Meyrier A, Buchet P, Simon P, Fernet M, Rainfray M, Callard P
Service de Néphrologie, Hôpital Avicenne, Bobigny, France.
Am J Med. 1988 Aug;85(2):139-46. doi: 10.1016/s0002-9343(88)80332-2.
Atheroma as a cause of renal failure has been largely overlooked. We wanted to report our experience with atheromatous renal disease over a 12-year period.
Observations on 32 cases of various forms of renal failure in patients with atheromatous renal disease are presented. These patients had been hypertensive for an average of 10.2 +/- 9.2 years. The length of deterioration was an average of 17 months, and at presentation renal insufficiency was severe, with serum creatinine levels of (mean +/- SD) 616 +/- 358 mumol/liter (6.8 +/- 4.0 mg/dl). At this stage, the clinical picture was indistinguishable from other common causes of chronic renal failure in the elderly. Thus, the precise diagnosis would have been overlooked without an aggressive diagnostic workup. All patients underwent angiography and six patients underwent renal biopsy.
In 22 cases, renal insufficiency was mainly due to atheromatous stenosis of renal arteries. In six of six patients, the results of renal biopsy showed cholesterol crystal embolism. In four additional cases, there was clinical or histologic evidence of extrarenal cholesterol embolism. In eight, renal artery plaques coexisted with cholesterol embolism. In two patients, renal failure was due only to cholesterol embolism. Renal atheromatous stenoses were developing, as shown on serial angiographies performed in five cases. In seven cases, stenoses involved both the main trunks of renal arteries and several intrarenal branches of too small a diameter to allow reconstructive surgery or percutaneous transluminal angioplasty. In addition, the general condition of most patients was so poor as to preclude surgery. Dialysis was begun in 11 patients, four other patients died, and renal failure was managed conservatively in 11. When undertaken, reconstructive surgery was successful in five of six patients.
Atheromatous renal disease is a frequent and easily overlooked cause of chronic renal insufficiency. It is not only due to renal artery stenosis but also to complex intrarenal lesions, with multiple stenoses of intrarenal vasculature and cholesterol embolism. It should be diagnosed by early angiography and renal biopsy, before the stage of multivisceral complications and at a time when surgery can still be undertaken.
动脉粥样硬化作为肾衰竭的一个病因在很大程度上被忽视了。我们想报告我们在12年期间对动脉粥样硬化性肾病的经验。
介绍了对32例患有动脉粥样硬化性肾病的各种形式肾衰竭患者的观察情况。这些患者平均高血压病史为10.2±9.2年。病情恶化时间平均为17个月，就诊时肾功能不全严重，血清肌酐水平（均值±标准差）为616±358μmol/升（6.8±4.0mg/dl）。在此阶段，临床表现与老年人慢性肾衰竭的其他常见病因难以区分。因此，若不进行积极的诊断检查，确切诊断将会被忽略。所有患者均接受了血管造影，6例患者接受了肾活检。
22例中，肾功能不全主要是由于肾动脉粥样硬化性狭窄。6例肾活检患者中有6例结果显示胆固醇结晶栓塞。另外4例有肾外胆固醇栓塞的临床或组织学证据。8例中，肾动脉斑块与胆固醇栓塞并存。2例患者肾衰竭仅由胆固醇栓塞引起。如5例患者的系列血管造影所示，肾动脉粥样硬化性狭窄在进展。7例中，狭窄累及肾动脉主干和几个肾内分支，其直径过小无法进行重建手术或经皮腔内血管成形术。此外，大多数患者的一般状况很差，无法进行手术。11例患者开始透析，另外4例患者死亡，11例患者对肾衰竭进行了保守治疗。进行重建手术时，6例患者中有5例成功。
动脉粥样硬化性肾病是慢性肾功能不全常见且易被忽视的病因。它不仅是由于肾动脉狭窄，还由于复杂的肾内病变，包括肾内血管系统的多处狭窄和胆固醇栓塞。应在多脏器并发症阶段之前且仍可进行手术时，通过早期血管造影和肾活检进行诊断。
