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Yousuf S, Busch D, Renner R, Schliep S, Erfurt-Berge C. Clinical characteristics and treatment modalities in uremic and non uremic calciphylaxis - a dermatological single-center experience. Ren Fail 2024; 46:2297566. [PMID: 38178572 PMCID: PMC10773653 DOI: 10.1080/0886022x.2023.2297566] [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: 08/10/2023] [Accepted: 12/15/2023] [Indexed: 01/06/2024] Open
Abstract
Calciphylaxis (CP) is a serious, potentially life-threatening disease that presents with medial calcification of small-sized vessels and painful ischemic ulcerations. Although calciphylaxis is frequently seen in patients with end-stage kidney disease on dialysis (calcific uremic arteriolopathy, CUA), there are reported cases of nonuremic calciphylaxis (NUC), which often remain undiagnosed. We conducted a retrospective chart review at our dermatological hospital and evaluated data concerning the epidemiology, comorbidities, medication, laboratory abnormalities, and therapeutic approaches of 60 patients diagnosed with calciphylaxis between 01/2012 and 12/2022. We identified 21 patients diagnosed with NUC and 39 with kidney disease. The predilection sites of skin lesions were the lower legs in 88% (n = 53), followed by the thigh and gluteal regions in 7% (n = 4). Significant differences were identified in comorbidities, such as atrial fibrillation (p < 0.001) and hyperparathyroidism (p < 0.01) accounting for CUA patients. Medication with vitamin K antagonists (p < 0.001), phosphate binders (p < 0.001), and loop diuretics (p < 0.01) was found to be associated with the onset of calciphylaxis. Hyperphosphatemia (p < 0.001), increased parathyroid hormone (p < 0.01) and triglyceride levels (p < 0.01), hypoalbuminemia (p < 0.01) and decreased hemoglobin values (p < 0.001) in the CUA cohort were significantly different from those in the NUC group. All patients with CUA received systemic medication. In contrast, only 38% (n = 8) of patients with NUC received systemic treatment. Striking discrepancies in the treatment of both cohorts were detected. In particular, NUC remains a disease pattern that is still poorly understood and differs from CUA in several important parameters.
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Affiliation(s)
- Sabine Yousuf
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Dorothee Busch
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | - Stefan Schliep
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Cornelia Erfurt-Berge
- Hautklinik, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Lajoie C, Ghanemi A, Bourbeau K, Sidibé A, Wang YP, Desmeules S, Mac-Way F. Multimodality approach to treat calciphylaxis in end-stage kidney disease patients. Ren Fail 2023; 45:2256413. [PMID: 37724534 PMCID: PMC10512890 DOI: 10.1080/0886022x.2023.2256413] [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: 06/26/2023] [Accepted: 09/02/2023] [Indexed: 09/21/2023] Open
Abstract
A multimodality approach has been proposed as an effective treatment for calciphylaxis in patients with end-stage kidney disease. In this retrospective study, we report the cases of 12 end-stage kidney disease patients from l'Hôtel-Dieu de Québec hospital (Canada) who were diagnosed with calciphylaxis between 2004 and 2012 and treated with a multimodality clinical approach including sodium thiosulfate (STS). Statistical analyses were performed to evaluate the impacts of patients characteristics, the different interventions as well as therapy regimen on the therapeutic response. The majority of patients (n = 9) were hemodialyzed. The patients-associated comorbidities were consistent with previously reported risk factors for calciphylaxis: Diabetes (n = 11), calcium-based phosphate binders use (n = 10), warfarin use (n = 9), obesity (n = 7), female gender (n = 8) and intravenous iron use (n = 8). STS was given for a median duration of 81 days. 75% of the patients had a response (total or partial) including a complete response in 42% of patients. One-year mortality rate was low (25%). STS was used during a mean duration of 83.33 ± 41.52 days and with a total cumulating dose of 1129.00 ± 490.58 g. The recorded mean time before a complete response was 102.20 days (51-143). Pain improvement occurred after a mean time of 8.67 ± 10.06 days. None of the studied factors was statistically associated with a complete or a partial response to the multimodality approach. Although our data have a limited statistical power, they support treating calciphylaxis with a multimodality approach including STS as its effects are independent from important clinical variables.
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Affiliation(s)
- Chloé Lajoie
- CHU de Québec, L’Hôtel-Dieu de Québec Hospital, Faculty and Department of Pharmacy, Université Laval, Québec, Canada
- Department of Pharmacy, CSSS de la Minganie, Québec, Canada
| | - Abdelaziz Ghanemi
- CHU de Québec Research Center, L’Hôtel-Dieu de Québec Hospital, Division of Nephrology, Faculty and Department of Medicine, Université Laval, Québec, Canada
| | - Kateri Bourbeau
- CHU de Québec, L’Hôtel-Dieu de Québec Hospital, Faculty and Department of Pharmacy, Université Laval, Québec, Canada
| | - Aboubacar Sidibé
- CHU de Québec Research Center, L’Hôtel-Dieu de Québec Hospital, Division of Nephrology, Faculty and Department of Medicine, Université Laval, Québec, Canada
| | - Yue-Pei Wang
- CHU de Québec Research Center, L’Hôtel-Dieu de Québec Hospital, Division of Nephrology, Faculty and Department of Medicine, Université Laval, Québec, Canada
| | - Simon Desmeules
- CHU de Québec Research Center, L’Hôtel-Dieu de Québec Hospital, Division of Nephrology, Faculty and Department of Medicine, Université Laval, Québec, Canada
| | - Fabrice Mac-Way
- CHU de Québec Research Center, L’Hôtel-Dieu de Québec Hospital, Division of Nephrology, Faculty and Department of Medicine, Université Laval, Québec, Canada
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Røndbjerg AK, Gyldenløve M, Krustrup D, Rix M, Vejborg I, Lonn L, Jørgensen NR, Pasch A, Skov L, Hansen D. Cutaneous vascular calcifications in patients with chronic kidney disease and calcific uremic arteriolopathy: a cross-sectional study. J Nephrol 2023; 36:1991-1999. [PMID: 37466817 PMCID: PMC10543801 DOI: 10.1007/s40620-023-01707-8] [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: 03/12/2023] [Accepted: 06/09/2023] [Indexed: 07/20/2023]
Abstract
INTRODUCTION Calcific uremic arteriolopathy is a life-threatening cutaneous condition in patients with chronic kidney disease. Often, clinical diagnosis is accompanied by histopathologic evaluations demonstrating vascular calcium deposits. We aimed to investigate the presence of cutaneous calcifications in non-lesional tissue in patients with chronic kidney disease, and the relation to systemic vascular calcification. METHODS We investigated the presence of cutaneous vascular calcifications in non-lesional skin biopsies from patients with current or previous calcific uremic arteriolopathy and patients with different stages of chronic kidney disease without calcific uremic arteriolopathy, and explored their association with vascular calcification in other vascular beds. Systemic vascular calcification was examined by mammography and lumbar X-ray. RESULTS Thirty-nine adults were enrolled (current or previous calcific uremic arteriolopathy, n = 9; end-stage chronic kidney disease, n = 12; chronic kidney disease stage 3b-4, n = 12; healthy controls, n = 6). All calcific uremic arteriolopathy patients had end-stage kidney disease. Cutaneous vascular calcifications were not present in any of the non-lesional skin punch biopsies. Breast arterial calcification was demonstrated in patients with calcific uremic arteriolopathy (75%) and chronic kidney disease (end-stage 67% and stage 3b-4 25%, respectively), but in none of the controls. All chronic kidney disease patients had systemic calcification on lumbar X-ray (median score 21, 22, and 15 in patients with calcific uremic arteriolopathy, end-stage kidney disease and chronic kidney disease stage 3b-4). The serum calcification propensity was significantly different between groups. DISCUSSION Despite a high burden of systemic vascular calcification, cutaneous calcium deposits in non-lesional tissue could not be demonstrated histopathologically in patients with chronic kidney disease (with or without current or previous calcific uremic arteriolopathy). Further studies to determine whether these findings are representative or attributed to other factors are warranted.
