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Matsushima T, Mitsunari K, Maekawa N, Yamada S, Ito H, Kurata H, Nakamura Y, Matsuo T, Ohba K, Imamura R. Partial penectomy for severe penile ulceration caused by cholesterol crystal embolization. IJU Case Rep 2023; 6:394-397. [PMID: 37928290 PMCID: PMC10622217 DOI: 10.1002/iju5.12631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/19/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Cholesterol crystal embolism is a rare microembolic disease caused by cholesterol crystals that can present with various symptoms after vascular surgery, catheterization, or anticoagulation therapy. We report a case of penile ulceration caused by cholesterol crystal embolism. Case presentation A 72-year-old man undergoing maintenance dialysis for end-stage renal failure presented with penile pain and a black glans ulcer. Despite low-density lipoprotein apheresis, he was referred to our hospital because of lack of improvement. Based on his medical history and clinical presentation, including artificial vascular replacement and right toe amputation, cholesterol crystal embolism was suspected and partial penectomy was performed, thus confirming the diagnosis. Penile pain resolved after surgery, and he was discharged on Day 10. Unfortunately, he died after small bowel perforation developed 2 months after surgery. Conclusion Penile ulcers caused by cholesterol crystal embolism may indicate the severity and progression of disease and typically require surgical intervention.
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Affiliation(s)
- Toshiki Matsushima
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kensuke Mitsunari
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Nobuhide Maekawa
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Shota Yamada
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Hidenori Ito
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Hiroki Kurata
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Yuichiro Nakamura
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Tomohiro Matsuo
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kojiro Ohba
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Ryoichi Imamura
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
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2
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Chaudhary S, Kashani KB. Acute Kidney Injury Management Strategies Peri-Cardiovascular Interventions. Interv Cardiol Clin 2023; 12:555-572. [PMID: 37673499 DOI: 10.1016/j.iccl.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
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.
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Affiliation(s)
- Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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3
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Shi C, Mammadova-Bach E, Li C, Liu D, Anders HJ. Pathophysiology and targeted treatment of cholesterol crystal embolism and the related thrombotic angiopathy. FASEB J 2023; 37:e23179. [PMID: 37676696 DOI: 10.1096/fj.202301316r] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/17/2023] [Accepted: 08/23/2023] [Indexed: 09/08/2023]
Abstract
Cholesterol crystal (CC) embolism is a complication of advanced atherosclerotic plaques located in the major arteries. This pathological condition is primarily induced by interventional and surgical procedures or occurs spontaneously. CC can induce a wide range of tissue injuries including CC embolism syndrome, a spontaneous or intervention-induced complication of advanced atherosclerosis, while treatment of CC embolism has remained empiric. Vascular occlusions caused by CC embolism may exceed the ischemia tolerance of many tissues, particularly when small arteries are affected. The main approach to CC embolism is primary prophylaxis in patients at risk by stabilizing atherosclerotic plaques and avoiding unnecessary catheter interventions. During CC embolism, the use of platelet inhibitors to avoid abnormal activation and aggregation and anticoagulants may reduce the risk of vascular occlusions and tissue ischemia. This probably explains the relatively low prevalence of clinical manifestations of CC embolism, which are frequently found in autopsy studies. In this review, we summarized the current knowledge on the pathophysiology of CC embolism syndrome deriving from clinical observations and experimental mouse models. Furthermore, we described the risk factors of CC embolism in humans as well as the experimental studies based on empiric treatments. We also discuss potential therapeutic interventions based on recent experimental data and emerging drug options evolving from other research domains. Given the substantial unmet medical need to improve the outcomes of CC embolism, the identification of effective treatment strategies is urgently needed.
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Affiliation(s)
- Chongxu Shi
- Nantong Laboratory of Development and Diseases, School of Life Sciences, Medical College, Nantong University, Nantong, China
| | - Elmina Mammadova-Bach
- Renal Division, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians University Munich, Munich, Germany
- Walther-Straub-Institute for Pharmacology and Toxicology, Ludwig-Maximilians University Munich, Munich, Germany
| | - Cong Li
- Renal Division, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians University Munich, Munich, Germany
| | - Dong Liu
- Nantong Laboratory of Development and Diseases, School of Life Sciences, Medical College, Nantong University, Nantong, China
| | - Hans-Joachim Anders
- Renal Division, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians University Munich, Munich, Germany
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4
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Tomoi Y, Soga Y, Imada K, Kodama K, Katsuki T, Hiramori S, Ando K. Use of Proprotein Converse Subtilisin/Kexin Type 9 Inhibitor to Treat Cholesterol Crystal Embolisms after Catheterization: A Report of Three Cases. Intern Med 2022; 61:857-860. [PMID: 34471031 PMCID: PMC8987251 DOI: 10.2169/internalmedicine.8088-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Cholesterol crystal embolism (CCE) is a serious complication that occurs after cardiac and vascular procedures. CCE involves multiple organs, and the prognosis and renal function of patients is poor. Although the efficacy of steroid, statin, and low-density lipoprotein apheresis has been reported, no definitive treatment has been established. We herein report three consecutive cases treated with conventional steroid therapy with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor after catheterization. The renal function was preserved, steroid therapy was stopped, and wound healing of blue toes was achieved. PCSK9 inhibitor therapy was safe in the present patient and may be a potential treatment option for CCE.
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Affiliation(s)
- Yusuke Tomoi
- Department of Cardiology, Kokura Memorial Hospital, Japan
| | | | - Kazuaki Imada
- Department of Cardiology, Kokura Memorial Hospital, Japan
| | - Kenji Kodama
- Department of Cardiology, Kokura Memorial Hospital, Japan
| | | | | | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Japan
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5
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Scott T, Ethier I, Hawley C, Pascoe EM, Viecelli AK, Ng A, Cho Y, Johnson DW. 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. BMC Nephrol 2021; 22:401. [PMID: 34856938 PMCID: PMC8638445 DOI: 10.1186/s12882-021-02604-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 11/03/2021] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Tahira Scott
- Department of Nephrology, Level 2, ARTS Building, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, QLD, 4102, Australia. .,School of Medicine, University of Queensland, Brisbane, Australia.
| | - Isabelle Ethier
- Department of Nephrology, Level 2, ARTS Building, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, QLD, 4102, Australia.,Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Carmel Hawley
- Department of Nephrology, Level 2, ARTS Building, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, QLD, 4102, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, Adelaide, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia
| | - Elaine M Pascoe
- School of Medicine, University of Queensland, Brisbane, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, Adelaide, Australia
| | - Andrea K Viecelli
- Department of Nephrology, Level 2, ARTS Building, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, QLD, 4102, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Arnold Ng
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Level 2, ARTS Building, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, QLD, 4102, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, Adelaide, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - David W Johnson
- Department of Nephrology, Level 2, ARTS Building, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, QLD, 4102, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, Adelaide, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia
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6
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Kondo Y, Kanzaki M, Ishima D, Usui R, Kimura A, Usui K, Amoh Y, Takeuchi Y, Kumabe T, Ako J, Miyaji K, Nishiyama K, Akutsu T. Cholesterol crystal embolism-related cerebral infarction: Magnetic resonance imaging and clinical characteristics. eNeurologicalSci 2021; 25:100388. [PMID: 34977369 PMCID: PMC8683713 DOI: 10.1016/j.ensci.2021.100388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/30/2021] [Accepted: 12/04/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND AIMS Cholesterol crystal embolism-related cerebral infarction (CCE-CI) is frequently misdiagnosed due to the lack of specific symptoms. To aid in differential diagnosis, this study comprehensively characterized the magnetic resonance imaging (MRI) and clinical manifestations of CCE-CI and compared these features to those of atherothrombotic cerebral infarction (ACI). METHODS This single-center, retrospective, observational study was conducted at Kitasato University Hospital, Kanagawa, Japan. We identified 37 clinically or histopathologically confirmed CCE-CI cases and 110 ACI cases treated from January 2006 to May 2020. Groups were compared for mean age, sex ratio, clinical presentations, imaging manifestations, precipitating factors, comorbid conditions, medications, and smoking history. RESULTS Of 37 eligible patients with CCE-CI, 10 (27.0%) received brain MRI, of which 8 (21.6%) exhibited high-intensity signals indicative of brain lesions on diffusion-weighted imaging (DWI). However, two patients with DWI lesions exhibited no detectable neurological abnormalities. Patients with CCE-CI frequently demonstrated bilateral DWI lesions involving the bilateral anterior and posterior circulation, a pattern absent in ACI (50% vs. 0%, p < 0.001). Compared to patients with ACI, CCE-CI patients also demonstrated significantly lower estimated glomerular filtration rate (p < 0.001) as well as more frequent eosinophilia (p = 0.006), atherosclerotic plaques ≥4-mm thick in the ascending aorta or proximal arch (p = 0.001), and aortic aneurysm (p < 0.001). CONCLUSIONS Patients with CCE-CI develop multiple DWI lesions across several vascular territories, even in the absence of neurological symptoms. Comorbid aortic aneurysm may increase CCE-CI risk. These findings could help in the differential diagnosis of CCE-CI.
