慢性肾脏病患者25-羟维生素D3水平的改变及其影响因素分析

Changes in 25-hydroxy-vitamin D3 level and relevant factors in chronic kidney disease

目的检测慢性肾脏病（chronickidneydisease，CKD）患者不同进展阶段25一羟维生素I）3125（OH）D3]的浓度，25（0H）D3水平与CKD发生、发展的关系，进一步探讨活性维生素D在CKD患者中的合理应用。方法收集2014年11月至2015年11月中国医科大学附属第一医院肾脏内科住院的非血液净化的CKD患者885例及急性肾损伤患者11例，分别测定25（0H）133及血红蛋白（hemoglobin，Hb）、血肌酐（SCr）、尿素氮（BIJN）、血清胱抑素C（CystatinC，Cys-C）、血钙、血磷、血碳酸氢根（HC03）、血尿酸（uricacid，UA）、血总胆固醇（totalcholesterol，TC）、三酰甘油（triglycer-ide，TG）、低密度脂蛋白胆固醇（10wdensity lipoprotein cholesterol，LDL-C）、高密度脂蛋白胆固醇（high density lipoprotein cholesterol，HDL-C）、血白蛋白（albumin，Alb）、血清碱性磷酸酶（alkalinephosphates，ALP）、C反应蛋白（C-reactiveprotein，CRP）、糖化血红蛋白（HbAlC）及采用化学发光法测量血清全段甲状旁腺素（immunoreactive parathyroid hormone，iPTH）。统计CKD不同阶段25（0H）D3不足及缺乏的发生率，分析不同维生素D水平分组下各项生化指标的变化趋势并进行相关性分析。结果①随肾脏病的进展，维生素D严重缺乏的发生率呈升高趋势。急性肾损伤患者25（OH）D3水平为（15．8±9．16）ng／ml，明显高于CKD各期（P〈O．05）。随25（OH）D3水平下降，患者的血压（收缩压、舒张压）水平升高，尿蛋白的程度加重，血白蛋白水平下降，钙磷代谢紊乱（血钙下降，血磷升高）及血脂代谢异常加重，不同维生素D水平分组间差异有统计学意义（P〈0．05），而年龄、左室射血分数、肾功能相关指标、骨代谢指标、血尿酸、血红蛋白、C反应蛋白则无统计学差异（P〉0．05）；②25（OH）D3水平与尿蛋白程度相关，中度尿蛋白组和大量尿蛋白组25（OH）D3浓度均明显低于正常尿蛋白组和低尿蛋白组（P〈0．05）；且随着蛋白尿病情加重，维生素D严重缺乏的发生率升高，在各尿蛋白组间差异有统计学意义（x^2=251．75，P=0．000）。③25（OH）D3水平与血白蛋白、血钙、血红蛋白水平呈正相关；与收缩压、舒张压、尿蛋白定量、磷、血脂水平呈负相关。血白蛋白、收缩压、尿蛋白定量、血红蛋白是25（OH）D3水平的独立危险因素。结论我国东北地区CKD患者维生素D缺乏更加严重。25（OH）D3水平与CKD临床重要指标相关。血白蛋白、收缩压、24h尿蛋白定量、血红蛋白是25（OH）D3水平的独立危险因素。

Objective To measure the plasma level of 25-hydroxy-vitamin D3 [25（OH）D3] in non-dialysis patients with chronic kidney disease（CKD） at different stages, and to investigate the cor- relations between the levels of 25（OH）D3 and the progression of CKD. Furthermore, we explored the effective application of active vitamin D in CKD. Methods We included 885 non-dialysis CKD patients and 11 patients with acute kidney disease （AKI） hospitalized in the Department of Nephrology in the First Affiliated Hospital of China Medical University from Nov. 2014 to Nov. 2015. Serum 25（OH） D3 levels and other clinical parameters were detected. We further analyzed the prevalence rate of vita- min D insufficiency and deficiency at different stages of CKD, the trend of other relevant biochemical parameters at various groups of vitamin D level, and the correlations between 25 （OH） D3 level and the factors. Results （ 1 ） With the progression of kidney disease, remarkable increasing trend was found in prevalence rate of vitamin D severe deficiency. The 25（OH） D3 concentration in AKI was （15.8 ± 9. 16） ng/mL, which was significantly higher than that of each stages of CKD （P〈0. 05）. With the decrease of 25（OH） D3 concentration, the level of blood pressure （systolic pressure and di- astolic pressure） increased, proteinuria deteriorated, the level of serum albumin decreased, calcium- phosphorus metabolic disorder （blood calcium decreased, blood phosphorus elevated） and lipid meta- bolic abnormality aggravated. The differences in 25（OH） D3 levels among the groups were statistical- ly significant （P〈0. 05）. But age, left ventricular ejection fraction, the kidney function indexes, bone metabolism indexes, serum uric acid, hemoglobin and C-ractive protein Were not statistically signifi- cant （P〈0. 05）. （2） 25（OH） D3 levels were correlated with proteinuria. The concentrations of 25 （OH） D3 in moderate proteinuria group and massive proteinuria group were remarkably lower than those in micro-proteinuria group and normal group-respectively （P〈0. 05）, Remarkable distinction was found in prevalence rate of vitamin D severe deficiency at various groups, and higher prevaleiace rate tended to favor more advanced proteinuria group. The discrepancies in deficiency prevalence were statistically significant （x^2 = 251.75, P = 0. 000）. （3） Pearson＇s correlation analyses revealed that se- rum albumin, calcium and hemoglobin were positively correlated with serum 25 （OH） D3, whereas systolic pressure, diastolic pressure, 24-h urine protein, serum phosphorous and blood lipids （TC, TG, LDL-C, and HDL-C） were negatively correlated with 25（OH） D3. Multiple linear regression an- alyses demonstrated that serum albumin, systolic pressure, 24-h urine protein and hemoglobin were the independent risk factors of vitamin D deficiency in non-dialysis CKI） patients. Conelusions In the northeast of China, vitamin D deficiency in non-dialysis CKD patients was frequent and serious. The change in 25（OH） D3 concentration was correlated with the clinical parameters of CKD. Serum albu- min, systolic pressure, 24-h urine protein and hemoglobin were the independ.ent risk factors of vitamin D deficiency.