补充钙和维生素D防治骨质疏松症的全球临床指南进展

补充钙和维生素D防治骨质疏松症一直是全球权威学术机构临床指南的基本策略。然而,近来一些研究对过量补充钙和维生素D的健康骨骼益处提出不同的观点,从而干扰了国际公认的防治骨质疏松症的基本策略,混淆了临床医师的视听。因此,笔者综述近几年来中国、美国、加拿大、英国、波兰、日本、韩国等权威学术机构的临床指南的观点,重点介绍骨质疏松症的发病机制和病理生理学关注的骨重建的主要局部调节剂[受体激活剂核因子kb(RANK)及其配体RANKL和诱饵受体骨保护素(OPG);罗列各国为防治骨质疏松症推荐的钙和维生素D摄入量;联合补充钙和维生素D有利于防治骨质疏松症和骨质疏松性骨折;分析补充钙和维生素D的健康骨骼争议,一般健康人每天服用钙补充剂不应该超过1000 mg。特别是基于亚洲人(中国人、日本人、韩国人)的膳食钙摄入量、血脂水平、身体体重指数(BMI)和维生素D营养状况,参考中国、日本、韩国的补充钙和维生素D防治骨质疏松症的临床指南,提出钙和维生素D补充的方法:每日一次服用碳酸钙和维生素D3补充剂的剂量以元素钙500~600 mg和维生素D3200 IU为宜,比较适合中国成年人群预防骨质疏松症。如果需要补充更多剂量的钙和维生素D,必须分成多次服用。这些信息供我国临床医师参考使用。     

口服钙和维生素D能预防老年人骨质疏松性骨折——评英国Lancet关于维生素D3和钙对骨折预防作用的论文

英国Grant文章的结论和大量科学研究结果相反，可能与背景材料不同有关，我们不予支持。在西安第五届国际骨质疏松研讨会上，刘忠厚主编已明确指出：我国居民的平均钙摄入量低，仅为389mg，维生素D能帮助钙吸收利用，我国居民需要补充钙和维生素D。钙和维生素D是骨质疏松治疗和预防的基础用药。我们编辑部刊登周建烈博士一文，评论Grant的文章，以便对此展开讨论。[编者按]     

维生素D对预防跌倒和降低骨质疏松骨折的作用

老年人由于下肢神经肌肉功能下降,反应性和平衡能力减退,易发生跌倒,导致骨折。本文重点分析了维生素D与骨质疏松性骨折风险、骨密度、肌力、跌倒风险及认知能力的关系。补充维生素D能有效减少跌倒的发生,从而预防老年人骨质疏松性骨折的发生。     

老年男性骨质疏松性骨折患者血清25羟维生素D 水平研究

目的探讨老年男性性骨质疏松合并骨折血清25羟维生素D的水平。方法选择2011年3月至2013年5月我科住 院的78例患者,包括老年男性骨质疏松性骨折患者38例,年龄76. 78 ±6.47岁,不伴骨折老年男性骨质疏松患者40例,年龄 73. 74 ±5. 09岁。采用美国Norland双光能X线骨密度检测仪对所有患者进行腰椎L244和左侧股骨近端(包括Neck、Troch、 Ward三角区）骨密度测量,并测定身高、体重、血谷丙转氨酶（ALT)、谷草转氨酶(AST)、肌酐(CRE)、尿素氮（BUN)。采用酶 联免疫吸附法测定两组患者血清25羟维生素D,比较两组25羟维生素D水平。结果老年男性骨质疏松性骨折组患者血清 25羟维生素D3(16. 11 ±4.46)ng/ml,较老年男性非骨折骨质疏松患者（18. 73 ±6.47) ng/ml低,差异具有统计学意义（P < 0.05);老年骨质疏松性骨折组患者 ALT(18. 87 ±6. 83) IU/L、AST(20. 75 ±6. 15) IU/L、CRE (70. 92 ± 12. 25 ) umol/L、BUN (5. 75 ± 1. 4 ) mmol/L 与骨质疏松组 ALT( 19. 17 士 10. 24) IU/L、AST( 18. 50 ±4. 56) IU/L、CRE (82. 22 ± 8. 7) umol/L、BUN (6. 2 ± 1. 02) mmol/L相比,差异无统计学意义(P > 0. 05 );老年骨质疏松性骨折患者L24、Neck、Troch、ward ’ s三角区的骨密度分 别为（0.81 ±0.21) g/cm2、（0. 68 ±0.15) g/cm2、（0. 74 ± 0. 63) g/m2、（0. 52 ± 0.15) gLm2 与对照组（0.95 ±0.20) g/cm2、 (0.67±0. 09)g/cm2、（0. 63 ±0. 85)g/cm2、（0.54±0.17)g/cm2 相比较,差异没有统计学意义（P > 0. 05)。结论老年男性骨 质疏松合并骨折患者较未合并骨折骨质疏松患者维生素D缺乏更严重。     

