Table 1.

Characteristics of the included studies.

Author Name	Year	Type of Study	N	Location of Calciphylaxis Skin Lesions	Sodium Thiosulfate			Other Adjunctive Treatments	Dialysis Adjustment	Outcomes (Description)
					Dose	Route	Treatment Duration
Cicone et al. [26]	2004	Case study	1	Bilateral calves and thighs	25 g 3×/week	IV	8 months (attempts at d/c earlier were met with resistance by family and patient)	Calcitriol and calcium acetate stopped, sevelamer binder, prednisone	None	Dramatic pain reduction at 2 weeks and no pain by 8 weeks, reduction in plaque size, improvement in bone scans
Danijela Mataic and Bahar Bastani [36]	2009	Case study	1	Proximal left arm and right lateral and left inner thigh	IV dose 25 g 3×/week; IP 25 g/2 L in long dwell every other day	IV initially; IP after recurrence at 25 g/2 L in long dwell every other day	2 months IV before d/c due to intolerance; 3 months of IP	low-calcium (2.5 meq/L) dialysate, wound care, parenteral antibiotics	Low calcium dialysate	Wounds improved but then recurrence due to poor compliance; IP Na thiosulfate introduced at this point— lesions progressed, sepsis and death
Amin et al. [49]	2010	Case study	1	Bilateral first metatarsals	25 g 3×/week	IV	Months	d/c calcium carbonate binder and vitamin d analogs, used noncalcium-based binders, HBO, dietary modification	Added mid-day exchange	Wound progressed and after 2 months, had to switch to HD
Finch et al. [48]	2010	Case study	1	Not listed	5 g 3/week	IV	6 months	Opioids for pain control	None	Complete resolution of wounds
New et al. [17]	2011	Observational retrospective cohort	5	Lower extremities	25 g IV (3 pts); 12.5 g IV (2 pts)	IV (3 pts) IP (3 pts)	IV- 3 mo, 6 mo, 5 weeks; IP- 3 mo	HBO, cinacalcet, parathyroidectomy, pamidronate, d/c calcium and calcitriol, change phosphate binders	3/5 patients eventually changed to HD after worsening wounds (2 pts) or 2 episodes of peritonitis (1 pt)	Resolution of wounds ×4; 1 died from sepsis Two patients who had resolution of wounds died much later from other causes (one due d/c dialysis due to functional decline; one due ischemic CCF)
Sood et al. [49]	2011	Case series	4	Lower extremities, buttocks, abdomen	25 g IV 3×/week	IV	4–14 weeks	D/c warfarin if able, d/c calcium-based binders/vit d analogs, used sevelamer, cinacalcet, IV pamidronate, antibiotics, wound care, opioids, parathyroidectomy	2 pts with increased intensity (what was done to increase is not described)	2/4 with reduced wounds (1 with complete resolution); 3/4 eventually had to switch to HD; 2/4 pts died r/t sepsis by 1 year; ¼ with reduction in pain
Dethloff, Steven B. [45]	2012	Case Study	1	Distal extremities	Initially 25 g, then decreased to 12.5 g due to nausea before transitioning to IP 25 g	IV initially but transitioned to IP due to intolerance of IV	10 weeks	Increased protein intake, phosphorus restriction, binders changed to noncalcium, calcitriol discontinued, strict BP control, pain control with hydrocodone	None described	Completely healed by 12 weeks
Gupta et al. [43]	2012	Case study	1	Medial calf (left)	25 g/2 L dialysate	IP	3 exchanges in a 12 h time frame	Calcitriol discontinued, wound care	Switched to CRRT after severe decompensation (not as part of calciphylaxis treatment plan)	Patient developed chemical peritonitis, decompensated rapidly and died days later
Mallett et al. [44]	2012	Case study	1	Distal left leg	25 g every other day ×3 doses, then 12.5 g every other day (decreased due to nausea)	IP	6 weeks	Binder changed to sevelamer, hyperbaric oxygen therapy, and wound care; aspirin; SLE was treated with mycophenolate, increase in prednisone, and hydroxychloroquine	No change	Healed lesion, biopsy 6 months later with no calciphylaxis or SLE; had successful pregnancy with post-partum SLE flare but no recurrence of calciphylaxis
Anupkumar Shetty, Jeffrey Klein [50]	2016	Case report	2	Pt 1- L middle finger, L first toe, abdominal all Pt 2-R fingers	1500 mg BID	Oral	11 mo, 6 mo	Amputation, gabapentin, opioids	None	Healed; 1 patient died of SBO 14 months later (not calciphylaxis related)
Zhang et al. [11]	2016	Cohort study—retrospective observational	4	Lower extremities, penis	25 g 3×/week	IV	2.8–5.1 months (3 m median)	Wound care/ debridement, opioids for pain, nutrition consult, surgical debridement, HBO	None	75% mortality at 1 year due to sepsis (also the same patients who eventually had to transition to HD)
Machavarapu et al. [51]	2018	Case Study	1	Esophagus	Not specified	IV	2 months	PPI, supplemental protein shakes	No change initially, transitioned to iHD eventually due to infected PD catheter	Died 2 months after presentation due to suspected spontaneous coronary event
Torres et al. [36]	2018	Case study /abstract	1	Penis	Not stated	IP	2 weeks—stopped due to severe nausea	Low calcium dialysate	Low calcium dialysate	Significant reduction in pain and some wound healing
Bara Zhaili, Khalid Al-Talib [52]	2019	Case Study	1	Right calf	4–5 mL once every 2 weeks	Intralesional	9 weeks	Wound care, PO sevelamer, IV ceftazidime, collagenase ointment	None	Complete resolution of wounds; eventually transitioned to HD due to peritonitis, not due to calciphylaxis
Tangkham et al. [53]	2019	Case study	1	Bilateral thighs (R first, then left)	12.5 mg 3×/week	IV	3 months	IV ciprofloxacin, wound care, discontinuation of calcium-containing phosphate	No changes, continued CAPD 8 h per day	Refused surgical debridement and died 3 months after presentation due to sepsis
Deng et al. [54]	2020	Case study	1	R shoulder and R fingers	6 g per day	IV	55 days	Parathyroidectomy, cinacalcet, sevelamer, antibiotics	6 days per week CAPD, 1 day per week iHD added	Amputation of 1 finger, improvement in wounds after 2 months
Di et al. [55]	2020	Case study	1	Neck, shoulders, upper extremities	6.4 g/day	Not listed	21 days	None listed	None listed	Diminished skin lesions
Janom K et al. [46]	2021	Case Study	1	Lower extremity	12.5 g in 1 L of NS as a long day dwell	IP (initially IV but severe nausea necessitated change)	3 months	Subtotal parathyroidectomy	None	Lesions healed after 6 months; mild decrease in kt/v; PD effluent cell counts monitored with no change noted
Lu et al. [30]	2022	Case study	1	Fingers and toes	3.2–6.4 g per day	IV	6 months	Calcium stopped, wound care, low calcium dialysate, lanthanum for binder, PD adjustment per Kt/V protocol	Per kt/v protocol	Healed after 9 months

Abbreviations: CAPD—continuous ambulatory peritoneal dialysis; CRRT—continuous renal replacement therapy; HBO—hyperbaric oxygen therapy; HD—hemodialysis; iHD—intermittent hemodialysis; IP—intraperitoneal; IV—intravenous; kt/v—parameter used to measure dialysis adequacy; NS—normal saline; PD—peritoneal dialysis; PPI—proton pump inhibitor; SBO—small bowel obstruction; SLE—systemic lupus erythematosus.