帕立骨化醇在透析患者继发性甲状旁腺功能亢进中的疗效分析

目的:探讨帕立骨化醇治疗骨化三醇或拟钙剂效果不佳的维持性血液透析患者继发性甲状旁腺功能亢进的疗效。方法:选取四川大学华西医院雅安市人民医院维持性血液透析伴继发性甲状旁腺功能亢进(iPTH>300 pg/ml),且对骨化三醇或拟钙剂疗效不佳的患者16例。检测其使用帕立骨化醇前及治疗后4、8、12周血钙、磷、甲状旁腺激素、碱性磷酸酶水平。结果:使用帕立骨化醇12周后,iPTH由1159.0(740.05,2104.50)pg/ml下降至738.35(462.58,944.58)pg/ml(P=0.002),并且37.50%(6/16)的患者iPTH水平下降≥30%,31.25%(5/16)的患者iPTH水平下降≥50%。血钙由(2.09±0.19)mmol/L上升至(2.38±0.13)mmol/L(P<0.001),血清ALP由(179.38±107.61)mmol/L下降至(99.58±21.37)mmol/L,差异具有统计学意义(P=0.009)。血磷在治疗前后差异无统计学意义。结论:帕立骨化醇对骨化三醇或拟钙剂疗效不佳的维持性血液透析患者的继发性甲状旁腺功能亢进仍然有效...     

帕立骨化醇治疗维持性血液透析患者继发性甲状旁腺功能亢进症的前瞻性研究

目的 观察帕立骨化醇治疗维持性血液透析患者继发性甲状旁腺功能亢进症（secondary hyperparathyroidism,SHPT）的疗效及安全性.方法 选择我科血液净化中心进行维持性血液透析治疗的13例患者,血全段甲状旁腺素（intact parathyroid hormone,iPTH）≥33 pmol/L,血钙水平＜2.55 mmol/L,钙磷乘积＜65,根据iPTH水平使用帕立骨化醇1～18 μg治疗,于每次透析治疗后给药,共观察12周.分别于治疗前及治疗后第2、4、6、8、10、12周测定患者的iPTH、血钙、血磷水平.结果 13例患者的血清iPTH水平在治疗后第2、4周已开始下降,但与治疗前相比差异无统计学意义.从治疗后第6周开始,iPTH水平与治疗前相比存在统计学差异（P＜0.05）,治疗后第12周时下降至（46.68±38.06） pmol/L,与治疗前（78.30±52.13） pmol/L比较,有统计学差异（P＜0.01）.治疗后第2、4周血钙水平升高,与治疗前比较有统计学差异（P＜0.05）,其中治疗后第4周时血钙水平升高尤为显著（P＜0.01）.经调整帕立骨化醇剂量后,治疗后第6周患者的血钙水平逐渐恢复正常并保持稳定,血磷、钙磷乘积水平在治疗前、后均无明显统计学差异.治疗过程中,患者耐受性良好,无相关不良反应的发生.结论 使用帕立骨化醇治疗维持性血液透析患者SHPT是有效、安全的.     

药用活性炭有效降低顽固性高磷血症透析患者血磷水平与钙磷乘积

目的 研究口服药用活性炭对未能控制的高磷血症透析患者血磷与钙磷乘积的作用.方法 采用单中心、前瞻性、自身前后对照研究.经含钙的磷结合剂治疗后仍存在高磷血症的血液透析或腹膜透析患者,餐中加服药用活性炭4.5～7.2 g/d治疗3个月.检测治疗前后血磷、钙、钙磷乘积、全段甲状旁腺激素( iPTH)、白蛋白、血红蛋白水平.用配对t检验进行统计学分析.结果 与治疗前比较,治疗3个月后患者血磷水平显著下降[(1.85±0.30)mmol/L比(2.16±0.34) mmol/L,P＜0.01];血钙磷乘积也相应显著下降[(54.12±8.37) mg2/dl2比(63.93±8.83) mg2/dl2,P＜0.01];有更多并发继发性甲状旁腺功能亢进症的患者可以接受维生素D治疗(83.3％比50％);血钙与iPTH水平无显著性变化(P=0.734,0.665).活性碳治疗期间血白蛋白水平较前下降[(40.1±2.2)g/L比(41.7±2.9) g/L,P=0.001].结论 顽固性高磷血症透析患者在继续原有磷结合剂治疗基础上,口服药用活性炭可以有效地降低血磷水平与钙磷乘积,对血钙及iPTH水平没有显著性影响.活性炭治疗可使患者血白蛋白水平轻度下降.     

