Skin Calcification Research Articles

Novel treatment for PXE: Recombinant ENPP1 enzyme therapy

Pseudoxanthoma elasticum (PXE) is a genetic multisystem ectopic calcification disorder caused by inactivating mutations in the ABCC6 gene encoding ABCC6, a hepatic efflux transporter. ABCC6-mediated ATP secretion by the liver is the main source of plasma inorganic pyrophosphate (PPi), a potent endogenous calcification inhibitor. The deficiency of plasma PPi underpins PXE. Recent studies demonstrated that INZ-701, a recombinant human ENPP1, the principal PPi-generating enzyme, restored plasma PPi levels and prevented ectopic calcification in the muzzle skin of an Abcc6-/- mouse model of PXE. This study examined the pharmacokinetics, pharmacodynamics, and potency of a new ENPP1-Fc isoform, BL-1118, in Abcc6-/- mice. When Abcc6-/- mice received a single subcutaneous injection of BL-1118 at 0.25, 0.5, or 1 mg/kg, they had dose-dependent elevations in plasma ENPP1 enzyme activity and PPi levels, with an enzyme half-life of approximately 100 hours. When Abcc6-/- mice were injected weekly from 5 to 15 weeks of age, BL-1118 dose-dependently increased steady-state plasma ENPP1 activity and PPi levels and significantly reduced ectopic calcification in the muzzle skin and kidneys. These results suggest that BL-1118 is a promising enzyme therapy for PXE, a disease currently lacking preventive or therapeutic options.

Do pseudoxanthoma elasticum patients have higher prevalence of kidney stones on computed tomography compared to hospital controls?

BackgroundPseudoxanthoma elasticum (PXE) is an autosomal recessive disease characterized by diminished inorganic plasma pyrophosphate (PPi), a strong calcification inhibitor. In addition to more typical calcification of skin, retina and arterial wall a diminished plasma PPi could lead to other ectopic calcification, such as formation of kidney stones.ObjectiveTo compare the prevalence of kidney stones between PXE patients and hospital controls on computed tomography (CT).MethodLow-dose CT images of PXE patients and controls were assessed by one radiologist, who was blinded for the diagnosis PXE. The number of kidney stones, and the size of the largest stone was recorded. Odds ratios (ORs) for having kidney stone were calculated using multivariable adjusted logistic regression.ResultsOur study comprised 273 PXE patients and 125 controls. The mean age of PXE patients was 51.5 ± 15.9 years compared to 54.9 ± 14.2 in the control group (p = 0.04) and PXE patients more often were women (63 vs. 50%, p = 0.013). The prevalence of kidney stones on CT was similar: 6.9% in PXE patients, compared to 5.6% in controls (p = 0.6). In the multivariate analysis adjusting for age and sex, there was no significantly higher odds for PXE patients on having stones, compared to controls: OR 1.48 (95% CI 0.62–3.96).ConclusionThere is no significant difference in the prevalence of incidental kidney stones on CT in PXE patients versus controls.

Elastic fiber alterations and calcifications in calcific uremic arteriolopathy

Calcific uremic arteriolopathy (CUA) is a severely morbid disease, affecting mostly dialyzed end-stage renal disease (ESRD) patients, associated with calcium deposits in the skin. Calcifications have been identified in ESRD patients without CUA, indicating that their presence is not specific to the disease. The objective of this retrospective multicenter study was to compare elastic fiber structure and skin calcifications in ESRD patients with CUA to those without CUA using innovative structural techniques. Fourteen ESRD patients with CUA were compared to 12 ESRD patients without CUA. Analyses of elastic fiber structure and skin calcifications using multiphoton microscopy followed by machine-learning analysis and field-emission scanning electron microscopy coupled with energy dispersive X-ray were performed. Elastic fibers specifically appeared fragmented in CUA. Quantitative analyses of multiphoton images showed that they were significantly straighter in ESRD patients with CUA than without CUA. Interstitial and vascular calcifications were observed in both groups of ESRD patients, but vascular calcifications specifically appeared massive and circumferential in CUA. Unlike interstitial calcifications, massive circumferential vascular calcifications and elastic fibers straightening appeared specific to CUA. The origins of such specific elastic fiber’s alteration are still to be explored and may involve relationships with ischemic vascular or inflammatory processes.

