肥胖相关性肾病患者肾小球滤过率影响因素分析

Obesity related glomerulopathy: glomerular filtration rate and its relevant factors

目的:分析肥胖相关性肾病(ORG)患者肾小球滤过率(GFR)影响因素。方法:26例经临床和肾活检明确诊断为ORG的患者,男性22例,女性4例,平均年龄(37.12±9.42)岁,平均体重指数(BMI)(29.99±2.99)kg/m2。以体表面积校正内生肌酐清除率(Ccr)反应GFR,根据Ccr值不同分3组:A组:Ccr≥120ml/min·m2,B组:Ccr80～120ml/min·m2,C组:Ccr<80ml/min·m2。比较三组临床一般情况、血脂和血尿酸水平、糖代谢指标的差异,同时比较肾活检组织学改变(肾小球肥大、球性/节段硬化的发生率以及内皮细胞病变程度等)。按照内皮细胞病变程度分为:无内皮细胞病变、轻度内皮细胞病变(<20%的肾小球见内皮细胞肿胀、增生)和重度内皮细胞病变(>20%的肾小球见内皮细胞肿胀、增生,并可见内皮性泡沫细胞)。分析内皮细胞病变程度和Ccr高低之间的关系。结果:三组体重指数比较无显著差异,C组患者病程最短。三组患者平均肾脏体积均增大,A组增大最明显。C组尿蛋白量和血肌酐水平最高。C组三酰甘油、三酰甘油/高密度脂蛋白胆固醇水平最高,其次分别为B组和A组,三组比较差异显著。糖耐量异常三组比较无明显差异。三组患者均存在高胰岛素血症,C组胰岛素抵抗值显著高于其他两组。A组合并内皮细胞病变比例最多(90.9%),但在病变程度上,C组重度内皮细胞病变患者所占比例最高(66.7%)。A组患者以OGM所占比例最多(63.64%),其球性硬化和节段硬化比例均低于B组和C组,组间比较无显著性差异。结论:①ORG患者Ccr升高组伴双肾体积增大,提示该部分患者确实存在肾小球高滤过和高灌注。②ORG患者Ccr升高与BMI异常增高的程度无关联,Ccr升高组、Ccr正常组和降低组之间BMI无显著差异。③未发现高胰岛素血症,胰岛素抵抗,高尿酸血症和高脂血症与Ccr变化之间存在相关关系。④Ccr下降组胰岛素抵抗状态尤为突出,同时内皮细胞病变重,提示胰岛素抵抗与ORG患者肾功能恶化有关,而内皮细胞病变轻重可能有助于预后判断。

Objective:To investigate glomerular filtration rate and its relevant factors in patients with obesity related glomerulopathy (ORG). Methodology:Twenty-six patients, who were diagnosed ORG, 22 male and 4 female, were enrolled in this study. The average age was (37.1±9.42) years old. The average BMI was (30.0±2.99)kg/m2. The patients were divided into three groups according to their clearance of creatinine (Ccr). They were group A: Ccr≥120 ml/min·m2; group B: Ccr 80-120 ml/ min·m2; and group C: Ccr<80 ml/ min·m2. The clinical, laboratory and pathological features were analyzed in three groups. We also defined these patients as 3 pathological patterns: without endothelial pathological changes, with mild endothelial pathological changes (<20% glomerular), and with severe endothelial pathological changes (>20% glomerular). The relationship between the extent of endothelial pathological changes and the range of Ccr was investigated. Results:①Group A had the largest kidney size. There was no significant difference of kidney size between group B and C. ②High Ccr had no directly relationship with BMI, because the difference of BMI in three groups had no statistical significance. ③The hyperinsulinemia and insulin resistance had no overt effect on Ccr. The patients with high Ccr had lower serum level of insulin and insulin resistance. The other metabolic abnormalities also had no obvious relationship with Ccr. ④Patients with low Ccr group had more insulin resistance, shorter course of disease and severe endothelial changes, which indicate that insulin resistance might be a factor to affect renal function of ORG patients. Conclusion:Our ORG patients with enlarging kidney size suggest that the hyperperfusion and hyperfiltration were really existed in those patients. The low Ccr ORG patients with more severe insulin resistance and shorter course of disease indicate that insulin resistance was an important factor to affect renal function.