精细化甲状腺被膜解剖技术联合环甲隙显露喉返神经方法在分化型甲状腺癌中的应用价值

背景与目的:分化型甲状腺癌以手术治疗为主,在切除病变甲状腺腺体时容易损伤组织结构或周围神经,故降低手术风险为目前研究的热点。本研究探讨精细化甲状腺被膜解剖技术联合环甲隙显露喉返神经方法在分化型甲状腺癌手术中的应用价值及其对患者血清甲状旁腺激素(PTH)、Ca~(2+)水平及喉返神经的影响。方法:回顾性分析2015年7月—2018年7月行手术治疗的90例分化型甲状腺癌患者的临床资料,根据喉返神经的不同解剖显露方式分为对照组和手术改良组,各组45例。对照组采用常规术式结合甲状腺下动脉显露喉返神经方法;手术改良组采用精细化甲状腺被膜解剖技术联合环甲隙显露喉返神经方法,对比两组患者的手术情况、术后1、3、7、30 d血清PTH、Ca~(2+)水平变化及喉返神经损伤等并发症发生率。结果:两组患者手术指标的差异均无统计学意义(P0.05)。术前,两组患者PTH水平无统计学差异(P0.05);术后各时间点PTH水平,手术改良组均高于对照组[(21.3±4.1)pg/mL vs.(5.4±1.3)pg/mL,(23.2±4.6)pg/mL vs.(14.2±3.2)pg/mL,(26.1±5.1)pg/mL vs.(15.1±3.1)pg/mL,(37.7±6.8)pg/mL vs.(25.4±4.5)pg/mL,均P0.05]。术前两组患者Ca~(2+)水平无统计学差异(P0.05);术后各时间点Ca~(2+)水平,手术改良组均高于对照组[(2.11±0.12)mmol /L vs.(1.82±0.33)mmol /L,(2.14±0.17)mmol /L vs.(1.83±0.22)mmol /L,(2.17±0.42)mmol /L vs.(1.84±0.36)mmol /L,(2.29±0.41)mmol/L vs.(1.89±0.34)mmol /L,均P0.05]。手术改良组未见喉返神经损伤,出现甲状旁腺功能减退1例;对照组喉返神经损伤2例、甲状旁腺功能减退3例,低钙血症1例;两组并发症发生率有统计学差异(P0.05)。术后随访6个月,手术改良组无复发,对照组复发1例,两组复发率无统计学差异(P0.05)。结论:精细化甲状腺被膜解剖技术联合环甲隙显露喉返神经方法治疗分化型甲状腺癌可减小机体PTH、Ca~(2+)的波动水平,降低喉返神经损伤的发生率,有助于降低手术风险。     

骨化三醇冲击治疗血透患者继发性甲旁亢的疗效观察

目的：对照观察常规和不同冲击剂量的骨化三醇对维持性血透患者继发性甲旁亢（SHPT）的疗效.方法：选择我院63例血液透析患者分为常规组30例、治疗组33例,每组根据全段甲状旁腺素（iPTH）浓度再分为2个亚组,A1、B1组（300 pg/ml≤PTHi≤600 pg/ml）,A2、B2组（iPTH＞600 pg/ml）.常规组给予口服骨化三醇0.25 μg/d,治疗组分别给予口服骨化三醇2 μg/次、每周2次和2 μg/次、每周3次,治疗终点指标为iPTH≤300 pg/ml,或用药12周.分别测定治疗前及后第4周、8周、12周的iPTH、血钙、血磷、钙磷乘积和碱性磷酸酶（AKP）.结果：治疗8周时,A1组iPTH开始下降[（290.38±61.90）vs（452.53±91.09）,P＜0.05],治疗12周时iPTH继续下降,但与4周相比变化不大（P＞0.05）.A2组治疗8周时iPTH明显下降[（521.60±226.37）vs（926.13±226.07）,P＜0.01],治疗12周时iPTH又有所上升,但仍低于治疗前[（644.95±88.16）vs（926.13±226.07）,P＜0.05].冲击治疗组与常规治疗组相比,iPTH明显降低,钙磷乘积升高,患者临床症状改善,达标率高,差异有统计学意义.结论：骨化三醇冲击治疗对于继发性甲旁亢疗效显著,安全性好,值得推广.     

