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糖尿病血脂异常的病理生理学。

Pathophysiology of Diabetic Dyslipidemia.

机构信息

Department of Medicine, Division of Diabetes, Metabolism, and Endocrinology, Showa University School of Medicine.

出版信息

J Atheroscler Thromb. 2018 Sep 1;25(9):771-782. doi: 10.5551/jat.RV17023. Epub 2018 Jul 12.


DOI:10.5551/jat.RV17023
PMID:29998913
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC6143775/
Abstract

Accumulating clinical evidence has suggested serum triglyceride (TG) is a leading predictor of atherosclerotic cardiovascular disease, comparable to low-density lipoprotein (LDL)-cholesterol (C) in populations with type 2 diabetes, which exceeds the predictive power of hemoglobinA1c. Atherogenic dyslipidemia in diabetes consists of elevated serum concentrations of TG-rich lipoproteins (TRLs), a high prevalence of small dense low-density lipoprotein (LDL), and low concentrations of cholesterol-rich high-density lipoprotein (HDL)2-C. A central lipoprotein abnormality is an increase in large TG-rich very-low-density lipoprotein (VLDL)1, and other lipoprotein abnormalities are metabolically linked to increased TRLs. Insulin critically regulates serum VLDL concentrations by suppressing hepatic VLDL production and stimulating VLDL removal by activation of lipoprotein lipase. It is still debated whether hyperinsulinemia compensatory for insulin resistance is causally associated with the overproduction of VLDL. This review introduces experimental and clinical observations revealing that insulin resistance, but not hyperinsulinemia stimulates hepatic VLDL production. LDL and HDL consist of heterogeneous particles with different size and density. Cholesterol-depleted small dense LDL and cholesterol-rich HDL2 subspecies are particularly affected by insulin resistance and can be named "Metabolic LDL and HDL," respectively. We established the direct assays for quantifying small dense LDL-C and small dense HDL(HDL3)-C, respectively. Subtracting HDL3-C from HDL-C gives HDL2-C. I will explain clinical relevance of measurements of LDL and HDL subspecies determined by our assays. Diabetic kidney disease (DKD) substantially worsens plasma lipid profile thereby potentiated atherogenic risk. Finally, I briefly overview pathophysiology of dyslipidemia associated with DKD, which has not been so much taken up by other review articles.

摘要

越来越多的临床证据表明,血清甘油三酯(TG)是动脉粥样硬化性心血管疾病的主要预测指标,在 2 型糖尿病患者中与低密度脂蛋白(LDL)-胆固醇(C)相当,超过了糖化血红蛋白(HbA1c)的预测能力。糖尿病的致动脉粥样硬化性血脂异常包括富含 TG 的脂蛋白(TRL)血清浓度升高、小而密 LDL 的高患病率以及富含胆固醇的高密度脂蛋白(HDL)2-C 浓度降低。脂蛋白异常的中心是大 TG 富含极低密度脂蛋白(VLDL)1 的增加,其他脂蛋白异常与 TRL 增加在代谢上相关。胰岛素通过抑制肝 VLDL 生成并通过激活脂蛋白脂肪酶刺激 VLDL 清除来严格调节血清 VLDL 浓度。目前仍在争论胰岛素抵抗代偿性高胰岛素血症是否与 VLDL 的过度产生有因果关系。本综述介绍了实验和临床观察结果,表明胰岛素抵抗而不是高胰岛素血症刺激肝 VLDL 生成。LDL 和 HDL 由具有不同大小和密度的异质颗粒组成。胆固醇耗尽的小而密 LDL 和富含胆固醇的 HDL2 亚类特别受胰岛素抵抗的影响,可以分别命名为“代谢性 LDL 和 HDL”。我们建立了定量测定小而密 LDL-C 和小而密 HDL(HDL3)-C 的直接测定法。从 HDL-C 中减去 HDL3-C 可得到 HDL2-C。我将解释我们的测定法确定的 LDL 和 HDL 亚类的测量的临床相关性。糖尿病肾病(DKD)大大恶化了血脂谱,从而增加了致动脉粥样硬化的风险。最后,我简要概述了与 DKD 相关的血脂异常的病理生理学,这在其他综述文章中并没有太多涉及。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/2703/6143775/405daf79959f/jat-25-771-g003.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/2703/6143775/beb4ef25e35d/jat-25-771-g001.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/2703/6143775/8f2394bb837d/jat-25-771-g002.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/2703/6143775/405daf79959f/jat-25-771-g003.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/2703/6143775/beb4ef25e35d/jat-25-771-g001.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/2703/6143775/8f2394bb837d/jat-25-771-g002.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/2703/6143775/405daf79959f/jat-25-771-g003.jpg

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本文引用的文献

[1]
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Mol Cell Biochem. 2017-8-21

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Small dense low-density lipoprotein-cholesterol concentrations predict risk for coronary heart disease: the Atherosclerosis Risk In Communities (ARIC) study.

Arterioscler Thromb Vasc Biol. 2014-2-20

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