滁州市维持性血液透析患者矿物质和骨异常现状调查

目的了解滁州地区维持性血液透析(maintenance hemodialysis,MHD)患者的矿物质和骨异常(mineral and bone disorder,MBD)现状。方法调查2014年4~6月滁州地区7家医院血液透析中心的MHD患者情况。调查内容包括患者一般人口学特征、实验室检查、临床表现及用药情况等。分别以肾脏疾病患者生存质量指导(Kidney Disease Outcomes Quality Initiative,KDOQI)和改善全球肾脏病预后组织(Kidney Disease:Improving Global Outcomes,KDIGO)指南为标准,观察血校正钙、血磷、全段甲状旁腺素(immunoreactive parathyroid hormone,iPTH)达标情况,将其达标率与透析预后和实践模式研究(the dialysis outcomes and practice patterns study,DOPPS)4比较;并比较三级医院与二级医院MHD者血校正钙、血磷、iPTH达标率。结果①入选病例1 021例,平均透析时间(46.6±37.3)月。原发病前3位是慢性肾小球肾炎(512例,占50.1%)、糖尿病肾脏疾病(206例,占20.2%)、高血压肾病(144例,占14.1%)。②以KDOQI指南为标准,滁州市MHD者血校正钙、磷、iPTH达标率分别为40.5%、37.4%、21.3%,低于DOPPS4的56.7%、52.6%、29.6%(均P0.01)。③以KDIGO指南为标准,上述指标达标率分别为51.5%、19.8%、46.2%。④以KDOQI指南为标准,三级医院患者血磷、血iPTH达标率高于二级医院(P0.05),而血校正钙达标率两者差异无统计学意义。⑤MBD治疗状况:以KDIGO指南为标准,低钙、高磷和继发性甲状旁腺功能亢进的不当治疗分别占47.5%、47.6%、32.5%。结论滁州地区MHD者血钙、血磷及iPTH达标率低。三级医院MHD患者MBD控制情况较二级医院好,加强检测和管理有望提高相关指标的达标率。     

广东省贫困地区维持性血液透析人群矿物质及骨代谢异常现况--梅州市五华县横断面调查

目的了解广东省贫困地区血液透析人群矿物质及骨代谢异常的流行病学情况。方法在广东省特困县梅州市五华县进行横断面调查。检测维持性血液透析患者的生化指标和全段甲状旁腺激素,访谈式问卷调查患者对矿物质及骨代谢异常的知晓情况和饮食习惯。结果调查46例患者,年龄（46±11）岁,均为客家人,80．4％为农村人口,中位透析时间35月,每2周中位透析次数4次。根据K/DOQI指南推荐标准,本组对象中41．3％血钙达标,但血磷和全段甲状旁腺激素分别只有6．5％和19．6％达标,没有3项指标同时达标的患者。在43例完成问卷调查的患者中,知晓甲状旁腺激素、肾性骨病、低磷饮食和药物降磷的比例分别为44．2％、55．8％、53．5％和69．8％;有喝肉汤习惯、没有控制肉类摄入、饮奶制品习惯和进食豆类习惯的比例分别为58．1％、46．5％、28．3％和21．7％。结论广东省贫困地区透析人群中防治矿物质及骨代谢异常的工作开展仍不充分。经济和医疗条件落后、健康宣教不足、患者遵医依从性低以及客家地区特殊的饮食习惯是这一地区开展矿物质及骨代谢异常健康管理面临的挑战。     

