Hemodialysis International 2015; 19:611–618
the risk for the development of calciphylaxis.1–3,5,6 Calciphylaxis independently increases the risk of death by eightfold,2 with estimated cause-specific survival rate at 1 year of 45.8% in a retrospective study.1 The optimal treatment for calciphylaxis is not known. Recent evidence suggests that a multi-interventional approach consisting of early diagnosis with trigger-agent cessation, wound management, intravenous sodium thiosulfate, and oxygen therapy may alter the course of disease and improve survival.7,8 The benefit of surgical parathyroidectomy has not been convincingly demonstrated and there is an emerging trend that cinacalcet may represent a medical alternative to parathyroidectomy in cases of calciphylaxis with hyperparathyroidism.9 In summary, calciphylaxis is a complex and devastating mineral bone disorder associated with a high mortality rate in ESRD patients on RRT. Further studies are needed to aid better understanding of risk factors and management of this disease.
2
3
4
5
6
7
8 Kian-Guan LEE, Amy Ee-Lin LIM, Jiunn WONG, Lina Hui-Lin CHOONG Department of Renal Medicine, Singapore General Hospital, Singapore
9
analysis, and outcome. J Am Acad Dermatol. 2007; 56:569–579. Mazhar AR, Johnson RJ, Gillen D, et al. Risk factors and mortality associated with calciphylaxis in end-stage renal disease. Kidney Int. 2001; 60:324–332. Fine A, Zacharias J. Calciphylaxis is usually nonulcerating: Risk factors, outcome and therapy. Kidney Int. 2002; 61:2210–2217. Angelis M, Wong LL, Myers SA, Wong LM. Calciphylaxis in patients on hemodialysis: A prevalence study. Surgery. 1997; 122:1083–1089. 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; 27:1580–1584. Brandenburg V, Sinha S, Specht P, Ketteler M. Calcific uraemic arteriolopathy: A rare disease with a potentially high impact on chronic kidney disease–mineral bone disorder. Pediatr Nephrol. 2014; 29:2289–2298. Lal G, Nowell AG, Liao J, Sugg SL, Weigel RJ, Howe JR. Determinants of survival in patients with calciphylaxis: A multivariate analysis. Surgery. 2009; 146:1028–1034. Baldwin C, Farah M, Leung M, et al. Multi-intervention management of calciphylaxis: A report of 7 cases. Am J Kidney Dis. 2011; 58:988–991. Vedvyas C, Winterfield LS, Vleugels RA. Calciphylaxis: A systematic review of existing and emerging therapies. J Am Acad Dermatol. 2012; 67:e253–e260.
REFERENCES 1 Weenig RH, Sewell LD, Davis MDP, McCarthy JT, Pittelkow MR. Calciphylaxis: Natural history, risk factor
“Angiography without contrast”: Severe vascular calcification in chronic kidney disease
To the Editor: A 97-year-old female patient with previously known chronic kidney disease (CKD) was hospitalized because of fatigue and
Correspondence to: Y. Solak, MD, Sakarya Universitesi Egitim ve Arastirma Hastanesi, 54100, Sakarya, Turkey. E-mail: [email protected]
impairment in oral intake. The patient had had myocardial infarction 7 years earlier and has been receiving cilazapril plus hydrochlorothiazide and aspirin. Basic laboratory values on admission were as follows: serum creatinine: 3.5 mg/dL (her baseline creatinine value was 2.9 mg/dL), urea: 241 mg/dL, calcium: 8.7 mg/dL, phosphorus: 4.3 mg/dL, parathormon: 46 pg/mL. Serum creatinine gradually reduced to 1.8 mg/dL with hydration with normal saline. The
© 2015 International Society for Hemodialysis DOI:10.1111/hdi.12300
613
Hemodialysis International 2015; 19:611–618
cells into chondrocyte or osteoblast-like cell, high total cumulative calcium and phosphorus in the body, impaired renal excretion, and high dietary phosphorus and calcium load.1 Advanced age cannot be held responsible per se for this amount of calcification in the absence of CKD. This widespread calcification is, unfortunately, associated with increased morbidity and mortality. Kidney Disease Improving Global Outcomes (KDIGO) guidelines2 recommended that in patients with CKD stages 3–5D, a lateral abdominal radiograph can be used to detect the presence or absence of vascular calcification and an echocardiogram can be used to detect the presence or absence of valvular calcification. This case illustrates an exaggerated example of arterial calcification in a patient with stage 4 CKD. Zeynep ERTURK,1 Seyyid Bilal ACIKGOZ,1 Yalcin SOLAK2 Department of Internal Medicine, School of Medicine, Sakarya University, Sakarya, Turkey; 2 Division of Nephrology, Department of Internal Medicine, Sakarya University Research and Training Hospital, Sakarya, Turkey
1
Figure 1 Plain leg radiographs showing right and left femoral arteries with widespread calcification.
