Zuccala' A, Cianci R, Presta P, Fuiano G
U.O.C. di Nefrologia e Dialisi Laerte Poletti, Ospedale S. Maria della Scaletta, AUSL, Imola (BO), Italy.
G Ital Nefrol. 2009 May-Jun;26(3):299-309.
Nephroangiosclerosis (NAS) is increasingly diagnosed in adult and elderly patients with slowly progressive chronic renal insufficiency. Since these patients usually present with arterial hypertension, this is considered the main cause of NAS (sometimes called, in fact, hypertensive NAS or hypertensive nephropathy). However, there is evidence that other factors such as aging, black race, smoking, and metabolic disturbances contribute to the development and progression of the disease. In some patients, these factors may be prominent while hypertension may be mild or even absent: this form has been denominated ischemic nephropathy (IN). Are NAS and IN really two different diseases or just different presentations of cardiovascular disease involving the kidney? The latter hypothesis is supported by evidence that (a) NAS and IN share a relative aspecificity in their clinical symptoms (low proteinuria, microhematuria, high blood pressure, dyslipidemia) and histopathological features (as determined in the few cases that undergo a kidney biopsy), and (b) there is a high likelihood that atheromatous and hypertensive lesions coexist in the same patient. In this ''Controversy in Nephrology'', Rosario Cianci and Alessandro Zuccala' analyze this issue and try to answer the following questions: 1 - Are NAS and IN two different diseases or two different expressions of the same disease? Rosario Cianci, ''They are two different diseases''. Alessandro Zuccala', ''They represent two different expressions of the same disease''. 2 - Is the pathogenesis different in nephroangiosclerosis and IN? Rosario Cianci, ''The pathogenesis is high blood pressure in NAS and renal ischemia in IN''. Alessandro Zuccala', ''NAS and IN share the same multifactorial pathogenesis: vascular metabolic alterations can cause chronic renal ischemia with or without hypertension''. 3 - Is a biopsy necessary for the diagnosis? Rosario Cianci, ''Yes, it is''. Alessandro Zuccala', ''No, it is not''. 4 - Is it possible to prevent or to slow the progression of the renal damage in this (these) disease(s)? Rosario Cianci, ''Yes it is, by reducing blood pressure''. Alessandro Zuccala', ''Normalization of blood pressure is not enough but all the other risk factors of vascular damage must be addressed, when possible''.
肾血管硬化症（NAS）在患有缓慢进展性慢性肾功能不全的成年和老年患者中越来越多地被诊断出来。由于这些患者通常伴有动脉高血压，这被认为是NAS的主要原因（实际上有时被称为高血压性NAS或高血压肾病）。然而，有证据表明，其他因素，如衰老、黑人种族、吸烟和代谢紊乱，也会导致该疾病的发生和发展。在一些患者中，这些因素可能较为突出，而高血压可能较轻甚至不存在：这种形式被称为缺血性肾病（IN）。NAS和IN真的是两种不同的疾病，还是仅仅是涉及肾脏的心血管疾病的不同表现形式呢？后一种假设得到了以下证据的支持：（a）NAS和IN在临床症状（低蛋白尿、镜下血尿、高血压、血脂异常）和组织病理学特征（在少数接受肾活检的病例中确定）方面具有相对的非特异性；（b）同一患者中动脉粥样硬化和高血压病变共存的可能性很高。在这篇“肾脏病学争议”中，罗萨里奥·钱奇和亚历山德罗·祖卡拉分析了这个问题，并试图回答以下问题：1 - NAS和IN是两种不同的疾病，还是同一疾病的两种不同表现形式？罗萨里奥·钱奇：“它们是两种不同的疾病”。亚历山德罗·祖卡拉：“它们代表同一疾病的两种不同表现形式”。2 - 肾血管硬化症和IN的发病机制是否不同？罗萨里奥·钱奇：“NAS的发病机制是高血压，IN的发病机制是肾缺血”。亚历山德罗·祖卡拉：“NAS和IN具有相同的多因素发病机制：血管代谢改变可导致慢性肾缺血，伴或不伴有高血压”。3 - 诊断是否需要活检？罗萨里奥·钱奇：“是的，需要”。亚历山德罗·祖卡拉：“不，不需要”。4 - 在这种（这些）疾病中是否有可能预防或减缓肾损害的进展？罗萨里奥·钱奇：“是的，通过降低血压”。亚历山德罗·祖卡拉：“血压正常化是不够的，但在可能的情况下，必须解决所有其他血管损伤的危险因素”。