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Affiliation(s)
- Anne Kristine Røndbjerg
- Department of Internal Medicine, University Hospital Zealand, Roskilde, Denmark
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Nephrology, Copenhagen University Hospital, Herlev, Denmark
| | - Mette Gyldenløve
- Department of Dermatology and Allergy, Copenhagen University Hospital, Gentofte, Denmark
| | - Dorrit Krustrup
- Department of Pathology, Copenhagen University Hospital, Herlev, Denmark
| | - Marianne Rix
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Ilse Vejborg
- Department of Breast Examinations, Copenhagen University Hospital, Gentofte, Denmark
| | - Lars Lonn
- Department of Radiology, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, Herlev, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, Herlev, Denmark
| | - Andreas Pasch
- Calciscon, Biel, Switzerland
- Department of Physiology and Pathophysiology, Johannes Kepler University Linz, Linz, Austria
| | - Lone Skov
- Department of Dermatology and Allergy, Copenhagen University Hospital, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Herlev, Denmark
| | - Ditte Hansen
- Department of Nephrology, Copenhagen University Hospital, Herlev, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Herlev, Denmark.
- Department of Nephrology, Herlev and Gentofte Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.
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Ficenec S, Gerstein B, Shamburger CD. Calcific uraemic arteriolopathy presenting as cellulitis of the dorsal foot. BMJ Case Rep 2023; 16:e251758. [PMID: 37015767 PMCID: PMC10083774 DOI: 10.1136/bcr-2022-251758] [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: 04/06/2023] Open
Abstract
Calcific uraemic arteriolopathy (CUA) is a rare and poorly understood entity that typically presents with painful lesions affecting adipose-rich areas of the lower extremities. We report an unusual case of CUA presenting as presumed cellulitis of the dorsal surface of the distal lower extremity with acute development of a bullous lesion. As CUA incidence is predicted to increase due to its relationship with end-stage renal disease, recognising the full clinical spectrum of this disease is essential to promote further understanding of this disorder and exploration of additional therapeutics to limit disease morbidity and mortality.
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Affiliation(s)
- Samuel Ficenec
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Brittany Gerstein
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
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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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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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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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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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9
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Bailleux S, Collins P, Nikkels AF. The Relevance of Skin Biopsies in General Internal Medicine: Facts and Myths. Dermatol Ther (Heidelb) 2022; 12:1103-1119. [PMID: 35430724 PMCID: PMC9110592 DOI: 10.1007/s13555-022-00717-x] [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: 01/11/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Non-dermatology medical specialties may refer patients for skin biopsies, searching for a particular diagnosis. However, the diagnostic impact of the skin biopsy is not clearly established. This article aims to assess the indications for, and evaluate the clinical relevance of, skin biopsies in non-dermatology medical specialties. Methods A questionnaire was sent to 23 non-dermatology specialty departments in a university medical center, requesting a list of indications for skin biopsies, as well as to 10 staff dermatologists to collect the indications of skin biopsies requested by non-dermatology specialties. Once the indications were collected, a literature search was performed to evaluate their clinical value and relevance. Results Eleven non-dermatology specialties provided a list of skin biopsy indications, to which staff dermatologists added seven more indications. A literature search revealed evidence-based medicine data for six diseases, that is, amyloidosis, peripheral autonomic neuropathy, Sneddon’s syndrome, intravascular lymphoma, sarcoidosis, and chronic graft-versus-host disease. Results were questionable concerning infectious endocarditis, acute graft-versus-host-disease, and the lupus band test. Skin biopsy were not evidenced as useful for the diagnosis of calciphylaxis, systemic scleroderma, Behçet’s disease, or hypermobile Ehlers–Danlos syndrome. For the diagnosis of Alport’s syndrome, pseudoxanthoma elasticum, and vascular Ehlers–Danlos syndrome, skin biopsy is currently outperformed by genetic analyses. For diagnoses such as Henoch–Schönlein purpura and Sjögren’s syndrome, skin biopsy represents an additional item among other diagnostic criteria. Conclusion The usefulness of skin biopsy as requested by non-dermatology specialties is only evidenced for amyloidosis, peripheral autonomic neuropathy, Sneddon’s syndrome, intravascular lymphoma, sarcoidosis, chronic graft-versus-host-disease, Henoch–Schönlein purpura, and Sjögren’s syndrome.
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Affiliation(s)
- Sophie Bailleux
- Department of Dermatology, University Hospital Centre, CHU du Sart Tilman, University of Liège, 4000, Liège, Belgium
| | - Patrick Collins
- Department of Dermatopathology, University Hospital Centre, CHU du Sart Tilman, Liège, Belgium
| | - Arjen F Nikkels
- Department of Dermatology, University Hospital Centre, CHU du Sart Tilman, University of Liège, 4000, Liège, Belgium.
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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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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.
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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
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Gonzalez DE, Foresto RD, Maldonado ALS, Padilha WSC, Roberto FB, Pereira MEVDC, Durão Junior MDS, Carvalho AB. Multiple extremity necrosis in fatal calciphylaxis: Case report. ACTA ACUST UNITED AC 2021; 43:274-278. [PMID: 32645129 PMCID: PMC8257280 DOI: 10.1590/2175-8239-jbn-2020-0025] [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: 02/07/2020] [Accepted: 05/04/2020] [Indexed: 11/22/2022]
Abstract
Introduction: The clinical impact of vascular calcification is well established in the
context of cardiovascular morbidity and mortality, but other clinical
syndromes, such as calciphylaxis, although less frequent, have a significant
impact on chronic kidney disease. Methods: Case report of a 27-year-old woman, who had complained of bilateral pain in
her toes for 3 days, with the presence of small necrotic areas in the
referred sites. She had a history of type 1 diabetes (25 years ago), with
chronic kidney disease, on peritoneal dialysis, in addition to rheumatoid
arthritis. She was admitted to the hospital, which preceded the current
condition, due to exacerbation of rheumatoid arthritis, evolving with
intracardiac thrombus due to venous catheter complications, when she started
using warfarin. Ischemia progressed to her feet, causing the need for
bilateral amputations. Her chirodactyls were also affected. Thrombophilia,
vasculitis, endocarditis or other embolic sources were investigated and
discarded. Her pathology report evidenced skin necrosis and superficial soft
parts with recent arterial thrombosis, and Monckeberg's medial
calcification. We started treatment with bisphosphonate and sodium
thiosulfate, conversion to hemodialysis and replacement of warfarin with
unfractionated heparin. Despite all the therapy, the patient died after four
months of evolution. Discussion: Calciphylaxis is a rare microvasculature calcification syndrome that results
in severe ischemic injuries. It has pathogenesis related to the mineral and
bone disorder of chronic kidney disease combined with the imbalance between
promoters and inhibitors of vascular calcification, with particular
importance to vitamin K antagonism. Conclusion: The preventive strategy is fundamental, since the therapy is complex with
poorly validated effectiveness.
