The Mysterious Calciphylaxis: Wounds with Eschar — To Debride or Not to Debride?
- 0 Comments
- 24084 reads
C alciphylaxis (CPX) is a potentially fatal complication of end-stage renal disease.1 Many authors have called calciphylaxis a rare phenomenon, a potentially fatal condition, and a syndrome that leads to ischemic ulcerations. Throughout the years, this mysterious disease has been described in the literature by a variety of names such as uremic gangrene syndrome,1,2 calcifying panniculitis, and calcific uremic arteriolopathy.3,4 According to Bliss and others,1,5 the most functional term may be the most recent: vascular calcification-cutaneous necrosis syndrome.
The pathogenesis of CPX is uncertain.1 Just as perplexing is wound care treatment, which is limited to aggressive surgical debridement of necrotic tissue. Srikureja6 states that debridement and regular wound care are necessary to promote healing and prevent serious complications from overwhelming secondary infection. Hadler7 recommends topical wound care products to facilitate debridement. Acknowledging the fact that these ischemic ulcerations of the skin are due to metastatic calcification of subcutaneous tissue and small arteries,8 debridement of ischemic wounds with stable eschar is contraindicated until perfusion status is determined.9 Furthermore, preventing wound infection is critical because sepsis related to wound infection is the leading cause of death for patients with CPX.10
According to Nunley,11 the obscure pathogenesis of CPX is likely the result of a multiplicity of comorbid factors or events. It is believed that patients develop this condition as a result of a hypersensitivity reaction to sensitizers such as increased parathyroid hormone (PTH), hypercalcemia, and hyperphosphatemia.3,12,13 According to Ledbetter,3 underlying vascular damage is present within the small vessels that may be related to the cause of renal failure; this predisposes patients to metastatic calcification in the setting of an elevated PTH level with an elevated calcium and phosphate product. Yet some patients with CPX have normal calcium, phosphate, and PTH concentrations.14 Also, the exact role of parathyroid hormone is uncertain because CPX may occur after total parathyroidectomy in the absence of measurable PTH levels.11
Exposure to challenging agents such as blood transfusions, albumin administration, corticosteroids, immunosuppressive agents, and local trauma are also thought to be responsible for the precipitating events of CPX.8,15 This belief is based on the experimental studies performed on rats by Selye16 that included exposing the subjects to challengers such as blood products, metals salts, and trauma. Functional protein C abnormality or protein S deficiency could be likely causes of thrombotic events, representing the cause of ischemia in clients who are susceptible to developing CPX.1,3,17
1. Bliss DE. Calciphylaxis: what nurses need to know. Nephrology Nursing Journal. 2000;29(5):433–442.
2. Edwards RB, Jaffe W, Arrowsmith J, Henderson HP. Calciphylaxis: a rare limb and life threatening cause of ischemic skin necrosis and ulceration. Br J Plast Surg. 2000;53:253–255.
3. Ledbetter LS, Khoshnevis MR, Hsu S. Calciphylaxis. Cutis. 2000;66(1):49–52.
4. Mawad HW, Sawaya BP, Sarin R, Mulluche HH. Calcific uremic arteriolpathy in association with low turnover uremic bone disease. Clin Nephrol. 1999;52(3):160–166.
5. Flanigan KM, Bromberg MB, Gregory M, et al. Calciphylaxis mimicking dermatomyositis: ischemic myopathy complicating renal failure. Neurology. 1998;51(6):1634–1640.
6. Srikurega W, Takahashi PY. 73-year old woman with painful lower extremity ulcers. Mayor Clinic Proceedings. 2001;76(7):745–748.
7. Hahler B. Calciphylaxis in the patient with chronic renal failure. Dermatology Nursing. 2001;13(6):435–437.
8. Mathur RV, Shortland JR, El Nahas AM. Calciphylaxis. Postgrad Med J. 2001;77(911):557–561.
9. Wound, Ostomy, Continence, Nurses Society. Conservative sharp debridement for registered nurses. Available at http://www.wocn.org/publications/posstate/debridement.htm. Accessed September 5, 2003.
10. Worth RL. Calciphylaxis: pathogenesis and therapy. J Cutan Med Surg. 1998;2(4):245–248.
11. Nunley JR. Calciphylaxis. Available at: http://www.emedicine.com/derm/byname/calciphylaxis.htm. Accessed September 19, 2003.
