维持性血液透析患者血清骨保护素与肾性骨营养不良的关系

骨保护素（OPG）是近年来在肿瘤坏死因子受体超家族中发现的一种具有调控破骨细胞产生和活化作用的生物活性物质。它与核因子κB活化子受体配体（RANKL,亦称骨保护素配体OPGL）和核因子κB活化子受体（RANK）组成的分子调控系统是体内维持骨代谢平衡的重要分子机制。在正常的骨转化中成骨细胞表面表达RANKL．它与破骨细胞前体或破骨细胞表面的RANK结合后启动了信号转导，使破骨细胞增殖和活化．溶骨活动增强。同时成骨细胞分泌OPG，它与RANK竞争性的抑制RANKL使溶骨作用不致过度强烈。     

A study on urinary free gamma-carboxyglutamic acid in patients with idiopathic urinary calcium stone]

Currently, urinary excretion of free gamma-carboxyglutamic acid (gamma-gla.), a terminal amino acid degraded from gamma-gla. containing protein including bone Gla. Estimated to be a more specific marker for bone metabolism and useful clinically rather than urinary excretion of hydroxyproline. In addition, serum levels of BGP have proved to be a significantly valuable indicator for bone metabolism, especially for process of bone formation, in recent studies. Therefore, we measured these parameters in 40 patients with idiopathic urinary calcium (Ca) stone and investigated bone metabolism in those patients. However, in majority of cases studied, urinary levels of gamma-gla. as well as that of hydroxyproline proved to be definite difference from that in healthy subjects (n = 12) and failed to suggest the presence of abnormality in bone turnover in the background of stone formation. Urinary excretion of hydroxyproline were 6.68 +/- 3.89 micrograms/mg.Cr in the patients and 6.95 +/- 3.08 micrograms/mg.Cr in healthy subjects. Urinary excretion of gamma-gla were 55.0 +/- 15.8 nmol/mg.Cr in the patients and 47.2 +/- 7.3 nmol/mg.Cr in healthy subjects.     

Bone density measurements in pediatric patients with renal osteodystrophy

Peripheral quantitative computed tomography (pQCT) can selectively measure the densities of cortical and trabecular bone, but there is limited information about its use in patients with renal osteodystrophy. Thus pQCT (Norland XCT-2000, Stratec, Pforzheim, Germany) was performed at the ultradistal radius in 21 patients aged 16+/-3.6 (SD) years on continuous cycling peritoneal dialysis. Trabecular bone density (TBD) was higher in patients, 206+/-16 mg/cm(3), than in controls, 182.7+/-24.8 mg/cm(3) ( P<0.0001), whereas cortical bone density (CBD) was lower in patients, 946.5+/-147.5 mg/cm(3), than in controls, 1,153+/-25.4 mg/cm(3) ( P<0.001). TBD was inversely correlated with age ( r=-0.59, P=0.05), height ( r=-0.59, P<0.01), and weight ( r=-0.51, P<0.05). In contrast, CBD was positively correlated with age ( r=0.53, P<0.05), height ( r=0.56, P<0.05), and weight ( r=0.53, P<0.05). CBD was inversely related to serum alkaline phosphatase ( r=-0.71, P<0.001) and parathyroid hormone levels ( r=-0.50, P<0.05). In patients with adynamic bone, TBD was less, 192+/-9 mg/cm(3), than in those with high-turnover lesions, 215+/-13 mg/cm(3), P<0.001. CBD, however, was lower in patients with high-turnover lesions, 900+/-151 mg/cm(3), than in those with low turnover, 1,022+/-111 mg/cm(3), P<0.05. Compared with controls, in patients with high-turnover lesions, CBD was lower ( P<0.0001) and TBD higher ( P<0.0001). These findings suggest that pQCT may be an additional tool in the assessment of renal osteodystrophy.     

Inconsistency in radiographic evaluation of progressive renal osteodystrophy.

Five radiologists graded 49 series of bone X-rays of 20 patients with chronic renal failure treated by hemodialysis. There was a high incidence of osteodystrophy which progressed identifiably over intervals exceeding 12 months. The severity grade of osteodystrophy was poorly reproducible among patients, among radiologists, and even between interpretations by the same radiologist after an interval of 10 months. Although the severity of osteodystrophy correlated with serum alkaline phosphatase values, the latter was not an accurate predictor of the severity of the bone lesions. Radiographic reassessment at intervals of one year or less in the asymptomatic patient has less reproducibility than the anticipated changes. More sensitive and reliable techniques are recommended.     

