcium urolithiasis and nephrocalcinosis. Recently, it has also been reported to be useful in treating severe cases of calciphylaxis with promising results. METHODS A resistant case of calciphylaxis in a patient on long-term haemodialysis was treated with sodium thiosulphate (50 ml solution with 50% sodium thiosulphate) three times a week during the end of each dialysis session. RESULTS The skin lesions started to heal after two weeks and completely resolved after five months of treatment. CONCLUSIONS Sodium thiosulphate can be a safe and effective treatment option for resistant and severe cases of calciphylaxis.
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Affiliation(s)
- Robert Burnie
- Department of Nephrology, Dartford and Gravesham NHS Trust, Dartford, UK
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Abstract
Parathyroid hormone (PTH) is a uremic toxin with multiple systemic effects including bone disorders (renal osteodystrophy), myopathy, neurologic abnormalities, anemia, pruritus, and cardiomyopathy. Hyperparathyroidism is common in CKD and results in significant morbidity and mortality if left untreated. Clinical practice guidelines from the Kidney Disease Improving Global Outcomes initiative broadened the optimal PTH range to >2 and <9 times the upper limit of normal for the assay measured. Furthermore, the guidelines recommend following trends in PTH to determine the appropriate therapy. These guidelines overcome issues with the assay variability and help clinicians make judgments when treating individual patients. They also require frequent measurement in order to determine trends and implement appropriate treatments.
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Affiliation(s)
- Stuart M Sprague
- Division of Nephrology and Hypertension, NorthShore University HealthSystem, Evanston, IL 60201, USA.
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29
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Shroff R, Long DA, Shanahan C. Mechanistic insights into vascular calcification in CKD. J Am Soc Nephrol 2012; 24:179-89. [PMID: 23138485 DOI: 10.1681/asn.2011121191] [Citation(s) in RCA: 255] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Cardiovascular disease begins early in the course of renal decline and is a life-limiting problem in patients with CKD. The increased burden of cardiovascular disease is due, at least in part, to calcification of the vessel wall. The uremic milieu provides a perfect storm of risk factors for accelerated calcification, but elevated calcium and phosphate levels remain key to the initiation and progression of vascular smooth muscle cell calcification in CKD. Vascular calcification is a highly regulated process that involves a complex interplay between promoters and inhibitors of calcification and has many similarities to bone ossification. Here, we discuss current understanding of the process of vascular calcification, focusing specifically on the discrete and synergistic effects of calcium and phosphate in mediating vascular smooth muscle cell apoptosis, osteochondrocytic differentiation, vesicle release, calcification inhibitor expression, senescence, and death. Using our model of intact human vessels, factors initiating vascular calcification in vivo and the role of calcium and phosphate in driving accelerated calcification ex vivo are described. This work allows us to link clinical and basic research into a working theoretical model to explain the pathway of development of vascular calcification in CKD.
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Affiliation(s)
- Rukshana Shroff
- Nephro-Urology Unit, Great Ormond Street Hospital for Children and University College London Institute of Child Health, London, UK.
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30
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Roncada EVM, Abreu MAMMD, Pereira MF, Oliveira CCMD, Nai GA, Soares DFG. Calciphylaxis, a diagnostic and therapeutic challenge: report of a successful case. An Bras Dermatol 2012; 87:752-5. [PMID: 23044570 DOI: 10.1590/s0365-05962012000500014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 09/29/2011] [Indexed: 11/21/2022] Open
Abstract
Calciphylaxis, also known as calcific uremic arteriolopathy, is a severe complication often observed in patients with hyperparathyroidism secondary to chronic renal failure, which occurs mainly in women. It is characterized by ischemic tissue loss secondary to progressive vascular compromise. This is a rare and severe condition and its pathogenesis is unclear. The best treatment is prevention, especially in order to maintain adequate levels of calcium and phosphorus. We describe a case of this disease in a patient with hyperparathyroidism secondary to chronic renal failure who underwent medical treatment, surgical debridement and total skin autografts, with resolution of symptoms after 6 months.