12. Bondi EE, Margolis DJ, Lazarus GS. Panniculitis. In: Freedberg IM, Eisen AZ, Wolff K, et al (eds). Fritzpatrick’s Dermatology in General Medicine. New York, NY: McGraw-Hill;1999:1282.
13. Trent TT, Kirsner RS. Calciphylaxis: diagnosis and treatment. Advances in Skin & Wound Care. 2001;14(6):309–312.
14. Kalaaji AN, Douglass MC, Chaffins M, Lowe L. Calciphylaxis, a cause of neurotic ulcers in renal failure. J Cutan Med Surg. 1998;2(4):242–244.
15. Beitz JM. Calciphylaxis: a case study with differential diagnosis. Ostomy/Wound Management. 2003;49(3):28–38.
16. Selye H. Calciphylaxis. Chicago, Ill.: The University of Chicago Press;1962.
17. Essary L, Wick M. Cutaneous calciphylaxis: an under-recognized clinicopathologic entity. Am J Clin Pathol. 2000;773:280–287.
18. Bleyer AJ, Choi M, Igwemezie B, de la Torre E, White WL. A case control study of proximal calciphylaxis. Am J Kidney Dis. 1998;32(3):376–383.
19. Hahler B. Calciphylaxis in chronic renal failure. Medsurg Nursing. 2000;9(6):311–312.
20. Saganich B. Calciphylaxis in renal failure. WOUNDS. 1996;8(2):49–52.
21. Green JA, Green CR, Minott SD. Calciphylaxis treated with neurolytic lumbar sympathetic block: case report and review of the literature. Reg Anesth Pain Med. 2000;25(3):310–313.
22. Pantanowitz L, Harton A, Bechwith B. Cutaneous gangrene in a renal dialysis patient. Postgrad Med J. 2001;77:735–737.
23. James LR, Lajoie G, Prajapati D, Gan BS, Bargman JM. Calciphylaxis precipitated by ultraviolet light in a patient with end-stage renal disease secondary to systemic lupus erythematous. Am J Kidney Dis. 1999;34(5):932–936.
24. Janigan D, Hitch D, Klassen G, et al. Calcified subcutaneous arterioles with infarcts of the subcutis and skin (calciphylaxis) in chronic renal failure. Am J Kidney Dis. 2000;35:588–597.
25. Ivker RA, Woosley J, Briggsman RA. Calciphylaxis in three patients with end-stage renal disease. Arch Dermatol. 1995;131:63–68.
26. Duh Q, Lim R, Clark O. Calciphylaxis in secondary hyperparathyroidism. Arch Surg. 1991;126(10):1213–1219.
27. Oh D, Eulau D, Tokugawa D., McGuire J, Kohler S. Five cases of calciphylaxis and a review of the literature. J Am Acad Dermatol. 1999;40:979–987.
28. Asirvatham S, Sebastian C, Sivaram CA, Kaufman C, Chandrasekaran K. Aortic valve involvement in calciphylaxis: uremic small artery disease with calcification and intimal hyperplasia. Am J Kidney Dis. 1999;32(3):499–505.
29. Roe SM, Graham LD, Brock WB, Barker DE. Calciphylaxis: early recognition and management. Am Surg. 1994;60(2):81–86.
30. Barr JE. Autolytic, mechanical , chemical, and sharp debridement. In: Milne CT, Corbett LQ, Dubuc DL, eds. Wound, Ostomy, Continence Nursing Society. Philadelphia, Pa.: Hanley & Belfus;2003:54–64.
31. Angelis M, Wong L, Meyers S, Wong L. Calciphylaxis in patients on hemodialysis: a prevalence study. Surgery. 1997;122:1083–1090.
32. Khafif RA, DeLima C, Silverberg A, Frankel R. Calciphylaxis and systemic calcinosis. Collective Review Archives of Internal Medicine. 1990;156:956–959.
33. Fowler E, van Rijswijk L. Using wound debridement to help achieve the goals of care. Ostomy/Wound Management.1995;41(7 Suppl):23S–34S.
34. Doughty DB, Waldrop J. Lower-extremity ulcers of vascular etiology. In: Bryant R (ed). Acute & Chronic Wound: Nursing Management. Philadelphia, Pa.: Mosby;2000:265–300.
35. Donovan A, Edmiston C. Practicing smart wound care. Available at: http://www.infectioncontroltoday.com/articles/111feat3.html. Accessed September 13, 2003.
36. Friedman SG. Leg revascularization in patients with calciphylaxis. Am Surg. 2002;68(7):591–592.