654 Successful Wound Closure in Patients with Large Total Body Surface Area Calciphylaxis with Aggressive Multi-modal Therapy Including Excision and Skin Grafting

Abstract

Introduction Calcific Uremic Arteriolopathy (CUA), commonly known as Calciphylaxis, is a rare disorder characterized by ischemic necrosis of the skin and histologically by arteriolar calcification. CUA is most commonly seen in patients with end-stage renal disease (ESRD) but can be seen in other patients as well. CUA carries an extremely high mortality rate, with up to 80% in some studies, even in patients with limited disease. In light of this, many surgeons have adopted a “do-not-touch” practice with these patients. Over the past several years, our institution has seen an increase in referrals for the management of large total-body-surface-area (TBSA) CUA. Methods Retrospective review of all patients with biopsy-proven (by dermatopathology) large TBSA (>=5% TBSA) CUA admitted to a Verified Adult and Pediatric Burn Center from 2015 to present. Demographics, laboratory data, treatment modalities and outcomes including mortality and wound closure were recorded. Results A total of 8 patients with large TBSA CUA were admitted after being transferred from outside hospitals. Average TBSA affected was 13.76% (SD 7.27). 6 of these patients (75%) were noted to have non-uremic calciphylaxis. All patients had positive wound cultures on admission, and 1 patient (12.5%) developed a bacteremia in hospital. There were no central line associated bloodstream infections, catheter associated urinary tract infections or ventilator associated infections. All patients underwent surgical debridement (average 4.125, range 2–5), and 5 patients (62.5%) underwent grafting, (average 1.6, range 2–5) and subsequently proceeded to wound closure. In-hospital mortality was 25% and another patient was referred to a hospice facility after being readmitted with medical complications of her calciphylaxis. Secondary findings included 50% of the patients recently experienced significant weight loss (>100 lbs). On admission, 2 patients (25%) had abnormal serum calcium, 3 patients (37.5%) had abnormal serum PO4, and 4 (50%) patients had abnormal PTH levels. 2 patients (25%) had a recent exposure to warfarin (within 6 months). Conclusions Utilizing a multi-modal management strategy that includes surgical debridement and skin grafting, patients with calciphylaxis can progress to wound closure.