肌少症维生素D缺乏在类风湿关节炎合并糖皮质激素诱发骨质疏松中的临床研究

目的:探讨肌少症和维生素D缺乏在RA患者合并糖皮质激素诱发骨质疏松(GIOP)患者中的临床意义。方法:选2017年1月至2018年12月我院311例RA患者和158名正常健康者,并详细记录RA患者临床、实验室指标及糖皮质激素(GC)使用情况。以生物电阻抗法测四肢骨骼肌质量,化学发光法测血清25羟维生素D水平,双能X线骨密度吸收仪测腰椎和髋部骨密度(BMD)。采用χ^2检验、非参数检验、多元Logistic回归进行统计分析。结果:①RA患者OP发生率33.4%(104/311)高于对照组12.7%(20/158)(χ^2=23.267,P<0.01);311例RA患者GC使用率为56.6%(176/311),其中GIOP发生率40.9%(72/176)。RA患者中肌少症发生率61.7%(192/311)高于对照组9.0%(14/156)(χ^2=117.310,P<0.01)。RA患者维生素D缺乏发生率为81.7%(254/311)高于对照组38.0%(60/158)(χ^2=90.415,P<0.01)。②在不考虑是否使用GC的情况下,无肌少症RA患者OP发生率17.6%(21/119)低于肌少症患者OP发生率43.2%(83/192)(χ^2=21.601,P<0.01)。在未服用GC的RA中,无肌少症患者OP发生率9.8%(6/61)低于肌少症患者OP发生率35.1%(26/74)(χ^2=11.834,P<0.01);在使用GC的RA中,无肌少症RA患者OP发生率25.9%(15/58)低于肌少症患者OP发生率48.3%(57/118)(χ^2=8.103,P<0.01)。③不考虑是否存在维生素D缺乏情况下,未服用GC患者OP发生率23.7%(32/135)低于服用GC患者GIOP发生率40.9%(72/176)(χ^2=10.161,P<0.01)。在维生素D不缺乏RA中,未服用GC患者OP发生率21.4%(6/28)与服用GC患者GIOP发生率31.0%(9/29)差异无统计学意义(χ^2=0.678,P>0.05);在维生素D缺乏的RA中,未服用GC患者OP发生率24.3%(24/107)低于服用GC患者GIOP发生率42.9%(63/147)(χ^2=9.3702,P<0.01)。④在服用GC的RA中,与不发生GIOP组比,发生GIOP组患者的年龄(t=5.313,P<0.01)和Sharp评分(Z=2.999,P<0.01)更高、病程(Z=2.141,P<0.05)和GC使用时间(Z=2.460,P<0.05)更长,而ESR(Z=2.262,P<0.05)、CRP(Z=2.551,P<0.05)和BMI(t=2.425,P<0.05)更低,X线分期构成比更差(χ^2=12.484,P<0.01)。⑤多元Logistic回归显示:女性[OR(95%CI)=14.240(3.878,52.288),P<0.01]、年龄[OR(95%CI)=1.079(1.042,1.118),P<0.01]、肌少症[OR(95%CI)=1.079(1.192,5.120),P<0.05]是RA患者发生GIOP的危险因素。结论:RA患者服用GC比例约60%,GIOP发生率高达40.9%,与肌少症和维生素D缺乏密切相关。

Clinical study of sarcopenia and vitamin D deficiency in patients with rheumatoid arthritis and gluco-corticosteroid induced osteoporosis

Objective To explore the clinical value of sarcopenia and vitamin D deficiency on gluco-corticoid induced osteoporosis(GIOP)in patients with rheumatoid arthritis(RA).Methods Three hundred and eleven patients with RA from January 2017 to December 2018 were enrolled in the study.One hundred and fifty-eight sex,age-matched normal subjects were recruited as control group.Clinical and laboratory features,daily dosage and treatment duration of glucocorticoid(GC)were recorded in detail.Skeletal muscle mass was measured by biological electrical impedance.Serum levels of 25-hydroxy vitamin D[25(OH)D]were examined using electro-chemiluminescence.Bone mineral density(BMD)at total hip and lumbar vertebra were detected by dual energy X-ray absorptiometry(DEXA).Numerical data and categorical data comparisons were analyzed usingχ^2 test,non-parametric test,Logistic regression analysis test.Results①The prevalence of osteoporosis(OP)in RA patients was 33.4%(104/311),which was higher than that in the control group 12.7%(20/158)(χ^2=23.267,P<0.01).Percentage of GC taking in 311 RA patients was 56.6%(176/311),and the prevalence of GIOP was 40.9%(72/176).The prevalence of sarcopenia in RA patients was 61.7%(192/311),which was higher than that in the control group[9.0%(14/156),χ^2=117.310,P<0.01].The prevalence of vitamin D deficiency in RA patients was 81.7%(254/311),which was higher than that in control group[38.0%(60/158),χ^2=90.415,P<0.01].②The prevalence of OP in RA without sarcopenia was 17.6%(21/119),which was lower than that in patients with sarcopenia[43.2%(83/192),χ^2=21.601,P<0.01].In condition without GC,the prevalence of OP in RA without sarcopenia was 9.8%(6/61),which was significantly lower than that in patients with sarcopenia[35.1%(26/74),χ^2=11.834,P<0.01].Under circumstances with GC,the prevalence of OP in RA without sarcopenia(25.9%,15/58),which was significantly lower than that in patients with sarcopenia(48.3%,57/118,χ^2=8.103,P<0.01).③No matter whether existing vitamin D deficiency or not,the prevalence of OP in RA without GC was 23.7%(32/135),which was significantly lower than that in patients with GC[40.9%(72/176),χ^2=10.161,P<0.01].In patients without vitamin D deficiency,the prevalence of OP in RA without GC was 21.4%(6/28),which was similar to that in patients with GC[31.0%(9/29),χ^2=0.678,P>0.05].In the case of vitamin D deficiency,the prevalence of OP in RA without GC was 24.3%(24/107),which was significantly lower than that in patients with GC[42.9%(63/147),χ^2=9.3702,P<0.01].④In RA patients with GC,age(t=5.313,P<0.01),Sharp score(Z=2.999,P<0.01),disease duration(Z=2.141,P<0.05)and treatment duration of GC(Z=2.460,P<0.05)were higher in group with GIOP than that in group without GIOP,while erythrocyte sedimentation rate(ESR)(Z=2.262,P<0.05),C-reactive protein levels(CRP)(Z=2.551,P<0.05)and body mass index(BMI)(t=2.425,P<0.05)were lower and the composition ratio of X-ray staging was worse(χ^2=12.484,P<0.01).⑤Logistic regression analysis(LR Backward)showed that female gender[OR(95%CI)=14.240(3.878,52.288),P<0.01],age[OR(95%CI)=1.079(1.042,1.118),P<0.01]and sarcopenia[OR(95%CI)=2.470(1.192,5.120),P<0.05]were the risk factors for GIOP in RA patients.Conclusion The proportion of treatment with GC in RA patients is very high(about 60%),and the prevalence of GIOP is 40.9%,which is closely related to sarcopenia and vitamin D deficiency.