Sodium Thiosulfate Therapy for Calcific Uremic Arteriolopathy

Abstract

SummaryBackground and objective Calcific uremic arteriolopathy (CUA) is an often fatal condition with no effective treatment. Multiple case reports and case series have described intravenous sodium thiosulfate (STS) administration in CUA, but no studies have systematically evaluated this treatment.Design, setting, participants, & measurements This study included 172 patients undergoing maintenance hemodialysis who had CUA and were treated with STS between August 2006 and June 2009 at Fresenius Medical Care North America. Of these, 85% completed STS therapy. Clinical, laboratory, and mortality data were abstracted from clinical information systems. Responses to survey questionnaires sent to treating physicians regarding patient-level outcomes were available for 53 patients. Effect on CUA lesions and mortality were summarized as CUA outcomes. Relevant laboratory measures, weight (using pairwise comparisons of values before, during, and after STS), and adverse events were summarized as safety parameters.Results Mean age of the cohort was 55 years, and 74% of patients were women. Median STS dose was 25 g, and median number of doses was 38. Among surveyed patients, CUA completely resolved in 26.4%, markedly improved in 18.9%, improved in 28.3%, and did not improve in 5.7%; in the remaining patients (20.8%), the response was unknown. One-year mortality in patients treated with STS was 35%. Adverse events, laboratory abnormalities, and weight-related changes were mild. Significant reductions in serum phosphorous (P=0.02) and parathyroid hormone (P=0.01) were noted during STS treatment in patients who completed the therapy.Conclusions Although conclusive evidence regarding its efficacy is lacking, a majority of patients who received STS demonstrated clinical improvement in this study.

Quantifying a Rare Disease in Administrative Data: The Example of Calciphylaxis

“…Our study cannot explain if the trend in mortality reduction is a result of treatments such as sodium thiosulfate, or whether it is due to increased awareness and early recognition of the disease. 36,37 A prospective study is needed to better understand calciphylaxis mortality rates and to assess the effectiveness of interventions to treat calciphylaxis. Similarly, unmasking detection signal bias and the possibility that increased awareness produced an apparent incidence increase cannot be entirely ruled out by any study of this nature.…”

Wound Healing in Patients With Impaired Kidney Function

“…The largest such study reported encouraging results for the use of this therapy: it found a significant improvement in as many as 80% patients after 18 months of therapy. 25 One disadvantage however is that the cost of intravenous sodium thiosulfate is substantially higher than that of its oral form (CAD 12,000 per month of therapy versus CAD 45). However, a case series including 4 patients treated with oral sodium thiosulfate showed positive responses, and therefore this therapeutic mode may be considered as a promising alternative to intravenous sodium thiosulfate infusion.…”

Sodium Thiosulfate

“…This is possible because STS is approved and available for the treatment of cyanide toxicity. In this issue of CJASN, Nigwekar et al present a large series of 147 patients who completed treatment with STS for CUA, by far the largest to date, which helps to fill this information gap (16). Although detailed information was available in only 43 patients, this study is still several times larger than any previous study.…”