Potential efficacy and mechanism of medicinal plants on chronic kidney disease-associated vascular calcification:a review

Vascular calcification is a crucial risk factor that affects the incidence and mortality of cardiovascular disease in chronic kidney disease patients.Modern medicine relies on calcium-phosphorus binding agents,calcium mimetics,active vitamin D,and hemodialysis to prevent and treat vascular calcification,however,their efficacy is unsatisfactory and adverse reactions often occur.Medical plant therapy can act as an integrative regulator in patients with chronic kidney disease-associated vascular calcification,which can significantly improve patients’symptoms,but its specific mechanism has not been fully elucidated yet.In this paper,we reviewed the domestic and international theoretical studies on the pathogenesis mechanism of chronic kidney disease-associated vascular calcification in recent years,summarized eight active ingredients of medicinal plants as well as four compound formulas for improving chronic kidney disease-associated vascular calcification,and explored the mechanism of action of herbal medicine,which will provide a new strategy for promoting the prevention and treatment of vascular calcification.

Significance of detection of serum HIF-1 α and β-catenin in rat model of vascular calcification in chronic kidney disease

Objective:To investigate the association between serum HIF-1α,β-catenin levels and the vascular calcification in the rat model of chronic kidney disease(CKD)vascular calcification.Methods:30 SD male rats were randomly divided into normal control group(CON group,n=10)and CKD vascular calcification group(CKD group,n=20).Rats in calcification group were fed with adenine combined with high phosphorus diet.At the end of the 6th week,the blood and urine of the two groups were collected to detect renal function,calcium,phosphorus and 24-hour urinary protein,the renal tissue was stained with HE,the aorta of rats was stained with Von Kossa and calcium content was determined,and the levels of HIF-1α and β-catenin in serum were detected by ElISA method.Results:compared with CON group,24-hour urinary protein,blood BUN,Scr,P,Ca×P,aortic calcium content,serum HIF-1α and β-catenin levels were significantly increased and serum calcium decreased in CKD group(P<0.05);Glomerular atrophy,renal tubule dilatation and interstitial fibrosis were seen in CKD group,Von Kossa staining of calcified nodules in aorta showed more black substance deposition.The levels of serum HIF-1α,β-catenin and serum P,Ca×P were positively correlated with the content of calcium in rat aorta.Conclusion:the levels of serum HIF-1α and β-catenin are significantly increased in patients with vascular calcification in CKD,and they are significantly related to the degree of aortic calcification.

Predictors of Vascular Calcification in Hemodialysis Patients

Background: The prevalence of both cardiovascular mortality and vascular calcification is much higher in patients with chronic kidney disease (CKD) than in the general population so early detection and intervention of VC may prevent or delay the progression and achieve improved patient outcomes. Objectives: To detect different predictors of vascular calcification in haemodialysis patients. Methods: This was a cross sectional observational study that included 85 patients with end stage renal disease (ESRD) on regular dialysis 47 males and 38 females ranged between 18 and 80 years old selected from Nephrology Unit, Internal Medicine Department, Menoufia University Hospital from April 2019 to May 2020. Serum calcium, phosphorus, alkhaline phosphatase, intact PTH, serum Matrix GLA protein, vitamin D and non-contrast CT for calcium scoring of femoral arteries were performed. Results: There was a significant correlation between age of the patient by years (p value 0.0001), serum calcium (p value 0.0001), phosphate (0.0001), calcium phosphate products (p value 0.0001) and alkhaline phosphatase (0.0001), and vascular calcification score detected by non-contrast CT on femoral arteries and negative correlation between serum Matrix GLA protein p value 0.0001) and the detected calcification score;the lower the MGP level the higher calcification score while there was no correlation between body mass index (BMI) (p value 0.021) intact PTH (p value 0.117), serum vitamin D level (p value 0.643), serum albumin (p value 0.643), serum haemoglobin (p value 0.257) and duration of dialysis (p value 0.260) and the detected score. Serum phosphate and calcium phosphorus product are independent risk factors for vascular calcification severity in haemodialysis patients. Conclusions: serum phosphate, calcium phosphate products are risk factors for vascular calcification while intact PTH vitamin D has no significant role in developing vascular calcification in hemodialysis patients. Matrix GLA protein was inversely correlated with vascular calcification score.

