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At least 469 records · Page 26Linked to original sources
PubMed2002

Acute digital gangrene in a long-term dialysis patient -- a diagnostic challenge.

BACKGROUND: Vascular complications are frequent in long-term dialysis patients. The differential diagnosis is complex and includes immunological derangement (underlying disease, uremia), vasculopathic-atheroembolic diseases, calciphylaxis, infections, neoplasm, coagulation disorders, and adverse drug effects. CASE REPORT: We report on a 50-year-old male patient with a long follow-up on renal replacement therapy (20 years), currently on daily hemodialysis. The patient's history of kidney transplantation was complicated by seven acute rejection episodes and by Kaposi sarcoma; comorbidity included HLA-B27 positive ankylosing spondylitis, diffuse vascular disease, recurrent atrial fibrillation, chronic hypotension, HCV positivity. Ten days after the start of warfarin for an atrial fibrillation episode, the patient developed digital necrotising ulcerations, rapidly evolving into partial symmetric digital gangrene at distal phalanxes. The timing and evolution of the lesions and the finding of protein S deficiency were the clues for diagnosing warfarin-induced skin necrosis (WISN); the drug was discontinued and therapy with low-molecular weight heparin, plasma and prostacyclin achieved slow resolution of lesions. CONCLUSIONS: According to a combined MEDLINE and EMBASE search, this is the first report of WISN in a hemodialysis patient: underlining the clinical relevance of this uncommon problem, this case exemplifies the difficult differential diagnosis of acute vascular skin lesions in dialysis

Anticoagulants↗
PubMedDate not supplied

Hyperbaric oxygen therapy for calcific uremic arteriolopathy: a case series.

Calcific uremic arteriolopathy (CUA), also referred to as calciphylaxis, is a syndrome of small vessel calcification of unknown etiology causing painful violaceous skin lesions that progress to non-healing ulcers and gangrene. It is observed mainly in patients with end-stage renal disease, is associated with high morbidity and mortality and has no standard treatment at the present time. Although parathyroidectomy (PTX) has been advocated in some cases, other studies have not found this effective. Hyperbaric oxygen therapy (HOT) consists of breathing 100% O2 at higher than ambient pressure, with the patient inside a sealed chamber. HOT has been used with some success in the treatment of selected problem wounds (those that fail to respond to established medical and surgical management). They are often severely hypoxic; restoration of tissue PO2 to normal or above-normal enhances fibroblast proliferation and collagen production as well as angiogenesis. The present is the largest retrospective case series of CUA treated by means of HOT reported so far and comprises 11 chronic uremic patients on dialysis (9 hemo- and 2 peritoneal dialysis, 6 females and 5 males, mean age 56 +/- 7 SD years, time on dialysis 163 +/- 84 SD months). Four patients had biopsy-proven CUA; 3 had diabetic nephropathy as a cause of uremia; 2 were obese and 3 had a consistent increase of serum calcium x phosphorus product; 3 patients had severe secondary hyperparathyroidism (II(nd) HPTH) and two had been submitted to subtotal PTX some years before CUA; two others had already had the limb amputated. Lesions were in the legs, except for one in a hand, and were prevalently ulcers and necrosis. The number of sessions in each HOT cycle ranged from a minimum of 20 to a maximum of 108 (mean 40.6 +/- 29.0). The results of two therapies cannot be evaluated (one was interrupted by the patient after 10 sessions, and one ended with the death of the patient due to ventricular arrhythmia after eight sessions). Eight of the nine remaining had excellent results with healing of the skin ulcers, but the ninth got worse, making it advisable to amputate the foot. In conclusion, CUA appears to result from a multitude of predisposing and/or sensitizing events that are commonly present in the uremic milieu. The specific factors that induce this disorder in an individual patient are not known. The present retrospective study supports a role of HOT in many cases of CUA, especially considering that, in the absence of severe II(nd) HPTH, there are very few therapeutic options.

Adult↗
PubMedDate not supplied

Determinants of coronary vascular calcification in patients with chronic kidney disease and end-stage renal disease: a systematic review.

