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      Calciphylaxis in a Patient on Home Hemodialysis

      case-report

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          Abstract

          Calciphylaxis is a rare and severe complication characterized by calcification of arterioles and capillaries in the dermis and subcutaneous adipose tissue that leads to ischemia, necrosis, and painful skin lesions in patients with end-stage renal disease (ESRD). It is also known as calcific uremic arteriolopathy. Calciphylaxis occurs most commonly with the ESRD with skin ulceration as a predominant presenting feature. Calcium-phosphorus dysregulation in dialysis patients are traditionally considered as a risk factor for the development of calciphylaxis. The involvement of an integrated interdisciplinary and multifaceted approach is key to the success of the calciphylaxis treatment. We present a case of a 51-year-old female with ESRD on home hemodialysis who developed calciphylaxis, which was successfully managed with increasing dialysis prescription, diligent wound care, and sodium thiosulfate infusion. Management of calciphylaxis in a patient receiving home hemodialysis has never been reported as per the review of the literature. Calciphylaxis is a sporadic disease, frequently encountered in the patients undergoing hemodialysis and carries a very grave prognosis. Current treatment is rarely effective, so preventive strategies play an important role by modifying the risk factors that promote the development of calciphylaxis.

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          Most cited references43

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          Calciphylaxis: risk factors, diagnosis, and treatment.

          Calciphylaxis is a rare but devastating condition that has continued to challenge the medical community since its early descriptions in the scientific literature many decades ago. It is predominantly seen in patients with chronic kidney failure treated with dialysis (uremic calciphylaxis) but is also described in patients with earlier stages of chronic kidney disease and with normal kidney function. In this review, we discuss the available medical literature regarding risk factors, diagnosis, and treatment of both uremic and nonuremic calciphylaxis. High-quality evidence for the evaluation and management of calciphylaxis is lacking at this time due to its rare incidence and poorly understood pathogenesis and the relative paucity of collaborative research efforts. We hereby provide a summary of recommendations developed by a multidisciplinary team for patients with calciphylaxis.
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            Opioids in renal failure and dialysis patients.

            This article reviews the literature pertaining to the metabolism of several of the commonly used opioids, and the known activity of their metabolites. The effect of renal failure on the pharmacokinetics of these drugs and metabolites is then reviewed. Finally, the effect of renal dialysis on opioid drugs and metabolites is reviewed. Based on the review, it is recommended that morphine and codeine are avoided in renal failure/dialysis patients; hydromorphone or oxycodone are used with caution and close monitoring; and that methadone and fentanyl/sufentanil appear to be safe to use. Note is made that the "safe" drugs in renal failure are also the least dialyzable.
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              Calcinosis cutis: part I. Diagnostic pathway.

              Calcinosis cutis is characterized by the deposition of insoluble calcium salts in the skin and subcutaneous tissue. The syndrome is separated into five subtypes: dystrophic calcification, metastatic calcification, idiopathic calcification, iatrogenic calcification, and calciphylaxis. Dystrophic calcification appears as a result of local tissue damage with normal calcium and phosphate levels in serum. Metastatic calcification is characterized by an abnormal calcium and/or phosphate metabolism, leading to the precipitation of calcium in cutaneous and subcutaneous tissue. Idiopathic calcification occurs without any underlying tissue damage or metabolic disorder. Skin calcification in iatrogenic calcinosis cutis is a side effect of therapy. Calciphylaxis presents with small vessel calcification mainly affecting blood vessels of the dermis or subcutaneous fat. Disturbances in calcium and phosphate metabolism and hyperparathyroidism can be observed. Copyright © 2010 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.
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                Author and article information

                Journal
                J Investig Med High Impact Case Rep
                J Investig Med High Impact Case Rep
                HIC
                sphic
                Journal of Investigative Medicine High Impact Case Reports
                SAGE Publications (Sage CA: Los Angeles, CA )
                2324-7096
                21 May 2020
                Jan-Dec 2020
                : 8
                : 2324709620922718
                Affiliations
                [1 ]The Nephrology Group Inc, Fresno, CA, USA
                [2 ]Adventist Medical Center, Hanford, CA, USA
                [3 ]Interfaith Medical Center, New York, NY, USA
                [4 ]Great Plains Health, North Platte, NE, USA
                [5 ]Wise Health System, Decatur, TX, USA
                [6 ]Kaweah Delta Medical Center, Visalia, CA, USA
                [7 ]Ashland Bellefonte Cancer Center, Ashland, KY, USA
                Author notes
                [*]Sreedhar Adapa, Kaweah Delta Medical Center, 400 West Mineral King Avenue, Visalia, CA 93291-6263, USA. Email: sadapa@ 123456kdhcd.org
                Author information
                https://orcid.org/0000-0001-5608-5654
                https://orcid.org/0000-0001-5194-9134
                https://orcid.org/0000-0003-1953-8815
                Article
                10.1177_2324709620922718
                10.1177/2324709620922718
                7243381
                32434389
                fda75b57-c1f7-4b3f-b8c9-6d2464e5a784
                © 2020 American Federation for Medical Research

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                : 25 January 2020
                : 31 March 2020
                : 3 April 2020
                Categories
                Case Report
                Custom metadata
                January-December 2020
                ts1

                calciphylaxis,home hemodialysis,calcific uremic arteriolopathy,end-stage renal disease,skin ulcers,sodium thiosulfate

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