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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p><p class="elsevierStylePara">Calcific uremic arteriolopathy &#40;calciphylaxis&#41; has an incidence of 1&#37; and prevalence of 4&#37; in the dialysis population&#46; The pathogenesis is not clear and the different treatments &#40;control of Ca-P metabolism&#44;&#160; parathyroidectomy&#44; adequate management of wounds&#44; hyperbaric chamber&#44; non-calcium based binders&#44; bisphosphonates&#44; sodium thiosulfate&#44; etc&#46;&#41; did not show any improvements in the prognosis&#46;</p><p class="elsevierStylePara">The clinical case of a male patient aged 55 diagnosed with Chronic Renal Failure &#40;CRF&#41; secondary to diabetic nephropathy and arterial hypertension is presented&#46; The patient was admitted to Haemodialysis in May 2003&#46;</p><p class="elsevierStylePara">He had antecedents of diabetes type 2 treated with oral hypoglycaemic drugs and then NPH insulin&#46;</p><p class="elsevierStylePara">Nonproliferative diabetic retinopathy&#46; Obesity &#40;Body Mass Index &#91;BMI&#93; 36&#46;&#41; Dyslipidaemia&#46; Ex smoker &#40;2 packets a day&#46;&#41; Long-term AHTN &#40;20 years&#41; treated with Angiotensin Converting Enzyme inhibitors &#40;ACE inhibitors&#41; and calcium channel blockers&#46; Peripheral vasculopathy without amputation &#40;Doppler study of the lower extremities with distal compromise and parietal calcifications in bilateral arterial vessels&#46;&#41; No Deep Vein Thrombosis &#40;DVT&#46;&#41; Echocardiography and valvular Doppler with slight deterioration of the RVSD and calcifications in the aortic and mitral valves&#46;</p><p class="elsevierStylePara">From 2003 to 2005&#44; the patient presented with slight-moderate secondary hyperparathyroidism with hyperphosphataemia that was difficult to treat due to lack of compliance with diet and phosphate binders&#46; A diet low in P was indicated with proteins and calcium binders &#40;first calcium carbonate&#44; then calcium acetate or aluminium sporadically&#46;&#41; Normocalcaemia&#46; KT&#47;V sp greater than 1&#46;4 &#40;15 hrs HD&#47;week&#41; with calcium dialysate 3mEq&#47;l&#46;</p><p class="elsevierStylePara">Laboratory Data&#58; average haematocrit 35&#37;&#59; haemoglobin 11g&#47;dl&#59; Alb&#46; 3&#46;4g&#47;dl&#59; Ca 8&#46;7mg&#47;dl&#59; P 7&#46;3mg&#47;dl&#59; PTH 538pg&#47;ml&#59; FAlc 350 IU&#46;</p><p class="elsevierStylePara">The patient was treated&#44; on a discontinuous basis&#44; with oral calcitriol&#44; which was then suspended due to hyperphosphatemia&#46;</p><p class="elsevierStylePara">In 2006 the patient presented with symmetric ulcers in the lower distal extremities &#40;legs and feet&#41;&#44; pruritic and very painful&#46; Some advanced with eschar and bacterial overinfection due to scatching&#46; The patient was treated with local antibiotic and systemic antibiotics&#46;</p><p class="elsevierStylePara">Collagen disease tests and coagulation studies were normal&#44; cryoglobulin and anticardiolipin negative&#46;</p><p class="elsevierStylePara">Skin biopsy showed necrosis of the superficial dermis and localised deposits of calcium in the middle arteriolar layer compatible with calciphylaxis&#46;</p><p class="elsevierStylePara">Parathyroid hormone &#40;PTH&#41; levels were greater than 800pg&#47;ml and the patient presented with hyperphosphatemia with normocalcaemia&#46; Ultrasound of parathyroids only detected the lower glands&#46; Scintography of the parathyroids with Tc99m and sestamibi detected hypercaptation in three glands&#46;</p><p class="elsevierStylePara">Patient with caliphylaxis&#44; PTHi greater than 800 and hight CaxP&#46; Daily dialysis was indicated with dialysate calcium 2&#46;5mEq&#47;l&#46; The patient did not improve&#44; due to the persistence of injuries&#44; and subtotal parathyroidectomy was indicated in 2006&#46;</p><p class="elsevierStylePara">At the end of 2006&#44; the lesions in the lower extremities persisted with PTHi 280pg&#47;ml &#40;range 150-435&#41; and hyper-P&#46; This was interpreted as persistence of HPT&#46;</p><p class="elsevierStylePara">In February 2007&#44; sevelamer was started&#44; 6 capsules a day&#44; daily dialysis and solution low in calcium &#40;2&#46;5mEq&#47;l&#41;&#44; low phosphate diet Oral ibandronate was added&#44; 150mg&#47;month&#46;</p><p class="elsevierStylePara">Calcaemia controls remained within normal ranges&#46; The lesions in the lower extremities improved and scarred after six months&#46; However&#44; the peripheral vasculopathy progressed and developed into dry gangrene&#46;</p><p class="elsevierStylePara">Different results with the use of bisphosphonates are described in the literature&#46; They have a potent inhibiting affect on osteoclastic activity and bone resorption&#44; reducing vascular calcification&#46; They also have an inhibiting affect on proinflammatory cytokines&#44; allowing an improvement in the clinical picture&#46;</p><p class="elsevierStylePara"><a href="grande&#47;24518078&#95;f1&#95;p93&#46;jpg" class="elsevierStyleCrossRefs"><img src="24518078_f1_p93.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p>"
