血透患者钙磷代谢紊乱的临床研究

本文检测了维持性血液透析(MHD)患者的血清总钙(Ca)、血清无机磷(P)、血清pH校正至7.4时的离子钙(nCa~(2+))、全血离子钙(bCa~(2+))、血清碱性磷酸酶(ALP)和全段甲状旁腺激素(I-PTH)。发现:(1)Ca反映bCa~(2+)误差常较大,但仍是一个有用的指标,nCa~(2+)反映透后bCa~(2+)可靠而反映透前bCa~(2+)常偏低。(2)I-PTH是判断MHD患者有、无甲状旁腺亢进(甲旁元)及甲旁亢程度的敏感和特异的指标,并有助于判断短期钙剂治疗的疗效及血透前后的甲状旁腺功能变化。(3)ALP易受潜在肝病的影响,反映甲状旁腺功能变化不够敏感。在测定ALP的同时监测γ-GT可以提高ALP对肾性骨病的诊断价值。(4)在本组患者,血离子钙水平可以精细地调节甲状旁腺功能,因而维持适当的bCa~(2+)水平可能控制多数患者的继发甲旁亢。     

日本国家医师考试试题答案及注解(内分泌疾病第六部分)

题51:d [注解]甲旁究分为原发和继发二种。后者反应为低钙血症(正确的说是离子化钙的低下),甲旁腺激素增加,此时,血清钙不超过正常值。 原发性甲旁亢多因甲旁腺单发性腺瘤而起,由于甲旁腺激素(PTH)作用增强而出现症状。 甲旁腺激素的作用是:抑制在肾小管磷的再吸收和骨吸收增加。因此,作为典型的检查结果是高     

SD食疗对于慢性尿毒症病人血清甘油三酯的影响

慢性尿毒症病人,血清甘油三酯(STG)常增高,其原因有组织对胰岛素敏感性降低,继发性甲状腺功能亢进(甲旁亢)和男性性腺功能减退等,SD食疗(低磷低氮辅以必需氨基酸或相应酮酸的饮食疗法)可防止慢性尿毒症的继发性甲旁亢,改善男性性腺功能和糖耐量试验,提示可能会纠正其高甘油三酯血症。     

口服冲击与每日口服1α(OH)D3治疗血液透析患者继发性甲状旁腺功能亢进的临床观察

目的探讨1α(OH)D3治疗血液透析患者继发性甲状旁腺功能亢进(甲旁亢,SHPT)的剂量,并比较口服冲击与每日口服两种方法的疗效及对钙、磷水平的影响.方法根据血清全段甲状旁腺激素(iPTH)水平将34例iPTH<200 ng/L的维持性血透患者随机分为口服冲击组及每日口服组.根据血清iPTH水平确定1α(OH)D3治疗的每周总剂量.以iPTH<200 ng/L作为观察终点,比较治疗前及治疗后4、8周的iPTH、血钙及磷的变化.结果 (1)34例患者治疗前血清iPTH为(686.07±283.65)ng/L,1α(OH)D3剂量为(5.44±4.38)μg/周,治疗8周时iPTH总达标率为82.35%;(2)与每日口服组比较,口服冲击治疗起效快,并对治疗前iPTH>500 ng/L的患者具有更高缓解率(100%比40%,P<0.05);(3)治疗中两组患者的血钙、磷水平均有上升,以每日口服组较为明显,其中13例需采用1.25 mmol/L钙透析液纠正透后高血钙,2例每日口服治疗组患者(5.9%)出现透析前高钙血症需减少1α(OH)D3用量.结论口服1α(OH)D3可有效治疗维持性血透患者SHPT.口服冲击治疗起效快,控制率高,高钙血症发生率低,优于每日口服治疗,尤其适用于中、重度SHPT患者.     

