Ritz Eberhard
Ruperto Carola University Heidelberg, Heidelberg, Germany.
Blood Purif. 2008;26(1):59-62. doi: 10.1159/000110566. Epub 2008 Jan 10.
The clustering of cardiovascular risk factors was noted already a century ago, but it is only recently that a link between the CV risk cluster and insulin resistance has been postulated - a proposal which is not unanimously accepted. There is no doubt, however, that obesity per se impacts on renal function and the risk of chronic kidney disease (CKD). Particularly obesity early in life is an important predictor of CKD in adult life, but in adults as well a high body mass index (BMI) is an independent predictor of ESRD. The BMI threshold is lower in Asians. The link between obesity and CKD is not fully explained by the association between obesity and diabetes or hypertension respectively. Obesity is associated with increased glomerular filtration rate and renal blood flow, glomerulomegaly and in extreme cases focal segmental glomerulosclerosis. The causal role of obesity is underlined by the effect of weight loss on proteinuria and glomerular hyperfiltration. An even better predictor than BMI is visceral obesity (waist circumference). For kidney disease in the metabolic syndrome it is relevant that insulin resistance is linked to salt sensitivity and increased tubular reabsorption of sodium. Recent evidence points to adverse effects of aldosterone on podocytes, mediated by reactive oxygen species and resulting from hypothetical stimulants of aldosterone synthesis by visceral adipocytes.
心血管危险因素的聚集现象早在一个世纪前就已被发现，但直到最近才有关于心血管风险簇与胰岛素抵抗之间存在联系的假说——这一假说并未得到一致认可。然而，毫无疑问，肥胖本身会影响肾功能和慢性肾脏病（CKD）的风险。尤其是早年肥胖是成年后CKD的重要预测因素，但在成年人中，高体重指数（BMI）也是终末期肾病（ESRD）的独立预测因素。亚洲人的BMI阈值较低。肥胖与CKD之间的联系不能完全用肥胖与糖尿病或高血压之间的关联来解释。肥胖与肾小球滤过率增加、肾血流量增加、肾小球肿大以及在极端情况下的局灶节段性肾小球硬化有关。体重减轻对蛋白尿和肾小球高滤过的影响突出了肥胖的因果作用。比BMI更好的预测指标是内脏肥胖（腰围）。对于代谢综合征中的肾脏疾病，胰岛素抵抗与盐敏感性及肾小管钠重吸收增加相关这一点很重要。最近的证据表明，醛固酮对足细胞有不良影响，这是由活性氧介导的，并且是由内脏脂肪细胞对醛固酮合成的假设性刺激物导致的。