持续质量改进对老年腹膜透析患者钙磷代谢紊乱的作用

目的:探讨应用持续质量改进(CQI)的方法纠正老年腹膜透析患者钙磷代谢紊乱的效果。方法:运用PDCA四步法,即设计、实施、检验和应用,设计并实施改善老年腹膜透析患者钙磷代谢紊乱的治疗措施。结果:45例腹膜透析时间>3个月的老年患者参与了此项研究。经9个月CQI,各种钙磷代谢紊乱总发生率由82.22%降至42.22%(P<0.05)。其中高钙血症组血钙由(2.71±0.25)mmol/L降至(2.52±0.31)mmol/L(P<0.05),低钙血症组血钙由(1.78±0.42)mmol/L升至(2.11±0.24)mmol/L(P<0.05),血磷水平由(2.13±0.62)mmol/L降至(1.67±0.53)mmol/L(P<0.05),钙磷乘积由(80.22±16.61)mg2/dl2降至(54.58±15.93)mg2/dl2(P<0.05),继发性甲状旁腺功能亢进患者的血清全段甲状旁腺素(iPTH)由(488.12±227.31)pg/ml降至(290.3±171.15)pg/ml(P<0.01),血清碱性磷酸酶水平由(108.75±35.31)U/L降至(88.75±38.14)U/L(P<0.05)。有残肾功能较无残肾功能组,虽KT/V差异不大,在CQI后纠正高磷血症、高钙血症、甲状旁腺功能亢进上差异均有统计学意义(P<0.05)。结论:持续质量改进措施显著改善了老年腹膜透析患者的钙磷代谢紊乱。     

维持透析时间对腹膜透析患者CKD-MBD的影响

目的 对维持腹膜透析患者的骨代谢指标进行横断面调查,并探讨腹膜透析时间对腹膜透析患者慢性肾脏疾病矿物质骨代谢异常(Chronic kidney disease-mineral and bone disorder,CKD-MBD)的影响.方法 以60例腹膜透析患者和30例健康体检者(对照组)作为研究对象,腹膜透析患者分为A组(腹膜透析时间＜24个月)和B组(腹膜透析时间≥24个月),比较各组间骨代谢指标,如血钙,血磷,25-羟维生素D3[25-hydroxyl vitamin D3,25 (OH) D3]、血清全段甲状旁腺素(intact parathyroid hormone,iPTH)和骨碱性磷酸酶(bone alkaline phosphatase,BALP)的变化.结果 与对照组相比,腹膜透析组的血磷升高,血钙降低且差异具有统计学意义(P1.40±0.29mmol/L vs 1.75±0.57mmol/L;Ca 2.33±0.19mmol/L 2.02±0.2mmol/L,P＜0.叭),iPTH,25 (OH) D3,BALP具有显著性差异[iPTH 436.41±368.28pg/mL vs 53.31±23.71pg/mL;25(OH)D3199.28±139.52ng/mL vs 36.04±14.17ng/mL;BALP80.24±39.41ng/mL vs 173.76±52.38ng/mL,P＜0.01].腹膜透析患者一项或多项骨代谢指标异常的发生率为100％.与对照组相比,A组、B组的血钙降低,血磷升高,且具有统计学意义;但A组与B组的血钙、血磷水平差异无统计学意义(P＞0.05).与对照组相比,A组、B组的iPTH显著升高(53.31±23.71pg/mL vs 596.57±449.91 pg/mL & 276.25±148.23pg/mL,P＜0.05);25(OH)D3显著减低[173.76±52.38ng/mL vs 58.99±25.79ng/mL & 101.48±39.67ng/mL,P＜0.05],A组BALP明显减低(36.04±14.18ng/mL vs 264.58±114.24ng/mL);与A组相比,B组的iPTH升高,25(OH)D3降低,BALP降低,且差异均具有统计学意义(BALP:133.97±133.90ng/mL vs 264.58±114.24ng/mL,P＜0.05).结论 腹膜透析患者存在明显的矿物质骨代谢异常.随着腹膜透析时间的增加,骨转化类型可能会发生变化,由于常规行骨活检较困难,需动态的检测患者的骨代谢血清学指标来辅助判断骨转化类型.腹膜透析患者矿物质骨代谢异常的治疗方案需根据骨转化类型进行调整.     