全身抽搐-低钙血症-低镁血症

报告一例CaSR激活突变致甲状旁腺功能减退症(简称甲旁减)病例。本例患者自幼反复发作肌肉抽搐,多次查血钙及血甲状旁腺素(parathyroid hormone, PTH)明显降低,伴低镁血症。病程中逐渐出现颅内钙化、白内障、肾结石等异位钙化表现。结合患者临床特点及基因检测,最后确诊为常染色体显性遗传性低钙血症1型。本文对肾小管CaSR调节尿钙、尿镁排泄的作用进行总结,并对CaSR突变甲旁减患者临床特点进行文献复习。     

低钙透析联合磷结合剂对血液透析患者钙磷代谢紊乱和冠状动脉钙化的影响

目的探讨低钙透析联合磷结合剂对血液透析患者钙磷代谢紊乱和冠状动脉钙化的影响。方法 80例伴冠状动脉血管钙化并行维持性血液透析(MHD)患者按照随机数字表法分为对照组和研究组各40例;对照组采取标准钙透析液及醋酸钙口服治疗,研究组采取低钙透析联合醋酸钙治疗,两组均进行12个月治疗;治疗前、治疗3、6、12个月后对血清钙、磷、甲状旁腺素进行检测,并采用螺旋CT对冠状动脉钙化积分进行检查。结果两组治疗前血清钙、磷及甲状旁腺素水平比较无明显差异(P>0.05)。研究组治疗3、6、12个月后血清钙及磷水平均明显低于对照组,而甲状旁腺素水平明显高于对照组(P<0.05);两组治疗前冠状动脉钙化积分比较无明显差异(P>0.05);研究组治疗3、6、12个月后冠状动脉钙化积分均明显低于对照组(P<0.05)。结论低钙透析联合含钙的磷结合剂可有效纠正钙磷代谢紊乱,延缓冠状动脉钙化进展,有效降低甲状旁腺功能亢进的发生率,适用于伴冠状动脉血管钙化的血液透析患者。     

长期低钙透析对持续性不卧床腹膜透析患者钙、磷、甲状旁腺素水平的影响

目的观察长期应用低钙透析液配合口服碳酸钙及活性维生素D3对持续性不卧床腹膜透析(CAPD)患者血钙、磷、甲状旁腺素(iPTH)水平的影响。方法对第四军医大学西京医院2003-03~2005-06收治的68例慢性肾衰患者使用低钙透析液(Ca2 1·25mmol/L),采用CAPD方式,每日交换透析液均在6L以上。透析1个月后根据化验结果调整碳酸钙和活性维生素D3的服用剂量。观察透析前及透析后1、2、3、6、9、12、18个月血钙(校正的血清总钙)、血磷、iPTH等指标变化。结果透析前血钙(2·28±0·25)mmol/L,血iPTH(163·9±78)ng/L,血磷(1·16±0·13)mmol/L。采用低钙透析液行CAPD治疗1个月后患者血钙水平较透前下降(1·97±0·44)mmol/L(P<0·05),血iPTH明显增加(P<0·001);血磷水平无明显变化(1·11±0·32)mmol/L(P>0·05),碱性磷酸酶和血浆白蛋白水平保持稳定。加服或增加碳酸钙和活性维生素D3的剂量治疗2个月后,血钙水平回升,iPTH下降,接近透前水平(P>0·05),血磷水平保持稳定。连续观察至18个月,54例患者钙、磷水平维持相对稳定,未发现明显的高钙血症及高磷血症,血iPTH水平保持不变。结论(1)长期进行低钙透析(Ca2 1·25mmol/L)可以导致CAPD患者血清iPTH水平增加,配合口服碳酸钙及活性维生素D3可以很好地纠正并维持血iPTH水平,防治高磷血症,避免高钙血症及负钙平衡。     

慢性肾功能不全时钙磷代谢异常的临床机理探讨

本文报告40例慢性肾功能不全(CRF)患者的钙磷代谢变化,主要表现为高磷血症、低钙血症和钙磷乘积逐渐升高,其变化和肾功能不全的严重程度相平行,并提出由于甲旁亢的影响,晚期血钙可以正常,血清离子钙亦能反映肾功能的变化。     

