03-07-2010, 10:29 AM
The most appropriate management for this patient is further increasing his captopril dose. This patient was hospitalized with scleroderma renal crisis. Angiotensin-converting enzyme (ACE) inhibitors are believed to be the most effective agents for preserving or improving renal function in scleroderma renal crisis. Therefore, continuation of these agents is indicated even if the creatinine level continues to increase and the patient requires hemodialysis, because improvements in renal function with this therapy have been reported even after 18 months of dialysis. One-year survival of scleroderma patients with renal crisis has been shown to increase from 15% to 76% with aggressive treatment using ACE inhibitors.
Discontinuation of captopril is contraindicated in this patient. Although his creatinine levels have increased, his underlying renal crisis is responsible, not the ACE inhibitor. In addition, his blood pressure has not been fully controlled. Plasmapheresis does not help to manage scleroderma renal crisis. Moreover, this therapy is contraindicated in patients taking ACE inhibitors. Flushing, hypotension, and gastrointestinal symptoms have been shown to develop during plasmapheresis in patients receiving ACE inhibitors, possibly due to increased kinin generation.
Captopril renography is not indicated because this patient does not have increased risk for bilateral renal artery stenosis. His increasing creatinine level is not unexpected and should not raise clinical suspicion for an underlying process in addition to scleroderma renal crisis.
Discontinuation of captopril is contraindicated in this patient. Although his creatinine levels have increased, his underlying renal crisis is responsible, not the ACE inhibitor. In addition, his blood pressure has not been fully controlled. Plasmapheresis does not help to manage scleroderma renal crisis. Moreover, this therapy is contraindicated in patients taking ACE inhibitors. Flushing, hypotension, and gastrointestinal symptoms have been shown to develop during plasmapheresis in patients receiving ACE inhibitors, possibly due to increased kinin generation.
Captopril renography is not indicated because this patient does not have increased risk for bilateral renal artery stenosis. His increasing creatinine level is not unexpected and should not raise clinical suspicion for an underlying process in addition to scleroderma renal crisis.