Calciphylaxis and its diagnosis: A review

Advanced Calciphylaxis in a Patient With End-Stage Renal Disease: A Case Report Highlighting Diagnostic and Therapeutic Challenges in Late-Stage Presentation

Calciphylaxis, also known as calcific uremic arteriolopathy, is a rapidly progressive, rare, and severe condition characterized by vascular calcification and skin necrosis. The pathophysiology involves cutaneous arteriolar calcification followed by subsequent tissue ischemia and infarction, which eventually causes extremely painful skin lesions. The condition is associated with substantial morbidity due to severe pain, non-healing wounds, increased susceptibility to infections, and frequent hospitalizations. Calciphylaxis is a highly fatal condition with one-year mortality rates greater than 50%, most frequently due to sepsis. This report presents a case of a 63-year-old male with end-stage kidney disease (ESKD) who presented with altered mental status and was found to have notable necrotic skin ulcers on the bilateral anterior thighs, a stage IV sacral decubitus ulcer, and necrotic lesions on the scrotum and penis. This case underscores the importance of maintaining a high clinical suspicion for rare conditions like calciphylaxis in patients with multiple risk factors. Diagnosing the disease earlier in its course may improve outcomes and overall prognosis. Unfortunately, in this case, the patient presented too late into the disease course, and ultimately discussions/placement with palliative care were undertaken.

Inhibition of Vascular Smooth Muscle Cell Proliferation by ENPP1: The Role of CD73 and the Adenosine Signaling Axis

The Ectonucleotide Pyrophosphatase/Phosphodiesterase 1 (ENPP1) ectoenzyme regulates vascular intimal proliferation and mineralization of bone and soft tissues. ENPP1 variants cause Generalized Arterial Calcification of Infancy (GACI), a rare genetic disorder characterized by ectopic calcification, intimal proliferation, and stenosis of large- and medium-sized arteries. ENPP1 hydrolyzes extracellular ATP to pyrophosphate (PPi) and AMP. AMP is the precursor of adenosine, which has been implicated in the control of neointimal formation. Herein, we demonstrate that an ENPP1-Fc recombinant therapeutic inhibits proliferation of vascular smooth muscle cells (VSMCs) in vitro and in vivo. Addition of ENPP1 and ATP to cultured VSMCs generated AMP, which was metabolized to adenosine. It also significantly decreased cell proliferation. AMP or adenosine alone inhibited VSMC growth. Inhibition of ecto-5'-nucleotidase CD73 decreased adenosine accumulation and suppressed the anti-proliferative effects of ENPP1/ATP. Addition of AMP increased cAMP synthesis and phosphorylation of VASP at Ser157. This AMP-mediated cAMP increase was abrogated by CD73 inhibitors or by A2aR and A2bR antagonists. Ligation of the carotid artery promoted neointimal hyperplasia in wild-type mice, which was exacerbated in ENPP1-deficient ttw/ttw mice. Prophylactic or therapeutic treatments with ENPP1 significantly reduced intimal hyperplasia not only in ttw/ttw but also in wild-type mice. These findings provide the first insight into the mechanism of the anti-proliferative effect of ENPP1 and broaden its potential therapeutic applications beyond enzyme replacement therapy.

Off the wall: incidental paraspinal and pelvic muscle pathology on abdominopelvic imaging

As the use of cross-sectional abdominal and pelvic imaging has increased exponentially in the past several decades, incidental musculoskeletal findings have become commonplace. These are often unrelated to the indication for the examination and are frequently referred to as the "radiologist's blind spot" on these studies. The differential diagnosis for abnormalities of the paraspinal and pelvic musculature is, in many cases, quite different from the anterior abdominal wall muscles. Furthermore, due to their relatively deep location, pathology involving the former muscle groups is more likely to be clinically occult, often presenting only incidentally when the patient undergoes cross-sectional imaging. Effective treatment of diseases of these muscles is dependent on adherence to a diverse set of diagnostic and treatment algorithms. The purpose of this review article is to familiarize the radiologist with the unique pathology of these often-overlooked muscles of the abdomen and pelvis.