Correlation between Vascular Calcification and Serum Sclerostin in MHD Patients

Objective Investigate the correlation between serum sclerostinlevel and chronic kidney disease-mineral and bone disorder(CKD-MBD),especially vascular calcification,in maintenance hemodialysis(MHD)patients.Methods This is across-sectional study,a total of 72 MHD patients were included from the first affiliated hospital of Jinan university.Measure the biochemical indicators of mineral metabolism,renal function,and serum sclerostin level by ELISA.The abdominal aorta calcification score(AACS)was assessed according to Kauppila method on lateral spine imaging using DEXA.Patients were distributed into two groups according to the level of serum sclerostin:low sclerostingroup(≤125 pg/ml)and high sclerostingroup(>125 pg/ml).Analyze the association of serum sclerostin level with the indicators of CKD-MBD.Results There was significant difference in i PTH level between high sclerost in group and low sclerost in group.Multivariate Logistic regression analysis demonstrated that dialysis duration,male and anuria were independent risk factor of high sclerostin level,and i PTH and Kt/V were protective factors.Conclusion Dialysis duration,man,anuria was independent risk factors and i PTH,Kt/V were protective factors of high serum sclerostin level in MHD patients.There was no correlation between abdominal aorta calcification and serum sclerostin level.

The Pathogenesis of the Mechanism of FGF23 in Chronic Kidney Disease Patients with Vascular Calcification

Fibroblast growth factor 23(FGF23)is a protein synthesized by bone cell and the osteoblast with endocrine function.The main role of FGF23 is to regulate serum phosphorus and 1,25(OH)2 D3 levels,it also plays an important role in calcium and phosphorus metabolism.The role of FGF23 in renal disease is to inhibit of phosphorus reabsorption,promote urinary phosphorus excretion and maintain a stable blood phosphorus level.Patients with chronic kidney disease(CKD)have more risk to suffer cardiovascular disease(CVD)which is related to the abnormal metabolism of calcium and phosphorus.FGF23,as newly discovered cardiovascular risk marker,several studies have shown that FGF23 level associates with multiple cardiovascular risk factors in CKD patients,especially in CKD patients with vascular calcification.To explore its pathogenesis of vascular calcification in CKD patients is particularly important,and that may help to take appropriate measures to improve the prognosis of CKD patients.

Vascular Calcification： Current Genetics Underlying This Complex Phenomenon

Objective： Vascular calcification is the consequence of the complex interaction between genetic, environmental, and vascular factors, which ultimately lead to the deposition of calcium in the tunica intima （atherosclerotic calcification） or tunica media （M6nckenberg＇s sclerosis）. Vascular calcification is also closely related to other pathologies, such as diabetes mellitus, dyslipidemia, and chronic kidney disease. It has been concluded that the degree of vascular calcification may vary from person to person, even if the associated pathologies and environmental factors are the same. Therefore, this suggests an important genetic contribution to the development of vascular calcification. This review aimed to find the most recent evidence about vascular calcification pathophysiology regarding the genetic aspects and molecular pathways. Data Sources： We conducted an exhaustive search in Scopus, EBSCO, and PubMed with the keywords ＂genetics and vascular calcification＂, ＂molecular pathways, genetic and vascular calcification＂ and included the main articles from January 1995 up to August 2016. We focused on the most recent evidence about vascular calcification pathophysiology regarding the genetic aspects and molecular pathways. Study Selection： The most valuable published original and review articles related to our objective were selected. Results： Vascular calcification is a multifactorial disease; thus, its pathophysiology cannot be explained by a single specific factor, rather than by the result of the association of several genetic variants, molecular pathway interactions, and environmental factors that promote its development. Conclusion： Although several molecular aspects of this mechanism have been elucidated, there is still a need for a better understanding of the factors that predispose to this disease.

Nano-hydroxyapatite accelerates vascular calcification via lysosome impairment and autophagy dysfunction in smooth muscle cells