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Key Words
- ACI, Atherothrombotic cerebral infarction
- Atheroembolism
- Atherothrombotic cerebral infarction
- CAS, Carotid artery stenting
- CCE, Cholesterol crystal embolism
- CI, Confidence intervals
- CRP, C-reactive protein
- CTA, Computed tomography angiography
- Cerebral infarction
- Cholesterol crystal embolism
- Cholesterol crystal embolism-related cerebral infarction
- DWI, Diffusion-weighted imaging
- Diffusion-weighted imaging
- IRB, Institutional review board
- LDL, Low-density lipoprotein
- MRA, Magnetic resonance angiography
- MRI, Magnetic resonance imaging
- OR, Odds ratios
- PCI, Percutaneous coronary intervention
- TIA, Transient ischemic attack
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Affiliation(s)
- Yuko Kondo
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Mami Kanzaki
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
| | - Daisuke Ishima
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
| | - Ryo Usui
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
| | - Ayato Kimura
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
| | - Kotaro Usui
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
| | - Yasuyuki Amoh
- Department of Dermatology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yasuo Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Toshihiro Kumabe
- Department of Neurosurgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kazutoshi Nishiyama
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
| | - Tsugio Akutsu
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
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7
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Baumer Y, McCurdy SG, Boisvert WA. Formation and Cellular Impact of Cholesterol Crystals in Health and Disease. Adv Biol (Weinh) 2021; 5:e2100638. [PMID: 34590446 PMCID: PMC11055929 DOI: 10.1002/adbi.202100638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 08/20/2021] [Indexed: 11/10/2022]
Abstract
Cholesterol crystals (CCs) were first discovered in atherosclerotic plaque tissue in the early 1900 and have since been observed and implicated in many diseases and conditions, including myocardial infarction, abdominal aortic aneurism, kidney disease, ocular diseases, and even central nervous system anomalies. Despite the widespread involvement of CCs in many pathologies, the mechanisms involved in their formation and their role in various diseases are still not fully understood. Current knowledge concerning the formation of CCs, as well as the molecular pathways activated upon cellular exposure to CCs, will be explored in this review. As CC formation is tightly associated with lipid metabolism, the role of cellular lipid homeostasis in the formation of CCs is highlighted, including the role of lysosomes. In addition, cellular pathways and processes known to be affected by CCs are described. In particular, CC-induced activation of the inflammasome and production of reactive oxygen species, along with the role of CCs in complement-mediated inflammation is discussed. Moreover, the clinical manifestation of embolized CCs is described with a focus on renal and skin diseases associated with CC embolism. Lastly, potential therapeutic measures that target either the formation of CCs or their impact on different cell types and tissues are highlighted.
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Affiliation(s)
- Yvonne Baumer
- Social Determinants of Obesity and Cardiovascular Risk Laboratory, National Heart, Lung, and Blood Institute, Building 10, 10 Center Drive, Bethesda, MD 20814, USA
| | - Sara G. McCurdy
- Dept. of Medicine, University of California San Diego, 9500 Gilman Street, La Jolla, CA 92093, USA
| | - William A. Boisvert
- Center for Cardiovascular Research, University of Hawaii, 651 Ilalo Street, Honolulu, HI 96813, USA
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8
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Yan X, Zhu Y, Wang X, Li Z. A case of acute renal injury and renal artery stenosis caused by cholesterol crystal embolization after coronary stenting: Improved by a combination therapy. Chronic Dis Transl Med 2021; 7:206-210. [PMID: 34505021 PMCID: PMC8413122 DOI: 10.1016/j.cdtm.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Indexed: 12/04/2022] Open
Affiliation(s)
- Xiaohui Yan
- Center of Nephropathy and Hemodialysis, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710061, China
| | - Yanting Zhu
- Center of Nephropathy and Hemodialysis, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710061, China
| | - Xiaoming Wang
- Center of Nephropathy and Hemodialysis, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710061, China
| | - Zhenjiang Li
- Center of Nephropathy and Hemodialysis, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710061, China
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9
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Cholesterol Embolization Syndrome After Kidney Transplantation: A Case Series and Systematic Review. Transplant Direct 2021; 7:e717. [PMID: 34476296 PMCID: PMC8384396 DOI: 10.1097/txd.0000000000001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/09/2021] [Accepted: 03/22/2021] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Cholesterol embolization syndrome (CES) is an uncommon but well-known cause of renal failure in native kidneys, but little is known about CES in kidney transplant recipients. The aim of this study was to determine the incidence, clinical characteristics, histopathology, and prognosis of CES after kidney transplantation. Methods. CES cases in both transplanted and native kidneys (control group) were identified by searching the databases of the divisions of Nephrology and Pathology of our institution. Clinical data were retrospectively collected. Biopsies were classified according to the latest Banff 2019 Update. Second, a systematic literature search was performed (December 01, 2020) of Ovid MEDLINE, EMBASE, the Cochrane Central Register of controlled trials, Google Scholar, and Web of Science. Results. CES was observed in for-cause biopsies of 11 out of 2350 (0.47%) kidney transplant recipients transplanted between January 1, 2006, and December 31, 2018 (0.0009 cases per person-year). All patients had ≥1 cardiovascular risk factor, and 9 donors were expanded criteria donors. Graft loss occurred in 27.3% of the patients diagnosed with CES. Eight transplant biopsies with CES were also classified as biopsy-proven acute rejection. Transplant biopsies showed signs of inflammation (arteritis, n = 7; interstitial inflammation, n = 5; tubulitis, n = 7). One patient with CES in a native kidney was identified. The biopsy of the native kidney only showed arteritis and classified as an isolated “v” lesion. The literature search resulted in 188 unique articles of which 20 were included. A total of 47 cases of CES after kidney transplantation was reported. Cholesterol emboli were found in <1% of all kidney transplant biopsies. In 57.8% of the kidney transplant biopsies with CES described in literature, concomitant inflammation was present. Conclusions. CES is an uncommon cause of kidney transplant failure, although the incidence of CES may be underestimated. CES may mimic rejection as it can be accompanied by arteritis.