Potential Role of Bone Scintigraphy in the Diagnosis of Calciphylaxis

Nonosseous abnormalities are often seen on bone scans and can be related to a wide variety of pathology ranging across vascular, infection, and inflammatory etiology. Diffuse soft tissue radiotracer uptake on bone scans is typically attributed to renal or metabolic derangements. Calciphylaxis is the deposition of calcium in small blood vessels, skin, and other organs leading to vascular obstruction and skin necrosis. It is a rare disorder with unknown pathophysiology. Diagnosis of calciphylaxis is challenging and requires an interdisciplinary approach including clinical findings, laboratory results, medical imaging, and skin biopsy. An early diagnosis is important as the disease is associated with high morbidity and mortality. The purpose of this review article is to highlight the role of bone scintigraphy in the evaluation of calciphylaxis and to correlate the findings with other imaging modalities and histopathology.

Mechanisms of Cardiovascular Calcification and Experimental Models: Impact of Vitamin K Antagonists

Cardiovascular calcification is a multifactorial and complex process involving an array of molecular mechanisms eventually leading to calcium deposition within the arterial walls. This process increases arterial stiffness, decreases elasticity, influences shear stress events and is related to an increased risk of morbidity and mortality associated with cardiovascular disease. In numerous in vivo and in vitro models, warfarin therapy has been shown to cause vascular calcification in the arterial wall. However, the exact mechanisms of calcification formation with warfarin remain largely unknown, although several molecular pathways have been identified. Circulating miRNA have been evaluated as biomarkers for a wide range of cardiovascular diseases, but their exact role in cardiovascular calcification is limited. This review aims to describe the current state-of-the-art research on the impact of warfarin treatment on the development of vascular calcification and to highlight potential molecular targets, including microRNA, within the implicated pathways.

A Peculiar Presentation of a Debilitating Condition: Calciphylaxis

Calciphylaxis is a debilitating condition associated with significant morbidity and mortality, often associated with patients with end-stage renal disease, in which the calcification of cutaneous arterioles and small arteries occurs, leading to subsequent ischemia and cutaneous infarction. Herein, we report the case of a diabetic patient with end-stage kidney disease on dialysis, presenting multiple intensely painful necrotic plaques on the lower extremities. The suspicion of calciphylaxis was raised based on the patient's medical history and clinical presentation, subsequently confirmed by radiological examination, which revealed calcifications along vascular pathways. Diagnosis can be established based on clinical and paraclinical grounds alone, and some clinicians may forego skin biopsy and initiate treatment presumptively. The management of calciphylaxis remains a challenge and requires a multidisciplinary approach since most patients experience intense pain that is often unresponsive to conventional analgesics, leading to a reduced quality of life.

Effects of sodium thiosulfate on serum calcification factors in patients undergoing maintenance hemodialysis

OBJECTIVE

To investigate the effect of sodium thiosulfate (STS) on serum calcification factors in patients undergoing maintenance hemodialysis.

METHODS

Forty-four Patients were randomly divided into control group (n = 22) and observation group (n = 22) by envelope method (block 4 randomization). The control group received routine treatment while observation group was treated with STS on the basis of routine treatment. The biochemical indicators, including BUN, UA, SCr, Ca2+ , P3- , calcium-phosphorus product, PTH, hs-CRP, TG, TC, HDL, LDL, and serum calcification factor MGP, FA, FGF-23, and OPG levels were compared before and after treatment.

RESULTS

Control group had no statistically significant difference in the levels of vascular calcification factors MGP, FA, FGF-23, and OPG before and after treatment (p > 0.05). Whereas observation group had higher levels of MGP and FA, and lower levels of FGF-23 and OPG after treatment than before treatment (p < 0.05). The levels of MGP and FA in observation group were higher than those in control group, and FGF-23 and OPG were lower than those in control group (p < 0.05).

CONCLUSION

It is speculated that sodium thiosulfate can alleviate the progression of vascular calcification by changing the levels of calcification factors.

