Cholesterol Crystal Embolization after Transcatheter Aortic-
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A 79-year-old man was admitted to the hospital after laboratory tests showed a serum creatinine level of 4.0 mg per deciliter (350 μmol per liter) (normal range, 0.7 to 1.2 mg per deciliter [60 to 100 μmol per liter]). He had no fevers, fatigue, weight loss, or myalgias. He had a history of ischemic cardiomyopathy and had chronic kidney disease (with a baseline serum creatinine level of 1.6 mg per deciliter [140 μmol per liter]), and he had undergone transcatheter aortic-valve replacement 1 month earlier. Physical examination showed cyanosis of both feet. Additional skin examination showed no livedo reticularis, and eye examination showed no Hollenhorst plaques. Additional laboratory tests showed a total white-cell count of 6800 per microliter with 15% eosinophils (absolute eosinophil count, 1050 per microliter; normal value, <500). Computed tomographic angiography that had been performed before transcatheter aortic-valve replacement showed diffuse atheroma in the aorta, with evidence of complex plaques (Panel A). Renal biopsy performed during the current admission revealed multiple needle-shaped clefts in arteries and glomeruli (Panel B, arrow), which confirmed cholesterol crystal embolization. The patient was treated with glucocorticoids and continued his previously prescribed treatment with aspirin and a statin. Hemodialysis was not initiated, and his renal function gradually improved. At a 6-month follow-up visit, the patient’s serum creatinine level was 2.2 mg per deciliter (190 μmol per liter).