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10
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Carande EJ, Brown K, Jackson D, Maskell N, Kouzaris L, Greene G, Mikhail A, Obaid DR. Acute Kidney Injury Following Percutaneous Coronary Intervention for Acute Coronary Syndrome: Incidence, Aetiology, Risk Factors and Outcomes. Angiology 2021; 73:139-145. [PMID: 34459224 DOI: 10.1177/00033197211040375] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We investigated the predictors, aetiology and long-term outcomes of acute kidney injury (AKI) following urgent percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Acute kidney injury occurred in 198 (7.2%) of 2917 patients: 14.1% of AKI cases were attributed to cardiogenic shock and 5.1% were classified as atheroembolic renal disease (AERD). Significant risk factors for AKI included age (odds ratio [OR] 1.05, 95% confidence limits [CI] 1.03-1.06), diabetes (OR 1.73, 95% CI 1.20-2.47), hypertension (OR 1.43, 95% CI 1.03-2.00), heart failure (OR 3.01, 95% CI 1.58-5.57), femoral access (OR 1.50, 95% CI 1.03-2.15), cardiogenic shock (OR 2.03, 95% CI 1.19-3.37) and ST-elevation myocardial infarction (STEMI) (OR 3.89, 95% CI 2.80-5.47). One-year mortality after AERD was 44.4% and renal replacement therapy (RRT) requirement 22.2% (compared with mortality 33.3% and RRT requirement 7.4%, respectively, in all other AKI patients). Mortality at 1 year was associated with AKI (OR 4.33, 95% CI 2.89-6.43), age (OR 1.08, 95% CI 1.06-1.09), heart failure (OR 1.92, 95% CI 1.05-3.44), femoral access (OR 2.05, 95% CI 1.41-2.95) and cardiogenic shock (OR 3.63, 95% CI 2.26-5.77). Acute kidney injury after urgent PCI is strongly associated with worse outcomes. Atheroembolic renal disease has a poor outcome and a high likelihood of long-term RRT requirement.
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Affiliation(s)
- Elliott J Carande
- Swansea Bay University Health Board, 97701Morriston Hospital, Swansea, UK
| | - Karen Brown
- Swansea Bay University Health Board, 97701Morriston Hospital, Swansea, UK
| | - David Jackson
- Swansea Bay University Health Board, 97701Morriston Hospital, Swansea, UK
| | - Nicholas Maskell
- Swansea Bay University Health Board, 97701Morriston Hospital, Swansea, UK
| | | | | | - Ashraf Mikhail
- Swansea Bay University Health Board, 97701Morriston Hospital, Swansea, UK
| | - Daniel R Obaid
- Swansea Bay University Health Board, 97701Morriston Hospital, Swansea, UK.,151375Swansea University Medical School, Swansea, UK
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11
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Ishiyama K, Sato T. Efficacy of LDL apheresis for the treatment of cholesterol crystal embolism: A prospective, controlled study. Ther Apher Dial 2021; 26:456-464. [PMID: 34216189 DOI: 10.1111/1744-9987.13706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/24/2021] [Accepted: 07/01/2021] [Indexed: 11/29/2022]
Abstract
This study was performed to evaluate the efficacy and safety of LDL apheresis (LDL-A) for the treatment of cholesterol crystal embolism (CCE) after cardiovascular procedures. We conducted a prospective multicenter study of 34 patients with CCE and 15 historical control patients. The present participants underwent six sessions of LDL-A for 4 weeks and underwent medical therapy with corticosteroids and statins. The mean creatinine concentration and estimated glomerular filtration rate at baseline were 3.82 ± 2.29 mg/dL and 17.8 ± 9.9 mL/min/1.73 m2 , respectively. The prevalence of maintenance dialysis at 24 weeks was significantly lower in the present participants than in the historical controls (3.1% vs. 40.0%, respectively; p < 0.0001), but the mortality rate at 24 weeks was comparable (19% vs. 33%, respectively). Although 45 adverse events occurred in 23 participants, there were no unexpected adverse events. LDL-A for CCE reduces the prevalence of maintenance dialysis 24 weeks later and is well tolerated. This study was registered in the Japan Registry of Clinical Trials (jRCTs022180029) and clinicaltrials.gov (NCT01726868).
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Affiliation(s)
- Katsuya Ishiyama
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, Sendai, Miyagi, Japan.,Department of Comprehensive Medicine for Kidney Disease-related Disorders, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.,Faculty of Medicines, Division of Nephrology and Endocrinology, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
| | - Toshinobu Sato
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, Sendai, Miyagi, Japan.,Department of Comprehensive Medicine for Kidney Disease-related Disorders, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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12
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Hamura R, Haruki K, Iwase R, Furukawa K, Shirai Y, Onda S, Gocho T, Ikegami T. Ischemic small bowel perforation caused by cholesterol crystal embolism following transcatheter arterial chemoembolization for recurrent hepatocellular carcinoma: a case report. Surg Case Rep 2021; 7:45. [PMID: 33566211 PMCID: PMC7876172 DOI: 10.1186/s40792-021-01116-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 01/14/2021] [Indexed: 11/17/2022] Open
Abstract
Background Cholesterol crystal embolism (CCE) following transcatheter arterial chemoembolization (TACE) is rare. Case presentation A 71-year-old man underwent TACE for recurrence of hepatocellular carcinoma (HCC). On postoperative day (POD) 5, he developed abdominal pain and fever. Computed tomography revealed intraperitoneal free air. The patient was diagnosed with gastrointestinal perforation with peritonitis, for which partial intestinal resection and covering ileostomy were performed. Histological examination revealed perforation of the small intestine caused by CCE. The patient made a satisfactory recovery and was discharged on POD 30. The patient showed no recurrence of cholesterol crystal embolism or HCC for 2 years after surgery. Conclusion We reported a successfully treated case of ischemic small bowel perforation due to cholesterol crystal embolism following transcatheter arterial chemoembolization for recurrent HCC.
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Affiliation(s)
- Ryoga Hamura
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Koichiro Haruki
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Ryota Iwase
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Kenei Furukawa
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yoshihiro Shirai
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shinji Onda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takeshi Gocho
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
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Morino J, Hirai K, Kaneko S, Minato S, Yanai K, Mutsuyoshi Y, Ishii H, Matsuyama M, Kitano T, Shindo M, Aomatsu A, Miyazawa H, Ito K, Ueda Y, Ookawara S, Morishita Y. Successful treatment of cholesterol crystal embolism with anti-proprotein convertase subtilisin/kexin type 9 (PCSK9) antibody: a case report. Ren Fail 2020; 42:173-178. [PMID: 32046605 PMCID: PMC7034108 DOI: 10.1080/0886022x.2020.1726383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background We report a unique case of renal cholesterol crystal embolism (CCE) induced by carotid artery stenting that was successfully treated with evolocumab, a fully human monoclonal antibody against proprotein convertase subtilisin kexin type 9 (PCSK9). Case presentation A 77-year-old man with hypertension, hyperlipidemia, and chronic kidney disease was referred to our department for decreased estimated glomerular filtration rate (eGFR)—from 32.0 to 13.9 mL/min/1.73 m2—5 weeks after carotid artery stenting. Further examination revealed livedo reticularis in the bilateral toes and eosinophilia (723/μL). Skin biopsy from livedo reticularis tissue in the bilateral toes showed cholesterol clefts in the small arteries. The patient was therefore diagnosed with CCE. After 25 weeks’ administration of evolocumab at a dose of 140 mg subcutaneously administered every 2 weeks, his eGFR had improved from 10.7 to 18.1 mL/min/1.73 m2. Conclusion Evolocumab may have a beneficial effect on renal involvement in patients with CCE.
