Influencia de la enfermedad renal crónica terminal en la aparición de pérdida de la integridad tisular

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Abstract

Introducción: La calcifilaxis se caracteriza por calcificación de arteriolas, fibrosis y trombosis que conduce a la aparición de úlceras cutáneas isquémicas y necrosis, y afecta con mayor frecuencia a pacientes con enfermedad renal crónica terminal. El tratamiento de la calcifilaxis es variado, sin existir una modalidad terapéutica eficaz, y presenta mal pronóstico, principalmente por la sepsis secundaria a infección de las lesiones cutáneas. Objetivo: Conocer la producción científica sobre la calcifilaxis relacionada con la enfermedad renal crónica. Metodología: Se ha llevado a cabo una revisión bibliográfica con una búsqueda de bibliografía en las principales bases de datos PubMed/Medline, Scielo, Cuiden, ProQuest/Health and Medical Complete, IME y Google Académico. Resultados: Se seleccionaron 61 artículos para la realización del estudio: 19 artículos de revisión, 13 originales y 29 casos clínicos. Las variables estudiadas han sido las alteraciones en el metabolismo del fósforo, calcio y hormona paratiroidea, varios factores de riesgo, distribución de las lesiones, fallecimiento por sepsis, tratamiento médico y cuidados de enfermería. Los factores más influyentes en la aparición de calcifilaxis son las alteraciones en el metabolismo, obesidad, diabetes, hipertensión, baja albúmina sérica y toma de anticoagulantes. El tratamiento implica múltiples medidas terapéuticas, dirigidas al control de las alteraciones del metabolismo y la cura de las manifestaciones cutáneas. Conclusiones: La calcifilaxis es una entidad poco frecuente y con una elevada mortalidad. La patogénesis es desconocida y desde el punto de vista terapéutico, no existe un tratamiento específico, por lo que es fundamental un enfoque multidisciplinar, para su prevención y detección precoz.

Translated abstract

Introduction: Calciphylaxis is characterized by calcification of arterioles, fibrosis and thrombosis which leads to the onset of ischemic skin ulcers and necrosis, and most often affects in patients with end stage renal disease. Treatment of calciphylaxis is varied, without effective therapeutic modality and poor prognosis, mainly due to sepsis secondary to infection of the skin lesions. Objective: To know the scientific production on calciphylaxis related to chronic kidney disease. Methodology: A literature review was conducted with a literature search in the following databases: PubMed / Medline, Scielo, Cuiden, ProQuest / Health and Medical Complete, IME and Google Scholar. Results: Sixty-one articles were selected for the study: 19 review articles, 13 originals and 29 clinical cases. The variables studied were: alterations in the metabolism of phosphorus, calcium and parathyroid hormone, several risk factors, distribution of injuries, death due to sepsis, medical treatment and nursing care. The most influential factors in the development of calciphylaxis are alterations in metabolism, obesity, diabetes, hypertension, low serum albumin and taking anticoagulants. Treatment involves multiple therapeutic measures aimed at controlling the metabolic disorders and cure of cutaneous manifestations. Conclusion: Calciphylaxis is an uncommon event with high mortality. The pathogenesis is unknown and from a therapeutic point of view, there is no specific treatment, so that a multidisciplinary approach is essential for its prevention and early detection.

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Risk factors and mortality associated with calciphylaxis in end-stage renal disease.

Alan C Breen, Sharon K. Davis, D. Gillen … (2001)

We conducted a case control study to determine risk factors and mortality associated with calciphylaxis in end-stage renal disease. Cases of calciphylaxis diagnosed between December 1989 and January 2000 were identified. Three controls were identified for each hemodialysis patient, with calciphylaxis matched to the date of initiation of hemodialysis. Laboratory data and medication doses were recorded during the 12 months prior to the date of diagnosis and at the time of diagnosis of calciphylaxis. Conditional logistic regression was used to identify risk factors for calciphylaxis. Cox proportional hazards models were used to estimate the risk of death associated with calciphylaxis. Nineteen cases and 54 controls were identified. Eighteen patients were hemodialysis patients, and one had a functioning renal allograft. Diagnosis was confirmed by skin biopsy in 16 cases. Women were at a sixfold higher risk of developing calciphylaxis (OR = 6.04, 95% CI 1.62 to 22.6, P = 0.007). There was a 21% lower risk of calciphylaxis associated with each 0.1 g/dL increase in the mean serum albumin during the year prior to diagnosis and at the time of diagnosis of calciphylaxis (OR = 0.79, 95% CI, 0.64 to 0.99, P = 0.037, and OR = 0.80, 95% CI, 0.67 to 0.96, P = 0.019, respectively). There was a 3.51-fold increase in the risk of calciphylaxis associated with each mg/dL increase in the mean serum phosphate during the year prior to diagnosis (95% CI, 0.99 to 12.5, P = 0.052). At the time of diagnosis of calciphylaxis, for each 10 IU/L increment in alkaline phosphatase, the risk of calciphylaxis increased by 19% (OR = 1.19, 95% CI, 1.00 to 1.40, P = 0.045). Body mass index, diabetes, blood pressure, aluminum, and higher dosage of erythropoietin and iron dextran were not independent predictors of calciphylaxis. Calciphylaxis independently increased the risk of death by eightfold (OR = 8.58, 95% CI, 3.26 to 22.6, P < 0.001). Female gender, hyperphosphatemia, high alkaline phosphatase, and low serum albumin are risk factors for calciphylaxis. Calciphylaxis is associated with a very high mortality.

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The mechanism of vascular calcification – a systematic review

Wojciech Karwowski, Beata Naumnik, Marek Szczepański … (2012)

Summary Calcification of vessels reduces their elasticity, affecting hemodynamic parameters of the cardiovascular system. The development of arterial hypertension, cardiac hypertrophy, ischemic heart disease or peripheral arterial disease significantly increases mortality in patients over 60 years of age. Stage of advancement and the extent of accumulation of calcium deposits in vessel walls are key risk factors of ischemic events. Vascular calcification is an active and complex process that involves numerous mechanisms responsible for calcium depositions in arterial walls. They lead to increase in arterial stiffness and in pulse wave velocity, which in turn increases cardiovascular disease morbidity and mortality. In-depth study and thorough understanding of vascular calcification mechanisms may be crucial for establishing an effective vasculoprotective therapy. The aim of this study was to present a comprehensive survey of current state-of-the-art research into the impact of metabolic and hormonal disorders on development of vascular calcification. Due to strong resemblance to the processes occurring in bone tissue, drugs used for osteoporosis treatment (calcitriol, estradiol, bisphosphonates) may interfere with the processes occurring in the vessel wall. On the other hand, drugs used to treat cardiovascular problems (statins, angiotensin convertase inhibitors, warfarin, heparins) may have an effect on bone tissue metabolism. Efforts to optimally control calcium and phosphate concentrations are also beneficial for patients with end-stage renal disease, for whom vessel calcification remains a major problem.

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Sodium thiosulfate therapy for calcific uremic arteriolopathy.

Sagar Nigwekar, Steven M. Brunelli, Debra Meade … (2013)

Calcific uremic arteriolopathy (CUA) is an often fatal condition with no effective treatment. Multiple case reports and case series have described intravenous sodium thiosulfate (STS) administration in CUA, but no studies have systematically evaluated this treatment.