Abstract
Calciphylaxis, also known as calcific uremic arteriolopathy (CUA), is a rare and life-threatening disorder that usually occurs in patients with end-stage renal disease (ESRD) and less frequently in non-uremic patients [1–3].
The term calciphylaxis, first coined by Dr. Seyle in 1961, literally means “protection by calcification.” Dr. Seyle described calciphylaxis in rats as an adaptive (phylatic) response that leads to calcium deposition in the affected tissues [4]. In 1963, Eisenberg and Bartholow reported a case of extensive metastatic calcification in a patient with chronic renal failure, which represented the human counterpart of calciphylaxis [5]. Over the course of the following years several cases of calciphylaxis have been described [6–10].
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References
Brandenburg VM, Cozzolino M, Mazzaferro S. Calcific uremic arteriolopathy: a call for action. Semin Nephrol. 2014;34:641–7.
Nigwekar SU, Kroshinsky D, Nazarian RM, et al. Calciphylaxis: risk factors, diagnosis, and treatment. Am J Kidney Dis. 2015;66:133–46.
Nigwekar SU. Multidisciplinary approach to calcific uremic arteriolopathy. Curr Opin Nephrol Hypertens. 2015;24:531–7.
Selye H, Gentile G, Prioreschi P. Cutaneous molt induced by calciphylaxis in the rat. Science. 1961;134(3493):1876–7.
Eisenberg E, Bartholow PV Jr. Reversible calcinosis cutis: calciphylaxis in man. N Engl J Med. 1963;268(22):1216–20.
Rees JK, Coles GA. Calciphylaxis in man. BMJ. 1969;2(5658):670–2.
Edelstein CL, Wickham MK, Kirby PA. Systemic calciphylaxis presenting as a painful, proximal myopathy. Postgrad Med J. 1992;68(797):209–11.
Bargman JM, Prichard SS. A usual peritoneal dialysis patient with an unusual skin disease. Perit Dial Int. 1995;15(6):252–8.
Budisavljevic MN, Cheek D, Ploth DW. Calciphylaxis in chronic renal failure. J Am Soc Nephrol. 1996;7(7):978–82.
Richens G, Piepkorn MW, Krueger GG. Calcifying panniculitis associated with renal failure. A case of Selye’s calciphylaxis in man. J Am Acad Dermatol. 1982;6(4 Pt 1):537–9.
Nigwekar SU, Thadhani R, Brandenburg VM. Calciphylaxis. N Engl J Med. 2018;378(18):1704–14.
Fine A, Zacharias J. Calciphylaxis is usually non-ulcerating:riskfactors, outcome and therapy. Kidney Int. 2002;61(6):2210–7.
Anderson DC, Stewart WK, Piercy DM. Calcifying panniculitis with fat and skin necrosis in a case of uraemia with autonomous hyper parathyroidism. Lancet. 1968;2:323–5.
Kodumudi V, Jeha GM, Mydlo N, Kaye AD. Management of cutaneous calciphylaxis. Adv Ther. 2020;37(12):4797–807.
Westphal SG, Plumb T. Calciphylaxis. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2018; https://www.ncbi.nlm.nih.gov/books/NBK519020. Accessed 12 Nov 2018.
Nigwekar SU. Calciphylaxis. Curr Opin Nephrol Hypertens. 2017;26:276–81.
Angelis M, Wong LL, Myers SA, Wong LM. Calciphylaxis in patients on hemodialysis: a prevalence study. Surgery. 1997;122(6):1083–9; discussion 1089–90.
Nigwekar SU, Zhao S, Wenger J, et al. A nationally representative study of calcific uremic arteriolopathy risk factors. J Am Soc Nephrol. 2016;27:3421–9.
Hayashi M, Takamatsu I, Kanno Y, et al. A case-control study of calciphylaxis in Japanese end-stage renal disease patients. Nephrol Dial Transplant. 2012;27:1580–4.
Kalajian AH, Malhotra PS, Callen JP, Parker LP. Calciphylaxis with normal renal and parathyroid function: not as rare as previously believed. Arch Dermatol. 2009;145(4):451–8.
Nigwekar SU, Wolf M, Sterns RH, Hix JK. Calciphylaxis from nonuremic causes: a systematic review. Clin J Am Soc Nephrol. 2008;3(4):1139–43.
