Calciphylaxis

[LucidSplash]

Trying to figure out if I’m nuts here.

Where I trained for Gen Surg, we did not routinely biopsy to confirm a dx of calciphylaxis. We would recommend labs, calculate Ca x P products, PTH, look for parathyroid hyperplasia and recommend parathyroidectomy as appropriate if medical tx wasn’t working. Generally the approach was to recommend tx for calciphylaxis if the dx was pretty obvious and to only do biopsy in the case of unclear/unusual lesions or maximized medical tx not being effective.

Where I am now for fellowship, the nephrologists/medicine docs want a biopsy to confirm calciphylaxis everytime, usually before they’ve done any of the standard medical workup, and refuse to tx until there is a confirmed tissue dx. And we do it every single time, after doing the appropriate workup to rule out ischemic or vasculitic lesions.

There are several papers out there that I’ve brought up, which recommend against routine biopsy in clear cases of calciphylaxis given the risk in these patients for further tissue loss or infection from a surgical wound.

For those of you involved in this, what is the practice where you are? I’ve given up the fight as a fellow because I don’t get to make the final call, but it drives me crazy. But I’ll be done with fellowship in less than a year and then it WILL be my final call. At this point I plan to advocate against routine biopsy and follow the care pathway I learned in residency. But I’m curious if what I experienced then was just super conservative vs the standards or if where I am now is super aggressive.

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[Dr.LeoSpaceman]

Where I'm at, we didn't biopsy unless there was diagnostic uncertainty. Same reasoning: That a wound in an area of calciphylaxis is only asking for trouble.

 

[doc05]

Aren't you a vascular fellow? Send it to the General surgeons

 

[Raryn]

I usually leave this question up to the nephrologists since these patients are almost always ESRD, but as an endocrinologist that sounds insane to me. If it looks like calciphylaxis and they have the typical lab findings thereof with other diagnoses appropriately considered (as you said, vasculitis workup) and rejected, a biopsy is just asking for trouble.

 

[LucidSplash]

Aren't you a vascular fellow? Send it to the General surgeons

Just the nature of the place I’m at. We even stay on board with “SMA syndrome” to “make sure they do the right thing” per the chair. So we do all these biopsies too.

 

[mimelim]

I trained where we did 50+ fistulas a week and ~25% of my patients are ESRD now. I've never once done a calciphylaxis biopsy. I would also openly question someone who asked for it as it will increase the likelihood of needing further procedures and potentially earlier amputation.

 

[Jolie South]

Just the nature of the place I’m at. We even stay on board with “SMA syndrome” to “make sure they do the right thing” per the chair. So we do all these biopsies too.

Same here. We don’t get routine requests, but I have done a few. Usually, the nephrologists are also against it except uncertain cases, which is good.

I hate following people because we have to make sure other people do their job.

 

[LucidSplash]

Thanks guys! Glad to know I’m not crazy for thinking this is a ridiculous practice.

 

[Jolie South]

Thanks guys! Glad to know I’m not crazy for thinking this is a ridiculous practice.

Additionally, in residency, we never got consults for calciphylaxis and I feel like every other day we were consulted to get a punch biopsy on someone because there was no derm and medicine sucked.

 

[MediCane2006]

Weirdly Plastics got consulted for a lot of these where I trained and the rule was NEVER to biopsy. One of our more junior faculty got bamboozled into doing it once and that patient turned into a wound healing nightmare, so I kinda have a visceral reaction every time someone brings it up...

 

[filter07]

I've seen this once and a biopsy was done but only because we weren't sure what was going on. Is calciphylaxis a common diagnosis elsewhere?

 

[Raryn]

I've seen this once and a biopsy was done but only because we weren't sure what was going on. Is calciphylaxis a common diagnosis elsewhere?

Depends on how big your ESRD population is.

 

[TMP-SMX]

I have no problem performing a punch biopsy for confirmation (academic dermatology)

 

[ItsSurgicallyComplicated]

Are we taling about non-uremic or uremic calciphylaxis?

 

[dpmd]

I have no problem performing a punch biopsy for confirmation (academic dermatology)

Until the wound never heals and gets bigger and is a disaster. Except maybe you would have already signed off and general surgery or plastics gets to deal with the aftermath.