老年甲状腺癌术后低钙血症与病理因素的相关性

目的分析老年甲状腺癌患者术后出现低钙血症的因素。方法老年甲状腺癌手术患者170例,均于术前1～5 d和术后1～2 d进行血清钙检测,血清钙<2.25 mmol/L视为低钙血症。结果大年龄组患者术后出现低钙血症明显高于小年龄组(P<0.05);切除组织中有甲状旁腺的患者出现低钙血症的明显高于无甲状旁腺(P<0.05);手术过程中进行淋巴结清扫患者出现低钙血症明显增高(P<0.05);甲状腺全切术出现低钙血症明显高于甲状腺腺叶加峡部切除术(P<0.05)。Logistic回归分析结果显示年龄越大、手术切除组织中有甲状旁腺、术中进行淋巴结清扫和手术范围越大的患者越容易出现术后低钙血症。结论老年甲状腺患者术后出现低钙血症与年龄、手术范围、手术切除组织中有甲状旁腺组织及淋巴结清扫密切相关。     

老年甲状腺癌患者术后低钙血症与病理因素相关性

目的分析影响老年甲状腺癌患者术后产生低钙血症的相关因素。方法老年甲状腺癌手术患者165例,均于术前1⁵ d和术后15 d和术后1² d进行血清钙检测,血清钙<2.25 mmol/L为低钙血症。结果≥65岁年龄组术后出现低钙血症明显高于<65岁年龄组(P<0.05);切除甲状腺病理组织中含有甲状旁腺的患者发生低钙血症明显高于病理组织中未发现甲状旁腺的患者(P<0.05);淋巴结清扫的患者发生低钙血症明显高于淋巴结未清扫患者(P<0.05);甲状腺全切术后发生低钙血症明显高于腺叶加峡部切除术者(P<0.05)。多因素分析结果显示:病理组织中含有甲状旁腺、手术切除甲状腺组织越大的患者更容易出现术后低钙血症。结论老年甲状腺患者术后容易出现血钙降低现象,低钙的发生与患者年龄、术式及是否误切除甲状旁腺组织关系密切,因此手术前应选择对于甲状腺损害小的术式,尽量避免手术过程中损伤甲状旁腺组织。     

高通量滤器干预维持血液透析患者后血清钙、磷、甲状旁腺激素的变化分析

目的：探讨高通量滤器干预维持血液透析患者后钙、磷以及甲状旁腺的变化。方法：将48例维持血液透析患者改用高通量滤器透析治疗3个月,比较治疗前后钙、磷、甲状旁腺素(iPTH)水平。所有患者B 超检测甲状旁腺,并分为增生(A组)、非增生(B组)两组进行比较。结果：高通量滤器透析患者血钙显著升高,差异具有统计学意义(P＜0.05),血磷、甲状旁腺素水平明显降低,差异具有统计学意义(P＜0.05),A组效果比B组效果更为显著,差异具有统计学意义(P＜0.05)。结论：高通量滤器透析能够有效改善尿毒症维持血液透析患者钙、磷、甲状旁腺代谢紊乱,值得在临床中推广应用。     

Relationships between bone mineral density, serum vitamin D metabolites and calcium:phosphorus intake in healthy perimenopausal women

OBJECTIVES: To determine the relationships between serum vitamin D metabolites, bone mass, and dietary calcium and phosphorus in a cohort of 510 healthy Danish perimenopausal women. DESIGN: A population-based cross-sectional study. SUBJECTS: A total of 510 healthy women aged 45-58 years, with amenorrhoea for 3-24 months. None of the women was using hormone replacement therapy. MEASUREMENTS: Measurements of total bone mineral content and regional bone mineral density were performed by dual-energy X-ray absorptiometry. Analyses of serum levels of 25-OHD and 1,25-(OH)2D, intact PTH, ionized calcium and phosphate, as well as biochemical markers of bone turnover in blood and urine. Assessment of calcium and phosphorus intake using dietary records. RESULTS: A consistent inverse relationship between serum 1,25-(OH)2D and bone mineral content/ density was found in whole-body mineral content (P = 0.001), spine (P = 0.005) and femoral neck (P<0.05). There was a positive relationship between levels of 1,25-(OH)2D and biochemical bone markers, indicating that high levels of 1,25-(OH)2D are accompanied by increased bone turnover. The dietary calcium:phosphorus ratio was inversely related to serum 1,25-(OH)2D (P = 0.04) and positively related to bone mineral density (P<0.0005). No relationships could be detected between levels of PTH, serum ionized calcium and phosphate, and serum vitamin D metabolites. CONCLUSION: Within normal physiological range, elevated levels of 1,25-(OH)2D were associated with decreased bone mineral density and content, reduced calcium:phosphorus ratio in the diet and increased bone turnover.     

