London Gérard M
Nephrology Department, Société de Nephrologie, Centre Hospitalier F H Manhès-Service d'hémodialyse, Fleury-Mérogis, France.
J Am Soc Nephrol. 2003 Sep;14(9 Suppl 4):S305-9. doi: 10.1097/01.asn.0000081664.65772.eb.
Cardiovascular disease is the leading cause of mortality among patients with ESRD (chronic kidney disease stage 5). Left ventricular hypertrophy and arterial diseases are the two principal risk factors for cardiovascular mortality in hemodialysis patients. Epidemiologic studies show that damage to large conduit arteries contributes to morbidity and mortality in patients with chronic kidney disease. Atherosclerosis is primarily an intimal disease characterized by the presence of plaques and occlusive lesions. Although atherosclerosis is the most frequent underlying cause of cardiovascular disease in patients with ESRD, it represents only one form of structural response to metabolic and hemodynamic alterations that interfere with the process of aging. Arterial alterations in ESRD include nonocclusive arterial remodeling accompanying the growing hemodynamic burden and humoral abnormalities that are associated with chronic uremia. The consequences of these alterations are different from those attributed to atherosclerotic plaques and are characterized principally by hardening (stiffening) of arteries. Arteriosclerosis, characterized by stiffening of the aorta and large capacitative arteries, is a major determinant of left ventricular pressure overload and of abnormal coronary perfusion. Atherosclerosis and arteriosclerosis are frequently comorbid and characterized by a high degree of both intimal and medial calcifications in patients with ESRD. The extent of calcifications and the degree of arterial stiffening are independent predictors of mortality. Studies in patients with ESRD have shown that attenuation of arterial stiffness can have a favorable effect, associated with regression of left ventricular hypertrophy, on survival. Calcium-free, metal-free phosphate binders such as sevelamer can reduce calcification scores.
心血管疾病是终末期肾病（慢性肾脏病5期）患者死亡的主要原因。左心室肥厚和动脉疾病是血液透析患者心血管死亡的两个主要危险因素。流行病学研究表明，大血管损伤会导致慢性肾脏病患者发病和死亡。动脉粥样硬化主要是一种内膜疾病，其特征是存在斑块和闭塞性病变。虽然动脉粥样硬化是终末期肾病患者心血管疾病最常见的潜在病因，但它只是对干扰衰老过程的代谢和血流动力学改变的一种结构反应形式。终末期肾病患者的动脉改变包括伴随血流动力学负担增加的非闭塞性动脉重塑以及与慢性尿毒症相关的体液异常。这些改变的后果与动脉粥样硬化斑块所致后果不同，主要表现为动脉变硬（僵硬）。以主动脉和大容性动脉僵硬为特征的动脉硬化是左心室压力超负荷和冠状动脉灌注异常的主要决定因素。在终末期肾病患者中，动脉粥样硬化和动脉硬化常合并存在，其特征是内膜和中膜高度钙化。钙化程度和动脉僵硬程度是死亡率的独立预测因素。对终末期肾病患者的研究表明，减轻动脉僵硬对生存有有利影响，并与左心室肥厚的消退相关。不含钙、不含金属的磷结合剂，如司维拉姆，可以降低钙化评分。
