Improvement in renal cholesterol emboli syndrome after simvastatin

Fatal Course of Cutaneous Cholesterol Embolization Syndrome: A Case Report

Cholesterol embolization syndrome is an increasing but underestimated problem after endovascular intervention or after the start of thrombolytic therapies. Embolies from the aortic wall involves abdominal organs and the skin of the lower extremities or buttocks. In our case a progressive ulceration and necroses occurs spontaneously. Endovascular treatment of the lower extremities was successful for a short period. Due to the progression of necrosis, both legs were amputated. Biopsies were taken from the skin were initially no directions to the diagnosis of Cholesterol embolization syndrome. After a second elliptical excision biopsy the diagnosis of cholesterol embolization syndrome was confirmed. Because the rapid progression of skin necroses despite the treatment of prednisone, patient died due to sepsis and renal failure. This case shows when arterial revascularization is performed and progression in skin necrosis occurs despite optimal arterial vascular status the diagnosis CES should be considered and treated in an early state of disease.

Acute Kidney Injury Management Strategies Peri-Cardiovascular Interventions

In many countries, the aging population and the higher incidence of comorbid conditions have resulted in an ever-growing need for cardiac interventions. Acute kidney injury (AKI) is a common complication of these interventions, associated with higher mortalities, chronic or end-stage kidney disease, readmission rates, and hospital and post-discharge costs. The AKI pathophysiology includes contrast-associated AKI, hemodynamic changes, cardiorenal syndrome, and atheroembolism. Preventive measures include limiting contrast media dose, optimizing hemodynamic conditions, and limiting exposure to other nephrotoxins. This review article outlines the current state-of-art knowledge regarding AKI pathophysiology, risk factors, preventive measures, and management strategies in the peri-interventional period.

Burden of kidney failure from atheroembolic disease and association with survival in people receiving dialysis in Australia and New Zealand: a multi-centre registry study

Background

Cardiovascular disease is a leading cause of mortality in kidney failure (KF). Patients with KF from atheroembolic disease are at higher risk of cardiovascular disease than other causes of KF. This study aimed to determine survival on dialysis for patients with KF from atheroembolic disease compared with other causes of KF.

Methods

All adults (≥ 18 years) with KF initiating dialysis as the first kidney replacement therapy between 1 January 1990 and 31 December 2017 according to the Australia and New Zealand Dialysis and Transplant registry were included. Patients were grouped into either: KF from atheroembolic disease and all other causes of KF. Survival outcomes were assessed by the Kaplan-Meier method and Cox regression analysis adjusted for patient-related characteristics.

Results

Among 65,266 people on dialysis during the study period, 334 (0.5%) patients had KF from atheroembolic disease. A decreasing annual incidence of KF from atheroembolic disease was observed from 2008 onwards. Individuals with KF from atheroembolic disease demonstrated worse survival on dialysis compared to those with other causes of KF (HR 1.80, 95% confidence interval [CI] 1.61–2.03). The respective one- and five-year survival rates were 77 and 23% for KF from atheroembolic disease and 88 and 47% for other causes of KF. After adjustment for patient characteristics, KF from atheroembolic disease was not associated with increased patient mortality (adjusted HR 0.93 95% CI 0.82–1.05).

Conclusions

Survival outcomes on dialysis are worse for individuals with KF from atheroembolic disease compared to those with other causes of KF, probably due to patient demographics and higher comorbidity.

Cholesterol-embolization syndrome: current perspectives

Cholesterol-embolization syndrome (CES) is a multisystemic disease with various clinical manifestations. CES is caused by embolization of cholesterol crystals (CCs) from atherosclerotic plaques located in the major arteries, and is induced mostly iatrogenically by interventional and surgical procedures; however, it may also occur spontaneously. Embolized CCs lead to both ischemic and inflammatory damage to the target organ. Therefore, anti-inflammatory agents, such as corticosteroids and cyclophosphamide, have been investigated as treatment for CES in several studies, with conflicting results. Recent research has revealed that CES is actually a kind of autoinflammatory disease in which inflammasome pathways, such as NLRP3 and IL1, are induced by CCs. These recent findings may have clinical implications such that colchicine and IL1 inhibitors, namely canakinumab, may be beneficial in the early stages of CES.

Atheromatous embolization

Atheromatous embolization is a multisystem disease complicating advanced atherosclerosis. It occurs most often as a complication of angiography, an endovascular procedure or cardiovascular surgery. Atheromatous embolization can present in a subtle manner where it is often under-recognized, or with catastrophic results including myocardial infarction, strake or acute renal failure. It may mimic other disease processes and often goes underdiagnosed and undertreated. A high clinical suspicion is the key to diagnosis. Atheromatous embolization results in significant morbidity and mortality; therefore, early recognition followed by aggressive management may help to prevent end-organ damage and improve overall clinical outcomes. Management strategies should include risk factor modification, prevention of further insults by discontinuing or avoiding predisposing factors, supportive treatment and interventional or surgical approaches to remove the atheroembolic source. Atheromatous embolization is expected to increase as our population ages and the epidemics of diabetes mellitus and obesity increase.