BACKGROUND: Vascular calcification (VC) is a recognized process involved in senescence and atherosclerosis. Chronic kidney disease (CKD) and end-stage renal disease (ESRD) are conditions associated with metabolic disorders related to soft tissue calcification. METHODS: We performed a systematic review of the literature confined to patients with CKD or ESRD with clinical observations of VC. Case reports of calciphylaxis were excluded. We identified 30 studies over 20 years: 11 prospective cohort, 7 cross-sectional, 11 case-control, and 1 retrospective cohort; n = 2918 subjects, mean age 51 years, 59% men and 41% women. Imaging methods used included: x-ray 43%, computed tomography 30%, ultrasound 17%, and other methods 10%. RESULTS: The most consistent determinants of VC were older age and dialysis vintage. Eight analyses determined a relationship between VC and measures of calcium-phosphate balance while 20 analyses specifically did not find such a relationship. Three studies suggested the degree of calcium loading, treatment with phosphate binders, or treatment with vitamin D analogues were related to VC. When taken into consideration, the lipid profile (primarily low high-density lipoprotein cholesterol, elevated triglycerides, elevated low-density lipoprotein, and elevated total cholesterol) were predictive factors in four analyses. CONCLUSIONS: VC is a common observation in CKD and ESRD and is mainly related to age, length of time on dialysis therapy, and possibly dyslipidemia. The calcium-phosphorus balance and its related treatments are likely not related to this unique form of vascular calcification. Further research into the determinants and potential treatments for vascular calcification is warranted.

Age Factors↗
PubMed2004

Medial arterial calcification mimicking temporal arteritis.

Medial arterial calcification, which has been increasingly recognized in end-stage renal disease (ESRD) patients, has been associated with acutely symptomatic vascular complications including calcific uremic arteriolopathy (calciphylaxis) and ischemic changes in the extremities. This report describes a 50-year-old ESRD patient on maintenance hemodialysis in whom medial arterial calcification developed with features mimicking the findings of temporal arteritis. He complained of persistent bilateral temporal area headaches with associated symptoms of blurred vision; pain in his shoulders, hips, and knees; and intermittent symptoms consistent with jaw claudication. He was not receiving calcium or vitamin D supplements. Superficial temporal arteries were dilated, tortuous, nodular, and tender to palpation. Ophthalmologic examination was unremarkable, except for the presence of peripapillary atrophy. Temporal artery biopsy results showed medial arterial calcification with mild inflammatory changes. No giant cells were identified. Additional long-term complications of medial arterial calcification have included the development of painful ischemic ulceration of the glans penis and extensive mitral annulus calcification detected by echocardiography. The findings in this patient show that clinical manifestations of medial artery calcification associated with ESRD can mimic those seen with other vascular diseases.

Arteriosclerosis↗
PubMed2004

[Vascular injury and mortality in renal osteodystrophy].

Cardiovascular disturbance occupied 43.7% on causes of death in dialysis patients. It was confirmed that their deaths were, at least partially, caused by accelerated vascular damage which originates from renal osteodystrophy. This review describes calciphylaxis with very poor prognosis, and advanced calcification in blood vessels and soft tissues in dialysis patients. The relation of coronary artery calcification, of which the quantitative evaluation recently became possible by ultra-first CT, is outlined with special concern to their effects on the mortality.

Calcinosis↗
PubMed2005

Forensic dermatopathology and internal disease.

The gross and microscopic analysis of skin lesions at autopsy can help the pathologist understand diseases and injuries inflicted premortem, perimortem, or postmortem. From January 2003 to January 2004, skin findings at autopsy were closely examined by a dermatologist and sampled for microscopic analysis at the Southwestern Institute of Forensic Sciences. Dermatologic abnormalities in some of these cases led to the discovery of internal disease and allowed for a more complete understanding of the pathologic disease processes affecting the individual. We present four autopsy cases with skin manifestations of internal disease, including pseudoxanthoma elasticum, calciphylaxis, the sign of Leser Trelat, and papular mucinosis, and demonstrate the usefulness of the dermatological assessment at autopsy. In all cases, discovery of these skin lesions and internal disease manifestations allowed contributing factors to the death of the individual to be uncovered.