Citrate anticoagulation for single-needle hemodialysis: safety and efficacy

Single-needle hemodialysis can be the only option in some patients and requires full heparinization. The aim of our retrospective clinical study was to evaluate the safety and efficacy of regional citrate anticoagulation for single-needle hemodialysis. Citrate anticoagulation was performed during 41 single-needle hemodialysis procedures in 24 patients at risk of bleeding, using 4% trisodium citrate, 1 M CaCl2 and calcium-free dialysate. Safety was assessed by the percentage of procedures that were terminated prematurely or changed to another modality due to citrate-related complications and by incidence of important hypocalcemia. Efficacy was evaluated by visually assessing clot formation in the circuit. Five per cent of the procedures were terminated prematurely. Important hypocalcemia was recorded in 34% of the procedures. Anticoagulation was suboptimal in 17% of the procedures, but none of the systems clotted. The median dialyzer assessment grade was excellent. The average protocol parameters were: blood flow 244 +/- 27 mL/min, starting rate of citrate 191 +/- 19 mL/h, starting rate of calcium 6.7 +/- 1.1 mL/h. In the first hour, ionized calcium decreased in 67% of the procedures by 0.08 +/- 0.05 mmol/L. During the entire procedure, ionized calcium decreased in 80% of the cases by 0.17 +/- 0.09 mmol/L. There was a significant, but small increase in sodium (135 +/- 4 vs 137 +/- 4 mmol/L) and no increase in bicarbonate. Citrate anticoagulation during single-needle hemodialysis, according to our protocol, is safe and effective. Close monitoring of ionized calcium is mandatory. The calcium infusion rate should frequently be increased to correct hypocalcemia. The increased starting rate of calcium should be evaluated.     

过量氟对大鼠肝细胞内钙水平和肝细胞凋亡的影响

目的 研究在大鼠过量摄氟后体内对肝细胞中游离钙([Ca~(2+)]i)水平和肝细胞凋亡的影响。方法 应用饮水加入氟化钠进行大鼠染毒实验,采用Fura-2/AM荧光指示剂测定慢性氟中毒大鼠肝细胞内[Ca~(2+)]i浓度的变化,同时利用流式细胞术测定肝细胞凋亡率。结果 过量氟可刺激肝细胞内[Ca~(2+)]i浓度增高,常食(高钙饮食)投氟组与常食对照组相比差异显著(P<0.05),偏食低钙投氟组高于低钙对照组,差异显著(P<0.05);肝细胞凋亡率在正常饮食加氟组与对照组相比差异无显著性(P>0.05),低钙饮食加氟组肝细胞凋亡率明显增高,与低钙对照组相比,差异显著(P<0.05);相关分析显示,低钙饮食投氟组肝细胞内[Ca~(2+)]i浓度增高与细胞凋亡率有相关性趋势(r=0.576)。结论(1)过量氟所致的大鼠肝细胞内[Ca~(2+)]i持续增高对肝细胞凋亡有不同程度的影响,可能在氟骨症病理过程中起重要作用;(2)投氟伴随低钙可加重细胞内[Ca~(2+)]i超负荷和细胞凋亡,提示钙营养与氟中毒发病有着重要联系;(3)肝细胞内[Ca~(2+)]i增高与肝细胞凋亡率之间有无相关性有待于进一步研究证实。     