Ramsey-Stewart G. Eutrophication: spontaneous progressive dermatoliponecrosis. A fatal complication of gross morbid obesity. Obes Surg. 1992;2(3):263–4.
Isoherranen K, O'Brien JJ, Barker J, Dissemond J, Hafner J, Jemec GBE, Kamarachev J, Läuchli S, Montero EC, Nobbe S, Sunderkötter C, Velasco ML. Atypical wounds. Best clinical practice and challenges. J Wound Care. 2019;28(Sup6):S1–S92.
Bertranou EG, Gonoraky SE, Otero AE. Martorell hypertensive arteriolar ulcer: outpatient outcome on 366 cases. Phlebologie. 2001;54:267–72; [Articles in French].
Baby D, Upadhyay M, Joseph MD, Asopa SJ, Choudhury BK, Rajguru JP, Gupta S. Calciphylaxis and its diagnosis: a review. J Family Med Prim Care. 2019;8(9):2763–7.
Schurgers LJ, Uitto J, Reutelingsperger CP. Vitamin K-dependent carboxylation of matrix Gla-protein: a crucial switch to control ectopic mineralization. Trends Mol Med. 2013;19:217–26.
Bessueille L, Fakhry M, Hamade E, Badran B, Magne D. Glucose stimulates chondrocyte differentiation of vascular smooth muscle cells and calcification: a possible role for IL-1β. FEBS Lett. 2015;589(19 Pt B):2797–804.
Chen NX, O’Neill K, Akl NK, Moe SM. Adipocyte induced arterial calcification is prevented with sodium thiosulfate. Biochem Biophys Res Commun. 2014;449:151–6.
Kramann R, Brandenburg VM, Schurgers LJ, et al. Novel insights into osteogenesis and matrix remodelling associated with calcific uraemic arteriolopathy. Nephrol Dial Transplant. 2013;28(4):856–68.
Luo G, Ducy P, McKee MD, et al. Spontaneous calcification of arteries and cartilage in mice lacking matrix GLA protein. Nature. 1997;386:78–81.
Cranenburg EC, Schurgers LJ, Uiterwijk HH, et al. Vitamin K intake and status are low in hemodialysis patients. Kidney Int. 2012;82(5):605–10.
Brandenburg VM, Kramann R, Rothe H, et al. Calcific uraemic arteriolopathy (calciphylaxis): data from a large nationwide registry. Nephrol Dial Transplant. 2017;32:126–32.
London GM, Guerin AP, Marchais SJ, Metivier F, Pannier B, Adda H. Arterial media calcification in end-stage renal disease: impact on all-cause and cardiovascular mortality. Nephrol Dial Transpl. 2003;18(9):1731–40.
London GM, Marty C, Marchais SJ, Guerin AP, Metivier F, de Vernejoul MC. Arterial calcifications and bone histomorphometry in end-stage renal disease. J Am Soc Nephrol. 2004;15(7):1943–51.
Ishida M, Yao N, Yachiku S, Anzai T, Kobayashi T, Ishida H. Management of calcium, phosphorus and bone metabolism in dialysis patients using sevelamer hydrochloride and vitamin D therapy. Ther Apheresis Dial. 2005;9(Suppl 1):S16–21.
Moe SM, Chen NX. Mechanisms of vascular calcification in chronic kidney disease. J Am Soc Nephrol. 2008;19(2):213–6.
Hayden MR, Tyagi SC, Kolb L, Sowers JR, Khanna R. Vascular ossification-calcification in metabolic syndrome, type 2 diabetes mellitus, chronic kidney disease, and calciphylaxis-calcific uremic arteriolopathy: the emerging role of sodium thiosulfate. Cardiovasc Diabetol. 2005;4:4.
Rogers NM, Teubner DJ, Coates PT. Calcific uremic arteriolopathy: advances in pathogenesis and treatment. Semin Dial. 2007;20(2):150–7.
Wozney JM, Rosen V, Celeste AJ, Mitsock LM, Whitters MJ, Kriz RW, et al. Novel regulators of bone formation: molecular clones and activities. Science. 1988;242(4885):1528–34.
Griethe W, Schmitt R, Jurgensen JS, Bachmann S, Eckardt KU, Schindler R. Bone morphogenic protein-4 expression in vascular lesions of calciphylaxis. J Nephrol. 2003;16(5):728–32.
