723 - Chronic Calciphylaxis Requiring Below the Knee Amputation

Case Diagnosis: Chronic calciphylaxis, status post right below knee amputation

Case Description: Patient is a 70-year-old female with a history of dialysis-controlled end-stage renal disease (ESRD) and peripheral vascular disease who presented to vascular surgery for follow-up for bilateral lower extremity wounds secondary to calciphylaxis. The patient’s right-sided plantar calciphylaxis ulcer worsened, and osteomyelitis was diagnosed with resultant bone destruction at the first metatarsal. Because of the potential for a non-healing draining distal wound, she elected to undergo right below knee amputation. Post-operative inpatient rehabilitation focused on regaining independence in ambulation and transfers, and she returned to her prior level of function. To prevent calcium reaccumulation in the post-rehabilitation setting, she was placed on a renal diet, instructed to restrict fluid intake to 1500mL daily, and scheduled for dialysis three days per week. Discharge plan included fitted knee immobilizer with vascular surgery follow-up. A physiatrist performed a thorough pre-prosthetic assessment to assess musculoskeletal and neurologic status and educate her regarding prosthetic options.

Discussions: Calciphylaxis is a rare, potentially fatal sequela of ESRD characterized by cutaneous and arteriolar calcification and ischemic skin necrosis with painful non-healing wounds. Close monitoring is critical as, when untreated, bone and soft tissue infection can precipitate sepsis and exacerbate local destruction requiring limb amputation. If not recognized early, a higher-level amputation may be needed, limiting her ability to become a functional ambulator with a prosthesis.

Conclusions: Calciphylaxis, or calcific uremic arteriolopathy, has high rates of morbidity and mortality due to superimposed infection and sepsis risk. ESRD, Caucasian race, and female sex are important risk factors for calciphylaxis. Primary prevention is paramount to prevent amputation and includes dialysis compliance counseling and dietary restrictions. The importance of early physiatry involvement is key when there are complications so the patient can be more accepting of amputation and understands the process for having a prosthesis prescribed.