The influence of dialysate calcium on the therapeutic effects of sevelamer hydrochloride in hemodialysis patients with secondary hyperparathyroidism under treatment of intravenous vitamin d metabolites

The management of hyperphosphatemia is essential to treat secondary hyperparathyroidism and to prevent ectopic calcification. Sevelamer hydrochloride (sevelamer), a new phosphate binder that contains neither aluminum nor calcium, which could be theoretically beneficial for the management of hyperphosphatemia in dialysis patients with secondary hyperparathyroidism who are receiving intravenous vitamin D metabolites (maxacalcitol or calcitriol). To reduce calcium loads, a dialysate calcium concentration of 2.5 mEq/L is recommended by Kidney Disease Outcome Quality Initiative (K/DOQI) guidelines. In Japan, a dialysate calcium concentration of 3.0 mEq/L prevails. We investigated the influence of dialysate calcium on the therapeutic effect of sevelamer in 40 hemodialysis patients who are under treatment of intravenous vitamin D metabolites for secondary hyperparathyroidism (VD(+)) and compared the results with those of 41 patients who had not received vitamin D metabolites (VD(-)). Serum phosphorus and calcium-phosphorus products showed no significant change by sevelamer in either the VD(+) subgroup of patients receiving hemodialysis with dialysate calcium of 2.5 mEq/L (DCa2.5) or those receiving hemodialysis with dialysate calcium of 3.0 mEq/L (DCa3.0), while serum phosphorus and calcium-phosphorus products decreased in both the VD(-) subgroups. Serum calcium decreased in the DCa2.5 subgroup and did not change in the DCa3.0 subgroup in both the VD(+) and the VD(-) subjects. Parathyroid hormone and alkaline phosphatase increased in the DCa2.5 subgroup and did not change in the Ca 3.0 subgroup in the VD(+) subjects. Serum calcium decreased in both subgroups in the VD(-) subjects. Parathyroid hormone obtained after sevelamer administration in the VD(-) group was within the target range of the K/DOQI guidelines. In conclusion, the concomitant use of sevelamer as a phosphate binder and the dialysate of calcium concentration of 2.5 mEq/L have possibilities for worsening secondary hyperparathyroidism in patients receiving intravenous vitamin D.     

Low Calcium Diet Enhances Development of Hypertension in the Spontaneously Hypertensive Rat

Young (5 week old) spontaneously hypertensive rats (SHR) were fed diets modified with respect to their calcium content. Control rats were given a normal calcium diet (0.3 per cent). During the experiment the systolic blood pressure (SBP), heart rate and serum level of total and ionized calcium were measured. Three diets were studied :calcium-free diet (0 per cent, h₁), low calcium diet (0.03 per cent, h₂) and high calcium diet (1.2 per cent, H). The h₁ diet induced a transitory increase (at week 2), then a long-lasting decrease in SBP for 12 weeks. Heart rate and calcemia were significantly decreased. The h₂ diet enhanced the increase in SBP and lowered heart rate for 10 weeks. Level of total and ionized serum calcium were unchanged. The high calcium diet (1.2 per cent) attenuated the increase in SBP for 44 weeks and enhanced the heart rate for 16 weeks. The serum level of total calcium remained stable but that of ionized calcium increased significantly at week 7. These data clearly establish that, in young SHR, a low calcium diet enhances the development of genetic hypertension and confirm earlier works obtained with calcium enriched diets. Experimental and clinical data lead us to emphasize the importance of alimentary calcium in the hypertensive pathology.     

