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Hatano M, Kitajima I, Yamamoto S, Nakamura M, Isawa K, Hirota Y, Hoshino J, Sawa N, Ubara Y. Case report: Osteomalacia due to bisphosphonate treatment in a patient on hemodialysis. BMC Nephrol 2021; 22:298. [PMID: 34479496 PMCID: PMC8414854 DOI: 10.1186/s12882-021-02509-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 08/20/2021] [Indexed: 01/23/2023] Open
Abstract
Background No publications have reported on osteomalacia in patients receiving intermittent cyclical therapy with etidronate (a bisphosphonate) and undergoing long-term hemodialysis (HD). Case presentation We report on a 46-year-old Japanese man admitted to our hospital for further examination of left forearm pain. Maintenance HD was started at age 24 years, and the man had been on HD since then. At age 38 years, surgical parathyroidectomy was performed for secondary hyperparathyroidism; iliac crest bone biopsy performed at the same time showed osteitis fibrosa. The active vitamin D3 preparation calcitriol was started, and intermittent cyclical etidronate therapy was introduced 2 years later for osteoporosis. At age 45 years, the patient stopped taking calcitriol because of hypercalcemia but continued with etidronate. At age 46 years, a pseudofracture with a Looser zone occurred in the left ulna, and left femur bone biopsy revealed osteomalacia. Etidronate was discontinued, and calcitriol was restarted; open reduction and internal fixation with an angular stability plate were performed. Union of the bone was achieved 10 months after the operation. At age 49 years, a lumber bone biopsy confirmed improved bone morphometry. Conclusions We believe that intermittent cyclical etidronate therapy without administration of active vitamin D3 during long-term HD might have induced osteomalacia, resulting in the ulna insufficiency fracture. Therefore, we propose that administration of active vitamin D3 is essential to prevent osteomalacia in patients on long-term HD who are receiving bisphosphonates and have potential vitamin D3 deficiency.
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Affiliation(s)
- Masaki Hatano
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan.
| | - Izuru Kitajima
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Seizo Yamamoto
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Masaki Nakamura
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Kazuya Isawa
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Yutaka Hirota
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Junichi Hoshino
- Department of Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan.,Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Naoki Sawa
- Department of Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan.,Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Yoshifumi Ubara
- Department of Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan. .,Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan.
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Ferreira AC, Cohen-Solal M, D'Haese PC, Ferreira A. The Role of Bone Biopsy in the Management of CKD-MBD. Calcif Tissue Int 2021; 108:528-538. [PMID: 33772341 DOI: 10.1007/s00223-021-00838-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/11/2021] [Indexed: 01/12/2023]
Abstract
A bone biopsy is still considered the gold standard for diagnosis of renal osteodystrophy. It allows to measure both static and dynamic parameters of bone remodeling and is the only method able to evaluate mineralization and allows analysis of both cortical and trabecular bone. Although bone volume can be measured indirectly by dual-energy X-ray absorptiometry, mineralization defects, bone metal deposits, cellular number/activity, and even turnover abnormalities are difficult to determine by techniques other than qualitative bone histomorphometry. In this review, we evaluate the role of bone biopsy in the clinical practice.
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Affiliation(s)
- Ana Carina Ferreira
- Nephrology Department, Centro Hospitalar e Universitário de Lisboa Central, Rua da Beneficência no. 8, 1050-099, Lisbon, Portugal.
- Nova Medical School, Nova University, Lisbon, Portugal.