A Rare Case of Post-parathyroidectomy Calciphylaxis in a Young Patient With End-Stage Renal Disease: A Case Report and Literature Review

Calciphylaxis is a serious complication in chronic kidney disease (CKD) patients and requires a multidisciplinary approach. Dialysis patients are the most affected, especially those who are obese and diabetic, have liver diseases and autoimmune diseases, or are on systemic glucocorticoids. Parathyroidectomy (PTx) is curative for secondary hyperparathyroidism (SHPT) and calciphylaxis in most cases. Calciphylaxis after parathyroidectomy is a rare presentation. We present a case of a young patient who developed calciphylaxis after parathyroidectomy, an uncommon presentation.

Penile calciphylaxis in a patient with concurrent haemodialysis and Coumadin treatment

A man in his 30s, with a medical history of end-stage renal disease on haemodialysis three times a week after kidney transplant rejection, anaemia of inflammatory disease, hypertension, atrial fibrillation, hyperlipidaemia, subtotal parathyroidectomy and aortic valve replacement on Coumadin treatment, presented to our institution with glans penis pain. Examination of the penis revealed a painful black eschar with ulceration on the glans penis with surrounding erythema. CT scan of the abdomen and pelvis and penile Doppler ultrasound revealed calcifications of the abdominal, pelvic and penile blood vessels. He was diagnosed with penile calciphylaxis, a very rare manifestation of calciphylaxis characterised by penile blood vessel calcification leading to occlusion, ischaemia and necrosis. Treatment with low calcium dialysate and sodium thiosulfate was initiated with haemodialysis. Five days after the treatment started, the patient's symptoms improved.

Skin lesions in a man with end-stage renal disease

ABSTRACT

Calciphylaxis is an uncommon condition most often seen in patients with end-stage renal disease. It is easily mistaken for other more common conditions and requires a high level of suspicion to make a timely diagnosis. Although various treatments such as IV sodium thiosulfate and bisphosphonates have been used for management, calciphylaxis remains a condition with a high mortality that requires an interdisciplinary approach for optimal management.

Calcific uraemic arteriolopathy presenting as cellulitis of the dorsal foot

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.

Calciphylaxis in a Patient With Lupus Nephritis and Acute Kidney Injury: A Rare Case Report and Literature Review

Calciphylaxis is a rare and severe disease characterized by calcification, fibrosis, and thrombosis of small blood vessels. Although it primarily affects patients with end-stage renal disease (ESRD) on dialysis, limited cases have been reported of calciphylaxis in patients with acute kidney injury (AKI) and lupus. This case report describes the occurrence of calciphylaxis in a 35-year-old female recently diagnosed with lupus nephritis class IV and AKI requiring dialysis.

Chronic wounds

Chronic wounds are characterized by their inability to heal within an expected time frame and have emerged as an increasingly important clinical problem over the past several decades, owing to their increasing incidence and greater recognition of associated morbidity and socio-economic burden. Even up to a few years ago, the management of chronic wounds relied on standards of care that were outdated. However, the approach to these chronic conditions has improved, with better prevention, diagnosis and treatment. Such improvements are due to major advances in understanding of cellular and molecular aspects of basic science, in innovative and technological breakthroughs in treatment modalities from biomedical engineering, and in our ability to conduct well-controlled and reliable clinical research. The evidence-based approaches resulting from these advances have become the new standard of care. At the same time, these improvements are tempered by the recognition that persistent gaps exist in scientific knowledge of impaired healing and the ability of clinicians to reduce morbidity, loss of limb and mortality. Therefore, taking stock of what is known and what is needed to improve understanding of chronic wounds and their associated failure to heal is crucial to ensuring better treatments and outcomes.

The Impact of Atorvastatin on RANKL Expression in Rats during the Retention Stage after Orthodontic Tooth Movement

Objective

To probe into the impact of atorvastatin on RANKL expression in rats during the retention stage after orthodontic tooth movement and its associated molecular mechanisms.