安徽省维持性血液透析患者矿物质和骨异常现状调查

目的 了解安徽省维持性血液透析(MHD)患者矿物质和骨异常(MBD)现状;探讨高磷血症相关危险因素.方法 调查2014年1月1日至2014年3月31日在安徽省皖南、皖中、皖北26家医院(其中三级医院19家,二级医院7家)血液透析中心的MHD患者情况.调查内容包括患者一般人口学特征、实验室检查、临床表现及用药情况等.分别以肾脏疾病患者生存质量指导(KDOQI)和改善全球肾脏病预后组织(KDIGO)指南为标准,观察血校正钙、血磷、全段甲状旁腺激素(iPTH)达标情况,将其达标率与透析预后和实践模式研究(DOPPS)3和DOPPS 4比较;并对不同等级医院MHD患者血校正钙、血磷、iPTH达标率进行比较.结果 (1)入选病例2774例,其中男性1662例,女性1112例,平均年龄(52.4±14.4)岁.平均透析龄(45.4±39.1)个月.原发病位于前3位的是慢性肾小球肾炎(49.8％)、高血压肾硬化症(18.7％)、糖尿病肾病(15.4％).(2)以KDOQI指南为标准,安徽省MHD患者校正钙、血磷、iPTH达标率分别为40.1％、36.9％、23.0％,低于DOPPS 3(50.4％、49.8％、31.4％)及DOPPS 4(56.7％、52.6％、29.6％)(均P＜ 0.01);与我国发达地区相比,iPTH达标率偏低(P＜0.05),而血校正钙、血磷达标率差异无统计学意义.(3)以KDIGO指南为标准,上述各指标达标率分别为52.0％、21.6％、47.8％.(4)不同等级医院进行比较:三级医院患者血磷、血iPTH达标率明显高于二级医院(均P＜ 0.05),而血校正钙达标率差异无统计学意义.(5)MBD治疗状况:以KDIGO指南为标准,低钙、高磷和继发性甲状旁腺功能亢进(SHPT)的不当治疗分别占46.4％、47.0％、31.8％.(6)性别、透析龄、血红蛋白、地区分布、经济收入水平与高磷血症发病率无关;超重、血清白蛋白升高为高磷血症的独立危险因素;入住三级医院、年龄增加是高磷血症的保护因素.结论 安徽省MHD患者血钙、血磷以及iPTH达标率不容乐观.三级医院MHD患者MBD控制情况较基层医院更为理想,提示加强监测与管理有望提高达标率.超重、血清白蛋白升高为高磷血症的独立危险因素;入住三级医院、年龄增加是高磷血症的保护因素.     

慢性肾脏病患者高血压现状的横断面调查

目的 对慢性肾脏病（CKD）患者高血压的发病和治疗情况进行横断面调查。 方法 调查对象为2006年11月至2007年3月本院肾内科门诊就诊的900例CKD患者,男性480例,女性420例,其中维持性透析患者354例（血透228例,腹透126例）。 结果 （1）本组CKD患者高血压患病率为80.2%,其中男性患病率高于女性患者（83.5% 比76.4%,P < 0.01）;维持性透析患者显著高于非透析患者（90.1% 比73.8%,P < 0.01）;血液透析与腹膜透析患者的高血压患病率分别为91.7%和87.3%,差异无统计学意义。（2）高血压治疗率为92.4%,透析患者显著高于非透析患者（95.6% 比89.8%,P < 0.01）。（3）非透析患者高血压控制率（<130/80 mm Hg为标准）为20.4%,而尿蛋白量（24 h）>1 g的未透析患者,其血压控制在125/75 mm Hg以下者仅占8.4%。透析患者高血压控制率（<140/90 mm Hg）显著低于非透析患者（45.2% 比55.5%,P < 0.01）,其中血液透析组高血压控制率显著高于腹膜透析组（49.8% 比36.5%,P < 0.05)。（4）CKD患者高血压患病率随肾功能减退和年龄增长逐渐增高;糖尿病肾病患者的高血压患病率高于原发性肾小球疾病患者。高龄、糖尿病、肥胖、肾功能减退、高脂血症均为CKD高血压发病的危险因素。（5）CKD患者服用1、2、3和4种降压药物及以上者分别为37.2%、37.5%、19.3%和5.9%。单药用药以钙通道阻滞剂(CCB)最多（74.1%）,血管紧张素受体阻滞剂（ARB）和血管紧张素转换酶抑制剂（ACEI）分别为48.4%和25.6%,α、β受体阻滞剂为24.7%。联合用药以CCB联合ACEI或ARB最常用。 结论 CKD患者中高血压患病率很高。年龄、肾功能减退、糖尿病、肥胖是CKD高血压的危险因素。CKD患者高血压的治疗率较高,但控制率较低,透析患者和尿蛋白量较多患者的高血压控制情况更是有待提高。     

