Elsevier

Surgery

Volume 130, Issue 4, October 2001, Pages 645-651
Surgery

Central Surgical Association
Parathyroidectomy promotes wound healing and prolongs survival in patients with calciphylaxis from secondary hyperparathyroidism*

Presented at the 58th Annual Meeting of the Central Surgical Association, Tucson, Ariz, March 7-10, 2001.
https://doi.org/10.1067/msy.2001.117101Get rights and content

Abstract

Background. Calciphylaxis is a rare but life-threatening condition occasionally affecting patients with secondary hyperparathyroidism. Parathyroidectomy has been advocated as the only potentially curative intervention. Methods. Between January 1989 and May 2000, 13 patients with pathologic/clinical criteria of calciphylaxis were treated at our institution. Of these 13 patients, 7 were managed with medical therapy alone, and 6 were referred for parathyroidectomy. The medical records were reviewed, and patients/relatives were interviewed. Results. All patients had cutaneous wounds requiring local debridement predominantly located on the lower extremities or abdominal wall. Six patients underwent subtotal (3.5 gland) parathyroidectomy without morbidity. All 6 had significant reductions in parathyroid hormone levels after surgery (mean decrease, 94% ± 0%), and all reported resolution of pain and healing of cutaneous wounds. Of the remaining 7 patients who had medical management alone, 5 eventually died of complications related to calciphylaxis. In comparing the 2 groups, patients who underwent parathyroidectomy had a significantly longer median survival than those who did not have surgery (36 vs 3 months, P =.021). Conclusions. Calciphylaxis frequently causes gangrene, sepsis, and eventual death. Parathyroidectomy can be performed with minimal morbidity and is associated with resolution of pain, wound healing, and a significantly longer median survival. Therefore, patients with secondary hyperparathyroidism and signs/symptoms of calciphylaxis should be referred promptly for consideration of parathyroidectomy. (Surgery 2001;130:645-51.)

Section snippets

Methods

Between January 1989 and May 2000, 13 patients with pathologic/clinical criteria of calciphylaxis were treated at the Johns Hopkins Bayview Medical Center. Patients were retrospectively identified through the pathology specimen database with the histologic diagnosis of calciphylaxis. Minimal pathologic criteria for biopsy diagnosis included the presence of dermal and epidermal necrosis, small and medium-sized vessel calcification and obliteration, and focal calcification in the dermis or

Demographic data

The mean age of the patients was 50.2 ± 11 years. Twelve patients were female and only 1 was male. All had significant renal disease, 12 of 13 requiring dialysis. Three had prior kidney transplants that had failed. In addition to kidney failure, patient comorbidities included obesity, hypertension, and diabetes but were not related to treatment group or outcome (Table I).

. Patient data

Patient no.Age (y)GenderComorbidityDialysis typeWound location
137FObesity, HTNHDThighs
236FObesity, HTN,

Discussion

Selye and Savoie2 coined the term calciphylaxis after a series of animal experiments. Their theory defined calciphylaxis as a systemic hypersensitivity induced by calcifying factors such as PTH, vitamin D, or phosphates, in which acute challengers induce extensive inflammation, tissue calcification, and necrosis. This experimental work remains the basis of present calciphylaxis theory. The 2 sensitizing agents frequently cited in the literature include PTH, commonly arising from the secondary

Discussion

Dr Michael J. Demeure (Milwaukee, Wis). Calciphylaxis is indeed a rare condition. One would infer from these data that surgical intervention in secondary parathyroidism patients at high risk for calciphylaxis could prevent the onset of this rather dreaded complication. However, at our institution only 1% of dialysis patients come to parathyroidectomy.

What are your indications for surgery in patients with secondary hyperparathyroidism, and what is the prevalence of calciphylaxis in your dialysis

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    Calciphylaxis: is there a role for parathyroidectomy?

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    *

    Reprint requests: Herbert Chen, MD, University of Wisconsin Medical School, H4/750 Clinical Science Center, 600 Highland Ave, Madison, WI 53792.

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