1
|
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.
Collapse
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
| |
Collapse
|
2
|
Giese D, Ernste K, Jnaneswaran G, Elkhedr A. Non-chronic kidney disease-induced calciphylaxis: a rare case report. J Surg Case Rep 2024; 2024:rjae404. [PMID: 38835946 PMCID: PMC11149559 DOI: 10.1093/jscr/rjae404] [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: 05/09/2024] [Accepted: 05/26/2024] [Indexed: 06/06/2024] Open
Abstract
Calciphylaxis is a disorder causing ischemic skin necrosis, typically associated with end-stage renal disease or those receiving dialysis. Occurrence is rare in those without end-stage renal disease, and treatment options are limited. This case report describes a patient with calciphylaxis without end-stage renal disease or history of dialysis. Treatment with sodium thiosulfate, a first line option, had to be stopped due to metabolic derangements, limiting the healing process. Diagnosis and treatment of this rare disorder are important to prevent further complications that may result.
Collapse
Affiliation(s)
- Drake Giese
- Medical College of Wisconsin - Central Wisconsin, Department of Education, 1900 Westwood Dr Suite 3100, Wausau, WI 54401, United States
| | - Katherine Ernste
- Medical College of Wisconsin - Central Wisconsin, Department of Education, 1900 Westwood Dr Suite 3100, Wausau, WI 54401, United States
| | - Geethu Jnaneswaran
- Marshfield Clinic, Division of Education - 1R61000 North Oak Avenue Marshfield, WI 54449, United States
| | - Ali Elkhedr
- Marshfield Clinic, Division of Education - 1R61000 North Oak Avenue Marshfield, WI 54449, United States
| |
Collapse
|
3
|
Khalayli N, Hodifa Y, Hodaifa A, Alsamarrai O, Kudsi M. Calciphylaxis during the course of psoriatic arthritis patient. Is it coincidence? A case report. Ann Med Surg (Lond) 2023; 85:5263-5266. [PMID: 37811033 PMCID: PMC10552990 DOI: 10.1097/ms9.0000000000001281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/27/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction and importance Calciphylaxis manifests clinically by skin ischemia and necrosis and histologically by calcification of dermal arterioles. Usually, it occurs in patients with end-stage renal disease on dialysis or in patients who had a kidney transplant. Here, the authors present a case of calciphylaxis occurring in a patient with psoriasis and psoriatic arthritis. Case presentation A 66-year-old Syrian male with a history of psoriatic arthritis presented for evaluation of 2-month nonpainful ulcers on his feet and hands that were treated with warfarin. Biopsies confirmed the diagnosis of calciphylaxis. The patient received sodium thiosulfate, zoledronic acid, intralesional sodium thiosulfate injections, and an intravenous infusion of vitamin K with dramatic improvement. At the 3-month follow-up, his wounds had been completely remitted. Discussion Nonuremic calciphylaxis occurs in many cases, like vitamin D administration, vitamin K antagonists' administration, chronic inflammation, and others. The association between calciphylaxis and psoriasis was reported only in four cases in the literature; meanwhile, this was the first case that described calciphylaxis in the setting of psoriatic arthritis. Conclusion A suspicion of calciphylaxis should be maintained in patients with underlying inflammatory mechanism diseases.
