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Ultrastructural study of the long-term development of two experimental cutaneous calcinoses (topical calciphylaxis and topical calcergy) in the rat.

Skin calcification induced by topical calciphylaxis was provoked by a subcutaneous injection of iron chloride in rats previously sensitized by dihydrotachysterol. A cutaneous topical calcergy was induced by an injection of potassium permanganate. An electron-microscopical study of the long-term evolution of both these models of calcification was made. After the initial stages, mineralization of the connective tissue continued by a secondary nucleation process without matrix vesicles. The mineral composed of needle-like structures, apatite in nature, was mainly deposited between and around collagen fibrils, and showed various arrangements in calcified plaques. Intrafibrillar calcification was rarely observed and appeared only in the later stages. The extension of calcified deposits then stopped. Finally, there was a fragmentation of the mineralized area which was progressively surrounded by uncalcified collagen fibrils. A demineralization process, caused by cells such as macrophages and multinucleated giant cells, rather than a resorption of the calcified deposits, was noted. It is important to emphasize that, in both models of ectopic calcification, an evolution toward ectopic ossification was never observed, which is perhaps due to the absence of extensive resorption mechanisms.

Animals↗

The effects of various diphosphonates on a rat model of cardiac calciphylaxis.

Seven diphosphonate analogs were treated for their effects on myocardial and cardiovascular degeneration and calcification in an experimental model of cardiac calciphylaxis. A single oral dose of dihydrotachysterol (DHT) administered to rats induced myocardial and vascular degeneration, focal myocarditis and vasculitis, and myocardial and vascular mineralization. The results demonstrated a considerable variation among the various diphosphonates in their ability to block the pathological changes observed in this model. Ethane-1-hydroxy-1,1-diphosphonate (EHDP) was the most effective diphosphonate in reducing myocardial and vascular degeneration and calcification, whereas diphosphonates such as ethane-1-amino-1,1-diphosphonate (EADP) and hydroxymethylene diphosphonate (HMDP) had little or no effect compared to saline controls. For those diphosphonates which were effective, e.g., EHDP, the tissue-protective effects were observed whether the rats were treated with drug prior to the administration of DHT, or whether drug treatment commenced after DHT administration. The results are discussed in terms of the known biological properties of the diphosphonate drugs.

Animals↗

Calciphylaxis: a condition mimicking necrotizing vasculitis.

A patient with end stage renal disease developed ischaemic skin necrosis and digital gangrene. He had diffuse arterial calcification associated with hyperparathyroidism secondary to renal failure. The patient received inappropriate cyclophosphamide therapy as he had been misdiagnosed as having an inflammatory vasculitis. This clinical picture, previously named "calciphylaxis" should come into the differential diagnosis of systemic vasculitis in a uraemic patient with hyperparathyroidism.

Arterioles↗

Serine phosphate, threonine phosphate and gamma-carboxyglutamic acid in normal and experimentally induced, pathologically calcified rat skin (topical cutaneous calciphylaxis).

The amount of non-collagenous proteins is increased greatly during the pathological calcification of rat skin experimentally induced by dihydrotachysterol (DHT) and Ovalbumin (topical cutaneous calciphylaxis). This is accompanied by an increase in the total amount and concentrations of protein-bound serine phosphate [Ser(P)], threonine phosphate [Thr(P)] and gamma-carboxyglutamic acid (Gla), almost all of which can be extracted from the tissue and can be dissociated from collagen in 0.5M EDTA. The EDTA-soluble, non-collagenous proteins are rich in aspartic and glutamic acids, similar to the non-collagenous, EDTA-soluble proteins of bone, cementum and calcified cartilage, and quite distinct from those of dentin and enamel.

1-Carboxyglutamic Acid↗

[Calciphylaxis of the skin as a sequela of terminal kidney failure. Report and discussion of 3 cases].

Calciphylaxis is a rare syndrome mostly affecting patients with secondary hyperparathyroidism and in some cases with functional protein C or protein S deficiency. Skin lesions begin as superficial painful patches that progress to deep necrotic lesions. The findings are often misdiagnosed as livedo vasculitis and the prognosis is poor. Histopathologically, calcification in the media of small arteries and arterioles with intimal hyperplasia is seen. It is unclear if this morphologic hallmark is pathogenetic. Therapeutically, the calcium-phosphate product should be lowered pharmacologically by an intensified and modified dialysis treatment and parathyroidectomy.

Aged↗

[Systematic calciphylaxis in chronic renal failure: fulminant course after kidney transplantation].

