A retrospective analysis of treatment of wounds caused by calciphylaxis: Hyperbaric oxygen therapy with and without sodium thiosulfate

Abstract

Calciphylaxis, or calcific uremic arteriolopathy, is a rare, but devastating condition with a mortality approaching 80% in the United States, often seen in patients with chronic kidney disease. It is characterized by calcification and intimal fibrosis with arteriolar stenosis and subsequent thrombosis. Skin changes such as livedo reticularis, tender papules, and violaceous plaques result and progress to necrotic ulceration. Management of calciphylaxis includes maintenance of normal levels of calcium, phosphorus and parathyroid hormone, and optimization of hemodialysis and nutritional status. In our cohort, aggressive wound management coupled with sodium thiosulfate and hyperbaric oxygen therapy (HBOT) has achieved improvement in rates of healing for recalcitrant wounds associated with calciphylaxis but limited evidence for the efficacy of either treatment exists. We conducted a retrospective analysis of 94 patients treated for calciphylaxis at a Wound and Hyperbaric Center at an academic institution between 2000 and 2017 who were considered for HBOT. We assessed whether response to therapy as measured by wound healing varied among patients who received sodium thiosulfate, hyperbaric oxygen treatment, both therapies, or neither therapy. We found HBOT to be beneficial in healing compared to no therapy - 81.7% or 36 of 44 patients with complete or substantial resolution of their wounds vs. neither therapy - 11.4% or 3 of 26 patients. We found sodium thiosulfate to be beneficial in healing compared to neither therapy - 66.6% or 2 of 3 patients with complete or substantial resolution of their wounds vs. no therapy. We found combined HBOT & sodium thiosulfate to be more beneficial in healing compared to either therapy alone and to neither therapy - 86.3% or 19 of 22 patients with complete or substantial resolution of wounds. Given the dramatic clinical improvement, HBOT in combination with sodium thiosulfate has an important adjunctive role in the treatment of calciphylaxis.