Collapse
Affiliation(s)
| | - Yara Hodifa
- Faculty of Medicine, Damascus University, Damascus, Syria
| | | | | | | |
Collapse
|
4
|
Martí Pelluch CC, Soler Sendra A, Vila Vall-Llovera M. Non-uremic calciphylaxis: case series. Med Clin (Barc) 2023; 160:318-319. [PMID: 36473774 DOI: 10.1016/j.medcli.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/05/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Affiliation(s)
| | - Anna Soler Sendra
- Servicio de Medicina Interna, Hospital General de Granollers, Granollers, Barcelona, España
| | | |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Safavi M, Sadeghi P, Hosseinlou S. Calciphylaxis in an adolescent without renal failure. Arch Dis Child 2022; 107:1137. [PMID: 35840314 DOI: 10.1136/archdischild-2022-324345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Moeinadin Safavi
- Pathology Department, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Payman Sadeghi
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran.,Children's Medical Center, Pediatrics Center of Excellence, Tehran, Iran.,Pediatric Rheumatology Society of Iran, Tehran, Iran
| | - Shima Hosseinlou
- Pathology Department, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
7
|
Pérez Haded I, Bayona D'vera JS, Blanco Espinoza AS, Llamas Castellanos BC, Rolón Cadena MC. Erythema nodosum with incidental calciphylaxis secondary to zoledronic acid and denosumab. Int J Rheum Dis 2022; 25:1441-1443. [DOI: 10.1111/1756-185x.14452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/05/2022] [Accepted: 09/22/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Iván Pérez Haded
- Dermatology Section Hospital Universitario Fundación Santa Fe de Bogotá Bogotá Colombia
| | | | | | | | | |
Collapse
|
8
|
Cucka B, Biglione B, Ko L, Nguyen ED, Khoury CC, Nigwekar SU, Robinson MK, Kroshinsky D. Calciphylaxis arising following bariatric surgery: A case series. JAAD Case Rep 2022; 28:4-7. [PMID: 36090194 PMCID: PMC9450058 DOI: 10.1016/j.jdcr.2022.07.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
9
|
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.
Collapse
|
10
|
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
| |
Collapse
|
11
|
Rick J, Strowd L, Pasieka HB, Saardi K, Micheletti R, Zhao M, Kroshinsky D, Shinohara MM, Ortega-Loayza AG. Calciphylaxis: Part I. Diagnosis and pathology. J Am Acad Dermatol 2022; 86:973-982. [PMID: 35114300 DOI: 10.1016/j.jaad.2021.10.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 11/18/2022]
Abstract
Calciphylaxis is an uncommon but devastating disorder characterized by vascular calcification and subsequent cutaneous tissue necrosis. This results in exquisitely painful and slow healing wounds that portend exceptionally high morbidity and mortality. The diagnosis of this condition can be complicated because there are no conclusive serologic, radiographic or visual signs that this disease is manifesting. The differential of tissue necrosis is broad, and identifying calciphylaxis requires an adroit understanding of the risk factors and physical signs that should raise suspicion of this condition. Reviews on this subject are uncommon and lack directed commentary from disease experts on the best diagnostic approach for patients suffering from this disease. The goal of this article is to update practicing dermatologists on the current standard of care for calciphylaxis.
Collapse
Affiliation(s)
- Jonathan Rick
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Lindsay Strowd
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Helena B Pasieka
- Georgetown University School of Medicine, Washington, DC; Uniformed Services University School of Medicine, Bethesda, Maryland
| | - Karl Saardi
- Georgetown University School of Medicine, Washington, DC
| | - Robert Micheletti
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Megan Zhao
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | - Michi M Shinohara
- University of Washington Division of Dermatology, Seattle, Washington
| | | |
Collapse
|
12
|
Byers A, Herrera N, Owoyemi I. Chronic inflammation and calciphylaxis. BMJ Case Rep 2022; 15:e248668. [PMID: 35487645 PMCID: PMC9058681 DOI: 10.1136/bcr-2021-248668] [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] [Accepted: 04/01/2022] [Indexed: 11/04/2022] Open
Abstract
Calciphylaxis also known as calcific uraemic arteriolopathy is a rare condition mostly seen in patients with end-stage kidney disease. We report a case of a simultaneous-kidney-pancreas transplant patient with functioning grafts developing biopsy-proven calciphylaxis in the setting of chronic inflammation. Despite several modalities of management, the patient developed progression of her disease leading to multiple amputations. This case illustrates chronic inflammation driven by persistent infection as a probable contributing factor to the development and progression of calciphylaxis in a simultaneous kidney-pancreas recipient. Calciphylaxis should be considered in the differential for a painful, non-healing ulcer even in the absence of common risk factors.
