少肌症、维生素D缺乏在类风湿性关节炎合并脊柱骨质疏松性骨折中的临床研究

Clinical research of sarcopenia and vitamin D deficiency in patients with rheumatoid arthritis and spinal osteoporotic fractures

目的探讨少肌症和维生素D缺乏在RA患者脊柱骨质疏松性骨折(OPF)中的临床意义。方法入选936例RA患者和158例年龄、性别相匹配的正常健康者,所有入选对象均摄脊柱正侧位X线片(T5-L5),并以半定量(SQ)法作为判断脊柱OPF的标准,其中648例RA患者和对照组采用DXA法测定了腰椎和髋部骨密度(BMD),267例RA患者和156例对照组以生物电阻抗法测定了四肢骨骼肌质量,化学发光法测定了234例RA患者和68例对照组血清25(OH)D水平,同时详细记录RA患者各临床及实验室指标等情况。结果 1RA患者中(141/936,15.1%)OPF的发生率明显高于对照组(6/158,3.8%)(χ2=18.658,P<0.0001);少肌症的发生率明显高于对照组(55.8%,149/267 vs 9.0%,14/156,χ2=91.176,P<0.0001);RA组血清25(OH)D水平明显低于对照组[(13.41±9.71)ng/m L,(22.40±6.26)ng/m L,t=9.063,P<0.0001],维生素D缺乏发生率明显高于对照组[80.8%(189/234)vs 36.8%(25/68),χ2=49.412,P<0.0001]。2RA患者OPF组25(OH)D水平明显低于无OPF组[(12.28±5.67)ng/m L vs(17.16±10.90)ng/m L,t=2.600,P=0.01];各部位肌肉量均明显低于无OPF组(P<0.01~0.05)。3线性相关分析发现:RA患者的25(OH)D与骨骼肌、右上肢、左上肢和躯干肌肉量呈正直线相关关系(P<0.05);RA患者的骨骼肌质量与髋部、腰椎各部位BMD呈正直线相关关系(P<0.05)。4多元回归分析显示:女性、HAQ积分和总髖部OP的发生为RA患者发生少肌症的危险因素;年龄为RA患者发生脊柱OPF的危险因素,骨骼肌质量指数(SMI)为RA患者发生脊柱OPF的保护因素。结论 RA患者具有高于正常健康者脊柱OPF的发生率,其25(OH)D水平缺乏普遍存在,少肌症发生率增高;RA患者维生素D缺乏、少肌症与RA患者脊柱OPF的发生密切相关。

Objective To explore the effect of vitamin D deficiency and sarcopenia on osteoporotic fracture（OPF） in patients with rheumatoid arthritis（RA）.Methods Nine-hundred and thirty-six patients with RA and 158 normal subjects（as controls）were enrolled.Anteroposterior and lateral X-rays scanning of vertebral column（T5-L5） were conducted for every individual and semi-quantity method was used as the standard for determining vertebral OPF.Bone mineral density（BMD） of the hip and lumbar vertebrae 2-4 in 648 RA and all the controls was detected with DEXA.Skeletal muscle mass of 267 cases and 156 controls was measured with the method of biological electrical impedance.Serum levels of 25-hydroxy vitamin D（25（OH） D） were examined using electro-chemiluminescence in 234 RA patients and 68 normal subjects.Meanwhile,clinical and laboratory index of the patients were recorded in details.Results（1） The prevalence of vertebral OPF in RA patinets was 15.1%（141/936）,which was higher than that in control group（6/158,3.8%,χ~2= 18.658,P 〈0.0001）.The total prevalence of sarcopenia in RA patients determined by skeletal muscle mass in limbs was 55.8%（149/261）,it was apparently higher than that in control group（9.0%,14/156,χ~2=91.176,P〈0.0001）.Compared to those in control group,RA patients had lower serum 25（OH） D levels（22.40 ± 6.26 ng/mL vs.13.41 ±9.71 ng/mL,t=9.063,P〈0.0001） and higher incidence of vitamin D deficiency（36.8%,25/68 vs 80.8%,189/234,χ~2 =49.412,P〈0.0001）.（2） Compared to those with RA but without OPF,patients with OPF had lower serum 25（OH） D levels（17.16 ± 10.90 ng/mL vs.12.28 ±5.67 ng/mL,t=2.600,P=0.01） and lower skeletal muscle mass at each detected site（P 〈0.01-0.05）.（3） Linear correlation analysis showed that skeletal muscle mass was positively correlated with serum 25（OH）D levels and BMD at the femurs and lumbar vertebrae in RA（P 〈 0.05）.（4） Logistic regression analysis（LR Backward） showed that female gender,HAQ,and occurrence of OP at the femur were the risk factors for sarcopenia in RA patients.Age was the risk factor for OPF in RA patients,while SMI was the protective factor.Conclusion Patients with RA have high incidence of spinal OPF and sarcopenia,and low serum 25（OH） D levels.Vitamin D deficiency and carcopenia are closely correlated with spinal OPF in RA patients.