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Huish S, Sinha S. New therapeutic perspectives for vascular and valvular calcifications in chronic kidney disease. Curr Opin Nephrol Hypertens 2024; 33:391-397. [PMID: 38573243 DOI: 10.1097/mnh.0000000000000985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Vascular and valvular calcification are associated with cardiovascular morbidity and mortality in people with chronic kidney disease (CKD). Uncertainty exists regarding therapeutic strategies to attenuate calcification. This review outlines the pathophysiological mechanisms contributing to vascular and valvular calcification, considers the mechanisms of action of therapeutic interventions, and reports the latest outcomes from interventional studies. RECENT FINDINGS Conventional therapies targeted at CKD-mineral and bone disorder (MBD) modulation have yielded conflicting or inconclusive results. Magnesium and vitamin K supplementation appear to offer attenuation of coronary artery calcification but inconsistent findings justify the need for further studies. Strategies targeting hydroxyapatite formation such as sodium thiosulphate and hexasodium fytate show promise and are worthy of further evaluation. The serum calcification propensity assay (T50) correlates with severity and progression; it holds promise as a potential future clinical tool for screening monitoring calcification risk. SUMMARY Whilst knowledge of the pathophysiology of vascular calcification has grown and therapeutic approaches appear promising, as yet no medication has been approved to treat vascular or valvular calcification, or calciphylaxis.
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Affiliation(s)
- Sharon Huish
- Department of Renal Dietetics, Royal Devon University Healthcare NHS Foundation Trust, and University of Exeter
| | - Smeeta Sinha
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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2
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Becker SL, Kody S, Fett NM, Hines A, Alavi A, Ortega-Loayza AG. Approach to the Atypical Wound. Am J Clin Dermatol 2024:10.1007/s40257-024-00865-0. [PMID: 38744780 DOI: 10.1007/s40257-024-00865-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
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.
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Affiliation(s)
- Sarah L Becker
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Shannon Kody
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Nicole M Fett
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | | | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA.
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3
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Yang Q, Fang X, Ren X, Pan Y, Wang M, Ding J. Effects of the Omicron variant of coronavirus disease 2019 on anaemia treatment for patients undergoing peritoneal dialysis. Nephrology (Carlton) 2024; 29:222-229. [PMID: 38382901 DOI: 10.1111/nep.14274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/10/2024] [Accepted: 01/15/2024] [Indexed: 02/23/2024]
Abstract
AIM Patients undergoing dialysis are at high risk for coronavirus disease 2019 (COVID-19). Haemoglobin (Hb) levels may be changed in patients infected with the Omicron variant of COVID-19 who are undergoing peritoneal dialysis (PD). Therefore, we aimed to explore the effect of anti-anaemia treatment on such patients. METHODS This study enrolled patients undergoing PD who were infected with the Omicron variant of COVID-19 at our centre between November 2022 and February 2023. We retrospectively analysed changes in Hb levels and explored the effectiveness of roxadustat and recombinant human erythropoietin (rhEPO) for patients infected with the Omicron variant of COVID-19. RESULTS Among 125 enrolled patients, 83 (66.4%) were infected with the Omicron variant and 75 (90.4%) patients mainly experienced mild or moderate disease. During infection, C-reactive protein (CRP) levels were higher than those before infection (p < .001). Additionally, their CRP levels were negatively correlated with Hb levels (p = .002). However, Hb levels were decreased 1 month after infection (109.61 ± 10.64 g/L vs. 115.69 ± 12.04 g/L; p < .001). The roxadustat treatment group did not exhibit significantly decreased Hb levels 1 month after infection (114.57 ± 14.11 vs. 117.51 ± 10.74 g/L; p = .225). Conversely, the rhEPO treatment group experienced a mild decrease in Hb levels (108.69 ± 11.20 vs. 115.03 ± 12.23 g/L; p = .001). Ferritin levels increased in both groups during infection (p = .495). Two months after infection, ferritin levels (median, 205.0 ng/mL) were significantly decreased compared with during infection (median, 377.4 ng/mL) (p < .001) in the roxadustat treatment group. CONCLUSION Roxadustat was effective than rhEPO for treating anaemia in patients undergoing PD who were infected with the Omicron variant of COVID-19.
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Affiliation(s)
- Qinghua Yang
- Department of Nephrology, Peking University International Hospital, Beijing, People's Republic of China
| | - Xiaowan Fang
- Department of Nephrology, Peking University International Hospital, Beijing, People's Republic of China
| | - Xiaoying Ren
- Department of Nephrology, Peking University International Hospital, Beijing, People's Republic of China
| | - Yujing Pan
- Department of Nephrology, Peking University International Hospital, Beijing, People's Republic of China
| | - Mei Wang
- Department of Nephrology, Peking University International Hospital, Beijing, People's Republic of China
| | - Jiaxiang Ding
- Department of Nephrology, Peking University International Hospital, Beijing, People's Republic of China
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4
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Yang C, Wei Z, Shi W, Xing J, Zhang X. SNF472: a novel therapeutic agent for vascular calcification and calciphylaxis. J Nephrol 2024:10.1007/s40620-024-01909-8. [PMID: 38512376 DOI: 10.1007/s40620-024-01909-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/15/2024] [Indexed: 03/23/2024]
Abstract
Vascular calcification is a common complication in patients with chronic kidney disease (CKD) and is strongly associated with an increased risk of cardiovascular events and all-cause mortality. Calciphylaxis is a specific and life-threatening manifestation of vascular calcifications that usually affects individuals with advanced kidney function impairment or those undergoing dialysis. Currently, the treatment of vascular calcification and calciphylaxis in CKD lacks approved treatments and focuses on controlling risk factors. SNF472, the intravenous formulation of myo-inositol hexaphosphate, is a novel vascular calcification inhibitor currently undergoing phase 3 clinical trials, demonstrating its ability to directly inhibit the formation of calcium and phosphorus crystals, thereby blocking the production and deposition of ectopic calcium. The efficacy and safety of SNF472 in inhibiting vascular calcification have been confirmed in recent clinical studies. This review summarizes the results of studies related to SNF472 to provide a comprehensive overview of its mechanism of action, efficacy, safety, and ongoing clinical studies.
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Affiliation(s)
- Canlin Yang
- Department of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhiyuan Wei
- Department of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Wen Shi
- Department of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jie Xing
- Department of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xiaoliang Zhang
- Department of Nephrology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China.
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5
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Turner ME, Beck L, Hill Gallant KM, Chen Y, Moe OW, Kuro-o M, Moe S, Aikawa E. Phosphate in Cardiovascular Disease: From New Insights Into Molecular Mechanisms to Clinical Implications. Arterioscler Thromb Vasc Biol 2024; 44:584-602. [PMID: 38205639 PMCID: PMC10922848 DOI: 10.1161/atvbaha.123.319198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Hyperphosphatemia is a common feature in patients with impaired kidney function and is associated with increased risk of cardiovascular disease. This phenomenon extends to the general population, whereby elevations of serum phosphate within the normal range increase risk; however, the mechanism by which this occurs is multifaceted, and many aspects are poorly understood. Less than 1% of total body phosphate is found in the circulation and extracellular space, and its regulation involves multiple organ cross talk and hormones to coordinate absorption from the small intestine and excretion by the kidneys. For phosphate to be regulated, it must be sensed. While mostly enigmatic, various phosphate sensors have been elucidated in recent years. Phosphate in the circulation can be buffered, either through regulated exchange between extracellular and cellular spaces or through chelation by circulating proteins (ie, fetuin-A) to form calciprotein particles, which in themselves serve a function for bulk mineral transport and signaling. Either through direct signaling or through mediators like hormones, calciprotein particles, or calcifying extracellular vesicles, phosphate can induce various cardiovascular disease pathologies: most notably, ectopic cardiovascular calcification but also left ventricular hypertrophy, as well as bone and kidney diseases, which then propagate phosphate dysregulation further. Therapies targeting phosphate have mostly focused on intestinal binding, of which appreciation and understanding of paracellular transport has greatly advanced the field. However, pharmacotherapies that target cardiovascular consequences of phosphate directly, such as vascular calcification, are still an area of great unmet medical need.
