Cholesterol atheromatous embolism: an increasingly recognized cause of acute renal failure

Abstract

Cholesterol atheromatous embolism is a systemic disease resulting from cholesterol crystal embolization to many organs, including the kidney. Vascular surgery, vascular radiology investigations and anticoagulation have been identified as inciting factors. Fifteen patients with extensive atherosclerosis, presenting with simultaneous occurrence of acute renal failure and peripheral ischaemic changes were diagnosed as having acute renal failure due to cholesterol atheromatous embolism. The patients, 12 men and three women, had an average age of 65 years. In one patient, spontaneous occurrence of the disease was observed. An inciting factor was identified in 14 patients: aortography in 10, aortic surgery in two, and thrombolysis in two. Clinical course of acute renal failure was quite variable. Four patients required dialysis; 11 were conservatively managed. All patients had concomitant skin lesions, including digital mottling, cyanosis and gangrene of the toes, and livedo reticularis of the lower limb and abdomen. Eosinophilia was the most common laboratory abnormality. The diagnosis of cholesterol atheromatous embolism was confirmed by tissue examination in eight; in three it was based on the finding of retinal cholesterol emboli; in four patients it was made on clinical grounds. Seven patients died within 36 months. Death was most commonly from cardiac causes. Since the population at risk for cholesterol embolism is growing and the disease is iatrogenic in origin, we should expect to detect cholesterol embolism with greater frequency as cause of acute renal failure in the future.