原发性肾病综合征患者应用糖皮质激素后对骨密度及骨钙素的影响

Impact of glucocorticoid therapy on bone mineral density and osteocalcin in patients with primary nephrotic syndrome

目的观察原发性肾病综合征(PNS)患者应用糖皮质激素(GC)后骨密度(BMD)及骨钙素(OC)的变化。方法 20例正常对照为A组,将73例原发性肾病综合征患者根据应用糖皮质激素的时间分为四组,B组(2-6个月)19例、C组(7-12个月)21例、D组(13-18个月)17例、E组(超过18个月)16例,所有研究对象收集临床资料,测定骨密度,检测血骨钙素水平。结果 1A-E组性别、年龄、体重指数无统计学差异,B-E组血红蛋白、血白蛋白、血碱性磷酸酶(ALP)、血钙、血磷的差异无统计学意义;2B组腰椎L1骨密度较A组减少(P<0.05),C组腰椎L1-L4骨密度较A组减少(腰椎L1、L3,P<0.01;腰椎L2、L4,P<0.05),D组腰椎L1-L4、股骨颈、大粗隆骨密度较A组减少(腰椎L1-L4、大粗隆,P<0.01;股骨颈,P<0.05),E组各部位骨密度均较A组减少(腰椎L1-L4,P<0.01;股骨颈、Wards三角区、大粗隆,P<0.05);3B组、C组骨钙素水平较A组降低(P<0.05),D组、E组骨钙素水平较A组的差异无统计学意义;4单纯钙剂组及不规律或未应用抗骨质疏松药物组的各部位骨密度均较规律应用钙剂+活性维生素D组减少(P<0.05),不规律或未应用抗骨质疏松药物组与单纯钙剂组比较,仅大粗隆骨密度减少有统计学意义(P<0.05)。结论原发性肾病综合征患者应用糖皮质激素治疗的早期发生血骨钙素降低,长期应用可致骨密度减少,腰椎骨密度减少最为显著,钙剂联合活性维生素D治疗可防治糖皮质激素相关性骨量丢失。

Objective To observe the changes of bone mineral density （BMD） and osteocalcin （OC） after the application of glucocorticoid （GC） in patients with primary nephrotic syndrome. Methods Group A was the control group containing 20 healthy cases. The experimental group consisted of 73 patients with primary nephrotic syndrome. Four groups were divided based on their different period of glucocorticoid therapy, including group B （2 - 6 months, n = 19 ）, group C （7 - 12 months, n = 21 ）, group D （13 - 18 months, n = 17）, and group E （more than 18 months, n = 16）. The clinical data were collected. Bone mineral density and serum OC were measured. Results （1） No statistically difference of sex, age, and body mass index was found among the subjects in group A-E. The levels of hemoglobin, serum albumin, serum alkaline phosphatase （ALP）, serum calcium, and serum phosphate were not statistically different among the subjects in group B-E. （2） BMD of L1 was lower in group B, than that in group A （P〈0.05）. BMDofLI-IA was lower in group C than that in group A （L1, L3, P〈0.01; L2, L4, P〈0.05）. BMDofL1- L4, the femoral neck, and the greater trochanter was lower in group D than that in group A （LI-IA, greater trochanter, P 〈 0.01 ; femoral neck, P 〈0.05）. BMD at each part was lower in group E than that in group A （LI-IA, P 〈0.01 ; femoral neck, greater trochanter, Ward＇s triangle region, P 〈 0.05 ） ; （ 3 ） Serum OC was lower in group B and group C than that in group A （ P 〈 0. 05） ,but there was no statistically significant difference of serum OC among group D, group E, and group A; （4） BMD of each bone location in calcium group and in the groups that did not use or only used anti-osteoporotic drugs irregularly decreased compared to the group that used calcium plus active vitamin D regularly （ P 〈 0.05 ）. BMD at the greater trochanter reduced significantly in the group that irregularly uses or did not use anti-osteoporotic drugs compared to the oral calcium group （ P 〈 0.05 ） Conclusion Serum OC decreases in patients with primary nephrotic syndrome during the early period of glucocorticoid therapy. Long-term therapy with GC can cause the loss of bone mineral density, and the decrease is mostly at the lumbar spine. The treatment with calcium plus active vitamin D can prevent glucocorticoid-induced bone mass loss.