Supportive treatment improves survival in multivisceral cholesterol crystal embolism

Disseminated cholesterol crystal embolism (CCE) is a devastating complicati on of atherosclerosis that is often considered beyond therapeutic resources . We designed and implemented a treatment protocol based on an analysis of the main causes of death in disseminated CCE with renal involvement. From 1 985 to 1996, we applied this protocol in 67 consecutive atherosclerotic pat ients admitted to our renal intensive care unit for acute renal failure (se rum creatinine level, 6 +/- 2.5 mg/dL) accompanied by signs and symptoms of CCE. The other principal clinical features in these patients were cardiac failure with pulmonary edema (61%), gastrointestinal ischemia (33%), cutane ous ischemia (90%), and retinal cholesterol embolism (22%). Disseminated CC E followed one or several precipitating factors, including angiographic pro cedure(s) (85%), anticoagulant treatment (76%), and cardiovascular surgery (33%), Our treatment schedule systematically addressed the identified cause s of death in these patients, (1) To avoid CCE recurrence, any form of anti coagulant treatment was withdrawn, and aortic catheterization and surgery w ere proscribed. (2) To treat or prevent cardiac failure, a high-dose vasodi lator regimen was instituted, including angiotensin-converting enzyme (ACE) inhibitors, In case of cardiac failure refractory to vasodilators, loop di uretics were added and, if necessary, overhydration was corrected by ultraf iltration/hemodialysis (II patients). (3) To avoid cachexia, severe metabol ic disorders were treated by hemodialysis (41 patients), and special attent ion was given to providing enteral or parenteral nutritional support. Patie nts with declining general status and laboratory evidence of inflammation, as well as those with new episodes of CCE, were treated with corticosteroid s, Statistical analysis found a significant correlation between the require ment for hemodialysis and previous anticoagulation, degree of renal insuffi ciency, and severity of cardiac failure. Conversely, there was no correlati on between requirement for hemodialysis and ACE inhibitor treatment or pres ence of atherosclerotic renal artery stenosis/thrombosis. The inhospital mo rtality rate was 16%, There were no clinical or laboratory elements found o n admission that were predictive of inhospital mortality. Among survivors, 32% had to remain on maintenance hemodialysis therapy for irreversible chro nic renal failure. Including initial hospitalization, the 1-year survival r ate was 87%, which compares favorably with reports in the literature indica ting a first-year mortality rate of 64% to 81%, Overall follow-up was 19 +/ - 20 months, ranging from 1 to 74 months. The 1-year survival rate was 52%, We conclude that an intensive-care, specific-treatment schedule reduces mo rtality in multivisceral cholesterol embolism. (C) 1999 by the National Kid ney Foundation, Inc.