单中心腹膜透析患者钙磷代谢不达标的影响因素分析

目的回顾性分析山西医科大学第二医院腹膜透析中心近5年腹膜透析(peritoneal dialysis,PD)患者钙磷及全段甲状旁腺素(intact parathyroid hormone,iPTH)等相关生化指标,分析矿物质及骨代谢异常产生的原因,进一步提高PD患者的生活质量和改善预后。方法选取山西医科大学第二医院2014年1月至2018年12月间进行长期维持性腹膜透析患者102例,随访3个月以上,回顾性分析患者的基线和最后一次回院随访资料。了解其钙磷代谢紊乱情况,并按血钙、血磷及iPTH水平分为达标组、不达标组,比较两组临床资料差异,探讨山西省部分地区PD患者钙磷代谢不达标的影响因素。结果 PD患者中,男女比0.79∶1,年龄(51.2±13.9)岁,基线血钙、血磷、iPTH及碱性磷酸酶(alkaline phosphatase,ALP)水平分别为(2.07±0.26)mmol/L、(1.8±0.5)mmol/L、(387.8±40.3)pg/mL、(103.9±10.3)U/L,最后一次随访时平均血钙、血磷、iPTH及ALP水平分别为(2.16±0.27)mmol/L、(2.0±0.8)mmol/L、(497.8±39.6)pg/mL、(101.4±10.0)U/L。血钙、血磷及iPTH达标率分别为37.25%、48.04%、19.61%,最后一次随访时血钙、血磷及iPTH达标率分别为48.04%、34.31%、13.73%。钙磷代谢指标控制不达标因素分析结果显示:基线血肌酐(Scr)是血钙不达标的影响因素;基线钙磷乘积是血磷不达标的影响因素;透析时间是iPTH不达标的影响因素;透析时间、基线ALP是ALP不达标的影响因素。结论山西地区PD患者钙磷代谢紊乱问题突出,血钙、磷及iPTH达标率不理想,影响钙磷代谢不达标的因素有Scr、透析时间、钙磷乘积。     

低钙透析液对血液透析伴继发性甲状旁腺功能减退患者的临床研究

目的：探讨应用含钙1.25mmol／L浓度透析液进行血液透析对维持性血液透析（MHD）伴相继发性甲状旁腺功能减退患者的钙磷代谢和甲状旁腺功能的影响。方法：选择MHD6个月以上、病情稳定、连续2次血iPTH〈100pg／ml的患者60例,随机分为对照组（含钙1.5mmol／L透析液）和治疗组（含钙1.25mmol／L透析液）,每组各30例,观察时间6个月。观察并记录研究前、研究后l、3、6个月等不同时期患者血iPTH、血清校正钙、磷、钙磷乘积等指标的变化以及相关不良反应。另外,选择使用含钙浓度1.5mmol／L和1.25mmol／L透析液进行MHD的患者各20例,检测单次透析前、透析结束时以及下次透析前的血清校正钙、磷和iPTH浓度。结果：（1）治疗组单次透析后血清校正钙、磷和钙磷乘积均较透析前明显下降,iPTH浓度较透前明显升高,P〈0.01;而对照组上述血钙和iPTH浓度无明显变化;（2）透析后治疗组血清校正钙和钙磷乘积较对照组明显下降,血iPTH浓度较对照组明显升高,P〈0.01;两组血磷浓度差异无统计学意义。（3）治疗组1个月后血清校正钙、磷和钙磷乘积较治疗前开始下降,3个月后进一步下降,P〈0.05,6个月后各项指标趋于稳定;iPTH水平1个月后较治疗前明显升高,并随着治疗时间的延长,逐渐升高,P〈0.01。（4）对照组治疗后1、3、6个月上述指标与治疗前比较差异无统计学意义。（5）两组透析过程中出现的不良反应差异无统计学意义。结论：对于血iPTH〈100pg／ml MHD患者应用含钙1.25mmol／L透析液进行血液透析能较好地控制其血清校正钙、磷、钙磷乘积水平,有效地改善被过度抑制的甲状旁腺功能,并且安全性良好。     

阿法骨化醇冲击治疗血液透析患者甲状旁腺功能亢进

目的 研究维持性血液透析患者继发性甲状旁腺功能亢进,应用阿法骨化醇治疗效果及安全性.方法 对32例血液透析甲状旁腺功能亢进患者检测甲状旁腺素(iPTH)在360-2000pg/ml,进行血液透析加阿法骨化醇冲击治疗8-12周.结果 32例均有不同程度下降.其中1例因甲状旁腺腺瘤,甲状旁腺素下降不明显行手术治疗,1例血钙升高.结论 血液透析加阿法骨化醇冲击治疗效果明显,高钙血症发生率低,安全性耐受性好.     

