1
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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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2
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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: 22] [Impact Index Per Article: 4.4] [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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3
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Jung SM. Treatment of Cholesterol Embolism With Corticosteroids and Alprostadil. Ann Geriatr Med Res 2019; 23:31-34. [PMID: 32743283 PMCID: PMC7387603 DOI: 10.4235/agmr.18.0045] [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: 11/19/2018] [Revised: 12/28/2018] [Accepted: 01/27/2019] [Indexed: 11/24/2022] Open
Abstract
Cholesterol embolism is a rare but serious disease that can lead to chronic renal failure or death. Despite the recent increase in the incidence of this disease, there is no consensus on the optimal treatment modality. Supportive care is usually the mainstay of treatment. We report a case of cholesterol embolism after renal artery stenting that was successfully treated with corticosteroids and alprostadil.
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Affiliation(s)
- Seung Mook Jung
- Department of Internal Medicine, Gimpowoori Hospital, Gimpo, Korea
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4
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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. ACTA ACUST UNITED AC 2018; 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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 06/28/2018] [Indexed: 11/27/2022]
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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5
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Oka H, Kamimura T, Hiramatsu Y, Fukumitsu K, Iwata R, Kondo M, Hirashima Y, Aihara S, Harada A, Tsuruya K. Cholesterol Crystal Embolism Induced by Direct Factor Xa Inhibitor: A First Case Report. Intern Med 2018; 57:71-74. [PMID: 28943551 PMCID: PMC5799060 DOI: 10.2169/internalmedicine.8660-16] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
An 80-year-old man presented at our hospital with renal failure. He had been treated with edoxaban, an oral direct factor Xa inhibitor, for deep vein thrombosis for 10 months prior to admission. Although the pulses in his bilateral pedal arteries were palpable, cyanosis was present in the bilateral toes. Laboratory data indicated azotemia and eosinophilia. A skin biopsy confirmed a diagnosis of cholesterol crystal embolism (CCE). Because no invasive vascular procedure was performed, we assumed that CCE was related to edoxaban. To the best of our knowledge, this is the first case report suggesting CCE induced by an Xa inhibitor.
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Affiliation(s)
- Hideaki Oka
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Taro Kamimura
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Yuki Hiramatsu
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Kento Fukumitsu
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Rei Iwata
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Mika Kondo
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | | | - Seishi Aihara
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Atsumi Harada
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Kazuhiko Tsuruya
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
- Department of Integrated Therapy for Chronic Kidney Disease, Graduate School of Medical Sciences, Kyushu University, Japan
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6
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Iardino A, Garner O, Ramirez A, Lotta F. Cholesterol embolism: it's always a good idea to look into the eye. BMJ Case Rep 2017; 2017:bcr-2017-222128. [PMID: 28939621 DOI: 10.1136/bcr-2017-222128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Alfredo Iardino
- Department of Internal Medicine, Texas Tech University at the Permian Basin, Odessa, Texas, USA
| | - Orlando Garner
- Department of Internal Medicine, Texas Tech University at the Permian Basin, Odessa, Texas, USA
| | - Ana Ramirez
- Department of Internal Medicine, Texas Tech University at the Permian Basin, Odessa, Texas, USA
| | - Franco Lotta
- Department of Critical Care Medicine, Centro Policlinico Valencia "La Viña", Valencia, Venezuela
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7
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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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8
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Igarashi Y, Akimoto T, Kobayashi T, Iwazu Y, Miki T, Otani-Takei N, Imai T, Sugase T, Masuda T, Takeda SI, Muto S, Nagata D. Performing Anticoagulation: A Puzzling Case of Cholesterol Embolization Syndrome. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2017; 10:1179547616684649. [PMID: 28469497 PMCID: PMC5398301 DOI: 10.1177/1179547616684649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 11/21/2016] [Indexed: 12/04/2022]
Abstract
The avoidance of any form of anticoagulation is advised in cases of cholesterol embolization syndrome (CES). We herein describe a case of CES in a man with a history of unprovoked pulmonary embolism for which warfarinization was performed. Despite anecdotal reports of successful anticoagulation in CES patients with certain indications, irreversible renal failure, which was sufficiently severe to require chronic hemodialysis, eventually developed in our patient. Our results emphasize the pitfalls of this procedure, which imply its limited feasibility and safety. Several therapeutic concerns associated with this case are also discussed.
