Enfermedad renal ateroembólica: un análisis de los factores clínicos y terapéuticos que influyen en su evolución / Atheroembolic renal disease: analysis of clinical and therapeutic factors that influence its progression

El embolismo de colesterol es una enfermedad causada por la suelta de cristales de colesterol desde las placas arterioscleróticas ulceradas de la aorta. Esta suelta puede ocurrir de forma espontánea o más frecuentemente tras procedimientos vasculares invasivos o tras tratamientos anticoagulantes o fibrinolíticos. Entre 1989 y 2005, en tres hospitales españoles, se diagnosticaron 45 casos de embolismo renal de colesterol. El diagnóstico fue confirmado mediante biopsia de cualquier órgano afectado o hallazgos típicos en el fondo de ojo. La mayoría de los pacientes eran varones (93,3%), ancianos (el 55,7% era mayor de 70 años), fumadores (91,1%), hipertensos (95,6%) y con varios factores de riesgo cardiovascular. Todos los pacientes presentaron un fracaso renal agudo en el momento del diagnóstico. La creatinina media al inicio fue de 4,3 ± 2,4 mg/dl. El fracaso renal agudo se acompañó frecuentemente de eosinofilia (64,4%) y lesiones cutáneas (57,7%). El 20% de los casos ocurrieron espontáneamente y el 46,7% tras manipulación endovascular (cateterismo/arteriografía); tan sólo un 8,9% ocurrió tras cambios en la anticoagulación. Tras un seguimiento de 12 ± 16,3 meses, el 55,6% (25) de los pacientes requerían diálisis crónica y un 64,4% (29) había fallecido, ocho de ellos tras haber entrado en diálisis crónica. Se observó una recuperación parcial de función renal en 9 pacientes (20%), que presentaban una creatinina media al final del seguimiento de 3 ± 1,7 mg/dl. La comorbilidad cardiovascular y la gravedad clínica del embolismo de colesterol no tuvieron impacto sobre la supervivencia renal o del individuo. La supervivencia renal (Kaplan-Meier) fue mayor en los casos de ateroembolismo espontáneo que en los iatrogénicos. 15 de los 45 pacientes recibieron esteroides. En los tratados se observó una mayor incidencia de fallecimientos (73,3% frente a 60%) y un menor porcentaje de recuperación de función renal (13,3% frente a 23%), aunque sin diferencias estadísticamente significativas. El tiempo medio de evolución a la diálisis fue significativamente más corto entre los tratados con esteroides (p = 0,017). El uso de estatinas no se asoció con una mejoría en el pronóstico renal o vital del individuo. En conclusión, la enfermedad renal ateroembólica constituye un tipo de fracaso renal agudo con unas características clínicas muy determinadas. La supervivencia renal y del paciente es mala, pero existe un porcentaje significativo de recuperaciones espontáneas de la función renal. La supervivencia renal fue significativamente mejor en los casos espontáneos y no observamos efectos beneficiosos del tratamiento esteroideo (AU)

Cholesterol embolism is a disease caused by distal showering of cholesterol crystal released from disintegration of arterial atheromatous plaques. It may occur spontaneously or more often after invasive vascular procedures or thrombolytic/anticoagulant agents. Forty five cases were diagnosed between 1989 and 2005 in three Spanish hospitals. The diagnosis was confirmed by histology or diagnostic ophthalmoscopic findings. The majority were male (93.3%), elder (55.5% were older than 70 years), smoker (91.1%), had hypertension (95.6%), with high prevalence of cardiovascular risk factors. At the time of diagnosis all patients presented acute renal failure. Mean serum creatinine at diagnosis was 4.3± 2.4mg/dl. The acute renal failure was accompanied with eosinophilia (64.4%) and cutanous lesions (57.7%). 20% of cases occur spontaneously and 46.7% after endovascular manipulation (coronary angiography/arteriography) and only 8% after changes in anticoagulant treatment. After a follow-up of 12 ± 16.3 months the 55.6% of patients need chronic dialysis, 64.4% died, 8 of them after the beginning of dialysis. Nine patients recovered renal function, with a mean creatinine of 3 ± 1.7 mg/dl at the end of follow-up. The cardiovascular comorbididy and the clinical severity of the embolism don´t have impact in the renal or patient survival. Renal survival (Kaplan-Mier) were better in spontaneous than in iatrogenic cholesterol embolism. Fifteen of 45 patients were treated with steroids. In treated patients we observed a high incidence of death (73.3% versus 60%) and fewer recovery of renal function (13.3% versus 23%), without statistical significance. The mean time to dialysis was shorter in treatment patients (p= 0.017). Statins treatment was not associated with outcome (renal or individual). In summary, atheroembolic renal disease represents an acute renal failure with special characteristics. Renal and individual outcome is poor, but some patients have spontaneous recovery of renal function. Renal survival was significantly better in spontaneous disease. We don´t observe beneficial effect of steroid treatment (AU)

