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arterial hypertension&#44; chronic ischaemic heart disease&#44; and severe aortic stenosis&#44; who required aortic valve replacement with initiation of anticoagulation with acenocoumarol two months before admission&#46; The patient also had secondary hyperparathyroidism and chronic kidney disease category G5 according to KDIGO 2012 of probable diabetic aetiology&#44; receiving chronic haemodialysis through a radiocephalic arteriovenous fistula placed in the left upper limb&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">She reported a two-week history characterised by the presence of initially small and erythematous lesions that progressed to being ulcerative&#44; some of them were circular with a blackish centre&#44; very painful&#44; and with exudate that was positive for <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#46; A skin biopsy of one of the lesions was consistent with calciphylaxis&#44; so the patient was admitted to nephrology ward&#46; The following blood test results were obtained&#58; procalcitonin 1&#46;49 ng&#47;m&#59; C-reactive protein 26&#46;6 mg&#59; neutrophil-to-lymphocyte ratio &#40;NLR&#41; 5&#46;75&#59; platelet-to-lymphocyte ratio &#40;PLR&#41; 413&#46;70 and systemic immune-inflammation index &#40;SII&#41; 1&#44;737&#59; calcium 10&#46;30 mg&#47;dl&#59; phosphate 5&#46;05 mg&#47;dl&#59; biointact parathyroid hormone &#40;PTH&#41; &#40;1&#8211;84&#41; 490 pg&#47;m and 25-OH-vitamin D 10&#46;8 ng&#47;m&#46; Cervical ultrasound showed a hypoechoic nodule 1&#46;38 cm in diameter suggesting parathyroid gland hyperplasia vs hypertrophy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Joint management with dermatology was decided upon with treatment every 48 hours with topical sodium thiosulfate&#44; in addition to intravenous sodium thiosulfate at a dose of 12&#46;5 g post-haemodialysis &#40;three times a week&#41;&#46; The dialysis dose was intensified with daily 210-minute sessions and changed to expanded haemodialysis with Theranova 500&#174; 2 m<span class="elsevierStyleSup">2</span> filter &#40;Baxter International Inc&#46;&#44; Deerfield&#44; IL&#44; USA&#41; with a mean Qb of 313 ml&#47;min&#44; a mean Qd of 500 ml&#47;min and a mean Kt of 41 L&#46; Among other measures&#44; the patient was changed to anticoagulation with enoxaparin and her treatment with paricalcitol&#44; vitamin D and iron was suspended&#46; Management of the patient&#39;s secondary hyperparathyroidism was optimised with cinacalcet&#44; non-calcium-based phosphate binders and a low-calcium dialysis bath &#40;1&#46;25 mEq&#47;L&#41;&#46; Combination antibiotic therapy with ceftazidime and vancomycin was administered&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">At discharge&#44; there was evidence of improved inflammatory parameters along with favourable skin lesion progression until their complete resolution five months after the start of treatment &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; However&#44; we observed a worsening of PTH despite progressively increasing the calcimimetic dose&#46; It was decided to start intradialysis etelcalcetide&#44; pending progression at the present time&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Despite correct treatment&#44; a large percentage of patients die &#40;35&#37; in one year&#44; despite treatment and 55&#37; if not treated&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It has been reported that the alteration of bone-mineral metabolism is the main predisposing factor for this disease&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; this case highlights the possible role other non-traditional factors might play given the persistence of hyperparathyroidism over time&#44; despite there being substantial and sustained improvement in both lesions and inflammatory parameters&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Intravenous and topical thiosulfate could play a very important role in this regard&#46; However&#44; this may not be enough to explain the patient&#39;s rapid inflammatory and cutaneous improvement&#46; In this sense&#44; it should be noted that within the pathophysiology of the disease&#44; the involvement of both an excess of cytokines and coagulation alteration has been postulated&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The possible role of adipokines deserves special mention&#44; including Vascular Endothelial Growth Factor A &#40;VEGF-A&#41;&#44; which induces calcification and could explain the higher frequency of calciphylaxis in POEMS syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Similarly&#44; leptin&#44; another adipokine&#44; has been linked to osteoblast promotion and smooth muscle cell mineralisation&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> These two proteins weigh 46 kDa and 16 kDa&#44; respectively&#44; and this places them within the group of medium-sized molecules<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#44; which are the main target of expanded haemodialysis through the new medium cut-off membranes&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Therefore&#44; in the absence of larger studies&#44; we conclude that expanded haemodialysis could be a good complement to thiosulfate treatment in the management of calciphylaxis in patients on chronic haemodialysis&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Please cite this article as&#58; Valga F&#44; Monz&#243;n T&#44; Rinc&#243;n M&#44; Vega-D&#237;az N&#44; de la Flor JC&#44; Aladro-Escribano S et al&#46; &#191;Sinergia del tratamiento con tiosulfato s&#243;dico y hemodi&#225;lisis extendida en el manejo de la calcifilaxis&#63; A prop&#243;sito de un caso&#46; Nefrologia&#46; 2022&#59;42&#58;354&#8211;356&#46;</p>"