Collapse
Affiliation(s)
- Aaron Byers
- Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nicholas Herrera
- Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Itunu Owoyemi
- Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| |
Collapse
|
13
|
Castillo FT, Seth D, Agnihothri R, Fox L, North J, Haemel A. Nonuremic Calciphylaxis Manifesting with Diffuse Dermal Angiomatosis. JAAD Case Rep 2022; 24:8-10. [PMID: 35518276 PMCID: PMC9062726 DOI: 10.1016/j.jdcr.2022.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
14
|
Podestà MA, Ciceri P, Galassi A, Cozzolino M. Calciphylaxis after Kidney Transplantation: a rare but life-threatening disorder. Clin Kidney J 2021; 15:611-614. [PMID: 35371446 PMCID: PMC8967658 DOI: 10.1093/ckj/sfab247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Indexed: 11/20/2022] Open
Abstract
Calciphylaxis is a rare disorder characterized by vascular calcification and thrombosis of the subcutaneous microcirculation, leading to painful necrotic skin lesions and bearing a dreadfully high mortality rate. This syndrome is frequently also termed uraemic calcific arteriolopathy, since most cases are observed in patients with kidney failure. However, it is increasingly clear that calciphylaxis may also affect patients with normal or only slightly impaired renal function, including kidney transplant recipients. A precise definition of the characteristics and risk factors of calciphylaxis developing after kidney transplantation has been hindered by the extreme rarity of this condition, which also hampered the development of effective therapeutic strategies. In the present issue of CKJ, Guillén and colleagues report the largest case series of calciphylaxis in kidney transplant recipients to date, outlining several features that are apparently specific to this population. In this editorial, we briefly present the epidemiology and pathogenesis of calciphylaxis in different patient populations and discuss recent findings for its therapeutic management.
Collapse
Affiliation(s)
- Manuel Alfredo Podestà
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
| | - Paola Ciceri
- Department of Nephrology, Dialysis and Renal Transplant, Renal Research Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
| | - Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
| |
Collapse
|
15
|
Abstract
Calcific uremic arteriolopathy, termed calciphylaxis, was previously considered a condition that developed mostly in patients requiring dialysis. It has now been described in kidney transplant patients, in advanced chronic kidney disease (CKD) patients not requiring dialysis, and in individuals with maintained kidney function. We describe an individual with CKD stage 3b with hypercalcemia who presented with features highly specific for calciphylaxis based on results of a skin biopsy. The condition has high morbidity and mortality, and thus prompts immediate cessation of the offending agents or treatment of the cause. The following case and literature review demonstrates a need for a detailed assessment of patients’ risks and exposures and expanding the differential diagnosis to include calciphylaxis in nonuremic patients with necrotic ulcers with a plan for early imaging and possible biopsy.
Collapse
|
16
|
Sánchez-Pujol M, Docampo Simón A, Illán Gambín F, Niveiro de Jaime M, Blanes Martínez M. Calciphylaxis: Risk Factors and Histologic Findings in a Case Series From a Tertiary Care Referral Hospital. ACTAS DERMO-SIFILIOGRAFICAS 2021. [DOI: 10.1016/j.adengl.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
17
|
DeClue C, Chinnakotla B, Gardner MJ. Non-Uremic Calciphylaxis: An Unexpected Complication With Recombinant Human Parathyroid Hormone. Cureus 2021; 13:e15014. [PMID: 34150377 PMCID: PMC8202451 DOI: 10.7759/cureus.15014] [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: 11/10/2022] Open
Abstract
Calciphylaxis is a rare syndrome of calcific microvascular occlusion, whereas non-uremic calciphylaxis (NUC) is a subset of this disease in which renal impairment is not observed. Recombinant human parathyroid hormone (rhPTH) (1-84) is a medication approved for the management of hypocalcemia in patients with hypoparathyroidism. We present a case report of a 38-year-old woman with postoperative hypoparathyroidism treated with rhPTH who subsequently developed calciphylactic lesions on her abdomen. Multidisciplinary interventions included intravenous and intralesional sodium thiosulfate therapy, laboratory monitoring, dermatological wound care, and pain management. Calciphylaxis can rarely be precipitated by rhPTH due to its effect on calcium and phosphorus balance even in the setting of normal renal function. The use of calcium and calcitriol supplementation, complicated by factors such as female sex and obesity, may have contributed in this patient’s case. Hence, regular follow-up with tapering off of calcium and calcitriol supplementation is important in patients receiving rhPTH.