Description of a 27 years old patient with chronic renal failure due to diabetes, which requires dialysis, and tertiary hyperparathyroidism, who developed fulminant systemic calciphylaxis after successful renal transplantation. Characteristic of this syndrome, there occurred soft tissue calcification, mediacalcinosis of the small and medium-sized arteries and ischemic skin necrosis. The pathogenesis is not completely clear, but challenging agents like corticosteroids or immunosuppressants, in a sensitized organism (at hypercalcemia or elevated parathormon) could lead to calcium deposits. These are showing a particular affinity for elastic tissue. Lungs, stomach, kidneys, cutis, heart and vascular system are most frequently involved. Treatment is primarily supportive; an early parathyroidectomy seems to have the best prognosis.

Adult↗

Uremic small-artery disease with medial calcification and intimal hyperplasia (so-called calciphylaxis): a complication of chronic renal failure and benefit from parathyroidectomy.

BACKGROUND: Uremic small-artery disease with medial calcification and intimal hyperplasia can lead to life-threatening skin necrosis or acral gangrene. It is a distinct complication of chronic renal failure that must be differentiated from soft-tissue calcification. An increased calcium-phosphate product and secondary hyperparathyroidism are the main underlying conditions. The benefit of parathyroidectomy is controversial. OBJECTIVE: This article is based on a literature search to determine prognostic factors and, in particular, the benefit of parathyroidectomy. METHODS: The literature on uremic small-artery disease (so-called calciphylaxis) was reviewed (full data set: 104 cases, including five of our own). The therapeutic benefit of parathyroidectomy and the relation between prognostic predictors (localization, dialysis, and transplant) and outcome were analyzed. The relation between diabetes and acral gangrene was also examined. Further epidemiologic data on the reviewed group of patients were established. RESULTS: Thirty-eight of 58 patients who underwent parathyroidectomy survived compared with 13 of 37 patients who did not undergo parathyroidectomy (p = 0.007, n = 95). Forty of 53 patients with distal localization of necrosis survived compared with 11 of 42 patients with proximal pattern (p < 0.00001; n = 95). Dialysis and kidney transplantation followed by immunosuppression showed no relation to disease outcome. No association was found between diabetes and acral gangrene (p = 0.50). CONCLUSION: Uremic small-artery disease is a distinct complication of chronic renal failure. Its recognition and early diagnosis should allow more effective treatment. In our retrospective study parathyroidectomy was significantly related to survival. Only a randomized, controlled, prospective trial (parathyroidectomy vs conservative treatment of secondary hyperparathyroidism) can establish the value of parathyroidectomy in uremic small-artery disease.

Adult↗

Calciphylaxis presenting with calf pain and plaques in four continuous ambulatory peritoneal dialysis patients and in one predialysis patient.

Calciphylaxis is a rare disease associated with hemodialysis or transplantation, high parathyroid hormone values, and increased serum calcium x phosphate (Ca x P) product. Only four patients on continuous ambulatory peritoneal dialysis have been reported with this condition. We report five cases presenting within a 2-year period with severe calf pain and tenderness with extensive nonulcerating large, hard, and tender subcutaneous plaques in the calves. Calcium deposition was confirmed radiologically and by bone scanning. Four patients were on continuous ambulatory peritoneal dialysis, and the other was not yet on dialysis. High serum Ca x P product was found in three of these patients at onset of the condition. Two patients had normal parathyroid hormone levels at onset. Calcium salts and/or calcitriol had been taken prior to onset in three patients. When presenting in this fashion, the diagnosis can be easily made by the uniqueness of the physical findings in the legs. Our observation suggests that the condition should no longer be considered rare and is not confined to hemodialysis patients. Furthermore, it can occur in predialysis patients.

Aged↗

Calciphylaxis associated with acute, reversible renal failure in the setting of alcoholic cirrhosis.

We describe a case of calciphylaxis in a 47-year-old man with alcohol-induced end-stage liver disease and acute renal failure secondary to hepatorenal syndrome. Possible contributing factors included transiently impaired renal function, protein C and S deficiencies, elevated calcium-phosphate product, hyperphosphatemia, low serum albumin, repeated albumin infusions, and elevated alkaline phosphatase level.

Acute Kidney Injury↗

Calciphylaxis.

Calciphylaxis is a condition with a generally poor prognosis about which relatively little is known. Possible improvement in prognosis is noted if the diagnosis can be made early to avoid progression of soft tissue lesions and resulting complications. The mainstays of therapy are wound care and therapy aimed at controlling infection and the progression of disease. Parathyroidectomy seems to benefit some patients, but controversy remains as to the extent of overall patient benefit and scenarios for its appropriate use.

Adenoma↗

[Calcific arteriolopathy (Calciphylaxis)].

