Acute renal failure occurs following aoic angiography in a 72-year-old man. His weight has been rising, his lungs show rales at both bases, and he is dyspneic. His fractional excretion of sodium is greater than 1. He has eosinophilia on his peripheral smear, an elevated erythrocyte sedimentation rate, and proteinuria with microscopic hematuria. Which of the following is the most likely cause of his renal failure?
Cholesterol atheroembolism is a known complication of angiography or aoic manipulation during surgery and can result in lower extremity ischemia, acute myocardial infarction, ischemic bowel, and acute or chronic renal failure. Eosinophilia is strongly suggestive of cholesterol atheroembolization, and other laboratory findings include microscopic hematuria or proteinuria and elevated inflammatory mediators such as erythrocyte sedimentation rate. A fractional excretion of sodium (FENa) of greater than 1 suggests a renal cause of acute renal failure as opposed to prerenal causes such as hypovolemia or cardiogenic shock. Thoracic aoic dissections can result in acute renal failure if they involve the renal aeries and may present with hematuria and elevations in BUN and creatinine. However, aoic dissections are typically associated with significant chest pain.
Hypovolemia
Renal aery cholesterol embolism
Acute tubular necrosis
Cardiogenic shock
Miscellaneous