1
|
Yousuf S, Busch D, Renner R, Schliep S, Erfurt-Berge C. Clinical characteristics and treatment modalities in uremic and non uremic calciphylaxis - a dermatological single-center experience. Ren Fail 2024; 46:2297566. [PMID: 38178572 PMCID: PMC10773653 DOI: 10.1080/0886022x.2023.2297566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/15/2023] [Indexed: 01/06/2024] Open
Abstract
Calciphylaxis (CP) is a serious, potentially life-threatening disease that presents with medial calcification of small-sized vessels and painful ischemic ulcerations. Although calciphylaxis is frequently seen in patients with end-stage kidney disease on dialysis (calcific uremic arteriolopathy, CUA), there are reported cases of nonuremic calciphylaxis (NUC), which often remain undiagnosed. We conducted a retrospective chart review at our dermatological hospital and evaluated data concerning the epidemiology, comorbidities, medication, laboratory abnormalities, and therapeutic approaches of 60 patients diagnosed with calciphylaxis between 01/2012 and 12/2022. We identified 21 patients diagnosed with NUC and 39 with kidney disease. The predilection sites of skin lesions were the lower legs in 88% (n = 53), followed by the thigh and gluteal regions in 7% (n = 4). Significant differences were identified in comorbidities, such as atrial fibrillation (p < 0.001) and hyperparathyroidism (p < 0.01) accounting for CUA patients. Medication with vitamin K antagonists (p < 0.001), phosphate binders (p < 0.001), and loop diuretics (p < 0.01) was found to be associated with the onset of calciphylaxis. Hyperphosphatemia (p < 0.001), increased parathyroid hormone (p < 0.01) and triglyceride levels (p < 0.01), hypoalbuminemia (p < 0.01) and decreased hemoglobin values (p < 0.001) in the CUA cohort were significantly different from those in the NUC group. All patients with CUA received systemic medication. In contrast, only 38% (n = 8) of patients with NUC received systemic treatment. Striking discrepancies in the treatment of both cohorts were detected. In particular, NUC remains a disease pattern that is still poorly understood and differs from CUA in several important parameters.
Collapse
Affiliation(s)
- Sabine Yousuf
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Dorothee Busch
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | - Stefan Schliep
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Cornelia Erfurt-Berge
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| |
Collapse
|
2
|
Toussaint ND, Davies CE, Bongetti E, Ruderman I, Elder GJ, Hawley CM, Krishnasamy R, Roberts MA, Jardine MJ, De Zoysa JR, McDonald SP. Calciphylaxis Episodes in the Australia and New Zealand Dialysis and Transplant Registry. Kidney Int Rep 2024; 9:951-959. [PMID: 38765561 PMCID: PMC11101771 DOI: 10.1016/j.ekir.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/06/2024] [Accepted: 01/11/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Calciphylaxis is a rare disorder associated with significant morbidity and mortality. Data registries are an invaluable source of information for rare diseases. We reviewed cases of calciphylaxis recorded in the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and evaluated associations and outcomes of this condition. Methods Data was obtained on all cases of calciphylaxis reported between 2019 and 2022 in Australian and New Zealand patients on kidney replacement therapy (KRT). This cohort was compared to all patients in the registry who received KRT from 2019 to 2022 without an episode of calciphylaxis. Cox proportional hazards regression including a time-varying covariate for calciphylaxis episode was conducted for mortality with models restricted to patients on dialysis only. Results From 2019 to 2022, 333 patients had calciphylaxis episodes reported. Overall incidence rate for patients on dialysis was 4.5 (4.1-5.1) episodes per 1000 patient-years on dialysis. Median age was 63 (interquartile range [IQR]: 55-73) years, 54% were female, 66% had diabetes, 59% were obese (body mass index [BMI] ≥ 30 kg/m2) and 77% were receiving hemodialysis (HD) treatment. Compared to patients without calciphylaxis (n = 46,526), patients with calciphylaxis were more likely to be older, female, and have diabetes, greater BMI, coronary artery, and peripheral vascular disease. The median time to calciphylaxis was 3.2 (IQR: 0.9-6.7) years after KRT commencement. Half of the patients with calciphylaxis died by 12 months from diagnosis. Adjusted hazard ratio (HR) of mortality for patients on dialysis with calciphylaxis <1 year and 1 to 4 years after an episode was 5.8 (4.9-6.9) and 1.5 (1.0-2.1), respectively compared to patients on dialysis without calciphylaxis. Conclusion Calciphylaxis is a rare but life-threatening condition in people on KRT with the greatest mortality burden within 12 months of diagnosis.
Collapse
Affiliation(s)
- Nigel D. Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Christopher E. Davies
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Elisa Bongetti
- Department of Nephrology, Monash Medical Centre, Clayton, Australia
| | - Irene Ruderman
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Grahame J. Elder
- School of Medicine, University of Notre Dame, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Skeletal Biology Program, Garvan Institute of Medical Research, Darlinghurst, Australia
- Department of Nephrology, Westmead Hospital, Sydney, Australia
| | - Carmel M. Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Rathika Krishnasamy
- Department of Nephrology, Sunshine Coast Hospital University Hospital, Birtinya, Australia
| | | | - Meg J. Jardine
- NHMRC Clinical Trials Centre, University of Sydney New South Wales, Australia
- Department of Nephrology, Concord Repatriation General Hospital, Sydney, Australia
- The George Institute for Global Health, UNSW, Sydney Australia
| | - Janak R. De Zoysa
- Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
- Te Whatu Ora Waitemata, Auckland, New Zealand
| | - Stephen P. McDonald
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
- Central and Northern Adelaide Renal and Transplantation Services, Royal Adelaide Hospital, Adelaide, Australia
| |
Collapse
|
3
|
Teh YK, Renaud CJ. Clinical experience with intraperitoneal sodium thiosulphate for calciphylaxis in peritoneal dialysis: A case series. Perit Dial Int 2024; 44:66-69. [PMID: 37131321 DOI: 10.1177/08968608231163669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
Calciphylaxis is an uncommon but life-threatening syndrome in end-stage kidney disease, characterised by painful medial and intimal calcification of the arterioles in the deep dermis and subcutaneous tissues. Intravenous sodium thiosulfate serves as an off-label but effective treatment in haemodialysis patients. However, this approach confers considerable logistical challenges for affected peritoneal dialysis patients. In this case series, we demonstrate that intraperitoneal administration can be a safe, convenient and long-term alternative.
