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Answer 3
  1. Cholesterol embolization to the small arteries and arterioles in the kidney. Acute renal failure following an invasive procedure using radiocontrast material has a limited differential diagnosis. Congestive heart failure with impaired renal perfusion is unlikely because the patient showed no other evidence to support a clinical diagnosis of decompensated cardiac pump function. The transient bout of hypotension was not severe enough to cause acute renal failure from ischemic acute tubular necrosis. Contrast nephrotoxicity is possible in view of the underlying risk factors (ie, diabetes mellitus, renal failure), the amount of contrast dye utilized, and the temporal association of renal failure. Yet, the combination of acute renal failure with severe hypertension, purple toes, and gastrointestinal bleeding following an invasive vascular procedure most strongly suggests a diagnosis of cholesterol embolization to the kidneys, lower extremities, and gastrointestinal tract. Atherosclerotic debris mobilized from aortic plaques during the procedure is the source of cholesterol emboli in this circumstance.

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