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Atheroembolic renal disease (AERD) is an underrecognised cause of progressive kidney dysfunction, often presenting with acute kidney injury (AKI), proteinuria, and systemic embolic features in patients with diffuse atherosclerosis. Diagnosis is frequently delayed owing to the limitations of contrast imaging in advanced chronic kidney disease (CKD), with renal biopsy remaining the gold standard.
Case Presentation:
We present the case of a 71year old man with a background of hypertension, known peripheral vascular disease, paroxysmal atrial fibrillation (AF), left ventricular systolic dysfunction (ejection fraction 44 %), type 2 diabetes mellitus, and prior embolic events (ischaemic stroke and retinal artery occlusion). In November 2024 he presented with lethargy, peripheral oedema and severe hypertension (systolic blood pressure 216 mmHg). Laboratory evaluation revealed AKI on underlying CKD (baseline creatinine 180 µmol/L, peak creatinine 380 µmol/L ), nephrotic range proteinuria (urine protein:creatinine ratio >300 mg/mmol) and microscopic haematuria. Prior to admission he had been taking nonsteroidal antiinflammatory drugs regularly.
Extensive workup including autoimmune, myeloma and infectious screens was negative. Transthoracic echocardiography demonstrated concentric left ventricular hypertrophy with regional wall motion abnormalities. Contrast enhanced vascular imaging was avoided due to CKD. A renal biopsy performed in November 2024 revealed classic atheroembolic renal disease characterised by cholesterol clefts within arterial lumina, chronic ischaemic changes in glomeruli and tubulointerstitium, and secondary adaptive focal segmental glomerulosclerosis (FSGS). Systemic embolic predisposing factors and manifestations in this patient comprised:
Ophthalmic: retinal microembolus (May 2024)
Neurological: hemispheric ischaemic stroke (July 2024), chronic MRI evidence of cerebral ischaemia
Renal: biopsy proven AERD
Cardiac: paroxysmal AF, left ventricular systolic dysfunction
Vascular: bilateral carotid stenoses (left 70–89 %, right 50–59 %)
Despite initiation of anticoagulation (edoxaban), antihypertensive therapy and lipid lowering medication, the patient’s estimated glomerular filtration rate (eGFR) declined to 14 mL/min/1.73 m² by early 2025, prompting preparation for dialysis.
Figure 1.
Panel A: Serial renal function trend showing rising creatinine (red, left axis) and declining eGFR (blue, right axis). The renal biopsy (November 2024) is marked with a dashed line. Progressive deterioration culminated in dialysis planning (February 2025).
Panel B: Systolic blood pressure (SBP) trend during hospital admissions and follow-up. Severe hypertension was noted during the first admission (November 2024; peak 216 mmHg), with persistent elevations despite therapy during the second admission (January 2025). Dialysis planning was initiated in February 2025.
Figure 2. Renal histopathology on PAS and HE stains (×10 magnification).
This case highlights the diagnostic challenge of atheroembolic renal disease (AERD), particularly in patients with multisystem involvement and pre-existing atherosclerotic disease. When contrast imaging is contraindicated due to CKD, renal biopsy remains crucial for definitive diagnosis. Management is primarily supportive, centred on withdrawal of precipitating agents (e.g., NSAIDs, dual antiplatelets), aggressive cardiovascular risk reduction, and early planning for renal replacement therapy. Clinicians should maintain a high index of suspicion for AERD in patients with progressive kidney dysfunction and systemic embolic manifestations.