Correlation of systemic involvement and presence of pathological skin calcification assessed by ex vivo nonlinear microscopy in Pseudoxanthoma elasticum

Pseudoxanthoma elasticum (PXE (OMIM 264800)) is an autosomal recessive connective tissue disorder mainly caused by mutations in the ABCC6 gene. PXE results in ectopic calcification primarily in the skin, eye and blood vessels that can lead to blindness, peripheral arterial disease and stroke. Previous studies found correlation between macroscopic skin involvement and severe ophthalmological and cardiovascular complications. This study aimed to investigate correlation between skin calcification and systemic involvement in PXE. Ex vivo nonlinear microscopy (NLM) imaging was performed on formalin fixed, deparaffinized, unstained skin sections to assess the extent of skin calcification. The area affected by calcification (CA) in the dermis and density of calcification (CD) was calculated. From CA and CD, calcification score (CS) was determined. The number of affected typical and nontypical skin sites were counted. Phenodex + scores were determined. The relationship between the ophthalmological, cerebro- and cardiovascular and other systemic complications and CA, CD and CS, respectively, and skin involvement were analyzed. Regression models were built for adjustment to age and sex. We found significant correlation of CA with the number of affected typical skin sites (r = 0.48), the Phenodex + score (r = 0.435), extent of vessel involvement (V-score) (r = 0.434) and disease duration (r = 0.48). CD correlated significantly with V-score (r = 0.539). CA was significantly higher in patients with more severe eye (p = 0.04) and vascular (p = 0.005) complications. We found significantly higher CD in patients with higher V-score (p = 0.018), and with internal carotid artery hypoplasia (p = 0.045). Significant correlation was found between higher CA and the presence of macula atrophy (β = − 0.44, p = 0.032) and acneiform skin changes (β = 0.40, p = 0.047). Based on our results, the assessment of skin calcification pattern with nonlinear microscopy in PXE may be useful for clinicians to identify PXE patients who develop severe systemic complications.

Ladies in armor: A micro-computed tomographic study of skin calcification in European toads (genus Bufo).

Micro-computed tomography is a powerful tool toward the detailed reconstruction of internal and external morphology, in particular for ossified and other dense tissues. Here, we document and compare the level of calcification in the skin of the head and the parotoids (the external skin glands) in males and females of common and spined toads, Bufo bufo and B. spinosus. In some anurans, including Bufo species, a specific acellular calcified tissue layer within the dermis has been documented (the Eberth-Katschenko, or EK-layer). By a combination of micro-computed tomography and classical histology, we detected additional calcium deposits located in the dermal layer stratum spongiosum, positioned above the EK-layer. We showed that the level of calcification and the presence of additional calcium deposits are size and sex related, increasing in the order B. bufo males, B. spinosus males, B. bufo females to B. spinosus females. The last of these groups is the least variable. Bufo spinosus females have dense calcium deposits in the parotoids and the dorsal and ventral skin. Three-dimensional volume renderings and cross-sectional slices obtained by micro-CT scanning indicate that this approach is a promising technique for further studies on bufonid skin anatomy and geographic variation in skin calcification.

Ozone therapy in clinical practice of the diabetic necrotizing foot.

