Clinical analysis on 50 chroic kidney disease patients complicated with secondary hyperparathyroidism

目的 探讨慢性肾脏病(CKD)合并继发性甲状旁腺功能亢进症(SHPT)患者血清甲状旁腺激素( PTH)、钙磷水平的变化及其治疗对策.方法 50例CKD合并SHPT患者随机分为治疗组(30例)和对照组(20例),对照组采用常规治疗,治疗组在对照组基础上加用骨化三醇、磷结合剂及低钙透析液治疗.检测两组血清PTH、血清碱性磷酸酶(ALP)、血清钙、磷浓度,计算钙磷乘积.结果 与对照组和治疗前相比,治疗组治疗期间的PTH、ALP水平和钙磷乘积下降(P＜0.05),治疗20周后心血管疾患、感染、肾性骨病、贫血等并发症减少(P＜0.05).结论 积极调整CKD患者钙磷代谢及血清PTH、ALP水平,对减少CKD患者并发症有重要意义.     

慢性肾脏病继发甲状旁腺功能亢进症50例临床分析

目的探讨慢性肾脏病(CKD)合并继发性甲状旁腺功能亢进症(SHPT)患者血清甲状旁腺激素(PTH)、钙磷水平的变化及其治疗对策。方法 50例CKD合并SHPT患者随机分为治疗组(30例)和对照组(20例),对照组采用常规治疗,治疗组在对照组基础上加用骨化三醇、磷结合剂及低钙透析液治疗。检测两组血清PTH、血清碱性磷酸酶(ALP)、血清钙、磷浓度,计算钙磷乘积。结果与对照组和治疗前相比,治疗组治疗期间的PTH、ALP水平和钙磷乘积下降(P<0.05),治疗20周后心血管疾患、感染、肾性骨病、贫血等并发症减少(P<0.05)。结论积极调整CKD患者钙磷代谢及血清PTH、ALP水平,对减少CKD患者并发症有重要意义。     

骨化三醇加钙剂治疗肾性骨营养不良

目的：探讨肾性骨营养不良（ＲＯＤ）的治疗方法。方法：对６８例（男性３９例,女性２９例,年龄５１ａ±ｓ６ａ）长期腹膜透析的慢性肾功能衰竭病人,采用单交叉设计,分别给予骨化三醇及骨化三醇加钙剂（葡萄糖酸钙）治疗,观察尺桡骨骨密度（ＢＭＤ）、血清钙、磷、甲状旁腺激素（ＰＴＨ）水平的变化,并对２种治疗方法的结果进行比较。结果：２种治疗均可显著增加ＢＭＤ,血清钙水平,降低血清磷及ＰＴＨ水平,但后一种治疗与前一种比较,疗效更为显著（Ｐ＜０．０１）。结论：钙剂加骨化三醇治疗ＲＯＤ优于单用骨化三醇。     

低钙透析联合骨化三醇冲击治疗继发性甲状旁腺功能亢进症的临床观察

目的探讨低钙透析骨化三醇冲击治疗慢性肾衰竭并发继发性甲状旁腺功能亢进症(SHPT)患者的临床疗效。方法将40例慢性肾衰竭并发SHPT患者随机分为联合组与对照组。对照组给予常规透析和骨化三醇冲击治疗,联合组给予低钙透析和骨化三醇冲击治疗。结果 (1)两组血甲状旁腺激素(PTH)水平在治疗第4、8、12周时均较治疗前显著降低(P<0.05),且组间同期比较,差异无统计学意义(P>0.05);(2)对照组血钙水平在治疗第4、8、12周时均较治疗前显著升高(P<0.05),且明显高于同期联合组(P<0.05),而联合组在治疗第4、8、12周与治疗前比较,差异无统计学意义(P>0.05);(3)两组血磷水平在治疗第4、8、12周时均较治疗前显著降低(P<0.05),且组间同期比较,差异无统计学意义(P>0.05)。结论低钙透析联合骨化三醇冲击治疗慢性肾衰竭并发SHPT,有效降低了PTH水平,而且也能有效纠正钙、磷紊乱,使之维持正常的平衡,值得临床推广应用。     