Vascular calcification(VC)is a common characteristic of aging,diabetes,chronic renal failure,and atherosclerosis.The basic component of VC is hydroxyapatite(HAp).Nano-sized HAp(nHAp)has been identified to play an essential role in the development of pathological calcification of vasculature.However,whether nHAp can induce calcification in vivo and the mechanism of nHAp in the progression of VC remains unclear.We discovered that nHAp existed both in vascular smooth muscle cells(VSMCs)and their extracellular matrix(ECM)in the calcified arteries from patients.Synthetic nHAp had similar morphological and chemical properties as natural nHAp recovered from calcified artery.nHAp stimulated osteogenic differentiation and accelerated mineralization of VSMCs in vitro.Synthetic nHAp could also directly induce VC in vivo.Mechanistically,nHAp was internalized into lysosome,which impaired lysosome vacuolar H+-ATPase for its acidification,therefore blocked autophagic flux in VSMCs.Lysosomal re-acidification by cyclic-3′,5′-adenosine monophosphate(cAMP)significantly enhanced autophagic degradation and attenuated nHAp-induced calcification.The accumulated autophagosomes and autolysosomes were converted into calcium-containing exosomes which were secreted into ECM and accelerated vascular calcium deposit.Inhibition of exosome release in VSMCs decreased calcium deposition.Altogether,our results demonstrated a repressive effect of nHAp on lysosomal acidification,which inhibited autophagic degradation and promoted a conversion of the accumulated autophagic vacuoles into exosomes that were loaded with undissolved nHAp,Ca^(2+),Pi and ALP.These exosomes bud off the plasma membrane,deposit within ECM,and form calcium nodules.Vascular calcification was thus accelerated by nHAP through blockage of autophagic flux in VSMCs.

Protection Effect of Exogenous Fibroblast Growth Factor 21 on the Kidney Injury in Vascular Calcification Rats

Background： Chronic kidney disease （CKD） is closely related to the cardiovascular events in vascular calcification （VC）. However, little has known about the characteristics of kidney injury caused by VC. Fibroblast growth factor 21 （FGF21 ） is an endocrine thctor, which takes part in various metabolic actions with the potential to alleviate metabolic disorder diseases, Even FGF21 has been regarded as a biomarker in CKD, the role of FGF21 in CKD remains unclear. Therefore, in this study, we evaluate the FGF21 on the kidney injury in VC rats. Methods： The male Sprague-Dawley rats were divided into three groups： （ 1 ） control group, （2） Vitamin D3 plus nicotine （VDN）-induced VC group, （3） FGF21-treated VDN group. After 4 weeks, the rats were killed and the blood was collected for serum creatinine, urea nitrogen, calcium, and phosphate measurement. Moreover, the renal tissues were homogenized for alkaline phosphatases （ALPs） activity and calcium content. The levels of FGF21 protein were measured by radioimmunoassay. The levels of β-Klotho and FGF receptor 1 （FGFR1） protein were measured by enzyme-linked immunosorbent assay （EL1SA）. The structural damage and calcifications in aortas were stained by Alizarin-red S. Moreover, the structure of kidney was observed by hematoxylin and eosin staining. Results： The renal lhnction impairment caused by VDN modeling was ameliorated by FGF21 treatment, inhibited the elevated serum creatinine and urea level by 20.5% （34.750 ± 4.334 pmol/L vs. 27.630± 2.387pamol/L） and 4.0% （7.038 ± 0.590 mmol/L vs. 6.763 ±0.374 mmol/L; P 〈 0.01 ）, respectively, together with the structural damages of glomerular atrophy and renal interstitial fibrosis. FGF21 treatment downregulated the ALP activity, calcium content in the kidney of VC rats by 42.1% （P 〈 0.01 ） and 11.7% （P 〈 0.05） as well as ameliorated the aortic injury and calcification as compared with VDN treatment alone group, indicating an ameliorative effect on VC. EL1SA assays showed that the expression of [3-Klotho, a component of FGF21 receptor system was increased in VDN-treated VC rats by 37.4% （6.588 ± 0.957 pg/mg vs. 9.054 ± 0.963 pg/mg; P 〈 0.01）, indicating an FGF2 l-resistant state. Moreover, FGF21 treatment downregulated the level of β-Klotho in renal tissue by 16.7% （9.054 ± 0.963 pg/mg vs. 7.544± 1.362 pg/mg, P 〈 0.05）. However, the level of FGFR1, the receptor of FGF21, kept unchanged under VDN and VDN plus FGF21 administration （0.191 ± 0.0376 rig/rag vs. 0.189 ± 0.032 ng/mg rs. 0.181± 0.034 mg/mg; P 〉 0.05）. Conclusions： In the present study, FGF21 was observed to ameliorate the kidney injury in VDN-induced VC rats. FGF21 might be a potential therapeutic factor in CKD by cutting offthe vicious circle between VC and kidney injury.

