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Kidney Week

Abstract: TH-PO125

Spontaneous Late Acute Cholesterol Emboli with Acute Hydrophilic-Polymer Kidney Injury in a Renal Allograft

Session Information

Category: Trainee Case Report

  • 101 AKI: Epidemiology, Risk Factors, and Prevention

Authors

  • Riaz, Asad, Indiana University School of Medicine, Indianapolis, Indiana, United States
  • Adebiyi, Oluwafisayo O., Indiana University School of Medicine, Indianapolis, Indiana, United States
  • Yaqub, Muhammad S., Indiana University, Indianapolis, Indiana, United States
  • Taber, Tim E., Indiana University School of Medicine, Indianapolis, Indiana, United States
  • Sharfuddin, Asif A., Indiana University School of Medicine, Indianapolis, Indiana, United States
Introduction

Hydrophilic coatings are used on intravascular devices to avoid thrombosis, and vasospasm during endovascular procedures. We report a very rare case of Acute Kidney Injury caused by this coating.

Case Description

58 year old male underwent his second left sided renal transplant in March 2017. Prior to transplant he has mild- to moderate aortic stenosis. However subsequent to his transplant in October 2017 he was found to have critical aortic stenosis. For which he underwent a transcatheter -aortic valve replacement via right transfemoral percutaneous approach with the insertion of a bioprosthetic aortic valve. His renal function function remained stable at 1.4mg/dl range at the time of the aortic valve replacement.
Three months in January 2018 later he presented with oliguric acute kidney injury with a creatinine of 5mg/dl. Urinalysis revealed microscopic hematuria and 1+ proteinuria. Doppler evaluation revealed elevated velocities within the proximal, midportion, the renal artery. with features suggestive of renal artery stenosis.
The biopsy showed Acute tubular necrosis ; Arteriole with isolated cholesterol embolus; Glomerular capillaries with intraluminal embolic material which was nonpolarizable which appeared weakly eosinophilic, periodic acid–Schiff (PAS)-negative, largely silver-negative with speckled granular positivity, and light blue-gray on trichrome stain. This was consistent with hydrophilic-polymer emboli per prior case reports.
The biopsy was complicated by acute hemorrhage and the patient had to have angiogram showing a severe 90% stenosis at the origin of the renal transplant artery. The lower pole segmental artery had to be embolized along with a 5 mm self-expanding bare-metal stent with
resultant brisk flow through the stent into the transplant kidney.

After 6 weeks of needing dialysis he recovered from his acute kidney injury with a creatinine back down to 1.6mg/dl.

Discussion

To date, only 4 cases of hydrophilic polymer emboli have been reported to involve the kidneys, of which 2 were in a renal allograft.(Chen et al NEJM 2015). This case provides evidence that renal lesions may be induced by hydrophilic-polymer emboli due to the transcatheter aortic valve procedures in conjunction with spontaneous acute atherosclerotic cholesterol emboli.