Methods

After establishing an orthodontic tooth movement model, the left teeth of the retention-stage rats were the maintained side, and the right teeth were the nonmaintained side, which were given physiological saline or atorvastatin dosing at 7d, 14d, and 21d, respectively, by tube feeding, in order to keep the rats as a control group at the beginning of the retention stage. A model of the rat's upper jaw gypsum in each group was made at various time points to measure the distance at which the teeth relapsed. The pathological slices of the upper jaw arch were taken separately for TRAP staining observation.

Results

Compared to the physiological saline group, the recurrence distance of rats in the atorvastatin group was visually lower (p < 0.05), and the number of bone-breaking cells was signally lower (p < 0.05); P-5b, PTH, VitD3, GC, IL-1, and IL-17 expressions (p < 0.05) were visually decreased, while IL-11 expression was elevated (p < 0.05).

Conclusion

The atorvastatin given to rats during the retention stage after orthodontic tooth movement inhibits RANKL expression and may function through OPG/RANKL/RANK system.

Calciphylaxis in End-Stage Renal Disease: A Rare Condition With High Mortality

Calciphylaxis is a rare but life-threatening condition, seen in patients with end-stage renal disease (ESRD) on renal replacement therapy. Its pathogenesis is not completely known, but microvascular calcification and thrombosis are considered the likely processes. It is characterized by significant morbidity due to severe pain and nonhealing wounds with frequent hospitalizations. Sepsis is the most common cause of mortality with more than 50% of patients dying within the first year after diagnosis. Optimal management requires a multidisciplinary approach. We describe a case of a 66-year-old female with ESRD on hemodialysis (HD) who presented with severe progressive calciphylaxis wounds on both lower extremities and died within two months after diagnosis. She had multiple admissions in the past for cellulitis when she presented with swelling in the legs and chronic wounds. Our goal is to increase awareness among physicians to include calciphylaxis in their differential diagnosis when treating ESRD patients with significant risk factors to detect it early and prevent morbidity and mortality.

Retinal artery and vein occlusion in calciphylaxis

Purpose

To report a case of branch retinal artery occlusion (BRAO) followed by branch retinal vein occlusion (BRVO) and paracentral acute middle maculopathy (PAMM) in a patient with confirmed calciphylaxis.

Observations

A 52-year-old female with a history of BRAO in the right eye one-year prior presented with decreased vision and a new inferotemporal scotoma. Computed tomography angiography of the head and neck demonstrated vascular calcifications at the origin of both ophthalmic arteries, which were otherwise poorly visualized. Ophthalmic examination demonstrated retinal whitening superiorly with intraretinal hemorrhages inferiorly. Optical coherence tomography (OCT) demonstrated middle retinal hyperreflectivity and a mild epiretinal membrane. Fluorescein angiography (FFA) demonstrated delayed perfusion of superior retinal arcade. On further questioning, patient was found to have a history of IgA nephropathy with end-stage renal disease, secondary hyperparathyroidism and calciphylaxis. Calciphylaxis is a systemic disease, characterized by high levels of calcium and progressive calcification of the vascular medial layer leading to ischemia. Anterior ischemic optic neuropathy (AION) and crystalline retinopathy have been reported as ocular manifestations of calciphylaxis, however, there are very few reports on ophthalmic manifestations of calciphylaxis.

Conclusion and importance

Clinical manifestations of calciphylaxis are variable and a detailed clinical history is important to suspect calciphylaxis. Calciphylaxis should be considered in the differential diagnosis of BRAO, BRVO, PAMM or any ophthalmic vascular manifestation in patients with end-stage renal disease.

Case Report: Idiopathic Subcutaneous Thrombotic Vasculopathy

Lower extremity ulcers have significant morbidity, with treatment determined by the underlying disorder. Reported is a 32-year-old female presenting with small skin nodules and bruises across her legs 4 weeks following her second COVID vaccination. These lesions progressed into large, necrotic ulcers over several months. Initial work-up showed widespread pannicular thrombotic vasculopathy with ischemic skin necrosis. The tissue was negative for calcification on Von Kossa histochemistry, and a working diagnosis of subcutaneous thrombotic vasculopathy was suggested. The ulcers progressed despite treatments with corticosteroids, therapeutic anticoagulation, intravenous immunoglobulin, plasmapheresis, sodium thiosulfate, wound care, and repeat debridement. Later debridement specimens demonstrated rare vascular and pannicular calcifications. This finding supports the hypothesis that subcutaneous thrombotic vasculopathy is a precursor to calciphylaxis, the patient’s current working diagnosis. However, based on the patient’s entire clinical picture, a definitive diagnosis has yet to be found. This report highlights the challenges of working with rare diseases and the importance of multidisciplinary cooperation.