Feng JQ, Xing L, Zhang JH, Zhao M, Horn D, Chan J, et al. NF- kappaB specifically activates BMP-2 gene expression in growth plate chondrocytes in vivo and in a chondrocyte cell line in vitro. J Biol Chem. 2003;278(31):29130–5.
Weenig RH. Pathogenesis of calciphylaxis: Hans Selye to nuclear factor kappa-B. J Am Acad Dermatol. 2008;58(3):458–71.
Mikhaylova L, Malmquist J, Nurminskaya M. Regulation of in vitro vascular calcification by BMP4, VEGF and Wnt3a. Calcif Tissue Int. 2007;81(5):372–81.
Yerram P, Chaudhary K. Calcific uremic arteriolopathy in end stage renal disease: pathophysiology and management. Ochsner J. 2014;14(3):380–5.
Schafer C, Heiss A, Schwarz A, Westenfeld R, Ketteler M, Floege J, et al. The serum protein alpha 2-Heremans-Schmid glycoprotein/fetuin-a is a systemically acting inhibitor of ectopic calcification. J Clin Investig. 2003;112(3):357–66.
Jeong HS, Dominguez AR. Calciphylaxis: controversies in pathogenesis, diagnosis and treatment. Am J Med Sci. 2016;351(2):217–27.
Wilmer WA, Magro CM. Calciphylaxis: emerging concepts in prevention, diagnosis, and treatment. Semin Dial. 2002;15(3):172–86.
Yu WY, Bhutani T, Kornik R, et al. Warfarin-associated nonuremic calciphylaxis. JAMA Dermatol. 2017;153:309–14.
Nigwekar SU, Bhan I, Turchin A, et al. Statin use and calcific uremic arteriolopathy: a matched case-control study. Am J Nephrol. 2013;37:325–32.
Storan ER, O’Gorman SM, Murphy A, Laing M. Case report of calciphylaxis secondary to calcium and vitamin D3 supplementation. J Cutan Med Surg. 2017;21:162–3.
Araki N, Misawa S, Shibuya K, et al. POEMS syndrome and calciphylaxis: an unrecognized cause of abnormal small vessel calcification. Orphanet J Rare Dis. 2016;11:35.
Monegal A, Peris P, Alsina M, et al. Development of multiorganic calciphylaxis during teriparatide, vitamin D, and calcium treatment. Osteoporos Int. 2016;27:2631–4.
Davis JM. The relationship between obesity and calciphylaxis: a review of the literature. Ostomy Wound Manage. 2016;62:12–8.
Nigwekar SU. An unusual case of nonhealing leg ulcer in a diabetic patient. Southern Med J. 2007;100:851–2.
Nigwekar SU, Bloch DB, Nazarian RM, et al. Vitamin K-dependent carboxylation of matrix gla protein influences the risk of calciphylaxis. J Am Soc Nephrol. 2017;28:1717.
Hafner J. Calciphylaxis and Martorell hypertensive ischemic leg ulcer: same pattern - one pathophysiology. Dermatology. 2016;232(5):523–33.
Ghosh T, Winchester DS, Davis MDP, El-Azhary R, Comfere NI. Early clinical presentations and progression of calciphylaxis. Int J Dermatol. 2017;56(8):856–61.
Weenig RH, Sewell LD, Davis MD, McCarthy JT, Pittelkow MR. Calciphylaxis: natural history, risk factor analysis, and outcome. J Am Acad Dermatol. 2007;56(4):569–79.
Handa SP, Strzelczak D. Uremic small artery disease: calciphylaxis with penis involvement. Clin Nephrol. 1998;50(4):258–61.
Barbera V, Di Lullo L, Gorini A, Otranto G, Floccari F, Malaguti M, et al. Penile calciphylaxis in end stage renal disease. Case Rep Urol. 2013;2013:968916, 1.
Kazanji N, Falatko J, Neupane S, Reddy G. Calciphylaxis presenting as digital ischemia. Intern Emerg Med. 2015;10(4):529–30.
Hafner J, Nobbe S, Partsch H, et al. Martorell hypertensive ischemic leg ulcer: a model of ischemic subcutaneous arteriolosclerosis. Arch Dermatol. 2010;146(9):961–8.
Schnier BR, Sheps SG, Juergens JL. Hypertensive ischemic ulcer. Am J Cardiol. 1966;17(4):560–5.
Polizzotto MN, Bryan T, Ashby MA, Martin P. Symptomatic management of calciphylaxis: a case series and review of the literature. J Pain Symptom Manag. 2006;32:186–90.
