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维生素 D 补充剂治疗慢性肾脏病患者:系统评价和荟萃分析试验,以调查补充剂的反应和概述指南。

Vitamin D Supplementation for Patients with Chronic Kidney Disease: A Systematic Review and Meta-analyses of Trials Investigating the Response to Supplementation and an Overview of Guidelines.

机构信息

Medical School, University of East Anglia, Norwich, UK.

University of Newcastle Upon Tyne, Freeman Hospital, Bone Clinic, Newcastle, UK.

出版信息

Calcif Tissue Int. 2021 Aug;109(2):157-178. doi: 10.1007/s00223-021-00844-1. Epub 2021 Apr 25.

Abstract

A large proportion of patients with chronic kidney disease (CKD) are vitamin D deficient (plasma 25-hydroxyvitamin D (25(OH)D) < 25 or 30 nmol/L per UK and US population guidelines) and this contributes to the development of CKD-mineral bone disease (CKD-MBD). Gaps in the evidence-base for the management of vitamin D status in relation to CKD-MBD are hindering the formulation of comprehensive guidelines. We conducted a systemic review of 22 RCTs with different forms of vitamin D or analogues with CKD-MBD related outcomes and meta-analyses for parathyroid hormone (PTH). We provide a comprehensive overview of current guidelines for the management of vitamin D status for pre-dialysis CKD patients. Vitamin D supplementation had an inconsistent effect on PTH concentrations and meta-analysis showed non- significant reduction (P = 0.08) whereas calcifediol, calcitriol and paricalcitol consistently reduced PTH. An increase in Fibroblast Growth Factor 23 (FGF23) with analogue administration was found in all 3 studies reporting FGF23, but was unaltered in 4 studies with vitamin D or calcifediol. Few RCTS reported markers of bone metabolism and variations in the range of markers prevented direct comparisons. Guidelines for CKD stages G1-G3a follow general population recommendations. For the correction of deficiency general or CKD-specific patient guidelines provide recommendations. Calcitriol or analogues administration is restricted to stages G3b-G5 and depends on patient characteristics. In conclusion, the effect of vitamin D supplementation in CKD patients was inconsistent between studies. Calcifediol and analogues consistently suppressed PTH, but the increase in FGF23 with calcitriol analogues warrants caution.

摘要

很大比例的慢性肾脏病(CKD)患者存在维生素 D 缺乏(根据英国和美国人群指南,血浆 25-羟维生素 D(25(OH)D)<25 或 30nmol/L),这导致了 CKD-矿物质骨病(CKD-MBD)的发生。在 CKD-MBD 相关的维生素 D 状态管理方面,证据基础存在差距,这阻碍了全面指南的制定。我们对 22 项 RCT 进行了系统回顾,这些 RCT 涉及不同形式的维生素 D 或类似物与 CKD-MBD 相关结局,以及甲状旁腺激素(PTH)的 meta 分析。我们提供了一个关于 CKD 患者透析前维生素 D 状态管理的当前指南的全面概述。维生素 D 补充对 PTH 浓度的影响不一致,meta 分析显示无显著降低(P=0.08),而 calcifediol、calcitriol 和 paricalcitol 则一致降低 PTH。所有 3 项报告 FGF23 的研究均发现类似物治疗后 FGF23 增加,但在 4 项维生素 D 或 calcifediol 研究中未改变。很少有 RCT 报告骨代谢标志物,标志物的变化范围阻止了直接比较。G1-G3a 期 CKD 遵循一般人群的建议。对于缺乏的纠正,一般或 CKD 特异性患者指南提供了建议。calcitriol 或类似物的给药仅限于 G3b-G5 期,并且取决于患者的特征。总之,维生素 D 补充在 CKD 患者中的效果在研究之间不一致。Calcifediol 和类似物一致地抑制 PTH,但 calcitriol 类似物增加 FGF23 需要谨慎。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/b3a6/8273061/a63bab089315/223_2021_844_Fig1_HTML.jpg

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