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Schnur J, Sinawe H, Yoham AL, Casadesus D. Vascular calcifications and calciphylaxis in a patient on concurrent haemodialysis and Coumadin therapy. BMJ Case Rep 2021; 14:14/3/e240310. [PMID: 33762282 PMCID: PMC7993223 DOI: 10.1136/bcr-2020-240310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Calciphylaxis is a rare life-threatening condition, with calcification of small and medium-sized vessels leading to skin necrosis. It has a high morbidity and mortality, and most of the patients die from wound superinfection and sepsis. A 48-year-old man with a history of end-stage renal disease on haemodialysis and Coumadin therapy for venous thromboembolism presented with pulmonary oedema after missing two haemodialysis treatment. At examination, he had bilateral lower extremity dark brown, possibly necrotic, painful ulcers. He was diagnosed with calciphylaxis and treated with sevelamer hydrochloride, low calcium dialysate and sodium thiosulfate with haemodialysis. He received daily wound care with topical collagenase. After daily wound care treatment for 4 months, the patient's ulcers completely healed. The patient had been followed for 8 months, which included 29 additional readmissions, 3 admissions related to bacteraemia and 26 admissions with the diagnosis of pulmonary oedema and hyperkalaemia requiring haemodialysis.
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Affiliation(s)
- Jack Schnur
- Internal Medicine, Jackson Memorial Hospital, Miami, Florida, USA
| | - Hadeer Sinawe
- Internal Medicine, Jackson Memorial Hospital, Miami, Florida, USA
| | | | - Damian Casadesus
- Internal Medicine, Jackson Memorial Hospital, Miami, Florida, USA
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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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Deen J, Schaider H. The use of cinacalcet for the treatment of calciphylaxis in patients with chronic kidney disease: A comprehensive review. Australas J Dermatol 2019; 60:e186-e194. [PMID: 30666627 DOI: 10.1111/ajd.12992] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 12/08/2018] [Indexed: 12/19/2022]
Abstract
Calciphylaxis is a rare but life-threatening condition, most commonly affecting patients with stage 4 or 5 chronic kidney disease. No universally accepted therapy exists so far. In an attempt to avoid surgical intervention with parathyroidectomy, which is of questionable efficacy and carries several risks, a number of noninvasive treatments have been trialled with variable success. These treatments are aimed at modifying risk factors for calciphylaxis, in particular hypercalcaemia, hyperphosphataemia and hyperparathyroidism. The aim of this review was to summarise the available evidence to determine the potential role of cinacalcet in the treatment of calciphylaxis in patients with chronic kidney disease. Demographic, clinical and laboratory data were retrospectively collected from the available English and non-English literature. Overall, there was a very high response rate (partial or complete) of calciphylaxis lesions to both cinacalcet monotherapy and cinacalcet as part of a combination therapy (83.4% and 82.8%, respectively). When examining complete response to treatment specifically, combination therapy with cinacalcet proved more efficacious than monotherapy (62.1% versus 41.7%). There was also an associated rapid reduction of intact parathyroid hormone over a period of 2-33 months in both groups. While there are limitations as to how our data can be interpreted due to the heterogeneity of the methods and follow-up of the included case reports and case series, prompt and consistent therapy including cinacalcet may help improve the disease outcome. Additional research needs to be performed in this area, to further define the optimal use of cinacalcet for the treatment of calciphylaxis.
