Kovesdy Csaba P, Ahmadzadeh Shahram, Anderson John E, Kalantar-Zadeh Kamyar
Division of Nephrology, Salem Veterans Affairs Medical Center, Salem, VA 24153, USA.
Arch Intern Med. 2008 Feb 25;168(4):397-403. doi: 10.1001/archinternmed.2007.110.
Treatment of secondary hyperparathyroidism (SHPT) with activated vitamin D analogues is associated with better survival in patients receiving dialysis. It is unclear whether such a benefit is present in patients with predialysis chronic kidney disease (CKD).
We examined the association of oral calcitriol treatment with mortality and the incidence of dialysis in 520 male US veterans (mean [SD] age, 69.8 [10.3] years; 23.5% black) with CKD stages 3 to 5 and not yet receiving dialysis (mean [SD] estimated glomerular filtration rate, 30.8 [11.3]). Associations were examined by the Kaplan-Meier method and in Poisson regression models with adjustment for age, race, comorbidities, smoking, blood pressure, body mass index, use of phosphate binders, estimated glomerular filtration rate, proteinuria, white blood cell count, percentage of lymphocytes, and levels of parathyroid hormone, calcium, phosphorus, albumin, bicarbonate, and hemoglobin.
Two hundred fifty-eight of 520 subjects received treatment with calcitriol, 0.25 to 0.5 microg/d, for a median duration of 2.1 years (range, 0.06-6.0 years). The incidence rate ratios for mortality and combined death and dialysis initiation were significantly lower in treated vs untreated patients (P < .001 for both in the fully adjusted models). Treatment with calcitriol was associated with a trend toward a lower incidence of dialysis. These results were consistent across different subgroups.
Treatment with the activated vitamin D analogue calcitriol appears to be associated with significantly greater survival in patients with CKD not yet receiving dialysis. Randomized clinical trials are required to verify the causality of these associations and to examine whether similar associations are seen with different activated vitamin D analogues.
在接受透析的患者中，使用活性维生素D类似物治疗继发性甲状旁腺功能亢进（SHPT）与更好的生存率相关。目前尚不清楚这种益处是否存在于透析前慢性肾脏病（CKD）患者中。
我们研究了520名美国男性退伍军人（平均[标准差]年龄为69.8[10.3]岁；23.5%为黑人）口服骨化三醇治疗与死亡率及透析发生率之间的关联，这些患者处于CKD 3至5期且尚未接受透析（平均[标准差]估计肾小球滤过率为30.8[11.3]）。通过Kaplan-Meier方法以及泊松回归模型进行关联分析，并对年龄、种族、合并症、吸烟、血压、体重指数、使用磷结合剂、估计肾小球滤过率、蛋白尿、白细胞计数、淋巴细胞百分比以及甲状旁腺激素、钙、磷、白蛋白、碳酸氢盐和血红蛋白水平进行调整。
520名受试者中有258人接受了骨化三醇治疗，剂量为0.25至0.5μg/d，中位治疗时间为2.1年（范围为0.06 - 6.0年）。治疗组与未治疗组相比，死亡率以及死亡和开始透析合并发生率的发病率比显著更低（在完全调整模型中两者P均<0.001）。骨化三醇治疗与透析发生率降低的趋势相关。这些结果在不同亚组中是一致的。
对于尚未接受透析的CKD患者，使用活性维生素D类似物骨化三醇治疗似乎与显著更高的生存率相关。需要进行随机临床试验来验证这些关联的因果关系，并研究不同的活性维生素D类似物是否也有类似的关联。