Gupta N, Haq KF, Mahajan S, et al. Gastrointestinal bleeding secondary to calciphylaxis. Am J Case Rep. 2015;16:818–22.
Brewster UC. Dermatological disease in patients with CKD. Am J Kidney Dis. 2008;51(2):331–44.
Dauden E, Onate MJ. Calciphylaxis. Dermatol Clin. 2008;26(4):557–68. ix
Brandenburg VM, Evenepoel P, Floege J, et al. Lack of evidence does not justify neglect: how can we address unmet medical needs in calciphylaxis? Nephrol Dial Transplant. 2016;31(8):1211–9.
Stavros K, Motiwala R, Zhou L, Sejdiu F, Shin S. Calciphylaxis in a dialysis patient diagnosed by muscle biopsy. J Clin Neuromuscul Dis. 2014;15(3):108–11.
Sreedhar A, Sheikh HA, Scagliotti CJ, Nair R. Advanced-stage calciphylaxis: think before you punch. Cleve Clin J Med. 2016;83(8):562–4.
Ha CT, Nousari HC. Surgical pearl: double-trephine punch biopsy technique for sampling subcutaneous tissue. J Am Acad Dermatol. 2003;48:609–10.
Fine A, Zacharias J. Calciphylaxis is usually non-ulcerating: risk factors, outcome and therapy. Kidney Int. 2002;61(6):2210–7.
Chang JJ. Calciphylaxis: diagnosis, pathogenesis, and treatment. Adv Skin Wound Care. 2019;32(5):205–15.
Burdorf BT. Calciphylaxis: the potential diagnostic role of radiologists. Radiol Case Rep. 2020;16(3):415–8.
Shmidt E, Murthy NS, Knudsen JM, Weenig RH, Jacobs MA, Starnes AM, et al. Net-like pattern of calcification on plain soft- tissue radiographs in patients with calciphylaxis. J Am Acad Dermatol. 2012;67(6):1296–301.
Han MM, Pang J, Shinkai K, Franc B, Hawkins R, Aparici CM. Calciphylaxis and bone scintigraphy: case report with histological confirmation and review of the literature. Ann Nucl Med. 2007;21(4):235–8.
Norris B, Vaysman V, Line BR. Bone scintigraphy of calciphylaxis: a syndrome of vascular calcification and skin necrosis. Clin Nucl Med. 2005;30(11):725–7.
Martineau P, Pelletier-Galarneau M, Bazarjani S. The role of bone scintigraphy with single-photon emission computed tomography-computed tomography in the diagnosis and evaluation of calciphylaxis. World J Nuclear Med. 2017;16(2):172–4.
Paul S, Rabito CA, Vedak P, Nigwekar SU, Kroshinsky D. The role of bone scintigraphy in the diagnosis of calciphylaxis. JAMA Dermatol. 2017;153(1):101–3.
Sowers KM, Hayden MR. Calcific uremic arteriolopathy: pathophysiology, reactive oxygen species and therapeutic approaches. Oxidative Med Cell Longev. 2010;3(2):109–21.
Dahl PR, Winkelmann RK, Connolly SM. The vascular calcification-cutaneous necrosis syndrome. J Am Acad Dermatol. 1995;33(1):53–8.
Magro CM, Simman R, Jackson S. Calciphylaxis: a review. J Am Coll Certif Wound Spec. 2010;2(4):66–72.
Essary LR, Wick MR. Cutaneous calciphylaxis. An underrecognized clinicopathologic entity. Am J Clin Pathol. 2000;113(2):280–7.
Zembowicz A, Navarro P, Walters S, Lyle SR, Moschella SL, Miller D. Subcutaneous thrombotic vasculopathy syndrome: an ominous condition reminiscent of calciphylaxis: calciphylaxis sine calcifications? Am J Dermatopathol. 2011;33(8):796–802.
Vedvyas C, Winterfield LS, Vleugels RA. Calciphylaxis: a systematic review of existing and emerging therapies. J Am Acad Dermatol. 2012;67(6):e253–60.
Erfurt-Berge C, Renner R. Management of patients with calciphylaxis: current perspectives. Chronic Wound Care Manag Res. 2019;6:109–15.
Sprague SM. Painful skin ulcers in a hemodialysis patient. Clin J Am Soc Nephrol. 2014;9:166–73.
