Wet gangrene in hemodialysis patients with calciphylaxisis is associated with a poor prognosis

[Calcific uremic arteriolopathy in hemodialysis patient, review of literature through five cases reports]

Calcific uremic arteriolopathy, also called calciphylaxis, is a rare and severe disorder that presents with skin ischemia and necrosis, sometimes it presents with systemic necrosis, the process is secondary to the obliteration of the arterioles first by sub-intimal calcium deposits and then by thrombosis. These lesions can often lead to death due to infectious complications and comorbidities such as diabetes, obesity, arteritis, diffuse vascular calcifications, heart disease and undernutrition. The diagnosis is suggested by the characteristic ischemic skin lesions and their distribution, often bilateral and painful, associeted with calcific uremic arteriolopathy risk factors (phosphocalcic abnormalities, anti-vitamin K). The presence of radiological vascular calcifications is highly suggesting the diagnosis, but remains not very specific. The indication of skin biopsy is rare and reserved for difficult diagnoses. The goals of treatment are: reduce the extension of calcification and treatment of mineral and bone metabolism disorders of end-stage renal disease, dialysis adequacy, local treatment of skin lesions, tissue oxygenation, pain management, discontinuation and contraindication of medications that may contribute to the disorder. We propose to discuss it from a review of the literature and illustrate it with five clinical cases.

Limb-threatening and life-threatening diabetic extremities: clinical patterns and outcomes in 56 patients

Limb- and life-threatening hand and foot infections in diabetic patients account for a large proportion of amputations and a substantial number of deaths. Between August 2006 and the end of July 2008, we conducted a prospective cohort study of consecutive diabetic patients with serious hand or foot infections, in an effort to identify clinical patterns and outcomes related to the treatment of these infections. Infections were categorized as dry, gas, and wet gangrene; necrotizing fasciitis or cellulitis; acute extensive osteomyelitis; and any of these infections involving the hand. All of the patients underwent a standard examination and treatment protocol, although none of the patients received vascular surgical care. End points included healing following debridement or minor amputation, major (transtibial or more proximal) amputation, or death. A total of 56 patients were included in the final analyses, and their mean age was 70 (range 51 to 86) years. Of the patients, 17 (30.36%) had necrotizing cellulitis, 12 (21.43%) had wet gangrene, 9 (16.07%) had acute extensive osteomyelitis, 5 (8.93%) had dry gangrene, 5 (8.93%) had gas gangrene, 4 (7.14%) had necrotizing fasciitis, and 4 (7.14) had diffuse hand infections. Five (8.93%) patients died (2 after prior amputation), 26 (46.43%) underwent debridement and/or minor amputation, and 27 (48.21%) required major amputations. Based on our findings, we concluded that 7 patterns of serious limb- or life-threatening infection were identified and, in the absence of vascular surgical intervention, mortality can be reduced at the expense of more amputations.

Successful Percutaneous Angioplasty and Stenting of The Radial Artery in a Patient with Chronic Upper Extremity Ischemia and Digital Gangrene

PURPOSE

To report percutaneous treatment of a chronic radial artery occlusion in a multimorbid patient with ischemic tissue loss.

CASE REPORT

A 62-year-old man with multiple comorbidities, including renal failure and severe coronary artery disease, presented with painful, ulcerated lesions of his right hand. He has severe peripheral vascular disease, with a history of 4 digital amputations of the left hand, a right above-knee amputation, and a left femoral to peroneal artery bypass. Arteriography demonstrated chronic occlusion of the radial and ulnar arteries, with a patent interosseous and collateral flow to the distal radial artery filling the palmar arch. Angioplasty and stenting of the radial artery was performed, relieving the patient's symptoms and allowing the lesions to heal.

CONCLUSION

Percutaneous intervention can treat severe upper extremity ischemia with gangrene in patients with severe chronic ischemia and multiple comorbidities.

