Low‐Density Lipoprotein Apheresis Ameliorates Renal Prognosis of Cholesterol Crystal Embolism

Abstract

Drugs such as corticosteroids and statins have been used to treat cholesterol crystal embolism (CCE), but the prognosis remains poor. This study evaluated the efficacy of low-density lipoprotein apheresis (LDL-A) in patients with CCE. Patients with CCE who showed renal deterioration after vascular interventions were studied retrospectively. Information on demographic variables, clinical measurements, and medication use was collected. The outcomes were incidence of maintenance dialysis and mortality at 24 weeks. A total of 49 patients with CCE were included, among whom 37 (76%) were diagnosed pathologically and the remainder were diagnosed clinically. The median estimated GFR at baseline and at diagnosis were 40.5 and 13.4 mL/min per 1.73 m(2) , respectively. Corticosteroids were used in 42 patients (86%), statins in 30 patients (61%), and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in 29 patients (59%). LDL-A was performed in 25 patients (LDL-A group), and not in 24 patients (control group). Smoking (100% vs. 72%, P = 0.02), white blood cell count (8900/mm(3) vs. 7000/mm(3) ) and corticosteroid use (96% vs. 75%) were higher in the LDL-A group compared with the control group, but there were no differences in other demographic and clinical parameters between the groups. Patients in the LDL-A group had a lower incidence of maintenance dialysis (2/25 (8%) vs. 8/24 (33%), P < 0.05), and a trend towards lower mortality (2/25 (8%) vs. 7/24 (29%), P = 0.074). These results suggest that LDL-A decreases the risk of maintenance dialysis in severe renal CCE patients after vascular interventions.

An Autopsy Case of Acute Pancreatitis Caused by Cholesterol Crystal Embolization

“…As an approach to this condition, HMG-CoA reductase inhibitors and steroids have been used to stabilize plaques and suppress inflammation, but their effects are limited (13). Recently, low-density lipoprotein (LDL) apheresis has occasionally been reported to be a more potent treatment (3)(4)(5). LDL apheresis reportedly exerts not only plaque-stabilizing effects by lowering the lipid levels (14), but also anti-inflammatory effects by removing inflammatory substances, and improvement of vascular function and blood flow by increasing nitric oxide, PG, and vascular endothelial growth factor, and so on (3-6).…”

“…A new drug, evolocumab, an anti-proprotein convertase subtilisin/kexin type 9 (PCSK9) antibody, may also have beneficial effects on renal involvement in patients with CCE (7). Almost all of the reports on CCE have involved the kidneys and skin (3)(4)(5)7), but the underlying pathology should be the same even for gastrointestinal organs. We therefore think these new treatments are worth investigating for CCE in the digestive field in the near future.…”

“…In addition, established treatments are lacking, and the prognosis is poor (1). Recently, new treatments have been reported for CCE of the kidneys and skin (3)(4)(5)(6)(7). We herein present a case of pancreatitis caused by CCE, in which the symptoms were mainly related to the digestive organs and standard therapy failed to avert a rapid deterioration thus resulting in death.…”

<p>Cholesterol-embolization syndrome: current perspectives</p>

“…In this study, baseline statin treatment was found to be associated with a lower risk of ESRD and improved 1-year cumulative survival. LDL apheresis was reported to decrease the need for dialysis in 49 patients with CES after 6 months 90. Also, in other studies it was reported that LDL apheresis improved clinical manifestations in patients with CES 91,92…”

Eosinophilia and Kidney Disease: More than Just an Incidental Finding?

“…Withdrawal of anticoagulants, if possible, is proposed by some authors, while the role of steroids remains controversial [111,118]. Lipid-lowering therapies with statins or low-density lipoprotein (LDL)-apheresis are being used in case reports but until now there are no randomized trials that support this strategy [119,120]. Considering the lack of therapeutic options for CES, prevention of further episodes is crucial.…”