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Skin biopsy: hematoxylin and eosin stain. Skin necrosis from calcification of the middle layer of small arterioles. B. Skin necrosis plates relative to calciphylaxis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Calciphylaxis is a rare entity characterized by the presence of circumferential calcifications in the middle layer of the arterioles of the skin, which initially manifests with livedo racemosa and panniculitis, progressing to ulceration and necrosis. It has a high mortality rate, which can reach 50–80% per year, mainly due to infection of these lesions.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> It appears more frequently in patients with advanced chronic renal failure (CRF), dialysis and kidney transplantation. There are many factors involved in the pathogenesis, such that non-uremic calciphylaxis is an entity to be included in the differential diagnosis of vascular etiology ulcers.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This is the case of a 68-year-old woman who had a kidney transplant 18 years ago, and recently secondary to chronic CRF graft dysfunction, with a stable glomerular filtration rate of 17<span class="elsevierStyleHsp" style=""></span>ml/min. Her personal history included the presence of obesity, hypertension and chronic atrial fibrillation. Her usual treatment included immunosuppressive medication, calcium supplements, cholecalciferol and acenocoumarol. In the last year she had presented a progressive increase in the levels of parathyroid hormone (PTH) and her nutritional status had deteriorated.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient visited our hospital because of the appearance of purple, painful and hard lesions on the inside of both her thighs. The rest of the physical examination was normal. Her analytic tests showed no abnormalities in calcium and phosphorus levels, PTH was 829<span class="elsevierStyleHsp" style=""></span>pg/ml and vitamin D<span class="elsevierStyleInf">3</span>-25-OH was 10<span class="elsevierStyleHsp" style=""></span>ng/ml. There were no changes in her baseline kidney function. A skin biopsy showed findings consistent with calciphylaxis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). After histologic confirmation, acenocoumarol, calcium supplements and cholecalciferol were suspended and treatment was initiated with cinacalcet. Despite these changes in her treatment, the skin lesions progressed in their extension and plates of necrosis appeared (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">During the following six months her kidney function worsened and renal replacement therapy was initiated with conventional haemodialysis. Currently the skin lesions are being closely monitored, which have also appeared in distal areas of the lower limbs.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Calciphylaxis presents painfully with ischemic necrosis on the skin. It can appear in acral areas with digital necrosis and gangrene, and at a proximal level, such as in the thighs and trunk. Obesity predisposes the proximal location due to the expansion of the subcutaneous fat compartment, subjecting the arterioles of the dermis to increased traction.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">A skin biopsy is the diagnostic test used to confirm. Other non-invasive tests such as an X-ray, high resolution CT scan and bone scan can also assist in its diagnosis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> A differential diagnosis is necessary with peripheral vascular disease, vasculitis, cellulite, atheroembolism and skin necrosis by Warfarin.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Traditional factors involved in the development of calciphylaxis are secondary and tertiary hyperparathyroidism, the imbalance of the calcium and phosphorus metabolism and the use of chelating calcium and vitamin D, which are common in dialysis and advanced CRF patients. It is worth noting that, although it is associated with high levels of phosphorus and calcium–phosphorus, their absence does not rule it out.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Its pathophysiological mechanism is not clearly established. The initial process occurs by depositing osteoid material in the vascular wall synthesized by osteoblast-like cells that emerge from the smooth muscle cells. Subsequently, these deposits are mineralized, promoted by inflammatory mediators and growth factors.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">There is no effective treatment. At the local level, signs of infection should be monitored closely. The use of hyperbaric oxygen has been suggested to improve tissue healing. Parathyroidectomy, the use of cinacalcet or intensification of renal replacement therapy are beneficial measures. Other pharmacological measures suggested include intravenous sodium thiosulfate, bisphosphonates and corticosteroids during the non-ulcerative phase.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Calciphylaxis is a rare disease with subcutaneous ischemia and necrosis. The pathogenesis is complex and multiple metabolic factors are involved. It has a high morbidity and mortality, making early diagnosis vital to improving patients’ prognosis.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cano Megías M, Casillas Sagrado E, Fernández Rodríguez A. Calcifilaxis proximal: una entidad metabólica poco frecuente. Med Clin (Barc). 2016;147:423–424.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1548 "Ancho" => 900 "Tamanyo" => 263897 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A. Skin biopsy: hematoxylin and eosin stain. Skin necrosis from calcification of the middle layer of small arterioles. B. 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Herman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.ajkd.2006.05.031" "Revista" => array:6 [ "tituloSerie" => "Am J Kidney Dis" "fecha" => "2006" "volumen" => "48" "paginaInicial" => "659" "paginaFinal" => "661" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16997063" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014700000009/v1_201612291447/S2387020616307434/v1_201612291447/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014700000009/v1_201612291447/S2387020616307434/v1_201612291447/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616307434?idApp=UINPBA00004N" ]