Calciphylaxis: diagnosis and clinical features

Calciphylaxis following liver transplantation in a patient with end-stage renal disease: A case report

BACKGROUND

Calciphylaxis, also called calcific uremic arteriolopathy, is characterized by microvascular calcification and occlusion, which is commonly seen in patients with end-stage renal disease (ESRD). Although several studies have demonstrated an association of calciphylaxis with ESRD, reports linking calciphylaxis to LT (LT) are scarce. This report presents a rare case of calciphylaxis in a patient who underwent LT, leading to microvascular occlusion and hyperbilirubinemia.

CASE SUMMARY

A 34-year-old man presented with a 7-day history of jaundice and severe bilateral leg pain. The patient had undergone LT and was put on hemodialysis for one year due to calcineurin inhibitor-induced ESRD. Physical examination revealed jaundice, leathery skin changes, severe muscle pain in both legs, and penile induration. Laboratory tests identified elevated bilirubin levels, gamma-glutamyltransferase, and alkaline phosphatase, while alanine aminotransferase and aspartate aminotransferase concentrations were within normal limits. Computed tomography (CT) revealed extensive calcifications in the subcutaneous tissue. Three-dimensional CT reconstruction indicated significantly reduced blood flow in the hepatic artery, primarily in the small to medium-sized branches. Contrast-enhanced ultrasonography confirmed hepatic ischemia, with no enhancement seen in hepatic artery branches. Liver biopsy specimen revealed no signs of rejection. The patient decided to receive conservative treatment and succumbed to the illness after six months.

CONCLUSION

This case indicates that calciphylaxis should be suspected in patients who have undergone LT with ESRD presenting with hyperbilirubinemia and skin lesions.

Multicenter Evaluation of Certainty and Reliability in Calciphylaxis Diagnosis Using a Digital Imaging Platform

The robustness of histopathologic criteria for diagnosing calciphylaxis depends both on dermatopathologists' confidence in the recognition of individual histologic features and on the interrater reliability (IRR) of these assessments. The aim of this study was to quantify interpretive challenges in calciphylaxis diagnosis through the evaluation of generalized and histopathological feature-specific certainty and IRR and establish which features are most reproducibly recognized. An online diagnostic survey was designed to evaluate accuracy, certainty, and IRR. Case materials comprised a clinical vignette, clinical photograph, and whole slide imaging scans of 1 hematoxylin and eosin and von Kossa-stained section in 20 patients with or without calciphylaxis. Dermatopathologists from multiple institutions independently rendered diagnoses and used a checklist to assess the presence of and certainty in specific histopathologic features. Twenty-three board-certified dermatopathologists (62%) representing 16 institutions responded. Diagnostic accuracy (53% vs 80%) and IRR (Krippendorff alpha [KA]) were lower for calciphylaxis cases compared with mimics (0.171 vs 0.257). Necrosis, finely stippled calcium, and intimal fibroplasia of pannicular arterioles most robustly differentiated calciphylaxis from mimics (P < .05). Among histopathologic features, IRR was the highest for ulceration (KA = 0.66) and necrosis (KA = 0.46) and the lowest for perieccrine calcification (KA = 0.19) and intimal fibroplasia of pannicular arterioles (KA = 0.07). Pathologists' confidence in correctly identifying the presence or absence of each feature correlated linearly with IRR. Digital imaging platforms can facilitate multi-institutional study of diagnostic concordance for uncommon entities. This study identified necrosis, finely stippled calcium, and intimal fibroplasia of pannicular arterioles as the most robust histopathologic features for diagnosing calciphylaxis, although inter-rater concordance for intimal fibroplasia was low. Quantitative trends in pathologists' subjective assessments of histologic features may help guide the development of diagnostic guidelines and inform medical education.

Anticoagulant-associated calciphylaxis: analysis of USFDA adverse event report system and clinical feature analysis of reported cases

BACKGROUND

Calciphylaxis is a serious, potentially fatal condition resulting in pathological calcification of soft tissues. While associated with chronic kidney disease, data regarding anticoagulant involvement remain limited.

RESEARCH DESIGN AND METHODS

The United States Food and Drug Administration Adverse Event Reporting System (USFDA AERS) database was searched to identify calciphylaxis reports linked to anticoagulants from 2004 to 2024. Disproportionality analyses compared reporting rates versus usage. Literature was reviewed to extract calciphylaxis case details with specific anticoagulants.

RESULTS

Disproportionality signals were observed between calciphylaxis and warfarin, heparin, and apixaban from 471 unique reports. Literature review confirmed an association between warfarin and calciphylaxis based on 54 cases from 48 reports. Risk factors for warfarin-associated calciphylaxis included older age, female sex, and longer duration. Approximately two-thirds responded to sodium thiosulfate, bisphosphonates, or hyperbaric oxygen therapy.

CONCLUSION

This evaluation characterized calciphylaxis safety signals from pharmacovigilance data and literature review. Warfarin emerged as the most strongly associat.ed based on both sources. While limitations preclude causality determination, findings warrant attention regarding warfarin's calciphylaxis risk profile, especially in higher-risk populations. Additional research is needed, including controlled trials, to validate this relationship and optimize management.