Efficacy and tolerability of intravenous paricalcitol in calcitriol-resistant hemodialysis patients with secondary hyperparathyroidism: 12-month prospective study

RATIONALE/OBJECTIVES: Data are limited regarding the use of paricalcitol in calcitriol-resistant patients with secondary hyperparathyroidism (SHPT). We aimed to evaluate the effects of paricalcitol in calcitriol-resistant hemodialysis patients with SHPT. METHODS: This is a 12-month, open-label, prospective study. Forty patients with calcitriol-resistant and/or calcitriol-intolerant SHPT were included. After a washout period, all patients converted to paricalcitol with a 1:3 conversion ratio. Serum calcium and phosphorus were monitored monthly, while serum intact parathyroid hormone (iPTH) once in every 3 months. Paricalcitol dose was reduced or discontinued in case of hypercalcemia and/or hyperphosphatemia. Pre- and posttreatment electrolyte and iPTH values were compared with Student's t-test and Wilcoxon signed-rank test, respectively. MAIN FINDINGS: Forty patients completed the study. Mean initiation dose of paricalcitol was 23 ± 7 μg/week. Mean serum calcium was 8.9 ± 0.8 mg/dL at baseline and 9.4 ± 0.7 mg/dL at study end (p = 0.07). Mean monthly serum phosphorus levels stayed stable. Paricalcitol was effective in reducing iPTH levels when compared with pretreatment values (747.9 ± 497.2 pg/mL, 307.3 ± 417.1 pg/mL, respectively; p < 0.001). Thirty-two patients had to discontinue intravenous (IV) paricalcitol at some time during their treatment. Main reasons for discontinuation were as follows: hyperphosphatemia (58%), hypercalcemia (25%), and iPTH < 150 pg/mL (17%). PRINCIPLE CONCLUSIONS: Paricalcitol was found to be effective in reducing iPTH levels in calcitriol-resistant patients with SHPT despite relatively frequent drug discontinuation rates.     

甲状旁腺切除术对血液透析患者合并继发性甲状旁腺功能亢进骨代谢及骨密度的影响

目的 观察甲状旁腺切除术(parathyroidectomy,PTX)对继发性甲状旁腺功能亢进(secondary hyperparathyroidism,SHPT)的维持性血液透析患者骨代谢及骨密度(BMD)的影响.方法 26例SHPT患者行PTX.术前及术后1、3、6、12、18、24个月时常规检测血钙、血磷、血清碱性磷酸酶,化学发光法检测血清全段甲状旁腺素(intact parathyroid,iPTH)、骨钙素(OC)、Ⅰ型前胶原氨基末端前肽(PINP)、β胶原蛋白(β-C TX),术前及术后24个月时双能X线法测定腰椎、股骨颈、骨盆各部位骨密度,观察患者甲状旁腺切除术前、术后骨代谢指标及骨密度变化.结果 (1)与术前比较,血清OC水平[(104.49±25.42) μg/L比(695.46±355.62) μg/L,P＜ 0.01]、PINP水平[(248.36±159.38) μg/L比(809.28±283.50) μg/L,P＜0.01]于手术3个月后明显降低,β-CTX水平于手术1个月后明显降低[(1.60±0.64) μg/L比(3.37±1.34) μg/L,P＜0.01].(2)与术前比较,术后24个月时腰椎BMD[(0.88±0.23) g/cm2比(0.78±0.23) g/cm2,P＜0.01]、股骨颈BMD[(0.96±0.19) g/cm2比(0.84±0.24) g/cm2,P＜ 0.01]及腰椎Z评分[(-1.24±0.55)比(-1.66±0.24),P＜0.01]、股骨颈Z评分[(-1.51±0.72)比(-1.93±0.40),P＜0.01]均升高.(3)相关分析显示,术前血清iPTH水平与⊿腰椎Z评分(r=0.584,P=0.002)、⊿股骨颈Z评分(r=0.400,P=0.043)呈正相关,术前血清OC水平与⊿腰椎Z评分(r=0.651,P＜0.001)、⊿股骨颈Z评分(r=0.509,P=0.008)呈正相关.结论 PTX术可以降低患者升高的iPTH、OC、PINP及β-CTX水平,增加骨密度,同时改善多项生化指标,提高患者生活质量.     