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Affiliation(s)
- Mandy E. Turner
- Division of Cardiovascular Medicine, Department of Medicine, Center for Interdisciplinary Cardiovascular Sciences, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Laurent Beck
- Nantes Université, CNRS, Inserm, l’institut du thorax, F-44000 Nantes, France
| | - Kathleen M Hill Gallant
- Department of Food Science and Nutrition, University of Minnesota, St. Paul, Minnesota, USA
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yabing Chen
- Department of Pathology, University of Alabama at Birmingham
- Research Department, Veterans Affairs Birmingham Medical Center, Birmingham, AL, USA
| | - Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Physiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Makoto Kuro-o
- Division of Anti-aging Medicine, Center for Molecular Medicine, Jichi Medical University 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Sharon Moe
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Elena Aikawa
- Division of Cardiovascular Medicine, Department of Medicine, Center for Interdisciplinary Cardiovascular Sciences, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Department of Medicine, Center for Excellence in Vascular Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Abdalla M, Faris ME, Saad E, Meng Q, Friedman H, Soifer N. Profound metabolic acidosis in association with sodium thiosulfate therapy in a patient with calcific uremic arteriolopathy: a case report and literature review. CEN Case Rep 2024; 13:59-65. [PMID: 37273129 PMCID: PMC10834920 DOI: 10.1007/s13730-023-00801-x] [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: 03/01/2023] [Accepted: 05/15/2023] [Indexed: 06/06/2023] Open
Abstract
Calciphylaxis, also known as Calcific uremic arteriolopathy (CUA), is a serious disorder that presents with skin necrosis due to calcification of dermal and subcutaneous adipose tissue capillaries and arterioles. The condition occurs primarily in patients with end-stage renal disease (ESRD) on dialysis, and it carries high morbidity and mortality, primarily due to sepsis, with an estimated six-month survival of approximately 50%. Although there are no high-quality studies to guide the optimal treatment approach for patients with calciphylaxis, many retrospective studies and case series support treatment with sodium thiosulfate (STS). Despite the frequent use of STS as an off-label treatment, data regarding its safety and efficacy are limited. STS has generally been considered a safe drug with mild side effects. However, severe metabolic acidosis associated with STS is a rare and life-threatening complication of STS treatment and is often unpredictable. Herein, we report a 64-year-old female with ESRD on peritoneal dialysis (PD) who presented with a profound high anion gap metabolic acidosis and severe hyperkalemia while on STS treatment for CUA. No other etiology for her severe metabolic acidosis other than STS was identified. ESRD patients receiving STS should be monitored closely for this side effect. Dose reduction, increasing the duration of infusion, or even discontinuing STS treatment should be considered if severe metabolic acidosis develops.
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Affiliation(s)
- Mohammed Abdalla
- Medical Residents, Department of Internal Medicine, Ascension Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA.
| | - Mohammed Elamin Faris
- Medical Residents, Department of Internal Medicine, Ascension Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Eltaib Saad
- Medical Residents, Department of Internal Medicine, Ascension Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Qingqing Meng
- Medical Residents, Department of Internal Medicine, Ascension Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Harvey Friedman
- Pulmonary and Critical Care Attending, Department of Critical Care and Pulmonology, Ascension Saint Francis Hospital, Evanston, IL, USA
| | - Neil Soifer
- Lakeside Nephrology, Ascension Saint Francis Hospital, Evanston, IL, USA
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7
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Al-Khazraji Y, Al-Khazraji M, Oluaderounmu O, Quintanilla B. Progression of Skin Ulcer Secondary to Calciphylaxis in a Patient With End-Stage Renal Disease (ESRD) on Hemodialysis and the Therapeutic Approach. Cureus 2024; 16:e55161. [PMID: 38558589 PMCID: PMC10980508 DOI: 10.7759/cureus.55161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
Calciphylaxis is a rare and severe medical condition characterized by the calcification of small blood vessels and soft tissues, leading to tissue damage, skin ulcers, and intense pain. It most commonly affects individuals with underlying health conditions such as kidney disease, particularly end-stage renal disease (ESRD), and is associated with high mortality rates. Understanding the diagnosis and management of calciphylaxis is crucial for improving patient outcomes. Diagnosing calciphylaxis can be challenging due to its rarity and overlapping symptoms with other skin conditions. Healthcare professionals typically use a combination of clinical evaluation and diagnostic tests to reach a conclusive diagnosis. The management of calciphylaxis is multifaceted and typically involves a collaborative effort between various healthcare specialists, including nephrologists, dermatologists, and wound care experts. The primary goals of treatment are to alleviate pain, promote wound healing, address underlying causes, and prevent further complications.
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8
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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.
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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
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9
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Yu Y, Chen Y, Yang F, Song Q. Black necrosis of the glans penis associated with calciphylaxis: A case report. Medicine (Baltimore) 2023; 102:e35609. [PMID: 37861559 PMCID: PMC10589551 DOI: 10.1097/md.0000000000035609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/21/2023] [Indexed: 10/21/2023] Open
Abstract
RATIONALE Calciphylaxis, known as calcific uremic arteriolopathy, is a rare cause of dry gangrene. Despite an increase in the clinical recognition of demographic characteristics and risk factors associated with calciphylaxis, it remains a poorly understood disease with high mortality. PATIENT CONCERNS AND DIAGNOSES We present a 45-year-old man, who was diagnosed with calciphylaxis disease, with a history of diabetes mellitus, end-stage renal disease and cirrhosis with a half-month evolution of painful dry gangrene on his glans penis and scrotum. The patient also presented with gangrene of fingers. INTERVENTIONS AND OUTCOMES The patient and his family opted for palliative care. However, he died eventually. LESSONS This case contributed to the current understanding of calciphylaxis. Since no standard treatment is available and the prognosis remained poor, early, and accurate diagnosis of calciphylaxis is important. We here report the current case and provide data for the diagnosis and treatment of this kind of disease.
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Affiliation(s)
- Youwei Yu
- Department of Emergency Medicine, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Yangxi Chen
- Department of Emergency Medicine, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Fan Yang
- Department of Emergency Medicine, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Qitai Song
- Department of Emergency Medicine, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
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10
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Liang S, Guan M, Liu Z, Ruan X, Huang H, Zhong H. Sailing between scylla and charybdis-anticoagulation dilemma in a patient with calciphylaxis and mechanical cardiac valve replacement: a case report and literature review. Ren Fail 2023; 45:2264401. [PMID: 37799073 PMCID: PMC10561572 DOI: 10.1080/0886022x.2023.2264401] [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: 08/22/2023] [Accepted: 09/23/2023] [Indexed: 10/07/2023] Open
Abstract
Calciphylaxis is a rare and life-threatening condition in patients with end-stage kidney disease (ESKD). In this case report, we reported a 72-year-old female who had undergone aortic and mitral mechanical valve replacement 22 years ago due to rheumatic aortic and mitral stenosis. Following the valve replacement, she initiated warfarin treatment. Five years ago, she received a diagnosis of uremia and has since been undergoing regular hemodialysis. Ten months prior to her current admission, she experienced excruciating pain and was diagnosed with calciphylaxis. Additionally, an electrocardiogram revealed atrial fibrillation, while echocardiography indicated that the aortic and mitral mechanical valves were appropriately positioned, with normal perivalvular surroundings and good valve leaflet activity. No noticeable thrombosis was observed in the left atrium or left atrial appendage. Color Doppler imaging showed moderate stenosis in the lower extremity arteries, with no venous thromboembolism present. Extensive eggshell-like calcification within the arterial media was detected. The patient was managed with regular hemodialysis, symptomatic treatments (including anticoagulation and analgesia), and sodium thiosulfate. Unfortunately, symptomatic management provided limited relief, and during the one-month follow-up period, the patient passed away due to septic shock. Currently, there is insufficient conclusive evidence regarding alternative influential anticoagulants or appropriate prosthetic valve selection. For individuals with ESKD receiving maintenance hemodialysis, early identification, diagnosis, and treatment of calciphylaxis are of paramount importance.
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Affiliation(s)
- Shichu Liang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Mingjing Guan
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyue Liu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaomiao Ruan
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - He Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hui Zhong
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
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11
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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.
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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
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12
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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.
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Affiliation(s)
| | - Yara Hodifa
- Faculty of Medicine, Damascus University, Damascus, Syria
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Smith R, Bulteel N, Alfonzo A, Gupta S. Successful treatment of severe calciphylaxis in a renal transplant patient with previous total parathyroidectomy. J R Coll Physicians Edinb 2023; 53:207-211. [PMID: 37427771 DOI: 10.1177/14782715231184519] [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: 07/11/2023] Open
Abstract
Calciphylaxis is a rare dermatological condition strongly associated with chronic kidney disease. The pathophysiology and optimum treatment remain uncertain. Calciphylaxis is known mostly to affect dialysis patients but is less frequently reported in renal transplant recipients. We report the case of a renal transplant recipient who had undergone previous total parathyroidectomy.