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Affiliation(s)
- Yusuke Igarashi
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Takahisa Kobayashi
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Yoshitaka Iwazu
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Takuya Miki
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Naoko Otani-Takei
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Toshimi Imai
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Taro Sugase
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Shin-Ichi Takeda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Shigeaki Muto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
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9
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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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10
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Ishiyama K, Sato T, Taguma Y. Low-Density Lipoprotein Apheresis Ameliorates Renal Prognosis of Cholesterol Crystal Embolism. Ther Apher Dial 2016; 19:355-60. [PMID: 26386224 DOI: 10.1111/1744-9987.12345] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Drugs such as corticosteroids and statins have been used to treat cholesterol crystal embolism (CCE), but the prognosis remains poor. This study evaluated the efficacy of low-density lipoprotein apheresis (LDL-A) in patients with CCE. Patients with CCE who showed renal deterioration after vascular interventions were studied retrospectively. Information on demographic variables, clinical measurements, and medication use was collected. The outcomes were incidence of maintenance dialysis and mortality at 24 weeks. A total of 49 patients with CCE were included, among whom 37 (76%) were diagnosed pathologically and the remainder were diagnosed clinically. The median estimated GFR at baseline and at diagnosis were 40.5 and 13.4 mL/min per 1.73 m(2) , respectively. Corticosteroids were used in 42 patients (86%), statins in 30 patients (61%), and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in 29 patients (59%). LDL-A was performed in 25 patients (LDL-A group), and not in 24 patients (control group). Smoking (100% vs. 72%, P = 0.02), white blood cell count (8900/mm(3) vs. 7000/mm(3) ) and corticosteroid use (96% vs. 75%) were higher in the LDL-A group compared with the control group, but there were no differences in other demographic and clinical parameters between the groups. Patients in the LDL-A group had a lower incidence of maintenance dialysis (2/25 (8%) vs. 8/24 (33%), P < 0.05), and a trend towards lower mortality (2/25 (8%) vs. 7/24 (29%), P = 0.074). These results suggest that LDL-A decreases the risk of maintenance dialysis in severe renal CCE patients after vascular interventions.
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Affiliation(s)
- Katsuya Ishiyama
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, Sendai, Japan
| | - Toshinobu Sato
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, Sendai, Japan
| | - Yoshio Taguma
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, Sendai, Japan
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11
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Efficacy of low-density lipoprotein apheresis combined with corticosteroids for cholesterol crystal embolism. Clin Exp Nephrol 2016; 21:228-235. [DOI: 10.1007/s10157-016-1272-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
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12
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Kim H, Zhen DB, Lieske JC, McBane RD, Grande JP, Sandhu GS, Melduni RM. Treatment of Cholesterol Embolization Syndrome in the Setting of an Acute Indication for Anticoagulation Therapy. J Med Cases 2014; 5:376-379. [PMID: 25197328 DOI: 10.14740/jmc1804w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Cholesterol embolization syndrome (CES) is a complication sometimes occurring after invasive endovascular procedures. CES is characterized by release of cholesterol crystals and particles from atheromatous plaques, which can occlude distal vessels and induce an inflammatory response, resulting in end-organ damage. We report the case of a 66-year-old man who presented with an acute ST-elevation myocardial infarction. An intra-aortic balloon pump was placed due to hemodynamic instability following percutaneous coronary intervention. Ten weeks after discharge, he presented with signs and symptoms of CES (e.g., livedo reticularis, acrocyanosis, acute renal failure), and a new left ventricular apical thrombus. Withdrawal of anticoagulation is often recommended in the setting of CES, on the presumption that anticoagulants favor plaque hemorrhage and subsequent cholesterol micro-embolization. Because of the potential disastrous consequences of an embolus, the patient was anticoagulated with warfarin concurrently with corticosteroids to suppress the inflammatory response to cholesterol crystals. His renal function continued to improve and was discharged without the need for dialysis. This case illustrates that anticoagulation therapy in CES is feasible and appears to be safe in patients with a coexisting urgent indication for anticoagulation.
