Ray S, Beatrice A M, Ghosh A, Pramanik S, Bhattacharjee R, Ghosh S, Raychaudhury A, Mukhopadhyay S, Chowdhury S
Department of Endocrinology, Institute of Post Graduate Medical Education & Research (IPGMER) and SSKM Hospital, Kolkata, India.
Department of Nephrology, Institute of Post Graduate Medical Education & Research (IPGMER) and SSKM Hospital, Kolkata, India.
Diabetes Metab Syndr. 2017 Dec;11 Suppl 2:S931-S937. doi: 10.1016/j.dsx.2017.07.019. Epub 2017 Jul 8.
Chronic kidney disease related-mineral bone disorder (CKD-MBD) has been poorly studied in pre-dialysis Indian CKD population. There are limited data on the pattern of these disturbances in diabetic CKD patients. Therefore, a study was conducted to find out the profile of mineral bone disorders in T2DM patients with pre-dialysis CKD.
In this cross-sectional design, diabetic patients with newly-diagnosed stage 4 and 5 CKD were evaluated. Serum levels of calcium, phosphorus, intact parathyroid hormone (iPTH), 25 hydroxy vitamin D and total alkaline phosphatase (ALP) were measured in all patients. Bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry (DXA).
A total of 72 eligible patients participated (44 males, 28 females; age 54.2±11.7). Patients with CKD Stage 5 had a lower level of corrected serum calcium and significantly higher level of inorganic phosphorus, total ALP and iPTH as compared to stage 4 patients. Overall, 38.5% were hypocalcemic, 31.43% were hyperphosphatemic. 24.2% of CKD subjects were vitamin D deficient (<10ng/ml) and 41.4% having vitamin D insufficiency (10-20ng/ml). In stage 4, hyperparathyroidism (iPTH>110pg/ml) was detected in nearly 43% of patients. In stage 5, only 32% patients was found to have hyperparathyroidism (iPTH>300pg/ml). There was a good correlation between iPTH and total ALP (r=0.5, p=0.0001) in this cohort. 25 (OH) vitamin D was inversely correlated with ALP (r=-0.39, P=0.001) and showed negative correlation with urine ACR (r=-0.37, P=0.002). As a group, the osteoporotic CKD subjects exhibited higher iPTH (220.1±153.8 vs. 119±108pg/ml, p<0.05) as compared to those who were osteopenic or had normal bone density. There was significant correlation between BMD and iPTH (adjusted r=-0.436; P=0.001). In the multivariate regression model, we found intact PTH to predict BMD even after adjustment of all the confounders.
The current study showed that adynamic bone disease is prevalent even in pre-dialysis CKD population. High bone turnover disease may not be the most prevalent type in diabetic CKD. However, it could contribute to the development of osteoporosis in CKD subjects. Serum total ALP can serve as a biochemical marker to identify pattern of bone turnover where intact PTH is not available.
慢性肾脏病相关矿物质骨病（CKD-MBD）在印度透析前慢性肾脏病患者中研究较少。关于糖尿病慢性肾脏病患者这些紊乱模式的数据有限。因此，开展了一项研究以明确透析前慢性肾脏病2型糖尿病患者的矿物质骨病情况。
采用横断面设计，对新诊断的4期和5期慢性肾脏病糖尿病患者进行评估。测定所有患者血清钙、磷、全段甲状旁腺激素（iPTH）、25羟维生素D和总碱性磷酸酶（ALP）水平。使用双能X线吸收法（DXA）测量骨密度（BMD）。
共有72例符合条件的患者参与研究（44例男性，28例女性；年龄54.2±11.7岁）。与4期患者相比，5期慢性肾脏病患者校正血清钙水平较低，无机磷、总ALP和iPTH水平显著较高。总体而言，38.5%的患者血钙过低，31.43%的患者血磷过高。24.2%的慢性肾脏病患者维生素D缺乏（<10ng/ml），41.4%的患者维生素D不足（10 - 20ng/ml）。在4期，近43%的患者检测到甲状旁腺功能亢进（iPTH>110pg/ml）。在5期，仅32%的患者被发现患有甲状旁腺功能亢进（iPTH>300pg/ml）。该队列中iPTH与总ALP之间存在良好相关性（r = 0.5，p = 0.0001）。25（OH）维生素D与ALP呈负相关（r = -0.39，P = 0.001），与尿ACR呈负相关（r = -0.37，P = 0.002）。作为一个整体，骨质疏松性慢性肾脏病患者的iPTH水平高于骨量减少或骨密度正常的患者（220.1±153.8 vs. 119±108pg/ml，p<0.05）。BMD与iPTH之间存在显著相关性（校正r = -0.436；P = 0.001）。在多变量回归模型中，我们发现即使在调整所有混杂因素后，全段甲状旁腺激素仍可预测骨密度。
当前研究表明，动力缺失性骨病在透析前慢性肾脏病患者中也很普遍。高骨转换疾病可能不是糖尿病慢性肾脏病中最常见的类型。然而，它可能导致慢性肾脏病患者骨质疏松的发生。血清总ALP可作为一种生化标志物，在无法检测全段甲状旁腺激素时识别骨转换模式。
