Renal Case: 63-year-old Man with Nausea, Fatigue, and Lethargy

00:01 Okay. let's move to another case.

00:04 You're asked to see a 63-year-old man who was admitted with nausea, fatigue and lethargy.

00:09 He's taking no new medications other than Clopidogrel which he started 5 weeks ago following coronary angiography with stent placement to his left circumflex.

00:19 His physical exam interestingly, has a skin exam that demonstrates livedo reticularis which is a lace-like purplish discoloration of the skin On his laboratory data, is remarkable for serum creatinine of 3.9 mg/dL and we can see that that's elevated.

00:37 On his CBC or complete blood count, he has an increased number of eosinophils on his differential and his serum complement levels are low.

00:46 His urine analysis is bland.

00:48 So the question is, what type of acute kidney injury does this gentleman have? Let's go through our case and see if we can answer that question.

00:56 So some important hings to note on the history is that temporal correlation between the percutaneous coronary intervention and his subacute manifestation of AKI.

01:06 So somewhere between 2 and 8 weeks after having any kind of aortic manipulation is very suggestive of having something like renal atheroembolic disease.

01:16 Also, on his skin exam is remarkable remember for livedo reticularis and that's caused by microvascular ischemia due to arterial occlusion and inflammatory response due to cholesterol crystals that embolize and move distally in the skin.

01:32 And finally on our laboratory data, in addition to his elevated creatinine, we actually have an increase in the number of eosinophils on the differential and low complement levels which can be very suggestive again of renal atheromboembolic disease.

01:47 The other thing that I think that's very important is the urine analysis.

01:50 It shows a bland urine sediment and that's very helpful for us because remember, this gentleman actually underwent coronary angiography so the other thing that we think about when it comes to AKI and radiocontrast exposure is ATN.

02:05 But we looked at his urine sediment and it's bland, there was no evidence of muddy brown cast.

02:09 So this, taken together with the time course and everything else in this history really points towards the picture of renal atheromboembolic disease which is what this gentleman has.