| | - Martine Cohen-Solal
- Bioscar, INSERM u1132, Paris, France
- Hopital Lariboisiere, Université de Paris, 75010, Paris, France
| | - Patrick C D'Haese
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Aníbal Ferreira
- Nephrology Department, Centro Hospitalar e Universitário de Lisboa Central, Rua da Beneficência no. 8, 1050-099, Lisbon, Portugal
- Nova Medical School, Nova University, Lisbon, Portugal
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Pimentel A, Ureña-Torres P, Bover J, Luis Fernandez-Martín J, Cohen-Solal M. Bone Fragility Fractures in CKD Patients. Calcif Tissue Int 2021; 108:539-550. [PMID: 33219822 PMCID: PMC8052229 DOI: 10.1007/s00223-020-00779-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/04/2020] [Indexed: 12/14/2022]
Abstract
Chronic kidney diseases (CKD) are associated with mineral and bone diseases (MBD), including pain, bone loss, and fractures. Bone fragility related to CKD includes the risk factors observed in osteoporosis in addition to those related to CKD, resulting in a higher risk of mortality related to fractures. Unawareness of such complications led to a poor management of fractures and a lack of preventive approaches. The current guidelines of the Kidney Disease Improving Global Outcomes (KDIGO) recommend the assessment of bone mineral density if results will impact treatment decision. In addition to bone density, circulating biomarkers of mineral, serum bone turnover markers, and imaging techniques are currently available to evaluate the fracture risk. The purpose of this review is to provide an overview of the epidemiology and pathogenesis of CKD-associated bone loss. The contribution of the current tools and other techniques in development are discussed. We here propose a current view of how to better predict bone fragility and the therapeutic options in CKD.
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Affiliation(s)
| | - Pablo Ureña-Torres
- AURA Paris-Nord, Saint-Ouen, France
- Necker Hospital, University of Paris Descartes, Department of Renal Physiology, Paris, France
| | - Jordi Bover
- Fundació Puigvert, Universitat Autònoma, IIB Sant Pau, REDinREN, Nephrology Department, Barcelona, Catalonia, Spain
| | - Jose Luis Fernandez-Martín
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), REDinREN del ISCIII, Hospital Universitario Central de Asturias. Universidad de Oviedo, Bone and Mineral Research Unit, Oviedo, Asturias, Spain
| | - Martine Cohen-Solal
- INSERM U1132 & Université de Paris, Hôpital Lariboisière, Department of Rheumatology, Paris, France.
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Cohen-Solal M, Funck-Brentano T, Ureña Torres P. Bone fragility in patients with chronic kidney disease. Endocr Connect 2020; 9:R93-R101. [PMID: 32168473 PMCID: PMC7219138 DOI: 10.1530/ec-20-0039] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/13/2020] [Indexed: 11/23/2022]
Abstract
Mineral and bone diseases (MBD) are predominant in patients with chronic kidney disease (CKD) and lead to several bone manifestations, from pain to skeletal fractures. Cumulative traditional clinical risk factors, such as age and gender, in addition to those related to CKD, enhance the risk of comorbidity and mortality related to fractures. Despite great advances in understanding MBD in CKD, clinical and biological targets are lacking, which leads to under-management of fractures. Optimal PTH control results in a net improvement in defining the levels of bone remodeling. In addition, circulating biomarkers such as bone-specific alkaline phosphatase and cross-linked collagen type I peptide will also provide additional information about remodeling rate, bone mineralization and the evaluation of fracture risk. Imaging techniques identify patients at risk by measurement of bone mineral density by DEXA or by high peripheral QCT, which allow the discrimination of trabecular and cortical bone. Here, we have reviewed the literature related to epidemiology and the pathophysiological role of mineral and biochemical factors involved in CKD-MBD with a special focus on fracture risk. We also provide an algorithm that could be used for the management of bone diseases and to guide treatment decisions. Finally, the combined expertise of clinicians from various disciplines is crucial for the best prevention of fractures.
