Commentary on The Mysterious Calciphylaxis: Wounds with Eschars - To Debride or Not to Debride?
As the author of this manuscript suggests, calciphylaxis is certainly a mysterious and confusing disorder and no longer uncommon. As more Americans with end-stage renal disease (ESRD) survive for longer time periods on dialysis, the occurrence of calciphylaxis is increasing. One of the greatest challenges associated with the disorder is the fact that its pathomechanisms are not fully understood and its treatment is controversial.
A major appropriate theme in this article is treatment of calciphylaxis in the context of the patient's situation. Because the condition and necrosis emerge over time, a patient's total status and ultimate prognosis may be poor. Although a clinician's first inclination is to arrange for prompt wound debridement of the sometimes substantial necrosis that occurs, caution is warranted. The trauma of surgery has been theorized as a potential "trigger" for the calcification process, so clinicians may be "between a rock and a hard place" (no pun intended).
In this author's experience, sharp debridement may not be the appropriate first step. Rather, patients may better tolerate slower enzymatic debridement because of lessened associated pain. Clinicians have to remember that the causes and treatments of calciphylaxis necrosis differ from the more common etiologies and approached to peripheral vascular disease.
Another aspect of the manuscript that deserves mention is the statement about "controlling and eliminating sensitizers and challengers." Clinicians have to view with caution an absolutist approach to this goal because the pathophysiology of calciphylaxis is still not fully understood. For an ESRD patient with severe anemia or protein depletion, blood transfusion or albumin therapy may be necessary. However, they are considered "challengers." Likewise, dialysis itself may be a form of sensitizer. Yet it cannot be stopped for persons requiring it. No easy answers emerge from the treatment of this disorder.
A final comment is warranted. The author's focus on early recognition and treatment of calciphylaxis is on target. Surgical approaches like parathyroidectomy, if enacted early, may slow the development process for some patients. The challenge is prompt recognition. Calciphylaxis may be difficult to correctly diagnose, especially if the patient has received intensive medical and surgical therapy. Other disorders can create necrosis in patients, including heparin-induced thrombocytopenia (HIT) necrosis and coumadin necrosis, among others. End-stage renal disease patients may receive these agents, and differential diagnosis may be involved and highly complex.
One thing about calciphylaxis is certain: it is increasing in incidence. Wound care clinicians can expect to encounter patients with the disorder and are likely to be challenged to the fullest degree of their expertise to provide quality care. Comprehensive understanding of the condition's etiology and its treatment uncertainties will make that a more likely reality.