Scolari F, Tardanico R, Zani R, Pola A, Viola B F, Movilli E, Maiorca R
Division and Chair of Nephrology and Department and Chair of Pathology, Spedali Civili and University, Brescia, Italy.
Am J Kidney Dis. 2000 Dec;36(6):1089-109. doi: 10.1053/ajkd.2000.19809.
Cholesterol crystal embolism, sometimes separately designated atheroembolism, is an increasing and still underdiagnosed cause of renal dysfunction antemortem in elderly patients. Renal cholesterol crystal embolization, also known as atheroembolic renal disease, is caused by showers of cholesterol crystals from an atherosclerotic aorta that occlude small renal arteries. Although cholesterol crystal embolization can occur spontaneously, it is increasingly recognized as an iatrogenic complication from an invasive vascular procedure, such as manipulation of the aorta during angiography or vascular surgery, and after anticoagulant and fibrinolytic therapy. Cholesterol crystal embolism may give rise to different degrees of renal impairment. Some patients show only a moderate loss of renal function; in others, severe renal failure requiring dialysis ensues. An acute scenario with abrupt and sudden onset of renal failure may be observed. More frequently, a progressive loss of renal function occurs over weeks. A third clinical form of renal atheroemboli has been described, presenting as chronic, stable, and asymptomatic renal insufficiency. The renal outcome may be variable; some patients deteriorate or remain on dialysis, some improve, and some remain with chronic renal impairment. In addition to the kidneys, atheroembolization may involve the skin, gastrointestinal system, and central nervous system. Renal atheroembolic disease is a difficult and controversial diagnosis for the protean extrarenal manifestations of the disease. In the past, the diagnosis was often made postmortem. However, in the last decade, awareness of atheroembolic renal disease has improved, enabling us to make a correct premortem diagnosis in a number of patients. Correct diagnosis requires the clinician to be alert to the possibility. The typical patient is a white man aged older than 60 years with a baseline history of hypertension, smoking, and arterial disease. The presence of a classic triad characterized by a precipitating event, acute or subacute renal failure, and peripheral cholesterol crystal embolization strongly suggests the diagnosis. The confirmatory diagnosis can be made by means of biopsy of the target organs, including kidneys, skin, and the gastrointestinal system. Thus, Cinderella and her shoe now can be well matched during life. Patients with renal atheroemboli have a dismal outlook. A specific treatment is lacking. However, it is an important diagnosis to make because it may save the patient from inappropriate treatment. Finally, recent data suggest that an aggressive therapeutic approach with patient-tailored supportive measures may be associated with a favorable clinical outcome.
胆固醇结晶栓塞，有时也被单独称为动脉粥样硬化栓塞，是老年患者生前肾功能不全日益增多且仍未得到充分诊断的一个原因。肾胆固醇结晶栓塞，也称为动脉粥样硬化栓塞性肾病，是由来自动脉粥样硬化主动脉的胆固醇结晶簇阻塞肾小动脉所致。虽然胆固醇结晶栓塞可自发发生，但它越来越被认为是一种医源性并发症，源于侵入性血管操作，如血管造影或血管手术期间对主动脉的操作，以及抗凝和纤维蛋白溶解治疗之后。胆固醇结晶栓塞可能导致不同程度的肾功能损害。一些患者仅表现出中度肾功能丧失；而另一些患者则会发展为需要透析的严重肾衰竭。可能会观察到急性肾衰竭突然发作的情况。更常见的是，肾功能在数周内逐渐丧失。已经描述了肾动脉粥样硬化栓塞的第三种临床形式，表现为慢性、稳定且无症状的肾功能不全。肾脏预后可能各不相同；一些患者病情恶化或持续需要透析，一些患者病情改善，还有一些患者则持续存在慢性肾功能损害。除肾脏外，动脉粥样硬化栓塞可能累及皮肤、胃肠道系统和中枢神经系统。肾动脉粥样硬化栓塞性疾病因该疾病多样的肾外表现而成为一个难以诊断且存在争议的疾病。过去，诊断往往在尸检时做出。然而，在过去十年中，对动脉粥样硬化栓塞性肾病的认识有所提高，使我们能够在一些患者中做出正确的生前诊断。正确诊断需要临床医生对这种可能性保持警惕。典型患者是一名60岁以上的白人男性，有高血压、吸烟和动脉疾病的基线病史。以诱发事件、急性或亚急性肾衰竭以及外周胆固醇结晶栓塞为特征的典型三联征强烈提示诊断。确诊可通过对包括肾脏、皮肤和胃肠道系统在内的靶器官进行活检来做出。因此，灰姑娘和她的鞋子现在在生前就能很好地匹配了。肾动脉粥样硬化栓塞患者的预后不佳。目前缺乏特异性治疗方法。然而，做出这一重要诊断很有必要，因为它可能使患者避免不恰当的治疗。最后，最近的数据表明，采用针对患者的支持措施的积极治疗方法可能会带来良好的临床结果。