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        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
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          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lesions on the right lower limb during hospital admission &#40;top&#41; and five months after treatment with thiosulfate and expanded daily haemodialysis &#40;bottom&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at0010"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">NLR&#58; neutrophil-to-lymphocyte ratio&#59; PLR&#58; platelet-to-lymphocyte ratio&#58; SII&#58; systemic immune-inflammation index&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2 days before admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Day 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Day 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Day 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Day 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Day 25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Day 27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Day 62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Day 64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Day 97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Day 125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Day 153&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C-reactive protein &#40;mg&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Procalcitonin &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NLR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PLR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">564&#46;58&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">413&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">378&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">362&#46;86&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">425&#46;42&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">261&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">253&#46;52&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">248&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">205&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Ferritin &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Total protein &#40;g&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Leukocytes &#40;10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Neutrophils &#40;10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Lymphocytes &#40;10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Haemoglobin &#40;g&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Platelets &#40;10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Calcium &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Phosphates &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">4&#46;45&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Biointact PTH &#40;1-84&#41; &#40;pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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Letter to the Editor
Synergy of sodium thiosulphate treatment and expanded hemodialysis in the management of calciphylaxis? A case report
¿Sinergia del tratamiento con tiosulfato sódico y hemodiálisis extendida en el manejo de la calcifilaxis? A propósito de un caso
Francisco Valgaa,b,
Corresponding author
fvalga@hotmail.com

Corresponding author.
, Tania Monzónc, Marian Rincóna, Nicanor Vega-Díaza,b, Jose Carlos de la Flord, Sara Aladro-Escribanoa, Adonay Santana-Quintanaa, Raquel Santana-Estupiñana, José Carlos Rodriguez-Pereza,b
a Nephrology Department, Doctor Negrín University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
b Doctoral Programme in Biomedical Research, Health Sciences Faculty, Clinical Sciences Department, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
c Avericum Negrín Haemodialysis Centre, Las Palmas de Gran Canaria, Las Palmas, Spain
d Nephrology Department, Gómez Ulla Central Military Hospital, Madrid, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lesions on the right lower limb during hospital admission &#40;top&#41; and five months after treatment with thiosulfate and expanded daily haemodialysis &#40;bottom&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Calciphylaxis&#44; also known as calcific uraemic arteriolopathy &#40;CUA&#41;&#44; is a serious and uncommon complication in patients on chronic haemodialysis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In its pathogenesis&#44; in addition to the involvement of bone-mineral metabolism&#44; the possible deleterious role that certain medium-sized molecules could play has been hypothesised&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Expanded haemodialysis &#40;HDx&#41; facilitates the effective removal of this type of molecules&#44; so we believe that they could play a role in the management of this condition&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 47-year-old woman with a history of long-standing and poorly-controlled type 1 diabetes mellitus&#44; arterial hypertension&#44; chronic ischaemic heart disease&#44; and severe aortic stenosis&#44; who required aortic valve replacement with initiation of anticoagulation with acenocoumarol two months before admission&#46; The patient also had secondary hyperparathyroidism and chronic kidney disease category G5 according to KDIGO 2012 of probable diabetic aetiology&#44; receiving chronic haemodialysis through a radiocephalic arteriovenous fistula placed in the left upper limb&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">She reported a two-week history characterised by the presence of initially small and erythematous lesions that progressed to being ulcerative&#44; some of them were circular with a blackish