Milas Mira, Bush Ruth L, Lin Peter, Brown Kathy, Mackay Greg, Lumsden Alan, Weber Collin, Dodson Thomas F
Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
J Vasc Surg. 2003 Mar;37(3):501-7. doi: 10.1067/mva.2003.70.
Calciphylaxis, a disorder of calcium-phosphate metabolism that can result in arterial calcification, skin and solid organ calcium deposits, and nonhealing ulcerations, is associated with significant morbidity and mortality. Although its most common cause is secondary hyperparathyroidism in patients with renal failure, vascular surgeons are frequently called on to evaluate these nonhealing extremity wounds. We reviewed our experience of a multidisciplinary approach in treating patients with calciphylaxis and nonhealing ulcers.
Over a 14-month period at a tertiary center, five patients were seen with calciphylaxis and nonhealing leg wounds. Demographics, disease characteristics, surgical treatment, and outcomes were analyzed.
All five patients were black women aged 40 +/- 8.9 years with hypertensive renal failure undergoing long-term hemodialysis (80 +/- 43 months). They had large, painful lower extremity wounds or necrotic ulcers (mean size, 135 cm(2)) that had developed over 2 to 4 months. Three patients had palpable pedal pulses, one patient had Doppler pedal signals, and one patient had absent pedal flow. Arteriogram was performed in the latter two patients, and one patient underwent lower extremity revascularization because of superficial femoral artery stenosis with symptomatic improvement. Four patients underwent aggressive debridement by the vascular surgical service, and two needed plastic surgeon-performed skin grafting. All patients had elevated parathyroid hormone levels (mean, 1735 pg/mL; > 25 x normal level); mean preoperative calcium levels were normal (10 mg/dL). After either subtotal (n = 4) or total (n = 1) parathyroidectomy by an experienced endocrine surgeon, a significant reduction in parathyroid hormone and calcium levels was seen (122 pg/mL and 7.9 mg/dL, respectively; P <.05). There were no postoperative complications or amputations; one patient died 12 months after parathyroidectomy of severe preexisting cardiopulmonary disease. Complete wound healing was observed by 4.8 +/- 2 months. During a mean follow-up period of 9 months (range, 1 to 18 months), all wounds remained healed without ulcer recurrence.
The diagnosis of calciphylaxis should be considered in patients with end-stage renal disease with atypical tissue necrosis or subcutaneous nodules. Early recognition of calciphylaxis and multidisciplinary treatment, including diligent wound care, frequent debridement, parathyroidectomy, and appropriate skin grafting or revascularization, can result in improved wound healing and limb salvage.
钙过敏症是一种磷酸钙代谢紊乱疾病，可导致动脉钙化、皮肤和实体器官钙沉积以及不愈合溃疡，与显著的发病率和死亡率相关。虽然其最常见的病因是肾衰竭患者的继发性甲状旁腺功能亢进，但血管外科医生经常被要求评估这些不愈合的肢体伤口。我们回顾了我们采用多学科方法治疗钙过敏症和不愈合溃疡患者的经验。
在一家三级中心的14个月期间，诊治了5例患有钙过敏症和腿部不愈合伤口的患者。分析了人口统计学、疾病特征、手术治疗及结果。
所有5例患者均为黑人女性，年龄40±8.9岁，患有高血压性肾衰竭，正在接受长期血液透析（80±43个月）。她们有大的、疼痛的下肢伤口或坏死性溃疡（平均面积135平方厘米），这些伤口在2至4个月内形成。3例患者可触及足背动脉搏动，1例患者有足背动脉多普勒信号，1例患者足背血流消失。后两名患者进行了动脉造影，其中1例因股浅动脉狭窄接受了下肢血管重建术，症状有所改善。4例患者接受了血管外科积极的清创术，2例需要整形外科医生进行皮肤移植。所有患者甲状旁腺激素水平均升高（平均1735 pg/mL；>正常水平的25倍）；术前平均钙水平正常（10 mg/dL）。在经验丰富内分泌外科医生进行次全甲状旁腺切除术（n = 4）或全甲状旁腺切除术（n = 1）后，甲状旁腺激素和钙水平显著降低（分别为122 pg/mL和7.9 mg/dL；P <.05）。术后无并发症或截肢；1例患者在甲状旁腺切除术后12个月因严重的原有心肺疾病死亡。4.8±2个月时观察到伤口完全愈合。在平均9个月（范围1至18个月）的随访期内，所有伤口均愈合且无溃疡复发。
终末期肾病伴有非典型组织坏死或皮下结节的患者应考虑钙过敏症的诊断。早期识别钙过敏症并进行多学科治疗，包括精心的伤口护理、频繁清创、甲状旁腺切除术以及适当的皮肤移植或血管重建术，可改善伤口愈合并挽救肢体。
