iloprost and Renal-Artery-Obstruction

Cholesterol crystal embolization (CCE) is a dreaded complication of radiology, vascular surgery, and/or anticoagulation in patients with atherosclerosis and ulcerated aortic plaques. It also represents a cause of early graft failure and of poor results of renal artery surgery. Crystals lodge in small caliber renal arteries, where they induce early, transitory thrombosis followed by delayed, definitive obstruction by endarteritis, accompanied by evidence of inflammation and eosinophilia. Massive CCE leads to early oligoanuria. In subacute forms, renal insufficiency is often delayed by weeks or months following the triggering event. A third, chronic subset of CCE is easily mistaken for atherosclerotic renal ischemia and/or nephrosclerosis. The kidney is rarely the sole organ involved in acute/subacute forms, in which the central nervous system, the coronary arteries, the spinal cord, and the mesenteric and pancreatic blood supply compromise represent the main causes of death. Cutaneous, retinal, and muscle involvement allow diagnosis by inspection or scarcely invasive biopsies in about 80% of cases, whereas renal biopsy as the only diagnostic procedure is required in 20% of cases. Prevention is based on avoidance of endovascular radiology maneuvers, vascular surgery, and excess anticoagulation in atherosclerotic patients. Treatment of acute/subacute forms of renal insufficiency consisting of stopping anticoagulation and forbidding any new radiologic and/or vascular surgery procedure; treating hypertension with angiotensin 2 antagonists and vasodilators, strict volemic control by loop diuretics and ultrafiltration, along with parenteral nutrition and prednisone, has been credited with improved outcome. Iloprost may obtain favorable results. Statins definitely ameliorate the renal and patient's prognosis.

Topics: Diagnosis, Differential; Embolism, Cholesterol; Humans; Iloprost; Nephrosclerosis; Renal Artery Obstruction; Treatment Outcome; Vasodilator Agents

Cholesterol embolism is a serious disease with a high morbidity and mortality rate. There is no clear evidence that any specific treatment helps this syndrome. We report a patient who developed acute renal failure due to cholesterol crystal embolism following percutaneous transluminal angioplasty of a renal artery. Treatment with iloprost for peripheral symptoms of cholesterol emboli resulted in rapid resolution of toe cyanosis, decrease in leg pain and a significant decrease in serum creatinine shortly after initiation of treatment. One month after initiation of iloprost therapy, skin signs of cholesterol emboli disappeared and leg pain diminished. Gradually reduction in serum creatinine level was also observed (from 390 to 160 micromol/L). Eighteen months after the arteriography, the patient had stable renal function with creatinine levels of 150-160 micromol/L, and he was asymptomatic.

Topics: Acute Kidney Injury; Angioplasty, Balloon; Embolism, Cholesterol; Follow-Up Studies; Humans; Iloprost; Male; Middle Aged; Renal Artery Obstruction; Vasodilator Agents

A 66-year-old woman presented with acute-onset rapid atrial fibrillation and right upper quadrant pain which had appeared 24 h prior to admission. The patient also manifested acute oliguric renal failure (serum creatinine 6.9 mg/dl). Selective renal angiography revealed total occlusion of the right renal artery with normal visualization of the left kidney vasculature. The patient was treated with intra-arterial urokinase and intravenous heparin, with no response. Intravenous administration of the prostacyclin analogue, iloprost, resulted in rapid resolution (within hours) of the oliguric acute renal failure, in spite of the continuing presence of a nonfunctioning right kidney. We conclude that the etiology of the acute renal insult in this patient is probably related to unilateral renal arterial embolization accompanied by arterial spasm of the unaffected kidney. The contralateral vasospasm can be reversed by iloprost, which then leads to a rapid recovery from acute renal failure. We are unaware of prior reports documenting the beneficial effect of iloprost in a clinical setting as described here.

Topics: Acute Kidney Injury; Aged; Atrial Fibrillation; Embolism; Female; Humans; Iloprost; Oliguria; Renal Artery Obstruction; Rheumatic Heart Disease; Vasodilator Agents