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A 72-year-old man develops acute renal failure after cardiac catheterization. Physical
examination is notable for diminished peripheral pulses, livedo reticularis, epigastric
tenderness, and confusion. Laboratory studies include (mg/dL) BUN 131, creatinine 5.2, and
phosphate 9.5. Urinalysis shows 10 to 15 WBC, 5 to 10 RBC, and one hyaline cast per high-
power field (HPF).
The most likely diagnosis is
A) acute interstitial nephritis caused by drugs
B) rhabdomyolysis with acute tubular necrosis
C) acute tubular necrosis secondary to radiocontrast exposure
D) cholesterol embolization
E) renal arterial dissection with prerenal azotemia
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the correct answer is CCCCCCCCCCCCCCCCCCCCCCC
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hey okt3..u discussed this already na...
n hey...cant we solve this qs in another way..in the q if we do bun/creat its >1/15....its pre renal azo...so options a b c knocked out...remains renal artery dissection n cholersterol embolization..may be dimished pulses is an indicator of some ath ... n gives furthur road to choleasterol embolization....
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cccccccccccccccccccccccccccccccccc
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accumulation of wbc and hyaline casts occurs after drugs or some materials lead to occlusion of vasa recta .......................then necrosis of tubules
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sorry harsh for delay, you must be Goljan fan, it is a pretty good way to answer based on BUN:Cr ratio, absolutly it is prenal azotemia, and by elimination D is the only possible answer.
Brother ebnalfady, in this case if you read the first part:
A 72-year-old man develops acute renal failure after cardiac catheterization
you will not go for answer for answer C, there is no mention of drugs.
I have some note about cholesterol embolization from UW step2 to share with you if you mind:
Atheroembolic disease (AED), also known as cholesterol embolization, is characterized by a
wide range of clinical manifestations due to showering of cholesterol crystals from the aorta
or other major arteries, usually following surgical or interventional manipulation of the
arterial tree, or by treatment with anticoagulants or thrombolytic agents.
Cholesterol embolism may involve any organ except the lungs; the skin, kidneys,
gastrointestinal tract, and central nervous system are the most common sites.
It is most commonly seen in elderly patients who have evidence of diffuse atherosclerotic
disease(coronary artery disease, carotid artery disease, peripheral vascular disease, etc.).
Skin manifestation including livedo reticularis, petechiae, gangrene, ulcers or mottling of toes
are the most common clinical features of cholesterol embolism. Renal failure (rise in
creatinine over several weeks) is common and often a critical manifestation of cholesterol
embolism.
Renal failure in presence of systemic eosinophilia should make you think of cholesterol
embolism, allergic interstitial nephritis, or polyarteritis nodosa (PAN). Urinalysis is often
abnormal but not specific; mild proteinuria, hematuria, and eosinophiluria, etc., is seen.
Other abnormal laboratory findings include a normochromic normocytic anemia,
leukocytosis, increased ESR, elevated C-reactive protein, and hypocomplementemia.
The definitive diagnosis is made by tissue biopsy, which shows cholesterol crystals.
Treatment is conservative. Anticoagulation should be stopped since it may prevent healing of the ruptured plaques. Steroids have been used with little success.
What you need to know:
Cholesterol embolization, usually follows surgical or interventional manipulation of the arterial tree. Renal failure, livedo reticularis, systemic eosinophilia, and low complement level should make you think of cholesterol embolism.
Hope that will help.
GL. okt3
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