Intravenous calcitriol versus paricalcitol in haemodialysis patients with severe secondary hyperparathyroidism

Aim:   Secondary hyperparathyroidism (SHPT) is common among haemodialysis patients. Intensive treatment with calcitriol is often complicated by hypercalcaemia, hyperphosphataemia and elevated calcium phosphorus (Ca X PO₄) product. Paricalcitol is a vitamin D analogue developed to overcome some of the limitations of calcitriol therapy. The study objectives were to compare the response of intact parathyroid hormone (iPTH) and the incidence of hypercalcaemia, hyperphosphataemia and elevated Ca X PO₄ product in patients with severe SHPT treated with either i.v. calcitriol or i.v. paricalcitol.
Methods:   This was a single centre randomized open label study. Patients with serum intact iPTH of 50 pmol/L or more were randomized to receive either i.v. calcitriol (0.01 ug/kg) or i.v. paricalcitol (0.04 ug/kg) during every haemodialysis treatment. Serum iPTH, calcium, phosphorus and alkaline phosphatase were measured at the beginning of the study and every 3 weeks for 12 weeks.
Results:   Twenty-five patients were enrolled into the study – 12 were randomized into the calcitriol group and 13 into the paricalcitol group. There were no differences in the baseline study parameters between both groups. Serum iPTH levels were significantly reduced ( P  = 0.003) only in the paricalcitol group but not in the calcitriol group ( P  = 0.101). On the other hand, serum calcium levels were significantly increased only in the calcitriol group ( P  = 0.004 vs P  = 0.242). Serum phosphorus, alkaline phosphatase and Ca X PO₄ product were not different.
Conclusion:   Intravenous paricalcitol may be superior to i.v. calcitriol for the treatment of severe SHPT in our chronic haemodialysis population. A larger randomized controlled trial is indicated to confirm these initial findings.     

Mineral and bone disorder in patients with chronic kidney disease: a cross - sectional single center study

Objective To investigate and analyze the mineral and bone disorder (MBD) in the patients with chronic kidney disease (CKD), reveal the change of related indexes of CKD-MBD. Methods A cross-sectional study was carried out in the First Affiliated Hospital of Harbin Medical University. From October 2011 to May 2014, 1318 inpatients and hemodialysis outpatients were enrolled. Parameters related to MBD, including serum phosphorus (P), total calcium (t - Ca), intact parathyroid hormone (iPTH) and alkaline phosphatase (AKP) were analyzed. Last, it was analyzed with multiple regression analysis to related factors of the secondary hyperparathyroidism (SHPT) in patients with CKD. Results Serum calcium, phosphorus and iPTH had no obvious abnormalities at the early stages of CKD [GFR＞60 ml•min-1•(1.73 m2）-1], and relatively stable before GFR＞30 ml•min-1•(1.73 m2)-1. After entering the CKD4 stage, serum phosphorus, iPTH increased sharply and serum calcium decreased obviously along with the decreased glomerular filtration rate (GFR). Serum P, t-Ca and iPTH levels were statistically significant in CKD 1 to 5D patients, respectively, serum P: (1.13±0.20) mmol/L, (1.14±0.22) mmol/L, (1.26±0.23) mmol/L, (1.48±0.34) mmol/L, (2.05±0.61) mmol/L and (2.08±0.58) mmol/L; serum t-Ca (mmol/L) (2.35±0.13) mmol/L, (2.35±0.12) mmol/L, (2.35±0.15) mmol/L, (2.26± 0.18) mmol/L, (2.07±0.29) mmol/L and (2.31±0.26) mmol/L; iPTH: 57.8(45.6, 91.8) ng/L, 54.1(37.8, 74.6) ng/L, 71.6(45.8, 102.2) ng/L, 131.1(81.7, 205.1) ng/L, 277.5(173.6, 395.3) ng/L and 354.9 (194.4, 720.3) ng/L; The stepwise logistic regression analysis showed: hypocalcemia (OR=3.32, P＜0.01) and decreased GFR (OR=5.28, P＜0.01) were independent risk factors of iPTH elevation at stage CKD3～5. Conclusions From the beginning of the CKD3 stage, serum t - Ca, P, iPTH level began to be relatively abnormal as renal function declined. Hyperphosphatemia, SHPT has not been improved significantly in CKD5D stage patients even with hemodialysis. The regulation of hemodialysis on serum calcium showed "overcorrecting" phenomenon.     