Inflammatory and vaso-occlusive ulcers: Part I - Clinical presentation and diagnosis

In this CME, we review 2 specific categories of ulcers: inflammatory (where inflammation is the primary pathologic process leading to ulceration) and vaso-occlusive (where occlusion is the primary process). Inflammatory ulcers include pyoderma gangrenosum and vasculitides, whereas livedoid vasculopathy, calciphylaxis, and Martorell ulcers are vaso-occlusive ulcers. Determining the causes of ulcers in these conditions may require laboratory evaluation, biopsy, and imaging.

Calcific Uremic Arteriolopathy (CUA) Among Malaysian Dialysis Patients: Clinical Characteristics, Treatment, and Outcomes

Background Calcific uremic arteriolopathy (CUA) is a rare but debilitating disease affecting patients with kidney disease. Reported risk factors of CUA in the literature include female sex, obesity, diabetes mellitus, and vitamin K antagonists' (VKAs) usage. CUA prevalence in Malaysia is unknown and has not been reported before. Methods A multicenter observational study was conducted in 13 centers all over Malaysia to study the clinical characteristics, treatment, and outcomes of CUA. The data of patients confirmed with CUA between January 1, 2016, and December 31, 2021, was collected from medical records by each center's nephrologists. Results Out of 33 confirmed CUA cases, 69.7% were females, and 66.7% were Malay with a mean age of 47.33 ± 13.80 years old. The mean BMI was 25.66 ± 9.77 kg/m2, and 18.2% were classified as obese (BMI > 30). Two-thirds of the patients were on hemodialysis (HD), and the mean dialysis vintage was 6.2 ± 4.11 years. A majority (87.9%) have hypertension, 33.3% are diabetic, and 27.3% have coronary artery disease. Only 15.2% of the patients were on warfarin at the time of diagnosis. A total of 78.8% of patients were taking calcium-based phosphate binders during diagnosis. Investigation results showed calcium, 2.44 ± 0.29 mmol/L; phosphate, 2.18 ± 0.67 mmol/L; CaXPO4 = 5.41 ± 1.90; and parathyroid hormone, 181.14 ± 153.23 pmol/L. About half (54.5%) had skin biopsy confirmation done. Distribution of lesions was 57.6% peripheral and 30.3% central. For treatment of CUA, there were 57.6% usage of non-calcium-based phosphate binders, 48.5% cinacalcet, 30.3% sodium thiosulphate, and 33.3% had parathyroidectomy. Half (54.5%) of our CUA patients died within three months from diagnosis. The mean time from diagnosis to mortality was 4.12 ± 5.59 months. A majority (45.5%) died from septicemia caused by infections. Interestingly, there were a few rare presentations of CUA such as pulmonary calciphylaxis, heart and lung calcifications, liver and spleen calcifications, and genital lesions. One patient had resistant CUA and was given a trial of lipid apheresis for 10 sessions. Conclusion This is the first and largest multicenter study looking into the characteristics, treatment, and outcome of CUA in Malaysia. Majority of patients in Malaysia undergo HD as kidney replacement therapy; hence, our results correlate with this. The incidence of CUA was estimated to be 6.6 per 10,000 dialysis patients in this study and the mortality rate is very high. This is consistent with worldwide data which reported mortality as high as 60%.

Hexasodium fytate for the treatment of calciphylaxis: a randomised, double-blind, phase 3, placebo-controlled trial with an open-label extension

Background

In the CALCIPHYX trial, we investigated hexasodium fytate, an inhibitor of vascular calcification, for the treatment of calcific uraemic arteriolopathy (calciphylaxis), a rare condition characterised by painful, non-healing skin lesions.

Methods

In this international, phase 3, randomised, double-blind, placebo-controlled trial, adults with an ulcerated calciphylaxis lesion and pain visual analogue scale (VAS) score ≥50/100 were randomised 1:1 to hexasodium fytate 7 mg/kg or placebo intravenously during maintenance haemodialysis. Primary efficacy outcomes were an 8-item modification of the Bates-Jensen Wound Assessment Tool (BWAT-CUA) and Pain VAS in the intention-to-treat population. ClinicalTrials.gov number: NCT04195906.

Findings

Overall, 34/37 patients randomised to hexasodium fytate and 26/34 patients randomised to placebo completed the 12-week randomised treatment period. At Week 12, both groups (hexasodium fytate versus placebo) showed similar improvements in BWAT-CUA (mean [standard deviation (SD)], -5.3 [5.2] versus -6.0 [6.2]; least squares mean difference, 0.3 [96% confidence interval (CI): -2.5, 3.0]; p = 0.88) and Pain VAS (mean [SD], -19.5 [26.9] versus -32.2 [38.5]; least squares mean difference, 11.5 [96% CI: -4.8, 27.8]; p = 0.15). One patient randomised to placebo briefly received hexasodium fytate in error. Serious adverse events through Week 12 included: calciphylaxis-related events leading to hospitalisation (2/38 [5%] versus 11/33 [33%]) and death (1/38 [3%] versus 5/33 [15%]). During the subsequent 12 weeks of open-label hexasodium fytate and 4 weeks of follow-up, there were no additional calciphylaxis-related events leading to hospitalisation. Over the course of the entire trial, deaths were 2/38 [5%] for the hexasodium fytate group and 7/33 [21%] for the placebo group.

