Do corticosteroids improve survival in acute renal failure due to cholesterol atheroembolism?

Sir, Recent reports suggest that corticosteroid therapy may favourably affect the clinical course of renal failure from cholesterol atheroembolism [1–3]. These reports prompted us to evaluate the effects of corticosteroid therapy in patients with acute renal failure from cholesterol atheroembolism observed in our unit. We analysed, retrospectively, 17 consecutive cases observed from 1 January 1992 to 31 December 1998. There were 14 males and three females, aged 69 years (range 53–83 years). The clinical pattern was highly suggestive for cholesterol atheroembolism in all cases; in four a kidney biopsy and in two skin biopsies confirmed the clinical diagnosis. In 13 cases the embolism was triggered by invasive vascular manoeuvres, while in the remaining four it was spontaneous. Ten patients required dialysis, which could be witheld in four, owing to partial recovery of kidney function. Three patients not requiring dialysis showed an improvement of renal function. Since 1995 all patients (n=7) received prednisone, in most cases 0.3 mg/kg BW/day for 3 months: in two cases oral therapy was preceded by daily intravenous pulses of methylprednisolone, 125 mg×5 in one case, 250 mg ×3 in the other. Supportive therapeutic regimens were similar between patients treated with corticosteroids or not, as well as all the demographic and clinical parameters described above. Corticosteroid treatment was well tolerated and no significant side effects were observed. Survival analysis, carried out with the Kaplan–Meier method, showed a better outcome in corticosteroid treated cases; the cumulative survival at 3 months was 86% vs 30% (log rank=3.55, P=0.059), with borderline statistical significance. Corticosteroids could exert this effect by reducing the inflammatory response which follows cholesterol atheroembolism. The limited number of cases and the heterogeneity of the disease impose caution in drawing firm conclusions. However, corticosteroid treatment is safe and could improve survival in patients with acute renal failure secondary to cholesterol atheroembolism. A prospective controlled trial is needed to evaluate this hypothesis.