口服冲击与每日口服1α(OH)D_3治疗血液透析患者继发性甲状旁腺功能亢进的临床观察

Treatment of secondary hyperparathyroidism with oral 1α-hydroxyvitamin D3: A comparison of pulse oral and daily oral methods

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 3 4例iPTH <2 0 0ng/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 <2 0 0ng/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) 3 4例患者治疗前血清iPTH为(686.0 7± 2 83 .65 )ng/L ,1α(OH )D3 剂量为 (5 .44± 4.3 8) μg/周 ,治疗 8周时iPTH总达标率为 82 .3 5 % ;(2 )与每日口服组比较 ,口服冲击治疗起效快 ,并对治疗前iPTH >5 0 0ng/L的患者具有更高缓解率 (10 0 %比 40 % ,P <0 .0 5 ) ;(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 1.2 5mmol/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。

Objective To explore the proper dosage of 1α(OH) D 3 in treating secondary hyperparathyroidism (SHPT),and compare the efficacy and safety of pulse oral and daily oral of 1α(OH) D 3 treatments in maintenance hemodialysis (HD) patients.Methods Thirty-four HD patients with elevated intact parathyroid hormone (iPTH >200ng/L) were randomly allocated to pulse oral group and daily oral group.The dosage of 1α(OH) D 3 was determined by the serum level of pretherapeutic iPTH,and the medication maintained until iPTH was lower than 200ng/L.Serum concentration of iPTH,calcium and phosphorous were tested before and at the 4th,8th week after 1α(OH) D 3 treatment.Results (1) The dosage of 1α(OH)D 3 used in the study,5.44±4.38μg/w,was lower than that reported from foreign documents.(2) After therapy of 1α(OH)D 3 for eight weeks,82.35% of patients reached target iPTH levels.For those with moderate to severe SHPT (iPTH>500ng/L),pulse medication showed obviously better remission rate (100% vs 40%,P<0.05).(3) Both serum calcium and phosphorous concentration were elevated in both groups.The pre-dialysis levels of serum calcium and phosphorous were higher in daily oral group than those in pulse oral group.Hypercalcemia occurred in 2 cases in daily oral group and their 1α(OH) D 3 dosage had to be reduced and their dialysate calcium concentration had to be changed from 1.5 mmol/L to 1.25mmol/L.Conclusion Oral 1α(OH) D 3 is highly efficacious for suppressing SHPT in HD patients. Pulse oral therapy is superior to daily oral therapy in efficacy and safety.