Adult↗
PubMed1975

Effects of dichloromethylene diphosphonate, ethane-1-hydroxy-1,1-diphosphonate, and rickets in rats.

This study compared bone remodeling, bone mineralization, and parathyroid hormone secretion in rats treated with ethane-1-hydroxy-1,1-diphosphonate (EHDP) or dichloromethylene diphosphonate (Cl2MDP). The results were compared with findings in rachitic and control rats. In addition, calcification was induced in the skin by administration of lead acetate intravenously and polymyxin B subcutaneously; the efficacies of EHDP and Cl2MDP in preventing the calcific plaque were compared. Both the serum biochemical values and the morphologic findings indicate that Cl2MDP and EHDP influence bone and mineral metabolism differently. Even with the relatively large doses used in this study, Cl2MDP had a minor or no effect while EHDP had a marked effect that, in general, is undersirable. EHDP caused increase in circulating immunoreactive parathyroid hormone to levels greater than those in rachitic rats. Both diphosphonates appear to have a similar effect on the ectopic mineralization produced by calciphylaxis, suggesting that Cl2MDP may be the agent of choice in this problem because the undersirable side-effects would be avoided.

Acetates↗
PubMed1990

[The characteristics of kidney function in pregnant women based on the data from an in-depth biochemical study of the urine].

Serial biochemical urinary tests have been done in 141 pregnant women (46 were healthy, 58 apparently healthy and 37 had late toxemia) and in normal nonpregnant women. Urine was tested for lipids, phospholipids, ethanolamine acylic compounds and certain qualitative characteristics which depict functional abnormality of the renal interstitial tissues in pregnancy. Late toxemia was found to be associated with marked evidence of dysmetabolic nephropathy which may be identified at an early phase using 10% calcium chloride precipitation of lipids, a highly revealing specific test for calciphylaxis.

Adult↗
PubMed1989

[Toxic organic damage].

Pathohistological findings are playing an important role in the advice of toxic organ damages. After presentation of some details about the frequency of toxic organ damages, the pathways of toxic agents in the organism are discussed. In cells toxic damage may induce cell necrosis, functional disturbance, inhibition of cell proliferation or malignant transformation; in extracellular structures it may lead to degradation phenomena in the connective tissue matrix. As demonstrated in example of calciphylaxis, a combination of different noxes may not only add but even potentiate the effects of the single noxes. In intracellular reparation processes the lysosomal system is involved. In case of necrosis regeneration is possible in most kinds of tissues, if connective tissue rails are preserved. Otherwise an irreversible reparative fibrotic alteration of organ structure is induced which develops according to particular general and schematic rules. As mostly character and course of the tissue reaction is unspecific, pathohistological findings do not enable conclusions on the type of inducing toxic agent. The following presentation of some examples of toxic damages with pathognomonic histological appearance deals with asbestosis, silicosis, chloroquine-induced cardiomyopathy, aluminum-induced osteopathy and a recently described liver cirrhosis in early childhood induced by copper-containing drinking water. Some limits of traditional pathohistological evaluation of toxic organ damages have been overcome by application of new morphological techniques. Own investigations revealed that the immunocytochemical demonstration of the C5b-9-complement complex enables a better and earlier detection of irreversibly damaged cells. Discrimination of toxic and virus-induced tissue damage is facilitated by the technique of in-situ-hybridization. Sometimes a specific recognition and localization of toxic agents is achieved by X-ray microanalysis, electron-spectroscopic imaging (= ESI) resp. laser microprobe mass spectrometry (= LAMMA); comparing these techniques X-Ray microanalysis and ESI, both, enable specific identification of chemical elements, while LAMMA, in addition, offers some information about the involved molecules and isotopes.

Cells↗
PubMed1986

[Secondary hyperparathyroidism in patients on long-term hemodialysis].

