HDCN Article Review/Hyperlink

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)