Correlation between clinical and pathological features of cutaneous calciphylaxis

Calciphylaxis of the Upper Limbs-A Rare and Serious Disease with Multidisciplinary Treatments-A Case Series and Literature Review

Background/Objectives: Calciphylaxis or calcific uremic arteriolopathy is a rare but highly lethal pathology that occurs most frequently in a uremic context, although it can also occur outside of this context. It is characterized by the appearance of necrotic skin lesions. Localization to the upper limbs is rare and has a similarly progressive evolution. Methods: We present a series of two cases-a male and a female-with calciphylaxis diagnoses (including biopsies) and with the patients undergoing dialysis for end-stage renal disease, both with infected and extensive necrotic lesions to the hands and fingers. Both cases required serial debridement treatments and amputations. A literature review was conducted using the precise search terms "calciphylaxis", "upper limb", "uremic calcific arteriolopathy", and "end-stage renal disease" from January 2010 to May 2024. Results: One of the two reported cases ended with the patient's death. The results of the literature review (comprising seven similar cases) confirmed the rarity of calciphylaxis lesion localization to the upper limbs and the high mortality rate among these patients despite administered treatments. No therapeutic protocol for these cases was confirmed. Conclusions: The treatment of calciphylaxis cases is multidisciplinary. Although surgical intervention is controversial, it is necessary in some cases, sometimes serially. Localization to the thoracic limbs has the same evolution and poor prognosis as other localizations. A standardized therapeutic protocol for these cases is still far from being established.

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

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

Characterization of Risk Factors for Calciphylaxis in Hemodialysis Patients in the Fraser Health Renal Program - A Matched Case-Control Retrospective Review

Introduction: Calciphylaxis is a lethal and rare disease characterized by ischemic and necrotic skin lesions caused by vascular calcification of adipose tissue. There have been many risk factors analyzed in the literature; however, the pathogenesis of calciphylaxis is still not well understood and treatment options are limited due to the lack of interventional studies. Our objectives were to describe risk factors, prevalence, incidence, and outcomes for calciphylaxis in hemodialysis patients within the Fraser Health Renal Program. Methods: This was a retrospective matched case-control study of hemodialysis patients within the Fraser Health Renal Program. Hemodialysis patients with calciphylaxis were matched to hemodialysis patients without calciphylaxis in a 1:2 ratio for age and sex from September 2, 2017 to July 3, 2020. Findings: There was a total of 40 calciphylaxis cases matched to 80 controls. In the univariate analysis, peritoneal dialysis, higher body mass index, lower serum iron, lower transferrin saturation, sevelamer, cinacalcet, warfarin, iron (PO), and insulin were associated with increased risk of calciphylaxis. In the multivariate analysis, only peritoneal dialysis, serum iron, sevelamer, and warfarin were identified as significant and strong risk factors associated with calciphylaxis. A low prevalence of 1.9% and high mortality rate of 57.5% at 12 months was found for calciphylaxis cases. Discussion: Significant risk factors associated with calciphylaxis were peritoneal dialysis, serum iron, sevelamer, and warfarin. Future studies should further investigate the impact of minimizing exposure to these risk factors to reduce calciphylaxis development.

Calciphylaxis and Kidney Disease: A Review

Calciphylaxis is a life-threatening complication most often associated with chronic kidney disease that occurs as a result of the deposition of calcium in dermal and adipose microvasculature. However, this condition may also be seen in patients with acute kidney injury. The high morbidity and mortality rates associated with calciphylaxis highlight the importance to correctly diagnose and treat this condition. However, calciphylaxis remains a diagnosis that may be clinically challenging to make. Here, we review the literature on uremic calciphylaxis with a focus on its pathophysiology, clinical presentation, advances in diagnostic tools, and treatment strategies. We also discuss the unique histopathological features of calciphylaxis and contrast it with those of other forms of general vessel calcification. This review emphasizes the need for multidisciplinary collaboration including nephrology, dermatology, and palliative care to ultimately provide the best possible care to patients with calciphylaxis.

Patient-Reported and Clinical Outcomes Among Patients With Calciphylaxis

Objective

To describe the pain intensity among hospitalized patients with calciphylaxis, elucidate the factors associated with pain improvement, and examine the link between pain improvement and clinical outcomes.

Patients and Methods

Patients were identified from the Partners Research Patient Data Registry and the Partners Calciphylaxis Registry and Biorepository (Clinicaltrials.gov ID: NCT03032835). Those with calciphylaxis requiring hospitalization for at least 14 consecutive days during the study period from May 2016 through December 2021 were included. Pain intensity was assessed using patient-reported pain scores on numerical rating scales from 0 to 10. Associations between pain improvement and clinical outcomes, including lesion improvement, amputation, and mortality, were examined using univariate and multivariate regression models.

Results

Our analysis included 111 patients (age, 58±14 years; men, 40%; on maintenance dialysis, 79%). No significant improvement of pain intensity was observed over the 14 days of hospitalization (mean difference, -0.71; P=.08). However, among 49 (44.1%) patients who showed at least 1-point improvement in the pain score, there was an association with surgical debridement during hospitalization (odds ratio, 3.37; 95% CI, 1.17-9.67; P=.02). Hyperbaric oxygen therapy was associated with pain improvement (odds ratio, 5.38; 95% CI, 1.14-25.50; P=.03) in patients on maintenance dialysis. Pain improvement was associated with lower rates of subsequent amputation at 6 months of follow up (6% vs 13%; P<.05) but did not predict lesion improvement or survival.

