中国血液净化

中国血液净化 ›› 2017, Vol. 16 ›› Issue (06): 378-382.doi: 10.3969/j.issn.1671-4091.2017.06.006

• 临床研究 • 上一篇    下一篇

碳酸镧对伴无动力骨病的糖尿病维持性血液透析患者骨密度和血管钙化的影响

张春华1,赵素梅1,张小东1   

  1. 1. 首都医科大学附属北京朝阳医院泌尿肾病中心
  • 收稿日期:2016-11-29 修回日期:2017-02-23 出版日期:2017-06-12 发布日期:2017-06-14
  • 通讯作者: 张小东 zxd581@263.net E-mail:dahai_zhangreview@163.com

Effect of lanthanum carbonate on vascular calcification and bone mineral density in maintenance hemodialysis patients with diabetes complicated with adynamic bone disease: a prospective pilot study

  • Received:2016-11-29 Revised:2017-02-23 Online:2017-06-12 Published:2017-06-14

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摘要： 目的探讨长期应用碳酸镧对伴无动力骨病的糖尿病维持性血液透析(maintenance hemodialysis，MHD)患者骨密度和血管钙化的影响及可能的机制。方法92 例伴无动力骨病的糖尿病MHD 患者随机分为碳酸镧组(LC 组)和碳酸钙组(CC 组)各46 例，治疗12 个月。以多层螺旋CT 评价冠状动脉钙化积分(coronary artery calcification score,CACS)，以双能x 线骨密度仪评价骨密度。比较两组患者治疗前后CACS、骨密度、磷酸盐代谢、成纤维细胞生长因子(fibroblast growth factors,FGF-23)、基质Gla 蛋白(matrix gla protein，MGP)、骨碱性磷酸酶(bone alkaline phosphate,BALP)、血清I 型胶原N-端前肽(procollagen I N- terminal peptide,PINP)、I 型胶原交联C-末端肽(C- terminal telopeptide of type I collagen,β-CTX)、微炎症等指标变化。结果与基线相比，第12 个月末碳酸镧组血磷、FGF23、MGP 明显降低，全段甲状旁腺激素(intact parathyroid hormone,iPTH)、BALP、PINP、β-CTX、骨密度T 值、CACS 明显升高而血钙无显著性变化[磷：t= 52.948, P＜0.001；FGF23：t=18.722, P＜0.001；MGP：t=5.981,P＜0.001；iPTH：t=33.042，P＜0.001；BALP：t=19.812,P＜0.001；PINP：t=35.278,
P＜0.001；β- CTX：t=20.491,P＜0.001；骨密度T 值(腰椎、股骨、前臂)：t=27.152,21.451,15.601,P=0.001,0.002,0.002；CACS：t=20.602，P=0.001; 钙：t=1.281，P=0.212]；碳酸钙组血磷(t=47.712,P＜0.001)、iPTH(t=12.601，P＜0.001)、BALP(t=5.336，P＜0.001)、PINP(t=2.033，P=0.041)、β-CTX (t=5.282, P=0.001)、MGP (t=21.479，P＜0.001)明显降低，血钙 (t=12.922，P＜0.001)、骨密度T值(腰椎、股骨、前臂) (t=23.571,14.222, 25.377，P=0.001, 0.002, ＜0.001)、CACS(t=26.571，P＜0.001)明显升高而FGF23 无显著性变化 (t=1.162，P=0.242)；第12 个月末，LC 组血磷(t=5.693，P＜0.001)、血钙(t=8.150，P＜0.001)、FGF23 (t=11.370, P＜0.001)、CACS (t=18.304, P＜0.001) 明显低于CC组；而iPTH (t=25.402, P＜0.001)、BALP (t=65.335，P＜0.001)、PINP(t=47.231，P＜0.001)、β-CTX(t=12.351，P＜0.001)、骨密度T 值(腰椎:t=17.872，P＜0.001；股骨:t=9.874，P＜0.001；前臂:t=5.625，P＜0.001)明显高于CC 组。pearson 相关分析显示前臂骨密度T 值与iPTH(r=0.363,P=0.021)、MGP(r=0.389,P =0.012)显著正相关，与CACS(r=-0.792,P =0.001)显著负相关；CACS 与腰椎骨密度T值 (r=-0.584, P=0.001)、股骨颈T值 (r=-0.642, P=0.001)、MGP (r=-0.294, P=0.002)显著负相关，与FGF23 (r=0.542, P=0.001)、血钙(r=0.244, P=0.002)、血磷 (r=0.474, P=0.001) 显著正相关。多元线性回归分析显示前臂骨密度T值变化 (B=-134.372, P=0.001)、股骨颈骨密度T值变化 (B=-72.211, P=0.001)、FGF23 变化(B=55.01, P=0.002)是CACS 变化的独立影响因素。结论碳酸镧使伴ABD 的糖尿病MHD 患者血管钙化进展延缓，骨转运改善，骨密度提高，可能与改善磷酸盐代谢、MGP 代谢及镧元素的直接作用有关。

关键词: 维持性血液透析, 无动力骨病, 碳酸镧

Abstract: Objective To explore the effect of lanthanum carbonate on vascular calcification and bone mineral density in maintenance hemodialysis (MHD) patients with diabetes complicated with adynamic bone disease. Methods A total of 92 MHD cases were divided into calcium carbonate (CC) group and lanthanum carbonate (LC) group. We compared serum calcium, phosphate, FGF23, bone alkaline phosphate (BALP), procollagen I N-terminal peptide (PINP), C-terminal telopeptide (β-CTX), matrix gla protein (MGP) and hsCRP, coronary artery calcification score (CACS) and bone mineral density at baseline and after 12 months between the two groups. SPSS 17.0 for Windows was used for statistical analyses. Results After the treatment for 12 months, serum levels of phosphate, FGF23 and MGP decreased significantly and serum levels of iPTH, BALP, PINP and β-CTX, CACS, and bone mineral density increased significantly in LC group, as compared with those at baseline (P＜0.05). After the treatment for 12 months, serum levels of calcium, phosphate, FGF23 and MGP, and CACS were lower in LC group than in CC group, and serum levels of iPTH, BALP, PINP and β-CTX, and bone mineral density were higher in LC group than in CC group. Pearson’s correlation analyses revealed that bone mineral density in forearm correlated positively with iPTH and MGP and negatively with CACS, and that CACS correlated positively with serum calcium, phosphate and FGF23 and negatively with serum MGP. Multivariate linear regression revealed that the changes of bone mineral density in forearm and collum femoris and serum FGF23 were the independent influence factors for the change of CACS (P＜0.05). Conclusions Slower progression of coronary artery calcification, improved bone turnover and increased bone mineral density occurred in the LC group as compared with those in the CC group. These results may result from the effects that lanthanum carbonate improves phosphate and MGP metabolism and directly antagonizes vascular calcification.

Key words: maintenance hemodialysis, adynamic bone disease, lanthanum carbonate