Utilization of Hyperbaric Oxygen Therapy in the Successful Treatment of Calcific Uremic Arteriolopathy (Calciphylaxis)

Introduction: Calcific Uremic Arteriolopathy (Calciphylaxis) usually occurs in patients with end stage renal disease and carries a high morbidity and mortality rate.  The disease is characterized by the calcification of capillaries and arterioles in the dermis and/or subcutaneous adipose tissue.  There is the development of reduced arterial blood flow leading to skin necrosis with extremely painful ischemic lesions (ulceration carries a mortality of > 80%).  Usual etiology of mortality involves the development of infection. The standard of care has been: Trial of Sodium Thiosulfate Medication adjustments (discontinuing - Vitamin D, Calcium Supplements and Warfarin) Medical management of hyperphosphatemia and hyperparathyroidism As needed surgical debridement of infected lesions and treatment of infection Methods: PRIMARY TREATMENT:Hyperbaric oxygen therapy implemented for 30 sessions:2.4 ATA x 90 minutes with 100% oxygen with two (5 min) air breaksSECONDARY TREATMENTS non contact real-time fluorescence wound imaging for bacteria presence and location non contact near infrared spectroscopy continuous diffusion of oxygen therapy - targeted on larger lesions Intravenous Sodium Thiosulfate given during hemodialysis Initial enzymatic debridement using Collagenase Sharp surgical debridement  As needed systemic and/or topical antibiotic therapy Pain medications Results:The multiple skin ulcerations that were caused by Calcific Uremic Arteriolopathy (Calciphylaxis) resolved.  Additional findings included: Non contact real time fluorescence wound imaging no longer showed any bacterial presence Non contact near infrared spectroscopy showed decreased inflammation/hyperemia with adequate oxygenation and microcirculation in the prior skin ulcerations Complete resolution of pain Discussion: The ICD-10 codes used to bill Medicare (Noridian) for the treatment of hyperbaric oxygen therapy were: I70.242 - Atherosclerosis of native arteries of left leg with ulceration of calf I70.235 - Atherosclerosis of native arteries of right leg with ulceration of other part of foot I70.232 - Atherosclerosis of native arteries of right leg with ulceration of calf E83.59  - Other disorders of calcium metabolism HOWEVER, MEDICARE ULTIMATELY DENIED PAYMENT FOR THE PATIENT'S TREATMENT.  The patient (and family) were able to pay out of pocket for the above treatment.There needs to be more clinical trials to validate the benefit of hyperbaric oxygen therapy in the treatment of Calcific Uremic Arteriopathy.References:An J, Devaney B, Ooi KY, Ford S, Frawley G, Menahem S. Hyperbaric oxygen in the treatment of calciphylaxis: A case series and literature review. Nephrology (Carlton). 2015 Jul;20(7):444-50. doi: 10.1111/nep.12433. PMID: 25707425. Martin R. Mysterious calciphylaxis: wounds with eschar--to debride or not to debride? Ostomy Wound Manage. 2004 Apr;50(4):64-6, 68-70; discussion 71. PMID: 15259802. PubMed Hyperbaric oxygen in the treatment of calciphylaxis: A case series and literature review. An J, Devaney B, Ooi KY, Ford S, Frawley G, Menahem S SO Nephrology (Carlton). 2015;20(7):444 UpToDate - Calciphylaxis (calcific uremic arteriolopathy), Sagar U Nigwekar, MD, MMScRavi I Thadhani, MD, MPH SECTION EDITOR:L Darryl Quarles, MD DEPUTY EDITOR:Eric N Taylor, MD, MSc, FASN: Apr 2024. topic last updated: Feb 16, 2024.