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Affiliation(s)
- Hidong Kim
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David B Zhen
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert D McBane
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph P Grande
- Division of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gurpreet S Sandhu
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Rowlens M Melduni
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
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Masuda J, Tanigawa T, Nakamori S, Sawai T, Murata T, Ishikawa E, Yamada N, Nakamura M, Ito M. Use of corticosteroids in the treatment of cholesterol crystal embolism after cardiac catheterization: a report of four Japanese cases. Intern Med 2013; 52:993-8. [PMID: 23648720 DOI: 10.2169/internalmedicine.52.9255] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Cholesterol crystal embolism (CCE) is a serious complication associated with invasive vascular procedures. The prognosis of the renal involvement type of CCE is very poor, and there is currently no established treatment, other than supportive therapy. We herein report four cases of CCE with severe atherosclerosis wherein the renal function progressively deteriorated after cardiac catheterization. In three of the four patients, low-dose corticosteroids (0.3 mg/kg/day) improved the renal function, whereas the fourth patient died from CCE of the digestive system. This report reviews the literature on CCE and discusses possible therapeutic options.
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Affiliation(s)
- Jun Masuda
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan.
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14
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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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15
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Yuda J, Honma R, Fukase S, Okawara S, Omoto E, Goto T, Suzuki M. [Case report: a case of cholesterol crystal embolism mimicking vasculitis]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2011; 100:2247-2249. [PMID: 21899155 DOI: 10.2169/naika.100.2247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Junichiro Yuda
- Department of Internal Medicine, Yamagata Prefecutural Central Hospital, Japan
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16
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Abstract
Retiform purpura consists of branching purpuric lesions caused by a complete blockage of blood flow in the dermal and subcutaneous vasculature. The differential diagnosis for retiform purpura is broad, including vasculitides of the small and medium vessels as well as microvascular occlusion due to thrombotic, infectious, and embolic phenomena. Determining the etiology of this important dermatologic sign can be a diagnostic challenge; however, an organized approach can improve the speed and accuracy of diagnosis and identify an effective treatment. This review focuses on early recognition, evaluation, and treatment of hospitalized patients with retiform purpura. Specifically, vasculitis, protein C and S deficiencies, heparin necrosis, warfarin necrosis, antiphospholipid antibody syndrome, disseminated intravascular coagulation, cryoglobulinemia, calciphylaxis, and cholesterol embolization syndrome will be discussed in detail. These conditions are commonly seen in consultative dermatology and can have multiorgan involvement, complicated laboratory evaluation, and long-term therapeutic implications.
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Affiliation(s)
- Ashley Wysong
- Department of Dermatology, Stanford University, Stanford, CA, USA
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17
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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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18
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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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19
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Hyperbaric oxygen therapy in a case of cholesterol crystal embolization. Am J Emerg Med 2010; 29:694.e3-6. [PMID: 20708883 DOI: 10.1016/j.ajem.2010.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 05/15/2010] [Indexed: 11/23/2022] Open
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20
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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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Abstract
Cardiovascular diseases may affect multiple organ systems including the skin. By identification of specific cutaneous findings, dermatologists may be the first physician to diagnose an underlying cardiovascular disease. This article discusses a number of cardiac disorders with prominent skin findings in addition to general dermatologic signs suggestive of cardiovascular disease.