PURPOSE: Calcific arteriolopathy (CA), also known as " Calciphylaxis " describes a phenomenon of necrosis, mainly cutaneous and sometimes systemic, due to the obliteration of the arteriole's lumen. Initially there are under-intimal calcium deposits, and then the thrombosis occurs leading to the necrosis. CA affects mainly the renal insufficient hemodialysed patient, but not exclusively. We present 4 cases which illustrate well the etiologic spectrum of CA: terminal renal insufficiency, neoplasia, primary hyperparathyroidism, proteinuria, vitamin K inhibitors. We describe the AC's epidemiology, its cutaneous and systemic clinical presentations, its treatment. We make the hypothesis that CA is a strong risk marker in matter of cardiac mortality and we discuss this point. CURRENT KNOWLEDGE AND KEY POINTS: In this article we describe the numerous breakthroughs that have been made in matter of research about calcification over the past few years: inhibitors of calcium phosphate deposition, vitamin D and PTH1R, protein-calcium complexes, cell death, induction of bone formation. These data are analysed from a clinical point of view with practical purposes. We present CA not only as a cutaneous disease but as a systemic pathology. FUTURE PROSPECTS AND PROJECTS: The CA epidemiology is an incentive to more diagnosis suspicion in front of organ infarct involving a patient likely to be concerned by CA. The scientific and therapeutic breakthroughs in matter of calcification enable a better prevention of the disease. Nevertheless it remains very difficult to cure when installed.

Aged↗

Breast infarction after internal mammary artery harvest in a patient with calciphylaxis.

The use of the internal mammary artery during coronary artery bypass grafting is commonplace. Complications associated with the harvest of the internal mammary artery have predominantly been wound related. These range from skin dehiscence to complete avascular necrosis of the sternum. This report documents complete ischemic necrosis of a breast in a patient with end-stage renal disease and a history of calciphylaxis, after the harvest of an internal mammary artery.

Breast↗

Calcifying panniculitis associated with renal failure. A case of Selye's calciphylaxis in man.

Nephrotic syndrome developed in a 45-year-old white woman who had insulin-dependent diabetes mellitus. Following diuretic therapy and intravenous infusions of albumin, painful induration developed in the thighs and abdomen. A biopsy of the affected subcutaneous tissue demonstrated interstitial deposition of calcium. In this case of calcifying panniculitis, the conditions for calciphylaxis appear to have been present.

Adipose Tissue↗

A case of difficult pain in a patient with chronic renal failure and calciphylaxis.

A difficult pain occurred in a man with chronic renal failure as a result of the underlying condition of calciphylaxis. In this condition, calcification of small and medium-sized arteries occurs, which may result in ischemia and gangrene. In general, the prognosis is poor, with mortality rates ranging from 23-63%. Pain associated with this condition has been previously reported. In this report, the pain occurred in the lower limbs and penis, and was associated with local necrosis. The pain was observed to be significantly worse on dialysis. A multiprofessional approach to care ultimately resulted in good symptom control.

Calciphylaxis↗

Progression to wet gangrene in penile necrosis and calciphylaxis.

We report a patient who presented with gangrene of the penis due to renal failure and calciphylaxis. In view of his advanced underlying conditions we pursued an expectant approach. Superinfection set in necessitating extensive debridement, demasculinisation and a perineal urethrostomy. Of the 34 reported cases in the literature, 12 (35%) were treated conservatively, 18 (53%) had been treated expectantly with delayed surgery following the development of complications and 4 (12%) underwent early surgery (penectomy). 20 (59%) of the patients subsequently died--8/12 (58%) treated conservatively, 11/18 (61%) treated with expectant surgery and 1/4 (25%) treated with early surgery. Progression to wet gangrene developed in the majority of patients--23/34 patients (68%). Penile gangrene is a symptom of severe systemic disease, where two thirds of affected patients decease within six months of onset of symptoms. Expectant treatment results in superinfection and wet gangrene in the majority of cases who ultimately require extensive surgery and debridement.

Calciphylaxis↗

Idiopathic calciphylaxis.

A 68-year-old woman presented with a painful necrotic ulcer on her right calf and necrotic breakdown of a left below-knee amputation stump as a result of calciphylaxis. No cause could be identified and corrected. Treatment comprised wound care, substituting low molecular weight heparin for warfarin, hyperbaric oxygenation and etidronate disodium, none of which were helpful and major limb amputations were considered the best option for this patient.

Aged↗

Calciphylaxis in two patients with end-stage renal disease.

Fatal calciphylaxis (CPX) occurred in two 71-year-old females both requiring haemodialysis for end-stage renal disease. Case 2 also had an associated follicular lymphoplasmocytoid lymphoma. Although laboratory tests disclosed normal coagulation parameters, this woman had a striking cutaneous histological picture of vessel thrombosis and finally died of disseminated intravascular coagulation. CPX is a rare but potentially life-threatening complication of renal failure. The clinical picture is primarily characterized by livedoid purpura with subsequent cutaneous ischaemia and painful ulcerations. Cutaneous ischaemic phenomena are sustained by a progressive process of vascular calcification and thrombosis involving small to medium size arteries of the dermis and subcutis. Although not yet clearly explained, the pathogenetic role of a predisposing hypercoagulability state is currently the most frequently considered hypothesis.

Aged↗