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Affiliation(s)
- Diego Ennes Gonzalez
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Hospital do Rim, São Paulo, SP, Brasil
| | - Renato Demarchi Foresto
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Hospital do Rim, São Paulo, SP, Brasil
| | - Ana Luiza Santos Maldonado
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Hospital do Rim, São Paulo, SP, Brasil
| | | | - Fernanda Badiani Roberto
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Hospital do Rim, São Paulo, SP, Brasil
| | | | - Marcelino de Souza Durão Junior
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Departamento de Medicina, São Paulo, SP, Brasil
| | - Aluizio Barbosa Carvalho
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Departamento de Medicina, São Paulo, SP, Brasil
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Abstract
Calciphylaxis is a cutaneous vasculopathy with high morbidity and mortality characterized by vascular intimal fibrosis, calcification, stenosis, thrombosis, and eventual tissue death due to ischemia. Histopathologic diagnosis is often difficult, frequently necessitating multiple tissues samples due to lack of specific histopathologic features and subtle changes on biopsies of early lesions. In this study, we review the reported clinical and histopathologic features of calciphylaxis, correlating them with relevant imaging, ancillary studies, and pathophysiology. Although many histopathologic changes seen in calciphylaxis are also reported in other conditions (eg, Mönckeberg sclerosis, lupus panniculitis, pancreatic panniculitis, and peripheral artery disease), calcification of subcutaneous small vessels, thrombosis and/or ischemic changes, pseudoxanthoma elasticum-like changes in the subcutis, and perieccrine calcification may serve as helpful clues. von Kossa and Alizarin red stains can assist in the identification of subtle calcification. Netlike calcification of the affected blood vessels on imaging further supports the diagnosis. Studies into the pathophysiology of calciphylaxis are ongoing and will hopefully facilitate the development of additional diagnostic adjuncts to increase sensitivity and specificity for the diagnosis of this disease.
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Jankowski J, Floege J, Fliser D, Böhm M, Marx N. Cardiovascular Disease in Chronic Kidney Disease: Pathophysiological Insights and Therapeutic Options. Circulation 2021; 143:1157-1172. [PMID: 33720773 PMCID: PMC7969169 DOI: 10.1161/circulationaha.120.050686] [Citation(s) in RCA: 634] [Impact Index Per Article: 211.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with chronic kidney disease (CKD) exhibit an elevated cardiovascular risk manifesting as coronary artery disease, heart failure, arrhythmias, and sudden cardiac death. Although the incidence and prevalence of cardiovascular events is already significantly higher in patients with early CKD stages (CKD stages 1-3) compared with the general population, patients with advanced CKD stages (CKD stages 4-5) exhibit a markedly elevated risk. Cardiovascular rather than end-stage kidney disease (CKD stage 5) is the leading cause of death in this high-risk population. CKD causes a systemic, chronic proinflammatory state contributing to vascular and myocardial remodeling processes resulting in atherosclerotic lesions, vascular calcification, and vascular senescence as well as myocardial fibrosis and calcification of cardiac valves. In this respect, CKD mimics an accelerated aging of the cardiovascular system. This overview article summarizes the current understanding and clinical consequences of cardiovascular disease in CKD.
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Affiliation(s)
- Joachim Jankowski
- Institute for Molecular Cardiovascular Research (J.J.), University Hospital, Rheinisch-Westfälische Technische Hochschule Aachen (RWTH), Aachen, Germany
- School for Cardiovascular Diseases, Maastricht University, The Netherlands (J.J.)
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology (J.F.), University Hospital, Rheinisch-Westfälische Technische Hochschule Aachen (RWTH), Aachen, Germany
| | - Danilo Fliser
- Department of Nephrology (D.F.), Saarland University Medical Centre, Homburg, Germany
| | - Michael Böhm
- Department of Cardiology, Angiology and Intensive Care Medicine (M.B.), Saarland University Medical Centre, Homburg, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I (Cardiology) (N.M.), University Hospital, Rheinisch-Westfälische Technische Hochschule Aachen (RWTH), Aachen, Germany
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15
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Kouiss Y, Aynaou M, Houmaidi AE, Mhanna T, Ahmed Y, Ouraghi A, Miri A, Bennani A, Barki A. Penile necrosis by calciphylaxis leading to gangrene in a patient with chronic renal failure on dialysis: A case report. Int J Surg Case Rep 2020; 71:187-191. [PMID: 32470914 PMCID: PMC7533627 DOI: 10.1016/j.ijscr.2020.04.091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/24/2020] [Accepted: 04/26/2020] [Indexed: 11/19/2022] Open
Abstract
Penile necrosis by calciphylaxis is a rare disease. The diagnosis of CUA is often difficult. The Management of this rare condition is still a matter of debate.
Introduction Penile calciphylaxis is a rare disease whose diagnosis is not easy. It is associated with chronic renal failure. It is a result of media calcification and blood vessels’ fibrosis such as penile arteries that eventually lead to gangrene formation in extremities and penis. Calcific uremic arteriolopathy is commonly associated with secondary hyperparathyroidism and high level of calcium and phosphate. Presentation of case In this paper, we report a case of penile necrosis induced by calciphylaxis associated with chronic renal failure and diabetic macroangiopathy. We performed a partial and total amputation in two stages because of the wound infection. The patient died one week after a total penectomy. Discussion The skin biopsy is the gold standard for the diagnosis despite being a risky process. In most cases, appropriate medical management is advocated. The treatment of this pathology is still controversial. Conclusion The management of this rare situation is controversial, and its diagnosis is still difficult due to the scarcity of reported cases.
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Affiliation(s)
- Youssef Kouiss
- Department of Urology, Mohamed VI University Hospital, Oujda, Morocco.
| | - Mohammed Aynaou
- Department of Urology, Mohamed VI University Hospital, Oujda, Morocco
| | - Amine El Houmaidi
- Department of Urology, Mohamed VI University Hospital, Oujda, Morocco
| | - Tarik Mhanna
- Department of Urology, Mohamed VI University Hospital, Oujda, Morocco
| | - Yacoub Ahmed
- Department of Urology, Mohamed VI University Hospital, Oujda, Morocco
| | | | - Achraf Miri
- Department of Pathology, Mohamed VI University Hospital, Oujda, Morocco
| | - Amal Bennani
- Department of Pathology, Mohamed VI University Hospital, Oujda, Morocco
| | - Ali Barki
- Department of Urology, Mohamed VI University Hospital, Oujda, Morocco
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16
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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.