Low-Density Lipoprotein Apheresis Ameliorates Renal Prognosis of Cholesterol Crystal Embolism

Drugs such as corticosteroids and statins have been used to treat cholesterol crystal embolism (CCE), but the prognosis remains poor. This study evaluated the efficacy of low-density lipoprotein apheresis (LDL-A) in patients with CCE. Patients with CCE who showed renal deterioration after vascular interventions were studied retrospectively. Information on demographic variables, clinical measurements, and medication use was collected. The outcomes were incidence of maintenance dialysis and mortality at 24 weeks. A total of 49 patients with CCE were included, among whom 37 (76%) were diagnosed pathologically and the remainder were diagnosed clinically. The median estimated GFR at baseline and at diagnosis were 40.5 and 13.4 mL/min per 1.73 m(2) , respectively. Corticosteroids were used in 42 patients (86%), statins in 30 patients (61%), and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in 29 patients (59%). LDL-A was performed in 25 patients (LDL-A group), and not in 24 patients (control group). Smoking (100% vs. 72%, P = 0.02), white blood cell count (8900/mm(3) vs. 7000/mm(3) ) and corticosteroid use (96% vs. 75%) were higher in the LDL-A group compared with the control group, but there were no differences in other demographic and clinical parameters between the groups. Patients in the LDL-A group had a lower incidence of maintenance dialysis (2/25 (8%) vs. 8/24 (33%), P < 0.05), and a trend towards lower mortality (2/25 (8%) vs. 7/24 (29%), P = 0.074). These results suggest that LDL-A decreases the risk of maintenance dialysis in severe renal CCE patients after vascular interventions.

Cholestrol emboli syndrome: acute renal insufficiency after a procedure or a thrombolytic therapy or anticoagulant therapy

Cholesterol emboli syndrome is due to dislodgment of cholesterol crystals from the atherosclerotic plaques lining the walls of major arteries resulting in an occlusion of small arteries. We describe a case of severe cutaneous and renal cholesterol emboli syndrome following coronary angiography showing our observation that this syndrome is often unrecognized or misdiagnosed and that a better evaluation of risks factors in patients undergoing invasive procedures could prevent this severe complication.

Favorable outcome in atheroembolic renal disease with pulse steroid therapy

Atheroembolic renal disease is characterized by renal failure secondary to occlusion of renal vasculature by cholesterol containing atheromatous plaques. Clinical presentations of this disease entity are myriad, with limited therapeutic options and unfavorable outcomes. This report describes an elderly male patient with peripheral vascular disease who developed acute renal failure during hospital admission for rectal bleed, and was diagnosed with atheroembolic renal disease on renal biopsy. The patient was managed with pulse steroid therapy and had a favorable outcome.

A patient with idiopathic cholesterol crystal embolization: effectiveness of early detection and treatment

A 72-year-old man was admitted to our hospital because of progressive renal dysfunction persisting for 1.5 months. Physical examination showed livedo reticularis of the toes of both feet, peripheral edema, and gait disturbance due to the toe pain. The levels of blood urea nitrogen (50.0 mg/dL) and creatinine (2.81 mg/dL) were elevated, and eosinophilia (10%, 870/µL) was noted. A biopsy of the area of livedo reticularis revealed cholesterin crystals. The patient had not undergone angiography, anticoagulation therapy, or antithrombotic treatment. Idiopathic cholesterol crystal embolization was diagnosed. Transesophageal echocardiography revealed intimal thickening of the aorta and plaque. Oral steroid therapy was started because of the progressive renal dysfunction. After steroid therapy, the symptoms improved. Early diagnosis and treatment are important. Renal dysfunction is a common symptom in elderly patients. Cholesterol crystal embolization should also be considered as a cause of unexplained renal dysfunction, especially in such patients.

Risks and complications of coronary angiography: a comprehensive review

Coronary angiography and heart catheterization are invaluable tests for the detection and quantification of coronary artery disease, identification of valvular and other structural abnormalities, and measurement of hemodynamic parameters. The risks and complications associated with these procedures relate to the patient’s concomitant conditions and to the skill and judgment of the operator. In this review, we examine in detail the major complications associated with invasive cardiac procedures and provide the reader with a comprehensive bibliography for advanced reading.