patient complained of left-sided hip pain. X-ray films of the legs and hip showed no fractures but a notable finding of diffuse vascular calcifications. Figure 1 shows easily recognizable bilateral femoral arteries because of widespread calcification of the vessel walls. The patient’s creatinine clearance calculated by Modification of Diet in Renal Disease (MDRD) equation was 19 mL/min/1.73 m2. Vascular calcification is common among patients with CKD. Several risk factors for vascular calcification have been proposed: transformation of vascular smooth muscle
REFERENCES 1 Moe SM, Chen NX. Mechanisms of vascular calcification in chronic kidney disease. J Am Soc Nephrol. 2008; 19:213– 216. Feb, [Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov’t Research Support, U.S. Gov’t, Non-P.H.S. Review]. 2 Moe S, Drueke T, Cunningham J, et al. Definition, evaluation, and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2006; 69:1945–1953. Jun, [Consensus Development Conference].
Extracellular superoxide dismutase release by enoxaparin and sparing effect of heparin-grafted hemodialyzer
Correspondence to: J. Borawski, MD, 1st Department of Nephrology and Transplantation with Dialysis Centre, Medical University Hospital, Building B, 14 Zurawia Street, 15-540 Bialystok, Poland. E-mail: [email protected]
To the Editor: In the recent article published in this journal, we reported on the striking increase in plasma myeloperoxidase (MPO) during hemodialysis (HD) procedure anticoagulated with enoxaparin (ENX).1 The MPO increase was minimal
© 2015 International Society for Hemodialysis DOI:10.1111/hdi.12308
614
the risk for the development of calciphylaxis.1–3,5,6 Calciphylaxis independently increases the risk of death by eightfold,2 with estimated cause-specific survival rate at 1 year of 45.8% in a retrospective study.1 The optimal treatment for calciphylaxis is not known. Recent evidence suggests that a multi-interventional approach consisting of early diagnosis with trigger-agent cessation, wound management, intravenous sodium thiosulfate, and oxygen therapy may alter the course of disease and improve survival.7,8 The benefit of surgical parathyroidectomy has not been convincingly demonstrated and there is an emerging trend that cinacalcet may represent a medical alternative to parathyroidectomy in cases of calciphylaxis with hyperparathyroidism.9 In summary, calciphylaxis is a complex and devastating mineral bone disorder associated with a high mortality rate in ESRD patients on RRT. Further studies are needed to aid better understanding of risk factors and management of this disease.
2
3
4
5
6
7
8 Kian-Guan LEE, Amy Ee-Lin LIM, Jiunn WONG, Lina Hui-Lin CHOONG Department of Renal Medicine, Singapore General Hospital, Singapore
9
analysis, and outcome. J Am Acad Dermatol. 2007; 56:569–579. Mazhar AR, Johnson RJ, Gillen D, et al. Risk factors and mortality associated with calciphylaxis in end-stage renal disease. Kidney Int. 2001; 60:324–332. Fine A, Zacharias J. Calciphylaxis is usually nonulcerating: Risk factors, outcome and therapy. Kidney Int. 2002; 61:2210–2217. Angelis M, Wong LL, Myers SA, Wong LM. Calciphylaxis in patients on hemodialysis: A prevalence study. Surgery. 1997; 122:1083–1089. 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; 27:1580–1584. Brandenburg V, Sinha S, Specht P, Ketteler M. Calcific uraemic arteriolopathy: A rare disease with a potentially high impact on chronic kidney disease–mineral bone disorder. Pediatr Nephrol. 2014; 29:2289–2298. Lal G, Nowell AG, Liao J, Sugg SL, Weigel RJ, Howe JR. Determinants of survival in patients with calciphylaxis: A multivariate analysis. Surgery. 2009; 146:1028–1034. Baldwin C, Farah M, Leung M, et al. Multi-intervention management of calciphylaxis: A report of 7 cases. Am J Kidney Dis. 2011; 58:988–991. Vedvyas C, Winterfield LS, Vleugels RA. Calciphylaxis: A systematic review of existing and emerging therapies. J Am Acad Dermatol. 2012; 67:e253–e260.