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Affiliation(s)
- Jacqueline Deen
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Helmut Schaider
- Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia.,Department of Dermatology, The Townsville Hospital and Health Service, Townsville, Queensland, Australia
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Peng T, Zhuo L, Wang Y, Jun M, Li G, Wang L, Hong D. Systematic review of sodium thiosulfate in treating calciphylaxis in chronic kidney disease patients. Nephrology (Carlton) 2018; 23:669-675. [PMID: 28603903 DOI: 10.1111/nep.13081] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 12/21/2022]
Abstract
AIM Calciphylaxis is a severe complication of advanced chronic kidney disease (CKD). Sodium thiosulphate (STS), an antioxidant and calcium chelating agent, has been used for the treatment of calciphylaxis. However, its efficacy and safety have not been systematically analysed and evaluated. METHODS MEDLINE, EMBASE, and the Cochrane Library database were systematically searched for case report or cases series on use of STS for calciphylaxis published between July 1974 and October 2016. We extracted data on clinical characteristics, laboratory tests result and medication use. The effective treatment was defined as improvement in skin lesion cicatrisation or pain relief without death. Non-responding effects were defined as stable skin lesions without remission or exacerbation of the disease in patients who remained alive. All-cause mortality after STS treatment was defined as death due to exacerbations of calciphylaxis or other complications of advanced CKD. We compared the baseline parameters of the patients as well as the efficacy and mortality of the STS therapy between case report and multi-case reports. Statistical analyses were performed using SPSS 19. RESULTS A total of 83 papers were screened, 45 of them (n = 358) met the inclusion criteria, including 36 case reports (n = 64) and nine multi-case reports (n = 294). The mean age of the patients with calciphylaxis was 58 ± 14 years (range 26-91 years). They were female predominant, accounting for 74.1%. Among the patients with calciphylaxis, 96.1% patients were on dialysis with median dialysis vintage of 44.5 months (range 24-84 months). STS was effective in 70.1% of patients, 37.6% patients died. The proportion of patients with sepsis was higher among those who received intravenous STS. There was no significant difference in efficacy between the different STS administration methods (P = 0.19). CONCLUSION Although the study was unable to assess the efficacy of sodium thiosulphate alone in the treatment of calciphylaxis, it still reveals a promising role of STS as an effective therapy for calciphylaxis. Further prospective studies to define the optimal therapy for calciphylaxis are needed.
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Affiliation(s)
- Ting Peng
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Ling Zhuo
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Ying Wang
- The George Institute for Global Health, University of Sydney, Australia
| | - Min Jun
- The George Institute for Global Health, University of Sydney, Australia
| | - Guisen Li
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Li Wang
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Daqing Hong
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,The George Institute for Global Health, University of Sydney, Australia
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Koratala A, Leghrouz M, Phillips MH, Bhatti V. Patterns of vascular calcification in patients with end-stage renal disease and calcific uremic arteriolopathy. Clin Case Rep 2017; 5:2143-2145. [PMID: 29225874 PMCID: PMC5715585 DOI: 10.1002/ccr3.1220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 09/19/2017] [Indexed: 11/09/2022] Open
Abstract
Calcific uremic arteriolopathy or calciphylaxis is a rare and potentially fatal condition, which manifests as skin ischemia and necrosis, usually seen in patients with end-stage renal disease. It is frequently associated with vascular calcification visible on plain radiographs, which can occur in various patterns.
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Affiliation(s)
- Abhilash Koratala
- Division of Nephrology, Hypertension and Renal Transplantation University of Florida Gainesville Florida
| | - Muhannad Leghrouz
- Division of Nephrology, Hypertension and Renal Transplantation University of Florida Gainesville Florida
| | - Melinda H Phillips
- Division of Nephrology, Hypertension and Renal Transplantation University of Florida Gainesville Florida
| | - Vikrampal Bhatti
- Division of Nephrology, Hypertension and Renal Transplantation University of Florida Gainesville Florida
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Qadri SI, Koratala A. Calciphylaxis with extensive arterial calcification. Clin Case Rep 2017; 5:1418-1419. [PMID: 28781873 PMCID: PMC5538074 DOI: 10.1002/ccr3.1068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 06/09/2017] [Indexed: 11/10/2022] Open
Abstract
Calciphylaxis is a clinical syndrome of arteriolar calcification with resultant tissue necrosis, most commonly seen in patients with end-stage renal disease (ESRD) on dialysis. This condition carries a high mortality rate mainly due to infection. Helpful interventions include adequate dialytic therapy, medical management of hyperparathyroidism, hyperphosphatemia, and intravenous sodium thiosulfate therapy.
