Wood Carla, González Esther A, Martin Kevin J
Division of Nephrology, Saint Louis University, 3635 Vista Avenue, St. Louis, MO 63110, USA.
Ther Apher Dial. 2005 Feb;9(1):4-8. doi: 10.1111/j.1774-9987.2005.00208.x.
Derangements in mineral metabolism are known to occur early in the course of chronic kidney disease (CKD). Recent clinical practice guidelines are designed to focus on the problem early in the course of kidney disease, when it is recommended to evaluate the levels of parathyroid hormone (PTH) and to try to intervene early if the levels are elevated. To begin early intervention for hyperparathyroidism in chronic kidney disease will require involvement of primary care physicians and other subspecialty groups to identify the patients at risk and begin to intervene with measures to control hyperparathyroidism and its consequences on mineral metabolism. It has recently been demonstrated that chronic kidney disease is a significant risk factor for vitamin D deficiency and since abnormalities in vitamin D metabolism are important in the generation of hyperparathyroidism, this is an issue that needs direct attention. Studies are needed to assess the effects of correcting this vitamin D deficiency in early CKD. As kidney disease progresses, efforts to control hyperparathyroidism will likely need to be intensified and several therapeutic options are available, such as phosphate binders, repletion of vitamin D, the use of active vitamin D sterols, or the use of vitamin D analogs. In addition, it is important to define the appropriate PTH values that need to be achieved to minimize complications on bone. Such studies are in progress at the present time to validate the current more specific PTH assays. Strict guidelines have been proposed for the management of bone and mineral metabolism in patients with CKD stage V on dialysis, and although these challenging recommendations were initially opinion-based, there is mounting evidence which provides confirmation of these targets as relevant. Treatment options for patients on dialysis involve the full spectrum of agents which include phosphate binders, active vitamin D sterols (often given parenterally), the use of calcimimetic agents, surgical parathyroidectomy, and evaluation of appropriate levels of dialysate calcium. Similar to early stages of CKD, studies are in progress to refine the PTH targets with the newer PTH assays. With increased focus on the complications of bone and mineral metabolism as part of the continuum of chronic kidney disease, and with a variety of new therapies available, it is anticipated that improved patient outcomes should be achievable in this patient group.
已知矿物质代谢紊乱在慢性肾脏病（CKD）病程早期就会出现。近期的临床实践指南旨在关注肾脏疾病病程早期的这一问题，建议在此时评估甲状旁腺激素（PTH）水平，若水平升高则尽早进行干预。要在慢性肾脏病中尽早开始对甲状旁腺功能亢进进行干预，需要初级保健医生和其他亚专业团队参与，以识别有风险的患者，并开始采取措施控制甲状旁腺功能亢进及其对矿物质代谢的影响。最近有研究表明，慢性肾脏病是维生素D缺乏的重要危险因素，且由于维生素D代谢异常在甲状旁腺功能亢进的发生中起重要作用，这是一个需要直接关注的问题。需要开展研究来评估纠正早期慢性肾脏病中维生素D缺乏的效果。随着肾脏疾病的进展，控制甲状旁腺功能亢进的力度可能需要加大，有多种治疗选择，如磷结合剂、补充维生素D、使用活性维生素D固醇或维生素D类似物。此外，确定为使骨骼并发症最小化而需要达到的合适PTH值也很重要。目前正在进行此类研究以验证当前更特异的PTH检测方法。已针对接受透析的CKD 5期患者的骨和矿物质代谢管理提出了严格的指南，尽管这些具有挑战性的建议最初基于观点，但越来越多的证据证实了这些目标的相关性。透析患者的治疗选择包括各类药物，如磷结合剂、活性维生素D固醇（通常经胃肠外给药）、使用拟钙剂、手术切除甲状旁腺以及评估透析液钙的合适水平。与慢性肾脏病早期类似，正在进行研究以利用更新的PTH检测方法优化PTH目标。随着对作为慢性肾脏病连续过程一部分的骨和矿物质代谢并发症的关注度增加，以及有多种新疗法可用，预计该患者群体的治疗效果会得到改善。