Collapse
Affiliation(s)
- Yuan Kai Teh
- Department of Medicine, Khoo Teck Puat Hospital, Singapore
| | | |
Collapse
|
4
|
Jang A, Mark Ho MH, Yan L. Characterization of Risk Factors for Calciphylaxis in Hemodialysis Patients in the Fraser Health Renal Program - A Matched Case-Control Retrospective Review. J Pharm Pract 2023; 36:1424-1437. [PMID: 36036088 DOI: 10.1177/08971900221118444] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Introduction: Calciphylaxis is a lethal and rare disease characterized by ischemic and necrotic skin lesions caused by vascular calcification of adipose tissue. There have been many risk factors analyzed in the literature; however, the pathogenesis of calciphylaxis is still not well understood and treatment options are limited due to the lack of interventional studies. Our objectives were to describe risk factors, prevalence, incidence, and outcomes for calciphylaxis in hemodialysis patients within the Fraser Health Renal Program. Methods: This was a retrospective matched case-control study of hemodialysis patients within the Fraser Health Renal Program. Hemodialysis patients with calciphylaxis were matched to hemodialysis patients without calciphylaxis in a 1:2 ratio for age and sex from September 2, 2017 to July 3, 2020. Findings: There was a total of 40 calciphylaxis cases matched to 80 controls. In the univariate analysis, peritoneal dialysis, higher body mass index, lower serum iron, lower transferrin saturation, sevelamer, cinacalcet, warfarin, iron (PO), and insulin were associated with increased risk of calciphylaxis. In the multivariate analysis, only peritoneal dialysis, serum iron, sevelamer, and warfarin were identified as significant and strong risk factors associated with calciphylaxis. A low prevalence of 1.9% and high mortality rate of 57.5% at 12 months was found for calciphylaxis cases. Discussion: Significant risk factors associated with calciphylaxis were peritoneal dialysis, serum iron, sevelamer, and warfarin. Future studies should further investigate the impact of minimizing exposure to these risk factors to reduce calciphylaxis development.
Collapse
Affiliation(s)
- Ashley Jang
- Department of Pharmacy, Burnaby Hospital, Burnaby, BC, Canada
| | - Man Hon Mark Ho
- Department of Pharmacy, Royal Columbian Hospital, New Westminster, BC, Canada
| | - Luzhi Yan
- Department of Pharmacy, Surrey Memorial Hospital, Surrey, BC, Canada
| |
Collapse
|
5
|
Liu Y, Zhang X. Early diagnosis strategy of calciphylaxis in dialysis patients. Ren Fail 2023; 45:2264407. [PMID: 37795796 PMCID: PMC10557543 DOI: 10.1080/0886022x.2023.2264407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 09/23/2023] [Indexed: 10/06/2023] Open
Abstract
Calciphylaxis, a rapidly progressive and potentially life-threatening vascular calcification syndrome that clinically presents with persistently painful, ulcerative, or necrotizing skin lesions in multiple parts of the body, is predominantly observed in patients treated with dialysis. Early diagnosis of calciphylaxis is a key measure for reducing high disability and mortality. At present, there is no unified diagnostic standard for calciphylaxis, and there is a lack of effective early screening strategies. This paper summarized and discussed the diagnostic accuracy of calciphylaxis based on the latest research worldwide. We propose a modified strategy for the early diagnosis of calciphylaxis, which is suitable for dialysis patients to help clinicians better identify such disease and improve prognosis.
Collapse
Affiliation(s)
- Yuqiu Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, Jiangsu, China
| | - Xiaoliang Zhang
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, Jiangsu, China
| |
Collapse
|
6
|
Khalayli N, Hodifa Y, Hodaifa A, Alsamarrai O, Kudsi M. Calciphylaxis during the course of psoriatic arthritis patient. Is it coincidence? A case report. Ann Med Surg (Lond) 2023; 85:5263-5266. [PMID: 37811033 PMCID: PMC10552990 DOI: 10.1097/ms9.0000000000001281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/27/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction and importance Calciphylaxis manifests clinically by skin ischemia and necrosis and histologically by calcification of dermal arterioles. Usually, it occurs in patients with end-stage renal disease on dialysis or in patients who had a kidney transplant. Here, the authors present a case of calciphylaxis occurring in a patient with psoriasis and psoriatic arthritis. Case presentation A 66-year-old Syrian male with a history of psoriatic arthritis presented for evaluation of 2-month nonpainful ulcers on his feet and hands that were treated with warfarin. Biopsies confirmed the diagnosis of calciphylaxis. The patient received sodium thiosulfate, zoledronic acid, intralesional sodium thiosulfate injections, and an intravenous infusion of vitamin K with dramatic improvement. At the 3-month follow-up, his wounds had been completely remitted. Discussion Nonuremic calciphylaxis occurs in many cases, like vitamin D administration, vitamin K antagonists' administration, chronic inflammation, and others. The association between calciphylaxis and psoriasis was reported only in four cases in the literature; meanwhile, this was the first case that described calciphylaxis in the setting of psoriatic arthritis. Conclusion A suspicion of calciphylaxis should be maintained in patients with underlying inflammatory mechanism diseases.