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Affiliation(s)
- Martine Cohen-Solal
- Department of Skeletal Diseases, INSERM U1132 & Université de Paris, Hôpital Lariboisière, Paris, France
- Correspondence should be addressed to M Cohen-Solal:
| | - Thomas Funck-Brentano
- Department of Skeletal Diseases, INSERM U1132 & Université de Paris, Hôpital Lariboisière, Paris, France
| | - Pablo Ureña Torres
- AURA Nord, Saint Ouen, France
- Department of Renal Physiology, Necker Hospital, Université de Paris, Paris, France
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Pimentel A, Ureña-Torres P, Zillikens MC, Bover J, Cohen-Solal M. Fractures in patients with CKD—diagnosis, treatment, and prevention: a review by members of the European Calcified Tissue Society and the European Renal Association of Nephrology Dialysis and Transplantation. Kidney Int 2017; 92:1343-1355. [DOI: 10.1016/j.kint.2017.07.021] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/12/2017] [Accepted: 07/17/2017] [Indexed: 01/29/2023]
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Vouri SM, Alvarez CA, Blaszczyk AT. Effects of oral bisphosphonate therapy on serum calcium in elderly veterans with poor kidney function. THE AMERICAN JOURNAL OF GERIATRIC PHARMACOTHERAPY 2012; 10:178-84. [PMID: 22542895 DOI: 10.1016/j.amjopharm.2012.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 03/16/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Limited data exist on the use of bisphosphonates in patients with poor kidney function due to a contraindication derived from inadequate experience among patients with kidney failure, accounting for as much as 25% of nonprescribing when otherwise appropriate. OBJECTIVES To determine whether bisphosphonate use in patients with decreased renal function, as outlined in the package insert (estimated creatinine clearance [eCrCl] <35 mL/min), would result in higher rates of hypocalcemia, as suggested in previous studies. METHODS This was a retrospective cohort study of elderly veterans 65 years of age and older at the Veterans Affairs North Texas Health Care System in Dallas, Texas. We identified 3089 patients who started oral bisphosphonate therapy between August 1, 2003 and July 12, 2010. Of the 252 patients meeting the inclusion criteria, 25 and 227 patients had an eCrCl <35 mL/min and eCrCl ≥35 mL/min, respectively. Analyses of changes in serum calcium from baseline to the 1-year study end point were performed within and between each renal function group. RESULTS Among the veterans with an eCrCl <35 mL/min and eCrCl ≥35 mL/min, there were decreases in median serum calcium levels from baseline to study end point from 9.8 mg/dL (interquartile range [IQR], 9.4-10.2 mg/dL) to 9.3 mg/dL (IQR, 9.0-10.0 mg/dL; P = 0.028) and 9.6 mg/dL (IQR, 9.3-9.9 mg/dL) to 9.4 mg/dL (IQR, 9.1-9.8 mg/dL; P < 0.001), respectively. However, there was no difference in Δcalcium: -0.2 mg/dL (IQR, 0-0.6 mg/dL) and 0.2 mg/dL (IQR, -0.2 to 0.5 mg/dL; P = 0.547), respectively. CONCLUSIONS This exploratory assessment may suggest that, in elderly veterans, the initiation of oral bisphosphonate therapy contributed to a statistically significant decrease in serum calcium levels regardless of baseline renal function; however, the clinical impact of this change does not appear to be significant. Future studies should assess serum calcium in a larger population of patients to confirm the safety of oral bisphosphonates in poor kidney function.
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Copley JB, Wüthrich RP. Therapeutic management of post-kidney transplant hyperparathyroidism. Clin Transplant 2011; 25:24-39. [PMID: 20572835 DOI: 10.1111/j.1399-0012.2010.01287.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Left uncontrolled, persistent post-kidney transplant hyperparathyroidism (HPT) may lead to or exacerbate pre-existing bone and cardiovascular disease. Parathyroidectomy has long been the primary treatment option for long-term uncontrolled HPT in post-kidney transplant patients. However, patients with contraindications for surgery and parathyroidectomy-associated complications, including graft loss, highlight the need for other approaches. Conventional medical therapies have limited impact on serum calcium (Ca) and parathyroid hormone (PTH) levels. Bisphosphonates and calcitonin, used to spare bone loss, and phosphorus supplementation, to correct hypophosphatemia, do not directly regulate PTH or Ca. Although vitamin D supplementation can reduce PTH, it is often contraindicated because of hypercalcemia. Studies of the calcimimetic cinacalcet in patients with post-kidney transplant HPT suggest that it can rapidly reduce serum PTH and Ca concentrations while increasing serum phosphorus concentrations toward the normal range. Although the clearest application for cinacalcet is the non-surgical treatment of hypercalcemic patients with persistent HPT, current indications for other transplant patients are as yet uncertain. Further studies are needed to determine the utility of cinacalcet in patients with spontaneous resolution of HPT or low bone turnover. This review discusses the pathophysiology of post-kidney transplant HPT, associated complications, and current options for clinical management.
