Zoccali Carmine, Enia Giuseppe, Tripepi Giovanni, Panuccio Vincenzo, Mallamaci Francesca
CNR-IBIM Epidemiologia Clinica e Fisiopatologia delle Malattie Renali e dell'Ipertensione Arteriosa, Ospedali Riuniti, Calabria, Italy.
Perit Dial Int. 2005 Feb;25 Suppl 3:S84-7.
End-stage renal disease (ESRD) is a situation with a cardiovascular (CV) risk profile of almost unique severity. While traditional risk factors dominate the scene in the general population, in chronic kidney disease (CKD), nontraditional risk factors play an increasingly important role, being perhaps dominant in ESRD patients.
We review the role inflammation [C-reactive protein (CRP)], hyperhomocysteinemia, high plasma norepinephrine, and accumulation of the endogenous inhibitor of the nitric oxide synthase asymmetric dimethylarginine (ADMA) in the high all-cause and CV mortality of patients on continuous ambulatory peritoneal dialysis (CAPD).
The association between CRP and clinical outcomes in patients on peritoneal dialysis (PD) was examined in six studies totaling 692 subjects. The largest of these studies in Caucasians indicates that the independent risk of CV events in patients in the top CRP quartile is about five times higher than in the bottom quartile. Seven prospective studies, including over 1000 hemodialysis and 176 CAPD patients, reported both positive and negative associations between homocysteine and mortality and/or CV events. Because homocysteine circulates bound to albumin, negative associations--rather than negating the vasculotoxicity of homocysteine--most likely reflect the very deleterious effects of malnutrition. Plasma norepinephrine is higher in CAPD than in hemodialysis patients, and multivariate analyses suggest the difference quantitatively entails a 16% higher risk of incident CV events. Likewise, ADMA is more elevated in CAPD patients and such an elevation corresponds to a 15% increase in risk.
Nontraditional risk factors are far more prevalent in ESRD patients than in the general population. ADMA and norepinephrine may play a greater role in CV risk in CAPD than in hemodialysis patients.
终末期肾病（ESRD）是一种心血管（CV）风险状况几乎具有独特严重性的情况。在普通人群中，传统风险因素占主导地位，而在慢性肾脏病（CKD）中，非传统风险因素发挥着越来越重要的作用，在ESRD患者中可能占主导地位。
我们综述炎症[C反应蛋白（CRP）]、高同型半胱氨酸血症、高血浆去甲肾上腺素以及一氧化氮合酶内源性抑制剂不对称二甲基精氨酸（ADMA）的蓄积在持续非卧床腹膜透析（CAPD）患者全因死亡率和心血管死亡率高企中的作用。
六项研究共纳入692名受试者，对腹膜透析（PD）患者中CRP与临床结局之间的关联进行了研究。其中规模最大的针对白种人的研究表明，CRP处于最高四分位数的患者发生心血管事件的独立风险比处于最低四分位数的患者高约五倍。七项前瞻性研究，包括1000多名血液透析患者和176名CAPD患者，报告了同型半胱氨酸与死亡率和/或心血管事件之间的正相关和负相关。由于同型半胱氨酸与白蛋白结合循环，负相关——而非否定同型半胱氨酸的血管毒性——很可能反映了营养不良的极其有害的影响。CAPD患者的血浆去甲肾上腺素高于血液透析患者，多变量分析表明，这种差异在数量上意味着发生心血管事件的风险高16%。同样，CAPD患者的ADMA升高更为明显，这种升高对应于风险增加15%。
非传统风险因素在ESRD患者中比在普通人群中更为普遍。ADMA和去甲肾上腺素在CAPD患者的心血管风险中可能比在血液透析患者中发挥更大作用。