维生素D与老年骨质疏松

目前维生素D缺乏巳成为一个世界性问题。近年来许多研究观察到很多国家的居民存在不同程度的维生素D( VitD) 缺乏,而老年人群又因为饮食因素、户外活动减少、胃肠吸收减少、肾功能减退等因素，使其成为VitD缺乏的最高危人群。目 前研究结论多来自国外研究，需要在中国开展不同人群VitD及其相关因素疾病的深人研究。本文旨在讨论老年人VitD与骨 质疏松的关系，进一步为老年人骨质疏松的防治和骨的健康提供理论依据。     

哈尔滨地区部分汉族人群维生素D受体Bsm I基因多态性与骨质疏松性骨折关系的研究

目的旨在了解哈尔滨地区部分汉族人群维生素D受体(VDR)BsmⅠ基因多态性与骨质疏松性骨折患者骨密度(BMD)的相关关系。方法98例研究对象按骨质疏松性骨折诊断标准分2组,骨量正常组:48人;骨质疏松性骨折组:50人。聚合酶链反应限制性片断长度多态性(PCR-RFLP)技术检测98例受试者VDRBsmⅠ基因型。测试受试者腰椎2～4(L2-4),股骨颈(Neck)、大转子(Troch)、Wards三角、桡骨远端(Radius)5个部位骨密度(BMD)。结果骨折组各部位骨密度均显著低于对照组各部位骨密度,差异具有显著性(P<0.01)。受试者VDR基因型未发现BB型,检出Bb型16人,占16.3%,bb型82人,占83.7%。b和B等位基因频率分别为91.8%、8.2%,Bb、bb两基因型在两组之间的分布无差异;VDR两基因型与各部位BMD之间,虽然在腰椎2～4、股骨颈、大转子和桡骨远端等4个部位Bb基因型比bb基因型的BMD高,但结果没有统计学意义。结论这组哈尔滨地区人群VDR基因型分布以bb型、Bb型为主,VDR基因BsmⅠ多态性与骨密度之间没有相关关系。     

维生素D与骨质疏松概述

作为营养尬发的维生素Ｄ在维持正常骨钙化,钙平衡及肠道钙吸收等方面起着十分重要的作用。然而维生素Ｄ本身并不是生物活性物质。维生素Ｄ经过肝脏及肾脏转化,形成其生物代谢活必平物－－１．２５（ＯＨ）２Ｄ３。１,２５（ＯＨ）２Ｄ３为甾体激素,其生物学效应由细胞核受体（ＶＤＲ）介导,在人体许多脏器包括肠道及骨组织发挥其生物学作用。在上述维生素Ｄ代谢系统中,任何环节发生异常均可导致人体疾病,包括骨质疏松（ＯＰ）     