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Copley JB, Germain M, Stern L, Pankewycz O, Katznelson S, Shah T, Wang O, Turner SA, Sprague SM. Evaluation of cinacalcet HCl treatment after kidney transplantation. Transplant Proc 2011; 42:2503-8. [PMID: 20832532 DOI: 10.1016/j.transproceed.2010.04.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Revised: 02/02/2010] [Accepted: 04/08/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hyperparathyroidism often remains or develops after kidney transplantation. Vitamin D sterol used as treatment for an elevated parathyroid hormone (PTH) level and associated bone disease may be contraindicated due to hypercalcemia. The calcimimetic cinacalcet HCl (cinacalcet), which lowers PTH and calcium (Ca) in chronic kidney disease patients, may represent an alternate therapeutic modality. METHODS This multicenter, retrospective, observational study examined 41 kidney transplant patients receiving cinacalcet for ≥3 months starting ≥3 months posttransplantation. Levels of intact PTH, Ca, and phosphorus (P) were examined during the assessment phase (3-6 months after initiation). RESULTS Median PTH decreased 21.8% during the assessment phase (P < .001), with 32.5% of patients exhibiting a ≥30% decrease in PTH from baseline. Median Ca decreased 6.8% (P < .0001). Median serum P rose 10.0% (P = .0124), but remained within normal limits. The estimated glomerular filtration rate was stable throughout the study. CONCLUSIONS Cinacalcet may be useful for the treatment of hyperparathyroidism after kidney transplantation. Randomized, prospectively designed clinical trials are required to confirm these results.
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Affiliation(s)
- J B Copley
- Cleveland Clinic Florida, Weston, Florida 33331, USA.
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Reversal of hypercalcemic acute kidney injury by treatment with intravenous bisphosphonates. Pediatr Nephrol 2009; 24:613-7. [PMID: 18839218 DOI: 10.1007/s00467-008-1011-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Revised: 08/20/2008] [Accepted: 08/23/2008] [Indexed: 10/21/2022]
Abstract
We present the details of three children with hypercalcemia-induced acute kidney injury (AKI). After traditional therapy with fluids, loop diuretics, steroids and calcitonin had failed to correct the hypercalcemia, they were given treatment with low doses of intravenous (i.v.) pamidronate, which resulted in normalization of serum calcium and kidney function. In one child Doppler renal ultrasound revealed dampened arterial blood flow, which resolved with normalization of serum calcium. On the basis of cumulative data and our experience, we suggest that i.v. application of bisphosphonates be moved from the second to the first line of treatment of hypercalcemic AKI.
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Ramezani M, Einollahi B, Asl MA, Nafar M, Pourfarziani V, Moradi M, Samadpour A, Alghasi M, Davoudi F. Calcium and Phosphorus Metabolism Disturbances After Renal Transplantation. Transplant Proc 2007; 39:1033-5. [PMID: 17524884 DOI: 10.1016/j.transproceed.2007.03.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Several studies have noted that, despite beneficial correction of abnormalities of mineral metabolism after successful renal transplantation, renal functional recovery is incomplete. Also, persistence of hyperparathyroidism and metabolic acidosis among patients with chronic impairment of graft function together with the use of loop diuretics and immunosuppressive drugs with adverse effects may alter mineral metabolism. We determined calcium and phosphorus levels in recipients. METHODS This cross-sectional study enrolled 398 recipients in 2 medical centers in Iran from 1988 to 2004 to evaluate serum calcium and phosphorus levels after 1 month in relation to graft and patient survivals. Cyclosporine was the constant part of the immunosuppressive treatment in all study subjects. RESULTS The median follow-up time was 8 months (range, 1-180 months). One and 10-year survival rates of patients were 97.9% and 91.1%. Mean (SD) serum calcium levels before and after transplantation were 8.79 (1.26) and 8.50 (1.39) mg/dL, respectively (P=.020). The mean (SD) phosphate levels before and after transplantation were 6.43 (2.42) and 3.64 (1.71) mg/dL, respectively (P=.000). There was no significant difference in survival considering changes in serum calcium and phosphorus levels. There was no correlation between serum calcium and phosphorus level changes among study patients. CONCLUSIONS Despite reports suggesting hypercalcemia as a posttransplantation finding, we did not observe this condition, but, consistent with other reports in this field, we observed a significant decrease in serum phosphorus levels showing correction of this mineral level.
