Hamano Takayuki, Fujii Naohiko, Matsui Isao, Nakano Chikako, Inoue Kazunori, Tomida Kodo, Mikami Satoshi, Okada Noriyuki, Tsubakihara Yoshiharu, Rakugi Hiromi, Isaka Yoshitaka
Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan.
Ther Apher Dial. 2011 Jun;15 Suppl 1:2-8. doi: 10.1111/j.1744-9987.2011.00918.x.
No study has reported the current status of the management of chronic kidney disease mineral bone disorder (CKD-MBD) in Japan. Using the Osaka Vitamin D Study in CKD (OVIDS-CKD), we examined the prevalence of patients with serum calcium, phosphate, parathyroid hormone (PTH), or 25-hydroxyvitamin D levels outside the target of KDOQI guidelines. Eighty-four percent of the patients had 25-hydroxyvitamin D <30 ng/mL. Significant determinants of poor vitamin D status were female gender, diabetes, high PTH, and high urinary protein (2+ or greater). The percentage of patients with intact PTH higher than the target was 8% in CKD stage 3a, while between 20-22% in stages 3b to 5. The patients indicated for ergocalciferol were 7, 18, and 19% in stages 3a, 3b, and 4, respectively, and those indicated for active vitamin D were 21% in stage 5. Since neither ergocalciferol nor cholecalciferol is available in 2011 in Japan, we have no choice but to prescribe alfacalcidol or calcitriol; however, the percent of patients receiving these drugs was only 1, 4, 8, and 14% in stages 3a, 3b, 4, and 5, respectively, indicating that PTH and vitamin D status are not well controlled in Japan. In contrast, more than 80% of the patients met the target of serum calcium and phosphate. Contrary to expectations, nearly 20% of the patients had hypophosphatemia in stage 3 and 5, possibly because of strict protein restriction. Given these results, nephrologists should consider prescribing active vitamin D, especially for females and patients with diabetes, massive proteinuria, or secondary hyperparathyroidism.
尚无研究报道日本慢性肾脏病矿物质与骨异常（CKD-MBD）的管理现状。利用大阪慢性肾脏病维生素D研究（OVIDS-CKD），我们调查了血清钙、磷、甲状旁腺激素（PTH）或25-羟维生素D水平未达KDOQI指南目标的患者的患病率。84%的患者25-羟维生素D<30 ng/mL。维生素D状态不佳的显著决定因素为女性、糖尿病、高PTH和高尿蛋白（2+或更高）。CKD 3a期患者中完整PTH高于目标值的比例为8%，而3b至5期为20%-22%。3a、3b和4期分别有7%、18%和19%的患者需要使用麦角钙化醇，5期有21%的患者需要使用活性维生素D。由于2011年日本既没有麦角钙化醇也没有胆钙化醇，我们只能开阿法骨化醇或骨化三醇；然而，3a、3b、4和5期接受这些药物治疗的患者比例分别仅为1%、4%、8%和14%，这表明日本的PTH和维生素D状态未得到良好控制。相比之下，超过80%的患者血清钙和磷达到目标值。与预期相反，3期和5期近20%的患者存在低磷血症，可能是由于严格的蛋白质限制。鉴于这些结果，肾病学家应考虑开活性维生素D，尤其是对于女性以及患有糖尿病、大量蛋白尿或继发性甲状旁腺功能亢进的患者。