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Affiliation(s)
- Rachel Smith
- Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
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14
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Gossett C, Suppadungsuk S, Krisanapan P, Tangpanithandee S, Thongprayoon C, Mao MA, Cheungpasitporn W. Sodium Thiosulfate for Calciphylaxis Treatment in Patients on Peritoneal Dialysis: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1306. [PMID: 37512116 PMCID: PMC10386543 DOI: 10.3390/medicina59071306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/08/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023]
Abstract
Limited data are available on the utilization of sodium thiosulfate (STS) treatment for calciphylaxis in peritoneal dialysis (PD) patients, while it is well-studied in hemodialysis (HD) patients. A systematic literature search was conducted using Ovid MEDLINE, EBM Reviews-Cochrane Central Register of Controlled Trials, and EBM Reviews-Cochrane Database of Systematic Reviews to identify reported cases of PD patients with calciphylaxis who received STS. The search covered the inception of the databases through August 2022. Across 19 articles, this review identified 30 PD patients with calciphylaxis who received STS. These included 15 case reports, 2 case series, and 2 cohort studies. The administration routes and doses varied depending on the study. For intravenous (IV) administration (n = 18), STS doses ranged from 3.2 g twice daily to 25 g three times weekly for 5 weeks to 8 months. Outcomes included 44% of patients experiencing successful wound healing, 6% discontinuing STS due to adverse effects, 67% transitioning to HD, and 50% dying from calciphylaxis complications. For intraperitoneal (IP) administration (n = 5), STS doses ranged from 12.5 to 25 g three to four times weekly for 12 h to 3 months. Results showed 80% of patients achieving successful wound healing, 80% discontinuing STS due to adverse effects, 40% transitioning to HD, and 20% dying from IP STS-related chemical peritonitis. In cases where patients switched from IV to IP STS (n = 3), doses ranged from 12.5 to 25 g two to three times weekly for 2.5 to 5 months. Among them, 67% experienced successful wound healing, while 33% died from sepsis. Two cases utilized oral STS at a dose of 1500 mg twice daily for 6 and 11 months, resulting in successful wound healing without adverse effects or need for HD. However, one patient (50%) died due to small bowel obstruction. This systematic review provides an overview of STS treatment for PD patients with calciphylaxis. Although successful treatment cases exist, adverse effects were significant. Further research, including larger clinical studies and pharmacokinetic data, is necessary to establish the optimal route, dose, and efficacy of STS in PD patients.
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Affiliation(s)
- Christy Gossett
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
| | - Supawadee Suppadungsuk
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10400, Thailand
| | - Pajaree Krisanapan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine Thammasat University, Pathum Thani 12120, Thailand
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10400, Thailand
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL 32224, USA
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15
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Zhou Y, Chen Y, Yin G, Xie Q. Calciphylaxis and its co-occurrence with connective tissue diseases. Int Wound J 2023; 20:1316-1327. [PMID: 36274216 PMCID: PMC10031236 DOI: 10.1111/iwj.13972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/23/2022] [Accepted: 09/27/2022] [Indexed: 03/23/2023] Open
Abstract
Calciphylaxis, also known as calcific uremic arteriopathy, is a rare calcification syndrome that presents as ischemic skin necrosis and severe pain. It has a high mortality rate and is characterised by calcification of the small and medium arteries and micro-thrombosis. Calciphylaxis mainly occurs in patients with end-stage renal disease. In recent years, there have been an increasing number of cases of calciphylaxis associated with connective tissue diseases. Given the absence of clear diagnostic criteria for calciphylaxis thus far, an early diagnosis is crucial for designing an effective multidisciplinary treatment plan. In this article, we review the research progress on calciphylaxis and describe its characteristics in the context of connective tissue diseases.
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Affiliation(s)
- Yueyuan Zhou
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuehong Chen
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Geng Yin
- Department of General Practice, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qibing Xie
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
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16
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Wu J, Chen L, Dang F, Zha P, Li R, Ran X. Refractory wounds induced by normal-renal calciphylaxis: An under-recognised calcific arteriolopathy. Int Wound J 2023; 20:1262-1275. [PMID: 36068658 PMCID: PMC10031205 DOI: 10.1111/iwj.13951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/21/2022] [Accepted: 08/22/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Normal-renal calciphylaxis (NRC) is a devastating calcific vasculopathy characterised by refractory wounds. It is more likely to be misdiagnosed because of the absence of renal insufficiency. Failure to effectively control may lead to rapid deterioration and ultimately death. However, current knowledge of it is still inadequate. OBJECTIVES To provide a relatively comprehensive review of NRC. METHODS Nine electronic medical databases including PubMed, Web of Science, Embase, the Cochrane Library and so on were searched from inception to April 1, 2022. Articles in which calciphylaxis was diagnosed in patients with normal renal function were included. RESULTS Totally 140 articles were retrieved with 187 patients (median age, 62 years [IQR, 49.63 ~ 75.70 years]; 83.42% female; 84.5% Caucasian). Vitamin K antagonism (43.32%) and diabetes (39.57%) accounted for most of the concomitant factors. Cutaneous presentations were the most common. Pathological confirmation was made in 97.86% of patients with an accuracy of 99.45%. Multidisciplinary therapeutic strategies were usually implemented while the final prognosis was not ideal, with a 6-month mortality rate of 21.10% and a 1-year mortality rate of 27.52%. CONCLUSION NRC is an under-recognised disease caused by a variety of factors; meanwhile, multidisciplinary efforts are required to inform diagnostic and therapeutic decisions.
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Affiliation(s)
- Jing Wu
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Lihong Chen
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Fangping Dang
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing/Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Panpan Zha
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Rao Li
- West China School of Nursing/Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Xingwu Ran
- Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing/Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
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17
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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.
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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
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18
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Chinnappan J, Aguirre J, Marcus H, Azher Q, Bachuwa G. A Fatal Case of Systemic Calciphylaxis in the Gastrointestinal Tract: A Case Report and Literature Review. Cureus 2023; 15:e36641. [PMID: 37101995 PMCID: PMC10123329 DOI: 10.7759/cureus.36641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 04/28/2023] Open
Abstract
Calciphylaxis is an infrequent yet lethal disease often associated with end-stage kidney disease (ESKD). The most common sites include proximal and distal extremities and the trunk, with few reported in the penis and very few as gastrointestinal (GI) disease. We report a case of systemic calciphylaxis in a middle-aged male, presenting with a colostomy leak and parastomal abscess. Workup revealed severe calcification of the intestinal arteries and ischemic colon necrosis. The patient underwent colectomy, antibiotic therapy, regular hemodialysis (HD), and sodium thiosulphate infusion with clinical stability. Histopathology of the colon revealed ischemic necrosis and pericolonic vessel calcification suggestive of calciphylaxis. It is an important differential to be considered in patients with risk factors presenting with symptoms of gastrointestinal hemorrhage and necrosis with perforation.
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Affiliation(s)
- Justine Chinnappan
- Internal Medicine, Hurley Medical Center - Michigan State University, Flint, USA
| | - Jesus Aguirre
- Internal Medicine, Hurley Medical Center - Michigan State University, Flint, USA
| | - Huda Marcus
- Internal Medicine, Hurley Medical Center - Michigan State University, Flint, USA
| | - Qazi Azher
- Pathology, Hurley Medical Center - Michigan State University, Flint, USA
| | - Ghassan Bachuwa
- Internal Medicine, Hurley Medical Center - Michigan State University, Flint, USA
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19
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Shabani J, Shah V, Jaiswal V, Sharma A, Song D. Chronic skin ulcers in hemodialysis patient: A fatal case of calciphylaxis. Radiol Case Rep 2023; 18:1522-1526. [PMID: 36824989 PMCID: PMC9941061 DOI: 10.1016/j.radcr.2023.01.053] [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: 12/22/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 02/10/2023] Open
Abstract
Calciphylaxis is a rare and deadly vascular disease with poorly understood pathophysiology and without definitive treatment. Early presentations include skin ulcers with risk factors including end stage renal disease on hemodialysis, hypertension, hyperlipidemia, and diabetes mellitus. In our case, we present an 80-year-old female with multiple risk factors including hemodialysis and clinical features of necrotic and gangrenous skin lesions diagnostic of calciphylaxis who became hemodynamically unstable and ultimately expired secondary to toxic sequelae. We illustrate this case to explore early clinical presentation, limitations of current disease management and treatments, and the role for further studies to improve diagnosis and reduce mortality.
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Affiliation(s)
- Jawad Shabani
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center, Queens, NY, USA
| | - Vaibhav Shah
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center, Queens, NY, USA
| | - Vikash Jaiswal
- Larkin Community Hospital, South Miami, FL, 33143, USA,Corresponding author at: Larkin Community Hospital, South Miami, FL, 33143, USA.
| | - Akanksha Sharma
- Department of Internal Medicine, UPMC Mercy, Pittsburg, PA, USA
| | - David Song
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center, Queens, NY, USA
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20
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Gallo Marin B, Aghagoli G, Hu SL, Massoud CM, Robinson-Bostom L. Calciphylaxis and Kidney Disease: A Review. Am J Kidney Dis 2023; 81:232-239. [PMID: 35970430 DOI: 10.1053/j.ajkd.2022.06.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/28/2022] [Indexed: 01/25/2023]
Abstract
Calciphylaxis is a life-threatening complication most often associated with chronic kidney disease that occurs as a result of the deposition of calcium in dermal and adipose microvasculature. However, this condition may also be seen in patients with acute kidney injury. The high morbidity and mortality rates associated with calciphylaxis highlight the importance to correctly diagnose and treat this condition. However, calciphylaxis remains a diagnosis that may be clinically challenging to make. Here, we review the literature on uremic calciphylaxis with a focus on its pathophysiology, clinical presentation, advances in diagnostic tools, and treatment strategies. We also discuss the unique histopathological features of calciphylaxis and contrast it with those of other forms of general vessel calcification. This review emphasizes the need for multidisciplinary collaboration including nephrology, dermatology, and palliative care to ultimately provide the best possible care to patients with calciphylaxis.