The present paper is the most extensive approach of the effect of ozone therapy on the diabetic foot. Out of all the 45 cases that have been studied in the timeline 2020-2022, some of them who were incredibly severe with little hope for improvement, had a tremendous impact on me and I will try to describe them in a few words and raise your awareness about this not yet explored field that has real potential in aiding those who suffer. A female patient of 49 years old had diabetes mellitus, multiple necrotic lesions, post peritoneal dialysis with skin calcifications of both legs, chronic kidney disease, renal osteodystrophy, calciphylaxis with secondary cutaneous necrosis in remission, renal lithiasis, secondary arterial hypertension, ischemic cardiac disease, paroxistic atrial fibrillation, polycystic kidney disease, hyperuricemia, calcium metabolism alterations, hyperphosphatemia, moderate proteic malnutrition. The first ozone therapy session was done according to ozone therapy protocol for the diabetic foot, after debridement, disinfection of the wounds and disposal of the necrotizing tissue. Drainage from the wound was examined and revealed an E. coli infection. After 30 sessions, the result was spectacular. A 51-year-old patient presented to the clinic with an open wound after amputation of his left leg. A year after, he came back to the clinic with an infected wet gangrene of his right leg, who also caught the first 3 toes. His medical history included type II diabetes mellitus, end stage renal disease with a double kidney transplant until the age of 28. In both cases debridement of the wound was done, exposing healthy tissue, antibiotics were administered according to antibiogram and the entire procedure of ozone therapy was done as follows: washing the wound with oxygenated water, disinfection of the wound, local infiltrations with ozone, major autohemotherapy and ozonized bag. The result: the left leg had a rapid favorable outcome, and after only 20 ozone sessions, the wound closed. The right leg had a total of 45 ozone therapy sessions done, with a 100% improvement. After 5 months, the patient came to the clinic with a postblockage necrotizing fistula on his right second finger, which healed after 6 ozone therapy sessions. Among those 45 patients included in the study, 10 of those who had major amputations presented to the clinic for a primary intervention and only 2 of them for a reintervention. Nevertheless, most of the minor amputations were done as a primary intervention. In many cases though, to obtain the healing of the patients, reinterventions were necessary. Analyzing these data, the necessity of applying a new method of correctly assessing the severity of the lesions to avoid an undervaluation of it, which would unnecessarily prolong the hospitalization and more importantly their suffering. I have encountered 4 cases of extensive wet gangrene associated with severe sepsis. The mortality in this category of patients was 50%. Studies and research in this field have a special and decisive con tribution in treating and recognizing the effects of ozone therapy in curing the diabetic foot. Through their results, studies will allow the free circulation of information in this field, because if we don’t communicate efficiently, we will not be able to present publicly the results we obtained from the studies and research regarding ozone therapy. Free circulation of information, of innovating ideas – can and has to surpass all frontiers, to allow all specialists in this field to contribute in solving the major problem that is the diabetic foot, this ailment of mankind. The most spectacular effects of ozone therapy in the case of diabetics can only be seen in well informed patients, who come to the doctor with impressive ulcerations of the calf. The clinical specter of the diabetic foot is very large, from the simple presence of neuropathy and/or arteriopathy of the legs, without any existing characteristic lesions, to the necessity of an amputation; ozone therapy can cure without an amputation.

INZ-701, a recombinant ENPP1 enzyme, prevents ectopic calcification in an Abcc6-/- mouse model of pseudoxanthoma elasticum.

Pseudoxanthoma elasticum (PXE), a heritable multisystem ectopic calcification disorder, is predominantly caused by inactivating mutations in ABCC6. The encoded protein, ABCC6, is a hepatic efflux transporter and a key regulator of extracellular inorganic pyrophosphate (PPi). Recent studies demonstrated that deficiency of plasma PPi, a potent endogenous calcification inhibitor, is the underlying cause of PXE. This study examined whether restoring plasma PPi levels by INZ-701, a recombinant human ENPP1 protein, the principal PPi-generating enzyme, prevents ectopic calcification in an Abcc6-/- mouse model of PXE. Abcc6-/- mice, at 6 weeks of age, the time of earliest stages of ectopic calcification, were injected subcutaneously with INZ-701 at 2 or 10mg/kg for 2 or 8 weeks. INZ-701 at both doses increased steady-state plasma ENPP1 activity and PPi levels. In the 8-week treatment study, histopathologic examination and quantification of the calcium content in INZ-701-treated Abcc6-/- mice revealed significantly reduced calcification in the muzzle skin containing vibrissae, a biomarker of the calcification process in these mice. The extent of calcification corresponds to the local expression of two calcification inhibitors, osteopontin and fetuin-A. These results suggest that INZ-701 might provide a therapeutic approach for PXE, a disease with high unmet needs and no approved treatment.

Inhibition of the DNA Damage Response Attenuates Ectopic Calcification in Pseudoxanthoma Elasticum