Torregrosa JV, Sánchez-Escuredo A, Barros X, et al. Clinical management of calcific uremic arteriolopathy before and after therapeutic inclusion of bisphosphonates. Clin Nephrol. 2015;83(4):231–4.
Pasch A, Schaffner T, Huynh-Do U, Frey BM, Frey FJ, Farese S. Sodium thiosulfate prevents vascular calcifications in uremic rats. Kidney Int. 2008;74(11):1444–53.
Nigwekar SU, Brunelli SM, Meade D, Wang W, Hymes J, Lacson E Jr. Sodium thiosulfate therapy for calcific uremic arteriolopathy. Clin J Am Soc Nephrol. 2013;8:1162–70.
Baldwin C, Farah M, Leung M, et al. Multi-intervention management of calciphylaxis: a report of 7 cases. Am J Kidney Dis. 2011;58(6):988–91.
Martin R. Mysterious calciphylaxis: wounds with eschar—to debride or not to debride? Ostomy Wound Manage. 2004;50(4):64–6, 68–70; discussion 71.
Bechara FG, Altmeyer P, Kreuter A. Should we perform surgical debridement in calciphylaxis? Dermatol Surg. 2009;35(3):554–5.
Wollina U, Helm C, Hansel G, et al. Deep ulcer shaving combined with split-skin transplantation in distal calciphylaxis. Int J Lower Extremity Wounds. 2008;7(2):102–7.
Basile C, Montanaro A, Masi M, Pati G, De Maio P, Gismondi A. Hyperbaric oxygen therapy for calcific uremic arteriolopathy: a case series. J Nephrol. 2002;15(6):676–80.
Podymow T, Wherrett C, Burns KD. Hyperbaric oxygen in the treatment of calciphylaxis: a case series. Nephrol Dial Transplant. 2001;16(11):2176–80.
Cole W, Yoder CM, Coe S. The use of topical oxygen therapy to treat a Calciphylaxis wound during a global pandemic: a case report. Wounds. 2020;32(11):294–8.
Sayadi LR, Banyard DA, Ziegler ME, Obagi Z, Prussak J, Klopfer MJ, Evans GR, Widgerow AD. Topical oxygen therapy & micro/nanobubbles: a new modality for tissue oxygen delivery. Int Wound J. 2018;15(3):363–74.
Tittelbach J, Graefe T, Wollina U. Painful ulcers in calciphylaxis—combined treatment with maggot therapy and oral pentoxyfillin. J Dermatolog Treat. 2001;12(4):211–4.
Picazo M, Bover J, de la Fuente J, Sans R, Cuxart M, Matas M. Sterile maggots as adjuvant procedure for local treatment in a patient with proximal calciphylaxis. Nefrologia. 2005;25(5):559–62.
Davison SN. The prevalence and management of chronic pain in end-stage renal disease. J Palliat Med. 2007;10(6):1277–87.
Cleary JF. Incident pain. Palliat Med. 2005;19(1):1e2.14.
Good P, Tullio F, Jackson K, Goodchild C, Ashby M. Prospective audit of short term concurrent ketamine, opioid and anti-inflammatory (‘triple-agent’) therapy for episodes of acute on chronic pain. Intern Med J. 2005;35:39e44.
Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manag. 2004;28(5):497–504.
Santos PW, He J, Tuffaha A, Wetmore JB. Clinical characteristics and risk factors associated with mortality in calcific uremic arteriolopathy. Int Urol Nephrol. 2017;49(12):2247–56.
JT MC, El-Azhary RA, Patzelt MT, et al. Survival, risk factors, and effect of treatment in 101 patients with calciphylaxis. Mayo Clin Proc. 2016;91:1384–94.
Riemer CA, El-Azhary RA, Wu KL, et al. Underreported use of palliative care and patient-reported outcome measures to address reduced quality of life in patients with calciphylaxis: a systematic review. Br J Dermatol. 2017;177:1510–8.
Lal G, Nowell AG, Liao J, Sugg SL, Weigel RJ, Howe JR. Determinants of survival in patients with calciphylaxis: a multi-variate analysis. Surgery. 2009;146(6):1028–34.
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Michelucci, A., Romanelli, P., Dini, V., Romanelli, M. (2023). Ulcers Caused by Calciphylaxis. In: Khanna, A.K., Tiwary, S.K. (eds) Uncommon Ulcers of the Extremities. Springer, Singapore. https://doi.org/10.1007/978-981-99-1782-2_8
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