Atheroembolic renal disease

Atheroembolic renal disease develops when atheromatous aortic plaques rupture, releasing cholesterol crystals into the small renal arteries. Embolisation often affects other organs, such as the skin, gastrointestinal system, and brain. Although the disease can develop spontaneously, it usually develops after vascular surgery, catheterisation, or anticoagulation. The systemic nature of atheroembolism makes diagnosis difficult. The classic triad of a precipitating event, acute or subacute renal failure, and skin lesions, are strongly suggestive of the disorder. Eosinophilia further supports the diagnosis, usually confirmed by biopsy of an affected organ or by the fundoscopic finding of cholesterol crystals in the retinal circulation. Renal and patient prognosis are poor. Treatment is mostly preventive, based on avoidance of further precipitating factors, and symptomatic, aimed to the optimum treatment of hypertension and cardiac and renal failure. Statins, which stabilise atherosclerotic plaques, should be offered to all patients. Steroids might have a role in acute or subacute progressive forms with systemic inflammation.

Pleiotropic effects of statins may improve outcomes in atherosclerotic renovascular disease

BACKGROUND

Atherosclerotic renovascular disease (ARD) coexists with arterial obstructive disease in the coronary, cerebral, and peripheral arteries that may remain underdiagnosed and untreated.

METHODS

This retrospective study compares overall survival and renal survival (i.e., time to doubling of serum creatinine or end-stage renal disease (ESRD)) over an 11-year period in 104 ARD patients of whom 68 received statin therapy (group S) because of elevated lipid levels and 36 had no statin (group NS) because of normal lipid profile at entry.

RESULTS

Atherosclerosis in another vascular bed was documented in 84%. Lipid profiles at end point were virtually identical in both the groups. Group S had mean survival 123months (confidence interval (CI) 113-134) with four deaths, and mean renal survival 122months (CI 113-131). Group NS had mean survival 33 months (CI 23-42) with 13 deaths, and mean renal survival 27 months (CI 17-37).

CONCLUSIONS

Statin therapy was associated with lesser rate of progression of renal insufficiency (with 7.4% of S patients reaching renal end points vs. 38.9% of NS patients) and lower overall mortality (5.9 % in S vs. 36.1% in NS patients), P < 0.001 for both. Although both groups received what was deemed optimal therapy, they did have other differences that may have affected the outcomes (a limitation addressed by Cox multiple regression analysis). These results suggest the need for prospective randomized controlled studies in ARD patients in order to explore potential benefits of statins that may not be attributable solely to lipid lowering.

Cholesterol embolization syndrome induced by thrombolytic therapy

Cholesterol embolization syndrome (CES) induced by thrombolytic therapy is a rare syndrome with a high incidence of morbidity and mortality. The variability in clinical presentations may cause a delay in diagnosis of CES. This article presents a comprehensive review of the English literature from January 1980 to December 2007 identifying all published case reports of CES induced by thrombolytic therapy. Multiple electronic databases were searched and relevant reference lists were hand searched to identify all case reports. Thirty cases of thrombolytic-induced CES were identified. Indications for thrombolysis were acute myocardial infarction (28 patients) and deep venous thrombosis (two patients). Skin and renal involvement were the most common presentations. Skin manifestations included livedo reticularis, rash, and skin mottling. Other clinical symptoms included cyanotic toes, gastrointestinal bleeding, or perforation, myalgias, retinal emboli, and CNS involvement. Morbidity and mortality were high. Outcomes included chronic hemodialysis in eight patients, four patients underwent amputations, seven patients developed or had progression of their chronic kidney disease, and seven deaths occurred.CES presents as multiorgan dysfunction and should be considered in the differential diagnosis of the symptom complex that may develop after thrombolytic therapy. Diagnosis of CES can be difficult as a result of the variable clinical presentations. A thorough clinical history and physical examination are essential first steps in establishing a diagnosis. Confirmatory diagnosis requires biopsy of the target organs. Measures to reduce the likelihood of recurrence should be taken and include avoidance of anticoagulation therapy and vascular procedures. Unfortunately, therapy remains supportive and the outcome is invariably poor.

Clinical characteristics and outcomes of Chinese patients with cholesterol crystal embolism after coronary intervention

BACKGROUND

Cholesterol crystal embolism (CCE) is a complication of atherosclerosis. Vascular surgery, vascular angiography, and anticoagulation have been identified as inciting factors.

HYPOTHESIS

This paper sought to analyze the clinical characteristics of patients with CCE after percutaneous coronary intervention.

METHODS

Six patients with atherosclerosis presenting with simultaneous occurrence of acute renal failure and peripheral ischemic changes were diagnosed with CCE and their clinical data were analyzed.

RESULTS

The average age of the patients was 72 years. Most had risk factors of atherosclerosis such as hypertension, diabetes, and smoking. The levels of serum creatinine increased progressively after coronary angiography. All patients had concomitant skin lesions, including blue toes. Cholesterol crystal emboli were found in arterioles by cutaneous biopsy in one patient. All patients received statins and two of these received dialysis therapy. Three patients died and three remained in chronic renal failure.

