Acute kidney injury induced by allergic conditions-associated renal cholesterol crystal embolism
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Most CCE occur following vascular surgery or radiological procedures, and the CCE which occur without history of interventional operation or surgery is often called “spontaneous CCE”.<span class="elsevierStyleSup">1</span> However, CCE is commonly accompanied by eosinophilia which is an important characteristic of allergy. Although eosinophilia is generally considered as the secondary reaction after CCE occurring, allergic disease has been proved to be the risk factor of atherosclerotic disease.<span class="elsevierStyleSup">2-4</span> So the relationship between CCE and allergy is still deserved to discuss. Here we describe a case of CCE which occurred after the attack of allergic disease. The patient had a long history of allergic disease (allergic asthma and eczema) over 20 years and an acute attack of eczema and asthma before kidney function decreasing. Satisfactory treatment was obtained with only corticosteroid. This case is a direct proof that allergy is not only the secondary reaction, but also be one of the important precipitating factors of CCE.</p><p class="elsevierStylePara">One month before admission, a 71-year-old male presented with asthma and eczema. Then he had lower limb edema, anorexia, and toe pain. He had a long history of eczema and asthma over 20 years, with no history of chest pain, anticoagulant therapy, cardiac catheterization, or angiography. Urinary sediment showed BLD±, PRO±. Blood chemistry showed renal function insufficiency (BUN: 118.8mg/dL, Cr: 4.28mg/dL). Blood routine showed anemia (90g/L), thrombocytopenia (81x10<span class="elsevierStyleSup">9</span>/L; normal range, 100 to 300×10<span class="elsevierStyleSup">9</span>/L) and eosinophilia (absolute eosinophil count, 1.6×10<span class="elsevierStyleSup">9</span>/L; normal range, 0 to 0.5×10<span class="elsevierStyleSup">9</span>/L). Immunological examination showed increased IgE level (3080IU/mL; normal range, 0 to 165IU/mL). The symptoms got worse gradually and the serum Cr had increased to 6.72mg/dL before admission. On admission, the patient presented with marked lower-extremity pitting edema with bilateral pre-tibial skin eczema. Feet pulses were preserved. The skin temperature of the first one-third of the dorsal feet decreased. Cyanosis was present in the toes with overt tenderness.</p><p class="elsevierStylePara">On admission, serum creatinine had increased to 7.88mg/dL. Urinalysis showed slight proteinuria (272mg/24h) and increased N-acetylglucosaminidase (29.9U/gCr; normal range, 2-21.6U/gCr). IgE level was very high (3650IU/mL). Doppler ultrasonic imaging study of arteries revealed atherosclerosis and small mural plaques of bifurcations for the common carotid artery, the internal carotid artery and the proximal and middle vertebral artery.</p><p class="elsevierStylePara">Percutaneous kidney biopsy was performed. The results revealed as follows (Figure 1 A). Among all 12 glomerulus, 5 glomerulus showed ischemic global sclerosis and 2 glomerulus showed ischemic atrophy. Others showed diffuse slight to mild proliferation of glomerular mesangial cells. Multifocal tubular atrophy and interstitial fibrosis were present and accompanied by focal infiltration of mononuclear cells, neutrophils and eosinophils in the interstitium. The most noticeable changes were found within the small arteries, arterioles and vascular pole of the glomeruli presenting with cholesterol crystal gaps. On immunofluorescence, mesangial deposits of FRA (+) were present while IgA, IgG, IgM, C3, and C1q were weak or negative.