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31
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O'Connell ML, Birkenkamp KE, Kleiner DE, Folio LR, Holland SM, Olivier KN. Lung manifestations in an autopsy-based series of pulmonary or disseminated nontuberculous mycobacterial disease. Chest 2011; 141:1203-1209. [PMID: 22194586 DOI: 10.1378/chest.11-0425] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Comparisons of lung manifestations in primary pulmonary vs disseminated nontuberculous mycobacterial disease have not been well described. The clinical, histopathologic, and radiologic disease manifestations of primary pulmonary or disseminated nontuberculous mycobacterial disease were compared in an autopsy series. METHODS Medical and microbiologic records, autopsy reports, histopathologic slides of the lungs, and chest CT scans were reviewed on patients at the National Institutes of Health with nontuberculous mycobacterial disease who died between 1996 and 2010. RESULTS The 11 patients with primary pulmonary nontuberculous mycobacterial disease were predominantly female (n = 9), with symptom onset at median 50 (range 35, 71) years and time from onset until death of 12 (3, 34) years. Bronchiectasis with cavity formation and necrotizing bronchocentric granulomatous inflammation predominated but extrapulmonary infection was absent. The five patients with disseminated disease and systemic immune defects were all men with age at onset of 2 (0.33, 33) years and time from onset of disease until death of 9 (1, 31) years. Miliary nodules and/or consolidation with poorly formed granulomatous inflammation were noted in the three disseminated patients with mycobacterial lung involvement. Significant extrapulmonary infection was noted in all five with a relative paucity of lung findings. CONCLUSIONS Nontuberculous mycobacteria can cause progressive, fatal disease. Primary pulmonary disease is bronchocentric and lacks extrathoracic infection consistent with impaired airway surface defenses. In contrast, fatal disseminated infections involving the lung have hematogenous spread, extensive extrathoracic disease, and a distinct pulmonary histopathology consistent with systemic immune dysfunction.
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Affiliation(s)
- Meghan L O'Connell
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - Kate E Birkenkamp
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD
| | - Les R Folio
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Steven M Holland
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - Kenneth N Olivier
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD.
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Haffner D, Fischer DC. Can bisphosphonates play a role in the treatment of children with chronic kidney disease? Pediatr Nephrol 2011; 26:2111-9. [PMID: 21267600 DOI: 10.1007/s00467-010-1739-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 12/06/2010] [Accepted: 12/07/2010] [Indexed: 01/09/2023]
Abstract
In patients with chronic kidney disease (CKD) renal osteodystrophy, in the form of either low- or high-turnover bone disease, is quite common. While renal transplantation is expected to reverse renal osteodystrophy, long-term treatment with glucocorticoids before and/or after transplantation may lead to osteoporosis instead. Osteoporosis is defined as a skeletal disease with low bone mineral density, microarchitectural deterioration, and concomitant fragility. In adults, bisphosphonates are widely used to treat osteoporosis and other diseases associated with excessive bone resorption. In pediatric CKD patients the efficacy and safety of these drugs have not yet been addressed adequately and thus no evidence-based recommendations regarding the optimal type of bisphosphonate, dosage, or duration of therapy are available. Furthermore, while in adults the determination of areal bone mineral density is sufficient to diagnose osteoporosis, this is not the case in children. Instead, in pediatric patients, careful morphological assessment of bone structure and formation is required. Indeed, data from studies with uremic rats indicated that bisphosphonates, via a deceleration of bone turnover, have the potential not only to aggravate pre-existing adynamic bone disease, but also to impair longitudinal growth. Thus, the widespread use of bisphosphonates in children with CKD should be discouraged until the risks and benefits have been carefully elucidated in clinical trials.
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Affiliation(s)
- Dieter Haffner
- Department of Pediatrics, University Hospital of Rostock, Ernst-Heydemann-Strasse 8, 18057, Rostock, Germany.
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Mallett A, John GT, Ranganathan D, Kark A, Berquier I, Casey J, Healy H, Francis L. Sustained remission of systemic lupus erythematosus related calciphylaxis. Lupus 2011; 21:441-4. [PMID: 22031536 DOI: 10.1177/0961203311425526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Calciphylaxis continues to present a clinical challenge for patient management. As in this case, it can be associated with connective tissue disease (CTD) such as systemic lupus erythematosus (SLE). Unlike previous reported cases, long-term remission has been attained. This provides some insight into methods of therapy as well as potential pathogenic models for this disease.
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Affiliation(s)
- A Mallett
- Department of Renal Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
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Auriemma M, Carbone A, Di Liberato L, Cupaiolo A, Caponio C, De Simone C, Tulli A, Bonomini M, Amerio P. Treatment of cutaneous calciphylaxis with sodium thiosulfate: two case reports and a review of the literature. Am J Clin Dermatol 2011; 12:339-46. [PMID: 21834598 DOI: 10.2165/11587060-000000000-00000] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Cutaneous calciphylaxis is a potentially fatal condition characterized by calcium deposition in dermal arterioles and the subsequent development of livedo reticularis, plaques, and extremely painful ulcers. This condition may be present in up to 4% of end-stage renal disease patients. Several treatments, which mainly attempt to control calcium phosphate metabolism, are available for this condition. We describe two patients treated with sodium thiosulfate with good results. Moreover, we also performed a PubMed literature search of sodium thiosulfate treatment for calciphylaxis. We found 41 cases of which most (> 90%) presented a rapid and sustained resolution, indicating this drug is a very good candidate for the treatment of this condition.
