中国血液净化

中国血液净化 ›› 2014, Vol. 13 ›› Issue (07): 510-514.doi: 10.3969/j.issn.1671-4091.2014.07.007

• 临床研究 • 上一篇    下一篇

维持性血液透析患者发生骨折与骨矿物质代谢紊乱的关系

李深,俞国旭,张改华,韩东彦,杨丽苹   

  1. 中国中医科学院广安门医院
  • 收稿日期:2014-01-13 修回日期:2014-04-18 出版日期:2014-07-12 发布日期:2014-07-12
  • 通讯作者: 俞国旭 ygxdoctor@aliyun.com E-mail:ygxdoctor@aliyun.com

Relationship between fractures and disordered bone mineral metabolism in patients with maintenance hemodialysis

  • Received:2014-01-13 Revised:2014-04-18 Online:2014-07-12 Published:2014-07-12

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摘要： 目的：观察维持性血液透析（MHD）患者发生骨折与患者预后的关系以及骨代谢指标监测对临床的指导意义。方法：采用前瞻队列研究，从2010～2012年对在我血透中心行MHD的158例患者进行随访，记录患者干体重变化，新发生骨折例数，新发骨折对患者生存以及心血管事件发生情况的影响，定期监测患者血钙、磷、碱性磷酸酶、iPTH、总VitD、I型胶原交联C末端肽，骨钙素，降钙素，比较新发生骨折者与未发生骨折者上述指标以及预后的差异。结果：随访期内新发骨折21例，平均骨折发生率为：4.43/100个患者年，均为脆性骨折。与未发现骨折者比较，新发生骨折患者年龄更大， ALP水平较高，女性所占比例较高，体质指数较低，干体重呈下降者更多（P＜0.05），规律使用活性维生素D者比例较低（42.86% vs72.26%），随访期内死亡及心血管事件发生率较高，分别为：66.67% vs 18.98% 和52.38% vs 10.95%，两组患者其余矿物质及骨代谢相关指标均未见明显差异。发生骨折后未接受骨科固定治疗者1年内死亡率明显高于接受治疗者（70.59% vs 25.00%），生存分析显示新发骨折使MHD患者累计生存率明显降低。Logistic回归表明干体重下降、女性是MHD患者发生骨折的独立危险因素，OR值分别为42.94（95%CI：9.31，196.34）和3.47（95%CI：1.11，10.84）。结论：老龄、女性、干体重下降、血ALP水平增高、未规律接受活性维生素D治疗可能与MHD者骨折风险增高有关；除ALP外，其余骨代谢指标对预测骨折风险意义有限。骨折与MHD患者死亡及心血管事件风险明显增高有关，一旦发生骨折需多学科合作尽快处理。

关键词: 维持性血液透析, 骨折, 骨矿物质代谢紊乱

Abstract: objective: to observe the relationship between new-onset bone fractures and their prognosis, and to assess clinical significance of testing bone mineral metabolism markers in patients with maintenance hemodialysis (MHD). Methods: a perspective cohort study, 158 MHD patients were followed up from 2010 to 2012 in our hemodialysis center. The change of dry body weight, new-onset bone fracture cases, survival and impact of cardiovascular events after fracture were recorded. Serum calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), intact PTH (i-PTH), total VitD, cross-linked C telopeptide of Collagen I, osteocalcin, and calcitonin were regularly tested. Outcomes above-mentioned and prognosis were compared between patients with and without fractures. Results: there were twenty-one new onset bone fractures in the follow-up period, the average incidence of fracture is: 4.43 per 100 patients-years, all were brittle fracture. Compared with patients without fracture, the new onset patients were older and more likely females, had higher ALP level and lower body mass index (BMI), and more to decline in dry weight (P < 0.05), moreover, had lower ratio （42.86% vs72.26%）of receiving active Vitamin D regular supplementation, and had higher impact of death and cardiovascular events (66.67% vs 18.98% and 52.38% vs 18.98%, respectively). There were no significant differences in the rest markers of bone metabolism between the two groups. Patients un-received fixation treatment after fracture had higher 1 year mortality than those who received treatment (70.59% vs 25.00%). Survival analysis showed that new onset fracture would greatly reduce the accumulative survival rate. Logistic Regression analyses revealed that dry body weight decline and female were independent risk factors for fracture in patients with MHD, the OR were 42.94 (95% CI: 9.31, 196.34) and 9.31 (95% CI: 1.11, 10.84) respectively. Conclusion: aging, female, decreased dry weight, elevated ALP level, and un-receiving active Vitamin D regular supplementation are associated with an increased risk of fracture in hemodialysis patients. It was limited clinical utility of mineral metabolism markers testing for fracture prediction in MHD patients, except ALP. Fractures associated with substantially high mortality and cardiovascular events in MHD patients, quickly treatments on account of multidisciplinary cooperation were urgently needed once fracture occurred.

Key words: maintenance hemodialysis（MHD）, fracture, bone mineral metabolism disorder