Clinical mimickers of calciphylaxis: A retrospective study

BACKGROUND

Calciphylaxis is an ischemic vasculopathy with high morbidity and mortality. Early and accurate diagnosis is critical to management of calciphylaxis. Clinical mimickers may contribute to delayed or misdiagnosis.

OBJECTIVE

To assess the rate and risk factors for misdiagnosis and to identify clinical mimickers of calciphylaxis.

METHODS

A retrospective medical record review was conducted of patients with calciphylaxis at a large urban tertiary care hospital between 2006 and 2018.

RESULTS

Of 119 patients diagnosed with calciphylaxis, 73.1% were initially misdiagnosed. Of patients not initially misdiagnosed, median time to diagnosis from initial presentation was 4.5 days (interquartile range, 1.0-23.3), compared to 33 days (interquartile range, 13.0-68.8) in patients who were initially misdiagnosed (P = .0002). The most common misdiagnoses were cellulitis (31.0%), unspecified skin infection (8.0%), and peripheral vascular disease (6.9%). Patients who were misdiagnosed frequently received at least 1 course of antibiotics. Patients with end-stage renal disease were less likely to be misdiagnosed than those without this disease (P = .001).

LIMITATIONS

Single-center, retrospective study.

CONCLUSIONS

Understanding the risk factors for misdiagnosis of calciphylaxis is an opportunity for further education concerning this rare disease.

Nonuremic Calciphylaxis Associated With Hypercalcemia and Rheumatologic Diseases

Calcific uremic arteriolopathy, termed calciphylaxis, was previously considered a condition that developed mostly in patients requiring dialysis. It has now been described in kidney transplant patients, in advanced chronic kidney disease (CKD) patients not requiring dialysis, and in individuals with maintained kidney function. We describe an individual with CKD stage 3b with hypercalcemia who presented with features highly specific for calciphylaxis based on results of a skin biopsy. The condition has high morbidity and mortality, and thus prompts immediate cessation of the offending agents or treatment of the cause. The following case and literature review demonstrates a need for a detailed assessment of patients’ risks and exposures and expanding the differential diagnosis to include calciphylaxis in nonuremic patients with necrotic ulcers with a plan for early imaging and possible biopsy.

Isolated Penile Calciphylaxis Diagnosed by Ultrasound Imaging in a New Dialysis Patient: A Case Report

RATIONALE

The recognition of calciphylaxis often eludes practitioners because of its multiple ambiguous presentations. It classically targets areas of the body dense with adipose tissue. A heightened suspicion for the disorder is therefore required in the case of penile calciphylaxis, given its unconventional location. The diagnosis of calciphylaxis is also challenging as the gold standard for diagnosis is biopsy which can often yield equivocal results. Unfortunately, in penile calciphylaxis, the utility of biopsies is further debated due to their potential to precipitate new lesions and their decreased sensitivity due to the limited depth of tissue that can be sampled. For these reasons, it is important that practitioners recognize other accessible and accurate investigative tools which can aid in their diagnosis.

PRESENTING CONCERNS OF THE PATIENT

We present the case of a 49-year-old man who presented to the emergency room with penile pain in the context of known chronic kidney disease secondary to diabetic nephropathy. The pain had been present for about a week, was exquisitely tender, and was initially associated with a faint violaceous lesion. This gentleman had just recently initiated peritoneal dialysis and had no other lesions on his body.

DIAGNOSIS

His pain was determined by ultrasound and plain radiograph to be secondary to calciphylaxis after two biopsies were nondiagnostic.