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22
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Paraskevas KI, Koutsias S, Mikhailidis DP, Giannoukas AD. Cholesterol Crystal Embolization:A Possible Complication of Peripheral Endovascular Interventions. J Endovasc Ther 2008; 15:614-25. [DOI: 10.1583/08-2395.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Andreux F, Marro B, El Khoury N, Seilhean D, Alamowitch S. Reversible encephalopathy associated with cholesterol embolism syndrome: magnetic resonance imaging and pathological findings. J Neurol Neurosurg Psychiatry 2007; 78:180-2. [PMID: 17229746 PMCID: PMC2077650 DOI: 10.1136/jnnp.2006.099770] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We describe a patient found to have acute diffuse and reversible encephalopathy on magnetic resonance imaging (MRI) associated with cholesterol emboli syndrome (CES). The initial MRI showed extensive white matter, basal ganglia and cortical damage without evidence of brain infarction. Dramatic clinical and MRI improvement was observed with corticosteroids. Pathologically, cholesterol crystal emboli were found in the lumen of skin and brain arteries and were associated with varying degrees of inflammation of the arteriole wall. This case suggests that CES may be responsible for extensive, acute and reversible encephalopathy underlined by an inflammation of brain arteries.
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Affiliation(s)
- F Andreux
- Stroke Unit, Department of Neurology, Tenon University Hospital, AP-HP, Paris, France
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24
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Abstract
A 74-year-old man was referred to our hospital because of hypertension, blue toe syndrome and an elevation of serum creatinine from 0.8 to 1.4 mg/dl for eleven months. He had no history of invasive vascular procedures. Atherosclerosis was initially suspected, but renal impairment was accelerated following anticoagulant therapy. A renal biopsy established the diagnosis of cholesterol crystal embolism. Withdrawal of anticoagulants and the combination therapy with LDL apheresis and corticosteroids led to stabilization of the renal function. In patients with risk factors for atherosclerosis, cholesterol crystal embolism should be included in the differential diagnosis of chronic kidney disease.
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Affiliation(s)
- Mio Enomae
- Department of Internal Medicine, Kurobe City Hospital, Toyama
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25
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Braem L, Paule P, Héno P, Morand JJ, Mafart B, La Folie T, Varlet P, Mioulet D, Fourcade L. [Thoracic aortic dissection revealed by systemic cholesterol embolism]. Ann Cardiol Angeiol (Paris) 2006; 55:300-3. [PMID: 17078270 DOI: 10.1016/j.ancard.2005.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Systemic cholesterol embolism is a rare complication of atherosclerosis, and has various presentations. Arterial catheterisms are a common cause. However, the association with an aortic dissection has been exceptionally reported. We report the observation of a 70 year-old man, with coronary artery disease, hypertension, diabetes and dyslipidemia. Six months before hospitalization, a coronary angioplasty was performed due to recurrent angina. The association of purpuric lesions on the feet, with acute renal failure confirmed cholesterol embolism syndrome. Transoesophageal echocardiography showed a dissection of the descending thoracic aorta associated with complex atheroma. The evolution was marked by the pulpar necrosis of a toe and by a worsening of the renal failure, requiring definitive hemodialysis. Further echographic control highlighted the rupture of the intimal veil of the dissection. Cholesterol embolism syndrome may reveal an aortic dissection in patients without thoracic symptoms. In such cases, transoesophageal echocardiography is a useful and non-invasive examination.
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Affiliation(s)
- L Braem
- Service de cardiologie, HIA Laveran, boulevard Alphonse-Laveran, BP 50, 13998 Marseille-Armées, France.
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26
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Sugimoto T, Morita Y, Yokomaku Y, Isshiki K, Kanasaki K, Eguchi Y, Koya D, Kashiwagi A. Systemic cholesterol embolization syndrome associated with myeloperoxidase-anti-neutrophil cytoplasmic antibody. Intern Med 2006; 45:557-61. [PMID: 16702752 DOI: 10.2169/internalmedicine.45.1553] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 75-year-old man was transferred to our department because of development of severe renal impairment after coronary artery bypass grafting. Hemodialysis was initiated for postsurgical oliguria and lung congestion. On transfer, he showed systemic purpura rashes and diffuse blue mottlings on his toes with marked eosinophilia and an elevated level of C-reactive protein. Cutaneous biopsy revealed cholesterol crystal embolism and leukocytoclastic vasculitis in dermal arterioles. Myeloperoxidase-anti-neutrophil cytoplasmic antibody titer was increased. Upon oral corticosteroid therapy following intravenous pulse steroid therapy, the purpura dramatically diminished, renal function improved, and hemodialysis was discontinued. Active treatment with corticosteroids may be effective for cholesterol embolization syndrome, particularly when clinical and laboratory manifestations mimic systemic vasculitis.