CONCLUSION

Since CCE is a severe complication of coronary intervention, special attention should be paid to this disease.

A Case of Cholesterol Embolism Confirmed by Skin Biopsy and Successfully Treated with Statins and Steroids

Although cholesterol embolism syndrome was recognized as a clinicopathologic entity more than 50 years ago, it is attracting growing attention recently. It is a multisystemic disorder in which cholesterol crystals released from atherosclerotic plaques obstruct small arterioles, resulting in local ischemia and end-organ damage. There are no established treatments, and with the limited treatment options available, it is important to make the diagnosis as early as possible. We present the case of a 68-year-old man with cholesterol embolism who had a few fluttering atheromas in the aorta, as demonstrated by transesophageal ultrasonography. The diagnosis was confirmed by skin biopsy, and treatment with statins and steroids proved effective, as renal failure progressively improved. This case emphasizes the importance of early diagnosis and shows the possible therapeutic effects of statins and steroids for patients with this syndrome.

Cholesterol embolization treated with corticosteroids--two case reports

Cholesterol embolization (CE) is a potentially serious complication associated with invasive arterial maneuvers, in which standard therapy has not been established. We experienced two cases of CE in patients with severe atherosclerosis whose renal function deteriorated within a few months after invasive arterial maneuvers. CE was confirmed either by renal biopsy (case 1) or skin biopsy (case 2). Oral administration of prednisolone at a daily dose of 30 mg (0.4 mg/kg) was effective to improve their renal function. Our observation suggests that corticosteroid therapy may be beneficial in some patients with CE.

Effect of pravastatin on rate of kidney function loss in people with or at risk for coronary disease

BACKGROUND

Limited data suggest that HMG-CoA reductase inhibitors (statins) reduce rates of kidney function loss. We performed this analysis to determine whether pravastatin reduced the rate of kidney function loss over approximately 5 years in people with or at high risk for coronary disease.

METHODS AND RESULTS

This was a post hoc subgroup analysis of data from 3 randomized double-blind controlled trials comparing pravastatin 40 mg/d and placebo in subjects with a previous acute coronary syndrome or who were at high cardiovascular risk. The primary outcome was the rate of change in estimated glomerular filtration rate (GFR; in mL/min per 1.73 m2/y). The Modified Diet and Renal Disease Study (MDRD) and Cockcroft-Gault equations were used to estimate GFR. We studied 18,569 participants, 3402 (18.3%) of whom had moderate chronic kidney disease as defined by an estimated GFR of 30 to 59.9 mL/min per 1.73 m2 body surface area. In subjects with moderate chronic kidney disease at baseline, pravastatin reduced the adjusted rate of kidney function loss by approximately 34%, although the absolute reduction in the rate of loss was small (0.22 mL/min per 1.73 m2/y by MDRD-GFR; 95% CI, 0.07 to 0.37). Pravastatin did not reduce the frequency of > or =25% decreases in kidney function in this group when MDRD-GFR was used to estimate GFR (relative risk [RR], 0.84; 95% CI, 0.66 to 1.06). When all 18,569 subjects were considered, pravastatin reduced the adjusted rate of kidney function loss by 8% (0.08 mL/min per 1.73 m2/y by MDRD-GFR; 95% CI, 0.01 to 0.15) and the risk of acute renal failure (RR, 0.60; 95% CI, 0.41 to 0.86) but did not significantly reduce the frequency of a > or =25% decline in kidney function by MDRD-GFR (RR, 0.94; 95% CI, 0.88 to 1.01).

CONCLUSIONS

Pravastatin modestly reduced the rate of kidney function loss in people with or at risk for cardiovascular disease. However, the primary indication for the use of statins in people with or at risk for coronary events remains the reduction in mortality that results from their use.

Management of Peripheral Vascular Disease

The management of patients with peripheral arterial occlusive disease (PAD) has to be planned in the context of natural history, epidemiology, and apparent risk factors that predict deterioration. The ankle-brachial index to date has proved to be the most effective, accurate, and practical method of PAD detection. Given that PAD is a powerful indicator of systemic atherosclerosis and (independent of symptoms) is associated with an increased risk of myocardial infarction and stroke, as well as a six times greater likelihood of death, the prevalence and demographic distribution of measurable PAD becomes particularly relevant. Reliable information on interventions to confer symptom relief is much weaker and reflects discrepancies between published reports from centers of excellence and the experience of patients routinely treated in communities around the world. The impact of newer treatment modalities, such as complex endovascular procedures and therapeutic angiogenesis, has been a subject of recent controversy.

