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LDL apheresis for cholesterol embolism following coronary artery bypass graft surgery--a case report
Toru Sanai1, Rei Matsui, Tadashi Hirano
1Division of Nephrology, Department of Internal Medicine and Clinical Research Institute, National Kyushu Medical Center, Fukuoka, Japan. sunny@m3.dion.ne.jp
Insights
Low-density lipoprotein (LDL) apheresis effectively treated cholesterol embolism (CE) complications, including acute renal failure and blue toe syndrome, following coronary artery bypass graft surgery (CABG). This intervention improved renal function and resolved vascular symptoms in a patient case study.
Area of Science:
- Nephrology and Cardiovascular Surgery
- Vascular Medicine and Atherosclerosis Research
Background:
- Coronary artery bypass graft surgery (CABG) can precipitate rare complications.
- Cholesterol embolism (CE) is a serious condition that can affect multiple organs, including the kidneys and peripheral vasculature.
Observation:
- A 76-year-old male developed acute renal failure and blue toe syndrome post-CABG.
- Initial treatments with alprostadil and limaprost alfadex showed limited efficacy.
- Elevated serum creatinine, proteinuria, and eosinophilia indicated significant renal and systemic involvement.
Findings:
- Diagnosis of cholesterol embolism (CE) was confirmed as the cause of renal dysfunction and blue toe syndrome.
- Sequential LDL apheresis treatment led to a significant reduction in LDL cholesterol levels.
- The patient experienced resolution of blue toe syndrome and improvement in renal function markers (serum creatinine, eosinophil count) following LDL apheresis.
Implications:
- LDL apheresis demonstrates therapeutic potential for managing cholesterol embolism (CE) with acute renal failure and blue toe syndrome.
- This case highlights the importance of considering CE in patients with post-surgical vascular and renal complications.
- Further research into LDL apheresis as a treatment modality for CE is warranted.
Abstract:
A 76-year-old man without any prior history of abnormal urinalysis findings or renal insufficiency demonstrated mild renal dysfunction after coronary bypass graft surgery (CABG). Two months after CABG, pain and blueness in the toes (blue toe syndrome) appeared and, the serum creatinine level (S-Cr) increased from 1.2 to 2.0 mg/dL. On admission (3 months later), the urinary protein level was 0.5 g/day, white blood cell count 8,300/microL with eosinophils (Eo) 10.5%, S-Cr 2.1 mg/dL, and low-density lipoprotein (LDL) 106 mg/dL. Acute renal failure and blue toe syndrome due to a cholesterol embolism (CE) were diagnosed. Alprostadil 40 microg/day orally for 2 weeks and alprostadil 40 microg/day intravenously were used for 5 weeks, and Eo were 250/microL, S-Cr 2.5 mg/dL; however, blue toe syndrome gradually developed. At 8 weeks after admission, limaprost alfadex 30 microg/day orally was used for 3 weeks. However, the Eo gradually rose to 1,520/microL, S-Cr to 3.0 mg/dL, and LDL to 135 mg/dL, and LDL apheresis was therefore performed 20 times for CE. The data just after LDL apheresis was performed 10 times were as follows: Eo 1,120/microL, S-Cr 4.0 mg/dL, and LDL 89 mg/dL, and blue toe syndrome had disappeared. At 10 months after the first LDL apheresis, the Eo were 630/microL, S-Cr 2.9 mg/dL, and LDL 109 mg/dL. As a result, LDL apheresis was found to be beneficial for the treatment of CE with acute renal failure and blue toe syndrome after CABG.
