慢性肾脏病3～5期患者维生素D治疗前后FGF-23水平变化及临床意义

Changes and clinical significances of FGF-23 levels in patients with chronic kidney disease stage 3～5 before and after vitamin D treatment

目的探讨慢性肾脏病(CKD)3~5期非透析患者维生素D治疗前后血清成纤维细胞生长因子23(FGF-23)、25羟维生素D[25(OH)D]、甲状旁腺素(PTH)等相关指标水平变化及临床意义。方法选取2015年7月至2017年5月在连云港市东方医院肾内科住院病情稳定的非透析CKD3~5期[按照肾小球滤过率(GFR)分期]患者66例,平均年龄53.4岁(22~76岁)。所有患者给予临床常规骨化三醇治疗,治疗剂量参照改善全球肾脏病预后组织(KDIGO)治疗标准,检测治疗前和治疗30、60、90 d时血清中25(OH)D,FGF-23,PTH,钙(Ca),磷(P)等水平。结果CKD3~5期患者服用骨化三醇治疗后,血清FGF-23、25(OH)D、Ca水平明显升高,治疗30、60、90 d时与治疗前比较,差异有统计学意义(P<0.05);治疗60、90 d时与治疗30 d时比较,差异有统计学意义(P<0.05);治疗90 d时与治疗60 d时比较,CKD5期患者25(OH)D水平和CKD3~5期患者Ca水平均明显升高,差异有统计学意义(P<0.05),而CKD3~5期患者FGF-23水平,CKD3~4期患者25(OH)D水平无明显变化。血清PTH、P水平明显降低,治疗30、60、90 d时与治疗前比较,差异有统计学意义(P<0.05);治疗60、90 d时与治疗30 d时比较,差异有统计学意义(P<0.05);治疗90 d时与治疗60 d时比较,CKD3~4期患者PTH和CKD3~5期患者P水平均明显降低,差异有统计学意义(P<0.05),而CKD5期患者PTH水平无明显变化。CKD3~5期患者治疗前后影响血清FGF-23水平的相关因素分析,logFGF-23与P、logPTH呈显著正相关(r=0.725,P<0.05;r=0.815,P<0.05),与GFR呈负相关(r=-0.765,P<0.05),与Ca无明显相关性。结论CKD3~5期患者骨化三醇治疗可以补充体内维生素D,刺激血清FGF-23水平升高,有助于降低CKD3~5期患者血清PTH、P水平,升高Ca水平,减轻甲状旁腺功能亢进,纠正Ca、P矿物质代谢紊乱,降低CKD3~5期患者并发症的发生率,减缓CKD的进程。

Objective To investigate the changes and clinical significance of serum fibroblast growth factor 23(FGF-23),25-hydroxyvitamin D[25(OH)D],parathyroid hormone(PTH)in patients with chronic kidney disease(CKD)stage 3-5 before and after vitamin D treatment.Methods From July 2015 to May 2017,66 patients[mean age 53.4 years old(22-76 years old)]with stable non-dialysis CKD3-5 stage[according to glomerular filtration rate(GFR)staging]were enrolled in the department of nephrology,Lianyungang Oriental Hospital.All patients were given routine clinical treatment with calcitriol.Serum levels of 25(OH)D,FGF-23,PTH,calcium(Ca)and phosphorus(P)were measured before treatment and 30,60 and 90 d after treatment according to the treatment standard of Kidney Disease Improving Global Outcomes(KDIGO).Results Serum levels of FGF-23,25(OH)D and Ca were significantly increased in CKD3-5 patients after treatment with calcitriol.There was significant difference between 30,60 and 90 d after treatment and before treatment(P<0.05);there was significant difference between 60,90 d after treatment and 30 d after treatment(P<0.05).The levels of 25(OH)D and Ca in CKD5 patients were significantly higher than those in CKD3-5 patients(P<0.05),but the levels of FGF-23 in CKD3-5 patients and 25(OH)D in CKD3-4 patients had no significant changes.The levels of PTH and P in serum were significantly lower than those before treatment(P<0.05).The levels of PTH and P in patients with CKD3-4 and CKD3-5 were significantly lower than those before treatment(P<0.05);the levels of P in patients with CKD3-4 and CKD3-5 were significantly lower than those before treatment(P<0.05);the levels of P in patients with CKD3-4 and CKD3-5 were significantly lower than those after 90 d of treatment(P<0.05),but there was no significant change in PTH level in CKD5 patients.The correlation factors of serum FGF-23 level in CKD3-5 patients before and after treatment were analyzed.Log FGF-23 was positively correlated with P and logPTH(r=0.725,P<0.05;r=0.815,P<0.05),negatively correlated with GFR(r=-0.765,P<0.05),but not with Ca.Conclusion Calcitriol therapy can supplement vitamin D and stimulate the increase of serum FGF-23 in patients with CKD3-5.It can help to reduce the levels of PTH and P in patients with CKD3-5,increase the level of Ca,alleviate hyperparathyroidism,correct the metabolic disorder of Ca and P minerals,reduce the incidence of complications in patients with CKD3-5,and slow the progression of CKD.