Letter to the Editor
Regression of vascular calcification in a patient with calciphylaxis
Regresión de calcificaciones vasculares en paciente con calcifilaxia
Rosa M. Ruiz-Calero
, Lilia M. Azevedo, Miguel A. Bayo, Boris Gonzales, Juan J. Cubero
Corresponding author
Servicio de Nefrología, Hospital Infanta Cristina, Badajoz, Spain
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Ruiz-Calero, Lilia M. Azevedo, Miguel A. Bayo, Boris Gonzales, Juan J. Cubero" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Rosa M." "apellidos" => "Ruiz-Calero" "email" => array:2 [ 0 => "rosruizca@yahoo.com" 1 => "rosruizca@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Lilia M." "apellidos" => "Azevedo" ] 2 => array:2 [ "nombre" => "Miguel A." "apellidos" => "Bayo" ] 3 => array:2 [ "nombre" => "Boris" "apellidos" => "Gonzales" ] 4 => array:2 [ "nombre" => "Juan J." "apellidos" => "Cubero" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Hospital Infanta Cristina, Badajoz, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Regresión de calcificaciones vasculares en paciente con calcifilaxia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1094 "Ancho" => 1808 "Tamanyo" => 258423 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Right (above) and left (below) mammograms in 2011 (A), in 2013 (B) and in 2015 (C).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We describe a case of calciphylaxis with severe vascular calcification (VC) in a patient with CKD, after initiation of treatment for hyperparathyroidism. The patient made satisfactory progress with healing of the lesions, but mammography revealed the return of the severe VC.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Calciphylaxis or calcific uraemic arteriolopathy is a rare but significant cause of morbidity and mortality in patients with chronic kidney failure (CKF). It consists of calcification of the media layer in skin arterioles and produces very painful lesions that begin as subcutaneous nodules and progress to ischaemia and necrosis with formation of ulcers. It has been linked to multiple factors, including hyperparathyroidism, hyperphosphataemia, use of vitamin D and calcium-chelating agents, calcification-inhibitor deficiency, proteins C and S, and use of oral anticoagulants, among other causes.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> VC is necessary but not sufficient for the disease to manifest itself clinically.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">VC and its aetiological mechanism is a subject of great interest, as it is an independent factor associated with cardiovascular mortality.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Classically, it has been thought to be an irreversible process, and the aim of nephrologists has been to prevent it or at least slow down its progression.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Our case was a 54-year-old woman with CKD secondary to extracapillary glomerulonephritis with IgA deposits since 1993. In April 2011, she was started on treatment with paricalcitol for hyperparathyroidism, being previously treated with calcium carbonate for hyperphosphataemia. The creatinine clearance (Cr) was 20<span class="elsevierStyleHsp" style=""></span>ml/m and PTH<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>2000<span class="elsevierStyleHsp" style=""></span>pg/ml.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A year later, she was referred to the Advanced Chronic Kidney Disease (ACKD) clinic, where calciphylaxis was suspected due to the swollen and painful subcutaneous nodular pretibial lesions, which had developed into ulcers over the previous 5 months. Reviewing the patient's mammogram from 3 months earlier, severe linear calcifications could be seen in both breasts which were not apparent on her previous mammogram from 2008. Likewise she presented VC in other areas.