Pseudoxanthoma elasticum (PXE) is a heritable ectopic calcification disorder with multiorgan clinical manifestations. The gene at default, ABCC6, encodes an efflux transporter, ABCC6, which is a critical player regulating the homeostasis of inorganic pyrophosphate, a potent endogenous anticalcification factor. Previous studies suggested that systemic inorganic pyrophosphate deficiency is the major but not the exclusive cause of ectopic calcification in PXE. In this study, we show that the DNA damage response (DDR) and poly(ADP-ribose) (PAR) pathways are involved locally in PXE at sites of ectopic calcification. Genetic inhibition of PAR polymerase 1 gene PARP1, the predominant PAR-producing enzyme, showed a 54% reduction of calcification in the muzzle skin in Abcc6‒/‒Parp1‒/‒ mice, compared with that of age-matched Abcc6‒/‒Parp1+/+ littermates. Subsequently, oral administration of minocycline, an inhibitor of DDR/PAR signaling, resulted in an 86% reduction of calcification in the muzzle skin of Abcc6‒/‒ mice. Minocycline treatment also attenuated the DDR/PAR signaling and reduced the calcification of dermal fibroblasts derived from patients with PXE. The anticalcification effect of DDR/PAR inhibition was not accompanied by alterations in plasma inorganic pyrophosphate concentrations. These results suggest that local DDR/PAR signaling in calcification-prone tissues contributes to PXE pathogenesis and that its inhibition might provide a promising treatment strategy for ectopic calcification in PXE, a currently intractable disease.

Minocycline Counteracts Ectopic Calcification in a Murine Model of Pseudoxanthoma Elasticum: A Proof-of-Concept Study.

Pseudoxanthoma elasticum (PXE) is an intractable Mendelian disease characterized by ectopic calcification in skin, eyes and blood vessels. Recently, increased activation of the DNA damage response (DDR) was shown to be involved in PXE pathogenesis, while the DDR/PARP1 inhibitor minocycline was found to attenuate aberrant mineralization in PXE cells and zebrafish. In this proof-of-concept study, we evaluated the anticalcifying properties of minocycline in Abcc6−/− mice, an established mammalian PXE model. Abcc6−/− mice received oral minocycline supplementation (40 mg/kg/day) from 12 to 36 weeks of age and were compared to untreated Abcc6−/− and Abcc6+/+ siblings. Ectopic calcification was evaluated using X-ray microtomography with three-dimensional reconstruction of calcium deposits in muzzle skin and Yasue’s calcium staining. Immunohistochemistry for the key DDR marker H2AX was also performed. Following minocycline treatment, ectopic calcification in Abcc6−/− mice was significantly reduced (−43.4%, p < 0.0001) compared to untreated Abcc6−/− littermates. H2AX immunostaining revealed activation of the DDR at sites of aberrant mineralization in untreated Abcc6−/− animals. In conclusion, we validated the anticalcifying effect of minocycline in Abcc6−/− mice for the first time. Considering its favorable safety profile in humans and low cost as a generic drug, minocycline may be a promising therapeutic compound for PXE patients.

Scrotal calcinosis in a patient treated with isotretinoin: a rare entity

Scrotal calcinosis is a rare disorder characterized by multiple papules or nodules of calcification in the scrotal skin. The pathogenesis of this disease is poorly understood. The condition presents as several brown to yellowish asymptomatic nodules on the scrotum. Excision followed by scrotal reconstruction is the treatment of choice. It leaves a good cosmetic result with low chances of recurrence. Newer treatments, such as ablative lasers, have been proposed with very good results. We describe the case of a 28-year-old patient with a history of severe acne treated with oral isotretinoin that presented for scrotal nodules. On laboratory examination, hypercalcemia was found with normal phosphorus, parathyroid hormone, and vitamin D hormone levels. Hypercalcemia was linked to his isotretinoin therapy. Serum calcium concentrations normalized after cessation of isotretinoin and hydration. Because the patient refused surgery, a biopsy of the lesion confirmed the diagnosis of scrotal calcinosis. Then the patient was referred to a cosmetic laser center to treat his condition.

Patients who experience systemic lupus erythematosus and leg ulcer: phenomenological approach.

To understand the experience of a woman with systemic lupus erythematosus and leg ulcers with cutaneous calcinosis. An experience report based on the social phenomenology of Alfred Schutz, conducted with a young woman undergoing treatment in an outpatient service. The disease manifested itself in adolescence and brought emotional instability associated with body image concern and social isolation. The discontinuation of the studies triggered financial limitations with implications for treatment. The presence of ulcers aggravated by skin calcification makes the process of getting sick tiring and painful. Interpersonal relationships are resources for coping with situations experienced. Patients with lupus may have social, affective, and family life, even in the face of the limitations imposed by the disease. However, the emergence of leg ulcer with calcinosis changes this situation.