强骨胶囊与维生素D对骨质疏松性骨折患者治疗有效性及安全性的系统评价

目的系统评价强骨胶囊与维生素D治疗骨质疏松性骨折的有效性及安全性。以期为临床骨质疏松性骨折患者的药物选择提供参考。方法计算机检索Pub Med、Web of science、Cochrane图书馆、中国期刊全文数据库(CNKI)、中国生物医学文献数据库(CBM)、中文科技期刊全文数据库(VIP)、万方数据库。搜集强骨胶囊与维生素D用于治疗骨质疏松性骨折的随机对照试验(RCT),检索年限均为建库以来至2017年1月27日。由两位研究者独立筛选文献、提取资料,并评价纳入研究的偏倚风险后,采用Rev Man 5.2软件进行Meta分析。结果最终纳入3个RCT,包括510例患者。Meta分析结果显示:强骨胶囊组患者的骨折愈合时间显著低于维生素D组,两组比较差异有统计学意义[MD=-3.68,95%CI(-4.60,-2.76),P0.00001]。强骨胶囊组的治疗后股骨颈骨密度(bone mineral density,BMD)高于维生素D组,且差异均具有统计学意义[MD=0.03,95%CI(0.01,0.04),P=0.0002]。强骨胶囊组患者轻度不良反应发生数显著高于维生素D组,两组比较差异有统计学意义[OR=23.89,95%CI(4.56,125.11),P=0.0002]。结论强骨胶囊可以减少骨质疏松性骨折患者的骨折愈合时间,增强骨密度,但相较于维生素D,仍需注意胃肠道的不良反应。     

维生素D预防和治疗肾移植术后骨质疏松的系统评价

目的 评价维生素D预防和治疗肾移植术后骨质疏松的安全性和有效性.方法 使用由国际循证医学Cochrane协作网推荐的方法,采用计算机检索1990年1月至2009年11月期间MEDLINE、EMBase、Cochrane图书馆临床对照试验数据库(CENTRAL)、中国期刊网(CNKI)等数据库,辅以手工检索及追查已纳入文献库的维生素D预防和治疗肾移植术后骨质疏松的临床随机对照试验(RCT).由2位评价者共同评价纳入的RCT质量,对符合标准的研究采用Revman 4.2软件进行Meta分析.结果 共纳入9个RCT,肾移植术后受者658例.研究质量评价结果为:A级4篇、B级2篇和C级3篇.Meta分析结果显示:维生素D治疗1年后,试验组和对照组受者比较,骨质密度值、Z值(被测人的骨密度与同性别、同年龄对照组平均骨密度的差值)或T值(被测人的骨密度与同性别年轻人对照组平均骨密度的差值)的差异均有统计学意义(P＜0.05);血清甲状旁腺激素(PTH)浓度差异有统计学意义(P＜0.01);血清钙、磷离子浓度差异无统计学意义(P＞0.05);高钙血症发生率差异无统计学意义(P＞0.05).结论 维生素D预防和治疗肾移植术后骨质疏松是安全和有效的.     

少肌症、维生素D缺乏在类风湿性关节炎合并脊柱骨质疏松性骨折中的临床研究

目的探讨少肌症和维生素D缺乏在RA患者脊柱骨质疏松性骨折(OPF)中的临床意义。方法入选936例RA患者和158例年龄、性别相匹配的正常健康者,所有入选对象均摄脊柱正侧位X线片(T5-L5),并以半定量(SQ)法作为判断脊柱OPF的标准,其中648例RA患者和对照组采用DXA法测定了腰椎和髋部骨密度(BMD),267例RA患者和156例对照组以生物电阻抗法测定了四肢骨骼肌质量,化学发光法测定了234例RA患者和68例对照组血清25(OH)D水平,同时详细记录RA患者各临床及实验室指标等情况。结果 1RA患者中(141/936,15.1%)OPF的发生率明显高于对照组(6/158,3.8%)(χ2=18.658,P0.0001);少肌症的发生率明显高于对照组(55.8%,149/267 vs 9.0%,14/156,χ2=91.176,P0.0001);RA组血清25(OH)D水平明显低于对照组[(13.41±9.71)ng/m L,(22.40±6.26)ng/m L,t=9.063,P0.0001],维生素D缺乏发生率明显高于对照组[80.8%(189/234)vs 36.8%(25/68),χ2=49.412,P0.0001]。2RA患者OPF组25(OH)D水平明显低于无OPF组[(12.28±5.67)ng/m L vs(17.16±10.90)ng/m L,t=2.600,P=0.01];各部位肌肉量均明显低于无OPF组(P0.01~0.05)。3线性相关分析发现:RA患者的25(OH)D与骨骼肌、右上肢、左上肢和躯干肌肉量呈正直线相关关系(P0.05);RA患者的骨骼肌质量与髋部、腰椎各部位BMD呈正直线相关关系(P0.05)。4多元回归分析显示:女性、HAQ积分和总髖部OP的发生为RA患者发生少肌症的危险因素;年龄为RA患者发生脊柱OPF的危险因素,骨骼肌质量指数(SMI)为RA患者发生脊柱OPF的保护因素。结论 RA患者具有高于正常健康者脊柱OPF的发生率,其25(OH)D水平缺乏普遍存在,少肌症发生率增高;RA患者维生素D缺乏、少肌症与RA患者脊柱OPF的发生密切相关。     

