Rivera F, Sánchez de la Nieta M D, Echarri R, Anaya S, Carreño A, Vozmediano M C, Alcaide M P
Sección de Nefrología, Hospital General de Ciudad Real.
Nefrologia. 2006;26(3):351-7.
The publication in 2003 of the K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease recommended targets levels for serum iPTH, Ca, P, and CaxP product. However, many patients do not achieved these target ranges. It is necessary to known the percentage of patients out of range in order to prevent the development of bone disease and to reduce mortality and morbidity.
To know the degree of control of Ca-P metabolism in haemodialysis patients in our haemodilalysis facilities and the achievement of target levels recommended by K/DOQI Guidelines.
We have retrospectively investigated in 190 prevalent haemodialysis patients (males 58.2%, ratio M/F 1.4, mean age 70 years, range 17-87 years, at least 3 months in haemodialysis) the serum levels of Ca, albumin-corrected serum Ca, P, CaxP product and iPTH in all analitycal determinations performed in 2004. In each patient we have obtained the average (and median) of these serum markers. Cut-off levels were carried out following the recommendations of the K/DOQI Guidelines.
The average of serum Ca and albumin-corrected serum Ca is normal (means +/- SD = 8.9 +/- 0.6 mg/dL and 9.2 +/- 0.7 mg/dL, respectively); however, 53.7% has normal values, 9.1% hypocalcemia and 37.1% hypercalcemia. The average of serum P is also normal (mean +/- SD = 5.0 +/- 1.3 mg/dL); however, only 57.2% has normal values, and 11.7% has hypophosphoremia and the remaining 31, 1% hyperphosphoremia. The CaxP product is normal (mean +/- SD = 46.3 +/- 13.3 mg2/mL2), 4.9% with low values and 23.4% with high values. The median of serum iPTH is 253 pg/mL, but only 31.1% of them have normal values, 25.1% low range values and 43.7% has hyperparathyroidism; 9.3% with iPTH higher than 800 pg/mL. The percentage of patients with hyperphosphoremia is higher in the group with iPTH higher than 300 pg/mL (23.3% vs. 40%, chi2, p= 0.006). In patients with PTHi in normal range, 3.6% have low CaxP product and the remaining 17.8% high CaxP product. Overall, only 25% of patients falls within recommended ranges for all indicators of mineral metabolism and 17% has all serum markers outside these recommendations.
The degree of control of mineral metabolism in haemodyalisis patients if clearly insufficient and a large percentage of them do not achieved the recommended serum targets recommended by K/DOQI Guidelines. This groups of patients are exposed to a increased risk for oseous and cardiovascular morbimortality. The analysis of adequacy must be performed with percentage of patients out of range in order to apply new therapeutical strategies.
2003年发布的《肾脏病预后质量倡议（K/DOQI）慢性肾脏病骨代谢和疾病临床实践指南》推荐了血清全段甲状旁腺激素（iPTH）、钙、磷及钙磷乘积的目标水平。然而，许多患者并未达到这些目标范围。有必要了解超出范围的患者百分比，以预防骨病的发生并降低死亡率和发病率。
了解我们血液透析机构中血液透析患者钙磷代谢的控制程度以及K/DOQI指南推荐的目标水平的达成情况。
我们回顾性调查了190例维持性血液透析患者（男性占58.2%，男女比例为1.4，平均年龄70岁，年龄范围17 - 87岁，血液透析至少3个月）2004年所有分析测定中的血清钙、校正白蛋白后的血清钙、磷、钙磷乘积及iPTH水平。在每位患者中，我们获取了这些血清标志物的平均值（及中位数）。根据K/DOQI指南的建议确定临界值。
血清钙及校正白蛋白后的血清钙平均值正常（均值±标准差分别为8.9±0.6mg/dL和9.2±0.7mg/dL）；然而，53.7%的值正常，9.1%为低钙血症，37.1%为高钙血症。血清磷平均值也正常（均值±标准差 = 5.0±1.3mg/dL）；然而，仅57.2%的值正常，11.7%为低磷血症，其余31.1%为高磷血症。钙磷乘积正常（均值±标准差 = 46.3±13.3mg²/mL²），4.9%的值低，23.4%的值高。血清iPTH中位数为253pg/mL，但仅31.（此处原文有误，推测为31.1%）1%的值正常，25.1%为低水平值，43.7%有甲状旁腺功能亢进；9.3%的iPTH高于800pg/mL。iPTH高于300pg/mL的组中高磷血症患者百分比更高（23.3%对40%，卡方检验，p = 0.006）。在iPTH在正常范围内的患者中，3.6%的钙磷乘积低，其余17.8%的钙磷乘积高。总体而言，仅25%的患者所有矿物质代谢指标在推荐范围内，17%的患者所有血清标志物超出这些推荐范围。
血液透析患者矿物质代谢的控制程度明显不足，其中很大一部分患者未达到K/DOQI指南推荐的血清目标。这组患者面临骨病和心血管疾病死亡风险增加的情况。必须通过超出范围的患者百分比进行充分性分析，以便应用新的治疗策略。
