Acute kidney injury induced by allergic conditions-associated renal cholesterol crystal embolism
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.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "Bibliografía" "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. J Am Soc Nephrol 2003;14:1584-90. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12761259" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Knoflach M, Kiechl S, Mayr A, Willeit J, Poewe W, Wick G. Allergic rhinitis, asthma, and atherosclerosis in the Bruneck and ARMY studies. 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| 2022 Abril | 130 | 54 | 184 |
| 2022 Marzo | 179 | 65 | 244 |
| 2022 Febrero | 151 | 51 | 202 |
| 2022 Enero | 126 | 48 | 174 |
| 2021 Diciembre | 130 | 46 | 176 |
| 2021 Noviembre | 152 | 47 | 199 |
| 2021 Octubre | 154 | 50 | 204 |
| 2021 Septiembre | 198 | 49 | 247 |
| 2021 Agosto | 225 | 43 | 268 |
| 2021 Julio | 172 | 42 | 214 |
| 2021 Junio | 173 | 28 | 201 |
| 2021 Mayo | 186 | 41 | 227 |
| 2021 Abril | 469 | 54 | 523 |
| 2021 Marzo | 259 | 37 | 296 |
| 2021 Febrero | 217 | 20 | 237 |
| 2021 Enero | 203 | 28 | 231 |
| 2020 Diciembre | 173 | 17 | 190 |
| 2020 Noviembre | 157 | 19 | 176 |
| 2020 Octubre | 172 | 24 | 196 |
| 2020 Septiembre | 176 | 11 | 187 |
| 2020 Agosto | 192 | 15 | 207 |
| 2020 Julio | 149 | 18 | 167 |
| 2020 Junio | 168 | 15 | 183 |
| 2020 Mayo | 198 | 19 | 217 |
| 2020 Abril | 176 | 22 | 198 |
| 2020 Marzo | 155 | 25 | 180 |
| 2020 Febrero | 165 | 24 | 189 |
| 2020 Enero | 155 | 23 | 178 |
| 2019 Diciembre | 135 | 40 | 175 |
| 2019 Noviembre | 165 | 19 | 184 |
| 2019 Octubre | 148 | 14 | 162 |
| 2019 Septiembre | 182 | 25 | 207 |
| 2019 Agosto | 174 | 11 | 185 |
| 2019 Julio | 207 | 22 | 229 |
| 2019 Junio | 169 | 19 | 188 |
| 2019 Mayo | 119 | 19 | 138 |
| 2019 Abril | 145 | 31 | 176 |
| 2019 Marzo | 93 | 24 | 117 |
| 2019 Febrero | 68 | 20 | 88 |
| 2019 Enero | 59 | 19 | 78 |
| 2018 Diciembre | 114 | 43 | 157 |
| 2018 Noviembre | 161 | 24 | 185 |
| 2018 Octubre | 148 | 13 | 161 |
| 2018 Septiembre | 105 | 12 | 117 |
| 2018 Agosto | 89 | 21 | 110 |
| 2018 Julio | 72 | 15 | 87 |
| 2018 Junio | 57 | 14 | 71 |
| 2018 Mayo | 78 | 17 | 95 |
| 2018 Abril | 79 | 10 | 89 |
| 2018 Marzo | 62 | 7 | 69 |
| 2018 Febrero | 44 | 4 | 48 |
| 2018 Enero | 48 | 9 | 57 |
| 2017 Diciembre | 55 | 9 | 64 |
| 2017 Noviembre | 44 | 8 | 52 |
| 2017 Octubre | 42 | 7 | 49 |
| 2017 Septiembre | 46 | 9 | 55 |
| 2017 Agosto | 55 | 11 | 66 |
| 2017 Julio | 63 | 6 | 69 |
| 2017 Junio | 52 | 7 | 59 |
| 2017 Mayo | 61 | 10 | 71 |
| 2017 Abril | 55 | 7 | 62 |
| 2017 Marzo | 56 | 4 | 60 |
| 2017 Febrero | 32 | 6 | 38 |
| 2017 Enero | 35 | 7 | 42 |
| 2016 Diciembre | 60 | 7 | 67 |
| 2016 Noviembre | 68 | 7 | 75 |
| 2016 Octubre | 91 | 9 | 100 |
| 2016 Septiembre | 116 | 5 | 121 |
| 2016 Agosto | 166 | 6 | 172 |
| 2016 Julio | 182 | 4 | 186 |
| 2016 Junio | 130 | 0 | 130 |
| 2016 Mayo | 133 | 0 | 133 |
| 2016 Abril | 90 | 0 | 90 |
| 2016 Marzo | 89 | 0 | 89 |
| 2016 Febrero | 119 | 0 | 119 |
| 2016 Enero | 123 | 0 | 123 |
| 2015 Diciembre | 103 | 0 | 103 |
| 2015 Noviembre | 99 | 0 | 99 |
| 2015 Octubre | 92 | 0 | 92 |
| 2015 Septiembre | 79 | 0 | 79 |
| 2015 Agosto | 89 | 0 | 89 |
| 2015 Julio | 88 | 0 | 88 |
| 2015 Junio | 55 | 0 | 55 |
| 2015 Mayo | 70 | 0 | 70 |
| 2015 Abril | 29 | 0 | 29 |
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