Effects of hemodialysis on secondary hyperparathyroidism in patients with chronic renal failure

In the first few weeks after the initiation of maintenance hemodialysis in nine patients with chronic renal failure, there was a progressive rise in both total and ionized serum calcium associated with a reciprocal and significant fall in the concentration of plasma parathyroid hormone. Studies in 36 additional patients with chronic renal failure already on hemodialysis indicated that this favorable trend did not continue; a progressive rise in parathyroid hormone concentration was associated with increasing duration of hemodialysis against the calcium concentration generally used by most centers. These observations are consistent with the increase in bone disease often associated with hemodialysis. Experimental increases in dialysate calcium concentration from 2.6 to 3.5 meq/liter for a 2-mo period failed to decrease parathyroid hormone secretion or cause a significant increase in predialysis calcium concentration in 36 uremic patients. Use of high calcium dialysis earlier in the course of the disease, alternate means of parathyroid suppression, and even subtotal parathyroidectomy may be necessary for the management of hyperparathyroidism in uremic patients undergoing hemodialysis.     

成年血液透析患者矿物质及骨代谢紊乱调查

目的 调查江苏省昆山市第一人民医院维持性血液透析（maintenance hemodialysis,MHD）患者的慢性肾脏病矿物质及骨代谢异常（chronic kidney disease-mineral and bone disorders,CKD-MBD）情况,比较分析老年和非老年患者CKD-MBD的特点,为临床治疗提供依据.方法 调查234例MHD患者的透析龄、透前肌酐、血小板、白蛋白、血色素、血钙、血磷、ALP及iPTH的水平及临床资料,与指南比较分析老年组和非老年组血钙、血磷、ALP及iPTH的特点.结果 我院MHD患者非老年组患病率高于老年组（P＜0.05）;透析龄、干体重、透前肌酐、白蛋白水平等指标两组间差异无统计学意义（P＞0.05）;血清钙、磷、iPTH达标率分别为83.76％、19.66％、40.17％.两组比较,老年组血清钙、磷、iPTH、ALP均不同程度的低于非老年组,差异有统计学意义（P＜0.05）.结论 老年组MHD患者CKD-MBD指标低于非老年组,提示两组患者CKD-MBD发生机制存在差异,老年患者容易合并低转运骨病（akinesis bone disease,ABD）.     

烟酰胺联合碳酸钙对血透患者高磷血症的治疗观察

观察在常规口服碳酸钙降磷无效的患者加用烟酰胺对血液透析患者高磷血症的疗效。方法：给予30例单纯碳酸钙降磷治疗无效或出现血钙水平偏高的维持性血液透析患者加服烟酰胺片,观察治疗前、治疗一个月及三个月时血磷、血钙、钙磷乘积及血清全段甲状腺旁素（iPTH）水平的影响。结果：与治疗前相比,治疗一个月及三个月时血磷水平[（2.135±0.56）mmol/L比（1.826±0.45）mmol/L比（1.721±0.31）mmol/L]、钙磷乘积[（59.517±10.7）mg2/dl 2比（51.513±9.8）mg2/dl 2比（47.123±8.6）mg2/dl 2]明显下降（P〈0.05,P〈0.01）;治疗3个月时62.5%的患者血磷水平达标,烟酰胺对血钙、iPTH水平无明显影响。结论：口服烟酰胺片可有效降低维持性血液透析患者血磷和钙磷乘积,不影响血清钙水平,无增加血管钙化的风险。     

Increasing parathyroid hormone concentrations in untreated primary hyperparathyroidism.

Twenty-four patients with mild to moderate primary hyperparathyroidism were followed for an average of 2.45 years with serial determinations of serum ionized calcium and intact parathyroid hormone (PTH). For the entire group serum ionized calcium remained stable, whereas serum PTH increased significantly. Eleven patients (group 1) demonstrated a significant increase in PTH with time. The remaining 13 patients formed group 2. Comparison of the changes (%) in each subgroup showed a small but significant increase in serum ionized calcium of 2.6% with time in group 1, while serum PTH increased by 78%. In group 2 serum ionized calcium remained stable whereas PTH increased modestly by 22%. Serum concentrations of creatinine were stable throughout the follow-up period in both groups. Despite the greater precision of serum ionized calcium, measurements of intact PTH are evidently more sensitive than measurements of serum ionized calcium for the detection of progression in primary hyperparathyroidism.