骨化三醇治疗肾性骨病疗效观察

目的 观察骨化三醇治疗肾性骨病的疗效.方法 对62例肾性骨病患者除治疗基础疾病、透析(血液或腹膜透析)、补充钙剂外,同时口服骨化三醇0.25 μg/d,根据血清钙、磷监测结果随时调整剂量,持续治疗2年.治疗前后应用全自动生化分析仪检测血清总钙、血磷、碱性磷酸酶(ALP)、尿素氮、肌酐;双能x线吸收测定法检测骨密度.结果 治疗后患者血清钙高于治疗前,血清磷、血尿素氮、血肌酐、碱性磷酸酶均低于治疗前,P<0.05具有统计学意义.结论 在肾性骨病患者中应用骨化三醇治疗,可显著减轻患者的骨病症状,对尿素氮、肌酐无不利影响,且其不良反应少.     

骨化三醇冲击治疗方案对中、重度继发性甲状旁腺功能亢进疗效观察

目的:观察维持性血液透析中、重度继发性甲状旁腺功能亢进(SHPT)患者对骨化三醇冲击治疗方案的疗效及安全性。方法:36例规律血液透析的患者按血清甲状旁腺激素(iPTH)水平分为中度iPTH升高组(iPTH600～1000pg/ml)和重度iPTH升高组(iPTH>1000pg/ml)两组,血清钙磷乘积均<4.04mol2/l2,均无高钙、高磷血症。两组均采用口服冲击治疗方案,每周口服两次,透析后服用,每月检测1次甲状旁腺激素,同时记录血钙、血磷、钙磷乘积、血iPTH的变化。结果两组治疗第4周、8周、12周iPTH均有明显下降(P<0.05),治疗前后有显著差异。结论:骨化三醇冲击疗法对iPTH中、重度升高患者治疗安全有效。     

西那卡塞联合骨化三醇对维持性血液透析继发甲状旁腺功能亢进骨及钙磷代谢的影响

目的:观察西那卡塞联合骨化三醇对维持性血液透析患者继发甲状旁腺功能亢进(SHPT)骨及钙磷代谢的影响.方法:选取2019-1 ～12于我院维持性血液透析合并SHPT的患者40例,随机分成两组,其中观察组20例,对照组20例.对照组患者根据《活性维生素D在慢性肾脏病继发性甲旁亢中合理应用的专家共识(修订版)》,给予骨化三醇冲击治疗;观察组根据指南在骨化三醇的基础上联合西那卡塞.观察所有患者治疗前及治疗后3个月血钙(Ca)、血磷(P)、甲状旁腺激素(iPTH)、骨特异性碱性磷酸酶(BALP).结果:经过治疗后,观察组的总有效率明显优于对照组的总有效率(P＜0.05);治疗前对两组患者血清Ca、P、iPTH及BALP水平进行比较,无统计学差异(P＞0.05);两组患者治疗后iPTH、BALP的血清水平均降低(P＜0.05);观察组较对照组P、iPTH、BALP水平下降更为明显(P＜0.05).结论:与骨化三醇相比,使用西那卡塞和骨化三醇可显著降低血清钙、磷、甲状旁腺激素和骨特异性碱性磷酸酶的水平,可以有效改善患者的矿物质及骨代谢异常,同时不良反应少,安全性好.     

低钙透析在维持血液透析患者继发性甲旁亢治疗的应用

目的 探讨低钙透析在维持性血液透析患者继发性甲状旁腺功能亢进行骨化三醇冲击治疗中的临床应用,方法采用浓度1.25mmol/L低钙透析液,观察32例维持性血液透析继发甲旁亢患者在骨化三醇冲击治疗中血清钙、磷、钙磷乘积、血清全段甲状旁腺素(iPTH)等指标变化.结果 所有患者治疗期间的血钙与治疗前比较差异无统计学意义(P>0.05),血磷、钙磷乘积、iPTH水平均较治疗前降低(P<0.05).结论 维持性血液透析患者继发甲状旁腺功能亢进在骨化三醇冲击治疗中同时应用低钙透析是安全有效的.避免了高钙血症,降低了骨外软组织钙化的风险.     

