低钙透析液对于持续性非卧床腹膜透析老年患者动力缺失性骨病的疗效分析

Low-calcium dialysate for adynamic bone disease in senile patients undergoing continuous ambulatory peritoneal dialysis

摘要:

目的 对患有动力缺失性骨病（ABD）的老年维持性腹膜透析患者使用低钙透析液, 观察其提高全段甲状旁腺激素（iPTH）和对钙磷代谢的影响, 评估其对老年腹膜透析患者ABD治疗的疗效和安全性。方法 选择患有ABD的老年腹膜透析患者（年龄＞60岁, iPTH＜100 μg/L）24例, 使用低钙腹膜透析液（百特PD4, 钙1.25 mmol/L）治疗, 回顾分析治疗18个月中患者血iPTH、血钙、血磷、钙磷乘积及骨密度、碱性磷酸酶（AKP）等指标变化情况。结果 使用低钙透析液治疗后, 第1个月血iPTH水平开始上升, 第2个月血iPTH水平与治疗前比较明显上升[（131.10±75.78）vs（46.16±22.58）ng/L, P＜0.01], 第6, 9, 12月逐步上升, 在第12至18个月中保持稳定, 并在目标安全范围内（150～300 ng/L）。在12个月内iPTH水平上升至150～300 ng/L的患者所占比例随着时间推移逐渐增加, 第2, 6, 9, 12个月分别为53.5%, 57.2%, 66.7%, 72.9%; 到12个月以后, 达标率无明显变化（第15个月和第18个月分别为71.6%和73.3%）。治疗后第2个月血钙、血磷水平以及钙磷乘积与治疗前比较均明显下降[血钙: （2.12±0.18）vs（2.60±0.21）mmol/L, 血磷: （1.43±0.49）vs（1.96±0.53）mmol/L, 钙磷乘积: -（48.79±20.03）vs（63.36±19.14）mg2/dl2; P＜0.01]; 治疗后AKP由治疗前（107±72）IU/L升高至（176±89）IU/L（P＜0.05）。治疗前后骨质疏松发生率增加12.5%。治疗中无严重低钙抽搐、精神状态改变、低血压和骨折等情况发生。结论 对ABD的老年腹膜透析患者使用低钙透析液能有效升高其iPTH水平、改善钙磷代谢, 从而达到治疗ABD的目的, 治疗安全性较好; 但是骨质疏松症发生率有所增高, 提示老年腹膜透析患者在治疗ABD的同时, 需要加强防治骨质疏松。

Abstract:

Objective The aim of the present study was to evaluate the indication and security of low-calcium dialysate (LCD) for adynamic bone disease (ABD) in senile patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Methods Twenty-four senile ABD patients(age＞60 years) who underwent CAPD (intact parathyroid hormone(iPTH)＜100 ng/L) were enrolled. LCD (Ca 1.25 mmol/L) was used in dialysis treatment instead of standard-calcium dialysate (SCD, Ca 1.75 mmol/L). At 1-, 2-, 6-, 9-, 12-, 18-month follow up respectively, the biochemical measurements were performed for plasma levels of i-PTH, calcium, phosphorus, calcium-phosphorus product and alkaline phosphatase(AKP). Additionally, the bone mineral density (BMD) was also detected. Results After using LCD, the level of plasma iPTH began to upgrade in the first month; increased evidently in the second month [baseline vs 2-month: (46.16±22.58) vs (131.10±75.78)ng/L, P＜0.01]; increased gradually at month 6, 9 and 12; maintained stable and remained in target range since 12-month(150~300 ng/L). The percentage of patients whose serum iPTH level reached to target range augmented gradually in initial 12 months of treatment, which at month 2, 6, 9, 12 were 53.5%, 57.2%, 66.7%, 72.9% respectively. The percentage did not change significantly during the following 6 months(71.6% and 73.3% at 15- and 18-month respectively). At 2-month, level of serum calcium, phosphorus and calcium-phosphorus product all declined significantly[serum calcium level: (2.60±0.21) vs (2.12±0.18)mmol/L; serum phosphorus level: (1.96±0.53) vs (1.43 ±049)mmol/L; calcium-phosphorus product scores: (63.36±19.14) vs 48.79±20.03)mg2/dl2, P＜0.01]. Meanwhile, the level of serum AKP increased from (107±72)IU/L to (176±89)IU/L (P＜0.05). The incidence of osteoporosis increased by 12.5%. The majority of patients tolerated LCD well, without sufferring from severe hyperspasmia, alteration of psyche, hypotension or catagma. Conclusions LCD can effectively increase iPTH level and improve calcium and phosphorus metabolism in senile ABD patients undergoing CAPD, thus to treat ABD satisfactorily, with good security. However, LCD, to some extent, increases the incidence of osteoporosis. So, for these patients, ABD should be taken into consideration, as well as osteoporosis.