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Affiliation(s)
- Matteo Auriemma
- Department of Dermatology, University of Chieti-Pescara, Chieti, Italy.
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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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Selk N, Rodby RA. Unexpectedly severe metabolic acidosis associated with sodium thiosulfate therapy in a patient with calcific uremic arteriolopathy. Semin Dial 2011; 24:85-8. [PMID: 21338397 DOI: 10.1111/j.1525-139x.2011.00848.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Calcific uremic arteriolopathy, formerly known as calciphylaxis is a devastating condition that primarily affects patients with end-stage renal disease. The lesions can progress to massive ulcerations of the subcutaneous tissue that are associated with a high degree of morbidity and mortality, usually related to sepsis. Although the pathophysiology of this condition is poorly understood, it appears to be related to a derangement in calcium-phosphate metabolism. Thus, treatments have focused on the treatment of hyperparathyroidism albeit with poor results. More recently, sodium thiosulfate (STS) has emerged as a promising therapy following multiple case reports of marked disease regression following its use. As STS is a strong acid, metabolic acidosis has been described following its administration, although relatively mild in degree. We report a case of a patient with calciphylaxis who repeatedly developed a severe anion gap metabolic acidosis following each dose of STS requiring a significant reduction in the dose.
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Affiliation(s)
- Natalie Selk
- Section of Nephrology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA.
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Kakagia D, Kriki P, Thodis E, Roumeliotis A, Vargemezis V. Calcific uremic arteriolopathy treated with cinacalcet, paricalcitol, and autologous growth factors. J Cutan Med Surg 2011; 15:121-4. [PMID: 21477562 DOI: 10.2310/7750.2011.10052] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Calcific uremic arteriolopathy is an uncommon cutaneous ischemic necrotizing disease, most commonly associated with renal disease and hyperparathyroidism, bearing a high mortality rate. OBJECTIVE AND METHOD A case of a 57-year-old female renal patient with hyperparathyroidism who was successfully treated with combined paricalcitol and cinacalcet systemically, while autologous growth factors were locally applied, is herein presented. RESULT AND CONCLUSION The combination of cinacalcet and paricalcitol is a reliable alternative to parathyroidectomy in patients with calcific uremic arteriolopathy and hyperparathyroidism. Meticulous débridement of necrotic tissues is essential and application of autologous growth factors promotes healing.
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Affiliation(s)
- Despoina Kakagia
- Department of Plastic and Reconstructive Surgery, Democritus University Hospital, Alexandrouplois, Greece.
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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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Calciphylaxis: no longer rare; no longer calciphylaxis? A paradigm shift for wound, ostomy and continence nursing. J Wound Ostomy Continence Nurs 2011; 38:379-84. [PMID: 21606862 DOI: 10.1097/won.0b013e31821e5807] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article challenges conventional wisdom that calciphylaxis is a rare condition. Rather, emerging evidence suggests that calciphylaxis is neither rare nor uncommon. In addition, the term calciphylaxis is questioned because misrepresents the underlying etiology of the condition. Multiple researchers and clinicians advocate abandoning the use of the term, but nursing literature has not yet followed suit. This article reviews the epidemiology, clinical manifestations, diagnosis, prevention, and treatment of this condition and associated wounds, and suggests areas for future research. The WOC nurse's role as an educator, leader, researcher, clinical expert, and patient advocate is summarized.
