A classic and an unusual presentation of atheroembolic renal disease

Abstract

BACKGROUND: Atheroembolic renal disease (AERD), the renal manifestation of cholesterol crystal emboli, is largely iatrogenic and associated with cardiovascular procedures. However, spontaneous cases of AERD have also been reported. AERD has diverse clinical presentations and microscopic examination is needed for a definitive diagnosis and to exclude other conditions. Aim(s): We present two patients with AERD with markedly different presentations. Cases: Two elderly patients presented with acute-on-chronic renal failure with negative glomerulonephritis and vasculitis screen. Patient 1: presented with minimal proteinuria and haematuria, lower limb livido reticularis and history of coronary-artery-bypass-graft 3 month prior. The clinical suspicion was cholesterol emboli syndrome. Patient 2: presented with sub nephrotic proteinuria and haematuria with no recent vascular intervention. The clinical suspicion was rapidly progressive glomerulonephritis. Both patients were subjected to a renal biopsy. RESULTS: Microscopic examination in both biopsies showed an artery with cholesterol clefts confirming the diagnosis. This led to optimisation of statin therapy, and changes to anticoagulation and steroid therapy. DISCUSSIONS: AERD is an underrecognided cause of renal failure which will invariably become more common as cardiovascular interventions are performed. While there is no treatment for AERD, definitive diagnosis helps exclude other causes of renal impairment allowing preventative management to minimise future embolic events.