Beneficial effect of berberine on atherosclerosis based on attenuating vascular inflammation and calcification

OBJECTIVE To investigate the beneficial effect of berberine(BBR)on atherosclerosisin Apo^(-/-) E mice and explore the underlying mechanisms based on attenuating vascular inflammation and modulating calcification in human umbilical vein endothelial cells(HUVECs) and smooth muscle cells(SMCs).METHODS 48 Apo-/-E mice,at 6-8 weeks old,were randomly allocated into 4 groups:normal,model,bbr and atorvastatin(positive control) groups with 12 mice in each group.They were fed with high-fat diet for 4 weeks except those in Normal group and then treated with indicated drugs orsolvent for another 4 weeks.The morphology and inflammation infiltration of aortic were examined with HE staining.The expression of BMP-2 in aortic was examined by immumohistochemical staining.Blood lipid levels were examined by automatic biochemical analyzer.The expression of IL-6,TNF-α and BMP-2 in serum and tissues was detected by ELISA method.The expression of ALP and the content of calcium were detected by commercially-available kits.HUVEC cells were stimulated with TNF-α and incubated with various concentrations of BBR for 24 h.The contents of intercellular cell adhesion molecule-1(ICAM-1),vascular cell adhesion molecule(VCAM-1),matrix metalloprotein-9(MMP-9) in the culture supernatant were detected by ELISA method.Calcification was induced with β-glycerophosphatein SMC cells and the effect of BBR on the content of calcium was examined.RESULTS 4-week berberine treatment markedly lowered serum TC and LDL-c levels and improved the plaque stability in Apo-/-E mice fed with a high-fat diet(P<0.05 or P<0.01) which was comparable with the effect of atorvastatin.Berberineal so significantly decreased the levels of IL-6 and TNF-α in mice serum and aortic tissues(P<0.05 or P<0.001).Berberine tended to decrease ALP,BMP-2 levels and the content of calcium in mice serum and aortic tissues(P<0.05,P<0.01 or P<0.001) which were not observed in atorvastatin group.Berberine significantly lowered the levels of ICAM-1,VCAM-1,and MMP-9 in TNF-α-stimulated HUVECs.It can also lowered the content of calcium in SMCs.CONCLUSION BBR can profitably regulate the levels of blood lipid in mice fed with a high-fat diet,decrease the injury caused by inflammation,and attenuate vascular calcification.It may improve atherosclerosis and play a role in cardiovascular protection.

Does treatment with statins have the potential of enhancing vascular calcification？

Vascular calcification is commonly found in atherosclerosis and recognized as a marker of atherosclerotic plaque burden. Many evdiences have demonstrated that vascular calcification is an active process and can be seen in all stages of development and intimately associated with atherosclerosis. The correlation between coronary calcifications and subclinical atherosclertotic disease has been well-known for some years. Bone morphogenetic protein-2 （BMP-2） has significant importance in bone development and the development of a wide array of tissues outside of bone. Zhang et al3,4 found mice genetically engineered to be deficient in BMP-2 die between days 7 and 10 of gestation of cardiac defects before bone formation. Many evidences have also confirmed that BMP-2 is a strong basic causative factor in vascular calcification and has been most frequently associated with calcific arteriopathy. Statins are the most powerful cholesterol-lowering drugs available. Although a major beneficial effect of statins in clinical studies is related to a marked reduction in low density lipoprotein （LDL） cholesterol levels, there are good evidences that statins hold multiple vascular protective effects,5 however, the effects of statins therapy in vascular calcification are more complex and less defined. The currently available reports of clinical trials about statins therapy of vascular calcification appeared to be paradoxical.

Effects of Vitamin K-1 and Menaquinone-7 on Vascular Function and Blood Pressure in Warfarin-Induced Calcification-Model in Rats

Given that vascular calcification is inversely correlated with the clinical intake of menaquinone, a rat model of warfarin-induced calcification may be useful for testing menaquinone and vitamin K-1 potential effects on vascular function. The aim of the present study was to investigate effects of vitamin K-1 and menaquinone-7 treatments on blood pressure and vascular function in warfarin-induced vascular calcification model during five-week intervention in normotensive Wistar-Kyoto rats. Blood pressure was measured weekly, and at the end of the intervention in vitro vascular reactivity measurements were done. Alizarin Red S and von Kossa stainings were used to record possible calcification of aortic sections. Routine clinical chemistry was done from serum and urine samples. Vascular calcification was seen only in a few warfarin-treated animals in histological staining. Warfarin-treatment did not change significantly blood pressure of the rats. Warfarin-treatment increased slightly the endothelium-dependent relaxation of aorta after the L-type calcium channels were blocked. Also the vascular relaxation improved after NOS inhibition in the aorta of the healthy controls and menaquinone-7 treated animals, indicating that the relaxation in those groups was not totally dependent on NO. Clinical chemistry from serum showed some differences in urea, creatinine as well as lipid and glucose metabolism between the healthy controls and warfarin-treated rats.

