Proximal calciphylaxis in a liver and kidney transplant patient
Calcifilaxis proximal en una paciente con trasplante hepático y renal
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Cuxart Pérez, R. Sans Lorman, C. Sardà Borroy" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Montserrat" "apellidos" => "Picazo Sánchez" "email" => array:1 [ 0 => "montserratpicazo@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "M." "apellidos" => "Cuxart Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "R." "apellidos" => "Sans Lorman" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "C." "apellidos" => "Sardà Borroy" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Fundació Salut Empordà. Hospital de Figueres, Figueres, Gerona, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Calcifilaxis proximal en una paciente con trasplante hepático y renal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "43018078_f1_pag489.jpg" "Alto" => 176 "Ancho" => 260 "Tamanyo" => 7119 ] ] ] ] "textoCompleto" => "<p class="elsevierStylePara">Dear Editor,</p><p class="elsevierStylePara">Studies suggest that incidence of calciphylaxis is 1% per year, with a prevalence of 4% among dialysis patients,<span class="elsevierStyleSup">1</span> however it is rarely present in kidney transplant patients or in those with stage 3 or 4 chronic kidney disease.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">The proximal distribution of lesions and the presence of ulceration are associated with a very poor prognosis, mainly because of wound infection and the subsequent death of the patient.<span class="elsevierStyleSup">3 </span>In the cases of calciphylaxis described in kidney transplant patients, the prognosis may be even worse<span class="elsevierStyleSup">4,5</span> and the possible role of corticosteroids as a precipitant of the disease has also been discussed. However, although the pathogenesis of this condition is not well known, there are risk factors that could possibly contribute to proximal calciphylaxis and distal calciphylaxis in different ways. Therefore, no specific treatment has been established and in some cases a multidisciplinary and even empirical approach is needed. In any case, it is important to focus on normalising the phosphocalcic product and PTHi levels if they are elevated, since these are potential precipitants.<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">We would like to present the case of a 66-year-old female patient who underwent her first liver transplant 11 years ago because of chronic alcoholinduced liver disease. She underwent a second kidney transplant three years before this admission because of mesangial glomerulonephritis caused by IgA deposits, which presented hardened lesions with central dermal necrosis that were symmetrical and very painful, located on the inner thigh on both legs and that indicated calciphylaxis (figure 1). A cutaneous punch biopsy was carried out and the diagnosis was confirmed. However, a bone scan showed no extraskeletal uptake. Her usual treatment consisted of furosemide, bisoprolol, prednisone, tacrolimus, mycophenolate mofetil, omeprazole and acenocoumarol (since she presented chronic atrial fibrillation) and subcutaneous darbopoetin. In the tests carried out, the following results stood out: CRP 51mg/l, Hb 10g/dl and creatinine 2.9mg/dl, because of chronic nephropathy of the graft, with proteinuria 2.6g/day, cholestatic pattern with GGT 230U/l and alkaline phosphatase 177U/l, corrected calcium concentration 8.6mg/dl, phosphorous 6.6mg/dl and initial PTHi 653pg/ml. Treatment with cinacalcet 30mg/day and aluminium hydroxide used as a phosphorus binder was administered. Phospocalcic products were normalised and PTHi values were stabilised at 150pg/ml. Despite this, large ulcers developed and enzymatic ointment (Iruxol Mono<span class="elsevierStyleSup">®</span>), and moist gauzes were applied locally on a daily basis. Opiate derivatives were administered orally for pain relief, as well as 50g intravenous sodium thiosulphate three times a week. Her clinical progress was not satisfactory and haemodialysis was necessary 38 days after diagnosis via a catheter in the right internal jugular vein because of deteriorated kidney function. At the same time, it was also necessary to maintain the correct plasma levels of tacrolimus and avoid any accompanying septic symptoms. A few hours later she suffered nonrecoverable cardiac arrest. No autopsy was carried out.</p><p class="elsevierStylePara">Despite our patient¿s fatal outcome, we would like to highlight the potential therapeutic benefits of cinacalcet in the treatment of proximal calciphylaxis with secondary hyperparathyroidism.