Collapse
Affiliation(s)
| | - Yara Hodifa
- Faculty of Medicine, Damascus University, Damascus, Syria
| | | | | | | |
Collapse
|
7
|
Ficenec S, Gerstein B, Shamburger CD. Calcific uraemic arteriolopathy presenting as cellulitis of the dorsal foot. BMJ Case Rep 2023; 16:e251758. [PMID: 37015767 PMCID: PMC10083774 DOI: 10.1136/bcr-2022-251758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023] Open
Abstract
Calcific uraemic arteriolopathy (CUA) is a rare and poorly understood entity that typically presents with painful lesions affecting adipose-rich areas of the lower extremities. We report an unusual case of CUA presenting as presumed cellulitis of the dorsal surface of the distal lower extremity with acute development of a bullous lesion. As CUA incidence is predicted to increase due to its relationship with end-stage renal disease, recognising the full clinical spectrum of this disease is essential to promote further understanding of this disorder and exploration of additional therapeutics to limit disease morbidity and mortality.
Collapse
Affiliation(s)
- Samuel Ficenec
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Brittany Gerstein
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | | |
Collapse
|
8
|
Jiao Y, Sun L, Xie X, Liu H, Zhao Y, Ni H, Zhang X. Clinical features and outcomes of calciphylaxis in Chinese patients with chronic kidney disease. Nephrology (Carlton) 2023; 28:305-314. [PMID: 36883928 DOI: 10.1111/nep.14156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 01/15/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023]
Abstract
AIM Calciphylaxis is a rare disease, predominantly in chronic kidney disease (CKD), characterized by high morbidity and mortality. Data from the Chinese population have been an invaluable resource for a better understanding of natural history, optimal treatments and outcomes of calciphylaxis. METHODS A retrospective study was conducted in 51 Chinese patients diagnosed with calciphylaxis at Zhong Da Hospital affiliated to Southeast University from December 2015 to September 2020. RESULTS Between 2015 and 2020, 51 cases of calciphylaxis were registered in The China Calciphylaxis Registry (http://www.calciphylaxis.com.cn), which was developed by Zhong Da Hospital. The mean age of the cohort was 52.02 ± 14.09 years, and 37.3% were female. Forty-three patients (84.3%) were on haemodialysis, with a median dialysis vintage of 88 months. Eighteen patients (35.3%) had a resolution of calciphylaxis and 20 patients (39.2%) died. Patients in later stages had higher overall mortality than those in earlier stages. Delay from skin lesions onset to diagnosis and calciphylaxis-related infections were risk factors in both early and overall mortality. Additionally, dialysis vintage and infections were significant risk factors in calciphylaxis-specific mortality. Among therapeutic strategies, only the use of sodium thiosulfate (STS) ≥3 courses (14 injections) was significantly associated with decreased hazard of death in both early and overall mortality. CONCLUSION For Chinese patients with calciphylaxis, delay from skin lesions onset to diagnosis and infections secondary to wounds are risk factors for the prognosis of patients with calciphylaxis. Additionally, patients in earlier stages have better survival and early continuous use of STS is highly suggested.
Collapse
Affiliation(s)
- Yongyi Jiao
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Li Sun
- Department of Nephrology, Xuyi People's Hospital, Huaian, China
| | - Xiaotong Xie
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Hong Liu
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Yu Zhao
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Haifeng Ni
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Xiaoliang Zhang
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| |
Collapse
|
9
|
Wen W, Portales-Castillo I, Seethapathy R, Krinsky S, Kroshinsky D, Kalim S, Goverman J, Nazarian RM, Chitalia V, Malhotra R, Kramann R, Malhotra CK, Nigwekar SU. Intravenous sodium thiosulphate for vascular calcification of hemodialysis patients-a systematic review and meta-analysis. Nephrol Dial Transplant 2023; 38:733-745. [PMID: 35521751 PMCID: PMC10111152 DOI: 10.1093/ndt/gfac171] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Vascular calcification (VC) is a common comorbidity among patients with chronic kidney disease (CKD), indicating major cardiovascular events. This study aimed to evaluate the effects and safety of intravenous sodium thiosulphate (STS) for VC in CKD patients. METHODS Electronic databases were searched for clinical trials that provided data comparing outcomes among patients treated with and without STS. The PRISMA guidelines were followed. Efficacy was assessed using calcification scores and arterial stiffness. Safety was examined by analyzing adverse symptoms, electrolytes and bone mineral density (BMD). Random-effects models were performed. Meta-regression and sensitivity analysis were done. The risk of bias was assessed using the Cochrane tools. RESULTS Among the 5601 publications, 6 studies involving 305 participants (mean age: 56 years, male: 56.6%) with all participants on maintenance hemodialysis met eligibility criteria. For efficacy, the progression in Agatston scores in the coronary arteries [107 patients, mean difference (MD): -241.27, 95% confidence interval (95% CI): -421.50 to -61.03] and iliac arteries (55 patients, MD: -382.00, 95% CI: -751.07 to -12.93) was lower in the STS treated group compared with controls. The increase in pulse wave velocity was lower in the STS group (104 patients, MD: -1.29 m/s, 95% CI: -2.24 to -0.34 m/s). No association was found between the change in calcification scores and STS regimen. For safety, gastrointestinal symptoms (e.g. nausea) and increased anion gap acidosis were noted. No reduction in BMD by STS was observed. CONCLUSIONS Intravenous STS may attenuate the progression of VC and arterial stiffness in hemodialysis patients. Large and well-designed randomized controlled trials are warranted.