Acute mesenteric ischemia due to percutaneous coronary intervention:A case report

BACKGROUND Percutaneous coronary intervention(PCI) is extensively used to treat acute coronary syndromes(ACS).Acute mesenteric ischemia is a life-threatening disease if untreated.CASE SUMMARY An 81-year-old female presented with 3 d of lethargy and 1 d of dyspnea.On November 16,2021,the patient developed a coma.Her oxygen saturation dropped to 70%-80%,the patient was admitted to the intensive care unit for further treatment.Chest computed tomography(CT) showed chronic bronchitis,emphysema,and multiple lung infections.Abdominal CT scan showed no obvious abnormalities,but have severely calcified abdominal vessels.The patient received assisted ventilation,and vasoactive,and anti-infection drugs.Troponin level was elevated.Since the patient was in a coma,it could not be determined whether she had chest pain.The cardiologist assumed that the patient had developed ACS;therefore,the patient underwent PCI via the left femoral artery approach,and no obvious abnormalities were found in the left and right coronary arteries.On the second postoperative day,the patient presented with abdominal distension and decreased bowel sounds;constipation was considered and a glycerin enema was administered.On day 4,the patient suddenly lost consciousness,and had decreased blood pressure,abdominal wall swelling with increased tension,and absence of bowel sounds.An urgent abdominal CT scan revealed gas in her hepatic portal system with extensive bowel wall necrosis.The patient died on day 5 due to intractable shock.CONCLUSION The potential serious complications in patients undergoing PCI,especially the patients who are hemodynamically unstable and have severely calcified abdominal vessels,should all be considered.

Calciphylaxis in Patients with Chronic Kidney Disease Case Presentation and Review

Calciphylaxis is a serious disorder that presents itself as ischemia and ne-crosis of the skin which occurs more frequently in patients with an end-stage chronic kidney disease, but not exclusively. The pathogenesis is a result of the reduction of arteriolar blood flow, caused by calcification, fibrosis, and thrombus formation that primarily involve the arterioles of the dermis and hypodermis, with a poor prognosis. Case presentation: A 44-year-old patient with a previous diagnosis of chronic kidney disease receiving hemodialysis secondary to polycystic kidney disease, with a history of parathyroidectomy due to primary hyperparathyroidism in 2011. In 2014 the patient presented skin lesions, for which a diagnostic biopsy of calciphylaxis was performed and began treatment with sodium thiosulfate with a poor progression and evolution. New histology compatible with the diagnosis of pyoderma gangrenosum and findings of calciphylaxis were performed. The patient begins treatment with corticosteroids and cyclosporine, with poor clinical evolution and the patient eventually passes away. The objective of this manuscript is to understand this pathology better, which is infrequent but with a high rate of morbidity and mortality.

Aortic Artery and Cardiac Valve Calcification are Associated with Mortality in Chinese Hemodialysis Patients： A 3.5 Years Follow-up

Background： This study was to investigate the relationship among aortic artery calcification （AAC）, cardiac valve calcification （CVC）, and mortality in maintenance hemodialysis （MHD） patients. Methods： All MHD patients in Shanghai Ruijin Hospital in July 2011 were included. To follow up tbr 42 months, clinical data, predialysis blood tests, echocardiography, and lateral lumbar X-ray plain radiography results were collected. Plasma FGF23 level was measured using a C-terminal assay. Results： Totally, 110 MHD patients were involved in this study. Of which, 64 （58.2%） patients were male, the mean age was 55.2 ± 1.4 years old, and the median dialysis duration was 29.85 （3.0-225.5） months. About 25.5% of the 110 MHD patients had CVC from echocardiography while 61.8% of the patients had visible calcification of aorta from lateral lumbar X-ray plain radiography. After 42 months follow-up, 25 （22.7%） patients died. Kaplan-Meier analysis showed that patients with AAC or CVC had a significant greater number of all-cause and cardiovascular deaths than those without. In multivariate analyses, the presence of AAC was a significant factor associated with all-cause±mortality （hazard ratio [HR]： 3.149, P = 0.025） in addition to lower albumin level and lower 25-hydroxy Vitamin D （25（OH）D） level. The presence of CVC was a significant factor associated with cardiovascular mortality （HR： 3.800, P - 0.029） in addition to lower albumin level and lower 25（OH）D level. Conclusion： Lateral lumbar X-ray plain radiography and echocardiography are simple methods to detect AAC and CVC in dialysis patients. The presence of AAC and CVC was independently associated with mortality in MHD patients. Regular follow-up by X-ray and echocardiography could be a useful method to stratify mortality risk in MHD patients.

