Chaudhary K, Wall B M, Rasberry R D
Department of Nephrology, University of Tennessee, Memphis, USA.
Am J Med Sci. 2001 May;321(5):348-51. doi: 10.1097/00000441-200105000-00008.
Cholesterol embolization syndrome (CES) is an increasingly recognized cause of acute renal insufficiency, which must be differentiated from other forms of systemic vasculitis by histologic examination of biopsies from involved organs. This report describes the optimal methods for detection and biopsy of areas of skin involved with livedo reticularis to confirm the diagnosis of CES.
This report describes 8 patients with unexplained acute renal insufficiency in whom the diagnosis of CES was suspected based on their clinical history.
A detailed skin examination performed in both supine and upright postures demonstrated the presence of previously unrecognized livedo reticularis, which was more evident during upright posture in all subjects. In 2 subjects, questionable areas of livedo reticularis noted in supine posture became readily demonstrable during upright posture. Livedo reticularis was apparent only during upright posture in 2 subjects. Biopsies of areas of skin involved with livedo reticularis demonstrated cholesterol emboli in 6 of 8 patients and were normal in the remaining 2 patients. One patient progressed to end-stage renal disease and one was lost to follow-up. In the remaining 6 patients, renal insufficiency initially progressed but did not require dialytic therapy. Renal function returned to baseline levels and livedo reticularis resolved without recurrence in these patients. No subjects developed clinical or laboratory evidence of systemic vasculitis.
Livedo reticularis is a common but often unrecognized finding in CES that may not be evident during routine examination performed in the supine posture. Deep cutaneous biopsy of areas of livedo reticularis can be safely used to confirm the presence of cholesterol emboli, thus avoiding the increased morbidity of biopsy of either pregangrenous skin lesions or visceral organs. Many patients with CES regain renal function during long-term follow-up.
胆固醇栓塞综合征（CES）是急性肾功能不全越来越常见的病因，必须通过对受累器官活检进行组织学检查，将其与其他形式的系统性血管炎相鉴别。本报告描述了检测和活检伴有网状青斑的皮肤区域以确诊CES的最佳方法。
本报告描述了8例不明原因急性肾功能不全患者，根据其临床病史怀疑为CES。
仰卧位和直立位均进行详细的皮肤检查，发现所有受试者均存在之前未被识别的网状青斑，在直立位时更明显。2例受试者仰卧位时发现的可疑网状青斑区域在直立位时变得易于观察。2例受试者的网状青斑仅在直立位时明显。对伴有网状青斑的皮肤区域进行活检，8例患者中有6例显示胆固醇栓子，其余2例正常。1例患者进展为终末期肾病，1例失访。其余6例患者，肾功能不全起初进展，但无需透析治疗。这些患者的肾功能恢复至基线水平，网状青斑消退且未复发。无受试者出现系统性血管炎的临床或实验室证据。
网状青斑在CES中常见但常未被识别，在仰卧位进行的常规检查中可能不明显。对网状青斑区域进行深部皮肤活检可安全地用于确认胆固醇栓子的存在，从而避免对坏疽前期皮肤病变或内脏器官进行活检增加的发病率。许多CES患者在长期随访中肾功能恢复。
