Calcific uraemic arteriolopathy (calciphylaxis) in patients on renal replacement therapy

Background. Calcific uraemic arteriolopathy (calciphylaxis) is an unusual and potentially fatal condition characterised by small-vessel calcification and ischaemic skin necrosis. It mainly affects patients with end-stage renal disease (ESRD) on haemodialysis, but may rarely occur in the absence of ESRD in conditions such as primary hyperparathyroidism, malignancy, alcoholic liver disease and connective tissue disease.Methods. We reviewed the records of all patients diagnosed with calciphylaxis while on renal replacement therapy at Tygerberg Hospital, Cape Town, South Africa, between 1990 and 2014, to describe its presentation, course and final outcome.Results. Nineteen patients developed calciphylaxis over this period. Their median age was 34 years and 13 (68.4%) were female. Fifteen (78.9%) had received a kidney transplant. All patients had painful skin lesions that rapidly progressed to infarction. Small-vessel calcification was seen on skin biopsy in 13 patients. Twelve patients had hyperparathyroidism. Several of the transplanted patients had been treated for graft rejection in the year preceding the diagnosis. Treatment consisted of good wound care and efforts to normalise serum calcium and phosphate levels. Five patients received an urgent parathyroidectomy. The outcome was fatal in 17 patients, with sepsis being the main cause of death.Conclusions. In our patients, calciphylaxis carried a worse prognosis than previously reported internationally. It should always be considered in the differential diagnosis of painful skin lesions in the dialysis or transplant patient

A review of diagnosis and modes of presentation of tropical idiopathic lower limb gangrene

Background:Tropical idiopathic lower limb gangrene (TILLG) is also known as Symmetrical gangrene in the African; Idiopathic gangrene in the African and Idiopathic peripheral gangrene of the tropics.The aetiopathogenesis of this clinical entity is a mystery. Objective: To review methods of diagnosing tropical idiopathic lower limb gangrene (TILLG) and highlight its clinical variants. Method: All Literature on idiopathic gangrene of the extremities was searched from libraries; colleagues and internet but only literature on TILLG (in Africans) from 1947 to date was scrutinised. Each case was studied to find out the basis of diagnosis. Result:TILLG is not fully understood and not easy to recognise.Two sets of criteria are known to be helpful in establishing diagnosis. These criteria can be classified as major and minor criteria. Major criteria are those clinical data that can establish the diagnosis of TILLG. No devices are required to identify them. Minor criteria are pathological changes that are consistent with TILLG. Devices are required to identify them.Three pathomorphological types of TILLG were described in literature and are classified as types A; B and C. Conclusions:This review is supposed to sensitise the clinician and make diagnosis easier.This will also encourage more researches.As more information becomes available; aetiopathogenesis of TILLG will be clearer and more clinical variants of the disease may be reported.This additional information will help in the prevention of gangrene; reducing the socioeconomic problems arising from amputation