长期小剂量糖皮质激素治疗对狼疮性肾炎骨密度的影响

Clinical Study on Bone Mineral Density of Lupus Nephritis Patients Receiving Long-term Low-dose Glucocorticoid Treatment

目的探讨长期小剂量糖皮质激素治疗对狼疮性肾炎患者骨密度变化的影响。方法选取2011年1月至2015年1月重庆市第五人民医院收治的狼疮性肾炎（初治）患者106例为研究对象，采用随机数字表法分为观察组和对照组，各53例。所有患者按美国风湿病学会指南推荐激素冲击治疗后逐渐减量直至长期小剂量激素维持治疗，观察组患者一旦发生骨密度异常均采用阿仑膦酸钠、阿法骨化醇、碳酸钙疗法进行治疗，对照组则不进行任何相关治疗。开始半年及以后每1年患者回访测其骨密度值。比较两组患者各阶段骨密度值变化，并测定和比较其骨钙素、骨源性碱性磷酸酶（BALP）、空腹尿钙／肌酐比值（Ca／Cr）等骨转换相关指标。结果对照组患者使用糖皮质激素后6、12、24、36、48、60个月腰椎及股骨头骨密度值较治疗前均降低（P〈0．05），观察组腰椎骨密度48、60个月随访值、股骨颈骨密度36、48、60个月随访值与糖皮质激素治疗前比较差异有统计学意义（P〈0．05）。观察组患者12、24、36、48、60个月腰椎及股骨颈骨密度值优于对照组，差异有统计学意义（P〈0．01）。腰椎及股骨头骨密度值与患者糖皮质激素摄入量呈负相关（P〈0．05），与激素使用时间呈负相关（P〈0．05）。糖皮质激素摄入量是骨密度值异常的危险因素（OR=5．793，95％ CI 1．365～107.142，P=0．005）。结论长期小剂量糖皮质激素治疗能降低狼疮性肾炎患者骨密度值，易发生骨质疏松症，抗骨质疏松临床干预能有效遏制患者骨密度较少趋势。

Objective To investigate the effect of long-term low doses of glucocorticoid on bone mineral density changes of lupus nephritis patients. Methods Total of 106 patients admitted to Chongqing Fifth People＇s Hospital from Jan. 2011 to Jan. 2015 were included in the study and divided into observation group and control group according to random number, 53 cases each. All patients received the American College of Rheumatology Guidelines recommended therapy of glucocorticoid shock then gradually reducing to a low dose and for long term maintain treatment. The observation group were treated with alendronate, alfacalcidol and calcium carbonate in the case of abnormal bone mineral density, while the control group was not treated in such cases. Bone mineral density and bone turnover markers such as osteocalcin, bonealkaline phosphatase （BALP）, urinary Ca/Cr values were measured and compared after half a year then every year of the begin- ning of the treatment. Results The lumbar and femoral bone mineral density value of the control group 6, 12,24,36,48,60 months after using glucocorticoid were decreased from before treatment（ P 〈 0.05 ） and lumbar bone mineral density value at 48 and 60 months follow-up and femoral neck bone density value at 36, 48,60 months follow-up of the observation group were statistically significantly different from before receiving glucocorticoid treatment（ P 〈 0.05 ）. And the 12,24,36,48,60 months lumbar spine and femoral neck bone mineral density value of the observation group were better than the control group with statistically significant difference（ P 〈0. 01 ）. Lumbar and femoral bone mineral density values were negatively correlated with glucocorticoid intake（ P 〈 0. 05 ）, and negatively correlated with hormone use time （ P 〈 0. 05 ）. Glucocorticoid intake was a risk factor for bone mineral density （ OR = 5. 793,95% Cl 107. 142-1. 365, P = 0. 005 ）, Conclusion Long-term low-dose giucocortieoids therapy could reduce the bone mineral density values of lupus nephritis patients and result in osteoporosis. Anti-osteoporesis clinical intervention can effectively curb the decline trend of bone mineral density.