Original Investigation
Supportive treatment improves survival in multivisceral cholesterol crystal embolism

https://doi.org/10.1016/S0272-6386(99)70415-4Get rights and content

Abstract

Disseminated cholesterol crystal embolism (CCE) is a devastating complication 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 1985 to 1996, we applied this protocol in 67 consecutive atherosclerotic patients admitted to our renal intensive care unit for acute renal failure (serum 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%), cutaneous ischemia (90%), and retinal cholesterol embolism (22%). Disseminated CCE followed one or several precipitating factors, including angiographic procedure(s) (85%), anticoagulant treatment (76%), and cardiovascular surgery (33%). Our treatment schedule systematically addressed the identified causes of death in these patients. (1) To avoid CCE recurrence, any form of anticoagulant treatment was withdrawn, and aortic catheterization and surgery were proscribed. (2) To treat or prevent cardiac failure, a high-dose vasodilator regimen was instituted, including angiotensin-converting enzyme (ACE) inhibitors. In case of cardiac failure refractory to vasodilators, loop diuretics were added and, if necessary, overhydration was corrected by ultrafiltration/hemodialysis (11 patients). (3) To avoid cachexia, severe metabolic disorders were treated by hemodialysis (41 patients), and special attention was given to providing enteral or parenteral nutritional support. Patients with declining general status and laboratory evidence of inflammation, as well as those with new episodes of CCE, were treated with corticosteroids. Statistical analysis found a significant correlation between the requirement for hemodialysis and previous anticoagulation, degree of renal insufficiency, and severity of cardiac failure. Conversely, there was no correlation between requirement for hemodialysis and ACE inhibitor treatment or presence of atherosclerotic renal artery stenosis/thrombosis. The inhospital mortality rate was 16%. There were no clinical or laboratory elements found on admission that were predictive of inhospital mortality. Among survivors, 32% had to remain on maintenance hemodialysis therapy for irreversible chronic renal failure. Including initial hospitalization, the 1-year survival rate was 87%, which compares favorably with reports in the literature indicating a first-year mortality rate of 64% to 81%. Overall follow-up was 19 ± 20 months, ranging from 1 to 74 months. The 4-year survival rate was 52%. We conclude that an intensive-care, specific-treatment schedule reduces mortality in multivisceral cholesterol embolism.

Section snippets

Patients

From January 1985 to December 1996, 2,102 patients were admitted to our tertiary renal intensive care unit (ICU) for an acute condition. This population included patients with various causes of acute renal failure or an acute complication in the course of chronic renal insufficiency. Among them, 67 patients, who form the basis of this study, were diagnosed as having systemic CCE on the basis of clinical and/or histological findings. No selection was made, and this series includes all patients

Past medical history

Past medical history and demographic features are listed in Table 1.There was a strong male predominance, with 65 men and 2 women. All patients were white, aged older than 45 years, and had one or more cardiovascular risk factors identified in their history. All but two patients had symptomatic atherosclerotic vascular disease. Aortic involvement included protrusive atheroma of the thoracic aorta (96%) and/or an abdominal aneurysm (67%). Renal angiography before admission to the ICU (42

Discussion

CCE represents an increasing cause of morbidity and mortality in the aging, atherosclerotic, white population. Its precise incidence is poorly defined, from 0.15% to 3.4% in autopsy series dealing with unselected populations5 to 25% to 77% in patients who died after angiography or vascular surgery (for review, see6). The current frequency of CCE diagnosed clinically is explained by the growing indications for vascular surgery, angiography by means of Seldinger catheter, and, more recently,

Acknowledgements

Acknowledgment: The authors thank Doreen Broneer for expert help in preparing the text and the bibliography.

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    Received August 5, 1998; accepted in revised form November 10, 1998.

    Address reprint requests to Alain Meyrier, MD, Service de Néphrologie and INSERM U 430, Assistance Publique–Hôpitaux de Paris, Hôpital Broussais, 96 rue Didot, 75674 Paris Cedex 14, France. E-mail: [email protected]

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    Copyright © 1999 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.