Cronin Susan C
Cytochroma, Inc.
Nephrol Nurs J. 2010 Jan-Feb;37(1):19-26, 36; quiz 27-8.
Vitamin D insufficiency and deficiency have been identified as having a correlation with poor clinical outcomes in patients with chronic kidney disease (CKD). The availability of vitamin D for metabolism into 25(OH)D and the ability to further metabolize to 1,25(OH)D are known to have a significant impact on the endocrine system and the modulation of iPTH, calcium, and phosphorus imbalances in patients with CKD. Until recently, the focus of care for these patients has been to support the endocrine need for 1,25(OH)D because the loss of kidney function eliminates the ability to synthesize calcitriol effectively. However, recent findings have identified an autocrine role for vitamin D and its metabolism at local sites as having a potentially profound impact on gene transcription and clinical outcomes in multiple body systems. The National Kidney Foundation Kidney Disease Outcomes Quality Improvement guidelines recommend the use of ergocalciferol in the treatment of vitamin D insufficiency in CKD Stages 3 and 4, and the use of active vitamin D hormone in the treatment of vitamin D deficiency in patients with CKD Stage 5 who also have secondary hyperparathyroidism. Data clearly identify that the insufficiency of 25(OH)D persists as patients progress through Stage 3 and Stage 4 CKD into Stage 5 CKD. This article discusses the treatment of both the deficiency and insufficiency by supplementing both the endocrine and autocrine pathways with appropriate vitamin D therapies.
维生素D不足和缺乏已被确定与慢性肾脏病（CKD）患者的不良临床结局相关。已知维生素D代谢为25（OH）D的可用性以及进一步代谢为1,25（OH）D的能力，对CKD患者的内分泌系统以及iPTH、钙和磷失衡的调节有重大影响。直到最近，对这些患者的护理重点一直是满足对1,25（OH）D的内分泌需求，因为肾功能丧失会消除有效合成骨化三醇的能力。然而，最近的研究发现，维生素D及其在局部部位的代谢具有自分泌作用，这可能会对多个身体系统的基因转录和临床结局产生深远影响。美国国家肾脏基金会的《肾脏病预后质量倡议》指南建议，在治疗3期和4期CKD患者的维生素D不足时使用麦角钙化醇，在治疗同时患有继发性甲状旁腺功能亢进的5期CKD患者的维生素D缺乏时使用活性维生素D激素。数据清楚地表明，随着患者从3期和4期CKD进展到5期CKD，25（OH）D不足的情况持续存在。本文讨论了通过适当的维生素D疗法补充内分泌和自分泌途径来治疗维生素D缺乏和不足的问题。