Collapse
Affiliation(s)
- Cory DeClue
- Internal Medicine, University of Missouri, Columbia, USA
| | | | | |
Collapse
|
18
|
Sánchez-Pujol MJ, Docampo Simón A, Illán Gambín F, Niveiro de Jaime M, Blanes Martínez M. Calciphylaxis: Risk Factors and Histologic Findings in a Case Series From a Tertiary Care Referral Hospital. ACTAS DERMO-SIFILIOGRAFICAS 2021; 112:S0001-7310(21)00164-2. [PMID: 33939992 DOI: 10.1016/j.ad.2020.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/19/2020] [Accepted: 08/22/2020] [Indexed: 11/29/2022] Open
Abstract
Recent years have seen important advances in our understanding of calciphylaxis, especially regarding newly identified risk factors and histologic findings that may aid diagnosis. This retrospective study of cases of calciphylaxis treated in our hospital in the last 13 years focuses on newly revealed aspects of this disease. We describe 16 patients (62.5% women; mean age, 67.9 years). In addition to advanced kidney disease (in 75% of our patients), other factors associated with the presence of calciphylaxis were a history of treatments related to phosphorus and calcium metabolism (75%) and anticoagulation (62.5%), usually with vitamin-K antagonists. Histology showed alterations in elastic fibers in only 25% of the biopsy specimens. Eleven of the patients died: sepsis was most often the cause.
Collapse
Affiliation(s)
- M J Sánchez-Pujol
- Servicio de Dermatología, Hospital General Universitario de Alicante. Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España.
| | - A Docampo Simón
- Servicio de Dermatología, Hospital General Universitario de Alicante. Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
| | - F Illán Gambín
- Servicio de Anatomía Patológica, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
| | - M Niveiro de Jaime
- Servicio de Anatomía Patológica, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
| | - M Blanes Martínez
- Servicio de Dermatología, Hospital General Universitario de Alicante. Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, España
| |
Collapse
|
19
|
Nonuraemic calciphylaxis: A case series. Ann Dermatol Venereol 2021; 148:127-129. [PMID: 33461791 DOI: 10.1016/j.annder.2020.09.575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/27/2020] [Accepted: 09/22/2020] [Indexed: 11/21/2022]
|
20
|
Herz-Ruelas M, García-Lozano J, Reyna-Rodríguez I, Sánchez-Meza E, Gómez-García L, Zapata-Salazar N, Vázquez-Martínez O. Non-uremic Calciphylaxis and Parathyroid Adenoma, An Uncommon Association Requiring Early Recognition. Indian J Dermatol 2021; 66:690-692. [PMID: 35283532 PMCID: PMC8906326 DOI: 10.4103/ijd.ijd_77_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
21
|
Bhamidipati T, Doan HL, Hossein-Javaheri N, Tang HT, Soliman M. Beneficial Effects of Amnion-Chorion Stem Cell Grafting in the Long Term Management of Nonuremic Calciphylaxis Wounds. Cureus 2020; 12:e12170. [PMID: 33489581 PMCID: PMC7813429 DOI: 10.7759/cureus.12170] [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: 12/04/2022] Open
Abstract