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Affiliation(s)
- Junki Morino
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keiji Hirai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shohei Kaneko
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Saori Minato
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Katsunori Yanai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuko Mutsuyoshi
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroki Ishii
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Momoko Matsuyama
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taisuke Kitano
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mitsutoshi Shindo
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Akinori Aomatsu
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Haruhisa Miyazawa
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kiyonori Ito
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuichiro Ueda
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Susumu Ookawara
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yoshiyuki Morishita
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Maadarani O, Alfayed H, Bitar Z, Daher M, Zaalouk T, Abdelfatah M. Acalculous Cholecystitis Complicated by Liver Abscess as a Manifestation of Cholesterol Embolization Syndrome - Infrequent Manifestation Precipitated by a Common Procedure. Eur J Case Rep Intern Med 2020; 7:001953. [PMID: 33313008 PMCID: PMC7727639 DOI: 10.12890/2020_001953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 08/25/2020] [Indexed: 11/05/2022] Open
Abstract
Cholesterol embolization syndrome (CES) is an atherosclerotic complication affecting different systems with various clinical manifestations, usually triggered iatrogenically by interventional and surgical procedures or thrombolytic therapy, although spontaneous cases have been reported. The hepatobiliary system can also be affected when the showered cholesterol crystals obliterate small vessels within this system causing both ischaemic and inflammatory responses. We describe a case of a male patient who initially developed multiple lacunar cerebral infarcts 10 days post-thrombolytic therapy and percutaneous coronary intervention (PCI) due to acute myocardial infarction. Several weeks later he developed acalculous cholecystitis complicated by liver abscess and kidney injury. The consequences and latency of manifestations within different organs and the temporal relationship with well-known trigger factors raised the suspicion of CES.
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Affiliation(s)
- Ossama Maadarani
- Internal Medical Department, Ahmadi Hospital - Kuwait Oil Company, Kuwait
| | - Hany Alfayed
- Internal Medical Department, Ahmadi Hospital - Kuwait Oil Company, Kuwait
| | - Zouheir Bitar
- Internal Medical Department, Ahmadi Hospital - Kuwait Oil Company, Kuwait
| | - Moataz Daher
- Internal Medical Department, Ahmadi Hospital - Kuwait Oil Company, Kuwait
| | - Tamer Zaalouk
- Internal Medical Department, Ahmadi Hospital - Kuwait Oil Company, Kuwait
| | - Mohamad Abdelfatah
- Internal Medical Department, Ahmadi Hospital - Kuwait Oil Company, Kuwait
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15
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Cholesterol Embolization Syndrome After Carotid Artery Stenting Associated with Delayed Cerebral Hyperperfusion Intracerebral Hemorrhage. World Neurosurg 2020; 142:274-282. [PMID: 32679361 DOI: 10.1016/j.wneu.2020.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The cholesterol embolization syndrome (CES) results from the distal embolization of cholesterol crystals from atheromatous plaques in large vessels such as the aorta and results in multiorgan damage. CASE DESCRIPTION We present the case of a patient with definite CES with skin manifestations (e.g., blue toes) and renal and neurological dysfunction, including parenchymal hematoma with cytotoxic and vasogenic edema after he had undergone left carotid artery stenting for symptomatic critical left carotid artery stenosis. CONCLUSIONS Our patient with CES had cutaneous involvement affecting the lower limbs and renal and neurological involvement. High clinical suspicion and early treatment can reduce the mortality and morbidity after endovascular procedures. The neurological symptoms had most likely resulted from delayed cerebral hyperperfusion syndrome resulting in intracerebral hemorrhage.
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16
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Tanaka H, Yamana H, Matsui H, Fushimi K, Yasunaga H. Proportion and risk factors of cholesterol crystal embolization after cardiovascular procedures: a retrospective national database study. Heart Vessels 2020; 35:1250-1255. [PMID: 32277287 DOI: 10.1007/s00380-020-01593-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/27/2020] [Indexed: 01/30/2023]
Abstract
Cholesterol crystal embolization (CCE) is a rare, mainly iatrogenic condition. The proportion of CCE after cardiovascular procedures has not been fully elucidated. The purpose of this study was to determine the proportion of CCE diagnosed after cardiovascular procedures and to identify risk factors for CCE occurrence. Data on patients aged older than 40 years who underwent cardiovascular procedures between July 2010 and March 2017 were extracted from the Japanese Diagnosis Procedure Combination database. Inpatients diagnosed with CCE within 1 year after procedures in the same hospital were identified. Logistic regression analysis was performed to identify factors associated with the occurrence of CCE. There were 962 patients with CCE in 2,190,300 patients who underwent cardiovascular procedures. The overall proportion of CCE after cardiovascular procedures was 4.4 per 10,000 patients (95% confidence interval 4.1-4.7). The overall in-hospital mortality among patients with CCE was 11% (107/962). Older age, male sex, smoking, heart failure, peripheral vascular disease, cerebrovascular disease, renal insufficiency, diabetes mellitus, hypertension, and aortic aneurism and dissection were significantly associated with the higher occurrence of CCE. Compared with cardioangiography, several procedures were significantly associated with higher occurrence of CCE, including intra-aortic balloon pumping, percutaneous transluminal angioplasty of the renal artery, and transcatheter aortic valve implantation or balloon aortic valvuloplasty. CCE is rare but remains a severe complication of cardiovascular procedures. Atherosclerotic risk factors and certain cardiovascular procedures were associated with CCE.
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Affiliation(s)
- Hiroyuki Tanaka
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan. .,Department of Nephrology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.
| | - Hayato Yamana
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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17
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Association between eosinophilia and renal prognosis in patients with pathologically proven cholesterol crystal embolism. Clin Exp Nephrol 2020; 24:680-687. [PMID: 32266635 PMCID: PMC7371646 DOI: 10.1007/s10157-020-01886-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 03/25/2020] [Indexed: 11/25/2022]
Abstract
Background Approximately, 20–70% of patients with cholesterol crystal embolism (CCE) have eosinophilia. However, it remains unknown how eosinophilia influences renal prognosis in patients with CCE. In this study, we investigated the association between eosinophil count (Eo) and renal prognosis in CCE patients on steroid therapy. Methods The present study is a single-centered retrospective cohort study in patients with renal dysfunction and CCE from April 2007 to May 2018. This study included the patients who were treated with neither maintenance dialysis nor steroid before CCE diagnosis, and followed-up for kidney function until November 2019. We assessed whether eosinophilia at the time of CCE diagnosis was related to renal death after treating with steroid therapy. Results Thirty patients with pathologically diagnosed CCE were enrolled and followed-up for 11.0 (5.2–43.4) months. There were significant differences in the white blood cell count (p = 0.01), hemoglobin (p = 0.009), serum creatinine levels (p = 0.008), phosphate (p = 0.049), and Eo (p = 0.008) between the renal survival and renal death groups. Using the receiver operating characteristic curve analysis with Youden index, Eo of 810/µL showed 100% sensitivity and 69.6% specificity for detecting renal death (area under the curve: 0.839). Comparing the outcomes in patients having Eo ≥ and < 810/µL using the log-rank test, there is a significantly higher renal death rate in CCE patients with Eo ≥ 810/µL (p = 0.0016). Conclusion Higher eosinophilia was a prognostic risk factor for renal death in the patients with CCE.
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Denis Le Seve J, Gourraud Vercel C, Connault J, Artifoni M. [Update on cholesterol crystal embolism]. Rev Med Interne 2020; 41:250-257. [PMID: 32088097 DOI: 10.1016/j.revmed.2020.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 12/19/2019] [Accepted: 02/01/2020] [Indexed: 10/25/2022]
Abstract
Cholesterol crystal embolism is a systemic pathology associated with diffuse atherosclerosis. Pathophysiology corresponds to tissue necro-inflammation secondary to arteriolar occlusion associated with microembolism from atherosclerotic plaques of large diameter arteries. The clinical presentation is heterogeneous and polymorphic. Multiple organs may be the targets, but preferential damage is skin, kidneys and digestive system. It is a serious pathology, underdiagnosed, with a poor prognosis. The risk factors for developing the disease remain the same risk factors as atheroma. The factors favouring migration of microembolism remain mainly vascular interventional procedures; easy to diagnose, they oppose spontaneous embolic migrations or secondary to the introduction of antithrombotic treatment, whose diagnosis is more difficult and the prognosis more severe. The diagnosis of the disease remains mostly a diagnosis of elimination and often refers to a bundle of clinical, biological, morphological and histologic arguments. The treatment is poorly codified and the subject of few publications. It will favour both symptomatic treatment (and mainly that of pain) and complications (high blood pressure, renal insufficiency). The aetiological support remains less consensual. The treatment of atherosclerotic plaques consists, of course, in the correction of classical cardiovascular risk factors, the introduction of a statin. It will be discussed in the implementation of surgery or angioplasty to exclude potentially responsible atherosclerotic lesions. Eviction of antithrombotic therapy should be considered in terms of the benefit-risk balance, but often in favour of maintaining it. Finally, other treatments may be proposed in a case-by-case basis, such as oral or intravenous corticosteroid therapy, colchicine or LDL aphaeresis.
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Affiliation(s)
- J Denis Le Seve
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France.
| | - C Gourraud Vercel
- Service de néphrologie et immunologie clinique, centre hospitalier universitaire de Nantes, 30, boulevard Jean-Monnet, immeuble Jean-Monnet, 44093 Nantes cedex 1, France
| | - J Connault
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - M Artifoni
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
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Hamroun A, Frimat M, Beuscart JB, Buob D, Lionet A, Lebas C, Daroux M, Provôt F, Hazzan M, Boulanger É, Glowacki F. [Kidney disease care for the elderly]. Nephrol Ther 2019; 15:533-552. [PMID: 31711751 DOI: 10.1016/j.nephro.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In our aging population, kidney disease management needs to take into account the frailty of the elderly. Standardized geriatric assessments can be proposed to help clinicians apprehend this dimension in their daily practice. These tools allow to better identify frail patients and offer them more personalized and harmless treatments. This article aims to focus on the kidney diseases commonly observed in elderly patients and analyze their specific nephrogeriatric care modalities. It should be noticed that all known kidney diseases can be also observed in the elderly, most often with a quite similar clinical presentation. This review is thus focused on the diseases most frequently and most specifically observed in elderly patients (except for monoclonal gammopathy associated nephropathies, out of the scope of this work), as well as the peculiarities of old age nephrological care.
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Affiliation(s)
- Aghilès Hamroun
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Marie Frimat
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | | | - David Buob
- Service d'anatomopathologie, Centre de biologie-pathologie, CHRU de Lille, 59037 Lille, France
| | - Arnaud Lionet
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Céline Lebas
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Maïté Daroux
- Service de néphrologie, hôpital Duchenne, allée Jacques Monod, 62200 Boulogne-sur-Mer, France
| | - François Provôt
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Marc Hazzan
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Éric Boulanger
- Service de gériatrie, CHRU de Lille, 59037 Lille, France
| | - François Glowacki
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France.
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20
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Ozkok A. Cholesterol-embolization syndrome: current perspectives. Vasc Health Risk Manag 2019; 15:209-220. [PMID: 31371977 PMCID: PMC6626893 DOI: 10.2147/vhrm.s175150] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/10/2019] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Abdullah Ozkok
- Department of Internal Medicine and Nephrology, Memorial Şişli Hospital, Istanbul, Turkey
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21
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Piranavan P, Rajan A, Jindal V, Verma A. A rare presentation of spontaneous atheroembolic renal disease: A case report. World J Nephrol 2019; 8:67-74. [PMID: 31363463 PMCID: PMC6656662 DOI: 10.5527/wjn.v8.i3.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/01/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Atheroembolic renal disease (AERD) is caused by occlusion of the small renal arteries from embolized cholesterol crystals arising from ulcerated atherosclerotic plaques. This usually manifests as isolated renal disease or involvement from systemic atheroembolic disease. Here we report a case of AERD that responded well to steroid therapy. CASE SUMMARY A 62-year-old woman with a history of hypertension and stage IIIa chronic kidney disease was referred for rapidly worsening renal function over a 4-mo period. She complained of swollen legs, dyspnea on exertion, and two episodes of epistaxis about a month prior to admission. She reported no history of invasive vascular procedures, use of radio contrast agents, or treatment with anticoagulants or thrombolytic agents. Urinalysis showed a few red blood cells and granular casts. Serology was positive for cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA). Non-contrast-enhanced computed tomography of the chest, abdomen, and pelvis showed diffuse atherosclerotic changes in the aortic arch. Thus, c-ANCA-associated vasculitis was suspected, and the patient was started on pulse intravenous methylprednisolone. Her renal biopsy showed evidence of AERD. She was discharged with oral prednisone, and her renal function continued to improve during the initial follow-up. CONCLUSION In cases of non-vasculitis-associated ANCA, a high degree of clinical suspicion is required to pursue the diagnosis of spontaneous AERD in patients with clinical or radiological evidence of atherosclerotic burden. Although no specific treatment is available, the potential role of statins and steroids requires exploration.
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Affiliation(s)
| | - Ashna Rajan
- Department of Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Vishal Jindal
- Department of Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Ashish Verma
- Division of Nephrology, Saint Vincent Hospital, Worcester, MA 01608, United States
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22
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Piranavan P, Rajan A, Jindal V, Verma A. A rare presentation of spontaneous atheroembolic renal disease: A case report. World J Nephrol 2019. [DOI: 10.5527/wjcc.v8.i3.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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23
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Falcão LP, Fernandes S, Costa AC, Teixeira C, Raimundo M, Silva S, Miranda M, Almeida ED. An atypical presentation of a severe and massive atheroembolic disease. J Bras Nefrol 2019; 41:142-144. [PMID: 30129967 PMCID: PMC6534016 DOI: 10.1590/2175-8239-jbn-2018-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 06/28/2018] [Indexed: 11/27/2022] Open
Abstract
Atheroembolic renal disease (AERD) is a kidney manifestation of atherosclerosis as a systemic disease. AERD is defined as a renal impairment secondary to embolization of cholesterol crystals with consequent occlusion of renal vascularization. The current case report describes one patient with multiple risk factors but without any inciting event history who presents a very atypical clinical course of a severe and massive atheroembolic disease that developed spontaneously and silently.
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Affiliation(s)
- Luis Pedro Falcão
- Hospital Beatriz Ângelo, Departamento de Nefrologia, Loures, Portugal
| | - Sara Fernandes
- Hospital Beatriz Ângelo, Departamento de Nefrologia, Loures, Portugal
| | | | - Catarina Teixeira
- Hospital Beatriz Ângelo, Departamento de Nefrologia, Loures, Portugal
| | - Mário Raimundo
- Hospital Beatriz Ângelo, Departamento de Nefrologia, Loures, Portugal
| | - Sónia Silva
- Hospital Beatriz Ângelo, Departamento de Nefrologia, Loures, Portugal
| | - Margarida Miranda
- Hospital Beatriz Ângelo, Departamento de Oftalmologia, Loures, Portugal
| | - Edgar De Almeida
- Hospital Beatriz Ângelo, Departamento de Nefrologia, Loures, Portugal
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24
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Gauckler P, Shin JI, Mayer G, Kronbichler A. Eosinophilia and Kidney Disease: More than Just an Incidental Finding? J Clin Med 2018; 7:E529. [PMID: 30544782 PMCID: PMC6306805 DOI: 10.3390/jcm7120529] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 11/29/2018] [Accepted: 12/05/2018] [Indexed: 02/07/2023] Open
Abstract
Peripheral blood eosinophilia (PBE), defined as 500 eosinophils or above per microliter (µL) blood, is a condition that is not uncommon but often neglected in the management of patients with chronic kidney disease (CKD), acute kidney injury (AKI), or patients on renal replacement therapy (RRT). The nature of PBE in the context of kidney diseases is predominantly secondary or reactive and has to be distinguished from primary eosinophilic disorders. Nonetheless, the finding of persistent PBE can be a useful clue for the differential diagnosis of underdiagnosed entities and overlapping syndromes, such as eosinophilic granulomatosis with polyangiitis (EGPA), IgG4-related disease (IgG4-RD), acute interstitial nephritis (AIN), or the hypereosinophilic syndrome (HES). For patients on RRT, PBE may be an indicator for bio-incompatibility of the dialysis material, acute allograft rejection, or Strongyloides hyperinfection. In a subset of patients with EGPA, eosinophils might even be the driving force in disease pathogenesis. This improved understanding is already being used to facilitate novel therapeutic options. Mepolizumab has been licensed for the management of EGPA and is applied with the aim to abrogate the underlying immunologic process by blocking interleukin-5. The current article provides an overview of different renal pathologies that are associated with PBE. Further scientific effort is required to understand the exact role and function of eosinophils in these disorders which may pave the way to improved interdisciplinary management of such patients.
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Affiliation(s)
- Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea.
- Department of Pediatric Nephrology, Severance Children's Hospital, Seoul 03722, Korea.
- Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul 03722, Korea.
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
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Çınar T, Rencüzoğulları I, Karabağ Y, Çağdaş M. Renal arterial atherothrombosis due to catheter-induced dissection: Necessity of urgent intervention in a patient with a solitary functioning kidney. Heart Lung 2018; 48:69-71. [PMID: 30121120 DOI: 10.1016/j.hrtlng.2018.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 07/17/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Renal artery stenosis (RAS) is a leading cause of hypertension, renal failure, pulmonary edema, and loss of renal mass. Atherothrombotic renal disease is a well-described entity, known primarily for its high mortality rate. CASE Here, we present a case of acute unrecognized atherothrombosis of RAS due to catheter-induced dissection in a patient with a limited functioning renal artery and solitary kidney. A fifty-two-year-old patient recently diagnosed with hypertension was admitted to our cardiology clinic showing symptoms of uncontrolled hypertension. A renal angiography revealed 90% stenosis in the proximal segment of the right renal artery and totally occluded left renal artery. We decided to perform a percutaneous revascularization. However, the patient did not accept it. During follow-up, the patient's clinical condition deteriorated abruptly due to acute iatrogenic atherothrombosis. A percutaneous transluminal angioplasty was performed, and the patency of the renal artery was secured. CONCLUSION Renal angiography may cause acute iatrogenic atherothrombosis due to catheter-induced dissection in patients with solitary functioning kidneys. Percutaneous transluminal angioplasty may secure the patency of the renal artery.
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Affiliation(s)
- Tufan Çınar
- Sultan Abdülhamid Han Training and Research Hospital, Health Sciences University, Tibbiye Street, Uskudar, Istanbul, Turkey.
| | | | - Yavuz Karabağ
- Department of Cardiology, Kafkas University Medical School, Kars, Turkey
| | - Metin Çağdaş
- Department of Cardiology, Kafkas University Medical School, Kars, Turkey
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Agrawal A, Ziccardi MR, Witzke C, Palacios I, Rangaswami J. Cholesterol embolization syndrome: An under-recognized entity in cardiovascular interventions. J Interv Cardiol 2017; 31:407-415. [PMID: 29243285 DOI: 10.1111/joic.12483] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 11/21/2017] [Accepted: 11/29/2017] [Indexed: 12/15/2022] Open
Abstract
Cholesterol embolization syndrome (CES) is a multi-systemic disease caused by embolization of atherosclerotic plaque contents from proximal large-caliber artery to distal small to medium arteries, occurring spontaneously or more commonly after vascular intervention. This report is a comprehensive review of the reported cases of CES found in our literature search. We discuss the risk factors, clinical manifestations, management, and prognosis of CES. The major predisposing factors for CES include older age, male sex, atherosclerotic cardiovascular risk factors, anticoagulation, and femoral access route. The composite incidence of atheroembolic renal disease was 92% and mortality 63%. Our review highlights the importance to recognize this disease entity for the cardiologist and nephrologist.
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Affiliation(s)
- Akanksha Agrawal
- Department of Internal Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania
| | | | - Christian Witzke
- Division of Cardiology, Albert Einstein Medical Center, Philadelphia, Pennsylvania
| | - Igor Palacios
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Janani Rangaswami
- Department of Internal Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania.,Division of Nephrology, Albert Einstein Medical Center, Philadelphia, Pennsylvania
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Li X, Bayliss G, Zhuang S. Cholesterol Crystal Embolism and Chronic Kidney Disease. Int J Mol Sci 2017; 18:E1120. [PMID: 28538699 PMCID: PMC5485944 DOI: 10.3390/ijms18061120] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 05/19/2017] [Accepted: 05/20/2017] [Indexed: 01/01/2023] Open
Abstract
Renal disease caused by cholesterol crystal embolism (CCE) occurs when cholesterol crystals become lodged in small renal arteries after small pieces of atheromatous plaques break off from the aorta or renal arteries and shower the downstream vascular bed. CCE is a multisystemic disease but kidneys are particularly vulnerable to atheroembolic disease, which can cause an acute, subacute, or chronic decline in renal function. This life-threatening disease may be underdiagnosed and overlooked as a cause of chronic kidney disease (CKD) among patients with advanced atherosclerosis. CCE can result from vascular surgery, angiography, or administration of anticoagulants. Atheroembolic renal disease has various clinical features that resemble those found in other kidney disorders and systemic diseases. It is commonly misdiagnosed in clinic, but confirmed by characteristic renal biopsy findings. Therapeutic options are limited, and prognosis is considered to be poor. Expanding knowledge of atheroembolic renal disease due to CCE opens perspectives for recognition, diagnosis, and treatment of this cause of progressive renal insufficiency.
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Affiliation(s)
- Xuezhu Li
- Division of Nephrology, Tongji University School of Medicine, Shanghai 200120, China.
| | - George Bayliss
- Department of Medicine, Rhode Island Hospital and Alpert Medical School, Brown University, Providence, RI 02903, USA.
| | - Shougang Zhuang
- Division of Nephrology, Tongji University School of Medicine, Shanghai 200120, China.
- Department of Medicine, Rhode Island Hospital and Alpert Medical School, Brown University, Providence, RI 02903, USA.
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Mulay SR, Anders HJ. Crystal nephropathies: mechanisms of crystal-induced kidney injury. Nat Rev Nephrol 2017; 13:226-240. [DOI: 10.1038/nrneph.2017.10] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
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.
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Affiliation(s)
- Yin Ping Liew
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Improvement in Renal Function and Reduction in Serum Uric Acid with Intensive Statin Therapy in Older Patients: A Post Hoc Analysis of the SAGE Trial. Drugs Aging 2016; 32:1055-65. [PMID: 26625880 PMCID: PMC4676790 DOI: 10.1007/s40266-015-0328-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background Improvement in renal function and decreases in serum uric acid (SUA) have been reported following prolonged high-intensity statin (HMG-CoA reductase inhibitor) therapy. This post hoc analysis of the SAGE trial examined the effect of intensive versus less intensive statin therapy on renal function, safety, and laboratory parameters, including SUA, in elderly coronary artery disease (CAD) patients (65–85 years) with or without chronic kidney disease (CKD). Methods Patients were randomized to atorvastatin 80 mg/day or pravastatin 40 mg/day and treated for 12 months. Patients were stratified using Modification of Diet in Renal Disease (MDRD) estimated glomerular filtration rates (eGFRs) in CKD (eGFR <60 mL/min/1.73 m2) and non-CKD populations. Results Of the 893 patients randomized, 858 had complete renal data and 418 of 858 (49 %) had CKD (99 % Stage 3). Over 12 months, eGFR increased with atorvastatin and remained stable with pravastatin (+2.38 vs. +0.18 mL/min/1.73 m2, respectively; p < 0.0001). MDRD eGFR improved significantly in both CKD treatment arms; however, the increased eGFR in patients without CKD was significantly greater with atorvastatin (+2.08 mL/min/1.73 m2) than with pravastatin (−1.04 mL/min/1.73 m2). Modest reductions in SUA were observed in both treatment arms, but a greater fall occurred with atorvastatin than with pravastatin (−0.52 vs. −0.09 mg/dL, p < 0.0001). Change in SUA correlated negatively with changes in eGFR and positively with changes in low-density lipoprotein cholesterol. Reports of myalgia were rare (3.6 % CKD; 5.7 % non-CKD), and there were no episodes of rhabdomyolysis. Elevated serum alanine and aspartate transaminase to >3 times the upper limit of normal occurred in 4.4 % of atorvastatin- and 0.2 % of pravastatin-treated patients. Conclusion Intensive management of dyslipidemia in older patients with stable coronary heart disease may have beneficial effects on renal function and SUA.
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Kim SH, Kang KM, Yu A, Lee JH, Nam BH, Lee ES. A Study of Relationship of Atheroembolic Risk Factors with Postoperative Recovery in Renal Function after Partial Nephrectomy in Patients Staged T1-2 Renal Cell Carcinoma during Median 4-Year Follow-up. Cancer Res Treat 2015; 48:288-96. [PMID: 25943322 PMCID: PMC4720065 DOI: 10.4143/crt.2014.297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 03/16/2015] [Indexed: 01/20/2023] Open
Abstract
Purpose The objective of this study is to evaluate the relationship of atheroembolic risk factors with postoperative recovery of renal function after on-clamp partial nephrectomy (PN) with warm ischemia in patients with staged T1-2 renal cell carcinoma (RCC). Materials and Methods A total of 234 patients from 2004 to 2012 were included, and their clinicopathologic and operative parameters, including atheroembolic risk factors were reviewed retrospectively. Renal function, as determined by estimated glomerular filtration rate (eGFR) and measurement of serum creatinine level (Cr) at each scheduled follow-up for a median four years, was compared between the high-risk (HR) group (n=49, ≥ five risk factors) and the low-risk (LR) group (n=185, < five risk factors). Results Except for baseline renal function and number of risk factors for atheroembolism, differences in characteristics between groups were comparatively insignificant. At 3 months after the operation, Cr and eGFR differed significantly between the two groups (p < 0.05), but no differences were observed afterward. Significant deterioration from baseline in Cr and eGFR was observed in both groups at 1 month after the operation, with a greater change in the HR group (p < 0.05). From measurement to measurement, significantly faster deterioration in Cr and eGFR was observed in the HR group than in the LR group until 6 months after the operation (Cr: LR, 0.02 mg/dL and HR, 0.13 mg/dL; eGFR: LR, 1.50 mL/min/1.73 m2 and HR, 6.38 mL/min/1.73 m2; p < 0.05). Conclusion The presence of atheroembolic risk factors may negatively influence postoperative recovery of renal function after PN in patients with localized RCC.
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Affiliation(s)
- Sung Han Kim
- Department of Urology, National Cancer Center, Goyang, Korea
| | - Kyung Min Kang
- Biometric Research Branch, National Cancer Center, Goyang, Korea
| | - Ami Yu
- Biometric Research Branch, National Cancer Center, Goyang, Korea
| | - Jung Hoon Lee
- Department of Urology, Seoul National University Hospital, Seoul, Korea
| | - Byung Ho Nam
- Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
| | - Eun Sik Lee
- Department of Urology, Seoul National University Hospital, Seoul, Korea
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Low-density lipoprotein apheresis ameliorates monthly estimated glomerular filtration rate declines in patients with renal cholesterol crystal embolism. J Artif Organs 2014; 18:72-8. [DOI: 10.1007/s10047-014-0801-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 10/12/2014] [Indexed: 02/06/2023]
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Higo S, Hirama A, Ueda K, Mii A, Kaneko T, Utsumi K, Iino Y, Katayama Y. A patient with idiopathic cholesterol crystal embolization: effectiveness of early detection and treatment. J NIPPON MED SCH 2012; 78:252-6. [PMID: 21869560 DOI: 10.1272/jnms.78.252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Seiichiro Higo
- Department of Neurological, Nephrological and Rheumatological Science, Graduate School of Medicine, Nippon Medical School, Japan
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Schneider F, Ricco JB. Part two: the vast majority of patients with atherosclerotic renal artery stenoses do not require intervention. Eur J Vasc Endovasc Surg 2011; 42:139-43. [PMID: 21816339 DOI: 10.1016/j.ejvs.2011.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- F Schneider
- Department of Vascular Surgery, University of Poitiers Medical Center, 86021 Poitiers, France
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Kashyap VS, Schneider F, Ricco JB. Role of interventions for atherosclerotic renal artery stenoses. J Vasc Surg 2011; 54:563-70;discussion 570. [DOI: 10.1016/j.jvs.2011.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Nakayama M, Izumaru K, Nagata M, Ikeda H, Nishida K, Hasegawa E, Ohta Y, Tsuchihashi T, Urabe K. The Effect of Low-Dose Corticosteroids on Short- and Long-Term Renal Outcome in Patients with Cholesterol Crystal Embolism. Ren Fail 2011; 33:298-306. [DOI: 10.3109/0886022x.2011.560403] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Abstract
Skin ulceration is a major source of morbidity and is often difficult to manage. Ulcers caused by an inflammatory cause or microvascular occlusion are particularly challenging in terms of diagnosis and treatment. The management of such ulcers requires careful assessment of associated systemic conditions and a thorough analysis of the ulcer's clinical and histologic findings. In this article, the authors discuss several examples of inflammatory ulcers and the approach to the diagnosis and treatment of these ulcers.
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Affiliation(s)
- Jaymie Panuncialman
- Department of Dermatology, Roger Williams Medical Center, 50 Maude Street, Providence, RI 02908, USA
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Faria B, Vidinha J, Pêgo C, Garrido J, Lemos S, Lima C, Sorbo G, Gomes EL, Carvalho T, Loureiro P, Sousa T. Atheroembolic renal disease with rapid progression and fatal outcome. Clin Exp Nephrol 2010; 15:159-63. [PMID: 21069411 DOI: 10.1007/s10157-010-0363-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Accepted: 09/29/2010] [Indexed: 11/24/2022]
Abstract
Atheroembolic renal disease is caused by foreign-body reaction to cholesterol crystals flushed from the atherosclerotic plaques into the small-vessel system of the kidneys. It is an underdiagnosed entity, mostly related to vascular procedures and/or anticoagulation, and prognosis is considered to be poor. Besides the benefit of aggressive medical prevention of further embolic events, use of steroid therapy has been associated with greater survival. Here we report a case of a patient with a multisystemic presentation of the disease days after performance of percutaneous coronary intervention and anticoagulation initiation due to an episode of myocardial infarction. Renal, cutaneous, ophthalmic, neurological, and possibly muscular and mesenteric involvement was diagnosed. Although medical treatment with corticosteroids and avoidance of further anticoagulation was applied, the patient rapidly progressed to end-stage renal disease requiring hemodialysis and died 6 months after diagnosis. This is a case of catastrophic progression of the disease resistant to therapeutic measures. Focus on diagnosis and more efficient preventive and therapeutic protocols are therefore needed.
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Affiliation(s)
- Bernardo Faria
- Nephrology and Dialysis Unit, Hospital São Teotónio-Viseu, Av Rei Dom Duarte, 3504 509 Viseu, Portugal.