Collapse
Affiliation(s)
- Wen Wen
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.,Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Scott Krinsky
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
| | - Sahir Kalim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeremy Goverman
- Sumner Redstone Burn Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Vipul Chitalia
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA, USA
| | - Rajeev Malhotra
- Cardiovascular Research Center and the Cardiology Division of the Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Rafael Kramann
- Division of Nephrology and Clinical Immunology, Medical Faculty RWTH Aachen University, Aachen, Germany.,Institute of Experimental Medicine and Systems Biology, Medical Faculty RWTH Aachen University, Aachen, Germany.,Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Cindy K Malhotra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
10
|
Wickens O, Rengarajan S, Chinnadurai R, Ford I, Macdougall IC, Kalra PA, Sinha S. The Role of Iron in Calciphylaxis—A Current Review. J Clin Med 2022; 11:jcm11195779. [PMID: 36233647 PMCID: PMC9570530 DOI: 10.3390/jcm11195779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/20/2022] [Accepted: 09/26/2022] [Indexed: 11/25/2022] Open
Abstract
Calcific uraemic arteriolopathy (CUA), also known as calciphylaxis, is a rare and often fatal condition, frequently diagnosed in end-stage renal disease (ESRD) patients. Although exact pathogenesis remains unclear, iron supplementation is suggested as a potential risk factor. Iron and erythropoietin are the main stay of treatment for anaemia in ESRD patients. Few observational studies support the role of iron in the pathogenesis of calciphylaxis although data from the pivotal trial was not strongly supportive of this argument, i.e., no difference in incidence of calciphylaxis between the low-dose and high-dose iron treatment arms. Elevated levels of vascular cell adhesion molecules in association with iron excess were postulated to the pathogenesis of CUA by causing inflammation and calcification within the microvasculature. In-addition, oxidative stress generated because of iron deposition in cases of systemic inflammation, such as those seen in ESRD, may play a role in vascular calcification. Despite these arguments, a direct correlation between cumulative iron exposure with CUA incidence is not clearly demonstrated in the literature. Consequently, we do not have evidence to recommend iron reduction or cessation in ESRD patients that develop CUA.
Collapse
Affiliation(s)
- Olivia Wickens
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
| | - Sharmilee Rengarajan
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
| | - Rajkumar Chinnadurai
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow G12 8QQ, UK
| | - Iain C. Macdougall
- Department of Renal Medicine, King’s College Hospital, London SE5 9RS, UK
| | - Philip A. Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Smeeta Sinha
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
- Correspondence:
| |
Collapse
|
11
|
Zulauf EE, Connors JC, Hardy MA. Manifestation of Nonuremic Calciphylaxis in the Extremities: Case Report and Review. J Foot Ankle Surg 2022; 61:e41-e47. [PMID: 34876341 DOI: 10.1053/j.jfas.2021.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 02/16/2021] [Accepted: 10/12/2021] [Indexed: 02/03/2023]
Abstract
Nonuremic calciphylaxis is a rare condition presenting with peripheral ischemic ulcerations. Calciphylaxis is the deposition of calcium and phosphate into arteriolar walls caused by exceeding their solubility range in the blood. It is most commonly seen in patients with end-stage renal disease; however, nonuremic calciphylaxis occurs in patients with normal or mildly impaired renal function. Risk factors for nonuremic calciphylaxis include Coumadin therapy, obesity, and diabetes mellitus. Histopathologic examination of deep skin biopsy containing subcutaneous adipose tissue reveals medial calcification of dermal and subcutaneous arterioles. This diagnosis must be managed locally with wound care and systemically by control of blood calcium solubility. Avoidance of infection is critical to survival. Here we report a case of calciphylaxis in a patient with normal renal function and serum levels of calcium and phosphorus who presented with gangrene of the extremities. Increased awareness of this debilitating disease will lead to earlier diagnosis, proper treatment and improved patient outcomes.
Collapse
Affiliation(s)
- Emily E Zulauf
- Grant Medical Center Foot & Ankle Surgery Resident, Columbus, OH.
| | - James C Connors
- Kent State University College of Podiatric Medicine, Independence, OH
| | - Mark A Hardy
- Kent State University College of Podiatric Medicine, Independence, OH
| |
Collapse
|
12
|
Liu Y, Yang C, Yang X, Xie X, Liu H, Zhang L, Ye J, Jiang D, Zhang X, Liu B. Prevalence and Clinical Characteristics of Calciphylaxis in Chinese Hemodialysis Patients. Front Med (Lausanne) 2022; 9:902171. [PMID: 35755071 PMCID: PMC9226545 DOI: 10.3389/fmed.2022.902171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background Calciphylaxis is a grievous life-threatening vascular disease that commonly affects dialysis population. This is the first epidemiological survey of calciphylaxis initiated in China. Methods In the cross-sectional survey, a stratified sampling method was used to select 24 dialysis centers in Jiangsu Province. The participants were all adult patients in each center who had been on hemodialysis for more than 6 months. Calciphylaxis patients were uniformly diagnosed based on characteristic skin lesions and histopathological features. Results A total of 3,867 hemodialysis patients (average age of 55.33 ± 13.89 years; 61.81% of males) were included. Forty eight cases were diagnosed with calciphylaxis, and prevalence was 1.24%. Among calciphylaxis patients, 33 cases were male, and the average age and median dialysis duration were 53.85 ± 15.17 years and 84.00 (48.00, 138.75) months, respectively. Skin biopsy was performed in 70.83% of calciphylaxis patients, and positive rate was 64.71%. Meanwhile, the positive rate of bone scintigraphy in the diagnosis of calciphylaxis was 62.5%. The prevalence of hyperparathyroidism in case group was as high as 72.92% with longer duration, and 42.86% had undergone parathyroidectomy. Multivariate analysis indicated that increased BMI, prolonged dialysis duration, warfarin therapy, hyperparathyroidism, diabetes, tumors, low serum albumin and high serum alkaline phosphatase levels were high-risk factors for calciphylaxis. Conclusions The prevalence of calciphylaxis in Chinese hemodialysis patients was 1.24% according to regional epidemiological survey, but its actual prevalence would be presumably far beyond present data. It's urgent to improve clinical understanding of calciphylaxis, and multifaceted diagnostic methods should be applied for early screening.