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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
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17
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Musso CG, Enz PA, Kowalczuk A, Cozzolino M, Brandenburg V, Nigwekar S. Differential diagnosis of calciphylaxis in chronic dialysis patients. Int Urol Nephrol 2020; 52:595-597. [DOI: 10.1007/s11255-020-02388-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/13/2020] [Indexed: 01/07/2023]
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18
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On the role of skin biopsy in the diagnosis of calcific uremic arteriolopathy: a case-based discussion. J Nephrol 2019; 33:859-865. [PMID: 31792896 DOI: 10.1007/s40620-019-00678-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/24/2019] [Indexed: 12/30/2022]
Abstract
Calciphylaxis is a rare disease characterized by ectopic calcification of skin arterioles resulting in ischemia, thrombosis and necrosis. Since end stage renal disease patients are those mainly affected, the term calcific uremic arteriolopathy (CUA) is also suggested. Early clinical manifestations are subtle, while overt necrotic ulcers may quickly spread and become infected so as to result in ominous outcome. Diagnosis might not be easy due to the number of other ischemic and non-ischemic skin lesions observed in uraemia. Skin biopsy, has been proposed as the diagnostic test and is often considered, but not systematically performed due to the hypothetical risk of further spreading of the lesions. Such ambiguity could be responsible for misdiagnosis or underdiagnosis. We review here five consecutive cases recorded in our Unit, all submitted to skin biopsy but with inconsistent results which generated some clinical frustration. Thus, we decided to carefully re-evaluate all of them together with pathologists and dermatologists. However, even after this ex-post discussion, we could not reach a complete agreement on the final diagnosis. In the meanwhile, papers were published in the literature that started to shed some light on the role of skin biopsy in the diagnosis of CUA.
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19
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Pasquali M, De Martini N, Mazzaferro S. Calciphylaxis: a conundrum for patients and nephrologists? J Nephrol 2019; 32:677-680. [DOI: 10.1007/s40620-019-00639-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 08/10/2019] [Indexed: 01/15/2023]
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20
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Kakani E, Elyamny M, Ayach T, El‐Husseini A. Pathogenesis and management of vascular calcification in CKD and dialysis patients. Semin Dial 2019; 32:553-561. [DOI: 10.1111/sdi.12840] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Elijah Kakani
- Division of Hospital Medicine University of Kentucky Lexington KY USA
| | - Mohamed Elyamny
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
| | - Taha Ayach
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
| | - Amr El‐Husseini
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
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21
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Tangkham R, Sangmala S, Aiempanakit K, Chiratikarnwong K, Auepemkiate S. Calciphylaxis mimicking ecthyma gangrenosum. IDCases 2019; 18:e00594. [PMID: 31360636 PMCID: PMC6639653 DOI: 10.1016/j.idcr.2019.e00594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/09/2019] [Accepted: 07/09/2019] [Indexed: 12/15/2022] Open
Abstract
Calciphylaxis is a rare cutaneous disease that may cause fatal complications in patients on long-term dialysis. Early diagnosis and proper management decrease complications. However, it can mimic cutaneous infections, especially ecthyma gangrenosum and cutaneous vasculitis. The authors report on a patient with chronic kidney disease (CKD) on dialysis for 10 years who developed painful skin necrosis on his right thigh. The tissue culture was positive for Enterobacter cloacae, Citrobacter freundii, and Pseudomonas aeruginosa, but the histopathology was compatible with calciphylaxis. This report aims to further the knowledge of physicians in order to help them recognize calciphylaxis in CKD patients with painful necrotic ulcers.
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Affiliation(s)
- Ranchana Tangkham
- Department of Family Medicine and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, 90110 Songkhla, Thailand
| | - Siripan Sangmala
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Kumpol Aiempanakit
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Kanokphorn Chiratikarnwong
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Sauvarat Auepemkiate
- Department of Pathology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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22
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Abstract
Calciphylaxis is an uncommon disease that presents with painful ulceration and necrosis of the skin secondary to small vessel calcification and microvascular occlusion. Calciphylaxis carries a poor prognosis as the nonhealing wounds provide a port of entry for pathogens, predisposing these patients to infection and sepsis. Ulcers caused by calciphylaxis are most commonly seen in patients with end-stage renal disease (ESRD) but can also present in patients with normal electrolytes and kidney function. We report a case of a 42-year-old woman with a 10-year history of ESRD who developed rapidly progressing calciphylaxis in her legs and hand, starting three months after successful kidney transplantation. The relationship between kidney transplantation and calciphylaxis remains unclear. There are a handful of cases in which calciphylaxis has been treated by successful kidney transplant, however, other cases have been reported in which calciphylaxis developed after kidney transplantation.
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Affiliation(s)
- Michael P Ryan
- Dermatology, University of Texas Medical Branch, Galveston, USA
| | - Lindy S Ross
- Dermatology, University of Texas Medical Branch, Galveston, USA
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23
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24
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Russ P, Russwurm M, Kortus-Goetze B, Hoyer J, Kamalanabhaiah S. Phenprocoumon based anticoagulation is an underestimated factor in the pathogenesis of calciphylaxis. BMC Nephrol 2019; 20:114. [PMID: 30940121 PMCID: PMC6444830 DOI: 10.1186/s12882-019-1301-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 03/18/2019] [Indexed: 11/21/2022] Open
Abstract
Background Calciphylaxis is a life threatening complication in renal patients. Of great importance is the identification of concomitant factors for calciphylaxis. Due to the variability of clinical presentation the evaluation of such factors may be obscured when calciphylaxis diagnosis is based just on clinical features. We aimed to characterize associated factors only in patients with calciphylaxis proven by histomorphological parameters in addition to clinical presentation. Methods In a single center retrospective study we analyzed 15 patients in an 8 year period from 2008 to 2016. Only patients with clinical features and histomorphological proof of calciphylaxis were included. Criteria for histological diagnosis of calciphylaxis were intimal hyperplasia, micro thrombi or von Kossa stain positive media calcification. Results The mean age of patients was 64.8 years. Nine patients (60%) were female; 12 (80%) were obese with a Body-Mass-Index (BMI) > 30 kg/m2; 3 (20%) had no renal disease; 12 (80%) had CKD 4 or 5 and 10 (66.7%) had end-stage renal disease (ESRD). One-year mortality in the entire cohort was 73.3%. With respect to medication history, the majority of patients (n = 13 (86.7%)) received vitamin K antagonists (VKA); 10 (66.7%) were treated with vitamin D; 6 (40%) had oral calcium supplementation; 5 (33.3%) had been treated with corticosteroids; 12 (80%) were on proton pump inhibitors (PPI); 13 (86.7%) patients had a clinical proven hyperparathyroidism. Ten (66.7%) patients presented with hypoalbuminemia at diagnosis. Conclusions The evaluation of biopsy proven calciphylaxis demonstrates that especially treatment with vitamin K antagonists and liver dysfunction are most important concomitant factors in development of calciphylaxis. As progression and development of calciphylaxis are chronic rather than acute processes, early use of DOACs instead of VKA might be beneficial and reduce the incidence of calciphylaxis.
