Spontaneous Renal Cholesterol Crystal Embolism in a Patient with Functionally Solitary Kidney

Abstract

Renal cholesterol crystal embolism (also called renal atheroembolism) is a cause of acute kidney injury with increasing frequency. It is usually seen in patients older than 60 years of age with diffuse atherosclerotic disease. Although it develops usually following vascular interventions; it may occur spontaneously. It presents with partial or total occlusion of small arteries due to distal embolization from cholesterol crystals from ruptured atherosclerotic plaques. It is in fact a part of systemic disease called cholesterol crystal embolization disease affecting kidneys, eyes, brain and gastrointestinal system. Livedo reticularis, especially purple discoloration of toes are clues for diagnosis. The pathognomonic finding of renal cholesterol crystal embolism is the cholesterol crystal clefts in renal biopsy specimen. Herein, we present a atypical case of acute kidney injury due to spontaneous cholesterol crystal embolization in a patient with functionally solitary kidney.

Keywords

• Acute kidney injury, atheroembolic disease, renal cholesterol crystal embolism

Spontaneous Renal Cholesterol Crystal Embolism in a Patient with Functionally Solitary Kidney

Öz

Renal kolesterol kristal embolizimi (renal ateroembolizim) akut böbrek hasarının artan nedenlerinden biridir. Genellikle yaygın aterosklerozu olan 60 yaşının üzerindeki hastalarda görülmektedir. Vasküler girişimler sonrasında ortaya çıkabileceği gibi spontan olarak da meydana gelebilir. Rüptüre aterosklerotik plaklardan serbestleşen kolesterol kristallerinin distaldeki küçük arterleri total yada parsiyel olarak tıkaması sonucu ortaya çıkmaktadır. Aslında sistemik bir hastalık olan, böbrekler, gözler, beyin ve gastrointestinal sistemi tutabilen kolesterol kristal embolizimi hastalığının bir parçasıdır. Livedo retikülaris ve ayak parmaklarında mor renk değişiklikleri hastalığın ipuçları olabilir. Renal kolesterol kristal emboliziminin patognomonik bulgusu böbrek biyopsisinde kolesterol kleftlerinin gösterilmesidir. Bu yazıda fonksiyonel olarak tek böbrekli bir hastada spontan kolesterol kristal embolisine bağlı gelişen bir akut böbrek hasarı olgusu sunduk

Anahtar Kelimeler

• Akut böbrek hasarı, atheroembolik hastalık, renal kolesterol kristal embolisi

Kaynakça

1. Scolari F, Bracchi M, Valzorio B, et al. Cholesterol athero- matous embolism: an increasingly recognized cause of acute renal failure. Nephrol Dial Transplant 1996; 11 (8): 1607-12
2. Thadhani RI, Camargo CA, Jr Xavier RJ, Fang LS. Atheroembolic renal failure after invasive procedures. Natural history based on 52 histologically proven cases. Medicine (Baltimore) 1995; 74: 350
3. Scolari F, Ravani P, Gaggi R, et al. The challenge of diag- nosing atheroembolic renal disease: clinical features and prognostic factors. Circulation 2007; 116: 298
4. Baumann DS, McGraw D, Rubin BG, et al. An institutional experience with arterial atheroembolism. Ann Vasc Surg 1994; 8: 258
5. Scolari F, Ravani P, Pola A, et al. Predictors of renal and patient outcomes in atheroembolic renal disease: a pro- spective study. J Am Soc Nephrol 2003; 14: 1584
6. Tunick PA, Kronzon I. Atheroembolism. In: Vascular Medicine. A Companion to Braunwald's Heart Disease. Creager, M, Dzau, VJ, Loscalzo, J (Eds), Saunders (Elsevier), 2006
7. Smith MC, Ghose MK, Henry AR. The clinical spectrum of renal cholesterol embolization. Am J Med 1981;71:174-80
8. Fine MJ, Kapoor W, Falanga V. Cholesterol crystal embo- lization: a review of 221 cases in the English literature. Angiology 1987; 38 (10): 769

9. Hyman BT, Landas SK, Ashman RF, Schelper RL, Robinson RA. Warfarin-related purple toes syndrome and choles- terol microembolization. Am J Med 1987; 82 (6): 1233-7
10. Gupta BK, Spinowitz BS, Charytan C, Wahl SJ. Cholesterol crystal embolization-associated renal failure after ther- apy with recombinant tissue-type plasminogen activator. Am J Kidney Dis 1993; 21 (6): 659-62
11. Rudnick MR, Berns JS, Cohen RM, Goldfarb S. Nephrotoxic risks of renal angiography: Contrast-media associated nephrotoxicity and atheroembolism-a critical review. Am J Kidney Dis 1994; 24: 713
12. Fukumoto Y, Tsutsui H, Tsuchihashi M, et al. The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study. J Am Coll Cardiol 2003; 42: 211
13. Wilson DM, Salazer TL, Farkouh ME. Eosinophiluria in ath- eroembolic renal disease. Am J Med 1991; 91: 186
14. Lye WC, Cheah JS, Sinniah R: Renal cholesterol embolic disease. Case report and review of the literature. Am J Nephrol 1993;13:489-93
15. Scolari F, Tardanico R, Zani R, et al. Cholesterol crystal embolism: A recognizable cause of renal disease. Am J Kidney Dis 2000;36:1089
16. Colt HG, Begg RJ, Saporito JJ, et al. Cholesterol emboli after cardiac catheterization. Eight cases and a review of the literature. Medicine (Baltimore) 1988; 67: 389
17. Dalakos TG, Streeten DHP, Jones D, Obeid A. "Malignant" hypertension resulting from atheromatous embolization predominantly of one kidney. Am J Med 1974; 57: 135
18. Smith MC, Ghose MK, Henry AR. The clinical spectrum of renal cholesterol embolization. Am J Med 1981; 71 (1): 174
19. Meyrier A, Buchet P, Simon P, et al. Atheromatous renal disease. Am J Med 1988; 85: 139
20. Richards AM, Eliot RS, Kanjuh VI, Bloemendaal RD, Edwards JE. Cholesterol embolism: A multiple–sys- tem disease masquerading as polyarteritisnodosa. Am J Cardiol 1965; 15: 696
21. Zuccala` A, Zucchelli P. A renal disease frequently found postmortem, but rarely diagnosed in vivo. Nephrol Dial Transplant 1997; 12: 1762-7
22. Belenfant X, Meyrier A, Jacquot C: Supportive treatment improves survival in multi visceral cholesterol crystal em- bolism. Am J Kidney Dis 1999; 33: 840-50
23. Bruns FJ, Segel DP, Adler S. Control of cholesterol embo- lization by discontinuation of anticoagulant therapy. Am J MedSci 1978; 275: 105-8
24. Kassirer J. Atheroembolic renal disease. N Engl J Med 1969; 280: 812-8
25. Woolfson RG, Lachmann H. Improvement in renal choles- terol emboli syndrome after simvastatin. Lancet 1998; 351: 1331-2
26. Waters D: Plaque stabilization: A mechanism forthe ben- eficial effect of lipid-lowering therapies in angiographic studies. Prog Cardiovasc Dis 1994; 37: 107-20
27. Dahlberg PJ, Frecentese DF, Cogbill TH. Cholesterol em- bolism: Experience with 22 histologically proven cases. Surgery 1989; 105: 737-46
28. Mannesse CK, Klankestijn PJ, Man in't Veld AJ, Schalekamp MA. Renal failure and cholesterol crystal embolization: A report of 4 surviving cases and a review of the literature. Clin Nephrol 1991; 36: 240