Interpretation

In patients with calciphylaxis, BWAT-CUA and Pain VAS improved similarly in hexasodium fytate- and placebo-treated patients; over the course of the entire trial, there were fewer deaths and calciphylaxis-related events leading to hospitalisation in the hexasodium fytate group.

Funding

Funded by Sanifit, a CSL Vifor company.

Approach to the Atypical Wound

The heterogeneity of atypical wounds can present diagnostic and therapeutic challenges; however, as the prevalence of atypical wounds grows worldwide, prompt and accurate management is increasingly an essential skill for dermatologists. Addressing the underlying cause of an atypical wound is critical for successful outcomes. An integrated approach with a focus on pain management and patient engagement is recommended to facilitate enduring wound closure. Advances in treatment, in addition to further research and clinical training, are necessary to address the expanding burden of atypical wounds.

The Histopathology of Leg Ulcers

Ulcerations of the lower extremities are a frequently encountered problem in clinical practice and are of significant interest in public health due to the high prevalence of underlying pathologies, including chronic venous disease, diabetes and peripheral arterial occlusive disease. However, leg ulcers can also present as signs and symptoms of various rare diseases and even as an adverse reaction to drugs. In such cases, correct diagnosis ultimately relies on histopathological examination. Apart from the macroscopic presentation, patient history and anatomic location, which are sometimes indicative, most ulcers have very distinct histopathological features. These features are found in different layers of the skin or even associated vessels. In this narrative review, we discuss and highlight the histopathological differences of several types of leg ulcers that can contribute to efficient and accurate diagnosis.

Early diagnosis strategy of calciphylaxis in dialysis patients

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.

Elastic fiber alterations and calcifications in calcific uremic arteriolopathy

Calcific uremic arteriolopathy (CUA) is a severely morbid disease, affecting mostly dialyzed end-stage renal disease (ESRD) patients, associated with calcium deposits in the skin. Calcifications have been identified in ESRD patients without CUA, indicating that their presence is not specific to the disease. The objective of this retrospective multicenter study was to compare elastic fiber structure and skin calcifications in ESRD patients with CUA to those without CUA using innovative structural techniques. Fourteen ESRD patients with CUA were compared to 12 ESRD patients without CUA. Analyses of elastic fiber structure and skin calcifications using multiphoton microscopy followed by machine-learning analysis and field-emission scanning electron microscopy coupled with energy dispersive X-ray were performed. Elastic fibers specifically appeared fragmented in CUA. Quantitative analyses of multiphoton images showed that they were significantly straighter in ESRD patients with CUA than without CUA. Interstitial and vascular calcifications were observed in both groups of ESRD patients, but vascular calcifications specifically appeared massive and circumferential in CUA. Unlike interstitial calcifications, massive circumferential vascular calcifications and elastic fibers straightening appeared specific to CUA. The origins of such specific elastic fiber's alteration are still to be explored and may involve relationships with ischemic vascular or inflammatory processes.

Clinical features and outcomes of calciphylaxis in Chinese patients with chronic kidney disease

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.

Hemodialysis Patient with Streptococcal Toxic Shock Syndrome and Penile Necrosis

A 72-year-old man on hemodialysis due to diabetic nephropathy presented with a fever and penile pain. Although his physical examination was unremarkable, his general condition deteriorated. Penile necrosis was observed by evening on the same day of presentation, and the patient died the next morning. Blood cultures revealed the presence of Group G Streptococcus, leading to a diagnosis of streptococcal toxic shock syndrome (STSS). Autopsy suggested penile necrosis due to septic shock. STSS in hemodialysis patients with vascular calcification, even in the absence of calciphylaxis, can lead to severe organ damage due to ischemia.

Surgical treatment of nonuremic calciphylaxis: a case report and review of literature

Calciphylaxis is characterized by extremely painful skin ulcers and develops in patients with or without severe kidney diseases. Herein, a female patient without renal dysfunction developed calciphylaxis in the right lower extremity and underwent successful surgical debridement and split-thickness skin grafting. Nevertheless, prompt wound evaluation and proper surgical approaches are essential.

Use of the optimized sodium thiosulfate regimen for the treatment of calciphylaxis in Chinese patients

BACKGROUND

Sodium thiosulfate (STS) can be used to treat patients diagnosed with calciphylaxis, which is a rare life-threatening syndrome. However, our patients treated with the recommended STS regimen presented with serious adverse events, resulting in treatment withdrawal. Then an optimized STS regimen was used to increase the tolerance of patients to STS and improve treatment continuation. The curative effect of the new regimen is not yet definite. Therefore, this study aimed to evaluate the response to the use of the optimized STS regimen for the treatment of calciphylaxis in Chinese patients during the first three courses of treatment.