A phytic acid analogue INS-3001 prevents ectopic calcification in an Abcc6-/- mouse model of pseudoxanthoma elasticum.

Pseudoxanthoma elasticum (PXE), a prototype of heritable ectopic calcification disorders, affects the skin, eyes and the cardiovascular system due to inactivating mutations in the ABCC6 gene. There is no effective treatment for the systemic manifestations of PXE. In this study, the efficacy of INS-3001, an analogue of phytic acid, was tested for inhibition of ectopic calcification in an Abcc6-/- mouse model of PXE. In prevention study, Abcc6-/- mice, at 6weeks of age, the time of onset of ectopic calcification, were treated with INS-3001 with 0.16, 0.8, 4, 20 or 100mg/kg/day administered by subcutaneous implantation of osmotic pumps, as well as 4mg/kg/day by subcutaneous injection thrice weekly or 14, 4 and 0.8mg/kg/day once weekly subcutaneous injection. Mice were necropsied at 12weeks of age. Histologic examination and quantitative calcium assay revealed that mice receiving 6weeks of continuous INS-3001 administration via osmotic pumps showed dose-dependent inhibition of muzzle skin calcification with complete response at 4mg/kg/day and a minimum effective dose at 0.8mg/kg/day. INS-3001 plasma concentrations were dose-dependent and largely consistent during treatment for each dose. thrice weekly and once weekly subcutaneous injections of INS-3001 also prevented calcification. In established disease study, 12-week-old Abcc6-/- mice with extensive calcification were continuously administered INS-3001 at 4mg/kg/day for a follow-up of 12weeks. INS-3001 treatment was found to stabilize existing calcification that had developed at start of treatment. These results suggest that INS-3001 may provide a promising preventive treatment strategy for PXE, a currently intractable ectopic calcification disorder.

Dystrophic calcifications in case of a patient with systemic lupus erythematosus – case report and literature review

Introduction: Cutis calcification is the deposition of calcium in the skin and subcutaneous tissues and is classified into four subsets. Dystrophic calcifications are the most common type of skin calcification, occurring mainly in damaged tissues or in course of autoimmune disease. However, the coexistance of systemic lupus erythematosus (SLE) and soft tissue calcification is described rarely. Aim: This article presents a case of dystrophic calcifications in the buttocks area in a 49-year-old woman with a 17-year history of SLE. Case study: We report a case of 49-year-old women with SLE who developed nodular lesions in the buttock area. The radiological and histopatological examinations of the nodules showed presence of calcifications. The calcium metabolism parameters were in a normal range. The diagnosis of dystrophic calcinosis in the course of SLE was established. Results and discussion: Dystrophic calcifications associated with autoimmune diseases are common, but occur rarely in SLE. It should be noted that patients with SLE can also develop calcifications of different types like metastatic or iatrogenic. Dystrophic calcifications in SLE usually present as small nodules on buttocks or limbs. The pathophysiology remains unclear, however, there are some theories that inflammation and vascular ischemia play a role in its process. Conclusions: Calcifications in case of patients with SLE rarely require treatment. Several pharmacologic and surgical therapies have been tested with variable results. Additional research to establish an accepted treatment algorithm should be conducted.

Relationship Between Mitochondrial Structure and Bioenergetics in Pseudoxanthoma elasticum Dermal Fibroblasts.

Pseudoxanthoma elasticum (PXE) is a genetic disease considered as a paradigm of ectopic mineralization disorders, being characterized by multisystem clinical manifestations due to progressive calcification of skin, eyes, and the cardiovascular system, resembling an age-related phenotype. Although fibroblasts do not express the pathogenic ABCC6 gene, nevertheless these cells are still under investigation because they regulate connective tissue homeostasis, generating the “arena” where cells and extracellular matrix components can promote pathologic calcification and where activation of pro-osteogenic factors can be associated to pathways involving mitochondrial metabolism. The aim of the present study was to integrate structural and bioenergenetic features to deeply investigate mitochondria from control and from PXE fibroblasts cultured in standard conditions and to explore the role of mitochondria in the development of the PXE fibroblasts’ pathologic phenotype. Proteomic, biochemical, and morphological data provide new evidence that in basal culture conditions (1) the protein profile of PXE mitochondria reveals a number of differentially expressed proteins, suggesting changes in redox balance, oxidative phosphorylation, and calcium homeostasis in addition to modified structure and organization, (2) measure of oxygen consumption indicates that the PXE mitochondria have a low ability to cope with a sudden increased need for ATP via oxidative phosphorylation, (3) mitochondrial membranes are highly polarized in PXE fibroblasts, and this condition contributes to increased reactive oxygen species levels, (4) ultrastructural alterations in PXE mitochondria are associated with functional changes, and (5) PXE fibroblasts exhibit a more abundant, branched, and interconnected mitochondrial network compared to control cells, indicating that fusion prevail over fission events. In summary, the present study demonstrates that mitochondria are modified in PXE fibroblasts. Since mitochondria are key players in the development of the aging process, fibroblasts cultured from aged individuals or aged in vitro are more prone to calcify, and in PXE, calcified tissues remind features of premature aging syndromes; it can be hypothesized that mitochondria represent a common link contributing to the development of ectopic calcification in aging and in diseases. Therefore, ameliorating mitochondrial functions and cell metabolism could open new strategies to positively regulate a number of signaling pathways associated to pathologic calcification.

