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which favour vascular calcification by means of inhibiting g-carboxylation of vitamin K&#44; depending on the matrix protein Gla &#40;protein that inhibits vascular calcification&#41;&#46;<span class="elsevierStyleSup">1&#44;4</span></p><p class="elsevierStylePara">We present the case of a 55-year-old male with a personal history of primary antiphospholipid syndrome with oral anticoagulant agents since 2003&#44; renal clear cell carcinoma&#46; He had a pacemaker because of an atrioventricular block&#44; severe mitral regurgitation and aortic regurgitation&#44; lymph node tuberculosis and operated right hydrocele&#46; In 1993&#44; he was included in a haemodialysis programme due to chronic renal failure of vascular origin&#46; He received three kidney grafts&#44; the last being in 1997&#44; later presenting with thrombosis&#44; for which he started peritoneal dialysis in March 1998&#46; He was transferred to haemodialysis in November 1999&#44; because of a peritonitis-related sepsis caused by <span class="elsevierStyleItalic">Pseudomonas</span>&#46;</p><p class="elsevierStylePara">He underwent subtotal parathyroidectomy in 2000&#44; due to severe secondary hyperparathyroidism&#44; manifested as elevated parathyroid hormone &#40;PTH&#41; in the biochemical tests that was treated with vitamin D analogues and cinacalcet&#46;</p><p class="elsevierStylePara">He was admitted in December 2008 for symptoms of heart failure and data showing protein-calorie malnutrition&#46; In the examination&#44; the patient presented with two ulcers on the heel of his left foot&#46; One was approximately 3&#46;5cmx2cm&#44; ulcerated rounded&#44; with red edges&#44; with a necrotic eschar&#46; It was very painful and had preserved distal pulse&#46;</p><p class="elsevierStylePara">Biochemical tests showed&#58; phosphorus&#58; 4&#46;5mg&#47;dl&#59; corrected calcium&#58; 10&#46;1mg&#47;dl&#59; PTH&#58; 537pg&#47;ml&#59; albumin&#58; 2&#46;2mg&#47;dl&#59; prealbumin&#58; 7&#46;44mg&#47;dl&#59; haemoglobin &#40;Hb&#41; 11&#46;5&#46; <span class="elsevierStyleItalic">Staphylococcus aureus</span> and <span class="elsevierStyleItalic">Clostridium perfringens</span> were found in the cultures&#46; Given that calciphylaxis was suspected&#44; a skin biopsy was performed&#44; confirming diagnosis&#46;</p><p class="elsevierStylePara">A multidisciplinary approach was adopted&#58; debridement and treatment of the lesions&#44; starting intravenous antibiotic therapy in accordance with the antibiogram&#46; Calcium-based phosphate binders and vitamin D were withdrawn and cinacalcet dose increased&#46; Given the patient&#39;s clinical situation &#40;dyspnoea on minimal efforts and poor tolerance to conventional sessions&#41; and with the aim of intensifying the dialysis dose&#44; long nightly haemodialysis was started on a daily basis&#46; Later&#44; to improve calcaemia control&#44; low-calcium dialysis fluid was used &#40;1&#46;75mmol&#47;l&#41;&#46; Once the dialysis session had finished&#44; treatment with 25&#37; sodium thiosulphate &#40;ST&#41; at 25g&#47;l&#47;1&#46;73m<span class="elsevierStyleSup">2</span> was started&#46;</p><p class="elsevierStylePara">ST treatment was maintained until the lesion was completely cured&#44; which took 9 months of treatment&#46; The only secondary effect was that the patient presented with nausea and vomiting&#44; but this was resolved with prokinetic and antiemetic agents&#46;</p><p class="elsevierStylePara">There is no treatment that is specific for calciphylaxis&#46; Special emphasis is currently made to controlling the calcium&#47;phosphate and hyperparathyroidism products&#44; <span class="elsevierStyleSup">4&#44;5</span> suspending treatment with calcium and vitamin D supplements&#44; increasing dialysis frequency to 5 or 6 weekly sessions&#44; reducing the calcium concentration in the dialysis solution to 1&#46;5-1mEq&#47;l and treating the lesions very carefullly&#46;<span class="elsevierStyleSup">1</span> Also&#44; measures aimed at improving tissue hypoxia were used&#44; such as hyperbaric oxygen therapy&#46;<span class="elsevierStyleSup">4&#44;6</span></p><p class="elsevierStylePara">Recently&#44; other treatment lines have become important&#44; such as intravenous ST&#44; an antioxidant that is capable of binding to the nitric oxide synthase enzyme and the calcium binder&#46; In the cases described&#44; ST rapidly alleviated pain but resolved ischaemic ulcers slower&#46;<span class="elsevierStyleSup">1-4&#44; 6&#44; 7</span> Its antioxidant properties correct endothelial dysfunction and favour vasodilatation&#46; Furthermore&#44; together with calcium it forms calcium thiosulphate&#44; which is more soluble than calcium phosphate &#40;present in vascular calcification&#41;&#44; which could help eliminate calcium deposits&#46;<span class="elsevierStyleSup">1-4&#44; 7</span> There is no consensus with regards treatment duration but most authors agree that it should be maintained until ulcers have completely healed&#46; Adverse reactions are often mild and includes nausea&#44; vomiting&#44; headaches&#44; nasal discharge and metabolic acidosis&#46;<span class="elsevierStyleSup">1</span> Less common reactions are disorientation&#44; hallucinations&#44; arthralgia&#44; cramps or high blood pressure&#44; among others&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">More cases have been reported in the literature&#44; patients treated with biphosphonates whose lesions regressed&#46;<span class="elsevierStyleSup">4&#44;7-9</span> Cinacalcet has also proven to be beneficial&#46; However&#44; current treatment continues to present with poor prognosis&#44; with a mortality rate between 60&#37; and 80&#37;&#44; and sepsis is the most common cause of mortality&#46;<span class="elsevierStyleSup">1-4&#44; 7</span></p><p class="elsevierStylePara"><a href="grande&#47;10954&#95;108&#95;21728&#95;en&#95;f1&#46;10954&#46;jpg" class="elsevierStyleCrossRefs"><img src="10954_108_21728_en_f1.10954.jpg" alt="Evolution of the lesion"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Evolution of the lesion</p>"
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