METHODS

Demographic, clinical, and laboratory data were retrospectively collected on 31 calciphylaxis patients with chronic kidney disease (CKD) or end-stage kidney disease (ESKD) treated with the optimized STS regimen. The primary outcome was a clinical improvement. The secondary outcomes included survival rate and adverse events.

RESULTS

Twenty-five patients (over 80%) achieved clinical improvement considering improvement or nonspecific changes of skin lesions (80.65%) and pain relief (100%). Furthermore, 54.84% of patients did not experience any adverse events and none died from complications. During a median follow-up of 9 months (interquartile range 4‒19), 27 patients (87.10%) survived; additionally, 13 patients (41.94%) survived after a one-year follow-up period.

CONCLUSION

The optimized STS regimen is relatively safe, associated with satisfactory outcomes, and well tolerated by patients for short to medium treatment duration. Hence, it is a promising approach for the treatment of patients diagnosed with calciphylaxis.

The Role of Iron in Calciphylaxis—A Current Review

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.

Prevalence and Clinical Characteristics of Calciphylaxis in Chinese Hemodialysis Patients

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.

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.

Calciphylaxis: Risk Factors and Histologic Findings in a Case Series From a Tertiary Care Referral Hospital

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.

Multiple extremity necrosis in fatal calciphylaxis: Case report

INTRODUCTION

The clinical impact of vascular calcification is well established in the context of cardiovascular morbidity and mortality, but other clinical syndromes, such as calciphylaxis, although less frequent, have a significant impact on chronic kidney disease.

METHODS

Case report of a 27-year-old woman, who had complained of bilateral pain in her toes for 3 days, with the presence of small necrotic areas in the referred sites. She had a history of type 1 diabetes (25 years ago), with chronic kidney disease, on peritoneal dialysis, in addition to rheumatoid arthritis. She was admitted to the hospital, which preceded the current condition, due to exacerbation of rheumatoid arthritis, evolving with intracardiac thrombus due to venous catheter complications, when she started using warfarin. Ischemia progressed to her feet, causing the need for bilateral amputations. Her chirodactyls were also affected. Thrombophilia, vasculitis, endocarditis or other embolic sources were investigated and discarded. Her pathology report evidenced skin necrosis and superficial soft parts with recent arterial thrombosis, and Monckeberg's medial calcification. We started treatment with bisphosphonate and sodium thiosulfate, conversion to hemodialysis and replacement of warfarin with unfractionated heparin. Despite all the therapy, the patient died after four months of evolution.

DISCUSSION

Calciphylaxis is a rare microvasculature calcification syndrome that results in severe ischemic injuries. It has pathogenesis related to the mineral and bone disorder of chronic kidney disease combined with the imbalance between promoters and inhibitors of vascular calcification, with particular importance to vitamin K antagonism.

CONCLUSION

The preventive strategy is fundamental, since the therapy is complex with poorly validated effectiveness.

Use of cryopreserved human amniotic membrane in the treatment of skin ulcers secondary to calciphylaxis

Calciphylaxis is a rare condition characterized by skin ulceration and necrosis as a result of vascular calcification of the small and medium blood vessels of skin and subcutaneous tissues. It mainly occurs in patients with advanced chronic kidney disease and sometimes leads to complications with a fatal outcome. In this report, we describe the case of a 67-year-old male patient with end stage renal disease presenting painful skin ulcers on his lower limbs. The lesions had progressively grown and were associated to severe pain and decreased quality of life. The ulcers did not respond to conventional treatments and the patient underwent skin biopsy of these lesions obtaining anatomopathological findings compatible with calciphylaxis. In this report, we present an innovative treatment for skin ulcers secondary to calciphylaxis using cryopreserved amniotic membrane (AM) as a dressing in order to promote epithelialization of the wounds. After four applications, healing of the main ulcer and reduction in pain was achieved. In summary, applying cryopreserved AM probed to be a promising strategy to reduce pain and to enhance epithelialization and healing of chronic non-responsive ulcers in calciphylaxis.

Severe calcification of systemic blood vessel walls caused by continuous hypercalcemia in a cat with congenital hypothyroidism

A 97-day-old male Japanese domestic cat was diagnosed as congenital hypothyroidism. During the treatment, continuous hypercalcemia was detected. Although fluid therapy was performed, the cat died at the age of 1785 days. At autopsy, both parathyroid glands were enlarged, and elastic arterial walls were increased in thickness and hardness. Histopathological examination revealed hyperplasia of both parathyroid glands and interstitial fibrosis of bilateral kidneys. Severe calcification of the tunica media and tunica externa in systemic elastic and muscular arteries were also observed. These calcifications were considered to be due to renal secondary hyperparathyroidism. In the present case, hypothyroidism might have caused hyperparathyroidism through renal failure. In veterinary medicine, this is the first reported case of hypothyroidism accompanied with hyperparathyroidism.

