[Atheroembolic renal disease]

Atheroembolic renal disease can be defined as renal failure due to occlusion of the renal arterioles by cholesterol crystal emboli usually dislodged from ulcerated atherosclerotic plaques of the aorta. Atheroembolic renal disease is part of multisystem disease, since the embolization usually involves other organ systems such as the gastrointestinal system, central nervous system, and lower extremities. The kidney is frequently involved because of the proximity of the renal arteries to the abdominal aorta, where erosion of atheromatous plaques is most likely to occur. Embolization may occur spontaneously or after angiographic procedures, vascular surgery, and anticoagulation. In the last decade, atheroembolic renal disease has become a recognizable cause of renal disease. An ante-mortem diagnosis of the disease is possible in a significant proportion of cases as long as the level of diagnostic suspicion is high. The disease can severely affect kidney and patient survival. Although no specific treatment has been proven efficacious, use of statins may be justifiable and such therapy would be a reasonable choice for future treatment trials.

[Choosing the right treatment approach in focal and segmental glomerular sclerosis with chronic renal failure]

Focal and segmental glomerular sclerosis (FSGS) is a heterogeneous disease from a clinical, etiological and clinical point of view. FSGS may be idiopathic, usually associated with nephrotic syndrome, which requires an ''etiological'' treatment approach. In addition, hereditary and secondary forms of FSGS have been described. The response to therapy, including steroids, cytotoxic drugs and calcineurin inhibitors, is considered the best clinical indicator of outcome. Many uncertainties exist regarding the best therapeutic approach to FSGS in patients presenting with chronic renal failure. In this setting, before planning any treatment, the physician should always assess the presence of superimposed functional renal insufficiency and evaluate the severity of the renal impairment, the histological picture, previous immunosuppressive treatments, and the individual patient's risk for side effects. Keeping in mind these considerations and in the absence of appropriate studies, we can formulate the following suggestions: 1. there is no absolute contraindication to the use of full-dose prednisone as initial therapy, although the likelihood of a good response is low; 2. the use of cytotoxic drugs is not recommended unless the patient presents with a steroid-responsive form of the disease; 3. in patients with a glomerular filtration rate of less than 40 mL/min, the use of calcineurin inhibitors should be avoided.

[Atheroembolic renal disease: a diagnostic challenge]

Atheroembolic renal disease is a part of a multisystem disease and can be defined as renal failure secondary to the occlusion of renal arterioles and glomerular capillaries with cholesterol crystal emboli deriving from the aorta and other major arteries. The kidney is usually involved because of the proximity of the renal arteries to abdominal aorta (where the erosion of atheromatous plaque is most likely to occur), and the high renal blood flow. Cholesterol crystal embolism can also occur in other visceral organs, as well as in the upper and lower extremities. Embolization may occur spontaneously or after angiographic and surgical procedures, and anticoagulation. Atheroembolic renal disease is an important yet underdiagnosed component of the spectrum of kidney diseases associated with atherosclerosis and remains an unexplored field of nephrology research.

[Renal involvement in systemic sclerosis]

Systemic sclerosis is an autoimmune disease characterized by fibrosis of the skin and internal organs. Raynaud's phenomenon generally precedes other disease manifestations. The distribution of skin lesions and the internal organ involvement are the basis for the classification into limited and diffuse forms of the disease. Clinically evident renal disease is observed in 10-40% of patients. The most common renal presentation is renal crisis, characterized by acute onset of renal failure and severe hypertension; some patients remain normotensive, showing microangiopathic hemolytic anemia. Renal complications due to penicillamine may occur in some patients. Finally, ANCA-associated glomerulonephritis is a rare complication of the disorder. In spite of treatment with ACE inhibitors, 20-50% of patients with renal crisis progress to end-stage renal disease. In the absence of a specific therapy, there is accumulating evidence supporting the effectiveness of prostacyclin derivatives, antifibrotic and immunosuppressive drugs. The evidence is strong that the ACE inhibitors that are used in renal crisis are disease modifying. In our series including 193 patients with systemic sclerosis, renal involvement was observed in 19 patients; 11 presented renal crisis (hypertensive in 8; normotensive in 3); 5 had chronic nephropathy; 2 developed penicillamine-induced nephrotic syndrome, and 1 ANCA-associated glomerulonephritis. Renal disease occurs in a minority of patients with systemic sclerosis, and may have a variable clinicopathological picture. As renal involvement is associated with a worse prognosis, careful monitoring of blood pressure, urine chemistry and renal function is required, particularly in patients with diffuse skin disease.