Cholesterol Emboli-induced Renal Failure and Gastric Ulcer After Thrombolytic Therapy

Cholesterol embolization syndrome is a rare but devastating complication of thrombolysis. Clinical presentations are variable, which has resulted in labeling this syndrome as the great masquerader. Almost every organ in the body may be affected, but the syndrome commonly involves the kidney, skin, central nervous system, and gastrointestinal tract. Treatment is mainly supportive, with an emphasis on reducing the risk of recurrence. The case presented is a unique one of thrombolytic-induced cholesterol embolization syndrome causing renal failure, in which the diagnosis was supported by a biopsy of a gastric ulcer.

Renal cholesterol embolism in patients with carotid stenosis: a severe and underdiagnosed complication following cerebrovascular procedures

Here, we report two cases with rapidly progressive renal failure, caused by cholesterol crystal embolism (CCE), after an angiography for carotid artery stenosis. The diagnosis was determined by histological examination and from clinical symptoms, including livedo reticularis and eosinophilia. Neurologists and neuroradiologists tend to underdiagnose CCE, which results from the same atherosclerotic risk factors as cerebrovascular disease. We need to understand more about CCE and identify its unique clinical symptoms to enable an early diagnosis and treatment.

The role of aortic stent grafting in the treatment of atheromatous embolization syndrome: Results after a mean of 15 months follow-up

BACKGROUND

Endovascular stent-graft (ESG) repair of abdominal aortic aneurysm (AAA) has emerged as an alternative to open surgery. The role of ESG in patients with challenging medical and anatomic problems remains an area of general debate. This study reviews an experience with stent grafts to treat patients with AAA and atheromatous embolization syndrome (AES) presenting with chronic distal embolization (CDE).

METHODS

Over a 5-year period 660 patients with AAA were treated with aortic stent grafts. Patients with AAA and ischemic ulcerations or toe gangrene due to CDE despite palpable foot pulses were investigated for successful aneurysm exclusion, resolution of ischemic symptoms, complications and survival. Follow-up averaged 15.3 +/- 14.9 months (range, 1 to 60 months).

RESULTS

Nineteen patients had AAA and manifestations of CDE. The population (16 males/3 females) had a mean age of 79 +/- 7 years and mean aneurysm diameter of 5.5 cm. Renal insufficiency was present in 5/19 (26 %). Ischemia presented as ischemic ulcers (16/19 [84.2%]) or toe gangrene (3/19 [15.8%]). Stent grafts included 6 aortouniiliac and 13 bifurcated devices. Exclusion was achieved in all but 2 patients who had type II lumbar endoleaks. At 30-day postoperative follow-up, mortality was 0 % and resolution of CDE/ischemia was noted in 2 of 19 (10.5%) patients. Eight of 9 patients with follow-up of 1 year had complete resolution of their ischemic symptoms, with no recurrent manifestations of AES. Complications included progression of renal insufficiency over an 18-month period in 1 patient and an unstable expanding pararenal aortic neck in 1 patient. Foot ischemia persisted at 1 year in a patient with severe coexisting thoracic aortic disease despite successful AAA exclusion. Six (31.6%) patients died during a mean follow-up of 15.3 months from causes unrelated to their AAA.

CONCLUSION

On the basis of this experience, stent-graft repair of AAA and CDE may be an effective strategy to prevent future embolization. Recognition of coexisting thoracic aortic disease is essential. ESG does not address the extremely high morbidity and mortality from cardiovascular causes in this population.

Atheroembolic renal disease: clinical findings of 11 cases

Atheromatous embolism is a systemic disease resulting from cholesterol crystal embolization in many organs, including the kidneys. To characterize atheroembolic renal disease (AERD), we retrospectively evaluated 11 patients with acute renal failure after vascular surgery, vascular radiology investigations, and anticoagulation at Miyazaki Medical College from 1994 to 2001. The diagnosis of cholesterol atheromatous embolism was confirmed by tissue examination or clinical grounds. The patients were all elderly men (average age of 66.8 years) with a history of hypertension (55%), diabetes mellitus (45%), hyperlipidemia (45%), and coronary artery disease (18%). Seven patients had livedo reticularis, and 4 had blood eosinophilia. Clinically, 7 patients were managed conservatively and 5 of them improved, whereas 4 patients required dialysis and developed chronic renal failure or died. The serum creatinine levels of the improved patients were significantly lower (1.28+/-0.3 mg/dl, p < 0.005) than the non-improved ones (7.70+/-3.6). The number of eosinophils was significantly higher in the improved patients (576+/-295 /ml, p < 0.05) than in the non-improved ones (208+/-206). However, no significant difference was observed in the levels of serum cholesterol and C-reactive protein among these patients. Since the population at risk for AERD is growing, we should recognize this disease as a cause of acute renal failure.