胆骨化醇与钙三醇治疗肾衰继发甲状旁腺机能亢进的对比研究

目的 比较胆骨化醇与钙三醇治疗肾衰长期透析患者继发性甲状旁腺机能亢进的疗效.方法随机分为胆骨化醇组31例,肌注胆骨化醇60万U,每周1次,血钙正常后改为每2周1次;钙三醇组33例,口服钙三醇 0.25 μg·d-1.两组分别于用药前及用药后2、4、8 wk 采用高效液相层析仪检测患者血1,25(OH)2D3浓度,用放射免疫法检测患者血清免疫甲状旁腺激素(iPTH)浓度,以及血钙、血磷、血碱性磷酸酶(ALP)等.结果1,25(OH)2D3浓度胆骨化醇组用药2 wk时升高,但未达正常水平,钙三醇组达正常水平(P＜0.05);治疗4 wk时两组均达正常水平.血钙、磷、ALP浓度的变化两组无明显差异.结论胆骨化醇组未出现高钙血症及钙磷乘积升高,以其用药次数少、价格低廉、安全有效而优于钙三醇.     

骨化三醇对腹透患者钙磷代谢及T淋巴细胞亚群的影响

目的 :了解骨化三醇 (1 ,2 5 (OH) 2 D3 ,罗钙全 )对腹膜透析患者钙磷代谢及免疫功能的影晌。方法 :观察 3 7例腹膜透析 (PD)患者服用骨化三醇前后血清T细胞亚群、IL 8以及血免疫反应甲状旁腺激素 (iPTH)、钙、磷水平变化。结果 :用药前PD组血清T淋巴亚群的CD4/CD8低于正常对照组 (P<0 .0 5 ) ,服用骨化三醇 4wk后 ,CD4/CD8从 0 .5 6±0 .1 0升至 0 .79± 0 .1 2 ;而iPTH显著降低 ,血钙显著升高 ,血磷明显下降。结论 :骨化三醇能改善PD患者钙磷代谢 ,进而改善其免疫功能     

Pathogenesis and treatment of secondary hyperparathyroidism in dialysis patients: the role of paricalcitol

Hemodialysis (HD) patients are commonly affected by secondary hyperparathyroidism (SHPT), in which 3 well-known factors are usually involved: hypocalcemia, hyperphosphatemia and calcitriol deficiency. Classically, high parathyroid hormone (PTH) levels cause bone-associated diseases, such as osteitis fibrosa and renal osteodystrophy, but more recently it has been demonstrated the link between SHPT and a systemic toxicity, with a major role in determining cardio-vascular disease, including arterial calcification, endocrine disturbances, compromised immune system, neurobehavioral changes, and altered erythropoiesis. Treatment with calcitriol (CT), the active form of vitamin D, reduces parathyroid hormone (PTH) levels, but may result in elevations in serum calcium (Ca) and phosphorus (P), increasing the risk of cardio-vascular calcification in the HD population. Several new vitamin D analogs have been developed and investigated with the rationale to treat SHPT with a reduced risk of hypercalcemia and hyperphosphatemia in HD patients. Paricalcitol (1,25-dihydroxy-19-nor-vitamin D(2), 19-Nor-D(2)) is a vitamin D analog that suppresses PTH secretion with minimal increases on serum calcium and phosphate levels. It was demonstrated that paricalcitol prevents vascular calcification in experimental models of renal failure, compared with calcitriol. Furthermore, 19-Nor-D(2) is the first analog approved for use in HD patients and is available for i.v. and oral administration, commonly 3 times weekly after HD. The purpose of the present review is to analyze the pathogenesis and treatment of SHPT in HD patients, and the role of paricalcitol in the prevention of arterial calcification.     