Calciphylaxis is a poorly understood disease with high morbidity and mortality. The current primary literature on treatment is lacking; however, disease management often involves a multifaceted approach with a primary focus on consistent wound care. This report describes a case outlining the long-term management of nonuremic calciphylaxis wounds in a patient with severe malnutrition with the use of human amniotic membrane grafts, aggressive surgical debridement, nutritional therapy, and advanced wound healing techniques. A 38-year-old African American female with a history of non-uremic calciphylaxis presented from a transitional facility with numerous non-healing wounds in the setting of severe malnutrition secondary to bariatric surgery. Biweekly wound debridement was initiated utilizing an amniotic stem cell skin graft, dry applicable absorbent dressing, high-frequency ultrasonic ablation, and wound vacuum-assisted closure (VAC) over the course of approximately nine months. Nutritional supplementation was given in the form of jejunostomy tube feed due to a gastric bypass and a perforated viscus. At the current date, the patient demonstrates significant improvement in pain and wound healing. The patient is also able to ambulate with care and has begun steps towards independent management of wounds. Future goals of care include independent bedside wound management, placement of allograft, and discharge to a long-term care facility. Most patients with refractory pain, widespread necrotic wounds, and dangerous comorbidities will inevitably be referred to palliative care. This case creates a framework for the long term management of medically complex patients with nonuremic calciphylaxis using human amniotic membrane stem cell grafts and appropriate advanced wound care techniques.
Collapse
Affiliation(s)
- Theja Bhamidipati
- General Surgery, Menorah Medical Center/Kansas City University, Overland Park, USA
| | - Huy L Doan
- General Surgery, Menorah Medical Center/Kansas City University, Overland Park, USA
| | | | - Hao T Tang
- General Surgery, Menorah Medical Center/Kansas City University, Overland Park, USA
| | - Mohsin Soliman
- General and Bariatric Surgery, Menorah Medical Center, Overland Park, USA
| |
Collapse
|
22
|
Kodumudi V, Jeha GM, Mydlo N, Kaye AD. Management of Cutaneous Calciphylaxis. Adv Ther 2020; 37:4797-4807. [PMID: 32997277 PMCID: PMC7595979 DOI: 10.1007/s12325-020-01504-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/11/2020] [Indexed: 12/21/2022]
Abstract
Calciphylaxis is a deadly, painful disease with a 1-year mortality of up to 50%. The disease is commonly associated with patients with end-stage kidney disease (ESKD), but it can manifest in non-uremic patients as well. In patients who are undergoing dialysis, the incidence of calciphylaxis can range from 0.04% to 4%. The progressive arterial calcification seen in calciphylaxis can affect multiple body organs, including the skin, brain, lungs, and muscle. In cutaneous calciphylaxis, painful and non-healing nodules, plaques, and ulcers may appear, increasing morbidity for patients. Diagnosis can be difficult, and the condition can clinically appear similar to other dermatological diseases, especially in non-uremic patients. Currently, skin biopsy with histological analysis is the most reliable method to help diagnose the condition. In certain cases, the use of medical imaging may be helpful. Treatment of pain in this condition can be difficult and should be multimodal and include wound care as well as modification of risk factors. Analgesic options include opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), as well as analgesic options that are targeted for specific patients. There are currently multiple clinical trials underway that are studying targeted therapies for this condition.
