Mrs D is admitted to the medical/surgical unit with multiple diagnoses, including end-stage renal disease. She has had chronic renal failure for 10 years. During the assessment, multiple large wounds on her right posterior calf and heel and a smaller wound on her left leg near the malleolus are noted. These wounds appear black, dry, indurated, and gangrenous; they have a foul odor. Mrs D says that because the odor is so offensive, she never leaves home except for routine trips to the dialysis center.
She makes facial grimaces and retracts her leg when the wounds are assessed. She rates her pain at that moment as a 10 on a scale of 0 to 10, where 0 equals no pain and 10 equals the worst pain imaginable. She admits that the pain prevents her from performing activities of daily living or comfortably resting her leg on a surface, such as the bed. She also has trouble placing her leg through clothing when she dresses.
Mrs D is suffering from calciphylaxis, a rare, life-threatening condition that occurs in patients with end-stage renal disease and secondary hyperparathyroidism. In calciphylaxis, calcium and phosphorous metabolism is abnormal and calcium is deposited in the tissues.
Mrs D has early and late lesions. Early lesions are subtle cutaneous vascular calcifications. Late lesions include obvious epidermal ulceration and necrosis through the dermal layer. The wound involves small vessels in the subcutaneous fat layer, leading to ischemia and tissue necrosis. Women are affected more often than men, and the mortality rate is as high as 80%.
Calciphylaxis wounds may be found anywhere on the body and it is important to distinguish these wounds from other, more common wounds. For example, venous ulcers are usually found on the gaiter areas of the lower legs. Arterial ulcers occur on the pretibial area or dorsum of the toes or feet.
Calciphylaxis wounds are secondary to a problem that can be managed medically; in this case, the inability to metabolize calcium and phosphorous normally. The multidisciplinary team caring for Mrs D consists of her primary care provider, nephrologist, anesthesiologist, nurse, dietitian, social worker, physical therapist, and occupational therapist. The team’s goals include preventing systemic infection (in this case, through wound debridement), managing the patient’s pain, providing maximum nutrition, maximizing the patient’s mobility to combat deconditioning, managing wound odor, and supporting the patient emotionally. Each patient is different, but improving calcium and phosphorus metabolism is important for all.
Monitor the patient’s lab values. These may include calcium phosphorous product (normal, <70 mg/dL), prealbumin level (normal, 20–43 mg/dL), parathyroid hormone level (normal, 10-65 picograms/mL), and total protein (normal 5.6–8 grams/dL). Teach her to limit foods that are high in calcium, such as cottage cheese, cream soup, eggnog, hot cocoa, ice cream, milk, milkshakes, pudding, and yogurt; and foods high in phosphorous, such as asparagus, beer, brussels sprouts, cheese, chocolate, cola drinks, corn, dried beans, nuts and seeds, peanut butter, spinach, sweet potato, and whole-grain and bran cereal.
Mrs D’s treatment consists of increasing the frequency of hemodialysis to manage her calcium and phosphorous levels, wound debridement when appropriate, pain management, and education on diet and performing regular skin assessments.
Managing the patient with calciphylaxis is a challenge. Distinguishing this wound from other, more common types is the first step toward managing the underlying disease and preventing life-threatening complications.