Obesity paradox in end-stage kidney disease patients.
Obesity paradox in end-stage kidney disease patients.
复制标题
DOI：
10.1016/j.pcad.2013.10.005
复制
发表时间：
2014-01
影响因子：
9.1
通讯作者：
Kalantar-Zadeh K
中科院分区：
文献类型：
--
作者：
Park J;Ahmadi SF;Streja E;Molnar MZ;Flegal KM;Gillen D;Kovesdy CP;Kalantar-Zadeh K
在一般人群中，肥胖与心血管风险增加和生存率降低有关。然而，在终末期肾病（ESRD）患者中，一直报告“肥胖悖论”或“反向流行病学”（包括脂质和高血压悖论），即较高的体重指数（BMI）与较好的生存率矛盾相关。尽管已发表的腹膜透析患者的结果不一，但大体型的生存优势在不同种族和地区的血液透析患者中相对一致。最近的数据表明，较高的骨骼肌质量和增加的全身脂肪都是保护性的，尽管内脏（腹内）脂肪的数据不一。ESRD中的肥胖悖论不太可能是由于单独的残余混杂因素造成的，并且具有生物学可解释性。肥胖悖论的可能原因包括蛋白质-能量消耗和炎症、竞争性风险因素（营养不足与营养过剩）之间的时间差异、血流动力学稳定性、循环细胞因子的改变、尿毒症毒素在脂肪组织中的隔离以及内毒素-脂蛋白相互作用。肥胖悖论可能对终末期肾病患者的管理具有重要的临床意义，特别是如果肥胖透析患者在移植等待名单上被迫减肥。精心设计的研究探索心血管危险因素的反向流行病学的原因和后果，包括肥胖悖论，在ESRD患者中可以提供更多的机制信息。这些可能包括营养和药物干预的对照试验，以检查瘦体重甚至体脂的增加是否可以改善这些患者的生存和生活质量。
In the general population, obesity is associated with increased cardiovascular risk and decreased survival. In patients with end-stage renal disease (ESRD), however, an “obesity paradox” or “reverse epidemiology” (to include lipid and hypertension paradoxes) has been consistently reported, i.e. a higher body mass index (BMI) is paradoxically associated with better survival. This survival advantage of large body size is relatively consistent for hemodialysis patients across racial and regional differences, although published results are mixed for peritoneal dialysis patients.. Recent data indicate that both higher skeletal muscle mass and increased total body fat are protective, although there are mixed data on visceral (intra-abdominal) fat. The obesity paradox in ESRD is unlikely to be due to residual confounding alone and has biologic plausibility. Possible causes of the obesity paradox include protein-energy wasting and inflammation, time discrepancy among competitive risk factors (undernutrition versus overnutrition), hemodynamic stability, alteration of circulatory cytokines, sequestration of uremic toxin in adipose tissue, and endotoxin-lipoprotein interaction. The obesity paradox may have significant clinical implications in the management of ESRD patients especially if obese dialysis patients are forced to lose weight upon transplant wait-listing. Well-designed studies exploring the causes and consequences of the reverse epidemiology of cardiovascular risk factors, including the obesity paradox, among ESRD patients could provide more information on mechanisms. These could include controlled trials of nutritional and pharmacologic interventions to examine whether gain in lean body mass or even body fat can improve survival and quality of life in these patients.