Key Points
- High mortality—prioritize pain control and wound care.
- Aggressively correct mineral metabolism; avoid calcium‑based binders.
- Consider sodium thiosulfate and multidisciplinary management.
Algorithm
- Primary survey and stabilization; focused history and exam.
- Order high‑yield tests first; escalate imaging as indicated.
- Initiate disease‑specific therapy and supportive care.
- Reassess clinical response; arrange consultation and disposition.
Clinical Synopsis & Reasoning
Dialysis patient with exquisitely painful violaceous plaques progressing to necrosis—consider calcific uremic arteriolopathy (calciphylaxis). Risk factors include hyperphosphatemia, warfarin use, obesity, diabetes, and high Ca×P product. Diagnosis is clinical; deep skin biopsy can confirm but may worsen lesions. Coordinate wound care, analgesia, and infection prevention.
Treatment Strategy & Disposition
Multimodal therapy: optimize mineral bone disease (lower phosphorus; non‑calcium binders; adjust calcitriol), stop warfarin if possible, consider sodium thiosulfate IV after dialysis; hyperbaric oxygen and parathyroidectomy in select cases; integrate palliative care.
Epidemiology / Risk Factors
- Epidemiology varies by setting; see citations for details.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Serum Ca/PTH/Phos | Assess CKD‑MBD | ↑Phos, variable Ca, ↑PTH | Trend Ca×P |
| Wound cultures (if infected) | Guide antibiotics | Pathogens per culture | Avoid empiric long courses |
| Skin biopsy (select) | Definitive histology | Medial calcification of arterioles | Risk of poor healing |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Sodium thiosulfate (IV) | Reduces calcification/chelates | Immediate | Adjunctive therapy post‑dialysis | Nausea, metabolic acidosis |
| Sevelamer/lanthanum | Phosphate binders | Hours | Control hyperphosphatemia | GI effects |
| Analgesics (multimodal) | — | Immediate | Pain control | Opioid risks in ESRD |
Prognosis / Complications
- Prognosis depends on timeliness of diagnosis, comorbid disease, and response to therapy.
Patient Education / Counseling
- Explain expected course, warning signs requiring urgent care, and follow‑up testing.
- Review medication use, interactions, and monitoring parameters.