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Affiliation(s)
- Benjamin Gallo Marin
- Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ghazal Aghagoli
- Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Susie L Hu
- Division of Kidney Disease and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Cathy M Massoud
- Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Leslie Robinson-Bostom
- Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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21
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Wen W, Krinsky S, Kroshinsky D, Durant O, He J, Seethapathy R, Hillien SAS, Mengesha B, Malhotra R, Chitalia V, Nazarian RM, Goverman J, Lyons KS, Nigwekar SU. Patient-Reported and Clinical Outcomes Among Patients With Calciphylaxis. Mayo Clin Proc Innov Qual Outcomes 2023; 7:81-92. [PMID: 36712824 PMCID: PMC9880339 DOI: 10.1016/j.mayocpiqo.2022.12.006] [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] [Indexed: 01/26/2023] Open
Abstract
Objective To describe the pain intensity among hospitalized patients with calciphylaxis, elucidate the factors associated with pain improvement, and examine the link between pain improvement and clinical outcomes. Patients and Methods Patients were identified from the Partners Research Patient Data Registry and the Partners Calciphylaxis Registry and Biorepository (Clinicaltrials.gov ID: NCT03032835). Those with calciphylaxis requiring hospitalization for at least 14 consecutive days during the study period from May 2016 through December 2021 were included. Pain intensity was assessed using patient-reported pain scores on numerical rating scales from 0 to 10. Associations between pain improvement and clinical outcomes, including lesion improvement, amputation, and mortality, were examined using univariate and multivariate regression models. Results Our analysis included 111 patients (age, 58±14 years; men, 40%; on maintenance dialysis, 79%). No significant improvement of pain intensity was observed over the 14 days of hospitalization (mean difference, -0.71; P=.08). However, among 49 (44.1%) patients who showed at least 1-point improvement in the pain score, there was an association with surgical debridement during hospitalization (odds ratio, 3.37; 95% CI, 1.17-9.67; P=.02). Hyperbaric oxygen therapy was associated with pain improvement (odds ratio, 5.38; 95% CI, 1.14-25.50; P=.03) in patients on maintenance dialysis. Pain improvement was associated with lower rates of subsequent amputation at 6 months of follow up (6% vs 13%; P<.05) but did not predict lesion improvement or survival. Conclusion Pain control remains a challenge among hospitalized patients with calciphylaxis. Surgical debridement and hyperbaric oxygen therapy may improve pain intensity. Pain improvement predicted a lower risk of future amputation.
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Affiliation(s)
- Wen Wen
- Division of Nephrology, Massachusetts General Hospital, Boston, MA,Correspondence: Address to Wen Wen, MD, MMSc, Division of Nephrology, Massachusetts General Hospital, 165 Cambridge St, Suite 302, Boston, MA 02114.
| | - Scott Krinsky
- Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | | | - Olivia Durant
- Bouvé College of Health Sciences, Northeastern University, Boston, MA
| | | | | | | | - Beza Mengesha
- Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Rajeev Malhotra
- Cardiovascular Research Center and the Cardiology Division of the Department of Medicine, Massachusetts General Hospital, Boston, MA,Cardiovascular Research Center and the Cardiology Division of the Department of Medicine, Harvard Medical School, Boston, MA
| | - Vipul Chitalia
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA,Veterans Affairs Boston Healthcare System, Boston, MA,Institute of Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA
| | | | - Jeremy Goverman
- Sumner Redstone Burn Center, Massachusetts General Hospital, Boston, MA
| | - Karen S. Lyons
- William F. Connell School of Nursing, Boston College, Chestnut Hill, MA
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22
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Roberson JL, Butt Z, Florez-Pollack S, Morgan E, Rosenbach M, Braslow BM, Yelon JA. An Intensive Multidisciplinary Approach in Management of Extensive Nonuremic Calciphylaxis of the Bilateral Lower Extremities with Angioinvasive Fungus and Mold. J Burn Care Res 2023; 44:218-221. [PMID: 36269818 DOI: 10.1093/jbcr/irac158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Indexed: 01/11/2023]
Abstract
Management of infected wounds related to calciphylaxis poses a significant clinical challenge with high morbidity and mortality. Given no definitive management guidelines exist specific to nonuremic calciphylaxis, multiple modalities including sodium thiosulfate, antibiotics, hyperbaric oxygen therapy, and surgical debridement with wound care must be considered. When occurring over a large surface area, standard daily dressing changes are especially labor intensive, inefficient, and ineffective. Negative pressure wound therapy with instillation and dwell time offers broad wound coverage with ongoing therapeutic benefit. We present the case of a previously healthy 19-year-old woman who was transferred for tertiary level care of extensive nonuremic calciphylaxis wounds of the bilateral lower extremities complicated by angioinvasive coinfection with fungus and mold that was managed with a multidisciplinary approach of intensive medical management, aggressive surgical debridement, and negative pressure wound therapy with instillation of hypochlorous acid solution. Ultimately, she achieved full granulation and wound coverage with skin grafting. Large area, infected wounds related to nonuremic calciphylaxis can be successfully managed with multidisciplinary medical management, aggressive surgical debridement, and negative pressure wound therapy that can instill and dwell hypochlorous acid solution.
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Affiliation(s)
- Jeffrey L Roberson
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zoya Butt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie Florez-Pollack
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Morgan
- Department of Pathology & Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Misha Rosenbach
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin M Braslow
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jay A Yelon
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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23
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Sutton NR, Malhotra R, Hilaire C, Aikawa E, Blumenthal RS, Gackenbach G, Goyal P, Johnson A, Nigwekar SU, Shanahan CM, Towler DA, Wolford BN, Chen Y. Molecular Mechanisms of Vascular Health: Insights From Vascular Aging and Calcification. Arterioscler Thromb Vasc Biol 2023; 43:15-29. [PMID: 36412195 PMCID: PMC9793888 DOI: 10.1161/atvbaha.122.317332] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/11/2022] [Indexed: 11/23/2022]
Abstract
Cardiovascular disease is the most common cause of death worldwide, especially beyond the age of 65 years, with the vast majority of morbidity and mortality due to myocardial infarction and stroke. Vascular pathology stems from a combination of genetic risk, environmental factors, and the biologic changes associated with aging. The pathogenesis underlying the development of vascular aging, and vascular calcification with aging, in particular, is still not fully understood. Accumulating data suggests that genetic risk, likely compounded by epigenetic modifications, environmental factors, including diabetes and chronic kidney disease, and the plasticity of vascular smooth muscle cells to acquire an osteogenic phenotype are major determinants of age-associated vascular calcification. Understanding the molecular mechanisms underlying genetic and modifiable risk factors in regulating age-associated vascular pathology may inspire strategies to promote healthy vascular aging. This article summarizes current knowledge of concepts and mechanisms of age-associated vascular disease, with an emphasis on vascular calcification.
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Affiliation(s)
- Nadia R. Sutton
- Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Rajeev Malhotra
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA USA
| | - Cynthia Hilaire
- Division of Cardiology, Departments of Medicine and Bioengineering, Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, University of Pittsburgh, 1744 BSTWR, 200 Lothrop St, Pittsburgh, PA, 15260 USA
| | - Elena Aikawa
- Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease; Baltimore, MD
| | - Grace Gackenbach
- Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Adam Johnson
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA USA
| | - Sagar U. Nigwekar
- Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA USA
| | - Catherine M. Shanahan
- School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London, London, UK
| | - Dwight A. Towler
- Department of Medicine | Endocrine Division and Pak Center for Mineral Metabolism Research, UT Southwestern Medical Center, Dallas, TX USA
| | - Brooke N. Wolford
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Yabing Chen
- Department of Pathology, University of Alabama at Birmingham and Research Department, Veterans Affairs Birmingham Medical Center, Birmingham, AL, USA
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24
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Gholizadeh Ghozloujeh Z, Rajasekaran A, Abdipour A, Norouzi S. Calciphylaxis in a Patient With Lupus Nephritis and Acute Kidney Injury: A Rare Case Report and Literature Review. J Investig Med High Impact Case Rep 2023; 11:23247096231215705. [PMID: 38097351 PMCID: PMC10725146 DOI: 10.1177/23247096231215705] [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: 08/24/2023] [Revised: 10/19/2023] [Accepted: 11/03/2023] [Indexed: 12/18/2023] Open
Abstract
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.