Assessment of Inflammation and Calcification in Pseudoxanthoma Elasticum Arteries and Skin with 18F-FluroDeoxyGlucose and 18F-Sodium Fluoride Positron Emission Tomography/Computed Tomography Imaging: The GOCAPXE Trial.

Background: Pseudoxanthoma elasticum (PXE) is an inherited metabolic disease characterized by elastic fiber fragmentation and ectopic calcification. There is growing evidence that vascular calcification is associated with inflammatory status and is enhanced by inflammatory cytokines. Since PXE has never been considered as an inflammatory condition, no incidence of chronic inflammation leading to calcification in PXE has been reported and should be investigated. In atherosclerosis and aortic stenosis, positron emission tomography combined with computed tomographic (PET-CT) imaging has demonstrated a correlation between inflammation and calcification. The purpose of this study was to assess skin/artery inflammation and calcification in PXE patients. Methods: 18F-FluroDeoxyGlucose (18F-FDG) and 18F-Sodium Fluoride (18F-NaF) PET-CT, CT-imaging and Pulse wave velocity (PWV) were used to determine skin/vascular inflammation, tissue calcification, arterial calcium score (CS) and stiffness, respectively. In addition, inorganic pyrophosphate, high-sensitive C-reactive protein and cytokines plasma levels were monitored. Results: In 23 PXE patients, assessment of inflammation revealed significant 18F-FDG uptake in diseased skin areas contrary to normal regions, and exclusively in the proximal aorta contrary to the popliteal arteries. There was no correlation between 18F-FDG uptake and PWV in the aortic wall. Assessment of calcification demonstrated significant 18F-NaF uptake in diseased skin regions and in the proximal aorta and femoral arteries. 18F-NaF wall uptake correlated with CS in the femoral arteries, and aortic wall PWV. Multivariate analysis indicated that aortic wall 18F-NaF uptake is associated with diastolic blood pressure. There was no significant correlation between 18F-FDG and 18F-NaF uptake in any of the artery walls. Conclusion: In the present cross-sectional study, inflammation and calcification were not correlated. PXE would appear to more closely resemble a chronic disease model of ectopic calcification than an inflammatory condition. To assess early ectopic calcification in PXE patients, 18F-NaF-PET-CT may be more relevant than CT imaging. It potentially constitutes a biomarker for disease-modifying anti-calcifying drug assessment in PXE.

Vascular calcification in skin and subcutaneous tissue in patients with chronic and end-stage kidney disease