Collapse
Affiliation(s)
- Yuqiu Liu
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Canlin Yang
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xin Yang
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xiaotong Xie
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Hong Liu
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Liuping Zhang
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jianming Ye
- Department of Nephrology, The First People's Hospital of Kunshan, Suzhou, China
| | - Dongsheng Jiang
- Department of Nephrology, Taizhou People's Hospital, Taizhou, China
| | - Xiaoliang Zhang
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Bicheng Liu
- Institute of Nephrology, Zhong Da Hospital, School of Medicine, Southeast University, Nanjing, China
| |
Collapse
|
13
|
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.
Collapse
|
14
|
Rick J, Strowd L, Pasieka HB, Saardi K, Micheletti R, Zhao M, Kroshinsky D, Shinohara MM, Ortega-Loayza AG. Calciphylaxis: Part I. Diagnosis and pathology. J Am Acad Dermatol 2022; 86:973-982. [PMID: 35114300 DOI: 10.1016/j.jaad.2021.10.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 11/18/2022]
Abstract
Calciphylaxis is an uncommon but devastating disorder characterized by vascular calcification and subsequent cutaneous tissue necrosis. This results in exquisitely painful and slow healing wounds that portend exceptionally high morbidity and mortality. The diagnosis of this condition can be complicated because there are no conclusive serologic, radiographic or visual signs that this disease is manifesting. The differential of tissue necrosis is broad, and identifying calciphylaxis requires an adroit understanding of the risk factors and physical signs that should raise suspicion of this condition. Reviews on this subject are uncommon and lack directed commentary from disease experts on the best diagnostic approach for patients suffering from this disease. The goal of this article is to update practicing dermatologists on the current standard of care for calciphylaxis.
Collapse
Affiliation(s)
- Jonathan Rick
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Lindsay Strowd
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Helena B Pasieka
- Georgetown University School of Medicine, Washington, DC; Uniformed Services University School of Medicine, Bethesda, Maryland
| | - Karl Saardi
- Georgetown University School of Medicine, Washington, DC
| | - Robert Micheletti
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Megan Zhao
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | - Michi M Shinohara
- University of Washington Division of Dermatology, Seattle, Washington
| | | |
Collapse
|
15
|
Win KM, Castelhano R, Dasgupta T. Concurrent development of encapsulating peritoneal sclerosis and calciphylaxis in a patient with peritoneal dialysis for end-stage renal disease. BMJ Case Rep 2022; 15:e245156. [PMID: 35321908 PMCID: PMC8943729 DOI: 10.1136/bcr-2021-245156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 12/29/2022] Open
Abstract
Both encapsulating peritoneal sclerosis (EPS) and calciphylaxis are rare but severe complications involving patients with end-stage renal disease. In this report, we discuss a unique case of a 73-year-old female patient who had undergone 8 years of peritoneal dialysis for IgA nephropathy and concurrently developed these two synchronous complications within 3 months of each other. Diagnosis and management of both conditions were discussed in detail as well as the possible association between the two. With surgical treatment for EPS and measures to minimise bone mineral disorder abnormalities, both complications have been successfully managed to date.
Collapse
Affiliation(s)
- Khine Myat Win
- Trauma and Orthopaedics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rute Castelhano
- Emergency General Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Tanaji Dasgupta
- Swindon Renal Unit, Great Western Hospital Foundation NHS Trust, Swindon, UK
| |
Collapse
|
16
|
Sinha S, Gould LJ, Nigwekar SU, Serena TE, Brandenburg V, Moe SM, Aronoff G, Chatoth DK, Hymes JL, Miller S, Padgett C, Carroll KJ, Perelló J, Gold A, Chertow GM. The CALCIPHYX study: a randomized, double-blind, placebo-controlled, Phase 3 clinical trial of SNF472 for the treatment of calciphylaxis. Clin Kidney J 2022; 15:136-144. [PMID: 35035944 PMCID: PMC8757410 DOI: 10.1093/ckj/sfab117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/14/2021] [Indexed: 12/30/2022] Open
Abstract
Background Calcific uraemic arteriolopathy (CUA; calciphylaxis) is a rare disease seen predominantly in patients receiving dialysis. Calciphylaxis is characterized by poorly healing or non-healing wounds, and is associated with mortality, substantial morbidity related to infection and typically severe pain. In an open-label Phase 2 clinical trial, SNF472, a selective inhibitor of vascular calcification, was well-tolerated and associated with improvement in wound healing, reduction of wound-related pain and improvement in wound-related quality of life (QoL). Those results informed the design of the CALCIPHYX trial, an ongoing, randomized, placebo-controlled, Phase 3 trial of SNF472 for treatment of calciphylaxis. Methods In CALCIPHYX, 66 patients receiving haemodialysis who have an ulcerated calciphylaxis lesion will be randomized 1:1 to double-blind SNF472 (7 mg/kg intravenously) or placebo three times weekly for 12 weeks (Part 1), then receive open-label SNF472 for 12 weeks (Part 2). All patients will receive stable background care, which may include pain medications and sodium thiosulphate, in accordance with the clinical practices of each site. A statistically significant difference between the SNF472 and placebo groups for improvement of either primary endpoint at Week 12 will demonstrate efficacy of SNF472: change in Bates-Jensen Wound Assessment Tool-CUA (a quantitative wound assessment tool for evaluating calciphylaxis lesions) or change in pain visual analogue scale score. Additional endpoints will address wound-related QoL, qualitative changes in wounds, wound size, analgesic use and safety. Conclusions This randomized, placebo-controlled Phase 3 clinical trial will examine the efficacy and safety of SNF472 in patients who have ulcerated calciphylaxis lesions. Patient recruitment is ongoing.
