UREMIC SMALL-ARTERY DISEASE WITH MEDIAL CALCIFICATION AND INTIMAL HYPERPLASIA (SO-CALLED CALCIPHYLAXIS) - A COMPLICATION OF CHRONIC-RENAL-FAILURE AND BENEFIT FROM PARATHYROIDECTOMY

Background: Uremic small-artery disease with medial calcification and intimal hyperplasia can lead to life-threatening skin necrosis or acra l gangrene. It is a distinct complication of chronic renal failure tha t must be differentiated from soft-tissue calcification. An increased calcium-phosphate product and secondary hyperparathyroidism are the ma in underlying conditions. The benefit of parathyroidectomy is controve rsial. Objective: This article is based on a literature search to dete rmine prognostic factors and, in particular, the benefit of parathyroi dectomy. Methods: The literature on uremic small-artery disease (so-ca lled calciphylaxis) was reviewed (full data set: 104 cases, including five of our own). The therapeutic benefit of parathyroidectomy and the relation between prognostic predictors (localization, dialysis, and r enal transplant) and outcome were analyzed. The relation between diabe tes and acral gangrene was also examined. Further epidemiologic data o n the reviewed group of patients were established. Results: Thirty-eig ht of 58 patients who underwent parathyroidectomy survived compared wi th 13 of 37 patients who did not undergo parathyroidectomy (p=0.007, n =95). Forty of 53 patients with distal localization of necrosis surviv ed compared with 11 of 42 patients with proximal pattern (p<0.00001; n =95). Dialysis and kidney transplantation followed by immunosuppressio n showed no relation to disease outcome. No association was found betw een diabetes and acral gangrene (p=0.50). Conclusion: Uremic small-art ery disease is a distinct complication of chronic renal failure. Its r ecognition and early diagnosis should allow more effective treatment, In our retrospective study parathyroidectomy was significantly related to survival. Only a randomized, controlled, prospective trial (parath yroidectomy vs conservative treatment of secondary hyperparathyroidism ) can establish the value of parathyroidectomy in uremic small-artery disease.