慢性肾脏病中、晚期患者矿物质和骨代谢紊乱的知晓率、治疗率和控制率

目的 调查我院慢性肾脏病（CKD）中、晚期非透析和透析患者矿物质和骨代谢紊乱的知晓率、治疗率和控制率。 方法 选取503例CKD 3期以上的非透析和透析患者,通过问卷的形式,结合实验室检查了解患者对矿物质和骨代谢紊乱的知晓率、治疗率和控制率。 结果 CKD中、晚期患者矿物质和骨代谢紊乱知识知晓率以血液透析患者最高,腹膜透析患者其次,非透析患者最低,差异有统计学意义（P < 0.01）。知识调查总得分显示,腹膜透析[11（9,12）]和血液透析[13（11,15）]患者显著高于非透析患者[6（5,8）]（P < 0.01）。相关知识的了解程度与年龄（r = -0.11,P < 0.05）呈负相关;与文化程度（r = 0.226,P < 0.01）、肾脏病病程（r = 0.597,P < 0.01）和透析龄（r = 0.366,P < 0.01）呈正相关。医护人员宣教是CKD中、晚期患者获取知识的主要渠道,在非透析、腹膜透析和血液透析患者中分别占94.0%、79.5%和69.4%。腹膜透析（88.6%）和血液透析（96.9%）患者的矿物质和骨代谢紊乱治疗率均显著高于非透析患者（58.2%）（均P < 0.01）。在控制率方面,以K/DOQI指南为标准,非透析患者血钙、血磷、钙磷乘积和甲状旁腺素（PTH）等的达标率明显优于透析患者;在各项指标的达标数量上也显著优于透析患者（均P < 0.01）。以KDIGO指南为标准,非透析（46.7%）和腹膜透析（36.9%）患者的血磷达标率均显著高于血液透析患者（23.6%）（均P < 0.01）。 结论 CKD中、晚期非透析患者矿物质和骨代谢紊乱的知晓率和治疗率较低,控制率较高;而透析患者的知晓率和治疗率较高,但控制率较低。     

Mineral and bone disorder after renal transplantation: a review

Chronic kidney disease–mineral bone disorder is a common clinical picture encountered in patients with end-stage renal disease and is the result of additive pathophysiological processes. Renal transplantation remains the treatment of choice for these patients, especially as advances in this field have allowed for enhanced allograft survival. However, with increasing success of renal transplantation has come a greater appreciation of some of its subsequent complications, such as posttransplantation bone disease. Recently, persistent hyperparathyroidism and osteopenia–osteoporosis have been given specific attention. Traditionally, persistent hyperparathyroidism has been treated with parathyroidectomy, although the role that calcimimetics may play in the future is promising. Newer aspects to medical management of osteopenia–osteoporosis, such as the efficacy of bisphosphonate therapy and early steroid withdrawal, are becoming apparent and some of the newer drugs for the treatment of osteoporosis are yet to be investigated in this subgroup of patients.     

Serum osteoprotegerin measurement for early diagnosis of chronic kidney disease-mineral and bone disorder

Aim: Chronic kidney disease‐mineral and bone disorder (CKD‐MBD) has been proposed to be the replacement of renal osteodystrophy by the Organization of Kidney Disease: Improving Global Outcomes since 2005 because the mineral disorder is not confined to the skeleton in CKD. Accordingly, laboratory and imaging tests have been emphasized for the clinical assessment of patients with CKD besides renal biopsy. The objective of the current study was to investigate whether osteoprotegerin (OPG) could be made a useful biomarker for early diagnosis of CKD‐MBD. Methods: Sixty pre‐dialysis patients with CKD 1–5 were enrolled in this study. The serum calcium, phosphorus, blood urea nitrogen, creatinine, alkaline phosphatase, Osteocalcin, Calcitonin, intact parathyroid hormone and OPG were measured. Bone mineral densities of the lumbar spine (L2–L4), femoral neck, Ward's triangle and trochanter were measured by dual‐energy X‐ray absorptiometry. Results: Among all measured serum bone metabolism indexes, the changing of serum OPG level happened at the earliest time (CKD 3) and its correlation coefficient with estimated glomerular filtration rate (eGFR) was also the highest (r = ?0.601, P = 0.001). In the multivariable analysis that included sex, age and eGFR as controlling factors, the serum OPG correlated with the bone mineral density (BMD) of Ward's triangle (r = ?0.390, P = 0.041). Conclusion: Serum OPG may be a useful biomarker for early diagnosis of CKD‐MBD.     

