维持透析时间对腹膜透析患者CKD-MBD的影响

Effect of maintenance dialysis periods on CKD-MBD in peritoneal dialysis patients

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.

Objectives To investigate the bone metabolic biomarkers of peritoneal dialysis and to study the effect of maintenance dialysis periods on chronic kidney disease-mineral and bone disorder（CKD-MBD） in peritoneal dialysis.Methods We observed the change of bone metabolic biochemical markers：serum calcium and phosphorus,intact parathyroid hormone （iPTH）,25-hydroxy vitamin D3 [25 （OH） D3）] and bone alkaline phosphatase （BALP） in the participants,which contained 60 peritoneal dialysis patients and 30 healthy controls.Furthermore,the peritoneal dialysis patients were grouped into A （maintenance dialysis periods ＜ 24 months） and B （maintenance dialysis periods ≥24 months）.Results Compared to the healthy control,the level of serum calcium went down,while serum phosphate went up obviously （P 1.40 ± 0.29mmol/L vs 1.75 ± 0.57mmoL/L; Ca 2.33 ± 0.19mmol/l 2.02 ± 0.2mmol/l,P ＜ 0.01）,at the same time,the level of iPTH,25 （OH） D3 and BALP showed obviously change in iPTH,25 （OH） D3 and BALP [iPTH 436.41 ± 368.28pg/ml vs 53.31 ± 23.71pg/ml; 25 （OH）D3 199.28 ± 139.52ng/ml vs 36.04 ±14.17ng/ml; BALP 80.24 ± 39.41ng/ml vs 173.76 ±52.38ng/ml,P ＜0.01].The rate was nearly 100％ that at least one of bone metabolic biochemical markers was abnormal.Compared to the healthy control,the level of serum calcium and phosphate changed obviously in group A and B.While the level of serum calcium and phosphate did not show difference obviously in group A and B （P ＞ 0.05）.Compared to the healthy control,the level of iPTH raised （iPTH 53.31 ± 23.71pg/ml vs 596.57 ±449.91pg/ml ＆ 276.25 ± 148.23pg/ml,P ＜ 0.05）,25 （OH） D3 declined [25 （OH） D3：173.76 ± 52.38ng/ml vs 58.99 ± 25.79ng/ml ＆ 101.48 ± 39.67ng/ml,P ＜0.05] in group A and B,while BALP went up （BALP：36.04 ± 14.18ng/ml vs 264.58 ± 114.24ng/ml） in group A.Compared to the level of iPTH,25 （OH）D3,BALP in group A,in group B,iPTH increased significantly,although the concentration of 25 （OH）D3 and BALP dropped obviously （BALP：133.97 ± 133.90ng/ml vs 264.58 ± 114.24ng/ml,P ＜ 0.05）.Conclusions CKD-MBD was widespread in peritoneal dialysis patients.The bone turnover type may be converted by the peritoneal dialysis time going on.Due to the difficulty of bone biopsy,the dynamic monitoring of bone metabolic biomarkers was necessary to explicit the bone turnover type.Therapies tailored particularly to different turnover bone should be taken appropriately in peritoneal dialysis.