A 73-year-old-man with 40 pack years of smoking history and hypertension was on treatment with amlodipine 5 mg per day. He was diagnosed with peripheral vascular disease when a surgical consultation for purplish discoloration of toes was sought 3 months ago [] and warfarin sodium 5.0 mg alternating with 2.5 mg per day was prescribed.\nIn the current admission, he presented with passage of black stools and fresh bleeding per rectum. Blood pressure at admission was 150/90 mmHg. There were no clinical features of dehydration or excessive fluid loss. Warfarin was stopped and an upper gastrointestinal endoscopic examination was performed, which showed a healed duodenal ulcer. Abdominal ultrasound examination revealed an abdominal aortic aneurysm. Renal artery Doppler study was normal. Urine output was adequate on the first two days of admission (about 1800 ml) and urine examination at this time showed trace proteinuria, 8-10 pus cells/hpf. There was no evidence of hematuria or heme granular casts on microscopic examination of urine sediment. On the third admission day, he developed abrupt swelling of both legs and sharp decline in urine output to 600 ml which further dropped to 400 ml on fourth day, with development of azotemia. The relevant laboratory parameters at presentation are depicted in . Broad spectrum antibiotics were administered and hemodialysis was initiated. Pending the results of serological investigations, a clinical suspicion of vasculitis was considered and three doses of injection methyl prednisolone 1 gm intravenous daily for three days were administered starting from fifth admission day, followed by oral prednisolone 60 mg per day from 4th day. Inj. cyclophosphamide 750 mg (i.v.) was given on 8th post admission day. A renal biopsy was meanwhile performed which revealed presence of biconvex needle shaped empty spaces in lumen of an interlobular sized artery, consistent with cholesterol atheroemboli []. Tubular atrophy and interstitial fibrosis involved about 40% of the cortex, and the proximal tubules in the viable areas showed features of acute tubular injury, including loss of brush borders, epithelial simplification luminal granular casts. Direct immunofluorescence examination was negative for immunoglobulins (IgA, IgG, IgM), complements (C3, C1q), and also for kappa and lambda light chains. No refractile crystals were noted in frozen sections of biopsy core submitted for Direct Immunofluoroscence (DIF) studies. A final diagnosis of renal failure secondary to atheroembolic renal disease possibly precipitated by oral anticoagulant therapy was rendered.\nPatient's clinical status gradually improved with progressive increase in urine output and reduction of serum creatinine to 2.3 mg/dl on 21st post admission day []. After review of kidney biopsy report, the oral prednisolone was tapered rapidly in 2 weeks, and cyclophosphamide was withdrawn. Hemodialysis was discontinued and patient was discharged, off dialysis in a clinically stable condition with advice for regular outpatient follow-up.
In May 2017, a 73-year-old male patient developed breathlessness. His echocardiography study showed global hypokinesia and ejection fraction of 45%. Cardiac angiogram was done and was started on aspirin. His creatinine increased from 1.7 mg/dl to 9.6 mg/dl. He was started on hemodialysis. He was diagnosed as having AERD by renal biopsy.