NDT Advance Access published online on March 7, 2008
Nephrology Dialysis Transplantation, doi:10.1093/ndt/gfn036
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Resolution of SLE-related soft-tissue calcification following haematopoietic stem cell transplantation
1 Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, MA 2 Division of Nephrology, University of Arizona, Tucson, AZ 3 Division of Immune Therapy, Northwestern University, Chicago, IL 4 Division of Renal Medicine, University of Colorado, Boulder, CO 5 Division of Nephrology and Hypertension, Northwestern University, Chicago, IL 6 Division of Oncology and Stem Cell Transplant, MaineGeneral Health Care and Alfond Cancer Center, Augusta, ME, USA
Correspondence and offprint requests to: Didier A. Mandelbrot, The Transplant Center, Beth Israel Deaconess Medical Center, 110 Francis Street, Boston, MA 02215, USA. Tel: +1-617-632-9805; Fax: +1-617-632-9804; E-mail: dmandelb{at}bidmc.harvard.edu
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Abstract |
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Background. Calciphylaxis and calcinosis can both cause severe morbidity and mortality in patients with systemic lupus erythematosus (SLE). Haematopoietic stem cell transplantation (HSCT) has been successfully used to treat patients with refractory SLE. It was hypothesized that in calciphylaxis and calcinosis, ongoing inflammatory activity contributes to the calcium deposition in the media of small arteries, as well as perivascular and periarticular tissues. We report three patients whose soft-tissue calcification syndromes dramatically resolved after undergoing HSCT.
Methods. Three patients referred for refractory SLE underwent HSCT at a tertiary care medical center. SLE serologies and clinical features before and after HSCT were recorded.
Results. Despite receiving >6 months of intravenous cyclophosphamide (CYC), three SLE patients showed signs of persistent lupus activity, including severe soft-tissue calcification. The first patient was on haemodialysis and developed severe calciphylaxis with large ulcers and tissue necrosis. The second patient had calcinosis, with palpable crystals extruding from ulcers. The third patient had calcinosis characterized by subcutaneous nodules and plaques. Because prior conventional therapies had failed, the three were treated with high-dose CYC, anti-thymocyte globulin and HSCT. They have been followed post-HSCT for 26–38 months, with excellent clinical responses, including sustained resolution of skin abnormalities.
Conclusions. The successful treatment of advanced calcium deposition by aggressive immune ablation underscores the contribution of SLE-mediated inflammation to soft-tissue calcification syndromes.
Keywords: calcinosis; calciphylaxis; haematopoietic stem cell transplantation; systemic lupus erythematosis
* Co-principal authors.
Received for publication: 18.11.07
Accepted in revised form: 18. 1.08