慢性肾脏病3～4期患者骨矿物质代谢紊乱的调查

目的 调查慢性肾脏病（chronickidney disease,CKD）3 ～4期患者慢性肾脏病矿物质及骨代谢紊乱（chronic kidney disease-mineral and bone disorder,CKD-MBD）的状况和检测有关骨代谢的指标.方法 检测111例CKD3～4期患者的血钙、血磷、血清全段甲状旁腺素（intact parathyroid hormone,iPTH）,并随机对其中20例患者行25羟维生素D[25（OH）D]及骨性碱性磷酸酶（bone-alkaline phosphare,b-ALP）的检测.结果 CKD3 ～4期患者矫正钙分别为（2.25 ±0.12 mmol/L）和（2.20±0.14 mmol/L）,血磷分别为（1.20 ±0.23 mmol/L）和（1.36 ±0.28 mmol/L）,iPTH分别为（73.18±51.77pg/mL）和（118.95±64.97pg/mL）,低钙血症的发生率分别为2.22％和6.06％,高磷血症的发生率分别为0％和7.58％,SHPT的发生率分别为37.78％和48.48％.CKD4期患者与CKD3期的患者相比,血钙显著性下降（P＜0.05）,iPTH水平显著升高（P＜0.05）,iPTH水平与血磷（r=0.103,P＞0.05）成正相关,与GFR（r=-0.422,P＜0.01）、血钙（r=-0.268,P＜0.01）成负相关.多元逐步回归分析显示,血钙、血磷、GFR是iPTH的独立影响因素（复相关系数R=0.482,p＜0.05）.CKD3～4期患者b-ALP（74.476±56.056ng/mL）,显著高于健康人（24.141±14.741ng/mL）（P＜0.01）,而25（OH）D（173.763±52.375ng/mL）显著低于健康人（306.995±93.085ng/mL）（P＜0.05）.结论 CKD早期患者存在CKD-MBD及骨代谢异常,且随着疾病的进展而愈加明显,应重视并早期干预,从而改善预后.     

碳酸镧联合不同血液净化方式对慢性肾脏病-矿物质和骨代谢异常患者钙磷代谢的影响

目的探讨碳酸镧联合不同血液净化方式对慢性肾脏病-矿物质和骨代谢异常(chronic kidney disease mineral and bone disorder,CKD-MBD)患者钙磷代谢的影响,为CKD-MBD患者选择最佳治疗方案,改善患者的生存质量。方法选择陕西省人民医院2014年1月至2015年5月行维持性血液透析的CKD-MBD患者76例,给予口服碳酸镧并按透析方式分为3组,血液透析(hemodialysis,HD)组24例、血液透析联合血液透析滤过(HD and hemodialysis filtration,HD+HDF)组27例,血液透析联合血液灌流(HD and blood perfusion,HD+HP)组25例,比较各组治疗前和治疗3个月后血钙、血磷、钙磷乘积及甲状旁腺素(parathyroid hormone,PTH)的变化。观察3组治疗中不良反应的发生率并进行比较。结果治疗3个月后,3组血钙较治疗前均升高,3组间血钙变化无统计学差异(P0.05);3组血磷及钙磷乘积较治疗前明显下降(P0.05),但HD+HDF组、HD+HP组较HD组下降更为明显(P0.05)。HD组门H在治疗前、后变化不大(P0.05),HD+HDF组和HD+HP组治疗3个月后PTH较前明显下降(P0.05)。HD组、HD+HDF组及HD+HP组患者并发症发生率分别为75.0%、18.5%、32.0%,HD组并发症明显高于HD+HDF组和HD+HP组,差异有统计学意义(P0.05),HD+HDF组并发症发生率最低。结论碳酸镧联合不同血液净化方式对血钙、血磷及PTH的清除效果不同,联合HDF和HP方式能明显清除血磷、PTH,改善钙磷代谢紊乱,不良反应小,适合临床应用治疗CKD-MBD。     

Risk factors of bone density disorder and vascular calcification in non-dialysis chronic kidney disease patients