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Affiliation(s)
- Philipp Russ
- Department of Nephrology, University Hospital of Marburg, UKGM GmbH, Baldingerstraße 1, 35033, Marburg, Germany
| | - Martin Russwurm
- Department of Nephrology, University Hospital of Marburg, UKGM GmbH, Baldingerstraße 1, 35033, Marburg, Germany
| | - Birgit Kortus-Goetze
- Department of Nephrology, University Hospital of Marburg, UKGM GmbH, Baldingerstraße 1, 35033, Marburg, Germany
| | - Joachim Hoyer
- Department of Nephrology, University Hospital of Marburg, UKGM GmbH, Baldingerstraße 1, 35033, Marburg, Germany.
| | - Sahana Kamalanabhaiah
- Department of Nephrology, University Hospital of Marburg, UKGM GmbH, Baldingerstraße 1, 35033, Marburg, Germany
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25
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Udomkarnjananun S, Kongnatthasate K, Praditpornsilpa K, Eiam-Ong S, Jaber BL, Susantitaphong P. Treatment of Calciphylaxis in CKD: A Systematic Review and Meta-analysis. Kidney Int Rep 2019; 4:231-244. [PMID: 30775620 PMCID: PMC6365410 DOI: 10.1016/j.ekir.2018.10.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/20/2018] [Accepted: 10/01/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Calciphylaxis is a life-threatening complication of chronic kidney disease (CKD). To inform clinical practice, we performed a systematic review of case reports, case series, and cohort studies to synthesize the available treatment modalities and outcomes of calciphylaxis in patients with CKD. METHODS Electronic databases were searched for studies that examined the uses of sodium thiosulfate, surgical parathyroidectomy, calcimimetics, hyperbaric oxygen therapy, and bisphosphonates for calciphylaxis in patients with CKD, including end-stage renal disease. For cohort studies, the results were synthesized quantitatively by performing random-effects model meta-analyses. RESULTS A total of 147 articles met the inclusion criteria and were included in the systematic review. There were 90 case reports (90 patients), 20 case series (423 patients), and 37 cohort studies (343 patients). In the pooled cohorts, case series, and case reports, 50.3% of patients received sodium thiosulfate, 28.7% underwent surgical parathyroidectomy, 25.3% received cinacalcet, 15.3% underwent hyperbaric oxygen therapy, and 5.9% received bisphosphonates. For the subset of cohort studies, by meta-analysis, the pooled risk ratio for mortality was not significantly different among patients who received sodium thiosulfate (pooled risk ratio [RR] 0.89; 95% confidence interval [CI] 0.71-1.12), cinacalcet (pooled RR 1.04; 95% CI 0.75-1.42), hyperbaric oxygen therapy (pooled RR 0.89; 95% CI 0.71-1.12), and bisphosphonates (pooled RR 0.77; 95% CI 0.44-1.32), and those who underwent surgical parathyroidectomy (pooled RR 0.88; 95% CI 0.69-1.13). CONCLUSION This systematic review found no significant clinical benefit of the 5 most frequently used treatment modalities for calciphylaxis in patients with CKD. Randomized controlled trials are needed to test the efficacy of these therapies.
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Affiliation(s)
- Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kitravee Kongnatthasate
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Bertrand L. Jaber
- Department of Medicine, St. Elizabeth’s Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Nigwekar SU, Nazarian RM. Cutaneous calcification in patients with kidney disease is not always calciphylaxis. Kidney Int 2019; 94:244-246. [PMID: 30031445 DOI: 10.1016/j.kint.2018.04.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 04/25/2018] [Accepted: 04/26/2018] [Indexed: 01/08/2023]
Abstract
Calciphylaxis, also referred to as calcific uremic arteriolopathy, is a rare disorder that predominantly afflicts patients with end-stage renal disease. In this issue of Kidney International, a report describing histologic features of calciphylaxis questions the specificity of histologic findings typically considered to be characteristic of calciphylaxis. Validated diagnostic criteria are much needed for the clinical care and the investigational studies of patients with calciphylaxis.
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Affiliation(s)
- Sagar U Nigwekar
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Rosalynn M Nazarian
- Department of Pathology, Division of Dermatopathology, Massachusetts General Hospital, Boston, Massachusetts, USA
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27
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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.
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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
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28
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Hassanein M, Laird-Fick H, Tikaria R, Aldasouqi S. Removing the problem: parathyroidectomy for calciphylaxis. BMJ Case Rep 2018; 11:11/1/e226696. [PMID: 30580300 DOI: 10.1136/bcr-2018-226696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Calcific uremic arteriolopathy (CUA), widely known as calciphylaxis, is a rare and lethal disease that usually affects patients with end-stage renal disease. It is characterised by widespread vascular calcification leading to tissue ischaemia and necrosis and formation of characteristic skin lesions with black eschar. Treatment options include sodium thiosulfate, cinacalcet, phosphate binders and in resistant cases, parathyroidectomy. We report a case of recurrent, treatment-resistant CUA successfully treated with parathyroidectomy. Her postoperative course was complicated by hungry bone syndrome and worsening of her wounds before they completely healed. We then discuss the morbidity of CUA, including the controversy around the use of parathyroidectomy and risk of aggressive management of hungry bone syndrome.
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Affiliation(s)
- Mohamed Hassanein
- Department of Internal Medicine, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Heather Laird-Fick
- Department of Internal Medicine, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Richa Tikaria
- Department of Internal Medicine, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Saleh Aldasouqi
- Department of Internal Medicine, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
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29
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Peng T, Zhuo L, Wang Y, Jun M, Li G, Wang L, Hong D. Systematic review of sodium thiosulfate in treating calciphylaxis in chronic kidney disease patients. Nephrology (Carlton) 2018; 23:669-675. [PMID: 28603903 DOI: 10.1111/nep.13081] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 12/21/2022]
Abstract
AIM Calciphylaxis is a severe complication of advanced chronic kidney disease (CKD). Sodium thiosulphate (STS), an antioxidant and calcium chelating agent, has been used for the treatment of calciphylaxis. However, its efficacy and safety have not been systematically analysed and evaluated. METHODS MEDLINE, EMBASE, and the Cochrane Library database were systematically searched for case report or cases series on use of STS for calciphylaxis published between July 1974 and October 2016. We extracted data on clinical characteristics, laboratory tests result and medication use. The effective treatment was defined as improvement in skin lesion cicatrisation or pain relief without death. Non-responding effects were defined as stable skin lesions without remission or exacerbation of the disease in patients who remained alive. All-cause mortality after STS treatment was defined as death due to exacerbations of calciphylaxis or other complications of advanced CKD. We compared the baseline parameters of the patients as well as the efficacy and mortality of the STS therapy between case report and multi-case reports. Statistical analyses were performed using SPSS 19. RESULTS A total of 83 papers were screened, 45 of them (n = 358) met the inclusion criteria, including 36 case reports (n = 64) and nine multi-case reports (n = 294). The mean age of the patients with calciphylaxis was 58 ± 14 years (range 26-91 years). They were female predominant, accounting for 74.1%. Among the patients with calciphylaxis, 96.1% patients were on dialysis with median dialysis vintage of 44.5 months (range 24-84 months). STS was effective in 70.1% of patients, 37.6% patients died. The proportion of patients with sepsis was higher among those who received intravenous STS. There was no significant difference in efficacy between the different STS administration methods (P = 0.19). CONCLUSION Although the study was unable to assess the efficacy of sodium thiosulphate alone in the treatment of calciphylaxis, it still reveals a promising role of STS as an effective therapy for calciphylaxis. Further prospective studies to define the optimal therapy for calciphylaxis are needed.
