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Atherosclerosis and the kidney Volume 16, issue 5, Mai 2004

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Service de Néphrologie, hôpital Broussais et HEGP, 20, rue Leblanc, 75015 Paris, France

Atherosclerosis induces renal artery stenoses in 15 to 30% of cases. The risk is correlated with coronary artery involvement. Renal ischemia fosters angiotensin 2 production that, through glomerular efferent arteriole vasoconstriction maintains the glomerular filtration rate. Renal ischemia must be suspected in case of renal asymmetry, of renal insufficiency following antihypertensive treatment, especially whith angiotensin 2 antagonists, when hypertension becomes resistant to previous therapy and\or in cases of "flash" pulmonary edema. The best diagnostic investigation is pulsed doppler which can also be used for long‐term surveillance of progressive stenoses, and is predictive of the results of revascularization, according to the renal resistance indices. When the kidney has not undergone ischemic atrophy, the indication of revascularization, which is not clearly codified, must take into account the risk\benefit ratio of angioplasty or surgery. In fact, renal function often remains stable for long periods of time, and the majority of these atherosclerotic patients dies from myocardial infarction. Cholesterol crystal embolism complicates surgery, angiography, angioplasty and anticoagulant treatment. It may also be spontaneous, characterized by renal insufficiency which can be slowly progressive or progress with episodes of acute exacerbation. Crystal migration in small caliber renal arteries is followed by a delayed inflammatory reaction leading to vascular obstruction. The clinical picture resembles vasculitis with signs and symptoms of inflammation and eosinophilia The diagnosis is based on typical cutaneous lesions, comprising purple toes, small areas of skin necrosis, lower limb livedo and in 1\5 of cases cholesterol crystals seen on funduscopy. Biopsies of skin and muscle usually make renal biopsy unecessary. Other localizations of cholesterol crystal embolism include mesenteric and brain vessels. Clinical and experimental data indicate that atherosclerosis and hyperlipidemia may be complicated by renal tissue injury. There is growing evidence that statin treatment is virtually always indicated in all forms of atheromatous renal disease.