Kalcynoza skóry jako jeden z najczęstszych zmian skórnych u pacjentów z przewlekłą chorobą nerek
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Kalcynoza skóry jako jeden z najczęstszych zmian skórnych u pacjentów z przewlekłą chorobą nerek

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Przewlekła choroba nerek PChN występuje u ok. 8-16 proc. dorosłych. Chorobie coraz częściej towarzyszą zmiany w obrębie skóry i jej przydatków. Bardzo często jest tak, że są one pierwszym symptomem choroby. Jak pomóc pacjentowi z kalcynozą skóry?

Chorobom nerek najczęściej towarzyszą takie zmiany w obrębie skóry, jak m.in. suchość skóry, świąd mocznicowy, zmiany zabarwienia skóry czy zmiany paznokciowe. U niektórych choroba może się objawiać zmianami w obrębie błon śluzowych jamy ustnej, nabytymi dermatozami perforującymi lub kalcynozą skóry. Część pacjentów z przewlekłą chorobą nerek cierpi na pseudoporfirię skórną późną, skazę krwotoczną, a nawet rozlane łysienie. Niekiedy, chorobie towarzyszy również wyprysk okolicy przetoki tętniczo-żylnej oraz zakażenie skóry.

Co to jest kalcynoza skóry?

Schorzenie to występuje stosunkowo często u pacjentów ze schyłkową niewydolnością nerek, którzy poddawani są dializom. Kalcynoza, in. wapnica skóry wywołana jest zaburzeniami metabolizmu wapnia i fosforanów, czyli gromadzeniem się jonów fosforanowych w surowicy i kompensacyjnym uwalnianiem jonów wapnia z kości. W przypadku pacjentów z PChN zwapnienia mogą się tworzyć nawet w przy niewielkich zaburzeniach gospodarki wapniowo-fosforanowej.

Inne czynniki ryzyka

Wśród pozostałych czynników ryzyka wyróżnia się nadczynność przytarczyc, cukrzycę, choroby wątroby oraz otyłość. Bardziej narażone na wystąpienie kalcynozy skóry są kobiety, osoby stosujące glikokortykosteroidy i doustne antykoagulanty oraz osoby o zwiększonej podaży produktów wapniowo –fosforanowych czy w stanie nadkrzepliwości.

Gdzie najczęściej występuje kalcynoza?

Na początku choroba najczęściej pojawia się w naczyniach krwionośnych i oczach, jednak należy pamiętać, że może wystąpić w obrębie wszystkich tkanek. Później złogi dotykają skóry i tkanki podskórnej, a także narządów wewnętrznych (płuc, nerek i żołądka).

Występujące w skórze i tkance podskórnej zwapnienia przyjmują postać grudek, blaszek a czasem guzków. Zazwyczaj są koloru porcelanowego. Co ważne, mogą ulegać rozpadowi. Wówczas najczęściej wydobywa się z nich masa w kolorze białym. Mogą pojawić się również owrzodzenia. Występujące w zwapnieniu złogi mogą wywołać odczyn zapalny, który objawia się wówczas rumieniem.

Przyczyny wystąpienia zwapnień

Wśród przyczyn wystąpienia zwapnień są także czynniki miejscowe, czyli urazy i niskie pH. Właśnie to powoduje, że zmiany wywołane kalcynozą często dotykają okolic stawów, w szczególności łokci i kolan oraz opuszków palców.

Co to jest kalcyfilaksja?

Zwapnienia, które tworzą się dość szybko nazwano kalcyfilaksją (in. wapniejącą arteriolopatią mocznicową. Schodzenie to dotyka ok. 1-4 proc. pacjentów poddawanych dializom. Obarczone jest dużą śmiertelnością.

Kalcyfilaksja polega na odkładaniu złogów wapnia w naczyniach krwionośnych skóry i tkanki podskórnej. To prowadzi do niedokrwienia, martwicy i powstania owrzodzeń. Na początku wapniejąca arteriolopatia mocznicowa objawia się twardymi, purpurowymi blaszkami i guzkami o siatkowatym układzie.

Zmiany najczęściej występują na dystalnych częściach kończyn, czyli stopach, rękach, przedramionach lub podudziach). Mogą się także pojawić się na tułowiu. Wówczas ich szanse na ich pozytywne rokowanie maleją. Kalcyfilaksja może wywołać również objawy układowe, które związane są zajęciem naczyń. Wśród  nich wymienia się udar, zawał mięśnia sercowego, martwicę jelit, hipotensję i miopatię.

Rodzaje kalcynozy

Wyróżnia się kilka rodzajów kalcynozy. Wśród nich kalcynoza przerzutowa w przebiegu nowotworów, nadczynności przytarczyc, chorób kości (m.in. szpiczak, przerzuty do kości, osteomyelitis), sarkoidozy czy choroby zapalne naczyń.

Jak twierdzą eksperci, terapię kalcynozy należy rozpocząć od leczenia choroby podstawowej i wyrównania zaburzeń gospodarki wapniowo-fosforanowej. Skuteczne w leczeniu tego schorzenia okazało się stosowanie bisfosfonianów, kalcymimetyków, analogów witaminy D oraz tkankowego aktywatora plazminogenu. Pojedyncze zmiany towarzyszące kalcynozie przerzutowej mogą być usuwane chirurgicznie. Aby uniknąć infekcji w przypadku powstałych owrzodzeń, szczególnie ważne jest ich odpowiednie zaopatrzenie. W tym celu należy zastosować opatrunki bioaktywne, antybiotykoterapię oraz leczenie w komorze hiperbarycznej.

Źródło: Batycka-Baran A., Szepietowski J., Zmiany skórne w chorobach ogólnoustrojowych. T.1, Skórne manifestacje chorób nerek, s.31-36

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