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Kidney function had deteriorated (Cr 5.37, Cr clearance with 24<span class="elsevierStyleHsp" style=""></span>h urine of 12.3<span class="elsevierStyleHsp" style=""></span>ml/m with PTH<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>2000<span class="elsevierStyleHsp" style=""></span>pg/ml, calcium [Ca] 9.2<span class="elsevierStyleHsp" style=""></span>mg/dl and phosphorus [P] 6.2<span class="elsevierStyleHsp" style=""></span>mg/dl) and it was decided to start haemodialysis and discontinue paricalcitol and calcium containing phosphate binders, She was started on cinacalcet, sevelamer, sodium thiosulfate (ST), antibiotics and opiates, and parathyroidectomy was scheduled. We decided not to take any biopsies due to the risk of infection of the lesions.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Presently there is no standard therapy for calciphylaxis. Parathyroidectomy may be indicated, but does not always change the prognosis. Cinacalcet and bisphosphonates have demonstrated benefits, generally in combination with other treatments. Hyperbaric oxygen can also improve tissue hypoxia. ST has been associated with a rapid improvement in the pain and resolution of the ischaemic ulcers thanks to its antioxidant properties and it may also facilitate the elimination of vascular deposits of Ca.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In our case, parathyroidectomy was performed a month later, with the development of hungry bone syndrome and the need for intravenous Ca and calcitriol supplementation for hypocalcaemia. After 5 months of treatment with ST and local wound care with silver patches, the ulcers healed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Since then, the patient's Ca levels have persistently remained below 8<span class="elsevierStyleHsp" style=""></span>mg/dl, even with oral calcitriol supplementation at low doses during the first year after parathyroidectomy. Control of serum phosphate has been difficult. Three or more chelating agents: sevelamer, lanthanum and calcium acetate at full doses and, on occasion, aluminium based chelating agents have been required, despite having instructed the patient on how to take the chelating agents correctly and advise on foods with a better P/protein ratio. She has been on online post-dilution HDF with a minimum duration of 4<span class="elsevierStyleHsp" style=""></span>h with good efficiency, with Kt/V and infusion volume within current recommendations.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Initially, our aim was to prevent the death associated with calciphylaxis, but also we set a longer-term goal, which was to prevent the progression of the VC. As can be seen on the mammograms, the change was remarkable, with striking regression of the calcifications which is sustained at present (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">We do not know which one of the various therapeutic actions applied brought about the regression of the severe VC presented at the start of haemodialysis. Correction of the hyperparathyroidism and discontinuation of vitamin D therapy, both of which could have been trigger factors, were probably decisive in the initial management. Starting haemodialysis and the treatment with ST also played an important role in the good calciphylaxis outcome. Control of P and Ca over the longer term are factors that we must not be complacent about.</p><p id="par0060" class="elsevierStylePara elsevierViewall">As a general conclusion, we would emphasise the multifactorial approach in the treatment of calciphylaxis, without forgetting that, in terms of VC, the most important aspect is prevention: control of mineral metabolism; judicious use of vitamin D; and knowledge of precipitating factors in susceptible patients.