Scleroderma renal crisis: poor outcome despite aggressive antihypertensive treatment.
BACKGROUND
Scleroderma renal crisis (SRC) is a rare but feared complication of scleroderma. Angiotensin--converting enzyme (ACE) inhibition has significantly improved survival, but it is unknown whether prophylactic ACE inhibitors will prevent this complication.


OBJECTIVE
To determine: (i) the frequency of SRC in our cohort of well-characterized scleroderma patients resident in South Australia, (ii) any predisposing clinical and serological features, (iii) median disease duration at which SRC occurs, (iv) possible precipitants, (v) disease outcome, and (vi) whether patients were taking ACE inhibitors prior to onset of SRC.


METHODS
Systematic review of the clinical course of all patients registered on the South Australian Scleroderma Register.


RESULTS
SRC occurred in 16 patients. This constituted 2.8% of a total scleroderma cohort and 15% of the diffuse scleroderma cohort identified in South Australia. All 16 patients had diffuse cutaneous scleroderma. SRC occurred at a median disease duration of 15 months (range 1 week-11 years). Disease outcome was poor (five deaths, three requiring long-term dialysis and only two patients regaining a normal creatinine) despite aggressive antihypertensive treatment (including ACE inhibitors) in an intensive care or specialized renal unit. Two patients were later able to discontinue dialysis. Only two patients were taking small doses of ACE inhibitors prior to the onset of their SRC. The frequency of Scl-70 was decreased in the SRC group (P = 0.003).


CONCLUSIONS
SRC is a rare event occurring in a small proportion of patients with diffuse scleroderma. The outcome of SRC was poor despite aggressive antihypertensive treatment. It is hypothesized that prophylactic ACE inhibition in susceptible patients might prevent or ameliorate this complication.
Walker
J G
JG
Department of Immunology, Allergy and Arthritis, Flinders Medical Centre, Bedford Park, Adelaide, South Australia 5042, Australia.
Ahern
M J
MJ
Smith
M D
MD
Coleman
M
M
Pile
K
K
Rischmueller
M
M
Cleland
L
L
Roberts-Thomson
P J
PJ
D000328:Adult; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001315:Australia / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007674:Kidney Diseases / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012595:Scleroderma, Systemic / Q000150:complications*; D016896:Treatment Outcome
D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents