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atheroembolic renal failure

Etiology: 1) idiopathic (spontaneous) - atherosclerosis 2) after an invasive procedure a) angiography b) angioplasty c) vascular surgery d) intra-aortic balloon pump 3) anticoagulation 4) thrombolysis Epidemiology: 1) older patients 2) often a history of smoking Pathology: 1) cholesterol emboli in distal small & medium-sized arteries - biconcave crystalline clefts 2) intense tubulointerstitial nephritis Clinical manifestations: 1) livedo reticularis of the extremities 2) emboli seen on funduscopic examination - Hollenhorst bodies 3) other organ system dysfunction may occur concurrently a) cerebral ischemia b) intestinal vascular insufficiency 4) ARF after 24 hr (slower onset than ARF secondary to radiographic contrast media) Laboratory: 1) rule/out alternative diagnosis a) high erythrocyte sedimentation rate (ESR) b) CH50: low level of complement c) complete blood count (CBC) - leukocytosis - eosinophilia - thrombocytopenia d) eosinophils in the urine -> AIN 2) biopsy of muscle, skin or kidney (see cholesterol embolism) Differential diagnosis: 1) vasculitis 2) glomerulonephritis 3) acute interstitial nephritis (AIN) 4) acute tubular necrosis 5) contrast-induced nephropathy Management: 1) correct the source of embolization a) atrial fibrillation b) cardiac valvular disease c) endocarditis 2) anticoagulation may aggravate the tendency for embolization 3) treatment of hypertension 4) dialysis may be necessary 5) prognosis: generally minimally reversible renal failure

General

renal failure; kidney failure atheroembolism; cholesterol embolism; aortic atheroembolism

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 599
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 18. American College of Physicians, Philadelphia 1998, 2012, 2018.
  3. Scolari F, Ravani P. Atheroembolic renal disease. Lancet. 2010 May 8;375(9726):1650-60. PMID: 20381857