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Volpini K, Kinonen C. Abdominal Catastrophe in a 43-Year-Old Female with End Stage Renal Disease. Semin Dial 2011; 24:79-82. [DOI: 10.1111/j.1525-139x.2010.00813.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sowers KM, Hayden MR. Calcific uremic arteriolopathy: pathophysiology, reactive oxygen species and therapeutic approaches. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2010. [PMID: 20716935 PMCID: PMC2952095 DOI: 10.4161/oxim.3.2.5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Calcific uremic arteriolopathy (CUA)/calciphylaxis is an important cause of morbidity and mortality in patients with chronic kidney disease requiring renal replacement. Once thought to be rare, it is being increasingly recognized and reported on a global scale. The uremic milieu predisposes to multiple metabolic toxicities including increased levels of reactive oxygen species and inflammation. Increased oxidative stress and inflammation promote this arteriolopathy by adversely affecting endothelial function resulting in a prothrombotic milieu and significant remodeling effects on vascular smooth muscle cells. These arteriolar pathological effects include intimal hyperplasia, inflammation, endovascular fibrosis and vascular smooth muscle cell apoptosis and differentiation into bone forming osteoblast-like cells resulting in medial calcification. Systemic factors promoting this vascular condition include elevated calcium, parathyroid hormone and hyperphosphatemia with consequent increases in the calcium × phosphate product. The uremic milieu contributes to a marked increased in upstream reactive oxygen species—oxidative stress and subsequent downstream increased inflammation, in part, via activation of the nuclear transcription factor NFκB and associated downstream cytokine pathways. Consitutive anti-calcification proteins such as Fetuin-A and matrix GLA proteins and their signaling pathways may be decreased, which further contributes to medial vascular calcification. The resulting clinical entity is painful, debilitating and contributes to the excess morbidity and mortality associated with chronic kidney disease and end stage renal disease. These same histopathologic conditions also occur in patients without uremia and therefore, the term calcific obliterative arteriolopathy could be utilized in these conditions.
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Strehl JD, Brandenburg V, Forster C, Willam C, Hartmann A, Amann K. [Calciphylaxis. A less well-known, clinically relevant disease]. DER PATHOLOGE 2010; 32:250-6. [PMID: 21053000 DOI: 10.1007/s00292-010-1411-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Calciphylaxis is a rare disease which has been increasingly reported in recent decades and has consequently shifted into the focus of clinical and scientific research. The clinical picture is characterized by extensive ischemic ulcerations of the skin and subcutis. Histologically, the small vessels in these lesions show prominent calcifications. Due to the extensive areas of ulceration and necrosis as well as frequently present comorbidities, patients with calciphylaxis are prone to infection and sepsis. In this work, we describe the case of a female kidney-transplant patient with vasculitis who, despite good graft function, developed a fulminant calciphylaxis of both thighs 4 years post transplantation and died of septic complications. The differential diagnoses as well as clinical procedures are described in detail in the case history. In the discussion, we give an overview of the current state of knowledge regarding the etiopathogenesis, risk factors, diagnostic measures and clinical management of calciphylaxis.
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Affiliation(s)
- J D Strehl
- Abteilung für Nephropathologie, Pathologisches Institut, Universitätsklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen
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Fodor D, Albu A, Poantă L, Porojan M. Vitamin K and vascular calcifications. ACTA PHYSIOLOGICA HUNGARICA 2010; 97:256-66. [PMID: 20843764 DOI: 10.1556/aphysiol.97.2010.3.2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The role of vitamin K in the synthesis of some coagulation factors is well known. The implication of vitamin K in vascular health was demonstrated in many surveys and studies conducted over the past years on the vitamin K-dependent proteins non-involved in coagulation processes. The vitamin K-dependent matrix Gla protein is a potent inhibitor of the arterial calcification, and may become a non-invasive biochemical marker for vascular calcification. Vitamin K(2) is considered to be more important for vascular system, if compared to vitamin K(1). This paper is reviewing the data from recent literature on the involvement of vitamin K and vitamin K-dependent proteins in cardiovascular health.
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Affiliation(s)
- D Fodor
- University of Medicine and Pharmacy, 2nd Internal Medicine, Clinic Iuliu Hatieganu, Cluj-Napoca, Romania.
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47
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Lucas JL, Rolston DDK. Calciphylaxis (calcific uremic arteriolopathy) in a patient with chronic kidney disease. J Hosp Med 2010; 5:E9-E11. [PMID: 20578051 DOI: 10.1002/jhm.659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jennifer L Lucas
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio, USA
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48
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Sulková SD, Válek M. Skin wounds associated with calciphylaxis in end-stage renal disease patients on dialysis. Nutrition 2010; 26:910-4. [PMID: 20692603 DOI: 10.1016/j.nut.2010.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 01/23/2010] [Indexed: 11/19/2022]
Affiliation(s)
- Sylvie Dusilová Sulková
- Division of Nephrology, Department of Gerontology and Metabolism, Medical Faculty of Charles University and Faculty Hospital, Hradec Králové, Czech Republic
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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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50
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Kolli S, Douglas J, Doumit E, Guglin M. Cardiomyopathy and calciphylaxis in a patient with normal renal function: a case report. ACTA ACUST UNITED AC 2010; 16:71-2. [PMID: 20412472 DOI: 10.1111/j.1751-7133.2009.00121.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Swathy Kolli
- University of South Florida, Tampa General Hospital, Tampa, FL 33606, USA
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