甲状旁腺激素和25羟维生素D对2型糖尿病患者并发骨质疏松症的影响

Effects of parathyroid hormone and 25-hydroxyvitamin D on osteoporosis in patients with type 2 diabetes mellitus

目的探讨甲状旁腺激素(PTH)和25羟维生素D(25OHD)对2型糖尿病患者并发骨质疏松症的影响。方法选择海南医学院第二附属医院内分泌科2014年6月至2016年6月收治的350例2型糖尿病患者,按照《中国骨质疏松性骨折诊疗指南》中的定义,将入组的患者分成骨量正常组,骨量减少组和骨质疏松症组,对三个组别患者的25OHD,PTH,Ⅰ型前胶原氨基端延长肽(PINP),β胶原特殊序列(β-CTX)和糖化血红蛋白(Hb A1c)等水平进行测定,并进行数据分析。结果三个组别患者的年龄,性别和体质量指数(BMI)三项指标数据结果差异无统计学意义(F=2.035,χ~2=0.157,F=1.985,P>0.05)。PTH对比中,骨量正常组[(33.62±9.85)ng·L^(-1)]<骨量减少组[(42.61±11.57)ng·L^(-1)]<骨质疏松症组[(58.64±12.27)ng·L^(-1)],三组差异有统计学意义(F=15.687,P=0.001);25OHD对比,骨量正常组[(22.48±7.95)μg·L^(-1)]>骨量减少组[(17.32±6.58)μg·L^(-1)]>骨质疏松症组[(13.57±5.24)μg·L^(-1)],三组差异有统计学意义(F=12.542,P=0.002)。在PTH比较方面,四个季节来医院就诊的DM患者的数据结果差异无统计学意义(F=1.368,P>0.05),在25OHD,四个季节来医院就诊的DM患者的数据结果差异有统计学意义(F=10.268,P<0.05),经过q检验,夏、秋季患者的25OHD水平明显高于冬季和春季患者(P<0.05)。通过对患者的性别,年龄,就诊季节,BMI和Hb A1c调整之后,PTH与PINP呈正相关(r=0.249,P=0.013),PTH与β-CTX呈正相关(r=0.378,P=0.022),25OHD与PTH呈负相关(r=-0.374,P=0.002),25OHD与PINP呈负相关(r=-0.142,P=0.011),25OHD与β-CTX呈负相关(r=-0.131,P=0.003),通过ROC曲线计算得出,PTH,25OHD,PINP和β-CTX对于骨质疏松症的诊断阈值依次分别为47.61 ng·L^(-1),15.24μg·L^(-1),37.54μg·L^(-1),382.64 pmol·L^(-1)。结论 PTH水平增高的患者更容易患骨量减少或骨质疏松症,25OHD的水平增高是骨量减少或骨质疏松症的保护因素,在不同的季节患者体内的25OHD水平不同,在缺乏日照季节,患者应注意25OHD的适当补充。

Objective To investigate the effeCTs of parathyroid hormone（ PTH） and 25-hydroxyvitamin D（ 25 OHD） on osteoporosis in patients with type 2 diabetes. Methods Three hundred and fifty cases of type 2 diabetes mellitus admitted to Department of Endocrinology,The Second Affiliated Hospital of Hainan Medical University from June 2014 to June 2016 were seleCTed. According to the definition in the Chinese guidelines for the diagnosis and treatment of osteoporotic fraCTures,the patients were assigned into normal bone mass group,osteopenia group and osteoporosis group. The levels of 25-hydroxyvitamin D,parathyroid hormone,parathyroid hormone,type I procollagen amino terminal lengthening peptide（ PINP）,beta collagen specific sequence（ beta-CTX） and glycated hemoglobin（ Hb Alc） were measured,and data analysis was carried out in three groups of patients. Results There were no significant differences in the age,gender,and BMI data between the three groups（ F = 2. 035,χ~2= 0. 157,F = 1. 985,P〉0. 05）. The level of parathyroid hormone（ PTH）,in the normal bone mass group,bone reduCTion group and osteoporosis group yield to[（ 33. 62 ± 9. 85） pg·mL^（-1）]〈[（ 42. 61 ± 11. 57） pg·mL^（-1）]〈 [（ 58. 64 ± 12. 27） pg·mL^（-1）],and the difference between the three groups was statistically significant（ F = 15. 687,P = 0. 001）. The level of 25-hydroxyvitamin D（ 25 OHD）,in the normal bone mass group,bone mass reduCTion group and osteoporosis group yield to [（ 22. 48 ± 7. 95） ng · mL^（-1）] 〉[（ 17. 32 ± 6. 58） ng·mL^（-1）]〉 [（ 13. 57 ± 5. 24） ng·mL^（-1）],and the difference between the three groups was statistically significant（ F = 12. 542,P = 0. 002）. Among the PTH indicators,there was no significant difference in the data of diabetes mellitus（ DM） patients who came to the hospital in the four seasons（ F =1. 368,P〉0. 05）. Among the 25 OHD indicators,the data of DM patients who came to the hospital in four seasons had statistically significant differences（ F = 10. 268,P〈0. 05）. After q test,the 25 OHD level of patients in summer and autumn was significantly higher than that in winter and spring（ P〈0. 05）. After adjusting for gender,age,visit season,BMI and Hb Alc,PTH was positively correlated with PINP and β-CTX（ r = 0. 249,P = 0. 013,r = 0. 378,P = 0. 022）. There was a negative correlation between 25 OHD and PTH（ r =-0. 374,P = 0. 002）,25 OHD was negatively correlated with PINP and β-CTX（ r =-0. 142,P = 0. 011,r =-0. 131,P = 0. 003）.According to the ROC curve,the diagnostic thresholds for PTH,25 OHD,PINP and β-CTX for osteoporosis were 47. 61 pg · mL^（-1）,15. 24 ng·mL^（-1）,37. 54 ng·mL^（-1） and 382. 64 pmol·L^（-1）,respeCTively. Conclusions Patients with elevated PTH levels are more likely to suffer from osteopenia or osteoporosis. Elevated levels of 25 OHD are proteCTive faCTors for osteopenia or osteoporosis,with varying levels of 25 OHD in different seasons. In the absence of sunshine during seasons,the patient should pay attention to the appropriate supplement of 25 OHD.