Malluche H H, Monier-Faugere M C
Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA.
Clin Nephrol. 2006 Apr;65(4):235-42. doi: 10.5414/cnp65235.
Renal osteodystrophy begins early in the course of chronic kidney disease and occurs almost without exception in all patients with Stage 5 disease (CKD-5). Bone biopsies and evaluation of mineralized bone sections after double tetracycline-labeling are currently considered the gold standard for diagnosis and classification of renal osteodystrophy. Nevertheless, bone biopsies are rarely employed. This is, at least in part, related to the paucity of nephrologists trained in performance of the procedure and the fact that reports of the histologic results are not easily translatable to clinical practice. Results are usually given qualitatively, using non-uniform classifications or by histomorphometric evaluations which are esoteric to most nephrologists. We suggest here that histomorphometric evaluation can be reserved for research and special situations. Also, the customarily used qualitative classification should be replaced by a clinically useful nomenclature, provided the interpretation is done by an individual with sufficient experience in bone pathology. We present a new interactive nomenclature for renal osteodystrophy that addresses abnormalities of turnover, abnormalities of bone balance, and abnormalities of mineralization. The new nomenclature, thus, includes disorders of high- and low-turnover with consideration of the interrelation with positive or negative bone balance with or without mineralization defect. In this schema, changes in bone status are described as deviations from a norm, and treatment is geared toward normalizing values rather than creating any absolute change in one direction or another. It is hoped that such a classification will be easily usable, clinically more relevant, and more amenable to individualized treatment guidance.
肾性骨营养不良在慢性肾脏病病程早期即开始出现，几乎所有5期疾病（CKD-5）患者均无一例外会发生。目前，双四环素标记后进行骨活检及矿化骨切片评估被认为是肾性骨营养不良诊断和分类的金标准。然而，骨活检很少被采用。这至少部分与缺乏接受过该操作培训的肾病学家以及组织学结果报告不易转化为临床实践这一事实有关。结果通常采用定性方式给出，使用的分类不统一，或者通过大多数肾病学家难以理解的组织形态计量学评估给出。我们在此建议，组织形态计量学评估可保留用于研究和特殊情况。此外，习惯使用的定性分类应由一种对临床有用的命名法取代，前提是由在骨病理学方面有足够经验的个人进行解读。我们提出了一种用于肾性骨营养不良的新的交互式命名法，该命名法涉及骨转换异常、骨平衡异常和矿化异常。因此，新的命名法包括高转换和低转换疾病，并考虑到与正性或负性骨平衡以及有无矿化缺陷的相互关系。在这个模式中，骨状态的变化被描述为与正常状态的偏差，治疗旨在使各项数值正常化，而不是在某一个方向上产生任何绝对变化。希望这样的分类易于使用、在临床上更具相关性，并且更适合个体化治疗指导。
