Anti-hypertensive Scleroderma Renal Crisis (SRC)

Q: Which of the following anti-hypertensive is relatively contraindicated in Scleroderma Renal Crisis (SRC)? (select one)

A) Labetalol 

B) Angiotensin-converting enzyme (ACE) inhibitors

C) calcium channel blockers

Answer: A

Scleroderma Renal Crisis (SRC) is one of the few rheumatological emergencies where early diagnosis and treatment can significantly affect the outcome. Wrong diagnosis may lead to wrong management pathway and eventually to a very high mortality. SRC is heralded with hypertensive crisis and is associated with acute renal failure. The pearl is to avoid IV Labetalol or nitroprusside and gradually decrease blood pressure with PO angiotensin-converting enzyme (ACE) inhibitors. calcium channel blockers may help. Renal dialysis is a last resort. Another important differential diagnosis is from SLE (renal). It has been suggested that the use of steroids is associated with the onset of scleroderma renal crisis.

Labetalol is known to cause vasospasm at the microcirculatory level.

References: 

1. Hudson M, Ghossein C, Steen V. Scleroderma renal crisis. Presse Med. 2021 Apr;50(1):104063. doi: 10.1016/j.lpm.2021.104063. Epub 2021 Feb 3. PMID: 33548376.

2. Bose N, Chiesa-Vottero A, Chatterjee S. Scleroderma renal crisis. Semin Arthritis Rheum. 2015 Jun;44(6):687-94. doi: 10.1016/j.semarthrit.2014.12.001. Epub 2014 Dec 11. PMID: 25613774.

3. Foocharoen C, Tonsawan P, Pongkulkiat P, Anutrakulchai S, Mahakkanukrauh A, Suwannaroj S. Management review of scleroderma renal crisis: An update with practical pointers. Mod Rheumatol. 2023 Jan 3;33(1):12-20. doi: 10.1093/mr/roac028. PMID: 35349704.

4. Nagaraja V. Management of scleroderma renal crisis. Curr Opin Rheumatol. 2019 May;31(3):223-230. doi: 10.1097/BOR.0000000000000604. PMID: 30870219.