Collapse
|
23
|
Assessment of outcomes of calciphylaxis. J Am Acad Dermatol 2020; 85:1057-1064. [PMID: 33130181 DOI: 10.1016/j.jaad.2020.10.067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Calciphylaxis is a rare thrombotic vasculopathy characterized by high morbidity and mortality. There is a paucity of studies examining longitudinal outcomes. OBJECTIVE To assess mortality, days spent in the hospital, and amputations in patients with calciphylaxis. METHODS A retrospective medical record review was conducted in 145 patients diagnosed with calciphylaxis at an urban tertiary care hospital from January 2006 to December 2018. RESULTS Six-month mortality was 37.2%, and 1-year mortality was 44.1%. Patients with nephrogenic calciphylaxis had worse survival than those with nonnephrogenic calciphylaxis (P = .007). This difference in survival disappeared when limiting mortality to deaths due to calciphylaxis. Age (P = .003) and end-stage renal disease (P = .01) were risk factors associated with 1-year mortality. Diabetes mellitus was associated with greater total hospitalization days (coefficient, 1.1; 95% confidence interval, 1.01-1.4); bedside debridement was associated with fewer hospitalization days (coefficient, 0.8; 95% confidence interval, 0.7-0.9). Amputations were not associated with any of the examined risk factors. The use of warfarin followed by a transition to nonwarfarin anticoagulation was associated with decreased hazard of death (P = .01). LIMITATIONS Retrospective nature. CONCLUSIONS Calciphylaxis remains a complex, heterogeneous disease. Mortality is lower in patients with nonnephrogenic disease. These findings may be incorporated during discussions regarding the goals of care to facilitate informed shared decision making.
Collapse
|
24
|
Calciphylaxis: Diagnostic and Treatment Advances for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00316-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
25
|
Neves JM, Cabete J, Fernandes C. Nonuraemic cutaneous calciphylaxis: our experience with a challenging disease. Clin Exp Dermatol 2020; 45:745-746. [PMID: 32304580 DOI: 10.1111/ced.14242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 01/17/2023]
Affiliation(s)
- J M Neves
- Department of Dermatology and Venereology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - J Cabete
- Department of Dermatology and Venereology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - C Fernandes
- Department of Dermatology and Venereology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| |
Collapse
|
26
|
Gaisne R, Péré M, Menoyo V, Hourmant M, Larmet-Burgeot D. Calciphylaxis epidemiology, risk factors, treatment and survival among French chronic kidney disease patients: a case-control study. BMC Nephrol 2020; 21:63. [PMID: 32101140 PMCID: PMC7045437 DOI: 10.1186/s12882-020-01722-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 02/11/2020] [Indexed: 11/10/2022] Open
Abstract
Background Calcific Uremic Arteriolopathy (CUA) is a rare disease, causing painful skin ulcers in patients with end stage renal disease. Recommendations for CUA management and treatment are lacking. Methods We conducted a retrospective cohort study on CUA cases identified in western France, in order to describe its management and outcome in average clinical practices. Selection was based on the Hayashi diagnosis criteria (2013) extended to patients with eGFR < 30 mL/min/1.73m2. Dialyzed CUA cases were compared with 2 controls, matched for age, gender, region of treatment and time period. Results Eighty-nine CUA cases were identified between 2006 and 2016, including 19 non dialyzed and 70 dialyzed patients. Females with obesity (55.1%) were predominant. Bone mineral disease abnormalities, inflammation and malnutrition (weight loss, serum albumin decrease) preceded CUA onset for 6 months. The multimodal treatment strategy included wound care (98.9%), antibiotherapy (77.5%), discontinuation of Vitamin K antagonists (VKA) (70.8%) and intravenous sodium thiosulfate (65.2%). 40.4% of the patients died within the year after lesion onset, mainly under palliative care. Surgical debridement, distal CUA, localization to the lower limbs and non calcium-based phosphate binders were associated with better survival. Risks factors of developing CUA among dialysis patients were obesity, VKA, weight loss, serum albumin decrease or high serum phosphate in the 6 months before lesion onset. Conclusion CUA involved mainly obese patients under VKA. Malnutrition and inflammation preceded the onset of skin lesions and could be warning signs among dialysis patients at risk. Trial registration ClinicalTrials.gov identifier NCT02854046, registered August 3, 2016.