Collapse
Affiliation(s)
- Smeeta Sinha
- Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Lisa J Gould
- South Shore Health Department of Surgery, South Shore Health Center for Wound Healing, Weymouth, MA, USA
| | - Sagar U Nigwekar
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Sharon M Moe
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | - Jeffrey L Hymes
- Global Head of Clinical Affairs, Fresenius Kidney Care, Waltham, MA, USA
| | - Stephan Miller
- Department of Clinical Development, Sanifit Therapeutics, San Diego, CA, USA
| | - Claire Padgett
- Department of Clinical Development, Sanifit Therapeutics, San Diego, CA, USA
| | | | - Joan Perelló
- University Institute of Health Sciences Research (IUNICS- IDISBA), University of the Balearic Islands, Palma, Spain
| | - Alex Gold
- Department of Clinical Development, Sanifit Therapeutics, San Diego, CA, USA
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
17
|
SURGICAL INTERVENTION EFFICACY IN METASTATIC SOFT TISSUE CALCIFICATION AND CALCIPHYLAXIS IN PATIENTS WITH CHRONIC KIDNEY DISEASE. WORLD OF MEDICINE AND BIOLOGY 2022. [DOI: 10.26724/2079-8334-2022-1-79-147-151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
18
|
Zhang L, Zhao Y, Guo Z, Ma J, Ma Y, Yang Z. Does serum calcium level play a practical role in calciphylaxis in hemodialysis patients? Ren Fail 2021; 43:1506-1507. [PMID: 34751597 PMCID: PMC8583828 DOI: 10.1080/0886022x.2021.1999828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Lijing Zhang
- Department of Medicine, Northwest Minzu University, Lanzhou, PR China
| | - Yu Zhao
- Department of Medicine, Northwest Minzu University, Lanzhou, PR China
| | - Zhong Guo
- Department of Medicine, Northwest Minzu University, Lanzhou, PR China
| | - Jianxiu Ma
- Department of Medicine, Northwest Minzu University, Lanzhou, PR China
| | - Yanqing Ma
- Department of Medicine, Northwest Minzu University, Lanzhou, PR China
| | - Zhanli Yang
- Department of Medicine, Northwest Minzu University, Lanzhou, PR China
| |
Collapse
|
19
|
Cases A, Gomez P, Broseta JJ, Perez Bernat E, Arjona Barrionuevo JDD, Portolés JM, Gorriz JL. Non-valvular Atrial Fibrillation in CKD: Role of Vitamin K Antagonists and Direct Oral Anticoagulants. A Narrative Review. Front Med (Lausanne) 2021; 8:654620. [PMID: 34604247 PMCID: PMC8484537 DOI: 10.3389/fmed.2021.654620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in chronic kidney disease (CKD), with a close bidirectional relationship between the two entities. The presence of CKD in AF increases the risk of thromboembolic events, mortality and bleeding. Vitamin K antagonists (VKA) have been the mainstay of treatment for the prevention of thromboembolic events in AF until recently, with confirmed benefits in AF patients with stage 3 CKD. However, the risk-benefit profile of VKA in patients with AF and stages 4-5 CKD is controversial due to the lack of evidence from randomized controlled trials. Treatment with VKA in CKD patients has been associated with conditions such as poorer anticoagulation quality, increased risk of bleeding, faster progression of vascular/valvular calcification and higher risk of calciphylaxis. Direct oral anticoagulants (DOACs) have shown equal or greater efficacy in stroke/systemic embolism prevention, and a better safety profile than VKA in post-hoc analysis of the pivotal randomized controlled trials in patients with non-valvular AF and stage 3 CKD, yet evidence of its risk-benefit profile in more advanced stages of CKD is scarce. Observational studies associate DOACs with a good safety/effectiveness profile compared to VKA in non-dialysis CKD patients. Further, DOACs have been associated with a lower risk of acute kidney injury and CKD development/progression than VKA. This narrative review summarizes the evidence of the efficacy and safety of warfarin and DOACs in patients with AF at different CKD stages, as well as their effects on renal function, vascular/valvular calcification and bone health.