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Affiliation(s)
- Toshiro Sugimoto
- Department of Medicine, Shiga University of Medical Science, Seta, Otsu
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27
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Affiliation(s)
- Kevin J O'Leary
- Division of General Internal Medicine, Feinberg School of Medicine of Northwestern University, Chicago, Ill 60611, USA.
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28
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Koga JI, Ohno M, Okamoto K, Nakasuga K, Ito H, Nagafuji K, Shimono N, Koga H, Hayashida A, Arita T, Maruyama T, Kaji Y, Harada M. Cholesterol embolization treated with corticosteroids--two case reports. Angiology 2005; 56:497-501. [PMID: 16079936 DOI: 10.1177/000331970505600420] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cholesterol embolization (CE) is a potentially serious complication associated with invasive arterial maneuvers, in which standard therapy has not been established. We experienced two cases of CE in patients with severe atherosclerosis whose renal function deteriorated within a few months after invasive arterial maneuvers. CE was confirmed either by renal biopsy (case 1) or skin biopsy (case 2). Oral administration of prednisolone at a daily dose of 30 mg (0.4 mg/kg) was effective to improve their renal function. Our observation suggests that corticosteroid therapy may be beneficial in some patients with CE.
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Affiliation(s)
- Jun-ichiro Koga
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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29
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Yücel AE, Kart-Köseoglu H, Demirhan B, Ozdemir FN. Cholesterol crystal embolization mimicking vasculitis: success with corticosteroid and cyclophosphamide therapy in two cases. Rheumatol Int 2005; 26:454-60. [PMID: 16025335 DOI: 10.1007/s00296-005-0012-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2004] [Revised: 04/16/2005] [Indexed: 01/03/2023]
Abstract
Cholesterol crystal embolization is a potential complication of atherosclerosis. Approximately one-third of the patients who develop this problem have a history of vascular surgery, angiography or angioplasty hours to weeks before onset. The skin and the kidneys are most frequently involved, but any organ can be affected. Livedo reticularis of the lower extremities and acrocyanosis (known as "blue toe syndrome") are the most common cutaneous manifestations. Histological examination is the only way to definitively diagnose cholesterol crystal embolization. Recently, it has been proposed that cholesterol embolization is associated with vasculitis, and some authors have labeled this condition a "vasculitis look-alike." There is still no specific treatment for this problem, even in cases that progress to renal failure. However, a few case reports in the literature have noted successful treatment with corticosteroids and cyclophosphamide in patients with deteriorating renal function. In this article, we describe two cases of severe cholesterol crystal embolization accompanied by renal dysfunction) and blue toe syndrome. Both patients benefited from corticosteroid and cyclophosphamide therapy.