</p><p class="elsevierStylePara">Although the creatinine clearance rate (Ccr) was as low as 7.3ml/min/1.73m<span class="elsevierStyleSup">2</span>, hemodialysis was not administered immediately because of no oliguria. Intravenous methylprednisolone was administered at a dose of 40mg/day. Three days later, the patient’s general condition improved dramatically. Pain of toes was obviously relieved and no further cutaneous lesions appeared. One week after treatment, the skin temperature of feet increased and the cyanosis turned shallower than before. Blood routine showed eosinophil count decreased to 0.18×10<span class="elsevierStyleSup">9</span>/L. Serum creatinine and IgE decreased to 5.57mg/dL and 2970IU/mL, respectively. Oral triamcinolone was given at a dose of 24mg/day. Three weeks after treatment, serum creatinine decreased to 4.26mg/dL. Pre-tibial skin eczema and pain of toes diminished. The temperature of feet skin recovered. Five weeks after treatment, serum creatinine decreased to 2.69mg/dL. Eosinophil count turned normal. Steroids were tapered 10% every 2-4 weeks. Triamcinolone has been tapered to 4 mg/day for maintenance treatment without CCE relapse so far. The serum creatinine of the patient was 2.81mg/dL during last visit (Figure 1 B).</p><p class="elsevierStylePara">The relationship between CCE and autoimmunity is an interesting issue. Details of the inflammatory response have been documented in animal models that cholesterol emboli could not only mechanically occlude the vessel but also trigger an inflammatory reaction.<span class="elsevierStyleSup">5</span> Although the role of immune system in the pathogenesis of CCE was only considered to be an inflammatory response after embolism, opposite proofs have also existed. Recently, there were two important studies which showed a significant correlation between allergic disease and atherosclerosis. In the Bruneck study of 826 middle aged and elderly Italian subjects, the risk for atherosclerosis development and progression increased significantly for 32 subjects with allergic disorders. Furthermore, serum IgE levels were significantly raised in subjects in whom atherosclerosis had developed or progressed.<span class="elsevierStyleSup">2</span> In the ARMY study which took 141 male Austrian subjects aged 17 and 18 years, the vascular intima-media thickness (IMT) measured by ultrasonography of the 34 subjects diagnosed as having allergic disease was higher than the healthy subjects.<span class="elsevierStyleSup">2,3</span> Although the exact mechanism is still not fully understood, components of the allergic process such as leukotrienes and mast cells may be involved in atherogenesis.<span class="elsevierStyleSup">2</span> Furthermore, IgE has been proved to be able to promote atherogenesis in Apoe<span class="elsevierStyleSup">-/-</span> mice.<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">There has not been a definite consensus of the treatment of CCE by now.<span class="elsevierStyleSup">6,7</span> Although the use of corticosteroid is still controversial, our patient received only corticosteroid treatment without other above drugs and satisfactory results were obtained. Previous reports indicated that Anticoagulant therapy, which is generally essential in hemodialysis, was harmful to patients with CCE because it was a potent risk factor for plaque rupture and cholesterol embolism.<span class="elsevierStyleSup">8</span> Since the present patient was cured successfully with corticosteroid, hemodialysis was avoided and the renal function kept stable to date. So we think treatment with corticosteroid should be a recommended alternative for patients with CCE, especially for patients who had obvious allergic conditions.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interest<br></br> </span></p><p class="elsevierStylePara">The authors declare that there is no conflict of interest associated with this manuscript.