Collapse
Affiliation(s)
- Raphaël Gaisne
- Department of Nephrology and Immunology, Institute of Transplantation Urology and Nephrology, Centre Hospitalier Universitaire de Nantes, Nantes, France. .,Service de Néphrologie et Immunologie Clinique, Centre Hospitalier Universitaire de Nantes, 30, bd Jean Monnet 44093, Nantes, Cedex 01, France.
| | - Morgane Péré
- Biostatistician, Direction de la Recherche, Plateforme de Méthodologie et Biostatistiques, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | | | - Maryvonne Hourmant
- Department of Nephrology and Immunology, Institute of Transplantation Urology and Nephrology, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - David Larmet-Burgeot
- Department of Nephrology and Immunology, Institute of Transplantation Urology and Nephrology, Centre Hospitalier Universitaire de Nantes, Nantes, France.,Department of Nephrology, Centre Hospitalier de Saint Nazaire, St Nazaire, France
| |
Collapse
|
27
|
Common and critical inflammatory dermatoses every pathologist should know. Mod Pathol 2020; 33:107-117. [PMID: 31676787 DOI: 10.1038/s41379-019-0400-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/08/2019] [Accepted: 10/08/2019] [Indexed: 12/26/2022]
Abstract
Inflammatory dermatopathology remains a challenging area for surgical pathologists. Yet every surgical pathologist encounters inflammatory dermatoses as part of routine practice. This review will focus on selected diagnoses that are either commonly encountered in the routine practice of surgical pathology or are critically important. The following entities will be covered: spongiotic dermatoses, lichen simplex chronicus, and early lichen sclerosus in the setting of vulvar biopsies, as well as graft versus host disease, Stevens-Johnson syndrome/toxic epidermal necrolysis, granuloma anulare, pyoderma gangrenosum, and calciphylaxis. Practical points and key histologic features will be emphasized.
Collapse
|
28
|
Seethapathy H, Noureddine L. Calciphylaxis: Approach to Diagnosis and Management. Adv Chronic Kidney Dis 2019; 26:484-490. [PMID: 31831126 DOI: 10.1053/j.ackd.2019.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 12/16/2022]
Abstract
Calciphylaxis is a rare disorder of poor prognosis that can lead to intense, painful lesions involving the skin and subcutaneous tissue. Although mostly described in dialysis patients, it can affect patients with normal kidney function. The diagnosis of calciphylaxis is complicated by the absence of a gold standard marker of disease such as a clear histopathological finding. Late diagnosis and advanced lesions can significantly shorten life expectancy. Calciphylaxis wounds can have a major influence on the quality of life of patients, usually due to the immense unbearable pain these patients suffer from. The management of calciphylaxis mainly comprises aggressive wound care and symptomatic management. Therapeutic options are few and far between and are limited to off-label uses. Recent understanding of the pathogenesis of lesions has enabled development of novel therapeutic options, some of which are being studied in clinical trials (sodium thiosulfate, vitamin K). Vascular calcification and thrombosis underlie development of these lesions and research has been aimed at studying drugs that counteract such processes. Future research is required to establish clear causal pathways and improve on the treatment options currently available to patients.
Collapse
|
29
|
|
30
|
Correlation between clinical and pathological features of cutaneous calciphylaxis. PLoS One 2019; 14:e0218155. [PMID: 31194797 PMCID: PMC6564670 DOI: 10.1371/journal.pone.0218155] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 05/27/2019] [Indexed: 02/07/2023] Open
Abstract
Calciphylaxis is a rare and life-threatening disease that classically manifests with painful skin lesions. It occurs mainly in patients with end-stage renal disease (ESRD) treated with dialysis, has poor outcomes, and has no FDA-approved treatment. Our cohort study aims to examine the clinical and pathological features of calciphylaxis and investigates the correlation between cutaneous clinical manifestations and histopathological findings. Data from 70 calciphylaxis patients who were evaluated at the Massachusetts General Hospital between January 2014 and April 2018 were collected from the institutional electronic database. The median age was 58 years (interquartile range [IQR]: 49–69 years), 60% were women, and 73% were of white race. Most (74%) patients reported severe pain at the time of calciphylaxis diagnosis with a median pain intensity score of 8/10 (IQR: 6–10) on a 0–10 pain scale. The median time from symptom onset to clinical diagnosis was 9 weeks (IQR: 6–16 weeks). The majority (87%) of patients presented with open necrotic wounds (advanced stage lesion) at the time of diagnosis. Common cutaneous clinical features included ulceration (79%), induration (57%), and erythema (41%), while common pathological features included cutaneous microvascular calcification (86%) and necrosis (73%). The presence of fibrin thrombi in skin biopsies was associated with pain severity (p = 0.04). The stage of a skin lesion positively correlated with the presence of necrosis on histological analyses (p = 0.02). These findings have implications for improving understanding of calciphylaxis origins and for developing novel treatments.