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25
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[Evolution of the incidence and results at 12 months of parathyroidectomy: 40 years of experience in a dialysis center with two successive surgical departments]. Nephrol Ther 2022; 18:616-626. [PMID: 36328900 DOI: 10.1016/j.nephro.2022.07.400] [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: 07/21/2021] [Revised: 05/18/2022] [Accepted: 07/19/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Secondary hyperparathyroidism remains the main complication of mineral and bone metabolism in patients with chronic kidney disease. In case of resistance to medical treatment (native and active vitamin D, calcium and calcimimetics), surgical parathyroidectomy is indicated. The aim of this retrospective study is to show the evolution of the incidence and results of surgical parathyroidectomy in our center between 1980 and 2020 as patient characteristics, diagnostic and therapeutic strategies have changed. PATIENTS AND METHODS We collected data from dialysis patients who had a first surgical parathyroidectomy between 2000 and 2020 (period 2) in the same surgical department and compared them with historical data between 1980 and 1999 (period 1) operated in one other center. RESULTS In period 1, 53 surgical parathyroidectomy were performed (2.78/year, 0 to 5, 8.5/1000 patients-year) vs.56 surgical parathyroidectomy in period 2 (2.8/year, 0 to 9, 8/1000 patients-year). The patients of the 2 periods were comparable except for the higher dialysis vintage in period 1 (149±170 vs.89±94 months; P=0.02). In comparison with dialysis patients not requiring surgical parathyroidectomy during the same period, patients who had surgical parathyroidectomy were younger, had higher dialysis vintage and lower diabetes prevalence, but more frequently carriers of glomerulopathy or polycystosis. Systematically performed in period 2, cervical ultrasound identified at least one visible gland in 78.6% of cases while the scintigraphy, performed only in 66% of cases, found at least one gland in 81% of cases. Twelve months after surgery, PTH > 300 pg/mL (marker of secondary hyperparathyroidism recurrence or surgery failure) was present in 30% of patients in period 1 vs. 5.3% in period 2. Hypoparathyroidism was also more frequently observed in period 2 (35.7 vs. 18.8%). Surgical complications were also higher in period 1. CONCLUSION Despite therapeutic and strategic advances, severe secondary hyperparathyroidism is still as common as ever. It is favored by excessively high PTH targets, by suboptimal prevention before dialysis and poor tolerance of calcimimetics. The surgical parathyroidectomy is effective and safe in the hands of a specialized team with an ultrasound and scintigraphic preoperative assessment.
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Yang X, Liu Y, Xie X, Shi W, Si J, Li X, Zhang X, Liu B. Use of the optimized sodium thiosulfate regimen for the treatment of calciphylaxis in Chinese patients. Ren Fail 2022; 44:914-922. [PMID: 35634730 PMCID: PMC9154757 DOI: 10.1080/0886022x.2022.2081179] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Xin Yang
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Yuqiu Liu
- 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
| | - Wen Shi
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Jiyi Si
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
| | - Xiaomin Li
- 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,CONTACT Xiaoliang Zhang Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Dingjiaqiao Road, 87th, Nanjing, 210009, China
| | - Bicheng Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, School of Medicine, Nanjing, China
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Issar R, Patwa J, Wang Y. Painless Scrotal Ulcers Become Something Unexpected: A Rare Case of Scrotal Calciphylaxis. Cureus 2022; 14:e28958. [PMID: 36237806 PMCID: PMC9547748 DOI: 10.7759/cureus.28958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2022] [Indexed: 11/05/2022] Open
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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.
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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
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Strand N, Maloney J, Wu S, Kraus M, Schneider R, Gomez D, Char S. Perioperative Management of Calciphylaxis: Literature Review and Treatment Recommendations. Orthop Rev (Pavia) 2022; 14:37573. [DOI: 10.52965/001c.37573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Calciphylaxis is a serious and rare medical condition that leads to substantial clinical manifestations including pain, creating perioperative and treatment challenges. No standard treatment protocol exists nor are comprehensive guidelines available for perioperative management of patients with calciphylaxis. In this review, we evaluate existing literature (January 2000 to May 2021) with the aim to offer guidance for treating patients with this challenging disease through the perioperative period. Although no therapies are currently considered standard for treating calciphylaxis, multiple interventions are available for improving symptoms. Preoperative and intraoperative management involves monitoring and optimizing patient comorbid conditions and any possible electrolyte imbalances. Postoperative management can be challenging when potential calciphylaxis triggers are indicated, such as warfarin and corticosteroids. In addition, poor wound healing and difficult pain control are common. Therefore, a multifactorial approach to controlling postoperative pain is recommended that includes the use of nerve blocks, renal-sparing opioids, benzodiazepines, and/or ketamine. We present preoperative, intraoperative, and postoperative recommendations for treating calciphylaxis with levels of evidence when appropriate.
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Sponseller BT, Wong DM, Ruby R, Ware WA, Wilson S, Haynes JS. Systemic calcinosis in a Quarter Horse gelding homozygous for a myosin heavy chain 1 mutation. J Vet Intern Med 2022; 36:1543-1549. [PMID: 35801821 PMCID: PMC9308413 DOI: 10.1111/jvim.16481] [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: 01/06/2022] [Accepted: 06/16/2022] [Indexed: 12/02/2022] Open
Abstract
Case Description A 9‐year‐old Quarter Horse gelding was presented for lethargy, decreased appetite, polyuria and polydipsia (PU/PD), and severe muscle wasting suggestive of immune‐mediated myositis. Clinical Findings The horse displayed lethargy, fever, tachyarrhythmia, inappetence, PU/PD, and severe epaxial and gluteal muscle wasting. Clinicopathologic findings were consistent with previously reported cases of systemic calcinosis in horses, including increased muscle enzyme activity, hyperphosphatemia, increased calcium‐phosphorus product, hypoproteinemia, and an inflammatory leukogram. A diagnosis of systemic calcinosis was established by histopathologic evaluation of biopsy specimens from skeletal muscle, lung, and kidney. Treatment and Outcome Symptomatic treatment was complemented by IV treatment with sodium thiosulfate to reverse calcium‐phosphate precipitation in soft tissue and PO aluminum hydroxide to decrease intestinal phosphorus absorption and serum phosphorus concentration. Clinical Relevance This is the first report in the veterinary literature of an antemortem diagnosis of systemic calcinosis in the horse that was successfully treated and had favorable long‐term outcome.
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Affiliation(s)
- Beatrice T Sponseller
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, Iowa, USA
| | - David M Wong
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, Iowa, USA
| | - Rebecca Ruby
- Veterinary Diagnostic Laboratory, College of Agriculture, Food and Environment, University of Kentucky, Lexington, Kentucky, USA
| | - Wendy A Ware
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, Iowa, USA
| | - Scott Wilson
- Mid-Atlantic Equine Dentistry, Myrtle Beach, South Carolina, USA
| | - Joseph S Haynes
- Department of Veterinary Pathology, College of Veterinary Medicine, Iowa State University, Ames, Iowa, USA
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Cao Y, Dominic W, Knezevich S, Kochubey M. Multiple Leg Wounds in an Obese Female with Normal Renal Function. Am J Med 2022; 135:e159-e161. [PMID: 35367179 DOI: 10.1016/j.amjmed.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Yangming Cao
- Division of Nephrology, Department of Internal Medicine, UCSF Fresno Center for Medical Education and Research, Fresno, Calif; The Nephrology Group, Fresno, Calif.
| | - William Dominic
- Burn Service, Department of Surgery, UCSF Fresno Center for Medical Education and Research, Fresno, Calif
| | | | - Mariya Kochubey
- Burn Service, Department of Surgery, UCSF Fresno Center for Medical Education and Research, Fresno, Calif
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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.
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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
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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.
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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.
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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
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Zeng ZL, Yuan Q, Zu X, Liu J. Insights Into the Role of Mitochondria in Vascular Calcification. Front Cardiovasc Med 2022; 9:879752. [PMID: 35571215 PMCID: PMC9099050 DOI: 10.3389/fcvm.2022.879752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/14/2022] [Indexed: 12/22/2022] Open
Abstract
Vascular calcification (VC) is a growing burden in aging societies worldwide, and with a significant increase in all-cause mortality and atherosclerotic plaque rupture, it is frequently found in patients with aging, diabetes, atherosclerosis, or chronic kidney disease. However, the mechanism of VC is still not yet fully understood, and there are still no effective therapies for VC. Regarding energy metabolism factories, mitochondria play a crucial role in maintaining vascular physiology. Discoveries in past decades signifying the role of mitochondrial homeostasis in normal physiology and pathological conditions led to tremendous advances in the field of VC. Therapies targeting basic mitochondrial processes, such as energy metabolism, damage in mitochondrial DNA, or free-radical generation, hold great promise. The remarkably unexplored field of the mitochondrial process has the potential to shed light on several VC-related diseases. This review focuses on current knowledge of mitochondrial dysfunction, dynamics anomalies, oxidative stress, and how it may relate to VC onset and progression and discusses the main challenges and prerequisites for their therapeutic applications.
