May 23, 2019
In this episode,
Dr. Vincent DeLeo talks to Dr. Robert G. Micheletti about
managing patients with calciphylaxis, a rare but potentially
fatal condition classically seen in patients with end-stage renal
disease (ESRD). Early recognition and diagnosis of calciphylaxis
are essential to reducing morbidity and mortality. Dr. Micheletti
describes the clinical features of calciphylaxis that
dermatologists may encounter bedside, noting that biopsy often is
nondefinitive. “It’s a tough disease to have," Dr. Micheletti
explains, "which is why you do need multidisciplinary care and the
help of a good dermatologist to be able to make the diagnosis and
address the wound situation.”
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Things you will learn in this episode:
- Although calciphylaxis commonly is associated with ESRD,
nonuremic calciphylaxis can be triggered by other clinical factors
in a subset of patients without ESRD.
- Risk factors for calciphylaxis include various medications,
clotting disorders, and autoimmune diseases, whether the patient
also has ESRD.
- The clinical presentation of calciphylaxis depends on the point
at which the area is examined. Early stages of calciphylaxis may
present as a tender subcutaneous nodule, while late stages may
present with more severe pain and ulceration. Maintain a high index
of suspicion for calciphylaxis in patients with ESRD on chronic
dialysis presenting with severely painful livedoid plaques or
retiform purpura, particularly in fat-rich body sites.
- Biopsy often is nondiagnostic because of insufficient tissue
sample size. Calcium stains will help highlight areas of vascular
calcification, but “don’t assume just because the biopsy doesn’t
show calcification that it is not calciphylaxis.” To improve
diagnostic accuracy, biopsy specimens should be evaluated by
experienced dermatopathologists who have seen calciphylaxis
- End-stage renal disease patients with calciphylaxis who are not
currently on dialysis may benefit from starting it.
- Dermatologists should work in conjunction with nephrologists to
optimize dialysis and other medications to treat underlying issues
associated with calciphylaxis in the setting of ESRD.
- Data-driven diagnostic criteria and management guidelines for
calciphylaxis are needed to improve patient care. The Society for
Dermatology Hospitalists is working on pooling cases of
calciphylaxis to generate a data-driven model of factors associated
with the diagnosis.
Hosts: Elizabeth Mechcatie; Terry Rudd; Vincent A. DeLeo, MD
(University of Southern California, Los Angeles).
Guest: Robert G. Micheletti, MD (Departments of Dermatology and
Medicine, University of Pennsylvania, Philadelphia).
Show notes by Alicia Sonners, Melissa Sears, and Elizabeth
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