Comparative effects of vitamin K and vitamin D supplementation on prevention of osteopenia in calcium-deficient young rats

The aim of this study was to clarify the difference in the effects of vitamin K and vitamin D supplementation on the development of osteopenia in young rats under mild calcium deficiency. Sixty female Sprague-Dawley rats, 6 weeks of age, were randomized by stratified weight method into six groups with 10 rats in each group: baseline control, 0.5% (normal) calcium diet, 0.1% (low) calcium diet, 0.1% calcium diet + vitamin K (30 mg/100 g, food intake), 0.1% calcium diet + vitamin D (25 microg/100 g, food intake), and 0.1% calcium diet + K + D. After 10 weeks of feeding, serum calcium, 25-hydroxyvitamin D(3) [25 (OH) D(3)], 1,25-dihydroxyvitamin D(3) [1,25 (OH)(2) D(3)], and parathyroid hormone (PTH) levels were measured, and intestinal calcium absorption and renal calcium reabsorption were evaluated. Bone histomorphometric analyses were performed on cortical bone of the tibial shaft and cancellous bone of the proximal tibia. Calcium deficiency induced hypocalcemia, increased serum PTH and 1,25 (OH)(2) D(3) levels with decreased serum 25 (OH) D(3) level, stimulated intestinal calcium absorption and renal calcium reabsorption, and reduced maturation-related cortical bone gain as a result of decreased periosteal bone gain and enlarged marrow cavity but did not significantly influence maturation-related cancellous bone gain. Vitamin K supplementation in calcium-deficient rats stimulated renal calcium reabsorption, retarded the abnormal elevation of serum PTH level, increased maturation-related cancellous bone gain, and retarded the reduction in maturation-related cortical bone gain. On the other hand, vitamin D supplementation in calcium-deficient rats stimulated intestinal calcium absorption via increased serum 1,25 (OH)(2) D(3) level with prevention of the abnormal elevation of serum PTH level, prevented hypocalcemia, reduced the maturation-related cancellous bone gain, and prevented the reduction in periosteal bone gain and enhanced enlargement of the marrow cavity with no significant effect on the reduction in maturation-related cortical bone gain. However, no synergistic effect of vitamin K and vitamin D on intestinal calcium absorption, renal calcium reabsorption, and cancellous and cortical bone mass was found. This study shows the differential effects of vitamin K and vitamin D supplementation on the development of osteopenia in young rats under mild calcium deficiency. Vitamin K supplementation stimulates renal calcium reabsorption, increases maturation-related cancellous bone gain, and retards the reduction in maturation-related cortical bone gain, whereas vitamin D supplementation stimulates intestinal calcium absorption and prevents the reduction in maturation-related periosteal bone gain by inducing accumulation of calcium from cancellous and endocortical bone.     

Role of calcium and vitamin D in the prevention (and treatment) of osteoporotic fracture