Objective To explore the risk factors of bone density disorder and vascular calcification in non-dialysis chronic kidney disease (CKD) patients. Methods Clinical data of non-dialysis CKD patients who were admitted to the First Affiliated Hospital of Fujian Medical University between January 2013 and June 2014 were retrospectively analyzed. Using dual energy X-ray absorptiometry to evaluate their bone mineral density (BMD) and T value. Patients were divided into normal BMD group (T≥-1), osteopenia group (-2.5＜T＜-1) and osteoporosis group (T≤-2.5). The vascular calcification was evaluated by pectoral computed tomography. Multi-factor stepwise logistic regression analysis was used to assess the risk factors for low bone density and vascular calcification in non-dialysis CKD patients. Results A total of 337 non-dialysis CKD patients were enrolled. There were 110 (32.6%) patients with normal BMD, and 146(43.3%) patients with osteopenia, and 81(24.0%) patients with osteoporosis. Gender, history of hypertension, 25-hydroxy vitamin D and N-terminal osteocalcin shown statistical differences among three groups (all P＜0.05). The incidence rate of 25-hydroxy vitamin D deficiency shown statistical difference among three groups (P=0.012). Further, the rates were increased with the decreased bone mass (χ2=7.100, P=0.008). The other mineral bone disorders, such as hypocalcemia, hyperphosphatemia, low intact parathyroid hormone (iPTH) and high iPTH had no statistical difference among three groups (all P＞0.05). Multi-factor stepwise logistic regression analysis revealed that increased iPTH (OR=1.938), and low bone density (OR=1.724) were independent risk factors for CKD patients with vascular calcification (all P＜0.05), while women (OR=3.312) and vascular calcification (OR=1.742) were independent risk factors for CKD patients with low bone density (all P＜0.05). Conclusion Increased iPTH and low bone density are independent risk factors for non-dialysis CKD patients with vascular calcification, while women and vascular calcification are independent risk factors for non-dialysis CKD patients with low bone density.     

Postoperative variations of bone turnover markers in uremic patients with secondary hyperparathyroidism after parathyroidectomy

Objective To study shortdated postoperative variation characteristics of bone turnover markers (BTMs) in uremic patients with secondary hyperparathyroidism (SHPT) underwent parathyroidectomy (PTX). Methods A total of 19 uremic patients with SHPT underwent successful PTX, hospitalized in the Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University from January 2017 to April 2017, were enrolled in the study. The operative model for all enrolled patients was total parathyroidectomy with forearm autotransplantation. The baseline epidemiological and clinical data before PTX and the levels of serum intact parathyroid hormone (iPTH) and serum BTMs after PTX (in the 1st, 3rd and 7th postoperative day) were collected. The correlations between serum iPTH and serum BTMs before PTX and the trend analysis of serum BTMs after PTX were studied. Results The levels of serum iPTH, serum alkaline phosphatase (ALP), serum type Ⅰcollagen cross-linked C-telopeptides (CTX) and serum tartrate-resistant acid phosphatase 5b (TRACP-5b) before PTX were increased, in turn, (1512.4±612.0) ng/L, 267.4(153.1, 424.2) U/L, (5.78±1.15) μg/L and (8.79±4.61) IU/L. Positive correlations between ALP and iPTH (r=0.577, P=0.010), TRACP-5b and iPTH (r=0.640, P=0.003), and ALP and TRACP-5b (r=0.698, P=0.001) were found. The serum levels of ALP increased, while the serum levels of CTX and TRACP-5b decreased within 7 days after PTX. Conclusions Renal osteodystrophy (ROD) with high bone turnover rate is common in uremic patients with severe SHPT. The activities of osteoblast and osteoclast are up-regulated in coupling with positive correlations to serum levels of iPTH. Increased activities of osteoblast and decreased activities of osteoclast were found shortdated postoperatively.     

上海市浦东新区成人慢性肾脏病流行病学调查

目的 了解上海市浦东新区社区居民慢性肾脏病（CKD）的患病率及主要危险因素。 方法 2008年4月至7月,在上海市浦东新区随机多阶段抽取20～80岁的社区居民5584人进行问卷调查,进行横断面研究。收集一般情况和生活方式等信息。收集空腹血和晨尿,检测Scr、尿肌酐（Ucr）及尿微量白蛋白等指标,计算尿白蛋白和肌酐比值（ACR）,并依Scr水平计算肾小球滤过率（eGFR）。 结果 上海浦东新区成年居民白蛋白尿、肾功能下降和CKD的标化患病率分别为9.9%（男性8.0%、女性12.4%）、1.1%（男性1.3%、女性0.9%）和11.0%（男性8.8%,女性12.7%）。女性CKD患病率高于男性,并随年龄增长而上升。调整年龄和性别后,城郊患病率间差异无统计学意义。多因素Logistic回归分析显示,高龄、女性、高血压、高空腹血糖、高三酰甘油血症、超重或肥胖是白蛋白尿、CKD的独立危险因素。 结论 上海市浦东新区成人CKD的患病率接近甚至高于国内外既往研究结果。肾脏损伤已成为危及该地区居民健康的重大公共卫生问题,需重视CKD的早期发现和干预,避免终末期肾脏病（ESRD）和相关并发症的发生。     

Clinical characteristics of the chronic kidney disease in the elderly: a cross - sectional study