Severe necrosis of the glans penis associated with calciphylaxis treated by partial penectomy

INTRODUCTION

Calciphylaxis is characterized by marked vascular calcification and painful skin ulcers, and it has a poor prognosis.

CASE PRESENTATION

The patient was a 72-year-old male. He was referred for penile pain. He had a 4-year history of dialysis therapy under a diagnosis of diabetic nephropathy. Black and yellow necrosis was observed involving the entire glans, accompanying severe pain. Computed tomography revealed marked calcification involving the thoracoabdominal aorta to iliac arteries, the dorsal artery of the penis and the corpus cavernosum, leading to a diagnosis of calciphylaxis. Penile pain gradually exacerbated and partial penectomy was performed. After surgery, penile pain promptly subsided. Pathological examination confirmed marked calcification of the microvascular wall and narrowing of the lumen.

CONCLUSION

We reviewed 15 Japanese patients with calciphylaxis who had undergone penile surgery. Surgical treatment was considered to be effective at relieving penile pain, but the prognosis remained poor.

Localization, Morphologic Features, and Chemical Composition of Calciphylaxis-Related Skin Deposits in Patients With Calcific Uremic Arteriolopathy

Importance

Calcific uremic arteriolopathy (CUA), a rare, potentially fatal, disease with calcium deposits in skin, mostly affects patients with end-stage renal disease who are receiving dialysis. Chemical composition and structure of CUA calcifications have been poorly described.

Objectives

To describe the localization and morphologic features and determine the precise chemical composition of CUA-related calcium deposits in skin, and identify any mortality-associated factors.

Design, Setting, and Participants

A retrospective, multicenter cohort study was conducted at 7 French hospitals including consecutive adults diagnosed with CUA between January 1, 2006, and January 1, 2017, confirmed according to Hayashi clinical and histologic criteria. Patients with normal renal function were excluded. For comparison, 5 skin samples from patients with arteriolosclerosis and 5 others from the negative margins of skin-carcinoma resection specimens were also analyzed.

Main Outcomes and Measures

Localization and morphologic features of the CUA-related cutaneous calcium deposits were assessed with optical microscopy and field-emission-scanning electron microscopy, and the chemical compositions of those deposits were evaluated with μ Fourier transform infrared spectroscopy, Raman spectroscopy, and energy dispersive radiographs.

Results

Thirty-six patients (median [range] age, 64 [33-89] years; 26 [72%] female) were included, and 29 cutaneous biopsies were analyzed. Calcific uremic arteriolopathy and arteriolosclerosis skin calcifications were composed of pure calcium-phosphate apatite. Calcific uremic arteriolopathy vascular calcifications were always circumferential, found in small to medium-sized vessels, with interstitial deposits in 22 (76%) of the samples. A thrombosis, most often in noncalcified capillary lumens in the superficial dermis, was seen in 5 samples from patients with CUA. Except for calcium deposits, the vessel structure of patients with CUA appeared normal, unlike thickened arteriolosclerotic vessel walls. Twelve (33%) patients died of CUA.

Conclusions and Relevance

Calcific uremic arteriolopathy-related skin calcifications were exclusively composed of pure calcium-phosphate apatite, localized circumferentially in small to medium-sized vessels and often associated with interstitial deposits, suggesting its pathogenesis differs from that of arteriolosclerosis. Although the chemical compositions of CUA and arteriolosclerosis calcifications were similar, the vessels' appearances and deposit localizations differed, suggesting different pathogenetic mechanisms.

Biomarkers of vascular calcification in serum

Over the last decades, the association between vascular calcification (VC) and all-cause/cardiovascular mortality, especially in patients with high atherogenic status, such as those with diabetes and/or chronic kidney disease, has been repeatedly highlighted. For over a century, VC has been noted as a passive, degenerative, aging process without any treatment options. However, during the past decades, studies confirmed that mineralization of the arteries is an active, complex process, similar to bone genesis and formation. The main purpose of this review is to provide an update of the existing biomarkers of VC in serum and develop the various pathogenetic mechanisms underlying the calcification process, including the pivotal roles of matrix Gla protein, osteoprotegerin, bone morphogenetic proteins, fetuin-a, fibroblast growth-factor-23, osteocalcin, osteopontin, osteonectin, sclerostin, pyrophosphate, Smads, fibrillin-1 and carbonic anhydrase II.

Calciphylaxis epidemiology, risk factors, treatment and survival among French chronic kidney disease patients: a case-control study

Background

Calcific Uremic Arteriolopathy (CUA) is a rare disease, causing painful skin ulcers in patients with end stage renal disease. Recommendations for CUA management and treatment are lacking.

Methods

We conducted a retrospective cohort study on CUA cases identified in western France, in order to describe its management and outcome in average clinical practices. Selection was based on the Hayashi diagnosis criteria (2013) extended to patients with eGFR < 30 mL/min/1.73m². Dialyzed CUA cases were compared with 2 controls, matched for age, gender, region of treatment and time period.