<span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><a href="grande/11652_108_34154_en_f114.jpg" class="elsevierStyleCrossRefs"><img src="11652_108_34154_en_f114.jpg" alt="The kidney biopsy and clinical course of the patient"></img></a></p><p class="elsevierStylePara">Figure 1. The kidney biopsy and clinical course of the patient</p>" "pdfFichero" => "P1-E544-S3783-A11652-EN.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11652_108_34154_en_f114.jpg" "Alto" => 553 "Ancho" => 1384 "Tamanyo" => 242115 ] ] "descripcion" => array:1 [ "en" => "The kidney biopsy and clinical course of the patient" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Scolari F, Ravani P, Pola A, Guerini S, Zubani R, Movilli E, et al. Predictors of renal and patient outcomes in atheroembolic renal disease: a prospective study. 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| 2022 September | 80 | 33 | 113 |
| 2022 August | 80 | 47 | 127 |
| 2022 July | 67 | 38 | 105 |
| 2022 June | 95 | 31 | 126 |
| 2022 May | 99 | 41 | 140 |
| 2022 April | 74 | 43 | 117 |
| 2022 March | 88 | 55 | 143 |
| 2022 February | 67 | 50 | 117 |
| 2022 January | 71 | 33 | 104 |
| 2021 December | 70 | 31 | 101 |
| 2021 November | 67 | 39 | 106 |
| 2021 October | 91 | 37 | 128 |
| 2021 September | 75 | 42 | 117 |
| 2021 August | 68 | 29 | 97 |
| 2021 July | 57 | 36 | 93 |
| 2021 June | 58 | 28 | 86 |
| 2021 May | 53 | 38 | 91 |
| 2021 April | 133 | 30 | 163 |
| 2021 March | 71 | 46 | 117 |
| 2021 February | 72 | 19 | 91 |
| 2021 January | 51 | 16 | 67 |
| 2020 December | 57 | 24 | 81 |
| 2020 November | 53 | 22 | 75 |
| 2020 October | 47 | 15 | 62 |
| 2020 September | 49 | 10 | 59 |
| 2020 August | 46 | 13 | 59 |
| 2020 July | 42 | 9 | 51 |
| 2020 June | 39 | 13 | 52 |
| 2020 May | 43 | 14 | 57 |
| 2020 April | 35 | 16 | 51 |
| 2020 March | 47 | 10 | 57 |
| 2020 February | 53 | 21 | 74 |
| 2020 January | 59 | 18 | 77 |
| 2019 December | 55 | 18 | 73 |
| 2019 November | 39 | 17 | 56 |
| 2019 October | 32 | 11 | 43 |
| 2019 September | 44 | 23 | 67 |
| 2019 August | 31 | 10 | 41 |
| 2019 July | 31 | 23 | 54 |
| 2019 June | 29 | 11 | 40 |
| 2019 May | 25 | 27 | 52 |
| 2019 April | 58 | 52 | 110 |
| 2019 March | 43 | 27 | 70 |
| 2019 February | 33 | 33 | 66 |
| 2019 January | 33 | 29 | 62 |
| 2018 December | 73 | 41 | 114 |
| 2018 November | 93 | 16 | 109 |
| 2018 October | 76 | 14 | 90 |
| 2018 September | 65 | 14 | 79 |
| 2018 August | 51 | 10 | 61 |
| 2018 July | 44 | 7 | 51 |
| 2018 June | 47 | 17 | 64 |
| 2018 May | 47 | 13 | 60 |
| 2018 April | 56 | 14 | 70 |
| 2018 March | 32 | 13 | 45 |
| 2018 February | 47 | 6 | 53 |
| 2018 January | 38 | 10 | 48 |
| 2017 December | 56 | 5 | 61 |
| 2017 November | 40 | 14 | 54 |
| 2017 October | 39 | 9 | 48 |
| 2017 September | 40 | 18 | 58 |
| 2017 August | 32 | 21 | 53 |
| 2017 July | 42 | 22 | 64 |
| 2017 June | 44 | 20 | 64 |
| 2017 May | 41 | 27 | 68 |
| 2017 April | 49 | 27 | 76 |
| 2017 March | 44 | 25 | 69 |
| 2017 February | 28 | 18 | 46 |
| 2017 January | 23 | 23 | 46 |
| 2016 December | 58 | 4 | 62 |
| 2016 November | 50 | 5 | 55 |
| 2016 October | 75 | 18 | 93 |
| 2016 September | 79 | 8 | 87 |
| 2016 August | 165 | 8 | 173 |
| 2016 July | 155 | 11 | 166 |
| 2016 June | 137 | 0 | 137 |
| 2016 May | 141 | 0 | 141 |
| 2016 April | 96 | 0 | 96 |
| 2016 March | 73 | 0 | 73 |
| 2016 February | 86 | 0 | 86 |
| 2016 January | 68 | 0 | 68 |
| 2015 December | 85 | 0 | 85 |
| 2015 November | 102 | 0 | 102 |
| 2015 October | 87 | 0 | 87 |
| 2015 September | 52 | 0 | 52 |
| 2015 August | 76 | 0 | 76 |
| 2015 July | 60 | 0 | 60 |
| 2015 June | 35 | 0 | 35 |
| 2015 May | 53 | 0 | 53 |
| 2015 April | 5 | 0 | 5 |
Show all