Objective To analyze the baseline clinical characteristics of the chronic kidney disease (CKD) in aged people in the clinic. Methods Patients aged 18 years or older in our CKD clinic from October 2003 to December 2012 were included in this study. According to their age patients were divided into 2 groups: aged CKD group: aged 65 or older and non-aged CKD group: younger than 65. A group of the elderly without CKD from health screening program were selected as aged non-CKD control group. Causes, distributions of stages and complications of CKD in three groups were analyzed. Results The major cause of the elderly CKD was hypertension, different from that of younger CKD . The distribution of CKD stage in the elderly was mainly in the G3b stage, different from that in the younger. Anemia and mineral bone disease presented in earlier CKD stage in the aged CKD patients and the prevalence was higher than in the aged non-CKD group. The prevalence of hypertension had no statistical difference between the two CKD groups, but hypertension control rate was lower in aged CKD patients. Conclusions The clinical characteristics including causes and renal stage are different between the young and aged CKD patients. Complications such as anemia and mineral bone disease presents in earlier renal stage in aged CKD patients which means we should monitor and interfere earlier.     

上海邮电系统慢性肾脏病患者高血压横断面研究

目的 对上海邮电系统职工慢性肾脏病(CKD)患者的高血压患病率、知晓率、控制率和降压药使用情况进行横断面研究.方法 回顾性分析在本院肾内科门诊就诊的上海邮电系统职工初诊CKD患者810例,其中男性422例(52.1％),女性388例(47.9％),年龄(26 ～96)岁.结果 ①83.58％的CKD患者伴高血压,高血压知晓率为占92.02％,治疗率达到了80.35％,高血压控制率为19.65％;②吸烟、肥胖、糖尿病、尿酸、肾功能减退、高龄,这些变量均为上海邮电系统职工CKD门诊患者高血压发病的危险因素;③上海邮电系统初诊CKD患者使用l、2和3种或以上降压药物者分别为72.8％ (493/677)、24.3％ (165/677)和2.9％(19/677).在已服药的544例中,单药服用的患者中,降压药物中使用比例最高药物是钙离子拮抗剂(CCB)48.0％ (261/544),血管紧张素受体Ⅱ受体拮抗剂(ARB) 31.6％ (172/544),其次为血管紧张素转换酶抑制剂(ACEI)9.9％ (54/544).联合治疗方案中,使用最多的是ARB+ CCB占18.8％(102/544);④上海邮电系统初诊CKD患者的CKD知晓率:46.67％.结论 上海邮电系统职工CKD患者的高血压发病率高,高血压知晓率与治疗率均较高,而CKD的知晓率低,且高血压的控制率仍低;吸烟、肥胖、糖尿病、尿酸、肾功能减退、高龄,这些变量均为CKD患者高血压发病的危险因素.     

慢性肾脏病伴肌少症患者骨密度改变的临床研究

目的探讨慢性肾脏病(chronic kidney disease,CKD)及伴肌少症患者的骨密度变化情况。方法健康对照组57例。CKD患者123例,男性61例,女性62例,平均年龄59. 8±12. 6岁。以核素肾动态显像获得的肾小球滤过率,将CKD组患者分为CKD1组(CKD1～2期)和CKD2组(CKD3～5期)。将研究对象分为肌少症组和非肌少症组,检测腰椎和髋关节骨密度及体质成份,评估肌肉质量、肌肉强度。结果①CKD2组患者腰椎、髋部和股骨颈骨密度T值均较对照组明显减低(P0. 05),差异有统计学意义;②CKD患者肌少症组腰椎、髋部和股骨颈骨密度均较非肌少症组骨密度T值显著减低(P0. 05),差异有统计学意义。肌少症组和非肌少症组骨质疏松发生率分别为41. 7%、20. 6%,差异有统计学意义(χ2=6. 367,P=0. 012)。结论骨密度随CKD病情进展而下降; CKD合并肌少症患者更易罹患骨质疏松。     

Using vertebral bone densitometry to determine aortic calcification in patients with chronic kidney disease