BackgroundVascular calcification (VC) is well described in large- and medium-sized vessels in patients with chronic kidney disease (CKD), especially in those with end-stage kidney disease (ESKD) on dialysis. Medial calcification is particularly prevalent in this population and contributes to arterial stiffness and increased cardiovascular mortality and morbidity. Apart from in the setting of calciphylaxis, few studies have assessed skin and subcutaneous calcification and associations with abnormalities of bone and mineral metabolism in patients with CKD.MethodsWe performed a single-centre observational study to evaluate incisional skin tissue samples from three anatomical sites in patients with different stages of CKD undergoing elective surgery. We compared these samples to skin samples of a control cohort without CKD. Staining for calcification was performed with von Kossa method. A subgroup of skin samples were assessed by RT-PCR for upregulation of pro-calcific gene transcripts for tissue non-specific alkaline phosphatase (TNAP) and Runt-related transcription factor 2 (RUNX2).ResultsForty-five patients were evaluated, 34 with CKD (including ESKD) and 11 control patients. VC was identified in 15 skin samples (13 CKD/ESKD and 2 controls). VC was present in the dermal and subcutaneous tissues of the neck, abdomen and arm samples. Two different histological types of VC were identified: speckled medial calcification and internal elastic lamina calcification. Presence of perieccrine calcification was identified in 14 samples, 10 with concurrent VC. There were no significant differences in serum parathyroid hormone, phosphate or calcium in patients with or without VC. Expression of TNAP or RUNX2 was not increased in samples from patients with ESKD or those with histological evidence of calcification.ConclusionThis study reports the novel finding of dermal and subcutaneous calcification in multiple anatomical locations in 38% of patients with advanced CKD/ESKD undergoing elective surgery but free from calciphylaxis.

Utility of tomosynthesis in decreasing skin calcification workup rate

Aim: Tomosynthesis permits some skin calcifications to be identified as such without diagnostic workup. We aim to quantify the reduction in skin calcification workups at our institution after the advent of tomosynthesis. Methods: This study was approved by the Institutional Review Board with waiver of informed consent. We searched the medical record from 3/1/2011 to 3/31/2017 for all cases of screening mammography with the terms “skin” or “dermal” included in the report. We excluded all cases that did not include a recommendation for skin/dermal calcification workup and/or tangential views. Of the included cases, note was made of whether the screening examination was done without or with tomosynthesis. We calculated the percentage of cases recalled for skin calcification workup that were done without and with tomosynthesis. We then compared the percentages using chi-squared to evaluate for significance. Results: 40 cases met the inclusion criteria. 24 cases (60%) were done without tomosynthesis, and 16 (40%) were done with tomosynthesis. There were 132,789 total screening mammograms done, 65,299 (49.2%) without tomosynthesis and 67,490 (50.8%) with tomosynthesis. The percentage of all cases recalled for skin calcification workup done without tomosynthesis was 0.037%, and done with tomosynthesis was 0.024% (chi-square statistic 8587744.4875, p < .00001). Conclusions: We found that since the addition of tomosynthesis to our screening protocol, the recall rate for skin calcification workup has decreased by 35%. However, tomosynthesis did not entirely eliminate the need for skin calcification workup.

Parycalcitol + J131 - A New Route to Treatment Secondary Hyperparathyroidism in Patients with Chronic Kidney Disease on Long-term Dialysis?

Two cases with the dramatic course of secondary hyperparathyroidism in patients with chronic kidney disease on long-term dialysis. Has anything possible been done in management of these patients? Complications associated with impaired bone mineralization among patients with chronic kidney disease on long-term dialysis are observed frequently with an array of pathologic processes being found. Kidney osteodystrophy may be associated with either increased or decreased (adynamic bone disease, osteomalacia, aluminum-induced osteopenia) bone metabolism, as well as mixed forms related to the B2 microglobulin amyloidosis. Differential diagnosis of various types of osteopathy is difficult and is usually based on the histologic assessment of the bone biopsy. The most typical bone complication in patients with impaired kidney function is osetodistophy with increased bone metabolism, caused by secondary hyperparathyroidism clinically manifesting as osteitis fibrosa. High serum levels of PTH induce osteoclast and osteoblast activity. Early changes, with characteristic increase in the woven osteoid suggesting early, increased osteoplastic bone resorption may be found in a significant percentage of patients with GFR&gt;60ml/min/1,73m2 of the body surface. Lower values of the GFR are associated with both faster bone synthesis and more active resorption with progressive increase in the intraosseous fibrosis and decreased bone mineralization. As the abnormalities progress, which is especially marked in patients on long-term dialysis, a rage of clinical symptoms, such as: severe bone and joint pain, bone deformation, pathological fractures, especially in the spinal region, calcifications of the soft tissues and vessels, including heart valves and lungs. In children, the most common abnormality is growth impairment. In some patient’s skin calcifications, with subsequent necrosis, due to increased calcium deposition in small and medium arteries. The diagnosis is based on the typical clinical picture, biochemical parameters (calcium and phosphate ratio, parathormone levels, characteristic radiologic charges and sometimes, bone histology. Prevention and treatment of these complications includes effective dialysis, appropriate low-phosphate diet with limitation of the protein supply to the 0.8g/kg of the body mass, adequate calcium and active Vitamin D3 supply, introduction of the phosphate binding medications (sevelamer or lantan) as well as calcimimetic use (substances activating parathyroid gland calcium receptors inhibiting both its up-regulation and PTH secretion). In the severe cases, with insufficient effect of the treatment described above, parathyroidectomy is required after close ultrasound and scintigraphy-based assessment of these glands. However, even such treatment may be insufficient in some cases, as presented below.