维持性血液透析患者缺血修饰白蛋白水平与腹主动脉钙化相关性分析

目的 研究维持性血液透析(maintenance hemodialysis,MHD)患者中缺血修饰白蛋白(ischemia-modified albumin,IMA)水平及其相关因素,并分析IMA与腹主动脉钙化(ab-dominal aortic calcification,AAC)的关系.方法 选取2016年1月至2...     

Bone histomorphometry of renal osteodystrophy in diabetic patients

Bone biopsies and plasma parathyroid hormone (PTH) from 27 diabetic dialysis patients were compared to biopsies and PTH levels from matched patients without diabetes to determine if PTH has a role in preserving bone mass in diabetic renal osteodystrophy. Significantly lower values were present in the diabetic group for mineralized bone area (p less than 0.003), osteoblastic osteoid (p less than 0.01), resorptive surface (p less than 0.001), fibrosis (p less than 0.005), bone apposition rate (p less than 0.01), bone formation rate (BMU level) (p less than 0.04), and plasma PTH (p less than 0.05). Bone-surface aluminum was higher in the diabetic group (44 +/- 5% vs. 20 +/- 5%, p less than 0.005). Linear regression analysis revealed significant positive correlations of mineralized bone area with time on dialysis, bone formation rate, bone resorption, and PTH only in the group without diabetes. While both groups had significant positive correlations of PTH with osteoblastic osteoid and bone resorption, only in the nondiabetic group was there a positive correlation of PTH with bone apposition and bone formation rate (BMU level), observations suggesting that the lower bone formation in the diabetic patients may have arisen in part from a failure of PTH to promote bone mineralization. We conclude that relatively low PTH levels and high bone aluminum in diabetic patients with chronic renal failure may be responsible in part for low bone mass when compared to uremic patients without diabetes.     

Clinical and economic burden of fractures in patients with renal osteodystrophy

Renal osteodystrophy is a key cause of fractures in patients with chronic kidney disease (CKD). AIMS: This article reviews the clinical and economic burden of fractures and explores the types of studies that need to be conducted in order to fully understand the impact of fractures in renal osteodystrophy. We also discuss the role that active vitamin D compounds and calcimimetics play in treating secondary hyperparathyroidism. MATERIALS AND METHODS: Medline was searched for relevant articles on renal osteodystrophy and fractures. RESULTS: CKD-related fractures are the source of significant morbidity and costs. Extensive osteoporosis research has been utilized to guide fracture prevention and improve disease management, but further costs and outcomes analyses are needed for renal osteodystrophy. Recent research regarding newer, present-day treatment paradigms has suggested that distinct cost savings and improved patient outcomes are possible. CONCLUSIONS: In order to realize such economic and human benefits, the medical community must first have sufficient pathologic, pharmacoeconomic and epidemiologic data to properly understand, manage and prevent renal osteodystrophy and fractures.     

1,25-Dihydroxycholesterol treatment of long-term haemodialysed patients with renal osteodystrophy

Renal osteodystrophy still poses major problems in the management of chronic renal failure, though it had been extensively studied over the last years. The present therapeutic possibilities—massive-dose vitamin D, aluminium hydroxide and supplementary Ca-intake, administration of active vitamin D metabolites—are discussed in the light of personal observations.     

Fractures and vertebral bone mineral density in patients with renal osteodystrophy

We investigated the relationship of CT determined vertebral bone mineral density (BMD), type of renal osteodystrophy, N terminal PTH levels and fracture history in 31 dialysis patients. BMD for patients with bone biopsy documented osteitis fibrosa was 1.6 standard deviation (SD) above the normal value for age and sex matched controls, while those patients with low turnover osteodystrophy had a mean BMD 1.2 SD below normal (p less than 0.0001). Three patients with osteitis fibrosa who had previously been treated with prednisone had a low BMD (1.8 SD below normal, different than O, p = 0.0015). There was no correlation between BMD and time on dialysis (r = 0.1). An N terminal PTH level greater than 150 pg/ml was a sensitive (94%) and specific (100%) method of separating those patients with osteitis fibrosa from those with low turnover osteodystrophy, while BMD was much less useful in this differentiation. A low BMD was not predictive of fracture history but the type of renal osteodystrophy was. Patients with low turnover osteodystrophy had a fracture rate of 0.2 fractures/dialysis year in comparison to those with osteitis fibrosis who had 0.1 fractures/dialysis year. Patients with the former bone disease fractured mainly axial rather than appendicular bones in contrast to those patients with osteitis fibrosa. In conclusion we found that patients with osteitis fibrosa had increased BMD compared to normal while those with low turnover osteodystrophy had decreased BMD, but that the N terminal PTH level was a better predictor of the type of bone disease present than was BMD.     