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Affiliation(s)
- ZL Zeng
- Department of Metabolism and Endocrinology, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
- Department of Clinical Medicine, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
- Key Laboratory for Arteriosclerology of Hunan Province, Department of Cardiovascular Disease, Hengyang Medical School, University of South China, Hengyang, China
| | - Qing Yuan
- Department of Metabolism and Endocrinology, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
- Department of Clinical Medicine, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
| | - Xuyu Zu
- Department of Metabolism and Endocrinology, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
- Department of Clinical Medicine, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
- *Correspondence: Xuyu Zu
| | - Jianghua Liu
- Department of Metabolism and Endocrinology, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
- Department of Clinical Medicine, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China
- Jianghua Liu
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Lee CH, Chen JY, Kuo PC, Chen WT. Parathyroidectomy for dialysis patients in the era of calcimimetics: The surgeons' point of view. J Chin Med Assoc 2022; 85:279-285. [PMID: 35259131 DOI: 10.1097/jcma.0000000000000694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Calcimimetics is a new drug for lowering serum parathyroid hormone (PTH), calcium and phosphate in patients with hyperparathyroidism (HPT) on long-term dialysis. It became available on market in 2006. The impact of calcimimetics on the treatment by parathyroidectomy (PTx) was reviewed from the surgeons' point of view. Cure of renal HPT by calcimimetics is not feasible, but calcimimetics can improve preoperative cardiac ventricle ejection fractions by lowering serum PTH. Heart failure is not necessarily a contraindication for PTx. PTx should be done before irreversible organ damage occurs. Limb gangrenes is an ominous sign and should be prevented by frequent checkup for peripheral arterial circulation. The impact of renal osteodystrophy on the quality of life and as indirect cause of mortality deserves more attention in patients with renal HPT. Delayed referral to PTx leads to more complicated patients. A consensus between nephrologists and surgeons about propitious timing for PTx is necessary. Future prospect on the surgical treatment of renal HPT is proposed. Supplemental figure; http://links.lww.com/ASAIO/A782.
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Affiliation(s)
- Chen-Hsen Lee
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Divisions of General Surgery, Departments of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Jui-Yu Chen
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Divisions of General Surgery, Departments of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Po-Chung Kuo
- Divisions of General Surgery, Departments of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wei-Ting Chen
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- National Yang Ming Chiao Tung University Hospital, I-Lan, Taiwan, ROC
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Rick J, Rrapi R, Chand S, Shinohara MM, Strowd L, Pasieka HB, Michelleti R, Kroshinsky D, Ortega-Loayza AG. Calciphylaxis: Treatment and Outlook CME Part II. J Am Acad Dermatol 2022; 86:985-992. [PMID: 35202773 DOI: 10.1016/j.jaad.2021.10.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Jonathan Rick
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Renajd Rrapi
- Harvard Medical School, Cambridge, Massachusetts, USA
| | | | | | | | - Helena B Pasieka
- Georgetown University School of Medicine, Washington, DC, USA; Uniformed Services University School of Medicine, Bethesda, MD, USA
| | - Robert Michelleti
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Qin L, Zhang J, Xiao Y, Liu K, Cui Y, Xu F, Ren W, Yuan Y, Jiang C, Ning S, Ye X, Zeng M, Qian H, Bian A, Li F, Yang G, Tang S, Zhang Z, Dai J, Guo J, Wang Q, Sun B, Ge Y, Ouyang C, Xu X, Wang J, Huang Y, Cui H, Zhou J, Wang M, Su Z, Lu Y, Wu D, Shi J, Liu W, Dong L, Pan Y, Zhao B, Cui Y, Gao X, Gao Z, Ma X, Chen A, Wang J, Cao M, Cui Q, Chen L, Chen F, Yu Y, Ji Q, Zhang Z, Gu M, Zhuang X, Lv X, Wang H, Pan Y, Wang L, Xu X, Zhao J, Wang X, Liu C, Liang N, Xing C, Liu J, Wang N. A novel long-term intravenous combined with local treatment with human amnion-derived mesenchymal stem cells for a multidisciplinary rescued uremic calciphylaxis patient and the underlying mechanism. J Mol Cell Biol 2022; 14:6526318. [PMID: 35142858 PMCID: PMC9205756 DOI: 10.1093/jmcb/mjac010] [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: 07/08/2021] [Revised: 11/23/2021] [Accepted: 02/07/2022] [Indexed: 11/12/2022] Open
Abstract
Calciphylaxis is a rare disease characterized histologically by microvessel calcification and microthrombosis, with high mortality and no proven therapy. Here, we reported a severe uremic calciphylaxis patient with progressive skin ischemia, large areas of painful malodorous ulcers, and mummified legs. Because of the worsening symptoms and signs refractory to conventional therapies, treatment with human amnion-derived mesenchymal stem cells (hAMSCs) was approved. Pre-clinical release inspections of hAMSCs, efficacy, and safety assessment including cytokine secretory ability, immunocompetence, tumorigenicity, and genetics analysis in vitro were introduced. We further performed acute and long-term hAMSC toxicity evaluations in C57BL/6 mice and rats, abnormal immune response tests in C57BL/6 mice, and tumorigenicity tests in neonatal Balbc-nu nude mice. After the pre-clinical research, the patient was treated with hAMSCs by intravenous and local intramuscular injection and external supernatant application to the ulcers. When followed up to 15 months, the blood-based markers of bone and mineral metabolism improved, with skin soft tissue regeneration and a more favorable profile of peripheral blood mononuclear cells. Skin biopsy after 1-month treatment showed vascular regeneration with mature non-calcified vessels within the dermis, and 20 months later, the re-epithelialization restored the integrity of the damaged site. No infusion or local treatment-related adverse events occurred. Thus, this novel long-term intravenous combined with local treatment with hAMSCs warrants further investigation as a potential regenerative treatment for uremic calciphylaxis with effects of inhibiting vascular calcification, stimulating angiogenesis and myogenesis, anti-inflammatory and immune modulation, multi-differentiation, re-epithelialization, and restoration of integrity.
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Affiliation(s)
- Lianju Qin
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Jing Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yujie Xiao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Kang Liu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yugui Cui
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Fangyan Xu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Wenkai Ren
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yanggang Yuan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Chunyan Jiang
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Song Ning
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Xiaoxue Ye
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Hanyang Qian
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Anning Bian
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Fan Li
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Shaowen Tang
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Zhihong Zhang
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Juncheng Dai
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Jing Guo
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Qiang Wang
- Department of Rheumatology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Bin Sun
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yifei Ge
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Chun Ouyang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Xueqiang Xu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Jing Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yaoyu Huang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Hongqing Cui
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Jing Zhou
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Meilian Wang
- Department of Obstetrics, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Zhonglan Su
- Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yan Lu
- Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Di Wu
- Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Jingping Shi
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Wei Liu
- Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Li Dong
- Department of Infection, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yinbing Pan
- Department of Anesthesiology and Pain Management, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Baiqiao Zhao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Department of Nephrology, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Ying Cui
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Department of Nephrology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Xueyan Gao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Department of General Medicine, Geriatric Hospital of Nanjing Medical University, Nanjing, China
| | - Zhanhui Gao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Department of Nephrology, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Xiang Ma
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Aiqin Chen
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Jie Wang
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Meng Cao
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Qian Cui
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Li Chen
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Feng Chen
- Department of Forensic Medicine, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, China
| | - Youjia Yu
- Department of Forensic Medicine, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, China
| | - Qiang Ji
- Department of Forensic Medicine, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, China
| | - Zhiwei Zhang
- Department of Forensic Medicine, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, China
| | - Mufeng Gu
- Department of Human Anatomy, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, China
| | - Xiaojun Zhuang
- Department of Human Anatomy, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, China
| | - Xiaolin Lv
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Hui Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yanyan Pan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Ling Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Xianrong Xu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Jing Zhao
- Department of Outpatient Treatment Clinic, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Xiuqin Wang
- Department of International Cooperation, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Cuiping Liu
- Department of Biological Specimen Repository, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Ningxia Liang
- Academy of Clinical and Translational Research, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Jiayin Liu
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
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O'Beirn E, Muheilan M, Casey R. Penile calciphylaxis-a complicated case managed with circumcision and glansectomy. J Surg Case Rep 2022; 2022:rjab590. [PMID: 35047175 PMCID: PMC8761251 DOI: 10.1093/jscr/rjab590] [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: 11/12/2021] [Accepted: 12/06/2021] [Indexed: 11/14/2022] Open
Abstract
Penile calciphylaxis is a serious manifestation of calcifying uremic arteriolopathy, with only a small number of cases reported in the literature. It is rare, characterized by calcification within the walls of small vessels, resulting in ischaemic changes to the skin, and is mainly seen in patients with end-stage renal failure (ESRF). Management of penile calciphylaxis is difficult, with both conservative and surgical approaches advocated for. Due to their comorbidity profile, patients with penile calciphylaxis can present multiple management challenges. We present a case of penile calciphylaxis in a patient with ESRF who was initially managed conservatively, and then underwent circumcision and glansectomy due to a necrotic glans penis and non-resolving penile pain. The patient was spared a partial penectomy and went on to make a full recovery.
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Affiliation(s)
- Ellen O'Beirn
- Department of Urology, Tallaght University Hospital, Dublin D24NR0A, Ireland
| | - Muheilan Muheilan
- Department of Urology, Tallaght University Hospital, Dublin D24NR0A, Ireland
| | - Rowan Casey
- Department of Urology, Tallaght University Hospital, Dublin D24NR0A, Ireland
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40
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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.