Cholesterol crystal embolization: an atherosclerotic disease with frequent and varied cutaneous manifestations

In this paper the basic pathogenesis of cholesterol crystal embolization (CCE) is described, its clinical characteristics are presented and diagnosis and therapy are discussed. The main focus will be on the cutaneous manifestations; however, considering that CCE is a systemic illness, findings in other organs will also be highlighted, particularly the commonly involved renal and gastrointestinal systems.

Apheresis in the treatment of cholesterol embolic disease

Cholesterol embolic disease is a devastating complication of atherosclerosis. Universally recommended treatment is lacking thus far. Recent data suggest that a therapeutic protocol aimed at specifically combating three causes of mortality, recurrent bouts of cholesterol embolism, cardiac failure, and cahexia, were associated with a favorable clinical outcome. As for drug therapy, corticosteroid has been reported to be beneficial in reducing local and general inflammatory responses. Concerning apheresis, combined therapy consisting of plasma exchange and low to intermediate-dose corticosteroid therapy has been shown to be effective in multivisceral cholesterol embolism. Low density lipoprotein (LDL) apheresis has been reported to be beneficial for cholesterol embolism-induced damage to the skin and brain.

Cholesterol crystal embolization to the digestive system: characterization of a common, yet overlooked presentation of atheroembolism

In the 1359 published patients with multiorgan cholesterol crystal embolism (CCE), the digestive system seems to be the third most frequently affected system. Yet, this system received hitherto only little attention in the medical literature. Therefore, the aim of the present study was to clinically characterize the subset of patients with CCE involving the digestive system, based on our institutional experience and a review of the literature. Cases with CCE in a 7-yr period (1995-2001) were sought in the computerized records of our medical center. Of the CCE patients, those with digestive system involvement that could be related to CCE were included in this study. The clinical features of CCE were determined and compared with those found in published series. Fourteen cases with CCE were identified, giving an annual incidence of 0.8 per 10(5). Digestive system involvement was found in five (36%) of the 14 patients. All five patients had established atherosclerosis. Precipitating factors were vascular manipulations or anticoagulation treatment in four of these five patients. Two patterns of disease appeared: acute catastrophic multiorgan disorder with poor prognosis and chronic and more indolent GI disease. Abdominal pain, GI bleeding, fever, and diarrhea were the most common manifestations, resulting from bowel infarction, mucosal ulcerations, hepatocellular liver disorder, and/or pancreatitis. CCE is a systemic disorder with a frequent involvement of the digestive system and protean clinical manifestations. It should, therefore, be considered in any gastroenterological patient with atherosclerosis and recent vascular manipulations or systemic anticoagulation.

Predictors of renal and patient outcomes in atheroembolic renal disease: a prospective study

Atheroembolic renal disease (AERD) is part of a multisystemic disease accompanied by high cardiovascular comorbidity and mortality. Interrelationships between traditional risk factors for atherosclerosis, vascular comorbidities, precipitating factors, and markers of clinical severity of the disease in determining outcome remain poorly understood. Patients with AERD presenting to a single center between 1996 and 2002 were followed-up with prospective collection of clinical and biochemical data. The major outcomes included end-stage renal disease (ESRD) and death. Ninety-five patients were identified (81 male). AERD was iatrogenic in 87%. Mean age was 71.4 yr. Twenty-three patients (24%) developed ESRD; 36 patients (37.9%) died. Cox regression analysis showed that significant independent predictors of ESRD were long-standing hypertension (hazard ratio [HR] = 1.1; P < 0.001) and preexisting chronic renal impairment (HR = 2.12; P = 0.02); use of statins was independently associated with decreased risk of ESRD (HR = 0.02; P = 0.003). Age (HR = 1.09; P = 0.009), diabetes (HR = 2.55; P = 0.034), and ESRD (HR = 2.21; P = 0.029) were independent risk factors for patient mortality; male gender was independently associated with decreased risk of death (HR = 0.27; P = 0.007). Cardiovascular comorbidities, precipitating factors, and clinical severity of AERD had no prognostic impact on renal and patient survival. It is concluded that AERD has a strong clinical impact on patient and renal survival. The study clearly shows the importance of preexisting chronic renal impairment in determining both renal and patient outcome, this latter being mediated by the development of ESRD. The protective effect of statins on the development of ESRD should be evaluated in a prospective study.

Atheroembolism in cardiac surgery

BACKGROUND

Atheroembolism is a recognized complication of cardiac surgery, but its incidence and various outcomes have not been completely described. A retrospective study was undertaken to better characterize the syndrome.

