限磷饮食下碳酸镧与醋酸钙降低腹膜透析患者高磷血症的效果比较

Comparison of the efficacy of lanthanum carbonate and calcium acetate with low phosphorus dietary on hyperphosphatemia among patients on peritoneal dialysis

目的在限磷饮食下比较碳酸镧和醋酸钙降低腹膜透析患者高磷血症的效果。方法纳入2014年12月~2015年5月期间在北京大学第一医院膜透析中心接受规律透析,并存在高磷血症（血磷≥1.78mmol/L）的患者,随机分为碳酸镧组和醋酸钙组,治疗3个月。研究期间合理使用低钙透析液,根据血钙、磷水平调整药物剂量。比较基线、1月、2月和3月的血磷、钙和全段甲状旁腺激素（intact parathyroid hormone,i PTH）水平的变化,同时检测饮食磷摄入,尿液和透析液排出磷及净磷蓄积水平。结果共有51例腹膜透析患者纳入研究并随机分组为碳酸镧25例,醋酸钙26例。研究期间除3例因胃肠道反应退出外,其余均完成3月随访,结束时2组服用磷结合剂的剂量分别为碳酸镧1500（750~1875）mg/天,醋酸钙2001（2001~4002）mg/天。2组在基线时人口学资料、生化参数及透析充分性均无差异[年龄：（52.48±13.55）岁比（58.12±11.41）岁,t=-1.669,P=0.101;血白蛋白：（37.90±0.80）g/L比（39.44±6.21）g/L,t=-1.032,P=0.307]。研究期间,碳酸镧和醋酸钙组间比较显示血钙（F=1.122,P=0.293）、磷（F=1.118,P=0.732）和i PTH（F=1.638,P=0.206）水平的变化趋势没有显著区别,2种药物均可有效降低血磷。其中碳酸镧组血磷从治疗前（2.12±0.37）mmol/l下降到（1.67±0.27）mmol/l（t=4.295,P〈0.001）,醋酸钙组从治疗前（2.04±0.33）mmol/L下降到（1.64±0.32）mmol/L（t=3.293,P〈0.001）。经限磷饮食教育,碳酸镧和醋酸钙组患者3月内平均饮食摄入磷控制在稳定的较低水平,在基线和3月2组患者的净磷蓄积水平无显著性差异[基线：175.98（84.12~414.93）比256.66（101.15~443.74）,t=2.065,P=0.735;3月：418.74（214.04~531.20）比361.0（210.48~394.37）,t=0.965,P=0.349]。结论本研究发现,在有效实施限磷饮食和合理使用低钙腹膜透析液的前提下,醋酸钙和碳酸镧的降磷效果类似,且未观察到醋酸钙增加高血钙的风险。

Objective To compare the efficacy of lanthanum carbonate and calcium acetate with low phosphorus dietary on hyperphosphatemia among patients on peritoneal dialysis （PD）. Methods PD pa- tients with hyperphosphatemia treated in the PD center of our hospital between Dec. 2014 and May 2015 were recruited into this study according to the inclusion and exclusion criteria. They were randomized into lantha- num carbonate group and calcium acetate group. Low calcium dialysate was prescribed appropriately during the study period. The drug doses were adjusted according to serum calcium and phosphorus levels. Serum cal- cium, phosphorus and intact parathyroid hormone were compared at baseline, after the treatment for one month, 2 months and 3 months. Dietary phosphorus intake, and phosphorus removed from urine and dialysate were measured. Results A total of 51 patients were recruited and randomized into lanthanum carbonate group （n=25） and calcium acetate group （n=26）. They completed the study except for 3 patients who dropped out due to gastrointestinal symptoms. At the end of the study, lanthanum carbonate was 1500 （750 - 1875） mg/ d and calcium acetate was 2001 （2001 - 4002） mg/d. Demographic data, biochemistry parameters, and dialy-sis adequacy were similar at baseline between the two groups. In the study period of 3 months, serum phos- phorus decreased significantly in both groups, and the changes of serum calcium （F=1.122, P=0.293）, phos- phorus （F=l.l18, P=0.732） and iPTH （F=1.638, P=0.206） had no differences between lanthanum carbonate group and calcium acetate group. After the education about dietary phosphorus restriction, lower phosphorus intake from dietary maintained during the study period in both groups. The net phosphorus accumulations at the baseline and at the 3rd month of therapy were similar between lanthanum carbonate group and calcium ac- etate group [at baseline： 175.98 （84.12 ~ 414.93） vs. 256.66 （101.15- 443.74）, t=-2.065, P=0.735; at the 3rd month： 418.74 （214.04 ~ 531.20） vs. 361.0 （210.48 ~ 394.37）, t=-0.965, P=0.349]. Conclusion By the ap- propriate use of lower phosphorus dietary and low calcium dialysate for PD, both lanthanum carbonate and calcium acetate treatment could effectively decrease serum phosphorus of similar extent. No extra risk of high- er serum calcium was observed in calcium acetate group.