Synopsis
Recognise delayed cholesterol crystal embolisation after vascular manipulation, distinguish it from contrast-associated AKI and vasculitis, and provide supportive renal and cardiovascular care without claiming an unproven disease-specific drug.
- Think AERD when AKI appears days to weeks after aortic or arterial instrumentation and is accompanied by livedo, blue toes or retinal cholesterol emboli despite preserved distal pulses.
- The renal trajectory is often delayed and staircase-like, unlike the earlier creatinine rise typical of uncomplicated contrast-associated AKI.
- Treatment is supportive—manage volume, electrolytes, blood pressure and dialysis indications, avoid unnecessary further arterial manipulation, and use atorvastatin for cardiovascular prevention rather than crystal removal. Do not give corticosteroids routinely or reflexively stop essential antithrombotics; evidence for steroids is unconfirmed and antithrombotic indications require specialist reconciliation. Eosinophilia, low complement and inflammatory markers remain supportive, not diagnostic.
Key red flags
Oliguria, refractory hyperkalaemia, acidosis, pulmonary oedema or uraemic complications require immediate nephrology and critical-care discussion of renal replacement therapy.
Severe abdominal pain, gastrointestinal bleeding or peritonism may represent mesenteric cholesterol embolisation and requires urgent imaging and surgical assessment.
New focal neurology, retinal ischaemia or rapidly progressive gangrene indicates a systemic embolic shower rather than isolated kidney injury.
Fever, a murmur and positive blood cultures raise infective endocarditis with septic emboli, which must be distinguished before immunosuppression.
Purpura with glomerular urine sediment, major proteinuria or disease-specific serology should prompt assessment for vasculitis or glomerulonephritis.
Retinal plaques, neurological events, myalgia, abdominal pain or gastrointestinal bleeding alongside AKI strengthen the diagnosis and indicate a larger embolic burden.
Oliguria, pulmonary oedema, resistant hypertension, hyperkalaemia, acidosis or uraemia signals advanced injury and requires urgent nephrology support.
Investigation priorities
Define timing, severity and renal-support needs rather than relying on one creatinine.
Management branches
Creatinine rises ten days after angiography and the patient has livedo, blue toes and preserved pedal pulses.
- Plot creatinine and procedures over time, assess urine output and emergencies, and examine skin, pulses, retina, abdomen and neurology for a systemic shower.
- Compare alternatives: early contrast-associated AKI, pre-renal injury, renal infarction, vasculitis and infective emboli; send urine, blood count, complement, inflammatory markers and cultures when infection is plausible.