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Affiliation(s)
- Ting Peng
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Ling Zhuo
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Ying Wang
- The George Institute for Global Health, University of Sydney, Australia
| | - Min Jun
- The George Institute for Global Health, University of Sydney, Australia
| | - Guisen Li
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Li Wang
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,School of Medicine, University of Electronic Science and Technology of China, China
| | - Daqing Hong
- Renal Division and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China (Chengdu, 610072), China.,The George Institute for Global Health, University of Sydney, Australia
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30
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Chettati M, Adnouni A, Fadili W, Laouad I. [Calcific uremic arteriolopathy in hemodialysis patient, review of literature through five cases reports]. Nephrol Ther 2018; 14:439-445. [PMID: 30401462 DOI: 10.1016/j.nephro.2018.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 04/14/2018] [Accepted: 04/16/2018] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Mariam Chettati
- Service de néphrologie-hémodialyse et transplantation rénale, université Cadi Ayyad, CHU Mohammed VI, BP 2360 Principal, avenue Ibn Sina, Marrakech, Maroc.
| | - Adil Adnouni
- Service de néphrologie-hémodialyse et transplantation rénale, université Cadi Ayyad, CHU Mohammed VI, BP 2360 Principal, avenue Ibn Sina, Marrakech, Maroc
| | - Wafae Fadili
- Service de néphrologie-hémodialyse et transplantation rénale, université Cadi Ayyad, CHU Mohammed VI, BP 2360 Principal, avenue Ibn Sina, Marrakech, Maroc
| | - Inass Laouad
- Service de néphrologie-hémodialyse et transplantation rénale, université Cadi Ayyad, CHU Mohammed VI, BP 2360 Principal, avenue Ibn Sina, Marrakech, Maroc
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Cucchiari D, Torregrosa JV. Calciphylaxis in patients with chronic kidney disease: A disease which is still bewildering and potentially fatal. Nefrologia 2018; 38:579-586. [PMID: 30415999 DOI: 10.1016/j.nefro.2018.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/11/2018] [Accepted: 05/09/2018] [Indexed: 11/30/2022] Open
Abstract
Calciphylaxis, also known as calcific uraemic arteriolopathy, is a rare syndrome that typically causes skin necrosis and usually affects dialysis patients. Its pathogenesis is multifactorial and is the consequence of many factors causing ectopic calcifications in patients with chronic kidney disease, such as calcium-phosphate metabolism disorders, hyper- or hypo-parathyroidism, diabetes, obesity, systemic inflammation and the use of vitamin K antagonists, among others. From a clinical point of view, calciphylaxis may progress from painful purpura to extensive areas of skin necrosis that can potentially lead to superinfection and the death of the patient due to sepsis. Treatment is primarily based on managing the wounds, eliminating all the possible precipitating factors of ectopic calcification and administering agents which are capable of inhibiting the process of calcification.
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Affiliation(s)
- David Cucchiari
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, España; Nephrology and Dialysis Unit, Humanitas Clinical Research Center, Rozzano, Italia
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Williams EA, Moy AP, Cipriani NA, Nigwekar SU, Nazarian RM. Factors associated with false-negative pathologic diagnosis of calciphylaxis. J Cutan Pathol 2018; 46:16-25. [DOI: 10.1111/cup.13364] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 08/03/2018] [Accepted: 09/19/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Erik A. Williams
- Massachusetts General Hospital; Dermatopathology Unit, Department of Pathology; Boston Massachusetts
- Harvard Medical School; Boston Massachusetts
| | - Andrea P. Moy
- Department of Dermatology; Northwell Health and Zucker School of Medicine at Hofstra/Northwell; Lake Success New York
| | - Nicole A. Cipriani
- The University of Chicago Medicine & Biological Sciences; Chicago Illinois
| | - Sagar U. Nigwekar
- Harvard Medical School; Boston Massachusetts
- Massachusetts General Hospital; Division of Nephrology, Department of Medicine; Boston Massachusetts
| | - Rosalynn M. Nazarian
- Massachusetts General Hospital; Dermatopathology Unit, Department of Pathology; Boston Massachusetts
- Harvard Medical School; Boston Massachusetts
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33
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Frunza-Stefan S, Poola-Kella S, Silver K. Non-uraemic calciphylaxis (NUC) postliver transplantation. BMJ Case Rep 2018; 2018:bcr-2018-226537. [PMID: 30361453 DOI: 10.1136/bcr-2018-226537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Calciphylaxis is a rare and life-threatening disease characterized by cutaneous arteriolar stenosis and vascular thrombosis leading to skin ischaemia and necrosis. While calciphylaxis occurs mostly in patients with end-stage renal disease, the disorder has been described in patients with normal renal function, namely non-uraemic calciphylaxis (NUC). A 41-year-old African-American woman presented with a painful ulcerative rash on her thighs and right buttock 2 months after undergoing an orthotopic liver transplantation. She underwent debridement of the lesions and an excisional biopsy of one of the lesions, which revealed calciphylaxis. She was treated with sodium thiosulfate, cinacalcet and hyperbaric oxygen with complete resolution of the lesions 4-5 months after presentation. While she was treated with a course of high-dose glucocorticoids after the transplant, she did not have other risk factors for calciphylaxis. NUC should be considered in the differential diagnosis of necrotic skin lesions in postliver transplant patients.
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Affiliation(s)
- Simona Frunza-Stefan
- Medicine; Endocrinology, Diabetes and Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
| | | | - Kristi Silver
- Medicine; Endocrinology, Diabetes and Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
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34
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Dusilová Sulková S, Horáček J, Vykoukalová E, Šafránek R, Malá A, Palička V. Parathyroidectomy in Hyperparathyroidism-Associated Calciphylaxis in End-Stage Renal Disease Should be Prompt and Radical - a Case Report with Two Original Therapeutic Modifications and Successful Outcome. ACTA MEDICA (HRADEC KRÁLOVÉ) 2018; 60:85-88. [PMID: 28976876 DOI: 10.14712/18059694.2017.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We present a case of severe calciphylaxis in both thighs and calves in a patient with end-stage renal disease and advanced secondary hyperparathyroidism with successful outcome after modified therapeutic approach. The cause of calciphylaxis is multifactorial. In our case, not only severe hyperparathyroidism and mediocalcinosis, but also medication (warfarin, calcium and active vitamin D) was involved. Because the initial conservative therapy was not successful, we indicated parathyroidectomy. However, we were not able to localize parathyroid glands and we contraindicated bilateral neck exploration due to the patient's critical status. Therefore, we decided for total thyroidectomy with total parathyroidectomy. Surgery was uncomplicated and histology confirmed that all four parathyroid glands were removed. The expected post-operative hypocalcaemia was asymptomatic and we did not use any calcium supplementation or vitamin D. Thyroid hormone replacement was easy. After surgery, the large and multiple subcutaneous defects started to heal. We achieved complete healing within several months of continuing dedicated care. There is no recurrence after three years. Prompt and radical surgical parathyroidectomy was extremely useful in our patient.