METHODS

Records of 49,377 autopsies and surgical specimens from the Johns Hopkins Hospital between 1973 and 1995 were reviewed. Three hundred twenty-seven patients (0.7%) had an identifiable atheroembolism on histologic examination. Of these patients, 29 (0.2%) had undergone a cardiac surgical procedure within 30 days of autopsy or surgical resection. Patient charts and pathology specimens were reviewed for operative findings, postoperative outcomes, and histology.

RESULTS

Six of the 29 patients (21%) had atheroembolism to the heart, 7 patients (24%) had embolism to the central nervous system, 19 patients (66%) had embolism to the gastrointestinal tract, 14 patients (48%) had embolism to one or both kidneys, and 5 patients (17%) had embolism to a lower extremity. Sixteen patients (55%) had atheroembolism in two or more areas. In 6 patients (21%), death was directly attributable to atheroembolism, including intraoperative cardiac failure from coronary embolism (n = 3), massive stroke (n = 2), and extensive gastrointestinal embolization (n = 1).

CONCLUSIONS

Atheroembolism in cardiac surgery has a broad spectrum of clinical presentations, including devastating injuries and death. Although the true incidence is probably underestimated in this retrospective study, the high attendant mortality and morbidity of atheroembolism have been documented. Improvements in outcome are likely to be associated with preoperative identification of patients at high risk, modifications of perfusion technique, and interventions to minimize secondary thrombosis and progressive organ ischemia.

Atheroembolism

The many manifestations of atheroembolism are apparent in all specialties. However, with increasing intervention in older patients with atherosclerotic disease, it has become an important renal clinical problem. Atheroembolic disease is widely recognized as a cause of acute catastrophic renal dysfunction and recent important data have suggested that effective management protocols can improve outcome. It is probable that the clinical course is insidious in the majority of patients with severe atherosclerotic aortic disease. The management of these patients is less clear and at present rests on small anecdotal reports.

[Skin lesions and renal failure after myocardial infarction]

We describe the clinical case of a patient with acute myocardial infarction treated with t-PA fibrinolysis, who developed renal failure and cutaneous lesions of the livedo reticularis type, probably caused by embolization of cholesterol crystals. The main characteristics of this rare clinical entity are reviewed.

Disseminated cholesterol embolism after coronary artery bypass grafting

Blue toe syndrome caused by cholesterol emboli is a relatively benign disease. However, disseminated cholesterol embolism is a life-threatening condition. We describe here the case of a 71-year-old female admitted because of anterior chest pain and intermittent claudication. Following cardiac catheterization, warfarin potassium was administered. However, the patient's toes soon darkened bilaterally, and BUN and creatinine levels increased from the normal value. Skin discoloration and renal failure were improved after stopping warfarin potassium administration. The patient underwent coronary artery bypass grafting and left femoropopliteal bypass. Cerebral infarction and renal failure occurred postoperatively due to disseminated cholesterol embolism. The patient died from renal failure on the 16th postoperative day without regaining consciousness following surgery. For high risk patients, interventional procedures to the ascending aorta must be avoided. When CABG cannot be avoided for coronary revascularization, off-pump bypass and use of arterial grafts are recommended.

Potential therapeutic effect of simvastatin on progressive renal failure and nephrotic-range proteinuria caused by renal cholesterol embolism

We report our experience with a 62-year-old Japanese man with cholesterol crystal embolism after angiographic procedures performed because of intermittent claudication. In addition to progressive renal failure and nephrotic-range proteinuria, cutaneous ischemia, consisting of livedo reticularis in the lower limbs and digital necrosis at the tip of the right toe, and fundoscopic findings showing several white spots in the branches of retinal artery were also observed. Progressive renal failure and nephrotic-range proteinuria were halted just after treatment with simvastatin. Thus, simvastatin can exert a beneficial therapeutic effect on renal cholesterol embolism.

Cholesterol embolism causing delayed healing of a foot ulcer

A cholesterol embolism presents with various systemic and local manifestations giving rise to a diagnostic dilemma. We report a case of cholesterol embolism of the leg that delayed the healing of a foot ulcer, necessitating a toe amputation. This report points to the potential of cholesterol emboli to cause a significant compromise in the vascular supply.