Secondary hyperparathyroidism and anemia. Effects of a calcimimetic on the control of anemia in chronic hemodialysed patients. Pilot Study

The main cause of resistance to erythropoiesis-stimulating agents (ESA) used for treatment of anemia in chronic hemodialysed patients (CHP) is the iron deficiency, absolute or functional. Secondary hyperparathyroidism (SHPT) is a secondary factor of resistance. Indeed, it has been reported in the literature an improvement of anemia parameters after surgical parathyroidectomy (PTX). The objective of this study is to assess in CHP, the impact of the correction of SHPT by a calcimimetic, cinacalcet (CI), (which is considered as a pharmacological PTX) on the response to ESA, measured by the erythropoietin resistance index (ERI). Twenty-two CHP with severe SHPT documented by an intact parathyroid hormone (iPTH) above 800pg/mL were included in this prospective pilot study. Mineral bone metabolism, anemia and nutritional parameters were measured baseline and after 6 months of treatment by CI. The effect on anemia was assessed at the end of study by the ERI, the change in Hb concentration, and the proportion of patients with Hb levels above 11g/dL. RESULTS: At the end of study there was a significant decrease (M6 vs M0) in iPTH (1302 vs 674pg/mL or -48%, p=0.006), serum calcium (2.39 vs 2.15mmol/L or -10%), serum phosphate (2 vs 1.7mmol/L or -15%), serum calcium-phosphorus product (CaxP) (4.8 vs 3.8mmol(2)/L(2) or - 20% (p<0.05), and the number of patients with CaxP>4.4mmol(2)/L(2) (64 vs 32%, p<0.05). The level of bone alkaline phosphatase remained stable during the study (28 vs 27?IU/L). The Hb levels increased from 11 to 11.4g/dL, as did the proportion of patients whose Hb concentration reached 11g/dL or higher (50 vs 70%, p<0.05) without important change of the median weekly ESA dosis in the majority of patients, 18?cases (81%) vs four (19%). Two subgroups were identified from the median decreases in iPTH (delta iPTH) between M0 and M6, Group?1 (delta iPTH≥400pg/mL, n=10) and group?2 (delta iPTH<400pg/mL, n=12): in group?1, we found a correlation between the decrease in iPTH by CI and the stability or decrease in ERI (group?1), at comparable dose of dialysis, nutritional and iron intakes and inflammatory profiles; in group?2 without a significant effect of CI on PTH reduction the levels of ERI and ESA dosis were more elevated. CONCLUSION: A treatment by calcimimetic improves the control of anemia by ESA in CHP and interferes positively on a cause of secondary resistance to ESA represented by SHPT. The mechanism of these effects could be linked to the decreased of bone marrow fibrosis and inflammation and to the triptych formed by the reduction in iPTH, CaxP and phosphate.     

Efficacy and safety of calcium acetate on hyperphosphatemia in patients undergoing hemodialysis

Objective To evaluate the efficacy and safety of calcium acetate in treating hemodialysis(HD) patients with hyperphosphatemia. Methods A randomized, controlled multicenter study was performed. Phosphate binders were discontinued during a two-week washout period． A total of 171 hemodialysis patients from 10 sites with serum phosphorus during 1.94-2.75 mmol/L after two-week washout period were randomized to calcium acetate or calcium carbonate for 8 - week treatment period. Patients with serum phosphorus between 1.94-2.26 mmol/L were given elemental calcium 1000 mg/d and between 2.27- 2.75 mmol/L were given elemental calcium 1500 mg/d. The dose was constant during the 8 - week treatment period. Results All of 171 patients entered the safety analysis set, including 123 cases who completed the study into effect analysis set. In terms of efficacy: compared with the baseline, serum phosphorus, calcium - phosphorus products, parathyroid hormone (iPTH) levels were significantly decreased (all P＜0.05) and serum calcium levels increased slightly in both groups; compared with the calcium carbonate group, calcium acetate group had a significant advantage in the change of serum phosphorus content [(1.73 ± 1.85) vs (0.99 ± 1.60) mmol/L, P＜0.05] and drug response ratio (compared with the baseline serum phosphorus level fell more than 25%) (51.6% vs 32.8%, P＜0.05). In safety aspects, calcium acetate group and the control group had no significant differences in the incidence of adverse events (19.8% vs 18.8%) and adverse reactions (8.1% vs 4.7%), all P＞0.05. The main adverse reactions of calcium acetate were mild to moderate gastrointestinal reactions, including nausea, vomiting. Conclusions In hemodialysis patients with hyperphosphatemia, calcium acetate can decrease serum phosphorus and reduce the levels of calcium - phosphorus product and iPTH. In the phosphate binding capacity, calcium acetate is superior to calcium carbonate. Mild to moderate gastrointestinal reactions are most common after administration.     