西那卡塞联合小剂量骨化三醇治疗终末期肾脏病继发性甲状旁腺功能亢进的疗效分析

目的 探讨西那卡塞联合小剂量骨化三醇与骨化三醇冲击疗法对终末期肾脏病继发性甲状旁腺功能亢进(甲旁亢)患者的疗效及安全性.方法 重庆市大足区人民医院2013年1月至2016年5月确诊为终末期肾脏病继发性甲旁亢患者150例,区组随机化分组将患者平均分为3组,每组50例,分别采用西那卡塞治疗、骨化三醇冲击治疗、西那卡塞联合小剂量骨化三醇治疗.其中,西那卡塞联合小剂量骨化三醇组采用盐酸西那卡塞片口服,初始25 mg·d-1,整片吞服;随后每2~4周根据患者耐受情况调整1次剂量,最大剂量75 mg·d-1;同时,口服骨化三醇胶丸,初始0.25μg·d-1,每2~4周调整1次剂量,最大剂量0.5μg·d-1.检测三组患者治疗前及治疗后6个月血钙、血磷含量水平,并对全段甲状旁腺激素(iPTH)进行检测.结果 骨化三醇冲击治疗组治疗后6个月血钙、血磷与治疗前比较明显升高[血钙(2.12±0.62)mmol·L-1比(2.47±0.59)mmol·L-1,t=2.827,P=0.007;血磷[(1.72±0.42)mmol·L-1比(1.95±0.56)mmol·L-1,t=2.366,P=0.022],而iPTH明显下降[iPTH 560.58(334.2~728.47)pg·mL-1比331.23(213.95~424.62)pg·mL-1,Z=4.387,P<0.001];西那卡塞治疗组与西那卡塞联合小剂量骨化三醇治疗组血清磷水平、iPTH与治疗前比较明显下降(P<0.05)[血磷西那卡塞治疗组(1.46±0.72)mmol·L-1比(1.73±0.58)mmol·L-1,t=2.034,P=0.047,血磷西那卡塞联合小剂量骨化三醇治疗组(1.44±0.63)mmol·L-1比(1.76±0.39)mmol·L-1,t=3.014,P=0.004,iPTH西那卡塞治疗组277.02(180.34~344.56)pg·mL-1比544.11(386.8~749.42)pg·mL-1,Z=5.237,P<0.001,iPTH西那卡塞联合小剂量骨化三醇治疗组194.85(132.04~295.64)pg·mL-1比575.49(438.04~665.65)pg·mL-1,Z=6.144,P<0.001],且西那卡塞联合小剂量骨化三醇治疗组血钙水平未见明显影响(P>0.05),而单纯西那卡塞治疗组的血钙水平较治疗前明显下降(P<0.05).结论 西那卡塞联合小剂量骨化三醇治疗终末期肾病继发性甲旁亢患者可降低血磷水平,还可以降低iPTH,但不影响血钙,不容易出现低钙血症,降低骨饥饿综合征的发生.     

Emerging drugs for secondary hyperparathyroidism

Introduction: Secondary hyperparathyroidism (SHPT), a common, serious, and progressive complication of chronic kidney disease (CKD), is characterized by elevated serum parathyroid hormone (PTH), parathyroid gland hyperplasia, and mineral metabolism abnormalities. These disturbances may result in CKD–mineral and bone disorder (CKD-MBD), which is associated with poor quality of life and short life expectancy.

Areas covered: The goal of SHPT treatment is to maintain PTH, calcium, and phosphorus within accepted targeted ranges. This review highlights the pathogenesis of SHPT and current SHPT therapeutic approaches, including the use of low-phosphate diets, phosphate binders, 1,25-dihydroxyvitamin D₃ (calcitriol) and its analogs, calcimimetics, and parathyroidectomy in addition to discussing emerging drugs in development for SHPT.

Expert opinion: Numerous studies indicate that mineral abnormalities occur early in the course of CKD, are prevalent by the time patients enter dialysis, and foreshadow a risk of cardiovascular and all-cause mortality. Several newly developed compounds may potentially overcome the limitations of current SHPT therapies. If emerging therapies can reduce PTH, normalize mineral metabolism, promote treatment adherence, and reduce the risk of side effects, they may provide the requisite features for improving long-term outcomes in patients with SHPT receiving dialysis and reduce the risks of CKD-MBD.     

