胆固醇结晶栓塞性肾病2例及文献复习

Two cases of cholesterol crystal embolism nephropathy and literature review

摘要

分析2例继发于血管介入术后的胆固醇结晶栓塞性肾病（CCEN）患者的临床与病理特征，探讨其诊断与个体化管理策略。病例1，男，75岁，腹主动脉瘤介入术后7个月发现血肌酐明显升高，伴嗜酸性粒细胞显著增高及足底紫红色瘀点、瘀斑。皮肤活检见真皮动脉壁胆固醇结晶，确诊为胆固醇结晶栓塞。该患者因合并右下肢腓静脉血栓，在启动糖皮质激素抗炎治疗的同时，联合利伐沙班抗凝。治疗后皮肤病变消退，肾功能稳定。病例2，男，70岁，主动脉弓动脉瘤介入术后出现血肌酐逐渐增高，伴嗜酸性粒细胞升高、全身水肿及足底网状青斑。肾活检提示肾小动脉胆固醇结晶，确诊CCEN。在糖皮质激素治疗期间因并发消化道出血而中止，但其后皮肤栓塞征象消退，肾功能趋于稳定。这2例提示，对于血管介入术后出现亚急性肾损伤，尤其当合并嗜酸性粒细胞增高及皮肤受累表现时，应高度警惕胆固醇结晶栓塞，组织活检是确诊的关键，本病的治疗核心在于早期启用糖皮质激素，并在其应用中贯穿个体化原则，以权衡治疗获益、出血风险及合并症管理。

Abstract

To analyze the clinical and pathological characteristics of two patients with cholesterol crystal embolism nephropathy (CCEN) following vascular interventional procedures, and to explore its diagnosis and individualized management strategies. Case 1: A 75-year-old male presented with significantly elevated serum creatinine levels 7 months after endovascular repair of an abdominal aortic aneurysm. This was accompanied by marked eosinophilia and purpuric lesions on the soles. A skin biopsy revealed cholesterol crystals within the dermal arteries, confirming the diagnosis of cholesterol crystal embolism (CCE). Given concomitant right peroneal vein thrombosis, anticoagulation with rivaroxaban was initiated alongside anti-inflammatory glucocorticoid therapy. Following treatment, the skin lesions resolved and renal function stabilized. Case 2: A 70-year-old male developed gradually increasing serum creatinine levels after endovascular repair of an aortic arch aneurysm, accompanied by eosinophilia, systemic edema, and plantar livedo reticularis. A renal biopsy demonstrated cholesterol crystals in the arterioles, confirming CCEN. Glucocorticoid treatment was discontinued due to the onset of gastrointestinal bleeding; nevertheless, the cutaneous embolic signs subsequently subsided and renal function stabilized. These two cases suggest that the development of subacute renal impairment after vascular intervention, particularly when accompanied by eosinophilia and cutaneous embolic signs, is highly suggestive of CCE. Tissue biopsy remains the cornerstone for definitive diagnosis. The mainstay of treatment involves the early initiation of glucocorticoid therapy, the application of which should be individualized to carefully balance potential benefits against the risks of bleeding and the management of comorbidities.

关键词

胆固醇结晶栓塞 / 支架植入术 / 肾损害 / 嗜酸性粒细胞增多 / 病理活检

Key words

cholesterol crystal embolism / stent implantation / renal impairment / eosinophilia / pathological biopsy

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基金资助

福建省免疫性慢性肾病临床医学研究中心(2021Y2016)

福建省自然科学基金面上项目(2024J011153)