Ruggian JC, Maesaka JK, Fishbane S
Proximal calciphylaxis in four insulin-requiring
diabetic dialysis patients
Am J Kidney Dis
(Sep) 28:409-414 1996

Calciphylaxis is a rare, sometimes fatal complication of ESRD
manifested by ischemic necrosis and calcification of the skin of
the abdomen or extremities. The pathogenesis is obscure.
Alterations in mineral metabolism, coagulation, and diabetes may
be predisposing factors. A role for trauma has also been
proposed. In this report, four diabetic ESRD patients with
proximal calciphylaxis at the sites of insulin injection are
described. Biopsy of the skin revealed calcifying panniculitis,
medial calcification of the medium and small arteries, intimal
edema, and intravascular thrombosis. Treatments included
steroids, antibiotics, and surgical debridement but all
eventually died. The authors propose that the trauma of insulin
injections with worsening ischemia may have predisposed these
patients to this complication.
Comment:
Calciphylaxis has been discussed previously in HDCN
(see
Ask the Prof re calciphylaxis). A recent intriguing hypothesis
is that at least some
patients may have a hypercoagulable state that predisposes to
thrombosis. Both protein C and S deficiencies have been
reported. In addition, some patients have high PTH levels and
may respond to parathyroidectomy. Therefore patients with this
syndrome should have measurements of calcium, phosphorus, PTH,
and protein C and S levels.
(David J. Leehey, M.D., Loyola University at Chicago)