[Atheroembolic renal disease: analysis of clinical and therapeutic factors that influence its progression]. / Enfermedad renal ateroembólica: un análisis de los factores clínicos y terapéuticos que influyen en su evolución.

Cholesterol embolism is a disease caused by distal showering of cholesterol crystal released from disintegration of arterial atheromatous plaques. It may occur spontaneously or more often after invasive vascular procedures or thrombolytic/anticoagulant agents. Forty five cases were diagnosed between 1989 and 2005 in three Spanish hospitals. The diagnosis was confirmed by histology or diagnostic ophthalmoscopic findings. The majority were male (93.3%), elder (55.5% were older than 70 years), smoker (91.1%), had hypertension (95.6%), with high prevalence of cardiovascular risk factors. At the time of diagnosis all patients presented acute renal failure. Mean serum creatinine at diagnosis was 4.3+/- 2.4 mg/dl. The acute renal failure was accompanied with eosinophilia (64.4%) and cutanous lesions (57.7%). 20% of cases occur spontaneously and 46.7% after endovascular manipulation (coronary angiography/arteriography) and only 8% after changes in anticoagulant treatment. After a follow-up of 12 +/- 16.3 months the 55.6% of patients need chronic dialysis, 64.4% died, 8 of them after the beginning of dialysis. Nine patients recovered renal function, with a mean creatinine of 3 +/- 1.7 mg/dl at the end of follow-up. The cardiovascular comorbididy and the clinical severity of the embolism don t have impact in the renal or patient survival. Renal survival (Kaplan-Mier) were better in spontaneous than in iatrogenic cholesterol embolism. Fifteen of 45 patients were treated with steroids. In treated patients we observed a high incidence of death (73.3% versus 60%) and fewer recovery of renal function (13.3% versus 23%), without statistical significance. The mean time to dialysis was shorter in treatment patients (p= 0.017). Statins treatment was not associated with outcome (renal or individual). In summary, atheroembolic renal disease represents an acute renal failure with special characteristics. Renal and individual outcome is poor, but some patients have spontaneous recovery of renal function. Renal survival was significantly better in spontaneous disease. We don t observe beneficial effect of steroid treatment.

Hidrotórax hepático refractario: tratamiento eficaz con octreótido / Refractory hepatic hydrothorax: successful treatment with octreotide

Describimos el caso de una paciente que presentó un hidrotórax como primera manifestación de una cirrosis hepática. Ante la ausencia de respuesta al tratamiento diurético, a la realización de una pleurodesis y a la colocación de una derivación portosistémica percutánea intrahepática, se inició tratamiento con octreótido conlo que se obtuvo la resolución del mismo. Se trata del tercer caso publicado en la literatura de hidrotórax hepático refractario con respuesta completa y mantenida al tratamiento con octreótido

We report the case of a patient that developed hepatic hydrothorax as the first complication of liver cirrhosis. Due to the lack of response to diuretics, pleurodesis and TIPS, treatment with octreotide was started with resolution of hydrothorax. To the best of our knowledge, this is the third reported case of refractory hepatic ;;hydrothorax with complete and sustained response to octreotide

Refractory hepatic hydrothorax: successful treatment with octreotide.

We report the case of a patient that developed hepatic hydrothorax as the first complication of liver cirrhosis. Due to the lack of response to diuretics, pleurodesis and TIPS, treatment with octreotide was started with resolution of hydrothorax. To the best of our knowledge, this is the third reported case of refractory hepatic hydrothorax with complete and sustained response to octreotide.