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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
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41
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Smilnak G, Jiang M, Jain B. Calciphylaxis of the penis and distal digits: a case report. J Med Case Rep 2022; 16:18. [PMID: 35039083 PMCID: PMC8764786 DOI: 10.1186/s13256-021-03231-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022] Open
Abstract
Background Calciphylaxis is a rare, often fatal disease resulting from calcification of dermal arterioles and capillaries. Usually diagnosed in patients with end-stage renal disease, this disorder typically presents as necrotic, nonhealing ulcers in acral or adipose areas. Here we report the case of an elderly man who was found to have calciphylaxis of the distal digits and penis, the latter of which is an uncommon site of disease that carries a particularly poor prognosis. Case presentation A 73-year-old African American man with multiple medical comorbidities including dialysis-dependent end-stage renal disease presented with worsening painful, necrotic lesions on his glans penis and several distal digits over the last 2 months. The wound on the glans was foul smelling with overlying purulence and had been unsuccessfully treated with amoxicillin–clavulanic acid. Discovery of diffuse intravascular calcification on computed tomography, in addition to a markedly elevated calcium–phosphate product immediately prior to the onset of his ulcers, led to the diagnosis of calciphylaxis. The patient was initiated on sodium thiosulfate without improvement in his lesions, and he died 3 months later after another prolonged hospitalization. Conclusions While calciphylaxis is a rare disease, involvement of the distal digits and especially the penis is even more uncommon and portends a particularly poor prognosis: 6-month mortality rates are reportedly as high as 70%. This suggests that prompt recognition and management of the disease is required; however, despite receiving standard therapy, our patient failed to experience improvement in his disease and instead developed several more fingertip ulcers at blood glucose sample points during his hospitalization. A corollary of the case presented here is the need for more effective management of calciphylaxis, especially for patients in whom uncommon sites, such as the penis, are involved.
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Affiliation(s)
- Gordon Smilnak
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael Jiang
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Hospital Medicine at Jesse Brown VAMC, Northwestern University Feinberg School of Medicine, 820 S Damen Ave, Suite 7566, Chicago, IL, 60612, USA
| | - Bijal Jain
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Division of Hospital Medicine at Jesse Brown VAMC, Northwestern University Feinberg School of Medicine, 820 S Damen Ave, Suite 7566, Chicago, IL, 60612, USA.
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42
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Lu Y, Shen L, Zhou L, Xu D. Success of small-dose fractionated sodium thiosulfate in the treatment of calciphylaxis in a peritoneal dialysis patient. BMC Nephrol 2022; 23:4. [PMID: 34979980 PMCID: PMC8722146 DOI: 10.1186/s12882-021-02648-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 12/21/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Calciphylaxis, or calcific uremic arteriolopathy (CUA), is a rare, fatal disorder of microvascular calcification and thrombosis that typically affects patients with end-stage renal disease (ESRD) receiving long-term dialysis. Fewer reports describe calciphylaxis in peritoneal dialysis patients than hemodialysis patients as per a literature review. To date, there are no clear guidelines for CUA diagnosis and treatment. While sodium thiosulfate (STS) has been increasingly used for treatment in recent years, there have also been reports of severe side effects. There is no uniform standard for its usage and dosage, especially for peritoneal dialysis patients. CASE PRESENTATION We present a case of a 40-year-old Chinese male patient with ESRD on peritoneal dialysis who developed calciphylaxis with severe painful cutaneous ulcers on the fingers and toes that were managed successfully for 6 months with comprehensive treatment composed mainly of small-dose fractionated sodium thiosulfate. CONCLUSIONS Our experience suggests that the treatment of calciphylaxis requires timely and multi-angle intervention. Treatment with small-dose fractionated sodium thiosulfate has proven effective and tolerated in this patient.
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Affiliation(s)
- Yuan Lu
- Department of Nephrology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215008, Jiangsu, China
| | - Lei Shen
- Department of Nephrology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215008, Jiangsu, China.
| | - Ling Zhou
- Department of Nephrology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215008, Jiangsu, China
| | - Deyu Xu
- Department of Nephrology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215008, Jiangsu, China
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43
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Roy S, Reddy SN, Garcha AS, Vantipalli P, Patel SS, Ur Rahman E, Adapa S. Successful Treatment of Calciphylaxis in a Young Female With End-Stage Renal Disease on Peritoneal Dialysis With Parathyroidectomy, Intensification of Dialysis, and Sodium Thiosulphate-A Case Report and Literature Review. J Investig Med High Impact Case Rep 2021; 9:23247096211060580. [PMID: 34845938 PMCID: PMC8637396 DOI: 10.1177/23247096211060580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Calcific uremic arteriolopathy, commonly referred to as “calciphylaxis,” is a rare life-threatening condition observed in patients with chronic kidney disease and end-stage renal disease on dialysis. This results in necrotic, ischemic, tender dermal lesions anywhere in the body, but mainly on the abdominal wall and lower extremities, where subcutaneous tissue is abundant. Histologically, it is defined by calcification in dermal capillaries, arterioles, and subcutaneous adipose tissues. It can occur in all advanced stages of chronic kidney disease as well as end-stage renal disease patients on hemodialysis or peritoneal dialysis. Our case highlights a successful case of calciphylaxis in a young female patient who underwent parathyroidectomy and intensification of peritoneal dialysis regimen along with the infusion of sodium thiosulphate injection resulting in complete resolution of the lesion in 3 months. With limited evidence of treatment options and increased frequency of this condition in a dialysis patient, our case highlights the key aspects of calciphylaxis management in a young end-stage renal disease patient who didn’t need a change of dialysis modality. We also review the risk factors and current practiced management options of this condition in our article.
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Affiliation(s)
- Sasmit Roy
- University of Virginia, Charlottesville, USA
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44
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Gabel CK, Blum AE, François J, Chakrala T, Dobry AS, Garza-Mayers AC, Ko LN, Nguyen ED, Shah R, John JS, Nigwekar SU, Kroshinsky D. Clinical mimickers of calciphylaxis: A retrospective study. J Am Acad Dermatol 2021; 85:1520-1527. [PMID: 33744358 DOI: 10.1016/j.jaad.2021.03.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/25/2021] [Accepted: 03/06/2021] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Colleen K Gabel
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Amy E Blum
- Harvard Medical School, Boston, Massachusetts
| | | | - Teja Chakrala
- Narayana Medical College and Hospital, Nellore, India
| | - Allison S Dobry
- Department of Dermatology, University of California, Irvine School of Medicine, Irvine, California
| | | | - Lauren N Ko
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Emily D Nguyen
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Radhika Shah
- Department of Dermatology, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jessica St John
- Department of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sagar U Nigwekar
- Department of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts.
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45
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Wylie NS, Sokumbi O, Starr JS. Painful Eruptions in a Patient With Cholangiocarcinoma Treated With Fibroblast Growth Factor Receptor Inhibitor. JAMA Oncol 2021; 7:1891-1892. [PMID: 34709371 DOI: 10.1001/jamaoncol.2021.5578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Natasha S Wylie
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida
| | - Olayemi Sokumbi
- Department of Dermatology, Mayo Clinic, Jacksonville, Florida
| | - Jason S Starr
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida
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46
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From the Old, the Best: Parathyroidectomy in the Management of Soft-Tissue and Vascular Calcification in Patients with Chronic Renal Disease. Case Rep Nephrol 2021; 2021:9985308. [PMID: 34796031 PMCID: PMC8595030 DOI: 10.1155/2021/9985308] [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: 03/16/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction. Bone mineral disease in patients with chronic kidney disease (CKD-MBD) is a clinical syndrome involving bone, biochemical changes, and extraosseous calcification. These complications increase morbidity and mortality. Prevalence reports are rare. Case Report. This case shows a young woman on peritoneal dialysis (PD) for 10 years with severe secondary hyperparathyroidism and soft-tissue calcifications in the hands, pelvis, and right knee, as well as severe vascular calcification, managed with calcimimetics without success. We decided to perform subtotal parathyroidectomy (STPTX). Three months after surgery, she had satisfactory evolution, despite notable hungry bone disease, without bone pain or functional limitation and almost no calcifications. Discussion. The benefit of hemodialysis has been shown with better volume management and improvement of calcium/phosphate products. STPTX allowed biochemical control and calcification improvement, with an evident better quality of life for our patient. Therapeutic alternatives need to be tailored to the patient's characteristics in the calcimimetics era.
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47
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Thomson BKA, Pilkey NG, Monteith B, Holden RM. A Scoping Review of Alternative Anticoagulation Strategies for Hemodialysis Patients with a Mechanical Heart Valve. Am J Nephrol 2021; 52:861-870. [PMID: 34784597 DOI: 10.1159/000519921] [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: 08/25/2021] [Accepted: 09/07/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with end-stage renal disease (ESRD) have high rates of cardiac valvulopathy but can develop contraindications for vitamin K antagonist (VKA) therapy. We explored the evidence for alternative anticoagulation strategies in patients with ESRD with a contraindication for VKA therapy. METHODS A scoping review was completed, searching MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Conference abstracts from inception to March 30, 2021. The study population was patients with ESRD who were on VKA therapy and developed a contraindication to VKA therapy use. All data regarding studies, patient characteristics, anticoagulation strategy, and clinical outcomes were summarized. RESULTS Twenty-three articles met inclusion criteria. These articles included 57 patients. Contraindications to VKA therapy included calcific uremic arteriolopathy (CUA) (n = 55) and warfarin-induced skin necrosis (n = 2). All studies were either case reports or case series. There were 10 anticoagulation strategies identified. Continuation of VKA therapy was associated with increased death and decreased rates of CUA resolution (80.0% and 10.0%, respectively), compared to apixaban (24.0% and 70.8%), subcutaneous (SC) low-molecular-weight heparin (LMWH) (14.3%, 85.7%), and SC unfractionated heparin (0.0%, 100.0%). While only 5 patient cases were reported with mechanical heart valves, SC LMWH use has been reported in this context with good outcomes. CONCLUSIONS In patients with ESRD who develop a contraindication to VKA therapy, several alternative anticoagulation strategies have been reported with superior outcomes to VKA continuation. While outcomes appear superior to continuation of VKA therapy, more data are required before definitive recommendations can be made for the patient with ESRD and a mechanical heart valve.
