维持性血液透析合并继发性甲状旁腺功能亢进患者骨代谢及骨密度变化

Bone metabolism and bone mineral density in maintenance hemodialysis patients with secondary hyperparathyroidism

目的观察维持性血液透析（maintenance hemodialysiS，MHD）合并继发性甲状旁腺功能亢进（secondary hyperparathyroidism，SHPT）患者骨代谢指标及骨密度（bone mineral density，BMD）变化。方法86例入选MHD合并SHPT患者按全段甲状旁腺激素（intact parathyroid，iPTH）水平分为A（150-300pg／ml，n=23）、B（300-600pg／ml，n=21）、C（6001000pg／ml，n-24）、D（〉1000pg／ml，n=18）4组；按是否合并糖尿病分为糖尿病组、非糖尿病组。测定腰椎、股骨BMD；检测iPTH、白蛋白、钙、磷、碱性磷酸酶水平。观察各组患者以上指标变化，分析iPTH与其相关性。结果①B、C组血磷（LSDf=2．030，P=0．049）、L1-L4BMD（LSD—t=4．591，P〈0．001）和L1-L4年轻成人T值（LSD—V=-4．813，P〈0．001）差异有统计学意义；②A、B、C、D组随着iPTH平的升高，左侧股骨BMD（1．07±0．18，1．00±0．16，0．84±0．15，0．78±0．43，F=5．616，P-O．001）、左侧股骨年轻成人T值（1．00±0．25，0．12±1．24，-1．08±1．20，1．05±30，F=16．377，P=-0．001）、左侧股骨Wards三角BMD（1．00±0．25，0．91±0．25，0．66±0．09，0．62±0．03，F6．915，P〈0．001）、左侧股骨Wards三角年轻成人T值（0．84±1．68，0．18±1．62，-1．45±0．60，-1．75±0．19，F=14．928，P〈0．001）呈下降趋势，4组间比较差异有统计学意义；③非糖尿病组iPTH水平明显高于糖尿病组（t=--7．387，P〈0．001），而左侧股骨BMD（t=-2．414，P=0．018）、左侧股骨年轻成人T值（F5．477，P〈0．001）、左侧股骨Wards三角BMD（t-3．252，P=-0．020）、左侧股骨Wards三角年轻成人T值（t=7．758，P〈0．001）均明显低于糖尿病组；④相关性分析：iPTH与ALP呈正相关（F0．782，P〈0．001），与左侧股骨BMD（R=-0．532，P=0.025）、左侧股骨年轻成人T值（r=-0．520，P=0．004）、左侧股骨Wards三角BMD（r=0．514，P〈0．001）、左侧股骨Wards三角年轻成人T值（r=-0．512，P〈0．001）呈负相关。结论MHD合并SHPT患者血磷可能成为反映腰椎骨代谢的标志物；iPTH水平可预估MHD合并SHPT患者股骨尤其是股骨Wards三角骨代谢情况。

Objective To observe the changes of bone metabolism and bone mineral density （BMD） in the maintenance hemodialysis （MHD） patients with secondary hyperparathyroidism （SHPT）. Methods Eighty-six MHD patients with SHPT were enrolled in this study and were assigned according to their serum intact parathyroid （iPTH） level into 4 groups, group A （150-300 pg/ml, n=23）, group B （300-600 pg/ml, n= 21）, group C （600- 1000 pg/ml, n=24） and group D （〉 1000 pg/ml, n=1 8）, and according to the presence or absence of diabetes into diabetes group and non-diabetes group. BMD and serum albumin, calcium, phosphorus, alkaline phosphatase （ALP） and iPTH were assayed. Changes of these parameters in different groups and their relevance to iPTH levels were analyzed. Results Serum phosphorus （LSD-t=-2.030, P=0.049）, L1-L4 BMD （LSD-t=4.591, P〈0.001） and young adult L1-L4 T value （LSD-t=4.813, P〈0.001） were significantly different between group B and group C. iPTH was significantly higher in non-diabetes group than in diabetes group （t=-7.387, P〈0.001）, while left femur BMD （t=-2.414, P =0.018）, young adult left femur T value （t=5.477, P〈0.001）, left femoral Wards triangle BMD （t=-3.252, P=0.020） and young adult left femoral Wards triangle T value （t=7.758, P〈0.001） were significantly lower in non-diabetes group than in diabetes group （ P〈 0.05）. In groups A, B, C and D, left femur BMD （1.07±0.18, 1.00±0.16, 0.84±0.15 and 0.78±0.43 respective- ly; F=-5.616, P=0.001）, young adult left femur T value （1.00±0.25, 0.12±1.24, -1.08±1.20 and -1.05±30 respectively; F=16.377, P =0.001）, left femoral Wards triangle BMD （1.00±0.25, 0.91±0.25, 0.66±0.09 and 0.62±0.03 respectively; F=-6.915, P〈0.001） and young adult left femoral Wards triangle T value （0.84±1.68, 0.18±1.62, - 1.45±0.60 and -1.75±0.19 respectively; F=-14.928, P〈0.001） decreased gradually along with the increase of serum iPTH level （P〈0.01）. Correlation study revealed that iPTH level was positively correlated with ALP （r=0.782, P〈0.001）, and negatively correlated with left femur BMD （r=-0.532, P=0.025）, young adult left femur T value （r=-0.520, P=0.004）, left femoral Wards triangle BMD （r=-0.514, P〈0.001）, and young adult left femoral Wards triangle T value （r=-0.512, P〈0.001）. Conclusions In MHD patients with SHPT, hyperphosphatemia may become a marker of lumbar bone metabolism abnormalities, and serum iPTH level can be used to estimate bone metabolism of femur, especially that of femoral Wards triangle.