Mineral and Bone Disorder and Its Association with Cardiovascular Parameters in Chinese Patients with Chronic Kidney Disease

Background：Mineral and bone disorder （MBD）,especially hyperphosphatemia,is an independently risk factor for adverse prognosis in patients with chronic kidney disease （CKD）.However,CKD-MBD among Chinese population was poorly studied.This study aimed to investigate the status of MBD and its association with cardiovascular parameters in Chinese patients with predialysis CKD.Methods：Chinese Cohort Study of Chronic Kidney Disease （C-STRIDE） is a prospective multicenter cohort study involving predialysis CKD patients in China.Markers of MBD,including serum phosphorus,calcium,and intact parathyroid hormone,were measured in baseline samples at the patients＆#39; entry.The association between serum phosphorus and abdominal aortic calcification （AAC）,left ventricular hypertrophy （LVH） were examined by logistic regression models.Results：Altogether 3194 predialysis patients with mean estimated glomerular filtration of 51.8 ± 33.1 ml·min^- 1· 1.73 m^- 2 were included.The proportion of patients with hyperphosphatemia were 2.6%,2.9%,6.8%,and 27.1% in CKD Stages 3a,3b,4,and 5,respectively.Moreover,71.6% of the patients with hyperphosphatemia did not receive any phosphate-binder （PB）.Lateral abdominal X-rays were obtained in 2280 patients,9.8% of the patients were diagnosed as having AAC.Altogether 2219 patients had data of echocardiography,and 13.2% of them were diagnosed with LVH.Multivariate logistic regression analysis showed that serum phosphorus was independently associated with the presence of AAC and LVH.Conclusions：In Chinese patients with CKD,the percentage of hyperphosphatemia is comparable to that of other countries while the usage of PBs is suboptimal.The prevalence of vascular calcification in Chinese patients is relatively lower compared with the Caucasian population.

A novel long-term intravenous combined with local treatment with human amnion-derived mesenchymal stem cells for a multidisciplinary rescued uremic calciphylaxis patient and the underlying mechanism

Calciphylaxis is a rare disease characterized histologically by microvessel calcification and microthrombosis,with high mortality and no proven therapy.Here,we reported a severe uremic calciphylaxis patient with progressive skin ischemia,large areas of painful malodorous ulcers,and mummified legs.Because of the worsening symptoms and signs refractory to conventional therapies,treatment with human amnion-derived mesenchymal stem cells(hAMSCs)was approved.Preclinical release inspections of hAMSCs,efficacy,and safety assessment,including cytokine secretory ability,immunocompetence,tumorigenicity,and genetics analysis in vitro,were introduced.We further performed acute and long-term hAMSC toxicity evaluations in C57BL/6 mice and rats,abnormal immune response tests in C57BL/6 mice,and tumorigenicity tests in neonatal Balbc-nu nude mice.After the preclinical research,the patient was treated with hAMSCs by intravenous and local intramuscular injection and external supernatant application to the ulcers.When followed up to 15 months,the blood-based markers of bone and mineral metabolism improved,with skin soft tissue regeneration and a more favorable profile of peripheral blood mononuclear cells.Skin biopsy after 1-month treatment showed vascular regeneration with mature noncalcified vessels within the dermis,and 20 months later,the re-epithelialization restored the integrity of the damaged site.No infusion or local treatment-related adverse events occurred.Thus,this novel long-term intravenous combined with local treatment with hAMSCs warrants further investigation as a potential regenerative treatment for uremic calciphylaxis due to effects of inhibiting vascular calcification,stimulating angiogenesis and myogenesis,anti-inflammatory and immune modulation,multidifferentiation,re-epithelialization,and restoration of integrity.