Background: Vascular calcification (VC) is a major contributor to increased cardiovascular (CV) disease in chronic kidney disease (CKD) and an independent predictor of mortality. VC is inversely correlated with bone mineral density (BMD). Screening for VC may be useful to determine those at greater CV risk and dual‐energy X‐ray absorptiometry (DXA) may have a dual role in providing VC measurement as well as BMD. Methods: We report cross‐sectional data on 44 patients with CKD stages 3–4 and aim to determine and validate measurement of VC using DXA. Patients had computed tomography (CT) of abdominal aorta and DXA of lateral lumbar spine, to determine both aortic VC and BMD. Semi‐quantitative measurement of VC from DXA was determined (blinded) using previously validated 8‐ and 24‐point scales, and compared with VC from CT. BMD determination from L2 to L4 vertebrae on CT was compared with DXA‐reported BMD. Results: Patients 66% male, 57% diabetic, had mean age 63.4 years and mean estimated glomerular filtration rate 31.4 ± 12 mL/min. Aortic VC was present in 95% on CT, mean 564.9 ± 304 Hounsfield units (HU). Aortic VC was seen in 68% on lateral DXA, mean scores 5.1 ± 5.9 and 1.9 ± 1.9 using 24‐ and 8‐point scales, respectively. Strong correlation of VC measurement was present between CT and DXA (r 0.52, P < 0.001). For DXA VC 24‐point score, intraclass correlations for intra‐rater and inter‐rater agreement were 0.91 and 0.64, respectively (8‐point scale, intraclass correlations 0.90 and 0.69). Vertebral BMD measured by CT (mean 469.3 HU L2–4) also significantly correlated with lateral DXA‐reported BMD (mean spine T‐score –0.67 ± 1.6) (r 0.56, P < 0.001). Conclusion: Despite limitations in CKD, DXA may be useful as lateral DXA images provide concurrent assessment of aortic calcification as well as lumbar spine BMD, both correlating significantly with CT measurements. Lateral DXA may provide VC screening to determine patients at greater CV risk although more studies are needed to evaluate their potential role.     

Chronic kidney disease mineral and bone disorder in children

Childhood and adolescence are crucial times for the development of a healthy skeletal and cardiovascular system. Disordered mineral and bone metabolism accompany chronic kidney disease (CKD) and present significant obstacles to optimal bone strength, final adult height, and cardiovascular health. Decreased activity of renal 1 alpha hydroxylase results in decreased intestinal calcium absorption, increased serum parathyroid hormone levels, and high-turnover renal osteodystrophy, with subsequent growth failure. Simultaneously, phosphorus retention exacerbates secondary hyperparathyroidism, and elevated levels contribute to cardiovascular disease. Treatment of hyperphosphatemia and secondary hyperparathyroidism improves growth and high-turnover bone disease. However, target ranges for serum calcium, phosphorus, and parathyroid hormone (PTH) levels vary according to stage of CKD. Since over-treatment may result in adynamic bone disease, growth failure, hypercalcemia, and progression of cardiovascular calcifications, therapy must be carefully adjusted to maintain optimal serum biochemical parameters according to stage of CKD. Newer therapeutic agents, including calcium-free phosphate binding agents and new vitamin D analogues, effectively suppress serum PTH levels while limiting intestinal calcium absorption and may provide future therapeutic alternatives for children with CKD.     

Cinacalcet versus standard treatment for chronic kidney disease: a systematic review and meta-analysis

Background: Chronic kidney disease-mineral and bone disorders (CKD-MBD) have been associated with poor health outcomes, including diminished quality and length of life. Standard management for CKD-MBD includes phosphate restricted diet, vitamin D and phosphate binders. Persistently elevated parathyroid hormone levels may require the addition of cinacalcet hydrochloride (cinacalcet), which sensitizes calcium receptors in the parathyroid gland.

Purpose: The objective of this systematic review is to compare, in patients with CKD-MBD the effect of cinacalcet versus standard treatment on patient-important outcomes, including parathyroidectomy, fractures, hospitalizations due to cardiovascular events, cardiovascular mortality, all-cause mortality, and intermediate outcomes, in particular Kidney Disease Outcome Quality Initiative targets.

Methods: Data sources included MEDLINE, EMBASE, the Cochrane Register of Controlled Trials and Web of Science from 1996 to June 2015. Teams of two reviewers, independently and in duplicate, screened titles and abstracts and potentially eligible full text reports to determine eligibility, and subsequently abstracted data and assessed risk of bias in eligible trials. We calculated the effect estimates (risk ratios or mean differences) and 95% confidence intervals, as well as statistical measures of variability in results across studies using random effect models. We used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to rate quality of evidence about estimates of effect on an outcome-by-outcome basis for all outcomes. We presented our results with a GRADE summary table.