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Affiliation(s)
- Benjamin K A Thomson
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Nathan G Pilkey
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Bethany Monteith
- Division of Hematology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rachel M Holden
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
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48
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Ababneh EI, Hassanein M, Saad AM, Cook EE, Ko JS, Fatica RA, Vachharajani TJ, Fernandez AP, Billings SD. Calciphylaxis in uraemic and nonuraemic settings: clinical risk factors and histopathological findings. Clin Exp Dermatol 2021; 47:700-708. [PMID: 34762763 DOI: 10.1111/ced.15009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Calciphylaxis is a life-threatening cutaneous ulcerative/necrotic disease characterized by vascular calcification/occlusion. It occurs most commonly in end-stage kidney disease (ESKD), known as uraemic calciphylaxis (UC) but can also occur in patients with chronic kidney disease (CKD) and normal kidney function (nonuraemic calciphylaxis; NUC). There are few large series of NUC in the literature. AIM To compare the clinicopathological features of UC and NUC. METHODS We retrospectively compared the clinicopathological features of 35 patients with NUC during the period 2010-2020 with those of 53 patients with UC (control group). Cases were classified as NUC in the absence of all of the following: ESKD, significant CKD (defined as serum creatinine > 3 mg/dL or creatinine clearance < 15 mL/min) and acute kidney injury requiring kidney replacement therapy or kidney transplantation. RESULTS NUC represented 40% of the total cases, and there was a higher number of women (P < 0.01) and a higher median body mass index (P = 0.06) compared with the control UC group. Elevated parathyroid hormone was present in 44% of patients with NUC. Most of the tested patients were positive for lupus anticoagulants (56%). NUC biopsies showed a higher rate of extravascular calcium deposits (73% vs. 47%, P = 0.03). Dermal reactive vascular proliferation was the most common dermal change (32%). CONCLUSIONS NUC is more common than previously reported and shows a higher predilection for obese postmenopausal women. Undiagnosed hyperparathyroidism shows a possible association with NUC. Lupus anticoagulants were positive in most patients. NUC biopsies are more likely than UC biopsies to display extravascular calcium deposition.
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Affiliation(s)
- E I Ababneh
- Department of, Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - M Hassanein
- Department of, Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH, USA.,Department of, Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - A M Saad
- Department of, Dermatology, Cleveland Clinic, Cleveland, OH, USA.,Department of Nephrology and Hypertension, University of Mississippi Medical Center, Mississippi, MO, USA
| | - E E Cook
- Department of, Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - J S Ko
- Department of, Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - R A Fatica
- Department of, Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - T J Vachharajani
- Department of, Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - A P Fernandez
- Department of Pathology, Detroit Medical Center, Detroit, MI, USA
| | - S D Billings
- Department of, Pathology, Cleveland Clinic, Cleveland, OH, USA
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Xu BC, Abeyaratne A, Wong YHS, Majoni SW. Benefit and harm of anticoagulation in the prevention of thromboembolic stroke for non- valvular atrial fibrillation in haemodialysis patients - a Top End of Northern Australia study. Intern Med J 2021; 53:517-524. [PMID: 34748260 DOI: 10.1111/imj.15605] [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: 05/18/2021] [Revised: 10/19/2021] [Accepted: 10/26/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Warfarin for the prevention of non-valvular atrial fibrillation related thromboembolic stroke in patients on maintenance haemodialysis is controversial. Despite the exclusion of haemodialysis patients in randomised control trials, the American Heart Association/American College of Cardiology has recommended warfarin in high-risk AF patients. AIM We retrospectively examined the utility of warfarin anticoagulation therapy in our prevalent haemodialysis patients over 10 years of follow-up. METHODS Eligible patients were retrospectively identified and stratified to two cohorts based on whether warfarin was prescribed. The outcomes of interest were ischaemic stroke, haemorrhagic stroke and death from any cause. Rate ratio and cox proportional hazard regression model were compare the differences in outcome between the two cohorts. The Kaplan-Meier method was used to analyse survival. RESULTS Three ischaemic strokes and four haemorrhagic strokes occurred in the unexposed group of 166 patients over 484.44 patient-years follow-up. One ischaemic stroke and no cases of haemorrhagic stroke occurred in the exposed warfarin group of 16 patients over 39.32 patient-years of follow-up. 87% of patients in both groups were indigenous. More than 90% of each cohort was had CHA2DS2VaSc score ≥2. 101 deaths occurred in the follow-up period, ninety in the unexposed group and eleven in the warfarin group. A non-statistically significant trend towards increasing mortality was observed in the warfarin group (Hazard ratio =1.63, p=0.13). CONCLUSION This retrospective study of prevalent haemodialysis patients with co-existing history of non-valvular AF failed to demonstrate sufficient evidence for the routine use of warfarin for prophylaxis of thromboembolic stroke. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- By Chi Xu
- Department of Nephrology, Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Asanga Abeyaratne
- Department of Nephrology, Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Flinders University and Northern Territory Medical Program, Royal Darwin Hospital Campus, Darwin, Northern Territory, Australia.,Wellbeing and Preventable Chronic Diseases, Menzies School of Health Research, Charles Darwin University, Northern Territory, Australia
| | - Yun Hui Sheryl Wong
- Department of Nephrology, Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Sandawana William Majoni
- Department of Nephrology, Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Flinders University and Northern Territory Medical Program, Royal Darwin Hospital Campus, Darwin, Northern Territory, Australia.,Wellbeing and Preventable Chronic Diseases, Menzies School of Health Research, Charles Darwin University, Northern Territory, Australia
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50
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Yu Q, Liu Y, Xie X, Liu J, Huang S, Zhang X, Ju S. Radiomics-based method for diagnosis of calciphylaxis in patients with chronic kidney disease using computed tomography. Quant Imaging Med Surg 2021; 11:4617-4626. [PMID: 34737928 DOI: 10.21037/qims-20-1211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 05/10/2021] [Indexed: 11/06/2022]
Abstract
Calciphylaxis is a rare, life-threatening condition that affects patients with chronic kidney disease (CKD) undergoing dialysis. Skin biopsy as the gold standard causes ulceration, bleeding, or infection. This study aimed to develop radiomic methods using CT as a noninvasive method for calciphylaxis diagnosis. The confirmed calciphylaxis patients (Group I), pathologically confirmed non-calciphylaxis patients (Group II), and CKD patients (Group III) from October 1, 2017, to November 30, 2019, were enrolled. Training: 70% of patients of Group I and all Group III. Test: 30% of patients of Group I and all Group II. ROI was set at the skin lesion including the soft tissue. First-order and texture features were extracted from each lesion unit. CT-based radiomic models were on the basis of logistic regression (LR) and support vector machine (SVM). Additionally, model performance was evaluated in the test dataset and compared with the plain radiography and bone scintigraphy. In total, 124 lesions and 38 lesions were identified in training and test datasets. Radiomic models were effective in detecting calciphylaxis in patients with CKD, with AUCs of 0.93 (95% CI: 0.924-0.953) and 0.93 (95% CI: 0.921-0.953) (SVM and LR) in test. The SVM model manifested a sensitivity and specificity of 0.89 and 0.8, and 0.78 and 0.90, at high-sensitivity and high-specificity operating points, respectively. Similar performance was found in the LR model. Radiomic models were more effective than plain radiography and bone scintigraphy (Delong test, P<0.05). Verification studies showed the features which manifested the real variability of lesions. In this research, it primarily developed a radiomic method for noninvasive detection of calciphylaxis in patients with CKD. Through this method, calciphylaxis can be detected when invasive procedures are not feasible.
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Affiliation(s)
- Qian Yu
- Department of Radiology, Jiangsu Key Laboratory of Molecular and Functional Imaging, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Yuqiu Liu
- Institute of Nephrology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Xiaotong Xie
- Institute of Nephrology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Jinqiang Liu
- Department of Radiology, Jiangsu Key Laboratory of Molecular and Functional Imaging, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Shan Huang
- Department of Radiology, Jiangsu Key Laboratory of Molecular and Functional Imaging, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Xiaoliang Zhang
- Institute of Nephrology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Shenghong Ju
- Department of Radiology, Jiangsu Key Laboratory of Molecular and Functional Imaging, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
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