Evidence of secondary hyperparathyroidism was evaluated in 233 autopsied patients with uremia (of whom 115 patients had been treated with long-term haemodialysis). Morphology of parathyroid glands correlates with serum level of immunoreactive parathormone. Extraskeletal soft tissue calcification was observed in three different forms: 1st calcifying arteriopathy, 2nd paraarticular soft-tissue calcification and 3rd classic metastatic calcification. Hypocalcemia may lead to any of these 3 forms of tissue calcification and only local factors play a decisive role in determining which type actually occurs. Arteriopathy and paraarticular calcification of soft tissues belong to calciphylaxis and different challenger factors are presumed.

Adrenal Glands↗
PubMed1978

[Corneal and conjunctival deposits in the eyes of patients treated with periodic haemodialysis. Study of 47 patients (author's transl)].

The study of 47 patients with terminal renal failure treated in the centre for haemodialysis of Geneva shows that 66% present corneo-conjunctival deposits. These deposits do not produce symptoms nor diminution of the vision. Their pathogenesis, linked to the important variations of calcaemia and phospho-calcic product, is not a function of duration of haemodialysis. Similarity seems evident between these deposits, other soft-tissue calcifications and experimentally induced topical calciphylaxis.

Blood Pressure↗
PubMed1983

[Uremic arteriopathy and ischemic skin changes].

The syndrome of uremic arteriopathy with ischemic skin manifestations--livedo reticularis, skin infarction and ulcerative necrosis--is described in a series of 6 patients. In all patients (3 female and 3 male, age 53-73 years) the syndrome occurred after slowly progressive renal failure and in 5 cases during temporary exacerbation of chronic renal failure and after alkalinizing treatment for marked metabolic acidosis. All patients had evidence of secondary hyperparathyroidism. In 4 the Ca X P product was in excess of 4.90, but only once above the critical product of 5.60 (greater than 70 when conventional units are used). Diagnosis was based on the clinical appearance of the skin involvement and the finding of vascular calcifications (x-ray and skin biopsy). The secondary hyperparathyroidism appears to play an important role in the pathogenesis of the syndrome. An increase in plasma phosphate or Ca X P product, calciphylaxis and/or alkalinizing therapy may release the precipitation of calcium salts in the interstitium or in the vessel walls. Therapy is confined to decreasing plasma phosphate and therewith the Ca X P product by means of phosphate binders or a diet low in phosphate. The unpredictable, often rapid success of parathyroidectomy awaits further clarification.

Aged↗
PubMed1978

Scanning electron microscopic observation of intimal surface of normal and atherosclerotic arteries.

A scanning electron microscopic study was made of the intimal surfaces of human normal and atherosclerotic thoracic aorta and rabbit normal thoracic aorta, and the thoracic aorta of rabbits with cholesterol atherosclerosis with consequential calciphylaxis. In normal human and rabbit arteries the intimal surface is smooth, the endothelial cells are clustered into regular mounds. In arteries affected by atherosclerosis at some sites the regular linear arrangement of endothelial cells disappears and the intimal surface is characterized by irregular protrusions of formations in the shape of scales or plates.

Adult↗
PubMed1995

Alternative methods for below-knee amputation: reappraisal of the Kendrick procedure.

BACKGROUND: In 1956, Kendrick described a technique for below-knee amputation (BKA) using anterior and posterior flaps in a length ratio of 1:2. There has been no review of the utility and safety of this technique over the past four decades. STUDY DESIGN: The Kendrick method was studied in 96 consecutive patients who underwent 100 BKAs from 1982 to 1995. Follow-up examination was continued through the period of rehabilitation and included all revisional surgery. RESULTS: Eighty-one patients had diabetes mellitus, 15 patients were nondiabetic, and the mean age was 67 years (range, 12 to 94 years). Fifty-seven patients underwent BKA for diabetic foot sepsis with healing failure after debridement or nonreconstructable vascular disease, 19 patients underwent BKAs for progressive necrosis despite a patent arterial reconstruction, and 24 patients underwent BKAs for other causes, including microembolism, calciphylaxis-related gangrene, bypass failure, trauma, frostbite, and calf-wound healing failure after coronary revascularization. Preliminary guillotine amputations were performed on three limbs. There was an incision in the calf from previous vascular surgery in 25 limbs. The 30-day mortality rate was 6 percent. Healing of the stump and knee salvage occurred in 93 limbs (93 percent). Four patients had local wound complications develop in the stump, yet they eventually healed. During the follow-up period, conversion to an above-knee amputation was necessary in seven patients, five within 30 days. Only one of these was in a limb with a previous arterial reconstruction in the calf. CONCLUSIONS: The Kendrick procedure for BKA with anterior and posterior flaps is efficacious and safe. This procedure is advantageous for its anatomic basis, the ease with which the flaps can be designed despite leg edema or overall size, and the ability of the surgeon to distance the posterior flap margin from sepsis in the lower one-third of the calf.