Pattern of renal osteodystrophy in haemodialysis patients in Saudi Arabia

In order to know the pattern of renal osteodystrophy in haemodialysispatients in Saudi Arabia we conducted a multicentre study involving209 patients. The mean age of the patients was 39.4±14(18–70) years, 128 were males and 81 females. All patientswere on acetate dialysate and their mean duration on dialysiswas 3.5 ± 1.5 years. The major symptom was bone and joint pain (25.8%). The meanserum calcium was 2.1 ±0.26 mmol/l, phosphorus 2.0 ±0.36mmol/l, alkaline phosphatase 19.7± 14.6 u/l and parathyroidhormone level was 8.9 ± 3.9mg/ml. The mean serum aluminium(AL) level was 25.4±17.7 µg/l, while that of 1,25vitamin D3 was 8.1±4.2ng/l and of fluoride was 92.2 ±31.4 µg/l. The major radiological finding was osteosclerosis(70%). Dual-photon absorptiometry (DPA) showed low bone mineraldensity (LBM) in 65% of the patients. Forty-one patients had bone biopsies with AL staining of thebiopsies. Of this group, 92% had changes of hyperparathyroidismand 66% of them were pure hyperparathyroidism. Sixty percentof them had variable degrees of AL intoxication. The radiologicalskeletal survey of those patients could detect abnormalitiesin only 46% while 70% of them had abnormal bone mineral density(BMD). In conclusion, osteosclerosis is the commonest radiologicalfinding in our dialysis patients while secondary hyperparathyroidismis the main histopathological diagnosis in bone biopsy, evenin patients with normal skeletal survey. AL intoxication isa significant problem in our population. DPA is more sensitivein detecting bone abnormalities than X-radiography.     

Changes in plasma free amino acid concentration in burned patients with sepsis]

The sequential changes in plasma free amino acid concentration were analyzed and compared in burned patients with sepsis (n = 12) and without sepsis (n = 19). After burn injury, phenylalanine, methionine, lysine, and the Phe/Tyr ratio were significantly increased in two groups (P < 0.05-0.01). Threonine, serine, histidine, arginine, proline and BCAA/AAA ratio were significantly decreased in two groups (P < 0.05-0.001). The Phel Tyr ratio in patients with sepsis was much higher than that in patients without sepsis on postburn days 14 and 21 (P < 0.05), while the BCAA/AAA ratio in patients with sepsis was much lower than that in patients without sepsis on postburn day 14 (P < 0.01). The level of proline in patients with sepsis was much higher than that in patients without sepsis on postburn days 3 and 7 (P < 0.05). It is suggested that these results, in collaboration with other clinical and laboratory findings, may be helpful in foretelling the probable development of sepsis in patients with major burns.     

血液透析串联血液灌流治疗血液透析患者肾性骨病

肾性骨病是维持性血透(MHD)患者的主要并发症之一.我们探讨血液透析串联血液灌流(HD+HF)对MHD患者肾性骨病的作用.     

The evaluation of renal osteodystrophy with cortical quantitative ultrasound at various bone sites

BACKGROUND: In this study we evaluated bone abnormalities of patients with chronic renal failure (CRF) by cortical quantitative bone ultrasound (QUS) measurements at different bone sites because these abnormalities may be of variable etiology and may start before symptoms or radiological changes are manifested. METHODS: Of fifteen patients with chronic renal failure, seven had moderate-severe disease and eight had been on chronic hemodialysis from 5 to 17 years, with renal osteodystrophy (ROD) confirmed by bone biopsies. Twelve normal subjects of similar age and gender volunteered for the control group. RESULTS: Patients and controls differed in creatinine clearance, in serum phosphate levels and in serum total alkaline phosphatase. Mean intact-PTH levels differed significantly amongst the three groups of subjects. All patients with ROD had intact-PTH higher than 200 pg/mL. The cortical ultrasound parameter, speed of sound (SOS), was slower in patients with more severe renal failure at all bone sites measured. The group with ROD had significantly lower cortical ultrasound values than the other patients and the control group at all sites. SOS values at the proximal phalanx, distal radius and midtibial sites were positively and significantly correlated. Cortical ultrasound measurements at the radial site correlated with midtibial and phalangeal sites but the correlation between midtibial and phalangeal sites did not reach significance. IPTH levels correlated negatively and significantly with cortical QUS values at all sites being the correlations higher at phalangeal and radial sites than at the midtibial region. CONCLUSIONS: The differences in cortical ultrasound observed indicate the potential clinical application of this methodology to evaluate bone abnormalities in chronic renal failure, especially in patients on chronic hemodialysis.     