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                  "referenciaCompleta" => "1-Price PA, Faus SA, Williamson MK. Bisphosphonates Alendronateand Ibandronate inhibit artery calcification at doses comparable to thosethat inhibit bone resorption. Arterioscler Thromb Vasc Biol 2001;21:817-824.2-Price PA, Omid N, Than NT Williamson MK. The aminobisphosphonate Ibandronate prevents calciphylaxis in the rat at dosesthat inhibit bone resorption. Calcif Tissue Int 2002; 71:356-363.3-Monney P, Nguyen QV, Perroud H. Rapid improvement of Calciphylaxis after intravenous pamidronate therapy in a patient with chronic renal failure. Nephrol Dial Transplant 2004; 19:2130-2132.4-Shiraishi N, Kitamura K, Miyoshi T, Adach M, Kohda Y, Nonoguchi H et al. Successful treatment of a patient with severe calcific uremic arteriolopathy (calciphylaxis) by etidronate disodium. Am J Kidney Dis 2006; 48: 151-154.5-Hanafusa T, et al. Intractable wounds caused by calcific uremic arteriolopathy treated with bisphosphonates. J Am Acad Dermatol. 2007 Dec; 57(6):1021-5"
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Treating distal calciphylaxis with therapy associated with sevelamer and bisphosphonates
Tratamiento de calcifilaxis distal con terapia asociada de sevelamer y bifosfonatos
Luís Leóna
a Diaverum CererSA Buenos Aires, Buenos Aires, Argentina,
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Obesity &#40;Body Mass Index &#91;BMI&#93; 36&#46;&#41; Dyslipidaemia&#46; Ex smoker &#40;2 packets a day&#46;&#41; Long-term AHTN &#40;20 years&#41; treated with Angiotensin Converting Enzyme inhibitors &#40;ACE inhibitors&#41; and calcium channel blockers&#46; Peripheral vasculopathy without amputation &#40;Doppler study of the lower extremities with distal compromise and parietal calcifications in bilateral arterial vessels&#46;&#41; No Deep Vein Thrombosis &#40;DVT&#46;&#41; Echocardiography and valvular Doppler with slight deterioration of the RVSD and calcifications in the aortic and mitral valves&#46;</p><p class="elsevierStylePara">From 2003 to 2005&#44; the patient presented with slight-moderate secondary hyperparathyroidism with hyperphosphataemia that was difficult to treat due to lack of compliance with diet and phosphate binders&#46; A diet low in P was indicated with proteins and calcium binders &#40;first calcium carbonate&#44; then calcium acetate or aluminium sporadically&#46;&#41; Normocalcaemia&#46; KT&#47;V sp greater than 1&#46;4 &#40;15 hrs HD&#47;week&#41; with calcium dialysate 3mEq&#47;l&#46;</p><p class="elsevierStylePara">Laboratory Data&#58; average haematocrit 35&#37;&#59; haemoglobin 11g&#47;dl&#59; Alb&#46; 3&#46;4g&#47;dl&#59; Ca 8&#46;7mg&#47;dl&#59; P 7&#46;3mg&#47;dl&#59; PTH 538pg&#47;ml&#59; FAlc 350 IU&#46;</p><p class="elsevierStylePara">The patient was treated&#44; on a discontinuous basis&#44; with oral calcitriol&#44; which was then suspended due to hyperphosphatemia&#46;</p><p class="elsevierStylePara">In 2006 the patient presented with symmetric ulcers in the lower distal extremities &#40;legs and feet&#41;&#44; pruritic and very painful&#46; Some advanced with eschar and bacterial overinfection due to scatching&#46; The patient was treated with local antibiotic and systemic antibiotics&#46;</p><p class="elsevierStylePara">Collagen disease tests and coagulation studies were normal&#44; cryoglobulin and anticardiolipin negative&#46;</p><p class="elsevierStylePara">Skin biopsy showed necrosis of the superficial dermis and localised deposits of calcium in the middle arteriolar layer compatible with calciphylaxis&#46;</p><p class="elsevierStylePara">Parathyroid hormone &#40;PTH&#41; levels were greater than 800pg&#47;ml and the patient presented with hyperphosphatemia with normocalcaemia&#46; Ultrasound of parathyroids only detected the lower glands&#46; Scintography of the parathyroids with Tc99m and sestamibi detected hypercaptation in three glands&#46;</p><p class="elsevierStylePara">Patient with caliphylaxis&#44; PTHi greater than 800 and hight CaxP&#46; Daily dialysis was indicated with dialysate calcium 2&#46;5mEq&#47;l&#46; The patient did not improve&#44; due to the persistence of injuries&#44; and subtotal parathyroidectomy was indicated in 2006&#46;</p><p class="elsevierStylePara">At the end of 2006&#44; the lesions in the lower extremities persisted with PTHi 280pg&#47;ml &#40;range 150-435&#41; and hyper-P&#46; This was interpreted as persistence of HPT&#46;</p><p class="elsevierStylePara">In February 2007&#44; sevelamer was started&#44; 6 capsules a day&#44; daily dialysis and solution low in calcium &#40;2&#46;5mEq&#47;l&#41;&#44; low phosphate diet Oral ibandronate was added&#44; 150mg&#47;month&#46;</p><p class="elsevierStylePara">Calcaemia controls remained within normal ranges&#46; The lesions in the lower extremities improved and scarred after six months&#46; However&#44; the peripheral vasculopathy progressed and developed into dry gangrene&#46;</p><p class="elsevierStylePara">Different results with the use of bisphosphonates are described in the literature&#46; They have a potent inhibiting affect on osteoclastic activity and bone resorption&#44; reducing vascular calcification&#46; They also have an inhibiting affect on proinflammatory cytokines&#44; allowing an improvement in the clinical picture&#46;</p><p class="elsevierStylePara"><a href="grande&#47;24518078&#95;f1&#95;p93&#46;jpg" class="elsevierStyleCrossRefs"><img src="24518078_f1_p93.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p>"
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