Multi-intervention management of calcific uremic arteriolopathy in 24 patients

Abstract

BackgroundCalcific uremic arteriolopathy (CUA), also known as calciphylaxis, is a rare but life-threatening condition predominately occurring in patients with end-stage renal disease on dialysis. In the absence of randomized clinical trials to guide management, clinicians must rely on observational data. We have previously reported the outcomes of our multi-intervention management in seven patients and now present a larger series of patients with extended follow-up.MethodsWe performed a retrospective analysis of all patients diagnosed with CUA at a single academic center between 2008 and 2017. We identified 24 patients including 13 hemodialysis, 8 peritoneal dialysis and 3 predialysis Stage 5 chronic kidney disease patients.ResultsMean age at diagnosis was 60.5 years (range 35–83) and mean follow-up 30.5 months (range <1–99). Patients were predominately female (71%) and Caucasian (83%) with diabetes mellitus diagnosed in 16 of 24 patients. Fifteen of 24 patients had ulcerating lesions suggestive of advanced disease and 20 of 24 had extensive involvement (bilateral disease or lesion size >5 cm). Treatment consisted of intensive hemodialysis (>20 h per week), sodium thiosulfate, wound care, analgesics and discontinuation of trigger medications including warfarin. Hyperbaric oxygen, cinacalcet, bisphosphonates and vitamin K were used in some cases. Overall 1 year mortality was 41% (9/22) and overall mortality at the end of follow-up was 64% (14/24). Cause of death was felt to be attributable to CUA in only four cases (16.7%). Complete or partial resolution of lesions occurred in 17 of 24 patients. One patient had recurrence of CUA 20 months after initial diagnosis.ConclusionsAlthough mortality remains high in this group, direct CUA-attributable mortality is lower than historic reports. We conclude that a multi-intervention approach can be successful in treating a group of patients with severe CUA lesions.

Calciphylaxis in end-stage kidney disease: outcome data from the United Kingdom Calciphylaxis Study

“…There are currently two randomised clinical trials (RCT) listed that are investigating the use of STS in calciphylaxis (ISRCTN73380053 and NCT03150420) [28]. To date, no single approach has been shown to be significantly beneficial in altering outcome and the approach in management in the UKCS has been multifaceted similar to that observed in other cohorts [29]. Due to the rarity and detrimental nature of CUA, obtaining RCT evidence on the management of this condition has been a challenge and identification of the optimal treatment strategy remains elusive but interest from commercial and academic groups has increased recently.…”

Calciphylaxis After Aortic Valve Replacement in a Patient with End-Stage Renal Disease

“…Thus, there is a need for further research in this area and for a proper biopsy technique. 2,6) This present case could have been diagnosed earlier as the patient had been exhibiting two risk factors, that is, ESRD on hemodialysis and warfarin therapy for the mechanical aortic valve.…”

A Case Report: Calciphylaxis Presenting as Digital Ischemia in Patient with End Stage Kidney Disease on Peritoneal Dialysis

“…The mortality rate was high at the end of the study, but the cause of death was felt to be attributable to calciphylaxis in only 4 cases. Complete or partial resolution of lesions occurred in 17 of 24 patients [2].…”