Pharmacology Department and Laboratory EA 7517, Amiens University Hospital, 80000 Amiens, France.
Arbor Research Collaborative for Health, Ann Arbor, MI, USA.
Bone. 2019 Dec;129:115058. doi: 10.1016/j.bone.2019.115058. Epub 2019 Sep 4.
Chronic kidney disease (CKD) is commonly associated with mineral and bone metabolism disorders, but these are less frequently studied in non-dialysis CKD patients than in dialysis patients. We examined and described international variation in mineral and bone disease (MBD) markers and their treatment and target levels in Stage 3-5 CKD patients.
DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Prospective cohort study of 7658 adult patients with eGFR <60mL/min/1.73m, excluding dialysis or transplant patients, participating in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) in Brazil, France, Germany, and the US. CKD-MBD laboratory markers included serum levels of phosphorus (P), calcium (Ca), intact parathyroid hormone (iPTH), and 25-hydroxyvitamin D (25-D). MBD treatment data included phosphate binders and vitamin D (nutritional and active). Nephrologist survey data were collected on target MBD marker levels.
Over two-thirds of the patients had MBD markers measured at time intervals in line with practice guidelines. P and iPTH increased and Ca decreased gradually from eGFR 60-20mL/min/1.73m and more sharply for eGFR<20. 25-D showed no relation to eGFR. Nephrologist survey data indicated marked variation in upper target P and iPTH levels. Among patients with P>5.5mg/dL, phosphate binder use was 14% to 43% across the four countries. Among patients with PTH >300pg/mL, use of active (calcitriol and related analogs) vitamin D was 12%-51%, and use of any (active or nutritional) vitamin D was 60%-87%.
Although monitoring of CKD-MBD laboratory markers by nephrologists in CKDopps countries is consistent with guidelines, target levels vary notably and prescription of medications to treat abnormalities in these laboratory markers is generally low in these cross-sectional analyses. While there are opportunities to increase treatment of hyperphosphatemia, hyperparathyroidism, and vitamin D deficiency in advanced CKD, the effect on longer-term complications of these conditions requires study.
慢性肾脏病（CKD）通常与矿物质和骨代谢紊乱相关，但在非透析 CKD 患者中，这些疾病的研究不如在透析患者中那么频繁。我们检查并描述了 3-5 期 CKD 患者中矿物质和骨疾病（MBD）标志物及其治疗和目标水平的国际差异。
设计、地点、参与者和测量：这是一项在巴西、法国、德国和美国参与慢性肾脏病结局和实践模式研究（CKDopps）的 7658 名 eGFR<60mL/min/1.73m 的成年患者的前瞻性队列研究，排除了透析或移植患者。CKD-MBD 实验室标志物包括血清磷（P）、钙（Ca）、全段甲状旁腺激素（iPTH）和 25-羟维生素 D（25-D）水平。MBD 治疗数据包括磷酸盐结合剂和维生素 D（营养性和活性）。收集了肾病学家关于目标 MBD 标志物水平的调查数据。
超过三分之二的患者在符合实践指南的时间间隔内测量了 MBD 标志物。P 和 iPTH 随着 eGFR 从 60-20mL/min/1.73m 逐渐升高，而 eGFR<20 时则急剧升高，Ca 则逐渐降低。25-D 与 eGFR 无关。肾病学家调查数据表明，目标 P 和 iPTH 水平存在显著差异。在 P>5.5mg/dL 的患者中，四个国家的磷酸盐结合剂使用率为 14%-43%。在 PTH>300pg/mL 的患者中，活性（骨化三醇和相关类似物）维生素 D 的使用率为 12%-51%，而任何（活性或营养性）维生素 D 的使用率为 60%-87%。
尽管 CKDopps 国家的肾病学家对 CKD-MBD 实验室标志物的监测符合指南，但目标水平差异显著，这些实验室标志物异常的药物治疗处方普遍较低。虽然在晚期 CKD 中增加治疗高磷血症、甲状旁腺功能亢进和维生素 D 缺乏症的机会很多，但这些治疗对这些疾病的长期并发症的影响仍需要研究。