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Affiliation(s)
- Syed Irfan Qadri
- Division of Nephrology, Hypertension and Renal Transplantation University of Florida Gainesville Florida
| | - Abhilash Koratala
- Division of Nephrology, Hypertension and Renal Transplantation University of Florida Gainesville Florida
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Chen NC, Hsu CY, Chen CL. The Strategy to Prevent and Regress the Vascular Calcification in Dialysis Patients. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9035193. [PMID: 28286773 PMCID: PMC5329685 DOI: 10.1155/2017/9035193] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/17/2017] [Indexed: 12/31/2022]
Abstract
The high prevalence of arterial calcification in end-stage renal disease (ESRD) is far beyond the explanation by common cardiovascular risk factors such as aging, diabetes, hypertension, and dyslipidemia. The finding relies on the fact that vascular and valvular calcifications are predictors of cardiovascular diseases and mortality in persons with chronic renal failure. In addition to traditional cardiovascular risk factors such as diabetes mellitus and blood pressure control, other ESRD-related risks such as phosphate retention, excess calcium, and prolonged dialysis time also contribute to the development of vascular calcification. The strategies are to reverse "calcium paradox" and lower vascular calcification by decreasing procalcific factors including minimization of inflammation (through adequate dialysis and by avoiding malnutrition, intravenous labile iron, and positive calcium and phosphate balance), correction of high and low bone turnover, and restoration of anticalcification factor balance such as correction of vitamin D and K deficiency; parathyroid intervention is reserved for severe hyperparathyroidism. The role of bone antiresorption therapy such as bisphosphonates and denosumab in vascular calcification in high-bone-turnover disease remains unclear. The limited data on sodium thiosulfate are promising. However, if calcification is to be targeted, ensure that bone health is not compromised by the treatments.
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Affiliation(s)
- Nai-Ching Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung City, Taiwan
| | - Chih-Yang Hsu
- Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chien-Liang Chen
- Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
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Russo D, Capuano A, Cozzolino M, Napolitano P, Mosella F, Russo L, Saviano C, Zoccali C. Multimodal treatment of calcific uraemic arteriolopathy (calciphylaxis): a case series. Clin Kidney J 2015; 9:108-12. [PMID: 26798470 PMCID: PMC4720199 DOI: 10.1093/ckj/sfv120] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 10/20/2015] [Indexed: 12/27/2022] Open
Abstract
Background This is an incident series of five dialysis patients with late-diagnosed calcific uraemic arteriolophathy (CUA), severe uncontrolled hyperparathyroidism and infected skin ulcerations. Methods A multimodal intervention was based on wound care, antibiotics, surgical debridement, sodium thiosulphate and cinacalcet and associated with regression of skin disease in four cases after varying treatment time periods ranging from 4 to 33 months. Results Multimodal treatment including sodium thiosulphate and cinacalcet was associated with very favourable local outcomes and survival. This series further confirms that the diagnosis of CUA is rarely made at the nodular, non-ulcerative phase of the disease. Conclusions This series contributes to the build-up of case series reporting on the treatment of CUA, and will hopefully serve as a basis of well-conceived comparative effectiveness studies investigating the value of the combined interventions applied so far in this severe condition.
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Affiliation(s)
- Domenico Russo
- Department of Nephrology , University of Naples , Napoli , Italy
| | - Alfredo Capuano
- Department of Nephrology , University of Naples , Napoli , Italy
| | | | - Paola Napolitano
- Department of Nephrology , University of Naples , Napoli , Italy
| | | | - Luigi Russo
- Department of Nephrology , Second University of Naples , Napoli , Italy
| | - Caterina Saviano
- Department of Internal Medicine , 'San Sebastiano' Hospital , Caserta , Italy
| | - Carmine Zoccali
- Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria Unit of CNR-IFC (National Research Council of Italy and Institute of Clinical Physiology), Reggio Calabria, Italy
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