Results: Twenty-four trials including 8311 CKD patients proved eligible. The results left considerable uncertainty regarding the impact of cinacalcet on reducing fractures (relative risk [RR] 0.59, 95% confidence interval [CI] 0.13–2.60; heterogeneity: p?=?0.03, I²=?78%; very low quality evidence), and indicated that cinacalcet did not reduce hospitalizations due to cardiovascular events (RR 0.93, 95% CI 0.85–1.02, moderate quality of evidence), cardiovascular mortality (RR 0.95, 95% CI 0.84–1.07; heterogeneity p=?0.61, high quality evidence) or all-cause mortality (RR 0.96, 95% CI 0.89–1.04; heterogeneity: p=?0.98, I²=?0%; moderate quality evidence). Cinacalcet reduced the need for parathyroidectomy (RR 0.30, 95% CI 0.22–0.42; heterogeneity: p=?0.70, I²=?0%; absolute effect 55 fewer per 1000 [95% CI 61 fewer to 45 fewer], high quality of evidence). The most common adverse event associated with cinacalcet therapy was gastrointestinal side effects. Cinacalcet increased nausea (RR 2.16, 95% CI 1.46–3.21, absolute effect 158 more per 1000 [95% CI 82 more to 302 more]) and vomiting (RR 2.15, 95% CI 1.66–2.80, absolute effect 63 more per 1000 [95% CI 109 more to 171 more]). Cinacalcet treatment increased the rate of hypocalcemia (RR 6.0, 95% CI 3.65–9.87; heterogeneity: p=?0.71, I²=?0%, absolute effect 20 more per 1000 [95% CI 11 more to 36 more], high quality of evidence).

Conclusions: In the hands of clinicians participating in these studies, cinacalcet decreased the rate of parathyroidectomy but had no influence on mortality. Patients and clinicians can trade of the benefit of fewer parathyroidectomies against the adverse effects.     

慢性肾脏疾病患者骨密度异常的研究

慢性肾脏疾病(chronic kidney disease,CKD)是肾脏内科常见疾病,需要经过长时间的治疗干预,治疗期间常伴有不同程度骨代谢异常,出现骨代谢相关指标的异常变化。在众多的骨代谢指标中以骨密度水平降低最为常见,骨密度的降低会导致CKD患者出现骨质疏松甚至发生骨折的风险。CKD患者出现骨折后会增加治疗难度、治疗费用,并在一定程度上导致患者残疾,甚至死亡。因此对CKD患者治疗期间进行骨密度监测,判断骨折发生风险,对于CKD疾病的治疗进程和改善患者预后至关重要。为此,本文对CKD患者治疗期间骨密度变化情况的国内外相关研究进行综述,以期为降低CKD患者治疗期间的骨密度异常发生率提供参考。     

西那卡塞治疗慢性肾脏疾病透析患者继发性甲状旁腺功能亢进症安全性与有效性的Meta分析

目的：综合分析西那卡塞治疗慢性肾脏疾病合并继发性甲状旁腺功能亢进症（second-ary hyperparathyroidism,SHPT）患者的安全性与有效性。方法在 Cochrane Central Register of Controlled Trials,Cochrane Database of Systematic Reviews,Embase,Medline四个数据库中检索应用西那卡塞治疗慢性肾脏疾病合并 SHPT 患者的随机对照分析。其纳入标准为慢性肾脏疾病合并SHPT且正在行透析治疗的患者,年龄≥18岁;治疗组接受西那卡塞加常规治疗,对照组接受安慰剂加常规治疗或只接受常规治疗,常规治疗包括维生素D类似物和（或）磷结合剂。结果共检索出14篇满足纳入标准的文献。结果显示西那卡塞明显降低了 SHPT患者血甲状旁腺素（parathyroid hor-mone,PTH）水平[MD,-285.89 ng/L （95% CI：-341.27,-230.51）]、血钙浓度[MD,-0.21 mmol/L（95% CI：-0.24,-0.18）]、血磷浓度[MD,-0.13 mmol/L（95% CI：-0.17,-0.08）]以及钙磷乘积的水平[MD,-8.99（95% CI：-10.37,-7.61）],但是西那卡塞对骨代谢方面作用不确定,也并不能降低患者的全因病死率[RR 0.97（95% CI：0.89,1.05）]。与对照组比较,使用西那卡塞治疗的患者更容易发生低钙血症、恶心、呕吐、上呼吸道感染。结论西那卡塞治疗能有效的改善SHPT患者血生化指标,但并没有有效降低患者的全因病死率。