Beneficial Effects of Amnion-Chorion Stem Cell Grafting in the Long Term Management of Nonuremic Calciphylaxis Wounds

Abstract

Calciphylaxis is a poorly understood disease with high morbidity and mortality. The current primary literature on treatment is lacking; however, disease management often involves a multifaceted approach with a primary focus on consistent wound care. This report describes a case outlining the long-term management of nonuremic calciphylaxis wounds in a patient with severe malnutrition with the use of human amniotic membrane grafts, aggressive surgical debridement, nutritional therapy, and advanced wound healing techniques. A 38-year-old African American female with a history of non-uremic calciphylaxis presented from a transitional facility with numerous non-healing wounds in the setting of severe malnutrition secondary to bariatric surgery. Biweekly wound debridement was initiated utilizing an amniotic stem cell skin graft, dry applicable absorbent dressing, high-frequency ultrasonic ablation, and wound vacuum-assisted closure (VAC) over the course of approximately nine months. Nutritional supplementation was given in the form of jejunostomy tube feed due to a gastric bypass and a perforated viscus. At the current date, the patient demonstrates significant improvement in pain and wound healing. The patient is also able to ambulate with care and has begun steps towards independent management of wounds. Future goals of care include independent bedside wound management, placement of allograft, and discharge to a long-term care facility. Most patients with refractory pain, widespread necrotic wounds, and dangerous comorbidities will inevitably be referred to palliative care. This case creates a framework for the long term management of medically complex patients with nonuremic calciphylaxis using human amniotic membrane stem cell grafts and appropriate advanced wound care techniques.

Keywords: advanced wound care; amnionic stem cell graft; non uremic calciphylaxis; wound debridement.

Figure 1. The initial presentation and improvement of wounds during the course of treatment

A) Ulcerated lesions demonstrated as black eschar were the initial presentation of wounds located on the buttocks, flanks, hips, thighs, and panniculus. B) Cleared necrotic wounds following the utilization of the Misonix ultrasonic debridement device. C) Gradual improvement of the initial calciphylaxis wounds in addition to developed epigastric ulcer due to complications from bowel resection procedure. D) Wound vacuum-assisted closure (VAC) and packing to accelerate healing. The blue arrows indicate a cranial to caudal orientation. The scale bar indicates an approximate 10cm scale.

Figure 2. Treatment improved morphology

Depicted A-C are anterior abdominal and pannicular wounds. White circles are referring to a minor wound at the abdominal right-lower-quadrant and the white lines are indicative of the right-pannicular wound.

Figure 3. Calciphylaxis wounds healed by secondary intention

The clear proliferation of granulation tissue in the right posterolateral (A) and left posterolateral (B) thighs. The right anteromedial thigh is represented within two months of treatment (progressive maturation from CI to CII). Images were obtained prior to covering the affected tissue with DuoDERM; however, when reached the level of CII, wounds were not covered at all as they were deemed healed.