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Affiliation(s)
- M Ramezani
- Department of Internal Medicine, Baqyiatollah University of Medical Sciences, Tehran, Iran
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Shiraishi N, Kitamura K, Miyoshi T, Adachi M, Kohda Y, Nonoguchi H, Misumi S, Maekawa Y, Murayama T, Tomita M, Tomita K. Successful treatment of a patient with severe calcific uremic arteriolopathy (calciphylaxis) by etidronate disodium. Am J Kidney Dis 2006; 48:151-4. [PMID: 16797398 DOI: 10.1053/j.ajkd.2006.04.062] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Accepted: 04/05/2006] [Indexed: 12/13/2022]
Abstract
A 59-year-old woman with a 10-year history of hemodialysis was admitted to our hospital for painful skin ulcers on her right thigh, right calf, and left upper arm. A whole-body plain computed tomographic scan showed diffuse calcification of the uterus and marked calcification of the mitral valve. Skin biopsy specimens from the left thigh showed calcium deposition in numerous small blood vessels in the dermis and fat, leading to a diagnosis of calcific uremic arteriolopathy (CUA). Despite antibiotic therapy and aggressive wound care for 2 months, the skin ulcers enlarged and the patient's general condition worsened. Surprisingly, oral administration of etidronate disodium (200 mg/d) strikingly improved the focal infection and decreased the size of the skin ulcers within several days. She was discharged from the hospital 2 months later, when epithelialization of the ulcers was almost complete. We report a case of CUA that was improved dramatically by treatment with etidronate. Etidronate therapy should be considered for refractory CUA.
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Affiliation(s)
- Naoki Shiraishi
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan.
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Duval A, Moranne O, Vanhille P, Hachulla E, Delaporte E. Artériolopathie calcique (Calciphylaxie). Rev Med Interne 2006; 27:184-95. [PMID: 16386823 DOI: 10.1016/j.revmed.2005.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2005] [Revised: 11/04/2005] [Accepted: 11/07/2005] [Indexed: 12/11/2022]
Abstract
PURPOSE Calcific arteriolopathy (CA), also known as " Calciphylaxis " describes a phenomenon of necrosis, mainly cutaneous and sometimes systemic, due to the obliteration of the arteriole's lumen. Initially there are under-intimal calcium deposits, and then the thrombosis occurs leading to the necrosis. CA affects mainly the renal insufficient hemodialysed patient, but not exclusively. We present 4 cases which illustrate well the etiologic spectrum of CA: terminal renal insufficiency, neoplasia, primary hyperparathyroidism, proteinuria, vitamin K inhibitors. We describe the AC's epidemiology, its cutaneous and systemic clinical presentations, its treatment. We make the hypothesis that CA is a strong risk marker in matter of cardiac mortality and we discuss this point. CURRENT KNOWLEDGE AND KEY POINTS In this article we describe the numerous breakthroughs that have been made in matter of research about calcification over the past few years: inhibitors of calcium phosphate deposition, vitamin D and PTH1R, protein-calcium complexes, cell death, induction of bone formation. These data are analysed from a clinical point of view with practical purposes. We present CA not only as a cutaneous disease but as a systemic pathology. FUTURE PROSPECTS AND PROJECTS The CA epidemiology is an incentive to more diagnosis suspicion in front of organ infarct involving a patient likely to be concerned by CA. The scientific and therapeutic breakthroughs in matter of calcification enable a better prevention of the disease. Nevertheless it remains very difficult to cure when installed.
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Affiliation(s)
- A Duval
- Clinique dermatologique, Hôpital Claude-Huriez, CHRU, 59037 Lille, France.
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