AERD - Atheroembolic Renal Disease Nephrology Grand Rounds...

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Atheroembolic Renal Disease Nephrology Grand Rounds October 12 th , 2010 Aditya Mattoo
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Introduction Atheroembolic renal disease (AERD), sometimes referred to as renal cholesterol crystal embolization (CCE), is a form of renal failure that is secondary to occlusion and inflammation of renal arteries, arterioles, and glomerular capillaries with cholesterol crystals originating from atheromatous plaques of the aorta and other major arteries. Atheromatous material can be dislodged spontaneously or after intravascular trauma or anticoagulation. Typically, embolization affects the kidneys, skin, gastrointestinal system, and brain. Scolari et al. Lancet, 2010.
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Background Panum first described atheroembolism in 1862, in the autopsy report of the Danish sculptor, Thorwaldsen, who died from a heart attack. In a coronary artery, a ruptured atheroma was identi fi ed, with atheromatous material filling the lumen distally. In 1945, Flory showed the embolic origin of cholesterol crystals from eroded aortic atheromatous plaques. 40 years later, Fine et al reviewed 221 cases of CCE, emphasizing the low rate of antemortem clinical diagnosis. In the past two decades, AERD has changed from being a pathological curiosity to a clinical syndrome. Panum PL. Virchows Arch Pathol Anat Physiol, 1862. Flory CM. Am J Pathol, 1945. Fine et al. Angiology, 1987. Scolari et al. Lancet, 2010.
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Epidemiology
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Epidemiology – Autopsy Series In unselected autopsy series, the frequency of CCE findings is low, ranging from 0.31% to 2%. However, in autopsy studies done in elderly patients who died after aortic surgery or aortography, researchers have reported an increased frequency of CCE, ranging between 12-77%. Moolenaar W. Arch Intern Med, 1996. Cross S. J Clin Pathol, 1991. Flory CM. Am J Pathol, 1945. Thurlbeck WM. NEJM, 1957.
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Epidemiology – Renal Biopsy Series Biopsy Study Number of Biopsies Incidence Jones and Innaccone 755 1.1% Greenberg 500 1.6% Lie 4589 1.1% Preston (age > 65) 334 4.25% Greenberg A et al. Am J Kidney Dis , 1997. Lie JT et al. Pathol Annu, 1992. Preston RA et al. J Am Geriatr, 1990.
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Risk Factors
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Predictors Fukumoto et al. JACC, 2003.
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Risk Factors Scolari et al. Lancet, 2010.
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Pathogenesis
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Pathogenesis The atherosclerotic plaque is characterized by a fibrous cap overlying a core containing necrotic cellular debris, foam cells, and lipids, including cholesterol crystals.
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