Outcomes of secondary hyperparathyroidism in chronic kidney disease and the direct costs of treatment

BACKGROUND: There has been an emphasis over the last several years to identify and treat chronic kidney disease (CKD) and its complications as they evolve rather than waiting until the patient reaches end-stage renal disease (ESRD), also known as CKD stage 5. The number of patients who will be identified and prescribed therapies for complications such as secondary hyperparathyroidism (SHPT) is greater than initially proposed. OBJECTIVE: To review the pathways, complications, management, and estimated treatment costs of CKD-related SHPT. METHODS: An electronic literature search of MEDLINE (January 1980 through January 2007) was conducted for English-language publications using the base search term secondary hyperparathyroidism. To refine subsequent searches, the authors added Boolean operators to the following secondary and tertiary search terms: parathyroid hormone, chronic kidney disease, renal osteodystrophy, adynamic bone disease, vascular calcification, cardiovascular disease, vitamin D, vitamin D analogs, hypercalcemia, hyperphosphatemia, calcimimetics, costs, prevalence, and economics. RESULTS: The initial MEDLINE search produced 278 relevant articles. After refining the search terms, the authors triaged the results for English-language publications relevant to the discussion of SHPT and its complications in CKD, eliminating 149 publications. The remaining 129 publications were accepted for review. These articles represent a growing body of primarily observational evidence that demonstrates that elevated intact parathyroid hormone (PTH) levels cause deleterious physiological results across a variety of organ systems, including the cardiovascular and skeletal systems. Specific complications associated with SHPT are left ventricular hypertrophy (LVH), renal osteodystrophy (ROD), and extraskeletal calcification. Medical management of the PTH/vitamin D/calcium and phosphorus imbalances in SHPT focus on regulating PTH levels via vitamin D therapy. The class of calcimimetics is a newer treatment modality that has favorable effects on biochemical laboratory values, such as serum calcium and phosphorus levels, but current data do not show differences on hard endpoint patient-oriented outcomes compared with standard generic agents. The direct drug costs in April 2007 U.S. dollars of treating CKD-associated elevations in PTH in predialysis patients range from $8.40 per patient per week ($437 per year) for oral generic calcitriol to $88.90 per patient per week ($4,623 per year) for oral paricalcitol (expressed as 85% of average wholesale price [AWP] for brand drugs or 70% of AWP for generic drugs). The direct drug costs of treating SHPT in hemodialysis patients range from $80.20 per patient per week ($4,170 per year) for generic calcitriol (IV) to $278.46 per patient per week ($14,480 per year) for oral cinacalcet. CONCLUSIONS: SHPT causes skeletal and cardiovascular complications in CKD patients. Calcitriol therapy is effective in managing PTH levels, but efforts to reduce the associated hypercalcemia and hyperphosphatemia have led to the development of newer, yet more expensive, vitamin D analogs. With the lack of evidence to support comparative superior outcomes in end-organ disease among SHPT therapy alternatives, future research is still needed to clearly identify which newer agents are most competitive with the historical gold standard of calcitriol therapy.     

长期血透患者甲状旁腺素测定的临床意义

目的　探讨检测长期血透患者甲状旁腺素对继发性甲状旁腺功能亢进的早期诊断、预防和治疗的临床意义。方法　选择 84例长期血液透析患者 ,分为服钙剂组与不服钙剂组 ,另选择 30例非肾功能减退患者为正常对照组 ,分别检测患者血清甲状旁腺素、钙、磷、尿素氮、肌酐等。结果　服钙剂组患者血清甲状旁腺素、磷明显低于不服钙剂组 ,两者之间有显著性差异 (P<0 .0 5) ;而两组患者间的血清钙没有显著性差异 (P>0 .0 5) ;长期血透患者的血清甲状旁腺素明显大于正常对照组 ,与尿素氮、肌酐和磷呈正相关。结论　甲状旁腺素检测对长期血透患者继发甲状旁腺功能亢进的早期诊断、预防和治疗有重要指导意义 ;服用钙剂能预防和治疗继发性甲状旁腺功能亢进 ,减少继发性甲状旁腺功能亢进的发生率     

