Renal Atheroembolic Disease

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					                                      Renal Atheroembolic Disease
Tunick et al, Clinical Characteristics of Renal Atheroemboli, Uptodate
Fukumoto et al, Incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac
catheterization: a prospective study. JACC 2003; 42:211.
Scolari, The Challenge of disagnosing atheroembolic renal disease: clinical features and prognostic factors.
Circulation 2007; 116:298

     Renal atheroembolic disease occurs most often in older patients with diffuse erosive
     Crystal emboli occurs with atherosclerotic plaque breaks off and embolizes distally
        causing occlusion of multiple small arteries
     Lesions can be either inflammatory or ischemic
Risk Factors
     Often seen after manipulation of the aorta after vascular interventions, can be
        spontaneous as well
     Aorta most common source of crystals, so can also see embolization to the kidneys,
        interstines, and legs
     Probably underdiagnosed
     Some studies place incidence at 1.5-2%
     One large JACC study showed incidence after cardiac cath to be 1.5%
Clinical Characteristics
     Usually associated with multiple emboli to small arteries
     Associated with other extra-renal manifestations, i.e. blue toe syndrome, livedo
        reticularis, GI manifestations
     While clot emboli present with flank pain and hematuria from complete occlusion of a
        large vessels atheroembolic disease generally results in incomplete occlusion causing
        ischemic atrophy
     Cholesterol crystals also cause a foreign body reaction in the vessel wall which also may
        explain clinical presentation
     May present acutely, but more commonly presents as progressive decline in renal
        function 3-8 weeks after inciting event
     Two clinical scenarios: a) Marked renal impairment days to 1-2 weeks after vascular
        procedure or anti-coagulation; b) Subuaccute presentation weeks after an insult with
        stepwise degradation in renal function
     UA shows mild sediment with few cells or casts, proteinuria is not a common feature
     Eosinophilia and hypocomplemntemia are associated with disease, and can present in a
        more active phase
     Biopsy in some cases may be necessary, can see characteristic cholesterol crystals on
Treatment and Prognosis
     No good treatment, prognosis is poor (30% at 24 months)
     Leading cause of death is cardiovascular
     Aggressive treatment for secondary prevention of cardiovascular disease
     May be some benefit to statin therapy (plaque stabilization) in particular