Meyrier A
Department of Nephrology, Hôpital Avicenne, Université Paris Nord, Bobigny, France.
Nephrol Dial Transplant. 1996;11 Suppl 9:45-52. doi: 10.1093/ndt/11.supp9.45.
In white Europeans, renal size and function decline with age. This phenomenon has long been attributed to nephrosclerosis, i.e. primary vascular lesions associated with glomerular obsolescence, tubulointerstitial lesions and fibrosis. The part played by ageing and by pre-existing hypertension is still a matter of debate. Nephrosclerosis is a diagnosis of exclusion when no renal histology is available. As renal biopsy is rarely carried out in an elderly patient with atrophic kidneys, a long history of hypertension and only microalbuminuria or no proteinuria, the diagnosis of nephrosclerosis is generally overestimated. Even when renal histology is available, only subtle differences in vascular lesions have been claimed to distinguish those due to ageing from those due to hypertension. At any rate, meticulous control of blood pressure is certainly the most efficient means of protecting the renal vessels from further deterioration. Atheromatous renal disease has more recently been recognized as a major cause of progressive renal failure in the elderly. Renal artery stenoses due to atheromatous plaques might well be the cause of 10-15% of end-stage renal failure in whites aged > 50 and be the fourth cause of uraemia in this age group. Such stenoses are usually bilateral and developing. Present imaging methods, such as duplex ultrasound scanning and renal scintigraphy, are valuable means of diagnosis. Renal angioplasty can halt the the pace of renal insufficiency, or even durably improve it in nearly half of the cases. Finally, aorto-renal atheroma is a common and underestimated cause of cholesterol embolism. Minor, spontaneous forms thereof are indistinguishable from nephrosclerosis. Massive embolism entails a dismal prognosis, in terms of both renal function and patient survival. In conclusion, renal vascular lesions in the elderly remain a major concern. Improving non-invasive diagnostic procedures and applying preventative as well as curative measures should significantly reduce the incidence of end-stage renal disease is such patients.
在欧洲白人中，肾脏大小和功能随年龄增长而衰退。长期以来，这种现象一直被归因于肾硬化，即与肾小球荒废、肾小管间质病变和纤维化相关的原发性血管病变。衰老和既往高血压所起的作用仍存在争议。当没有肾脏组织学检查结果时，肾硬化是一种排除性诊断。由于老年萎缩性肾脏患者很少进行肾活检，且有高血压病史较长，仅有微量白蛋白尿或无蛋白尿，肾硬化的诊断通常被高估。即使有肾脏组织学检查结果，也只有血管病变的细微差异被认为可区分衰老所致与高血压所致的病变。无论如何，严格控制血压肯定是保护肾血管避免进一步恶化的最有效方法。动脉粥样硬化性肾病最近被认为是老年人进行性肾衰竭的主要原因。由动脉粥样硬化斑块导致的肾动脉狭窄很可能是50岁以上白人终末期肾衰竭的10% - 15%的病因，并且是该年龄组尿毒症的第四大病因。此类狭窄通常是双侧且进展性的。目前的成像方法，如双功超声扫描和肾闪烁显像，是有价值的诊断手段。肾血管成形术可以减缓肾功能不全的进展速度，甚至在近一半的病例中能持久改善肾功能。最后，主动脉 - 肾动脉粥样硬化是胆固醇栓塞常见且被低估的原因。其轻微的自发形式与肾硬化难以区分。大量栓塞在肾功能和患者生存方面都预后不佳。总之，老年人的肾血管病变仍然是一个主要问题。改进非侵入性诊断程序并应用预防和治疗措施应能显著降低这类患者终末期肾病的发生率。