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Affiliation(s)
- Sylvie Dusilová Sulková
- Academic Department of Internal Medicine, Charles University, Faculty of Medicine in Hradec Králové, Czech Republic. .,Haemodialysis Centre, University Hospital Hradec Králové, Czech Republic.
| | - Jiří Horáček
- 4th Department of Internal Medicine - Haematology, University Hospital Hradec Králové, Czech Republic.,Academic Department of Internal Medicine, Charles University, Faculty of Medicine in Hradec Králové, Czech Republic
| | - Eva Vykoukalová
- Internal Medicine Centre, Regional Hospital Liberec, Czech Republic
| | - Roman Šafránek
- Academic Department of Internal Medicine, Charles University, Faculty of Medicine in Hradec Králové, Czech Republic.,Haemodialysis Centre, University Hospital Hradec Králové, Czech Republic
| | - Alena Malá
- Haemodialysis Centre, University Hospital Hradec Králové, Czech Republic
| | - Vladimír Palička
- Institute of Clinical Biochemistry and Diagnostics, University Hospital Hradec Králové, Czech Republic
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35
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Affiliation(s)
- Sagar U Nigwekar
- From the Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston (S.U.N., R.T.); the Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Los Angeles (R.T.); and the Department of Cardiology, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen University Hospital, Aachen (V.M.B.), and the Department of Cardiology, Rhein-Maas Klinikum, Würselen (V.M.B.) - both in Germany
| | - Ravi Thadhani
- From the Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston (S.U.N., R.T.); the Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Los Angeles (R.T.); and the Department of Cardiology, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen University Hospital, Aachen (V.M.B.), and the Department of Cardiology, Rhein-Maas Klinikum, Würselen (V.M.B.) - both in Germany
| | - Vincent M Brandenburg
- From the Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston (S.U.N., R.T.); the Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Los Angeles (R.T.); and the Department of Cardiology, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen University Hospital, Aachen (V.M.B.), and the Department of Cardiology, Rhein-Maas Klinikum, Würselen (V.M.B.) - both in Germany
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Abstract
PURPOSE OF REVIEW Calciphylaxis remains a poorly understood vascular calcification disorder with predilection for patients with end-stage renal disease (ESRD). Recent data from large patient registries and databases have begun to provide information regarding incidence, risk factors, and outcomes in patients with calciphylaxis. RECENT FINDINGS The most recent estimate places the incidence of calciphylaxis at 3.5 new cases/1000 patient-years among the patients with ESRD on chronic hemodialysis. It is possible that misdiagnosis or subclinical disease may attribute to lower than the true incidence. There is a suggestion that the incidence is higher in peritoneal dialysis patients compared with patients with hemodialysis. Recent studies have identified a number of risk factors and point to the effects of vitamin K deficiency mediated impairment in Matrix Gla Protein carboxylation as one of the likely pathogenic mechanisms. The outcomes in calciphylaxis patients remain poor with mortality approaching 30% at 6 months and 50% at 12 months. SUMMARY The present review describes recent literature in the field of calciphylaxis. Calciphylaxis registries and specimen biorepositories promise to provide insights into the pathogenesis of calciphylaxis and will pave the way for much needed clinical trials.
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Cassius C, Moguelet P, Monfort J, Fessi H, Michel P, Boulahia G, Cury K, Frances C, Senet P. Calciphylaxis in haemodialysed patients: diagnostic value of calcifications in cutaneous biopsy. Br J Dermatol 2017; 178:292-293. [DOI: 10.1111/bjd.15655] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- C. Cassius
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - P. Moguelet
- Department of Pathology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - J.B. Monfort
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - H. Fessi
- Department of Nephrology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - P.A. Michel
- Department of Nephrology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - G. Boulahia
- Department of Nephrology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - K. Cury
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - C. Frances
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
| | - P. Senet
- Department of Dermatology Hôpital Tenon Assistance Publique‐Hôpitaux de Paris (APHP) Paris France
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38
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Nigwekar SU, Jiramongkolchai P, Wunderer F, Bloch E, Ichinose R, Nazarian RM, Thadhani RI, Malhotra R, Bloch DB. Increased Bone Morphogenetic Protein Signaling in the Cutaneous Vasculature of Patients with Calciphylaxis. Am J Nephrol 2017; 46:429-438. [PMID: 29130990 DOI: 10.1159/000484418] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 10/06/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND The objective of this study was to investigate the role of bone morphogenetic protein (BMP) signal transduction in the pathogenesis of calciphylaxis. METHODS Skin biopsy specimens were obtained from 18 patients with, and 12 patients without, calciphylaxis. Tissue sections were stained with antibodies directed against BMP effector proteins phosphorylated-SMAD (p-SMAD) 1/5/9, inhibitor of DNA 1 (Id1), inhibitor of DNA 3 (Id3), and Runx2. The intensity of staining was scored semi-quantitatively as strong versus weak or absent. RESULTS Of the 18 patients with calciphylaxis (mean age: 59 ± 8 years), 9 were women and 15 had end-stage renal disease. Of the 12 control patients (mean age: 57 ± 10 years), 8 were women and 8 had end-stage renal disease. Strong staining for p-SMAD 1/5/9 was detected in blood vessels from all calciphylaxis patients. In 1 patient with calciphylaxis, strong staining for p-SMAD 1/5/9 was detected in a blood vessel that did not have evidence of calcification. Id1 and Id3 immunoreactivity was detected in blood vessels from all 12 patients with calciphylaxis that were tested. Runx2 staining was detected in all 6 patients with calciphylaxis who were tested. p-SMAD 1/5/9 immunoreactivity was weak or absent in blood vessels of 10 of the 12 control samples. CONCLUSIONS The BMP signal transduction pathway is activated in the cutaneous vasculature of calciphylaxis patients. The ability to detect p-SMAD 1/5/9, Id1, and Id3 in cutaneous vasculature may assist in the diagnosis of calciphylaxis. As BMP signaling inhibitors become available, this pathway may serve as a future therapeutic target for calciphylaxis.