Adolescent↗
PubMedDate not supplied

[Subcutaneous phlebopathic calcifications].

A detailed history of 3 cases of subcutaneous calcifications. A review of the present therapeutic alternatives (other than surgery). A discussion of Selye's theory of calciphylaxis. Its application to one clinical case.

Aged↗
PubMedDate not supplied

Foot alterations in the hemodialyzed patient.

On the basis of their experience, the authors refer to complications observable at the foot level in chronic uremic patients in long-term hemodialytic treatment. These complications, termed renal osteodystrophy, are attributed to alterations in the phosphocalcium metabolism and to hyperparathyroidism. From an anatomopathologic viewpoint, they are characterized by alteration in bone tissue (osteomalacia and/or fibrous osteitis) and by soft tissue alterations. Alterations in the foot are the same as those observed in other osteoarticular regions. They consist of bone subperiosteal reabsorption of the phalanges, vascular calcifications, articular and para-articular calcifications, spontaneous disinsertion of the Achilles tendon and peripheral canalicular neuropathies specifically represented by the tarsal tunnel syndrome. Another complication of this pathology is represented by "Calciphylaxis," characterized by calcifications of the middle tunica of arteries and small arteries, by ulcerations and tissue necrosis at the foot level.

Chronic Kidney Disease-Mineral and Bone Disorder↗
PubMed1996

Fulminant metastatic calcinosis with cutaneous necrosis in a child with end-stage renal disease and tertiary hyperparathyroidism.

Metastatic calcinosis is a common feature of chronic renal failure. Its first manifestations are bone demineralization and non-visceral and/or visceral calcification with mostly mural deposits in arteries and arterioles. It is initially characterized by hyperphosphataemia followed by secondary or tertiary hyperparathyroidism. Cutaneous involvement is a rare complication. Histologically, the lesions show vascular calcification with ischaemic skin necrosis. Extreme cases may produce calcinosis cutis (calciphylaxis), i.e. disseminated calcification of the subcutaneous tissue and dermis in the form of hard painful cutaneous nodules and plaques with subsequent ulceration. Metastatic calcinosis is a disease affecting adults, while the dystrophic or idiopathic type can develop in children. We present the case of a 6-year-old boy with end-stage renal disease, attributed to congenital renal hypoplasia, and accompanied by secondary hyperparathyroidism. He developed fulminant tertiary hyperparathyroidism and metastatic calcinosis of the lungs, as well as cutaneous necrosis of the buttocks and legs, subsequent to calcification of arteries and arterioles. A maternal renal transplant failed to function. The serum parathormone, calcium and phosphate levels could not be controlled by maintenance dialysis, phosphate binders and calcitriol. Total parathyroidectomy without autotransplantation of parathyroid tissue rapidly returned the serum parathormone, calcium and phosphate levels to normal. In addition, topical treatment using merbromine solution and hydrocolloid dressings, healed the ulcers with significant scar formation, within 2.5 months after parathyroidectomy. A renewed increase of the calcium x phosphate product, 2 months after parathyroidectomy, was attributed to mobilization of calcium compounds from the viscera, as confirmed by a chest X-ray.

Calcinosis↗
PubMedDate not supplied

[Use of Masson's trichrome method for staining decalcified bone tissue].

The trichrome method of staining undecalcified tissues according to Masson is adjusted for staining decalcified bone sections. The basis for the modification is the authors' data on the preservation of the affinity to staining of the calciphylaxis zones after their decalcification. The adapted Masson's method stains differently a mineralized bone (blue) and an osteoid (red).

Animals↗