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Abstract
Renovascular disease remains among the most prevalent and important causes of secondary hypertension and renal dysfunction. Many lesions reduce perfusion pressure including fibromuscular diseases and renal infarction, but most are caused by atherosclerotic disease. Epidemiologic studies establish a strong association between atherosclerotic renal-artery stenosis (ARAS) and cardiovascular risk. Hypertension develops in patients with renovascular disease from a complex set of pressor signals, including activation of the renin-angiotensin system (RAS), recruitment of oxidative stress pathways, and sympathoadrenergic activation. Although the kidney maintains function over a broad range of autoregulation, sustained reduction in renal perfusion leads to disturbed microvascular function, vascular rarefaction, and ultimately development of interstitial fibrosis. Advances in antihypertensive drug therapy and intensive risk factor management including smoking cessation and statin therapy can provide excellent blood pressure control for many individuals. Despite extensive observational experience with renal revascularization in patients with renovascular hypertension, recent prospective randomized trials fail to establish compelling benefits either with endovascular stents or with surgery when added to effective medical therapy. These trials are limited and exclude many patients most likely to benefit from revascularization. Meaningful recovery of kidney function after revascularization is limited once fibrosis is established. Recent experimental studies indicate that mechanisms allowing repair and regeneration of parenchymal kidney tissue may lead to improved outcomes in the future. Until additional staging tools become available, clinicians will be forced to individualize therapy carefully to optimize the potential benefits regarding both blood pressure and renal function for such patients.
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The uncertain value of renal artery interventions: where are we now? JACC Cardiovasc Interv 2010; 2:175-82. [PMID: 19463422 DOI: 10.1016/j.jcin.2008.12.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Revised: 12/05/2008] [Accepted: 12/11/2008] [Indexed: 11/23/2022]
Abstract
Improved technology for detection of and endovascular procedures for renal artery stenosis due to atherosclerosis has been associated with increases in renal artery intervention. Hypertension with accelerated target organ injury, reduced kidney function, and episodic circulatory congestion in patients with renovascular disease predict reduced patient survival. Recent studies indicate that activation of pressor mechanisms depends upon hemodynamic gradients that are often overrated by visual estimates. Although activation of the renin-angiotensin system initiates renovascular hypertension, additional mechanisms perpetuate vascular remodeling and kidney injury that may not depend upon large vessel occlusion. Major advances in medical therapy have led to initiation of at least 4 major prospective trials comparing optimal medical therapy with or without stenting. Up to now, outcome data fail to support broad application of renal revascularization, including results from a recent large, prospective trial from the United Kingdom, despite small groups of patients that experience major clinical benefit. The ambiguity of these results partly reflect poor characterization of the severity of vascular lesions and competing risks within the population related to aging and pre-existing disease. Many patients currently undergoing renal artery interventions derive little net benefit and some are exposed to significant complications, including atheroembolic disease. Determining the appropriate role for renal artery interventions will depend on developing better methods for judging the role of large vessel occlusive disease regarding tissue oxygenation, activation of profibrotic pathways, and irreversible injury in the post-stenotic kidney.
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Affiliation(s)
- Christopher J White
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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Biesenbach P, Gremmel T, Hörl WH, Kain R, Säemann MD. Gross proteinuria and subacute renal failure after coronary angiography - a case report of cholesterol crystal embolization. Wien Klin Wochenschr 2010; 122:251-4. [PMID: 20503025 DOI: 10.1007/s00508-010-1367-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We report on a 55-year-old man who was admitted with increased serum-creatinine (3.4 mg/dl), gross proteinuria (4.6 g/24 h) and arterial hypertension. The medical history included hyperlipidemia, coronary artery disease (CAD) and a recent coronary angiography, but normal serum-creatinine and no proteinuria before coronary intervention. Serology and urinary analysis did not show any signs of a systemic disease. A renal biopsy, however, revealed multiple cholesterol crystal emboli in small vessels along with a typical infiltration of eosinophilic granulocytes. The patient was subsequently treated with an angiotensin-receptor-1 (AT1R) blocker and high-dose statins and was then evaluated for LDL-apheresis. Gross proteinuria was largely unaffected by (AT1R) blockade and renal function further declined necessitating, initiation of hemodialysis. Renal CCE with profound proteinuria is an unusual presentation of acute renal failure, potentially misleading and thereby prolonging correct diagnostics of a rare entity. Identification of high-risk patients is of utmost importance as efficient therapeutic strategies do not exist.
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Affiliation(s)
- Peter Biesenbach
- Internal Medicine III/Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria.
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Abstract
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.
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Ravani P, Gaggi R, Rollino C, Santostefano M, Stabellini N, Colla L, Dallera N, Ravera S, Bove S, Faggiano P, Scolari F. Lack of association between dialysis modality and outcomes in atheroembolic renal disease. Clin J Am Soc Nephrol 2010; 5:454-9. [PMID: 20019115 PMCID: PMC2827570 DOI: 10.2215/cjn.06590909] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Accepted: 11/25/2009] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Atheroembolic renal disease (AERD) can require dialytic support. Because anticoagulation may trigger atheroembolization, peritoneal dialysis may be preferred to hemodialysis. However, the effect of dialysis modality on renal and patient outcomes in AERD is unknown. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS A subcohort of 111 subjects who developed acute/subacute renal failure requiring dialysis was identified from a larger longitudinal study of AERD. The main exposure of interest was dialysis modality (peritoneal versus extracorporeal therapies). Logistic regression was used to study the probability of renal function recovery. Times from dialysis initiation to death were studied using Cox's regression. RESULTS Eighty-six patients received hemodialysis and 25 received peritoneal dialysis. The probability of renal function recovery was similar by dialysis modality (25% among hemodialysis patients and 24% among peritoneal dialysis patients; P = 0.873). During follow-up, 58 patients died, 14 among peritoneal patients and 44 among hemodialysis patients (P = 0.705). In multivariable analysis, gastrointestinal tract involvement and use of statins maintained an independent effect on the risk of patient death. CONCLUSIONS This study does not support the notion that one dialysis modality is superior to the other. However, the observational nature of the data precludes any firm conclusions.
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Affiliation(s)
- Pietro Ravani
- Division of Nephrology, Departments of Medicine and Community Health Sciences, University of Calgary, Alberta, Canada
| | - Rossella Gaggi
- Division of Nephrology, Ospedale Malpighi, Bologna, Italy
| | | | | | | | - Loredana Colla
- Chair and Division of Nephrology, University and Ospedale Molinette, Torino, Italy
| | | | - Sara Ravera
- Chair of Nephrology, University of Brescia, Italy
| | - Sergio Bove
- Division of Nephrology, Montichiari Hospital, Italy; and
| | - Pompilio Faggiano
- Division of Cardiology, University and Spedali Civili, Brescia, Italy
| | - Francesco Scolari
- Chair of Nephrology, University of Brescia, Italy
- Division of Nephrology, Montichiari Hospital, Italy; and
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Chronopoulos A, Cruz DN, Ronco C. Hospital-acquired acute kidney injury in the elderly. Nat Rev Nephrol 2010; 6:141-9. [DOI: 10.1038/nrneph.2009.234] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Abstract
The aging kidney undergoes several important anatomic and physiologic changes that increase the risk of acute kidney injury (formerly acute renal failure) in the elderly. This article reviews these changes and discusses the diagnoses frequently encountered in the elderly patient with acute kidney injury. The incidence, staging, evaluation, management, and prognosis of acute kidney injury are also examined with special focus given to older adults.
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Maladie des embolies de cristaux de cholestérol révélée par un tableau de mononeuropathie. Rev Med Interne 2009; 30:982-4. [DOI: 10.1016/j.revmed.2009.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2008] [Revised: 01/03/2009] [Accepted: 01/22/2009] [Indexed: 11/18/2022]
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Pathophysiologie, Prophylaxe und Therapie von Herzchirurgie-assoziierten Nierenfunktionsstörungen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00398-009-0743-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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50
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Charabaty S, Shanmugam V. A 65-year-old man with longstanding seropositive rheumatoid arthritis and lower extremity ulceration. ACTA ACUST UNITED AC 2009; 61:1275-80. [PMID: 19714596 DOI: 10.1002/art.24700] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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