INTERVENTIONS

The patient had already made changes to his diet to reduce phosphate and calcium intake, and had been on phosphate-lowering therapy with both calcium and phosphate being within their respective target range. Following his diagnosis, this patient was promptly converted from peritoneal dialysis to hemodialysis with sodium thiosulphate and initiated hyperbaric oxygen therapy. This patient continues to be followed by nephrology and urology specialists.

Calciphylaxis - Case Report

Introduction

Calciphylaxis is a rare, but serious, kidney complication. Calciphylaxia is a vasculopathy of small blood vessels characterized by the deposition of calcium deposits in intimal arterioles with the consequent proliferation of intima, fibrosis and thrombosis.

Aim

The aim was to show the significance of recognition of calciphylaxis relies on heightened clinical awareness of the presence of atypical skin nodules or ulcers that occur in patients with hemodialysis dependence and to characterize features of calciphylaxis or components of treatment that may lead to improved outcome.

Case report

We present the case of 84-year-old woman with chronic kidney disease and diabetes mellitus as well as severely painful, firm, indurated plaques on the lower extremities. The plaques progressed to involve larger areas with associated local ulceration and necrosis. Laboratory testing revealed hyperparathyroidism and incisional skin biopsy confirmed calciphylaxis. Wound microbiology confirmed Staphylococcus aureus.

Conclusion

The diagnosis can be based on clinical grounds, supported by histological analysis if possible. The laboratory workout must cover all the possible implications of chronic kidney disease with special attention to Ca+ and P+ values and evidence of skin or systemic infection. Calciphylaxis must be known by dermatologist as early diagnosis and proper management can be decisive for better prognosis.

Warfarin-Induced Calciphylaxis in a COVID-19 Patient

Calciphylaxis is a rare but highly fatal vascular calcification disorder with a predilection for patients with end stage renal disease (ESRD). The pathogenesis of calciphylaxis is unknown, however, several risk factors have been identified such as hypercalcemia, hyperphosphatemia, hyperparathyroidism, low serum albumin, and history of warfarin therapy. This article presents a case of calciphylaxis induced by warfarin in a COVID-19 patient.

Vascular Calcification-New Insights Into Its Mechanism

Vascular calcification (VC), which is categorized by intimal and medial calcification, depending on the site(s) involved within the vessel, is closely related to cardiovascular disease. Specifically, medial calcification is prevalent in certain medical situations, including chronic kidney disease and diabetes. The past few decades have seen extensive research into VC, revealing that the mechanism of VC is not merely a consequence of a high-phosphorous and -calcium milieu, but also occurs via delicate and well-organized biologic processes, including an imbalance between osteochondrogenic signaling and anticalcific events. In addition to traditionally established osteogenic signaling, dysfunctional calcium homeostasis is prerequisite in the development of VC. Moreover, loss of defensive mechanisms, by microorganelle dysfunction, including hyper-fragmented mitochondria, mitochondrial oxidative stress, defective autophagy or mitophagy, and endoplasmic reticulum (ER) stress, may all contribute to VC. To facilitate the understanding of vascular calcification, across any number of bioscientific disciplines, we provide this review of a detailed updated molecular mechanism of VC. This encompasses a vascular smooth muscle phenotypic of osteogenic differentiation, and multiple signaling pathways of VC induction, including the roles of inflammation and cellular microorganelle genesis.

Concomitant calciphylaxis and COVID-19 associated thrombotic retiform purpura

While initial reports regarding coronavirus disease 2019 (COVID-19) focused on its pulmonary manifestations, more recent literature describes multisystem abnormalities related to its associated microvascular angiopathy. Calciphylaxis is a rare systemic condition characterized by tissue necrosis in the setting of systemic microvascular calcifications. Both COVID-19 and calciphylaxis are procoagulant diagnoses associated with vascular-mediated cutaneous findings. To our knowledge, this is the first report to document the coexistence of COVID-19 associated retiform thrombotic purpura and calciphylaxis in a single patient, to link the pathologic etiologies of the two entities, and to describe the concomitant diagnoses' associated radiologic findings.