尿毒症继发性甲状旁腺功能亢进症患者应用甲状旁腺全切除加自体移植术5年随访资料分析

目的:观察慢性肾脏病(5D期)患者因继发性甲状旁腺功能亢进症(SHPT)行甲状旁腺全切除加自体移植术(TPTX+AT)的远期临床疗效。方法:回顾性分析2011年3月—2014年12月慢性肾脏病(5D期)患者因继发性甲状旁腺功能亢进症行TPTX+AT的41例患者的临床资料(随访至2019年12月),收集患者术前、术后全段甲状旁腺激素及血清钙、磷、碱性磷酸酶等变化情况,临床症状改善情况,复发和死亡情况,判断临床疗效。结果:共41例患者,年龄(47.0±9.0)岁,透析(76.0±38.9)个月。患者术后1周、1个月、6个月各时间点血全段甲状旁腺素(iPTH)、血清磷、血清钙均较术前显著下降(P<0.001)。术后早期甲状旁腺功能亢进持续状态2例,术后第1年复发5例,其中3例共行5次移植物切除手术。随访期满共有27例存活,血清钙(2.17±0.26)mmol/L,血清磷(2.16±0.47)mmol/L,iPTH达标率70.4%(19/27)。结论:甲状旁腺全切除加自体移植术,能安全、有效治疗尿毒症难治性SHPT,可以改善SHPT患者远期预后。     

尿毒症透析患者不同剂量钙三醇治疗继发性甲状旁腺功能亢进的疗效观察

目的 比较常规剂量钙三醇与较大剂量冲击疗法防治尿毒症维持性透析患者继发性甲状旁腺功能亢进(SHPT)的疗效.方法 48例尿毒症透析患者,分常规治疗组(A组)22例,钙三醇0.25～0.5 μg/d,同时补钙,治疗时间6个月;未治疗组(B组)21例,皆因经费困难不愿意治疗;冲击治疗组(C组)21例(其中16例来自A组),钙三醇每周4μg,分2次于血液透析后口服,观察3个月.结果 A组与B组比较,血清甲状旁腺激素(PTH)、碱性磷酸酶(AKP)差异无统计学意义(P>0.05),但A组中,低血钙、高血磷得到部分纠正(P>0.05),骨痛、肌肉抽搐、无力、皮肤瘙痒等症状均有改善.结论 较大剂量间歇冲击治疗能有效治疗尿毒症血液透析患者SHPT.     

甲状旁腺全切除加上臂移植术治疗尿毒症继发性甲状旁腺功能亢进

目的 研究尿毒症患者因继发性甲状旁腺功能亢进（SHPT）行甲状旁腺全切除加自体上臂移植术（TPTX＋AT）的临床疗效.方法 回顾分析我院30例因慢性肾脏病长期接受规律性透析的患者发生难治性SPTH,予行甲状旁腺全切除加自体上臂移植术,比较患者术前、术后全段甲状旁腺激素（iPTH）、血清钙、磷及碱性磷酸酶（ALP）、血红蛋白（Hb）的变化情况、临床症状改善情况,从而判断疗效.结果 30例患者中,无一例死亡;2例患者发生喉返神经损伤,发生率为6.67％.术后低钙发生率高（79.5％,25/30）,均经积极静脉补钙后有效控制.患者术后各时间点（1天、1周、1、3、6个月）血iPTH、血清磷、血清钙均较术前显著下降（P＜0.01）.术后3、6个月血清ALP较术前显著下降（P＜0.01）,而Hb较术前明显升高（P＜0.05）.术后患者骨痛、皮肤瘙痒、肌无力、失眠、不宁腿、贫血等得到明显改善,全身营养状态好转.结论 甲状旁腺全切除加自体上臂移植术能安全、有效治疗尿毒症难治性SHPT.     

阿法骨化醇胶丸联合碳酸钙片治疗慢性肾衰继发甲状旁腺功能亢进的疗效观察

目的:观察阿法骨化醇胶丸联合碳酸钙片治疗慢性肾衰继发甲状旁腺功能亢进(SHPT)的疗效。方法:将55例慢性肾衰继发SHPT患者分为透析组(28例)和非透析组(27例),均在服用阿法骨化醇胶丸的同时加用碳酸钙片,连用3mo。观察治疗前、后血钙(Ca2+)、磷(P3-)、甲状旁腺激素(PTH)、碱性磷酸酶(AKP)、肌酐(Cr)的变化。结果:2组治疗后血Ca2+均明显升高(P<0.05),血PTH均明显下降(P<0.01)。结论:阿法骨化醇胶丸联合碳酸钙片治疗慢性肾衰继发SHPT早期患者安全、有效、经济。