Results

Eighty-nine CUA cases were identified between 2006 and 2016, including 19 non dialyzed and 70 dialyzed patients. Females with obesity (55.1%) were predominant. Bone mineral disease abnormalities, inflammation and malnutrition (weight loss, serum albumin decrease) preceded CUA onset for 6 months. The multimodal treatment strategy included wound care (98.9%), antibiotherapy (77.5%), discontinuation of Vitamin K antagonists (VKA) (70.8%) and intravenous sodium thiosulfate (65.2%). 40.4% of the patients died within the year after lesion onset, mainly under palliative care. Surgical debridement, distal CUA, localization to the lower limbs and non calcium-based phosphate binders were associated with better survival. Risks factors of developing CUA among dialysis patients were obesity, VKA, weight loss, serum albumin decrease or high serum phosphate in the 6 months before lesion onset.

Conclusion

CUA involved mainly obese patients under VKA. Malnutrition and inflammation preceded the onset of skin lesions and could be warning signs among dialysis patients at risk.

Trial registration

ClinicalTrials.gov identifier NCT02854046, registered August 3, 2016.

Epidemiology and Treatment of Calcinosis Cutis: 13 Years of Experience

Background:

Calcinosis cutis is a rare condition associated with different diseases, which is difficult to manage.

Aims and Objectives:

In this retrospective study, the epidemiology of calcinosis cutis and the effectiveness of various treatment regimens in its management were assessed in a single center.

Materials and Methods:

The data of 34 patients suffering from calcinosis cutis (male:female = 12:22; mean age = 48.6 ± 18.6 years) treated at our department between 2003 and 2016 were analyzed retrospectively.

Results:

Dystrophic, idiopathic, metastatic subtype, and calciphylaxis occurred in 70.6%, 11.8%, 5.9%, and 11.8% of the cases, respectively. Underlying diseases of dystrophic calcinosis included autoimmune connective tissue disease, skin trauma, cutaneous neoplasm, and inherited disorder in 58.3%, 20.8%, 12.5%, and 8.3% of the cases, respectively. Extremities were most frequently affected (n = 18). In the management, diltiazem was most frequently used in monotherapy with partial response in five of eight cases. Other drugs in monotherapy or in combination were administered in single cases. Surgical treatment resulted in least partial response in all of the cases followed (n = 7).

Conclusion:

Dystrophic was the most common subtype and autoimmune connective tissue disease was the most frequent underlying disease. We conclude that lower doses of diltiazem have only partial efficiency, and surgical therapy is at least partially effective in localized calcinosis.

On the role of skin biopsy in the diagnosis of calcific uremic arteriolopathy: a case-based discussion

Calciphylaxis is a rare disease characterized by ectopic calcification of skin arterioles resulting in ischemia, thrombosis and necrosis. Since end stage renal disease patients are those mainly affected, the term calcific uremic arteriolopathy (CUA) is also suggested. Early clinical manifestations are subtle, while overt necrotic ulcers may quickly spread and become infected so as to result in ominous outcome. Diagnosis might not be easy due to the number of other ischemic and non-ischemic skin lesions observed in uraemia. Skin biopsy, has been proposed as the diagnostic test and is often considered, but not systematically performed due to the hypothetical risk of further spreading of the lesions. Such ambiguity could be responsible for misdiagnosis or underdiagnosis. We review here five consecutive cases recorded in our Unit, all submitted to skin biopsy but with inconsistent results which generated some clinical frustration. Thus, we decided to carefully re-evaluate all of them together with pathologists and dermatologists. However, even after this ex-post discussion, we could not reach a complete agreement on the final diagnosis. In the meanwhile, papers were published in the literature that started to shed some light on the role of skin biopsy in the diagnosis of CUA.

Gastrointestinal Manifestations in a Patient with Calciphylaxis: A Case Report

Calciphylaxis is a rare condition usually seen in patients with significant renal disease, affecting 1-4' of patients undergoing haemodialysis. Although the disease usually manifests as lesions in the subcutaneous tissue, there have been rare occurrences of calciphylaxis presenting as lesions in the gastrointestinal tract, leading to complications of bowel necrosis and haemorrhage. In view of this, we report the case of suspected gastrointestinal tract calciphylaxis in a 63-year-old patient with end-stage kidney disease (ESKD) who presented with painful swelling in the medial and lateral aspect of both thighs. Physical examination revealed extensive tender subcutaneous tissue nodules suggestive of calciphylaxis. During her hospital admission, the patient developed an episode of gastrointestinal bleeding requiring multiple blood transfusions. A computed tomography scan of the abdomen showed widespread vascular calcification within the aorta and its somatic and visceral branches as well as a splenic infarct. Oesophagogastroduodenoscopy revealed a large gastric ulcer, while flexible sigmoidoscopy revealed necrosis of the rectal mucosa. She was started on vitamin D supplementation and intravenous sodium thiosulphate during each dialysis session. She clinically improved with no further gastrointestinal haemorrhage and partial resolution of her rectal necrosis and was transferred to a rehabilitation facility for further care and discharge planning.

