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Diagnosis: Cholesterol Embolism
Cholesterol embolism or atheroembolism is a phenomenon where cholesterol crystals and atheroma debris such as cholesterol, platelets, and fibrins embolizes from proximal large arteries such as the aorta and its major branches to distal small arteries. It frequently occurs after the intraarterial procedures, but it can also occur spontaneously. Multiple organs can be involved, including the brain, skin, eyes, kidneys, and gastrointestinal tract. Organ damage usually manifests when cholesterol crystals break off from atherosclerotic plaques and shower to downstream vascular beds causing mechanical obstruction and inflammatory response to the target organ. Cholesterol crystal embolization is seen on microscopic examination as an arterial lumen filled with large cholesterol crystal spaces or clefts surrounded by hyperplastic intimal tissue and giant cells. Cholesterol crystal spaces are seen as crystals dissolve during the preparation (Shah N, Nagalli S. Cholesterol Emboli. [Updated 2021 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. [Page Link]).
In the kidneys, atheroembolism causes two types of manifestations: acute to subacute or chronic. Acute or subacute form of kidney injury from embolization manifests clinically as microscopic hematuria, eosinophiluria, and minimal proteinuria on urine analysis; AKI can also be the clinical manifestation. Whereas, chronic form most often manifests as heavy, nephrotic range proteinuria. Cholesterol embolism should be a differential diagnosis when the intrinsic renal disease is suspected and especially in the case where secondary focal segmental glomerulosclerosis is high on the differential (Shah N, Nagalli S. Cholesterol Emboli. [Updated 2021 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. [Page Link]).
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References
- Shah N, Nagalli S. Cholesterol Emboli. 2021 Jul 5. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 32310551. [PubMed link]
- Mochida Y, Ohtake T, Ishioka K, Oka M, Maesato K, Moriya H, Hidaka S, Kobayashi S. Association between eosinophilia and renal prognosis in patients with pathologically proven cholesterol crystal embolism. Clin Exp Nephrol. 2020;24(8):680-687. [PubMed link]
- Toriu N, Sumida K, Mizuno H, Hasegawa E, Suwabe T, Kawada M, Ueno T, Hayami N, Sekine A, Hiramatsu R, Yamanouchi M, Hoshino J, Sawa N, Takaichi K, Ohashi K, Fujii T, Ubara Y. Long-term outcome of biopsy-proven cholesterol crystal embolism. Clin Exp Nephrol. 2019;23(10):1181-1187. [PubMed link]
- Li X, Bayliss G, Zhuang S. Cholesterol Crystal Embolism and Chronic Kidney Disease. Int J Mol Sci. 2017;18(6):1120. [PubMed link]
- Ghanem F, Vodnala D, K Kalavakunta J, Durga S, Thormeier N, Subramaniyam P, Abela S, S Abela G. Cholesterol crystal embolization following plaque rupture: a systemic disease with unusual features. J Biomed Res. 2017;31(2):82-94. [PubMed link]
- Lusco MA, Najafian B, Alpers CE, Fogo AB. AJKD Atlas of Renal Pathology: Cholesterol Emboli. Am J Kidney Dis. 2016;67(4):e23-4. [PubMed link]