Localization, Morphologic Features, and Chemical Composition of Calciphylaxis-Related Skin Deposits in Patients With Calcific Uremic Arteriolopathy

Calcific uremic arteriolopathy (CUA), a rare, potentially fatal, disease with calcium deposits in skin, mostly affects patients with end-stage renal disease who are receiving dialysis. Chemical composition and structure of CUA calcifications have been poorly described. To describe the localization and morphologic features and determine the precise chemical composition of CUA-related calcium deposits in skin, and identify any mortality-associated factors. A retrospective, multicenter cohort study was conducted at 7 French hospitals including consecutive adults diagnosed with CUA between January 1, 2006, and January 1, 2017, confirmed according to Hayashi clinical and histologic criteria. Patients with normal renal function were excluded. For comparison, 5 skin samples from patients with arteriolosclerosis and 5 others from the negative margins of skin-carcinoma resection specimens were also analyzed. Localization and morphologic features of the CUA-related cutaneous calcium deposits were assessed with optical microscopy and field-emission-scanning electron microscopy, and the chemical compositions of those deposits were evaluated with μ Fourier transform infrared spectroscopy, Raman spectroscopy, and energy dispersive radiographs. Thirty-six patients (median [range] age, 64 [33-89] years; 26 [72%] female) were included, and 29 cutaneous biopsies were analyzed. Calcific uremic arteriolopathy and arteriolosclerosis skin calcifications were composed of pure calcium-phosphate apatite. Calcific uremic arteriolopathy vascular calcifications were always circumferential, found in small to medium-sized vessels, with interstitial deposits in 22 (76%) of the samples. A thrombosis, most often in noncalcified capillary lumens in the superficial dermis, was seen in 5 samples from patients with CUA. Except for calcium deposits, the vessel structure of patients with CUA appeared normal, unlike thickened arteriolosclerotic vessel walls. Twelve (33%) patients died of CUA. Calcific uremic arteriolopathy-related skin calcifications were exclusively composed of pure calcium-phosphate apatite, localized circumferentially in small to medium-sized vessels and often associated with interstitial deposits, suggesting its pathogenesis differs from that of arteriolosclerosis. Although the chemical compositions of CUA and arteriolosclerosis calcifications were similar, the vessels' appearances and deposit localizations differed, suggesting different pathogenetic mechanisms.

Dietary Pyrophosphate Modulates Calcification in a Mouse Model of Pseudoxanthoma Elasticum: Implication for Treatment of Patients

Pseudoxanthoma elasticum is a heritable disease caused by ABCC6 deficiency. Patients develop ectopic calcification in skin, eyes, and vascular tissues. ABCC6, primarily found in liver and kidneys, mediates the cellular efflux of ATP, which is rapidly converted into inorganic pyrophosphate (PPi), a potent inhibitor of calcification. Pseudoxanthoma elasticum patients and Abcc6-/- mice display reduced PPi levels in plasma and peripheral tissues. Pseudoxanthoma elasticum is currently incurable, although some palliative treatments exist. In recent years, we have successfully developed therapeutic methodologies to compensate the PPi deficit in animal models and humans. Here, we inadvertently discovered that modulating dietary PPi can also be an effective approach to reducing calcification in Abcc6-/- mice. Our findings were prompted by a change in institutional rodent diet. The new chow was enriched in PPi, which increased plasma PPi, and significantly reduced mineralization in Abcc6-/- mice. We also found that dietary PPi is readily absorbed in humans. Our results suggest that the consumption of food naturally or artificially enriched in PPi represents a possible intervention to mitigate calcification progression in pseudoxanthoma elasticum, that dietary preferences of patients may explain pseudoxanthoma elasticum heterogeneous manifestations, and that animal chow has the potential to influence data reproducibility.