A Catastrophic Case of Idiopathic Cholesterol Crystal Embolism with Multiple Lethal Complications: A Labyrinth Underneath the Diagnosis of Skin Ulcers in Chronic Kidney Disease Patients

A 66-year-old man was admitted to our hospital because of multiple refractory skin ulcers. Based on his severe systemic arterial calcification and severe calcium-phosphate imbalance due to severe kidney dysfunction, we initially considered calciphylaxis. However, a skin biopsy provided a diagnosis of cholesterol crystal embolization. Although we initiated hemodialysis, steroid treatment, and low-density lipoprotein-cholesterol apheresis, he died of multiple intestinal perforation. An autopsy showed cholesterol crystals occluding multiple organ arterioles. This case suggests that skin ulcers in patients with chronic kidney disease may be an important diagnostic hallmark and may be associated with several serious diseases.

Calcific uremic arteriolopathy (calciphylaxis) calls into question the validity of guidelines of diagnosis and treatment

Background: Calciphylaxis is associated with end-stage renal failure or kidney transplant, although, cases of non-uremic calciphylaxis have been reported. It is a rare disorder, with high mortality, characterized by vascular calcification within cutaneous vessels; vascular calcification can occur in other organs, besides skin, like heart, lung, or pancreas, which is named visceral calciphylaxis.Objective: The purpose was to review current knowledge regarding diagnosis and therapeutic approach to cutaneous calciphylaxis.Methods: A literature review has been conducted associated to word "calciphylaxis".Results: The diagnosis is based mainly on clinical features and histologic findings. Therapeutic options are still controversial.Conclusions: Cutaneous calciphylaxis is a puzzling disease, with a challenging diagnosis, and a complex treatment, which requires a multidisciplinary team and expertise.

Calciphylaxis in patients with chronic kidney disease: A disease which is still bewildering and potentially fatal

Calciphylaxis, also known as calcific uraemic arteriolopathy, is a rare syndrome that typically causes skin necrosis and usually affects dialysis patients. Its pathogenesis is multifactorial and is the consequence of many factors causing ectopic calcifications in patients with chronic kidney disease, such as calcium-phosphate metabolism disorders, hyper- or hypo-parathyroidism, diabetes, obesity, systemic inflammation and the use of vitamin K antagonists, among others. From a clinical point of view, calciphylaxis may progress from painful purpura to extensive areas of skin necrosis that can potentially lead to superinfection and the death of the patient due to sepsis. Treatment is primarily based on managing the wounds, eliminating all the possible precipitating factors of ectopic calcification and administering agents which are capable of inhibiting the process of calcification.

Non-uraemic calciphylaxis (NUC) postliver transplantation

Calciphylaxis is a rare and life-threatening disease characterized by cutaneous arteriolar stenosis and vascular thrombosis leading to skin ischaemia and necrosis. While calciphylaxis occurs mostly in patients with end-stage renal disease, the disorder has been described in patients with normal renal function, namely non-uraemic calciphylaxis (NUC). A 41-year-old African-American woman presented with a painful ulcerative rash on her thighs and right buttock 2 months after undergoing an orthotopic liver transplantation. She underwent debridement of the lesions and an excisional biopsy of one of the lesions, which revealed calciphylaxis. She was treated with sodium thiosulfate, cinacalcet and hyperbaric oxygen with complete resolution of the lesions 4-5 months after presentation. While she was treated with a course of high-dose glucocorticoids after the transplant, she did not have other risk factors for calciphylaxis. NUC should be considered in the differential diagnosis of necrotic skin lesions in postliver transplant patients.

Digital gangrene and pneumatosis intestinalis associated with calciphylaxis

Reports of calciphylaxis or calcific uremic arteriolopathy associated with acral and gastrointestinal involvement are rare. We describe a 36-year-old white woman with end-stage renal disease on hemodialysis after failed kidney and pancreas transplantation who developed dry gangrene of bilateral digits, osteomyelitis, and small bowel ischemia within several months of each presentation. She had multiple débridements of a septic right ankle. Computed tomography angiography showed severe vascular calcification and pneumatosis intestinalis. She underwent intestinal resection for gangrenous small bowel. A multidisciplinary approach with aggressive medical and surgical management may improve survival. Our case and the literature confirm the high morbidity of patients with calciphylaxis and vascular complications. Careful follow-up remains necessary for diagnosis and management to prevent complication, infection, and death.