<span class="elsevierStyleSup">7</span> Its usefulness in transplant patients with calciphylaxis is yet to be demonstrated, although its effectiveness in controlling hyperparathyroidism has already been described.<span class="elsevierStyleSup">8</span> Nor have we found any descriptions of other kidney transplant patients who were administered sodium thiosulphate, although its effectiveness has been demonstrated in several published studies involving dialysis patients. It has been observed that this drug is highly soluble in calcium thiosulphate form as it inhibits calcium precipitation and dissolves calcium deposits in tumours and calciphylaxis.<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">We hope that by describing other cases of calciphylaxis in kidney transplant patients we are able to raise awareness about the use of treatments like cinacalcet, sodium thiosulphate and bisphosphonates, among others. Although, in this case, bone scan was uninformative, it seems that this procedure has a high sensitivity for diagnosing this disease, showing an abnormal isotope uptake on a subcutaneous level in 97% of cases.<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara"><a href="grande/43018078_f1_pag489.jpg" class="elsevierStyleCrossRefs"><img src="43018078_f1_pag489.jpg"></img></a></p><p class="elsevierStylePara">Figure 1. </p>" "pdfFichero" => "P-E-S-A430-EN.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "43018078_f1_pag489.jpg" "Alto" => 176 "Ancho" => 260 "Tamanyo" => 7119 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Angelis M, Wong LL, Myers SA, Wong LM. Calciphylaxis in patients on hemodialysis: a prevalence study. Surgery 1997;122:1083-90." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Marron B, Coronel F, López-Bran, Barrientos A. Calcifilaxia. Una patogenia incierta y un tratamiento controvertido.Nefrología 2001;21:596-600. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11881431" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mazhar AR, Johnson RJ, Gillen D, et al. Risk factors and mortality associated with calciphylaxis in end-stage renal disease. Kidney Int 2001;60:324-32. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11422768" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Vanbelleghem H, Terryn W, Leuven LV, et al. A dramatic case of calciphylaxis 20 years after kidney transplantation. Nephrol Dial Transplant 2004;19:3183-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15575010" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mañas MD, Vozmediano C, Alcázar R, García M. Calcifilaxis severa fatal en una paciente trasplantada renal con paratiroidectomía previa. Nefrología 2005;25:211-2. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15912663" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Llach F. The evolving pattern of calciphylaxis: therapeutic considerations. Nephrol Dial Transplant 2001;16:448-51. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11239014" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mohammed IA, Sekar V, Bubtana AJ, Mitra S, Hutchinson AJ. Proximal calciphylaxis treated with calcimimetic ¿cinacalcet¿. Nephrol Dial Transplant 2008;23:387-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17911087" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Serra AL, Savoca R, Huber AR, et al. Effective control of persistent hyperparathyroidism with cinacalcet in renal allograft recipients. Nephrol Dial Transplant 2007;22:577-83. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17005527" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Cicone JS, Petronis JB, Embert CD, Spector DA. Successful treatment of calciphylaxis with intravenous sodium thiosulfate. Am J kidney Dis 2004;46:1104-8." 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| 2017 June | 45 | 14 | 59 |
| 2017 May | 36 | 8 | 44 |
| 2017 April | 29 | 13 | 42 |
| 2017 March | 29 | 12 | 41 |
| 2017 February | 36 | 4 | 40 |
| 2017 January | 27 | 9 | 36 |
| 2016 December | 57 | 14 | 71 |
| 2016 November | 65 | 14 | 79 |
| 2016 October | 134 | 13 | 147 |
| 2016 September | 249 | 1 | 250 |
| 2016 August | 145 | 3 | 148 |
| 2016 July | 145 | 3 | 148 |
| 2016 June | 149 | 0 | 149 |
| 2016 May | 121 | 0 | 121 |
| 2016 April | 91 | 0 | 91 |
| 2016 March | 79 | 0 | 79 |
| 2016 February | 90 | 0 | 90 |
| 2016 January | 82 | 0 | 82 |
| 2015 December | 119 | 0 | 119 |
| 2015 November | 72 | 0 | 72 |
| 2015 October | 68 | 0 | 68 |
| 2015 September | 61 | 0 | 61 |
| 2015 August | 57 | 0 | 57 |
| 2015 July | 70 | 0 | 70 |
| 2015 June | 34 | 0 | 34 |
| 2015 May | 40 | 0 | 40 |
| 2015 April | 5 | 0 | 5 |
Show all