血液灌流联合血液透析治疗尿毒症患者肾性骨病疗效的观察

目的 观察血液灌流联合血液透析对肾病患者的临床疗效及对血浆中甲状旁腺激素的清除作用.方法 选择30例长期经血液透析合并有肾性骨病的患者,按随机数字表法分为常规治疗组(15例)和血液灌流组(15例).常规治疗组以控制钙摄入和应用维生素D受体激动剂为主.血液灌流组在常规治疗的基础上予以血液灌流,每周1次,共6个月,治疗前以...     

Efficacy and safety of long-term oral falecalcitriol treatment in patients with renal osteodystrophy

We investigated, in a multicenter study, the efficacy and safety of long-term administration of falecalcitriol, a new active vitamin D₃, in patients with renal osteodystrophy of the osteitis fibrosa type associated with secondary hyperparathyroidism caused by chronic renal failure. Falecalcitriol was orally administered every day for 48 weeks. Administration was started at a dosage of 0.3 μg/day, and the dosage was changed whenever necessary according to serum calcium (Ca) level. As a result, significant inhibition of the bone resorption markers, i.e., intact parathyroid hormone (i-PTH), pyridinoline (Pyr), and deoxypyridinoline (D-Pyr), was observed from the 8th week, and the bone formation markers, i.e., total activity and bone fraction of alkaline phosphatase, were also significantly inhibited from the 12th week. The bone mineral density (BMD) change rate in the bones of the whole body determined by dual-energy X-ray absorptiometry remained almost constant. When subjects were stratified according to the inhibition rate of bone metabolic parameters, BMD tended to increase in the group with strong inhibition and to decrease in the group with weak inhibition. Mean serum Ca level significantly increased from 9.5 mg/dl, but mean level was subsequently maintained at about 10 mg/dl until the end of administration by adjustment of the doses. These findings suggested that falecalcitriol may inhibit and normalize accelerated bone metabolic turnover without inducing excessive increases in serum Ca level in secondary hyperparathyroidism. With respect to safety, no specific adverse reactions associated with the prolonged administration period were observed. Received: July 1, 1997 / Accepted: Aug. 29, 1997     

Improvements in renal osteodystrophy in patients treated with lanthanum carbonate for two years

AIMS: To investigate the evolution of renal osteodystrophy in patients on maintenance dialysis, treated with lanthanum carbonate (LC) vs. standard phosphate-binder therapy (Stx). MATERIALS AND METHODS: This was a 2-year, randomized, prospective, open-label study during which patients on dialysis received LC titrated to a maximum of 3,000 mg/day or their previous phosphate binder treatment with the aim to achieve target phosphorus levels of < or = 5.9 mg/dl. Paired bone biopsy samples for histomorphometric analysis were available at baseline and 1 year (LC 32, Stx 33), and at baseline and 2 years (LC 32, Stx 24). RESULTS: With similar phosphorus control, Stx was associated with numerically higher serum calcium levels at most visits. Results of osteocalcin and bone-specific alkaline phosphatase in LC patients were higher throughout the study and correlated with parameters of bone formation; however, the differences were not significant. Histological changes in bone turnover and volume were analyzed with respect to normal ranges. There was an improvement in bone turnover in the LC group, which was significant in the 1-year group, and an improvement in bone volume which was significant in the 2-year group. No significant changes in bone turnover or bone volume were observed in the Stx groups. In the 2-year LC group, 1 patient had osteomalacia at baseline and end of therapy, and a mineralization defect developed in 2 other patients. Several possible factors for a mineralization defect were present in these patients, but no single cause could be clearly identified. Histomorphometric parameters of bone, including formation and mineralization, did not correlate with bone lanthanum. No mineralization defect was observed in the Stx groups. CONCLUSION: These findings show that similar phosphorus control with Stx and LC results in higher bone turnover after 1 year and higher bone volume after 2 years with LC.