Questionable specificity of histologic findings in calcific uremic arteriolopathy

A variety of criteria exist for histopathologic diagnosis of calciphylaxis, also known as calcific uremic arteriolopathy but data on their specificity are limited. To assess this, histologic findings of 38 skin biopsies performed for a suspicion of calcific uremic arteriolopathy were compared with histologic findings in skin obtained from healthy margins of 43 amputations in patients with end-stage renal disease (ESRD) without evidence of calcific uremic arteriolopathy. Abnormalities in small arteries or arterioles were present in 35% of amputation specimens and 55% of skin biopsies, and among these only thrombosis but not calcification was significantly more prevalent in skin biopsies. The prevalence of extravascular calcification did not differ. Vascular lesions were more common in skin biopsies from patients with high clinical suspicion of calcific uremic arteriolopathy (81%), significantly driven by increases in both calcification and thrombosis, compared to amputations (35%). The combination of medial calcification and thrombosis was six-fold more prevalent in high-suspicion skin biopsies than in amputation specimens. The location of affected vessels did not differ. In two autopsy cases, some but not all findings of involved skin were also present in uninvolved skin. Thus, histopathologic findings historically associated with calcific uremic arteriolopathy can also occur in viable tissue from unaffected patients with ESRD, calling into question the specificity of individual histologic findings for calcific uremic arteriolopathy. However, the combination of medial calcification and thrombosis was rare in unaffected patients and may provide a higher degree of specificity.

3DTEE imaging of a descending aorta floating thrombus in a patient with calciphylaxis

We present a case of a 68-year-old man with calciphylaxis, who was found to have a floating thrombus in the descending aorta on a transesophageal echocardiogram. The use of 3D echocardiography demonstrated nicely the free motion of the thrombus, emerging from an atherosclerotic plaque in the descending aorta. Anticoagulation was started for thromboembolism prevention.

Clinical Assessment of Warfarin Therapy in Patients with Maintenance Dialysis-Clinical Efficacy, Risks and Development of Calciphylaxis

Recent years, multiple studies regarding clinical efficacy and risks of Warfarin therapy in dialysis patients have been reported, and not a few reports conclude that clinical advantage of Warfarin is questionable in dialysis patients. Conversely, its hemorrhagic risk might be a little more serious in dialysis patients comparing to non-dialysis patients. Basically, it is assumed that long-term administration of Warfarin accelerates the development of vascular athelosclerosis because of the abolished anti-calcification effect of Gla-protein activation by decreased vitamin K activity. This assumption is recently confirmed by multiple reports, suggesting that the Warfarin administration might be worse harmful than ever expected in dialysis patients who are essentially considered to have higher risk of calcification comparing to non-dialysis patients. In addition, it is recently well considered that the Warfarin administration would be a risk factor to cause Warfarin skin necrosis or calciphylaxis, therapy resistant ulcerative skin lesions, which are considered to be highly related to the Warfarin-induced transient hypercoagulable state or acceleration of calcification. Therefore, it is considered that the indication of Warfarin administration to dialysis patients should be carefully assessed. (This is a translation of Jpn J Vasc Surg 2017; 26: 83–90.)

Penile Calciphylaxis: The Use of Radiological Investigations in the Management of a Rare and Challenging Condition

Penile calciphylaxis is a rare phenomenon of penile necrosis observed in patients with hemodialysis-dependent end-stage renal failure. Multiple treatments have been proposed including conservative management, surgical debridement and penectomy; yet, the prognosis remains extremely poor. Here, we describe a patient with protracted resolution of dry gangrene of the glans, which failed conservative management of wound care and pain management. Radiological studies revealed extensive calcification of abdominal aorta and branching vessels including the penile arteries. Due to intolerable pain, the patient required total penectomy. Earlier surgical intervention guided by findings on radiological studies may improve quality of life in this population.

Calciphylaxis following acute renal injury: a case and literature review

Background

Calciphylaxis following acute renal failure is rare.

Findings

We report A 57-year-old male with an acute renal failure associated with necrotizing fasciitis. We also review the cases of calciphylaxis due to acute renal disorder further.

Conclusions

It should be kept in mind that calciphylaxis is observed in patient with not only chronic renal disease but also acute renal failure.

Development of multiorganic calciphylaxis during teriparatide, vitamin D, and calcium treatment

Non-uremic calciphylaxis is a severe rare disorder characterized by ischemic necrosis. Recently, three cases of cutaneous calciphylaxis have been described in the context of teriparatide treatment. We present a 51-year-old woman with alcoholic cirrhosis who developed multiorganic calciphylaxis shortly after starting teriparatide treatment associated with calcium and 25-hydroxyvitamin D supplements for severe osteoporosis. After lengthy care of the infectious complications and treatment with bisphosphonates and sodium thiosulfate progressive improvement was observed over a 3-year period. The time between the initiation of teriparatide and the development of calciphylaxis suggests that this agent may have been the triggering factor of this process. Nevertheless, other non-negligible risk factors for calciphylaxis such as alcoholic liver disease, obesity, and vitamin D treatment must also be considered in this patient. Considering the severity of this extremely rare clinical condition, better knowledge of the risk factors related to calciphylaxis development is mandatory.

Calciphylaxis - A case study in a patient with Maori heritage

This case history describes a rare complaint - Calciphylaxis, seen in a New Zealand Maori patient undergoing renal dialysis. This condition causes non-healing tissue ulceration, typically with sepsis and is associated with a very high mortality rate. The need for vigilance among health professionals is highlighted, including the risk factors that may faciliate an early diagnosis; together with the value associated with a multi-disciplinary team approach to management.