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Affiliation(s)
- A E Yücel
- Division of Rheumatology, Baskent University Faculty of Medicine, 5.sok No:48, Bahcelievler, Ankara, Turkey
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30
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Ehara T, Yazawa M, Konishi K, Hora K, Shigematsu H. Renal cholesterol embolism: Analysis of two spontaneous autopsy cases. Case Report. Nephrology (Carlton) 2005; 10:90-6. [PMID: 15705188 DOI: 10.1111/j.1440-1797.2005.00358.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Two cases of spontaneous cholesterol embolism, which followed different clinical courses, acute and chronic renal failure, are presented and histopathological lesions are compared. Both cases were diagnosed as cholesterol embolism post-mortem. Case 1 (a 66-year-old man) had acute onset of illness with fever, leucocytosis and renal failure, diagnosed as vasculitis, and died of rupture of an abdominal aortic aneurysm. Case 2 (an 84-year-old man) had eosinophilia of unknown aetiology for 7 years with intermittent worsening of renal function and died of sepsis. Case 1 had diffuse cholesterol crystal emboli in the interlobular arteries and arterioles of the kidney, but case 2 had patchy cholesterol emboli in the interlobular arteries of the kidney. The aorta of case 1 was diffusely ulcerated, which is in contrast to that of case 2, who had limited ulceration in thoracic aorta, which might have contributed to the long duration of illness. Immunohistochemically, the number of macrophages and T cells that infiltrated around cholesterol emboli in the arteries was more in case 1 (macrophages 27.7, T cells 36.1/mm(2)) than in case 2 (2.7, 1.38/mm(2)). Focal interstitial inflammation occurred in both cases. In case 1, marked tubulitis was observed. Case 2 had rather severe atrophy of the tubules and fibrotic interstitium where mast cells were rich (31.9/mm(2)). The number of B cells and eosinophils was few in case 2 (11.35, 0.7/mm(2)) compared with case 1 (101.9, 16.15/mm(2)). These results suggest that in acute lesions of renal cholesterol embolism, macrophages and T cells accumulate around cholesterol crystals and cause tubulointerstitial inflammatory lesions with other inflammatory cells. In chronic lesions, macrophages, T cells and mast cells are the major inflammatory cells present in the interstitium.
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Affiliation(s)
- Takashi Ehara
- Department of Histopathology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan.
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Hara S, Asada Y, Fujimoto S, Marutsuka K, Hatakeyama K, Sumiyoshi A, Eto T. Atheroembolic renal disease: clinical findings of 11 cases. J Atheroscler Thromb 2003; 9:288-91. [PMID: 12560589 DOI: 10.5551/jat.9.288] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Atheromatous embolism is a systemic disease resulting from cholesterol crystal embolization in many organs, including the kidneys. To characterize atheroembolic renal disease (AERD), we retrospectively evaluated 11 patients with acute renal failure after vascular surgery, vascular radiology investigations, and anticoagulation at Miyazaki Medical College from 1994 to 2001. The diagnosis of cholesterol atheromatous embolism was confirmed by tissue examination or clinical grounds. The patients were all elderly men (average age of 66.8 years) with a history of hypertension (55%), diabetes mellitus (45%), hyperlipidemia (45%), and coronary artery disease (18%). Seven patients had livedo reticularis, and 4 had blood eosinophilia. Clinically, 7 patients were managed conservatively and 5 of them improved, whereas 4 patients required dialysis and developed chronic renal failure or died. The serum creatinine levels of the improved patients were significantly lower (1.28+/-0.3 mg/dl, p < 0.005) than the non-improved ones (7.70+/-3.6). The number of eosinophils was significantly higher in the improved patients (576+/-295 /ml, p < 0.05) than in the non-improved ones (208+/-206). However, no significant difference was observed in the levels of serum cholesterol and C-reactive protein among these patients. Since the population at risk for AERD is growing, we should recognize this disease as a cause of acute renal failure.
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Affiliation(s)
- Seiichiro Hara
- First Department of Internal Medicine, Miyazaki Medical College, Kiyotake, Miyazaki, Japan.
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32
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Abstract
Cholesterol embolic disease is a devastating complication of atherosclerosis. Universally recommended treatment is lacking thus far. Recent data suggest that a therapeutic protocol aimed at specifically combating three causes of mortality, recurrent bouts of cholesterol embolism, cardiac failure, and cahexia, were associated with a favorable clinical outcome. As for drug therapy, corticosteroid has been reported to be beneficial in reducing local and general inflammatory responses. Concerning apheresis, combined therapy consisting of plasma exchange and low to intermediate-dose corticosteroid therapy has been shown to be effective in multivisceral cholesterol embolism. Low density lipoprotein (LDL) apheresis has been reported to be beneficial for cholesterol embolism-induced damage to the skin and brain.
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Affiliation(s)
- Midori Hasegawa
- Department of Nephrology, Fujita Health University School of Medicine, Toyake, Aichi, Japan.
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