centre&#44; very painful&#44; and with exudate that was positive for <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#46; A skin biopsy of one of the lesions was consistent with calciphylaxis&#44; so the patient was admitted to nephrology ward&#46; The following blood test results were obtained&#58; procalcitonin 1&#46;49 ng&#47;m&#59; C-reactive protein 26&#46;6 mg&#59; neutrophil-to-lymphocyte ratio &#40;NLR&#41; 5&#46;75&#59; platelet-to-lymphocyte ratio &#40;PLR&#41; 413&#46;70 and systemic immune-inflammation index &#40;SII&#41; 1&#44;737&#59; calcium 10&#46;30 mg&#47;dl&#59; phosphate 5&#46;05 mg&#47;dl&#59; biointact parathyroid hormone &#40;PTH&#41; &#40;1&#8211;84&#41; 490 pg&#47;m and 25-OH-vitamin D 10&#46;8 ng&#47;m&#46; Cervical ultrasound showed a hypoechoic nodule 1&#46;38 cm in diameter suggesting parathyroid gland hyperplasia vs hypertrophy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Joint management with dermatology was decided upon with treatment every 48 hours with topical sodium thiosulfate&#44; in addition to intravenous sodium thiosulfate at a dose of 12&#46;5 g post-haemodialysis &#40;three times a week&#41;&#46; The dialysis dose was intensified with daily 210-minute sessions and changed to expanded haemodialysis with Theranova 500&#174; 2 m<span class="elsevierStyleSup">2</span> filter &#40;Baxter International Inc&#46;&#44; Deerfield&#44; IL&#44; USA&#41; with a mean Qb of 313 ml&#47;min&#44; a mean Qd of 500 ml&#47;min and a mean Kt of 41 L&#46; Among other measures&#44; the patient was changed to anticoagulation with enoxaparin and her treatment with paricalcitol&#44; vitamin D and iron was suspended&#46; Management of the patient&#39;s secondary hyperparathyroidism was optimised with cinacalcet&#44; non-calcium-based phosphate binders and a low-calcium dialysis bath &#40;1&#46;25 mEq&#47;L&#41;&#46; Combination antibiotic therapy with ceftazidime and vancomycin was administered&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">At discharge&#44; there was evidence of improved inflammatory parameters along with favourable skin lesion progression until their complete resolution five months after the start of treatment &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; However&#44; we observed a worsening of PTH despite progressively increasing the calcimimetic dose&#46; It was decided to start intradialysis etelcalcetide&#44; pending progression at the present time&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Despite correct treatment&#44; a large percentage of patients die &#40;35&#37; in one year&#44; despite treatment and 55&#37; if not treated&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It has been reported that the alteration of bone-mineral metabolism is the main predisposing factor for this disease&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; this case highlights the possible role other non-traditional factors might play given the persistence of hyperparathyroidism over time&#44; despite there being substantial and sustained improvement in both lesions and inflammatory parameters&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Intravenous and topical thiosulfate could play a very important role in this regard&#46; However&#44; this may not be enough to explain the patient&#39;s rapid inflammatory and cutaneous improvement&#46; In this sense&#44; it should be noted that within the pathophysiology of the disease&#44; the involvement of both an excess of cytokines and coagulation alteration has been postulated&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The possible role of adipokines deserves special mention&#44; including Vascular Endothelial Growth Factor A &#40;VEGF-A&#41;&#44; which induces calcification and could explain the higher frequency of calciphylaxis in POEMS syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Similarly&#44; leptin&#44; another adipokine&#44; has been linked to osteoblast promotion and smooth muscle cell mineralisation&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> These two proteins weigh 46 kDa and 16 kDa&#44; respectively&#44; and this places them within the group of medium-sized molecules<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#44; which are the main target of expanded haemodialysis through the new medium cut-off membranes&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Therefore&#44; in the absence of larger studies&#44; we conclude that expanded haemodialysis could be a good complement to thiosulfate treatment in the management of calciphylaxis in patients on chronic haemodialysis&#46;</p></span>"
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                  \t\t\t\t">C-reactive protein &#40;mg&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Procalcitonin &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">NLR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">458&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total protein &#40;g&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Leukocytes &#40;10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">5&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">5&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Neutrophils &#40;10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">4&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">4&#46;01&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Lymphocytes &#40;10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">Haemoglobin &#40;g&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Platelets &#40;10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#41;&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 20132514
Original language: English
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