A 70-year-old man develops livedo reticularis over both feet, bluish discoloration of the toes, and a creatinine rising from 1.2 to 3.6 mg/dL over 3 weeks following coronary angiography. Total leukocyte count is elevated with 14 percent eosinophils, complement C3 is low, and erythrocyte sedimentation rate is 60 mm/hr. Urinalysis shows bland sediment. What is the most likely diagnosis?

• A Contrast induced acute kidney injury
• B Atheroembolic renal disease ✓
• C ANCA associated pauci-immune glomerulonephritis
• D Radiocontrast triggered acute interstitial nephritis

Explanation

Cholesterol crystal embolisation after arterial instrumentation causes a subacute progressive renal failure appearing days to weeks after the procedure, unlike contrast nephropathy which peaks within 48 to 72 hours. The combination of livedo reticularis, blue toes, peripheral eosinophilia, low complement, raised ESR, and bland urine sediment is characteristic. ANCA vasculitis would show active urinary sediment with red cell casts, and acute interstitial nephritis typically follows drugs rather than catheterisation and lacks cutaneous embolic signs.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.