Conclusion

Pain control remains a challenge among hospitalized patients with calciphylaxis. Surgical debridement and hyperbaric oxygen therapy may improve pain intensity. Pain improvement predicted a lower risk of future amputation.

Manifestation of Nonuremic Calciphylaxis in the Extremities: Case Report and Review

Nonuremic calciphylaxis is a rare condition presenting with peripheral ischemic ulcerations. Calciphylaxis is the deposition of calcium and phosphate into arteriolar walls caused by exceeding their solubility range in the blood. It is most commonly seen in patients with end-stage renal disease; however, nonuremic calciphylaxis occurs in patients with normal or mildly impaired renal function. Risk factors for nonuremic calciphylaxis include Coumadin therapy, obesity, and diabetes mellitus. Histopathologic examination of deep skin biopsy containing subcutaneous adipose tissue reveals medial calcification of dermal and subcutaneous arterioles. This diagnosis must be managed locally with wound care and systemically by control of blood calcium solubility. Avoidance of infection is critical to survival. Here we report a case of calciphylaxis in a patient with normal renal function and serum levels of calcium and phosphorus who presented with gangrene of the extremities. Increased awareness of this debilitating disease will lead to earlier diagnosis, proper treatment and improved patient outcomes.

Calciphylaxis: Part I. Diagnosis and pathology

Calciphylaxis is an uncommon but devastating disorder characterized by vascular calcification and subsequent cutaneous tissue necrosis. This results in exquisitely painful and slow healing wounds that portend exceptionally high morbidity and mortality. The diagnosis of this condition can be complicated because there are no conclusive serologic, radiographic or visual signs that this disease is manifesting. The differential of tissue necrosis is broad, and identifying calciphylaxis requires an adroit understanding of the risk factors and physical signs that should raise suspicion of this condition. Reviews on this subject are uncommon and lack directed commentary from disease experts on the best diagnostic approach for patients suffering from this disease. The goal of this article is to update practicing dermatologists on the current standard of care for calciphylaxis.

Chronic inflammation and calciphylaxis

Calciphylaxis also known as calcific uraemic arteriolopathy is a rare condition mostly seen in patients with end-stage kidney disease. We report a case of a simultaneous-kidney-pancreas transplant patient with functioning grafts developing biopsy-proven calciphylaxis in the setting of chronic inflammation. Despite several modalities of management, the patient developed progression of her disease leading to multiple amputations. This case illustrates chronic inflammation driven by persistent infection as a probable contributing factor to the development and progression of calciphylaxis in a simultaneous kidney-pancreas recipient. Calciphylaxis should be considered in the differential for a painful, non-healing ulcer even in the absence of common risk factors.

Leukocytoclastic Vasculitis and Microvascular Occlusion: Key Concepts for the Working Pathologist

Although clinicians often put vasculitis and microvascular occlusion in the same differential diagnosis, biopsy findings often are either vasculitis or occlusion. However, both vasculitis and occlusion are present in some cases of levamisole-associated vasculopathy and certain infections. Depth of dermal involvement and vessel size should be reported, because superficial and deep small vessel leukocytoclastic vasculitis and/or involvement of medium-sized vessels may be associated with systemic disease. Microvascular occlusion of vessels in the fat should prompt consideration of calciphylaxis. Clues to ultimate clinical diagnosis can be garnered from depth of involvement, size of vessels affected, and presence of both vasculitis and occlusion.

Clinical and Histopathologic Characteristics of the Main Causes of Vascular Occusion - Part II: Coagulation Disorders, Emboli, and Other

Vascular occlusion has multiple, diverse clinical manifestations, some of which can have grave consequences for patients. It also has a wide variety of causes, including thrombi, which we recently addressed in partI of this review. In this second part, we look at additional causes of vascular occlusion.

A detailed analysis of the distribution, morphology, and histopathology of complex purpura in hospitalized patients: A case series of 68 patients

BACKGROUND

Purpura in inpatients commonly leads to dermatologic consultation. The differential diagnosis is broad and algorithms are intricate.

OBJECTIVE

We evaluated inpatient consultations for complex purpura to document the most common diagnoses and to validate the true diagnostic utility of histopathology, clinical morphology, and distribution.

METHODS

We reviewed a case series of 68 inpatients during a 4-year period with a dermatologic consultation for purpura and biopsy findings of vasculitis or microvascular occlusion.

RESULTS

Key features of complex purpura are nonbranching (round) versus branching (retiform) morphology, dependent versus acral or generalized distribution, and leukocytoclastic vasculitis versus microvascular occlusion (with emphasis on depth of involvement). Dependent nonbranching purpura with only superficial vessels involved by leukocytoclastic vasculitis was most often due to IgA vasculitis or cutaneous single-organ small-vessel vasculitis. In contrast, deeper involvement by leukocytoclastic vasculitis was suggestive of systemic disease (eg, antineutrophil cytoplasmic antibody-associated vasculitis). Branching purpura was concerning, with greater than 90% sensitivity and specificity for microvascular occlusion and associated high mortality (≈50%). The majority of patients who died had acral branching lesions.

LIMITATIONS

Small sample size, inpatients at a tertiary care center, and retrospective nature are some limitations.

CONCLUSION

Nonbranching dependent purpura corresponded to leukocytoclastic vasculitis, with the most common diagnoses being IgA vasculitis or skin-limited small-vessel vasculitis; patients with deep involvement often had systemic diseases. In this series, branching purpura was due to microvascular occlusion rather than medium-vessel vasculitis, and had associated high mortality.