Zoccali Carmine
Consiglio Nazionale delle Ricerche-Instituto di Bio-Medicina, Clinical Epidemiology & Pathophysiology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy.
J Am Soc Nephrol. 2006 Apr;17(4 Suppl 2):S61-3. doi: 10.1681/ASN.2005121344.
Renal insufficiency in essential hypertension represents the expression of a medium- and small-size arteriolopathy characterized by intimal hyperplasia, hyalinosis, and smooth muscle cell hypertrophy (nephroangiosclerosis). Because in animal models endothelial dysfunction plays a role in this alteration, nephroangiosclerosis and the attendant renal insufficiency may be the expression of a systemic dysfunction of vascular endothelium. Endothelial function in the kidney vasculature of hypertensive individuals has been investigated little because studies on the hemodynamic response of the kidney to nitric oxide activation and blockade are laborious to perform. There is no direct proof that endothelial dysfunction in the forearm or in the coronary circulation is paralleled by a similar hemodynamic dysfunction in the kidney. A recent study in a large population of patients with essential hypertension showed that, independent of other risk factors, the GFR in these patients is strongly related to the forearm blood flow response to acetyl choline (an established test of endothelial function). Furthermore, in this study, C-reactive protein was inversely related to the GFR and with the vasodilatory response to acetyl choline, pointing to inflammation as a likely mechanism to explain the association between endothelial dysfunction and impaired renal function in essential hypertension. A dysfunctional endothelium may represent a critical link accounting for the risk for both renal impairment and cardiovascular complications in essential hypertension.
原发性高血压中的肾功能不全表现为一种中小动脉病变，其特征为内膜增生、玻璃样变和平滑肌细胞肥大（肾血管硬化）。因为在动物模型中，内皮功能障碍在这种改变中起作用，所以肾血管硬化及随之而来的肾功能不全可能是血管内皮系统性功能障碍的表现。高血压患者肾血管系统的内皮功能很少被研究，因为关于肾脏对一氧化氮激活和阻断的血流动力学反应的研究很难进行。没有直接证据表明前臂或冠状动脉循环中的内皮功能障碍与肾脏中类似的血流动力学功能障碍同时存在。最近一项针对大量原发性高血压患者的研究表明，独立于其他危险因素，这些患者的肾小球滤过率（GFR）与前臂对乙酰胆碱的血流反应（一种既定的内皮功能测试）密切相关。此外，在这项研究中，C反应蛋白与GFR以及对乙酰胆碱的血管舒张反应呈负相关，这表明炎症可能是解释原发性高血压中内皮功能障碍与肾功能受损之间关联的一种机制。功能失调的内皮可能是一个关键环节，解释了原发性高血压中肾功能损害和心血管并发症风险的原因。