不同钙浓度腹膜透析液对长期CAPD患者矿物质和骨代谢影响的分析

目的观察腹膜透析液钙离子浓度对持续性不卧床腹膜透析(CAPD)患者矿物质和骨代谢的影响。 方法回顾性分析我院腹膜透析中心行CAPD治疗2年以上的123例患者,根据腹膜透析液钙离子浓度分为低钙腹膜透析液组(LCD组,钙离子浓度为1.25 mmol/L)和标准钙腹膜透析液组(SCD组,钙离子浓度为1.75 mmol/L),观察不同钙浓度腹膜透析液对患者血清钙、磷、全段甲状旁腺激素(iPTH)、颈动脉厚度、心脏瓣膜钙化及骨痛、皮肤瘙痒等情况的影响。使用SPSS 18.0统计软件包进行数据处理。 结果2组患者治疗前人口学特征、腹膜转运特性、钙磷代谢等指标的基线水平差异无统计学意义(P>0.05)。治疗2年后,2组患者血钙浓度及达标率较治疗前均显著增高(P<0.05),SCD组血钙浓度增幅高于LCD组,但差异无统计学意义(0.26±0.31 mmol/L与0.17±0.29 mmol/L, t＝1.621,P＝0.108);2组间治疗后血清钙、磷、iPTH平均水平及其达标率、颈动脉厚度、心脏瓣膜钙化比例、骨痛及皮肤瘙痒累计发生率差异均无统计学意义(P>0.05);LCD组活性维生素D使用比例显著高于SCD组(χ² ＝6.373,P<0.05)。 结论采用低钙与标准钙腹透液治疗2年,对CAPD患者矿物质和骨代谢的影响无显著性差异。     

Oral paricalcitol versus oral calcitriol in continuous ambulatory peritoneal dialysis patients with secondary hyperparathyroidism

Background

Secondary hyperparathyroidism (SHPT) is common in end-stage renal disease. Our primary objective was to evaluate the efficacy of oral paricalcitol versus oral calcitriol on serum intact parathyroid hormone (iPTH) and mineral bone parameters in continuous ambulatory peritoneal dialysis (CAPD) patients with SHPT. The secondary objective was to analyze highly sensitive C-reactive protein (hsCRP) and peritoneal membrane function in both groups.

Methods

This was a prospective randomized control trial. CAPD patients with SHPT were randomized to paricalcitol or calcitriol for 15 weeks. Serum intact iPTH, calcium, phosphate and alkaline phosphatase (ALP) were measured at baseline and every 3 weeks. Serum hsCRP and peritoneal membrane functions were measured at baseline and at week 15.

Results

A total of 26 patients were enrolled and randomized—12 to paricalcitol and 14 to calcitriol. Serum iPTH reduced significantly in both groups and there was no difference in the incidence of ≥50 % reduction of iPTH between both groups. There was a significant increase in serum calcium in both groups but there were no differences in serum phosphorus across the visits. The incidence of hypercalcemia was the same in both groups. Serum calcium–phosphorus (Ca × P) product increased in the paricalcitol group but decreased in the calcitriol group. Serum ALP decreased significantly in both groups. There were also no differences in pre- and post-treatment serum hsCRP and peritoneal function test (PFT) in both groups.

Conclusion

Both oral paricalcitol and calcitriol were equally efficacious in reducing serum iPTH but were associated with significantly higher serum calcium. Serum Ca × P product increased in the paricalcitol group and decreased in the calcitriol group. Serum hsCRP level and PFT were not affected by either treatment. A larger randomized controlled trial is indicated to confirm these initial findings.