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Supportive treatment improves survival in multivisceral cholesterol crystal embolism
X Belenfant1, A Meyrier, C Jacquot
1Service de Néphrologie and Institut National de la Santéet de la Recherche Médicale U 430, Hôpital Broussais, Paris, France.
Insights
Disseminated cholesterol crystal embolism (CCE) treatment protocol significantly reduced mortality in atherosclerotic patients with renal involvement. This intensive care approach improved survival rates compared to historical data.
Area of Science:
- Nephrology
- Cardiology
- Vascular Medicine
Background:
- Disseminated cholesterol crystal embolism (CCE) is a severe complication of atherosclerosis, often with limited therapeutic options.
- High mortality rates are associated with CCE, particularly when renal involvement is present.
- Previous treatments lacked a systematic approach to address the multifaceted causes of death in CCE.
Purpose of the Study:
- To design and implement a specific treatment protocol for disseminated CCE with renal involvement.
- To reduce mortality and improve survival rates in patients with multivisceral cholesterol embolism.
- To analyze the effectiveness of interventions targeting the main causes of death in CCE patients.
Main Methods:
- A treatment protocol was developed based on identified causes of death in CCE patients.
- The protocol involved withdrawing anticoagulants, avoiding aortic procedures, using high-dose vasodilators (including ACE inhibitors), and managing cardiac failure.
- Hemodialysis was used for metabolic disorders, nutritional support was provided, and corticosteroids were administered for inflammation or CCE recurrence.
Main Results:
- The in-hospital mortality rate was 16%, a significant improvement over literature rates (64-81%).
- The 1-year survival rate was 87% among patients treated with the protocol.
- 32% of survivors required long-term hemodialysis for chronic renal failure; 4-year survival was 52%.
Conclusions:
- An intensive-care, specific-treatment schedule effectively reduces mortality in multivisceral cholesterol embolism.
- The protocol addresses key complications like cardiac failure, renal failure, and metabolic disorders.
- This approach offers a more favorable prognosis for patients with disseminated CCE compared to historical outcomes.
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.