REFERENCES 1 Weenig RH, Sewell LD, Davis MDP, McCarthy JT, Pittelkow MR. Calciphylaxis: Natural history, risk factor
“Angiography without contrast”: Severe vascular calcification in chronic kidney disease
To the Editor: A 97-year-old female patient with previously known chronic kidney disease (CKD) was hospitalized because of fatigue and
Correspondence to: Y. Solak, MD, Sakarya Universitesi Egitim ve Arastirma Hastanesi, 54100, Sakarya, Turkey. E-mail: [email protected]
impairment in oral intake. The patient had had myocardial infarction 7 years earlier and has been receiving cilazapril plus hydrochlorothiazide and aspirin. Basic laboratory values on admission were as follows: serum creatinine: 3.5 mg/dL (her baseline creatinine value was 2.9 mg/dL), urea: 241 mg/dL, calcium: 8.7 mg/dL, phosphorus: 4.3 mg/dL, parathormon: 46 pg/mL. Serum creatinine gradually reduced to 1.8 mg/dL with hydration with normal saline. The
© 2015 International Society for Hemodialysis DOI:10.1111/hdi.12300
613
Hemodialysis International 2015; 19:611–618
cells into chondrocyte or osteoblast-like cell, high total cumulative calcium and phosphorus in the body, impaired renal excretion, and high dietary phosphorus and calcium load.1 Advanced age cannot be held responsible per se for this amount of calcification in the absence of CKD. This widespread calcification is, unfortunately, associated with increased morbidity and mortality. Kidney Disease Improving Global Outcomes (KDIGO) guidelines2 recommended that in patients with CKD stages 3–5D, a lateral abdominal radiograph can be used to detect the presence or absence of vascular calcification and an echocardiogram can be used to detect the presence or absence of valvular calcification. This case illustrates an exaggerated example of arterial calcification in a patient with stage 4 CKD. Zeynep ERTURK,1 Seyyid Bilal ACIKGOZ,1 Yalcin SOLAK2 Department of Internal Medicine, School of Medicine, Sakarya University, Sakarya, Turkey; 2 Division of Nephrology, Department of Internal Medicine, Sakarya University Research and Training Hospital, Sakarya, Turkey
1
Figure 1 Plain leg radiographs showing right and left femoral arteries with widespread calcification.
patient complained of left-sided hip pain. X-ray films of the legs and hip showed no fractures but a notable finding of diffuse vascular calcifications. Figure 1 shows easily recognizable bilateral femoral arteries because of widespread calcification of the vessel walls. The patient’s creatinine clearance calculated by Modification of Diet in Renal Disease (MDRD) equation was 19 mL/min/1.73 m2. Vascular calcification is common among patients with CKD. Several risk factors for vascular calcification have been proposed: transformation of vascular smooth muscle
REFERENCES 1 Moe SM, Chen NX. Mechanisms of vascular calcification in chronic kidney disease. J Am Soc Nephrol. 2008; 19:213– 216. Feb, [Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov’t Research Support, U.S. Gov’t, Non-P.H.S. Review]. 2 Moe S, Drueke T, Cunningham J, et al. Definition, evaluation, and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2006; 69:1945–1953. Jun, [Consensus Development Conference].
Extracellular superoxide dismutase release by enoxaparin and sparing effect of heparin-grafted hemodialyzer
Correspondence to: J. Borawski, MD, 1st Department of Nephrology and Transplantation with Dialysis Centre, Medical University Hospital, Building B, 14 Zurawia Street, 15-540 Bialystok, Poland. E-mail: [email protected]
To the Editor: In the recent article published in this journal, we reported on the striking increase in plasma myeloperoxidase (MPO) during hemodialysis (HD) procedure anticoagulated with enoxaparin (ENX).1 The MPO increase was minimal
© 2015 International Society for Hemodialysis DOI:10.1111/hdi.12308
614