Collapse
Affiliation(s)
- Aleix Cases
- Departament de Medicina, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Pablo Gomez
- Unidad de Factores de Riesgo Vascular, Servicio de Nefrología, Hospital Universitario de Jerez, Jerez de la Frontera, Spain
| | | | | | | | | | - Jose Luis Gorriz
- Departament de Medicina, Universitat de Valencia, Valencia, Spain
- Hospital Clínico Universitario de Valencia, Valencia, Spain
- Instituto de Investigación del Hospital Clinico Universitario, Valencia (INCLIVA), Valencia, Spain
| |
Collapse
|
20
|
Sánchez-Pujol M, Docampo Simón A, Illán Gambín F, Niveiro de Jaime M, Blanes Martínez M. Calciphylaxis: Risk Factors and Histologic Findings in a Case Series From a Tertiary Care Referral Hospital. ACTAS DERMO-SIFILIOGRAFICAS 2021. [DOI: 10.1016/j.adengl.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
21
|
Palomares-Casasús S, Pérez-Santiago L, Martí-Fernández R, Giménez-Civera E, Mata-Cano D, García-Botello S. Long-term leg ulcers resistant to antibiotic therapy. Clin Exp Dermatol 2021; 46:1150-1153. [PMID: 34120360 DOI: 10.1111/ced.14717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/20/2021] [Accepted: 04/26/2021] [Indexed: 11/26/2022]
Affiliation(s)
- S Palomares-Casasús
- Department of General and Digestive Surgery, Hospital Clínico Universitario, Valencia, Spain
| | - L Pérez-Santiago
- Department of General and Digestive Surgery, Hospital Clínico Universitario, Valencia, Spain
| | - R Martí-Fernández
- Department of General and Digestive Surgery, Hospital Clínico Universitario, Valencia, Spain
| | - E Giménez-Civera
- Departments of, Department of, Nephrology, Hospital Clínico Universitario, Valencia, Spain
| | - D Mata-Cano
- Department of, Pathology, Hospital Clínico Universitario, Valencia, Spain
| | - S García-Botello
- Department of General and Digestive Surgery, Hospital Clínico Universitario, Valencia, Spain
| |
Collapse
|
22
|
Sánchez-Pujol MJ, Docampo Simón A, Illán Gambín F, Niveiro de Jaime M, Blanes Martínez M. Calciphylaxis: Risk Factors and Histologic Findings in a Case Series From a Tertiary Care Referral Hospital. ACTAS DERMO-SIFILIOGRAFICAS 2021; 112:S0001-7310(21)00164-2. [PMID: 33939992 DOI: 10.1016/j.ad.2020.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/19/2020] [Accepted: 08/22/2020] [Indexed: 11/29/2022] Open
Abstract
Recent years have seen important advances in our understanding of calciphylaxis, especially regarding newly identified risk factors and histologic findings that may aid diagnosis. This retrospective study of cases of calciphylaxis treated in our hospital in the last 13 years focuses on newly revealed aspects of this disease. We describe 16 patients (62.5% women; mean age, 67.9 years). In addition to advanced kidney disease (in 75% of our patients), other factors associated with the presence of calciphylaxis were a history of treatments related to phosphorus and calcium metabolism (75%) and anticoagulation (62.5%), usually with vitamin-K antagonists. Histology showed alterations in elastic fibers in only 25% of the biopsy specimens. Eleven of the patients died: sepsis was most often the cause.
Collapse
Affiliation(s)
- M J Sánchez-Pujol
- Servicio de Dermatología, Hospital General Universitario de Alicante. Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España.
| | - A Docampo Simón
- Servicio de Dermatología, Hospital General Universitario de Alicante. Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
| | - F Illán Gambín
- Servicio de Anatomía Patológica, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
| | - M Niveiro de Jaime
- Servicio de Anatomía Patológica, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
| | - M Blanes Martínez
- Servicio de Dermatología, Hospital General Universitario de Alicante. Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
| |
Collapse
|
23
|
Development of the BWAT-CUA Scale to Assess Wounds in Patients with Calciphylaxis. Diagnostics (Basel) 2021; 11:diagnostics11040730. [PMID: 33924020 PMCID: PMC8073812 DOI: 10.3390/diagnostics11040730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/09/2021] [Accepted: 04/11/2021] [Indexed: 11/26/2022] Open
Abstract
Calcific uremic arteriolopathy (CUA; calciphylaxis) is a severe form of vascular calcification with no approved therapies. A standardized wound assessment tool is needed to evaluate changes in calciphylaxis wounds over time. A prospective, single-arm study of 14 patients with calciphylaxis reported improvement for the primary endpoint of wound healing using the 13-item Bates-Jensen Wound Assessment Tool (BWAT), although that tool was developed for assessment of pressure ulcers. This report describes development of BWAT-CUA, an 8-item modification of BWAT focusing on prototypical features of calciphylaxis lesions. The BWAT-CUA has a range of 8 (best) to 40 (worst) and was used ad hoc to analyze BWAT data collected in the prospective study. Using BWAT-CUA, relative improvement in calciphylaxis wounds was 30% overall (from 21.2 to 14.9; p = 0.0016) and 34% in the subset of 12 patients with ulceration at baseline (from 23.3 to 15.3; p = 0.0002). BWAT-CUA is a primary endpoint in an ongoing randomized, placebo-controlled phase 3 study of SNF472 recruiting patients with end-stage kidney disease and at least one ulcerated calciphylaxis lesion. BWAT-CUA, a newly developed tool for assessment of calciphylaxis wound severity and improvements over time, may be used in clinical research and in clinical practice.