 

[dpmd]

Thanks guys! Glad to know I’m not crazy for thinking this is a ridiculous practice.

I'm beginning to wonder if your attendings get kickbacks for testing and procedures or something.

 

[LucidSplash]

I'm beginning to wonder if your attendings get kickbacks for testing and procedures or something.

I think it has to do with the quaternary nature of the center. “They were sent here for X and they aren’t going to be disappointed.” It is a super aggressive kind of place. Which in some cases there have to be the places for the cases that are 6 sigma from the mean.

But not everything has to be that dramatic, like calciphylaxis.

 

[Jolie South]

Until the wound never heals and gets bigger and is a disaster. Except maybe you would have already signed off and general surgery or plastics gets to deal with the aftermath.

In my situation, when we are seeing these patients, they have huge ugly wounds already. Doing a punch isn’t going to change much.

 

[deleted547339]

I think it has to do with the quaternary nature of the center. “They were sent here for X and they aren’t going to be disappointed.” It is a super aggressive kind of place. Which in some cases there have to be the places for the cases that are 6 sigma from the mean.

But not everything has to be that dramatic, like calciphylaxis.

Yea - where I did fellowship, we had surgeons who operated on people who had no business in the OR. I think there is a time and place for that and that time and place is primarily quaternary care centers. As crazy as it made me at times, I did value the fact that many of them didn’t care about their numbers.

 

[Chillbo Baggins]

In my situation, when we are seeing these patients, they have huge ugly wounds already. Doing a punch isn’t going to change much.

I've only seen it twice, but was under the impression they often need debridement anyway.

 

[LucidSplash]

I've only seen it twice, but was under the impression they often need debridement anyway.

Actually the rule is no debridement unless infected. These are not normal wounds.

 

[dpmd]

Actually the rule is no debridement unless infected. These are not normal wounds.

Yeah, I have been consulted a few times for these and they were all horrendous. Wouldn't touch with ten foot pole kind of thing.

 

[armybound]

Our practice has been to avoid intervention. IIRC studies show worse outcomes in patients who are biopsied or operated on, at least in the urologic literature. We will routinely get asked to debride but decline.

 

[310prolene]

PRS resident at a very big hospital. At my place, PRS manages surgical aspects and derm will often be involved in some of the medical management. We get a lot of these consults — probably one every week or every other week. Here, many of them end up needing debridement as their wounds are gnarly by the time they’ve been transferred to us. Most of the patients do not do well, not necessarily from the wound itself but from their other medical issues. These consults are a drag every time — very sad and unsatisfying outcomes.

 

[ANCAdoc]

I've unfortunately seen a number cases of CUA between training and practice, probably about 1-2 per year. Oftentimes they are ESRD patients generally not very compliant with dialysis or treatment of hyperparathyroidism (sensipar, etc). In those cases they typically progress to ulcerated lesions that are fairly classic and biopsy need not be done. Wound care, dialysis to achieve adequacy goals, and IV STS with HD (not proven beneficial by the way). Outcomes are poor, high mortality rate.

I have referred a couple patients who have had painful lesions that were not yet classic - a subcutaneous nodule or discolored firm plaque without ulceration, sign of eschar, etc would fit that criteria. Early possible CUA lesion, with possible other differentials. If proven CUA, perhaps early treatment would improve their outcome. If ruled out, well then great. IV STS is not benign. I've had inpatient derm, general surgery, and vascular surgery do the biopsy (depending on hospital, in private practice had a skilled vascular surgeon with a large hospital do it, on the academic side at our institution it tended to be GNS or derm). Again, not in classic cases, rather the atypical cases.

Remember, CUA can present in non-CKD patients and CKD patients not yet on HD, in patients who have normal PTH, phos. The etiology of the disease process is not known. UTD has a good review on this. I had one CKD patient develop it, despite frequent clinic visits! It just developed, with normal CKD-MBD axis. Had aggressive disease with ulcerations that became infected and did require debridement by our vascular surgeon, it actually affected parts of lower leg, thigh. With aggressive wound care, debridement with eventual vacs, IV STS, and a lot of time they actually improved and they survived.

 

[HighPriest]

Whenever I see this problem, I say "what the hell is that??" and I google it, and then I find out who knows how to deal with it. Definitely have never biopsied it.