AM REPORT PEARLS 6/10/16: Calciphylaxis and HRS!

Thanks to Meghan for presenting the case of a middle-aged man with cirrhosis and acute kidney injury with hyperkalemia. Thanks also to Chi for educating us on management of this patient, as well as on calciphylaxis!

Calciphylaxis review:

  • New name for calciphylaxis is calcific uremic arteriolopathy (CUA). Hooray for easy names to remember!
  • Systemic calcification of arteries
  • Most commonly in ESRD patients
  • Risk factors:
    • Hyperphosphatemia
    • Calcium-based phosphate binders
    • Vitamin D supplements
    • Glucocorticoids
    • Warfarin
  • Clinical manifestations:
  • Livedo reticularis
  • Painful violaceous subcutaneous nodules that progress to necrotic ulcers
    • Often superinfected
    • Lesions classically on adipose areas including abdomen, thighs, buttocks
  • Diagnosis:
    • Skin biopsy shows arterial occlusion and calcification without vasculitic changes
  • Treatment:
    • Aggressive wound care, avoidance of trauma including injections
    • Oxygen therapy! 2 options:
      • 10-15L face mask for 2 hours daily
      • Hyperbaric oxygen (2.5 atm x 90 mins per day)
    • Sodium thiosulfate (also the antidote for cyanide poisoning!)
      • Dosed three times weekly during HD sessions until resolution of lesions
    • Increase dialysis frequency until resolution of lesions
    • Correct abnormalities in calcium and phosphorous
      • Lower calcium x phosphate product below 55
    • Non-calcium based phos binder if phos > 5.5
      • Sevelamer or lanthanum carbonate
    • Discontinue contributing meds
      • Vitamin D, calcium supplements, iron, warfarin (if possible!)

Hepatorenal syndrome review:

  • A cause of AKI in patents with acute or chronic liver disease
  • Splanchnic vasodilation triggered by portal hypertension leads to poor renal perfusion
  • Features:
    • Progressive creatinine rise and oliguria
    • Bland urine sediment, minimal proteinuria (<500 mg/day)
    • Low sodium excretion (UNa < 10, low FeNa)
  • 2 forms:
    • Type 1: Creatinine doubles to >2.5 in less than 2 weeks
    • Type 2: Less severe/progressive AKI than type 1
  • Diagnosis (of exclusion!):
    • Rule out pre-renal disease (shock, nephrotoxins), obstruction, parenchymal renal disease, ATN, SBP
    • Lack of improvement after 1 g/kg albumin challenge x 2 days and withdrawal of diuretics
  • Treatment:
    • Treat underlying liver disease if possible
    • Norepinephrine if in ICU
    • Midodrine, octreotide, and albumin (terlipressin not available in U.S.)
      • Want to raise MAP by 10-15 mmHg
      • If no improvement in 2 weeks, these drugs are futile
    • TIPS can be considered as bridge to transplant
    • Dialysis if all else fails and not TIPS candidate (challenging in HRS)

Patiromer (Veltassa): New potassium binder to treat acute and chronic hyperkalemia! Better than kayexalate! Available at Moffitt!

  • Non-absorbable organic polymer
  • Powder suspension, used like kayexalate
  • Binds potassium in the colon in exchange for calcium
  • Most common side effects were constipation and hypomagnesemia
  • Can help patients tolerate ACEi/ARB when they otherwise wouldn’t due to hyperK!




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