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Affiliation(s)
- Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Pawina Jiramongkolchai
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Florian Wunderer
- Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Emily Bloch
- Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rika Ichinose
- Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rosalynn M Nazarian
- Pathology Service, Dermatopathology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ravi I Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rajeev Malhotra
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Donald B Bloch
- Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Aoun M, Koubar SH, Antoun L, Tamim H, Makki M, Chelala D. Reduction of intracerebral hemorrhage in hemodialysis patients after reducing aspirin use: A quality-assurance observational study. PLoS One 2017; 12:e0185847. [PMID: 28968454 PMCID: PMC5624631 DOI: 10.1371/journal.pone.0185847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 09/20/2017] [Indexed: 12/16/2022] Open
Abstract
There is so far no international consensus concerning the prescription of antithrombotic agents in hemodialysis patients. It is not clear yet why they cause more bleeding in some patients and are beneficial in others. We therefore tried to find out what triggers bleeding in this population. This is an observational before-and-after study that included all patients undergoing hemodialysis in our center between 2005 and 2015. We divided the study into two phases: phase one (125 patients) where aspirin was used without restrictions and phase two (110 patients) where aspirin was avoided in severe hypertension and primary prevention. We aimed to assess the differential occurrence of intracerebral hemorrhage between the two phases and the cardiovascular mortality of patients whether on aspirin or not. Bleeding events occurred in 12.8% of patients in phase one and 13.6% in phase two (p = 0.85). Seven out of 125 patients (6%) in phase one experienced intracerebral hemorrhage and none in phase two. Intracerebral hemorrhage was significantly increased in those with the combination of aspirin and severe hypertension (p = 0.003). Aspirin and acenocoumadin were significantly associated with total bleeding (OR = 3.81 and 4.85 with p = 0.005 and 0.001 respectively). Cardiovascular mortality did not differ between phase one and two whether patients were on aspirin or not (p = 0.45 and 0.31 respectively). Minimizing aspirin use in hemodialysis patients with severe hypertension reduced intracerebral bleeding without a significant difference in cardiovascular mortality.
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Affiliation(s)
- Mabel Aoun
- Department of Nephrology, Saint-Georges Hospital, Ajaltoun, Lebanon
- Department of Nephrology, Saint-Joseph University, Beirut, Lebanon
- * E-mail:
| | - Sahar H. Koubar
- Department of Internal Medicine, Division of Nephrology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Leony Antoun
- Department of Internal Medicine, Holy Spirit University, Kaslik, Lebanon
| | - Hani Tamim
- Biostatistics Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maha Makki
- Biostatistics Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Dania Chelala
- Department of Nephrology, Saint-Joseph University, Beirut, Lebanon
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40
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King BJ, El-Azhary RA, McEvoy MT, Shields RC, McBane RD, McCarthy JT, Davis MDP. Direct oral anticoagulant medications in calciphylaxis. Int J Dermatol 2017; 56:1065-1070. [PMID: 28856671 DOI: 10.1111/ijd.13685] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/10/2017] [Accepted: 05/22/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recent studies suggest that calciphylaxis is a thrombotic condition in which arteriolar thrombosis leads to painful skin infarcts and consequent morbidity and mortality. Paradoxically, warfarin is implicated as a risk factor for calciphylaxis. Our objective is to report the use of oral direct thrombin and factor Xa inhibitors (termed direct oral anticoagulants [DOACs]) in patients with calciphylaxis. METHODS We retrospectively reviewed records of 16 patients with calciphylaxis who received concomitant administration of novel anticoagulants. Patient data, including demographics, comorbidities, other treatments, and adverse events, were abstracted from the health records. RESULTS Eleven patients (69%) had chronic kidney disease (stage ≥3A), and eight (50%) received dialysis. Apixaban was the most frequently used agent (n = 11 [69%]). Dabigatran (n = 4 [25%]) and rivaroxaban (n = 2 [13%]) were reserved for patients with mild renal impairment (stage ≤2). One clinically relevant but nonmajor bleeding event occurred. There were no major bleeding events. Nine patients (56%) were alive at last follow-up, and five (31%) had complete resolution of their calciphylaxis (mean follow-up, 523 days; range, 26-1884 days). CONCLUSION DOACs were safe and well tolerated in patients with calciphylaxis, in this initial experience. Several patients had improvement or resolution of calciphylaxis in response to therapy that included DOACs. The degree of renal impairment should guide DOAC choice. Randomized trials are required to determine treatment efficacy.
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Affiliation(s)
- Brian J King
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Raymond C Shields
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Robert D McBane
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - James T McCarthy
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Mark D P Davis
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
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41
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Aoun M, Makki M, Azar H, Matta H, Chelala DN. High Dephosphorylated-Uncarboxylated MGP in Hemodialysis patients: risk factors and response to vitamin K 2, A pre-post intervention clinical trial. BMC Nephrol 2017; 18:191. [PMID: 28592319 PMCID: PMC5463325 DOI: 10.1186/s12882-017-0609-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 05/31/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Vascular calcifications are highly prevalent in hemodialysis patients. Dephosphorylated-uncarboxylated MGP (dp-ucMGP) was found to increase in vitamin K-deficient patients and may be associated with vascular calcifications. Supplementation of hemodialysis patients with vitamin K2 (menaquinone-7) has been studied in Europe with a maximum 61% drop of dp-ucMGP levels. The aim of this study is to assess first the drop of dp-ucMGP in an Eastern Mediterranean cohort after vitamin K2 treatment and second the correlation between baseline dp-ucMGP and vascular calcification score. METHODS This is a prospective, pre-post intervention clinical trial involving 50 hemodialysis patients who received daily 360 μg of menaquinone-7 for 4 weeks. At baseline they were assessed for plasma dp-ucMGP levels and vascular calcification scores (AC-24) as well as for other demographic, clinical and biological variables. Dp-ucMGP levels were measured a second time at 4 weeks. RESULTS At baseline, dp-ucMGP levels were extremely elevated with a median of 3179.15 (1825.25; 4339.50) pM and correlated significantly with AC-24 (Spearman's rho = 0.43, P = 0.002). Using a bivariate regression analysis, the association between dp-ucMGP levels and AC-24 was most significant when comparing dp-ucMGP levels less than 1000 to those more than 1000 pM (P = 0.02). Dp-ucMGP levels higher than 5000 pM were significantly associated with females, patients with recent fracture and patients with lower serum albumin (respectively P = 0.02, 0.004 and 0.046). The average drop of dp-ucMGP at 4 weeks of treatment was found to be 86% with diabetics having the lowest drop rate (P = 0.01). CONCLUSION Vitamin K deficiency, as assessed by high dp-ucMGP levels, is profound in hemodialysis patients from the Eastern Mediterranean region and it is significantly correlated with vascular calcifications. Daily 360 μg of menaquinone-7, given for 4 weeks, effectively reduces dp-ucMGP in this population. Future studies are needed to assess the changes in vascular calcifications in hemodialysis patients treated with vitamin K2 over a longer follow-up period. TRIAL REGISTRATION The clinical trial was registered on clinicaltrials.gov (Identification number NCT02876354 , on August 11, 2016).
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Affiliation(s)
- Mabel Aoun
- Nephrology Department, Saint-Georges Hospital, Ajaltoun, Lebanon
- Nephrology Department, Saint-Joseph University, Beirut, Lebanon
| | - Maha Makki
- Biostatistics Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hiba Azar
- Nephrology Department, Hôtel Dieu de France, Beirut, Saint-Joseph University, Beirut, Lebanon
| | - Hiam Matta
- Laboratory Division, Saint-Georges Hospital, Ajaltoun, Lebanon
| | - Dania Nehme Chelala
- Head of the Nephrology Department, Hôtel Dieu de France, Beirut. Saint-Joseph University, Beirut, Lebanon
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