Cholesterol crystal embolism: A recognizable cause of renal disease

Cholesterol crystal embolism, sometimes separately designated atheroembolism, is an increasing and still underdiagnosed cause of renal dysfunction antemortem in elderly patients. Renal cholesterol crystal embolization, also known as atheroembolic renal disease, is caused by showers of cholesterol crystals from an atherosclerotic aorta that occlude small renal arteries. Although cholesterol crystal embolization can occur spontaneously, it is increasingly recognized as an iatrogenic complication from an invasive vascular procedure, such as manipulation of the aorta during angiography or vascular surgery, and after anticoagulant and fibrinolytic therapy. Cholesterol crystal embolism may give rise to different degrees of renal impairment. Some patients show only a moderate loss of renal function; in others, severe renal failure requiring dialysis ensues. An acute scenario with abrupt and sudden onset of renal failure may be observed. More frequently, a progressive loss of renal function occurs over weeks. A third clinical form of renal atheroemboli has been described, presenting as chronic, stable, and asymptomatic renal insufficiency. The renal outcome may be variable; some patients deteriorate or remain on dialysis, some improve, and some remain with chronic renal impairment. In addition to the kidneys, atheroembolization may involve the skin, gastrointestinal system, and central nervous system. Renal atheroembolic disease is a difficult and controversial diagnosis for the protean extrarenal manifestations of the disease. In the past, the diagnosis was often made postmortem. However, in the last decade, awareness of atheroembolic renal disease has improved, enabling us to make a correct premortem diagnosis in a number of patients. Correct diagnosis requires the clinician to be alert to the possibility. The typical patient is a white man aged older than 60 years with a baseline history of hypertension, smoking, and arterial disease. The presence of a classic triad characterized by a precipitating event, acute or subacute renal failure, and peripheral cholesterol crystal embolization strongly suggests the diagnosis. The confirmatory diagnosis can be made by means of biopsy of the target organs, including kidneys, skin, and the gastrointestinal system. Thus, Cinderella and her shoe now can be well matched during life. Patients with renal atheroemboli have a dismal outlook. A specific treatment is lacking. However, it is an important diagnosis to make because it may save the patient from inappropriate treatment. Finally, recent data suggest that an aggressive therapeutic approach with patient-tailored supportive measures may be associated with a favorable clinical outcome.

Recurrent renal cholesterol embolism

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Individual kidney function in atherosclerotic nephropathy is not related to the presence of renal artery stenosis

BACKGROUND

Atherosclerotic renovascular disease is increasingly recognized as an important cause of renal failure in patients over 60 years of age but the processes leading to renal dysfunction have not been defined. We have examined the relationship between renal artery stenosis and individual renal function in patients with atherosclerotic renal artery stenosis.

METHODS

In this prospective descriptive study over a 25-month period, we examined the relationship between the presence of renal artery stenosis and single kidney glomerular filtration rate (SKGFR). SKGFR was measured using a novel method of synchronous (51)Chromium ethylenediamine tetraacetic acid glomerular filtration rate ((51)CrEDTA-GFR) and (99m)Technetium dimercaptosuccinic acid ((99m)TcDMSA) scintigraphy. We studied 79 patients with a mean age of 68.9 years (25.2-88.2), 44 males and 35 females. The mean age of the males was 70 years (60-80) and females 67 years (25.2-88.2).

RESULTS

We found that the precision of the SKGFR was 2 ml/min. For paired kidneys we found: (i) no significant difference between kidneys with stenosis (17.3 ml/min) compared to those without stenosis (13.6 ml/min) (P=0.22); (ii) kidneys with occluded renal arteries had significantly less function (2.6 ml/min) than those without occlusion (24.5 ml/min) (P<0.05). When degree of renal arteries stenosis was correlated with SKGFR there was a reduction with an increasing degree of stenosis (<30% 27 ml/min, 30-60% 17.7 ml/min, >60% stenosis 15 ml/min, P=0. 016).

CONCLUSIONS

These data demonstrate that SKGFR provides a reproducible measure of individual kidney function. There was a similar impairment of function in paired kidneys with and without renal artery stenosis, but occlusion was associated with significant reduction in function compared to the contralateral kidney. This suggests that there is a process causing renal dysfunction in patients with atherosclerotic disease independent of renal artery narrowing.

Atherosclerotic nephropathy

BACKGROUND

Lipid moieties may have direct or indirect effects on the kidney. The association of aortic atherosclerosis and renal artery stenosis has focused interest on this as an important cause of end-stage renal failure. This article seeks to examine the evidence for the entity of atherosclerotic nephropathy.

METHODS

Published data on the incidence of atherosclerotic renal artery stenosis as the cause of end-stage renal failure are presented, as well as the associated features of atherosclerotic renal stenosis.

RESULTS

Atherosclerotic renal artery stenosis (ARAS) has been estimated to be the cause of between 14 and 25% of patients reaching end-stage renal failure in older age groups. There is considerable evidence of proteinuria in patients with ARAS. Recent data have shown that renal length may decrease by 1 cm or more in 35% of kidneys with > 60% stenosis. However, other data suggest that renal function in kidneys without renal artery stenosis but with contralateral renal artery stenosis may be similarly decreased.

CONCLUSION

Many processes contribute to renal dysfunction in atherosclerotic aortic disease. Although ischemia may play a role, there is considerable evidence that processes such as atheroembolic disease may be important, and it would be better to use the term "atherosclerotic nephropathy" for this important disease entity.