Collapse
|
24
|
Liu Y, Zhang X, Xie X, Yang X, Liu H, Tang R, Liu B. Risk factors for calciphylaxis in Chinese hemodialysis patients: a matched case-control study. Ren Fail 2021; 43:406-416. [PMID: 33641601 PMCID: PMC7927988 DOI: 10.1080/0886022x.2021.1884094] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Introduction Calciphylaxis is a rare but potentially fatal disease commonly occurred in dialysis patients. Despite some previous studies on risk factors for calciphylaxis, there is still a lack of data from Chinese population. Methods The retrospective matched case–control study about calciphylaxis was performed in Zhongda Hospital affiliated to Southeast University. The case group involved 20 hemodialysis patients who were newly diagnosed with calciphylaxis from October 2017 to December 2018. The 40 noncalciphylaxis patients undergoing dialysis with the same age and duration of dialysis were randomly selected as controls. Results Most of calciphylaxis patients were male and elderly, while overweight people were more susceptible to the disease. Although incidence of secondary hyperparathyroidism was higher in calciphylaxis patients, the differences in duration of elevated serum intact parathyroid hormone (iPTH) and its highest value did not reach statistical significance compared with controls. No significant difference in warfarin therapy was discernible between two groups. The univariate regression analysis indicated that male, score of use of activated vitamin D and its analogues, corrected serum calcium level, serum phosphate, Ca × P product, iPTH, albumin, and alkaline phosphatase (ALP) level were significantly associated with calciphylaxis. Elevated levels of serum phosphate (OR 4.584, p = 0.027) and ALP (OR 1.179, p = 0.036), decreased level of serum albumin (OR 1.330, p = 0.013) were independent risk factors after multivariate analysis. Conclusion This is the first report of risk factors associated with calciphylaxis in China. Increased levels of serum phosphate and ALP, decreased level of serum albumin were vital high-risk factors for calciphylaxis in Chinese hemodialysis population.
Collapse
Affiliation(s)
- Yuqiu Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Xiaoliang Zhang
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Xiaotong Xie
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Xin Yang
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Hong Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Rining Tang
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Bicheng Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| |
Collapse
|
25
|
Calciphylaxis in end-stage kidney disease: outcome data from the United Kingdom Calciphylaxis Study. J Nephrol 2021; 34:1537-1545. [PMID: 33548054 PMCID: PMC8494680 DOI: 10.1007/s40620-020-00908-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 11/10/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND AIMS Calciphylaxis is a rare condition associated with very high mortality in patients with end-stage kidney disease. Data from country-based registries have been an invaluable resource for a better understanding of the natural history and management for this condition. This study aimed to investigate the current management strategies and outcomes of patients enrolled in the United Kingdom Calciphylaxis study (UKCS). METHODS The study was conducted on 89 patients registered in the UKCS since 2012. The initial analysis included a description of the baseline characteristics, management strategies and outcomes on follow-up until May 2020. Further analysis included a comparison of the mortality outcome of the UKCS patients who were receiving haemodialysis with a propensity score matched cohort of haemodialysis patients from the Chronic Renal Insufficiency Standards Implementation Study- Haemodialysis (CRISIS-HD). RESULTS Median age of the cohort was 59 years, with a predominance of females (61%) and Caucasian (95%) ethnicity. About 54% of the patients were diabetic and 70% were receiving haemodialysis at study entry. The skin lesions were mostly distributed in the lower extremities (48%). Sodium thiosulphate and calcimimetic were the most widely used management strategies. The mortality rate was 72 deaths per hundred patient-years (50 deaths observed in 69.5 patient years). Complete wound healing was noted in 17% and bacteraemia was reported in 26% of patients. In a comparative analysis of the matched haemodialysis patients, the presence of calciphylaxis in 62 patients showed a strong association with all-cause mortality (HR 6.96; p < 0.001), with annual mortality 67% versus 10.2% in haemodialysis patients without calciphylaxis. CONCLUSIONS This UK wide study strengthens the evidence that calciphylaxis is a strong and independent risk factor associated with all-cause mortality; no significant benefit was shown with any individual treatment modality. Until further evidence becomes available, a multifaceted approach would be the appropriate treatment strategy in the management of this extremely serious condition.
Collapse
|
26
|
Abstract
Inorganic phosphate is a vital constituent of cells and cell membranes, body fluids, and hard tissues. It is a major intracellular divalent anion, participates in many genetic, energy and intermediary metabolic pathways, and is important for bone health. Although we usually think of phosphate mostly in terms of its level in the serum, it is needed for many biological and structural functions of the body. Availability of adequate calcium and inorganic phosphate in the right proportions at the right place is essential for proper acquisition, biomineralization, and maintenance of mass and strength of the skeleton. The three specialized mineralized tissues, bones, teeth, and ossicles, differ from all other tissues in the human body because of their unique ability to mineralize, and the degree and process of mineralization in these tissues also differ to suit the specific functions: locomotion, chewing, and hearing, respectively. Biomineralization is a dynamic, complex, and lifelong process by which precipitations of inorganic calcium and inorganic phosphate divalent ions form biological hard tissues. Understanding the biomineralization process is important for the management of diseases caused by both defective and abnormal mineralization. Hypophosphatemia results in mineralization defects and osteomalacia, and hyperphosphatemia is implicated in abnormal excess calcification and/or ossification, but the exact mechanisms underlying these processes are not fully understood. In this review, we summarize available evidence on the role of phosphate in biomineralization. Other manuscripts in this issue of the journal deal with other relevant aspects of phosphate homeostasis, phosphate signaling and sensing, and disorders resulting from hypo- and hyperphosphatemic states.
Collapse
Affiliation(s)
| | - Sudhaker D Rao
- Division of Endocrinology, Diabetes, and Bone & Mineral Disorders, Henry Ford Hospital, New Center One; Suite # 800, Detroit, MI, 48202, USA.
- Bone & Mineral Research Laboratory, Henry Ford Hospital, Detroit, MI, USA.
| |
Collapse
|
27
|
Calciphylaxis: Diagnostic and Treatment Advances for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00316-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|