A Closer Look at Calciphylaxis: Insights from SAWC

My name is Basil Khalaf. I am a MD based out of Houston, Texas. I started my own company called the Medi-Kal Group. And my practice is mainly focused on wound care and wound solutions for patients with diverse wounds, whether it's lower extremity, upper extremity, truncal areas. So my background is an MD. I did training in general surgery, emergency medicine, and I did a fellowship in hyperbaric and wound medicine. And so I combined my general surgery years and my emergency medicine years into this fellowship and decided to create a kind of a program where we have a specialized system for every patient that we see from every point of contact, whether it's from the ER, whether it's inpatient, whether it's in the outpatient clinics. And also we have, especially in these days, telehealth solutions.

Can you share some of the parameters surrounding your case series on calciphylaxis?

So this actually, how we ended up with the matrix solution is for me to try and find a solution for our patients who are developing calciphylaxis. As you know, calciphylaxis is a complex disease that is normally attributed to end -stage renal disease, but by the sheer fact that there's end -stage renal disease, there's a lot of comorbidities that go along with them. So the patients in general are not in the tip-top health, and so there's a lot of comorbidities that need to be attributed to their disease.

And so what we were trying to figure out is how to treat this complex wound that develops in fairly advanced end -stage renal disease patients in such a way that we maximize the healing but also minimize the time to healing. And so we created a model in which we did a multidisciplinary approach, which included getting in contact with their primary care physicians, sometimes with endocrinology, with their nephrologists, and kind of set the stage to create a multimodality treatment that helps expedite the healing process.

And when we got to that point, we wanted at the end to find a product or something to get us over that last hump in terms of closing the wound quickly, healing it, because the longer we leave the wound untreated, the more it turns into a chronic condition, which by virtue of starting to the chronic condition and with our treatment, we're trying to make it into a more of an acute wound that can heal quickly and kind of have the body recognize that this is not a normal condition for it. And so time is of the essence, and that's how we ended up with the matrix as a way to help expedite the treatment process. 

What were your findings, specifically in the case of lower extremity calciphylaxis?

So this is a young, well, not young as relative. He's in his late sixties with a calciphylaxis wound secondary to his end stage renal disease that developed on the left lateral leg, a little bit proximal to the lateral malleolus, and he started complaining of pain, pain, pain, and so when somebody thankfully had done a punch biopsy and we had the benefit of knowing that it is a calciphylaxis wound, and so in doing that, we had to touch base with their nephrologist who helped us with starting sodium theosulfate and also getting his liquids and fluid intake and some compression of his lower extremity to help with the wound healing, and we did a serial debridement process with him until we got to fresh, good, healthy tissue, and then when that was all done, then we used the product to help heal it, and the beauty of it is we used one application, we left it on for two weeks, and we saw the progression of the healing so we did the upfront work for it and then we used our product at the end to kind of take us towards the healing process. 

What would you most like DPMs to know about this research?

This research is really important because it's showing us that a lot of wounds that happen on the lower extremity in this patient population who having diabetes and end stage renal disease really goes hand in hand in most of them. Sometimes they get classified in a Wagner criteria, but there are certain nuanced things that you need to take a look at such as the pain of the wound. The underlying problem with calciphylaxis is it's a microvascular problem. So it's basically creating a ischemic environment in the wound. So treating it by big debridements without dealing with the complexity that surrounds it such as giving medications like sodium thiosulfate and dealing with the volume status and doing compression is paramount in healing those wounds. And just for DPMs to keep on the lookout just by the history and by the pain that this could be a contributing factor in them because I think it's underrepresented, our numbers are under representative of what we're actually dealing with.