The skeleton requires optimum development and maintenance of its integrity to prevent fracture throughout the life cycle. It is now generally accepted that bones break because the loads placed on them exceed their ability to absorb the energy involved. Current figures for the UK suggest that 1 in 3 women and 1 in 12 men over the age of 55 years will suffer from osteoporosis in their lifetime, at a cost of £1.7 billion per annum to the NHS. The pathogenesis of osteoporosis is multifactorial. Both the development of peak bone mass and the rate of bone loss are determined by key endogenous and exogenous factors. Re-defining vitamin D requirements in the UK is urgently needed because there is evidence of extensive hypovitaminosis D in men and women, which is especially prevalent in Asian population groups. Low vitamin D status is associated with an increased risk of falling and a variety of other health outcomes, and is an area that requires urgent attention. Calcium supplementation seems to have little effect on bone mineral density in younger post-menopausal women (< 5 years past the menopause) who are not vitamin D deficient, but calcium supplements may be effective in reducing bone loss in late menopausal women (> 5 years post-menopause), particularly in those with low habitual calcium intake (< 400 mg/day). Vitamin D and calcium supplementation have been shown to reduce fracture rates in the institutionalized elderly, but controversy remains about whether supplementation is effective in reducing fracture in free-living populations.     

A comparison of the effects of alfacalcidol treatment and vitamin D2 supplementation on calcium absorption in elderly women with vertebral fractures

Although vitamin D supplementation in the frail elderly improves calcium absorption, suppresses parathyroid hormone, decreases bone loss and reduces the risk of fractures, such treatment may be ineffective in patients with vertebral osteoporosis, because of impaired vitamin D metabolism or resistance to the action of vitamin D metabolites on the bowel. We have therefore performed a randomized, single masked study comparing the effects of alfacalcidol treatment (0.25 µg twice daily) and vitamin D₂ supplementation (500-1000 units daily) on calcium absorption and bone turnover in 46 elderly women (median age 69 years, range 64–79 years) with radiological evidence of vertebral fractures. Serum 25-hydroxyvitamin D increased significantly after 3 and 6 months of treatment with vitamin D₂ (p<0.001), but was unchanged in the group receiving alfacalcidol. Serum 1,25-dihydroxyvitamin D did not change significantly in either group over the study period. Fractional⁴⁵Ca absorption increased after 3 months of treatment with alfacalcidol (p<0.05), but was unchanged with vitamin D₂. There was also a reduction in plasma intact parathyroid hormone and serum alkaline phosphatase after 6 months of treatment with alfacalcidol (p<0.05) which was not seen in the group receiving vitamin D₂. Our study shows that vitamin D₂ supplementation is ineffective in stimulating calcium absorption in elderly women with vertebral osteoporosis. By increasing calcium absorption in such patients, alfacalcidol may prove more effective than vitamin D in the management of vertebral osteoporosis.     

Nonpharmacological prevention of osteoporotic fractures

In postmenopausal women, the nonpharmacological prevention of osteoporotic fractures pursues the dual objective of minimizing bone loss and preventing falls. In women with a low fracture risk, optimizing the dietary intake of calcium is the main nutritional goal. Regular sustained physical activity should be encouraged. In older women, the high risk of proximal femoral fractures warrants a number of preventive measures, including calcium and vitamin D supplementation, correction of protein deficiency if needed, and minimization of the risk of falls. Hip protectors may be useful in institutionalized women at high risk for falls. These nonpharmacological measures should be part of a comprehensive customized management program used to complement standard pharmacological therapy.     

绝经后骨质疏松患者的缺钙和补钙的作用

２４例绝经后骨质疏松症患者分两组进行了钙平衡试验，年龄５６．３１±２．９９和５８．６６±４．２６，绝经年限１２．５±７．１１和１０．７７±４．５６，该组妇女平均食物钙摄入４２２．６ｍｇ／日，未补钙者平均负钙平衡１２．８８ｍｇ／日，补钙５００ｍｇ／日者平均正钙平衡３１８．２２ｍｇ／日，摄入钙的利用率占３３％，经２年单纯补钙，ＱＣＴ腰椎骨密度增高１３％，低钙摄入的妇女单纯补钙有一定预防骨质疏松的作用。     

Effects on bone mineral density of calcium and vitamin D supplementation in elderly women with vitamin D deficiency

OBJECTIVE: Calcium and vitamin D deficiency is common in older individuals, particularly those who live in nursing homes, and increases the risk of osteoporosis and fractures. METHODS: We conducted a randomized double-blind placebo-controlled study of combined supplementation with 500 mg of elemental calcium, as carbonate, and 400 IU of vitamin D bid for 12 months in women older than 65 years of age with vitamin D deficiency, defined as serum 25(OH)D concentrations 相似文献