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ruiz-Calero RM, Azevedo LM, Bayo MA, Gonzales B, Cubero JJ. Regresión de calcificaciones vasculares en paciente con calcifilaxia. Nefrologia. 2016;36:569–571.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 551 "Ancho" => 1550 "Tamanyo" => 143720 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Healing of calciphylaxis lesions after parathyroidectomy. At the beginning (A) and after 2 months (B) of treatment with ST.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1094 "Ancho" => 1808 "Tamanyo" => 258423 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Right (above) and left (below) mammograms in 2011 (A), in 2013 (B) and in 2015 (C).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sensitization to calciphylaxis by endogenous parathyroid hormone" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 0 | 2 |
| 2024 October | 39 | 60 | 99 |
| 2024 September | 44 | 43 | 87 |
| 2024 August | 52 | 69 | 121 |
| 2024 July | 32 | 23 | 55 |
| 2024 June | 81 | 37 | 118 |
| 2024 May | 61 | 25 | 86 |
| 2024 April | 60 | 32 | 92 |
| 2024 March | 56 | 20 | 76 |
| 2024 February | 44 | 31 | 75 |
| 2024 January | 39 | 29 | 68 |
| 2023 December | 44 | 28 | 72 |
| 2023 November | 47 | 30 | 77 |
| 2023 October | 48 | 23 | 71 |
| 2023 September | 30 | 31 | 61 |
| 2023 August | 45 | 23 | 68 |
| 2023 July | 43 | 27 | 70 |
| 2023 June | 41 | 14 | 55 |
| 2023 May | 61 | 25 | 86 |
| 2023 April | 37 | 15 | 52 |
| 2023 March | 37 | 17 | 54 |
| 2023 February | 44 | 9 | 53 |
| 2023 January | 34 | 27 | 61 |
| 2022 December | 48 | 27 | 75 |
| 2022 November | 58 | 24 | 82 |
| 2022 October | 43 | 32 | 75 |
| 2022 September | 59 | 31 | 90 |
| 2022 August | 51 | 45 | 96 |
| 2022 July | 36 | 33 | 69 |
| 2022 June | 45 | 28 | 73 |
| 2022 May | 42 | 28 | 70 |
| 2022 April | 33 | 36 | 69 |
| 2022 March | 52 | 42 | 94 |
| 2022 February | 39 | 45 | 84 |
| 2022 January | 33 | 27 | 60 |
| 2021 December | 46 | 29 | 75 |
| 2021 November | 33 | 33 | 66 |
| 2021 October | 74 | 41 | 115 |
| 2021 September | 49 | 35 | 84 |
| 2021 August | 51 | 43 | 94 |
| 2021 July | 52 | 42 | 94 |
| 2021 June | 52 | 38 | 90 |
| 2021 May | 74 | 48 | 122 |
| 2021 April | 125 | 63 | 188 |
| 2021 March | 64 | 18 | 82 |
| 2021 February | 52 | 22 | 74 |
| 2021 January | 59 | 25 | 84 |
| 2020 December | 35 | 17 | 52 |
| 2020 November | 37 | 16 | 53 |
| 2020 October | 38 | 16 | 54 |
| 2020 September | 32 | 13 | 45 |
| 2020 August | 40 | 11 | 51 |
| 2020 July | 24 | 11 | 35 |
| 2020 June | 35 | 14 | 49 |
| 2020 May | 31 | 14 | 45 |
| 2020 April | 24 | 18 | 42 |
| 2020 March | 33 | 17 | 50 |
| 2020 February | 42 | 16 | 58 |
| 2020 January | 38 | 21 | 59 |
| 2019 December | 47 | 24 | 71 |
| 2019 November | 32 | 22 | 54 |
| 2019 October | 21 | 9 | 30 |
| 2019 September | 29 | 13 | 42 |
| 2019 August | 25 | 11 | 36 |
| 2019 July | 26 | 23 | 49 |
| 2019 June | 34 | 18 | 52 |
| 2019 May | 29 | 19 | 48 |
| 2019 April | 67 | 36 | 103 |
| 2019 March | 34 | 23 | 57 |
| 2019 February | 29 | 24 | 53 |
| 2019 January | 35 | 17 | 52 |
| 2018 December | 113 | 44 | 157 |
| 2018 November | 265 | 15 | 280 |
| 2018 October | 291 | 21 | 312 |
| 2018 September | 115 | 11 | 126 |
| 2018 August | 71 | 19 | 90 |
| 2018 July | 83 | 12 | 95 |
| 2018 June | 61 | 13 | 74 |
| 2018 May | 97 | 13 | 110 |
| 2018 April | 112 | 11 | 123 |
| 2018 March | 112 | 7 | 119 |
| 2018 February | 147 | 12 | 159 |
| 2018 January | 146 | 10 | 156 |
| 2017 December | 148 | 8 | 156 |
| 2017 November | 81 | 11 | 92 |
| 2017 October | 40 | 3 | 43 |
| 2017 September | 47 | 9 | 56 |
| 2017 August | 40 | 6 | 46 |
| 2017 July | 33 | 3 | 36 |
| 2017 June | 48 | 7 | 55 |
| 2017 May | 54 | 11 | 65 |
| 2017 April | 169 | 7 | 176 |
| 2017 March | 36 | 17 | 53 |
| 2017 February | 34 | 7 | 41 |
| 2017 January | 40 | 7 | 47 |
| 2016 December | 33 | 5 | 38 |
| 2016 November | 3 | 1 | 4 |
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