肾病综合征患儿钙磷代谢、骨密度变化及1,25-二羟维生素D_3的干预作用

Changes of calcium and phosphorus metabolism, bone mineral density and intervention effect of 1,25-(OH)_2-vitamin D_3 in children with nephrotic syndrome

目的观察肾病综合征患儿钙磷代谢、骨密度变化及1,25-二羟维生素D_3的干预作用。方法选取2013年1月至2016年12月海南省人民医院儿科收治住院的首次发病肾病综合征患儿62例作为观察组,采用随机数表法分为活性维生素D+钙剂组(n=20)、活性维生素D组(n=20)和维生素D+钙剂组(n=22),疗程7~9个月。选取正常健康儿童20例为对照组。检测各组患儿治疗前、治疗后2个月、6个月及停激素后2个月的血清钙、磷、骨碱性磷酸酶、25-羟维生素D_3水平和骨密度Z值,并分别与对照组进行比较。结果观察组患者的血钙、25-羟维生素D_3较对照组明显降低,血磷、骨碱性磷酸酶较对照组升高,差异均有统计学意义(P<0.05);治疗后2个月、6个月及停激素后2个月血钙、25-羟维生素D_3较治疗前增高,差异均有统计学意义(P<0.05);观察组患者的骨密度Z值在治疗后6个月达最低值,与治疗前、治疗后2个月比较差异均有统计学意义(P<0.05),而治疗前与停激素后2个月的骨密度Z值比较差异无统计学意义(P>0.05);治疗组各组间治疗前的血清钙、磷、25-羟维生素D_3、骨碱性磷酸酶、骨密度Z值比较差异均无统计学意义(P>0.05);治疗后2个月及停药后2个月,活性维生素D+钙剂组患者的血25-羟维生素D_3水平明显高于其他两组,差异均有统计学意义(P<0.05);治疗后6个月,维生素D+钙剂组患者的骨密度Z值明显低于其他两组,差异均有统计学意义(P<0.05);停激素后2个月,血清钙磷、骨碱性磷酸酶、骨密度各组间比较差异均无统计学意义(P>0.05)。结论肾病综合征患儿存在钙磷代谢紊乱,在糖皮质激素治疗过程中骨密度Z值降低,通过给予维生素D、1,25-二羟维生素D_3及钙剂治疗均可以改善钙磷代谢紊乱及骨密度。对比三种治疗方案,活性维生素D+钙剂组能明显提高25羟维生素D水平。

Objective To observe the changes of calcium and phosphorus metabolism, bone mineral density （BMD） and intervention effect of 1, 25-（OH）2-Vit D3 in children with nephrotic syndrome （NS）. Methods Sixty-two children with first-onset nephrotic syndrome who admitted to Department of Pediatrics from January 2013 to December 2016 were selected as observation group, which were divided into three groups： active vitamin D＋ calcium group （n= 20）, active vitamin D group （n=20） and vitamin D＋calcium group （n=22）, with the course of treatment for 7-9 months. Twenty cases of normal healthy children were selected as the control group. The serum calcium, phosphorus, bone alka- line phosphatase, 25-hydroxyvitamin D3 levels and Z values of BMD were detected in each group at 4 different time points （the initiation of corticosteroids treatment, 2 months, 6 months after the initiation of treatment and 2 months after corticosteroids withdrawal）, and compared with those in the control group separately. Results The levels of serum cal- cium and 25-hydroxyvitamin D3 in the observation group were significantly lower than those in the control group, while the levels of serum phosphorus and bone alkaline phosphatase were higher than those in the control group （P〈0.05）. Se- rum calcium and 25-hydroxyvitamin D3 2 months and 6 months after treatment and 2 months after corticosteroid with- drawal were higher than those before the treatment, and the differences were statistically significant （P〈0.05）. The Z val- ue of BMD in observation group 6 months after treatment reached the lowest point, which were significantly lower than those before treatment and 2 months after treatment （P〈0.05）; However, Z value of BMD before treatment compared with 2 months after corticosteroids withdrawal showed no statistically significant difference （P〉0.05）. There were no sta- tistically significant difference in serum calcium, phosphorus, 25-hydroxyvitamin D3, bone alkaline phosphatase, and Z value of bone mineral density before treatment between each treatment group （P〉0.05）. The level of 25-hydroxyvitamin D3 in the active vitamin D＋calcium group 2 months after treatment and 2 months after corticosteroids withdrawal was higher than that in the other two treatment groups, and the differences were statistically significant （/9〈0.05）. Z value of BMD 6 months after treatment in Vitamin D＋calcium group was lower than that in the other two treatment groups, and the differences were statistically significant （P〈0.05）. There was no significant difference in serum calcium, phosphorus, bone alkaline phosphatase and bone mineral density between each group after 2 months of corticosteroids withdrawal （P〉0.05）. Conclusion Children with nephrotic syndrome had calcium and phosphorus metabolism disorder, and Z val- ue of the bone mineral density will decrease during glucocorticoid therapy, which could be improved by the treatment with vitamin D, 1,25-dihydroxyvitamin D3 and calcium. Among the three treatment options, active vitamin D＋calcium could significantly increase the 25-hydroxy vitamin D levels.