Collapse
|
31
|
|
32
|
Seethapathy H, Brandenburg VM, Sinha S, El-Azhary RA, Nigwekar SU. Review: update on the management of calciphylaxis. QJM 2019; 112:29-34. [PMID: 30304522 DOI: 10.1093/qjmed/hcy234] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Indexed: 01/07/2023] Open
Abstract
Calciphylaxis is a disease of significant morbidity and mortality, predominantly affecting dialysis patients. The term 'calciphylaxis' was coined by Seyle et al. in 1961 to describe calcium deposition in the skin and subcutaneous soft tissue of uremic rats in response to 'triggers' (e.g. trauma, metallic salts) after exposure to 'sensitizing agents' (e.g. vitamin D and parathyroid hormone). In humans, calciphylaxis, however, is not a disorder of induced hypersensitivity. Instead, it is a disorder of cutaneous microvascular occlusion caused by thrombosis and calcification. Progressive, excruciatingly painful, non-healing wounds develop in these patients, pre-disposing them to high risk of sepsis and death. Calciphylaxis has no approved therapies. Increased awareness and research in this field have facilitated identification of risk factors and causation pathways. Development of therapeutic options and wound care management, however, are still at a nascent stage. Certain therapies have shown a promise that needs evaluation in prospective clinical trials. It is hoped that ongoing research will help us better understand the pathogenesis of this complex disease and develop efficacious treatment options. In this review, we outline the components involved in calciphylaxis diagnosis and treatment.
Collapse
Affiliation(s)
- H Seethapathy
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - V M Brandenburg
- Department of Cardiology and Nephrology, Rhein-Maas Klinikum, Würselen, Germany
| | - S Sinha
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford, UK
| | - R A El-Azhary
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - S U Nigwekar
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
33
|
Portales-Castillo I, Kroshinsky D, Malhotra CK, Culber-Costley R, Cozzolino MG, Karparis S, Halasz CL, Goverman J, Manley HJ, Malhotra R, Nigwekar SU. Calciphylaxis-as a drug induced adverse event. Expert Opin Drug Saf 2018; 18:29-35. [DOI: 10.1080/14740338.2019.1559813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
| | - Cindy K. Malhotra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Roberta Culber-Costley
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Mario Gennaro Cozzolino
- Renal Division, Department of Health Sciences, University of Milan, San Paolo Hospital, Milan, Italy
| | - Shelly Karparis
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Charles L. Halasz
- Department of Dermatology, Columbia University Medical Center, New York, NY, USA
| | - Jeremy Goverman
- Burn Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Harold J. Manley
- Reach Medication Therapy Management, Dialysis Clinic, Inc., Albany, NY, USA
| | - Rajeev Malhotra
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sagar U. Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
34
|
Albright RC. Calciphylaxis in Patients With Preserved Renal Function: Worrisome Wounds. Mayo Clin Proc 2018; 93:1164-1166. [PMID: 30193670 DOI: 10.1016/j.mayocp.2018.07.009] [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: 07/25/2018] [Accepted: 07/25/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Robert C Albright
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
| |
Collapse
|