Calciphylaxie : une complication grave et méconnue de l'insuffisance rénale chronique terminale. À propos de deux cas

Calciphylaxis presents like subcutaneous lesions with livedo reticularis leading to necrotic and painful ulcers, predominantly in the lower limbs and the abdomen. They initially simulate dermohypodermitis. Biology reveals secondary hyperparathyroidism, phosphocalcic metabolism abnormalities and state of hypercoagulability. Histological signs are constant: calcifications in the media of small and sub-cutaneous arteries, intimal hyperplasia and intravascular thrombosis. This complication occurs in 4% of end-stage renal disease patients. Its prognostic is awful with a rate of mortality of 60% due to sepsis. Treatment is based upon the normalization of phosphocalcic rates and local debridement.

Successful treatment of severe calciphylaxis in a hemodialysis patient using low-calcium dialysate and medical parathyroidectomy: case report and literature review

This investigation presents a case report of the successful treatment of severe calciphylaxis using zero- and low-calcium dialysate for hemodialysis, repeated wound debridement and skin grafting and medical parathyroidectomy with local injection of parathyroid glands with alcohol. To the authors' knowledge, this is the first case report of the use of medical parathyroidectomy and hemodialysis with low calcium dialysate to treat calciphylaxis in a dialysis patient. Finally, relevant English language articles on calciphylaxis from Medline are reviewed.

Upper extremity bypass grafting for limb salvage in end-stage renal failure

OBJECTIVE

Patients with end-stage renal failure and upper-extremity arterial occlusive disease sometimes have painful digital ulceration. We evaluated the efficacy of distal bypass grafting from the brachial artery for limb salvage in this setting.

METHODS

All patients with end-stage renal disease with painful digital ulceration or gangrene of the hand seen from 1992 to 2002 were evaluated with clinical examination and noninvasive studies. Those with evidence of occlusive disease underwent conventional angiography. Individuals with forearm occlusive disease underwent bypass grafting, from the brachial artery to either the distal radial artery or ulnar artery at the level of the wrist or proximal hand. Follow-up was scheduled at regular intervals, and included duplex scanning. Limb salvage and bypass graft patency were determined with life table analysis.

RESULTS

Over 10 years, 18 forearm bypass procedures were performed in 15 patients. The outflow artery was the radial artery in 15 procedures and the ulnar artery in 3 procedures. Bypass conduit was autogenous in all patients. No patient had a functioning arteriovenous fistula at bypass grafting; six limbs had previously occluded fistulas. Two bypass grafts (11%) occluded in the early postoperative period, with resultant progression of gangrene. In the remaining 16 grafts patency was maintained (mean follow-up, 18 months), with pain control and tissue healing.

CONCLUSION

Treatment in patients with renal failure with upper extremity occlusive disease may be facilitated with brachiodistal bypass grafting. Pain control and reversal of progression of hand necrosis can be achieved.

Calciphylaxis in chronic, non-dialysis-dependent renal disease

Background

Calciphylaxis cutis is characterized by media calcification of arteries and, most prominently, of cutaneous and subcutaneous arterioles occurring in renal insufficiency patients.

Case Report

A 53-year-old woman with chronic cardiac and renal failure complained of painful crural, non-varicosis ulcers. She was hospitalized in an immobilized condition due to both the crural ulcerations and the existing heart-failure state (NYHA III-IV) having pleural and pericardial effusions, atrial fibrillation and weight loss of 30 kg over the past year. Despite normalization of calcium-phosphorus balance and improvement of renal function, the clinical course of crural ulcerations deteriorated during the following 3 months. After failure of surgical debridements, multiple courses of sterile-maggot therapy were introduced at a late stage to stabilize the wounds. The patient died of recurrent wound infections and sepsis paralleled by exacerbations of renal malfunction.

Conclusions

The role of renal disease in vascular complications is discussed. Sterile-maggot debridement may constitute a therapy for the ulcerated calciphylaxis at an earlier stage, i.e. when first ulcerations appear.