Holden Rachel M, Norman Patrick A, Day Andrew G, Silver Samuel A, Clemens Kristen K, Iliescu Eduard
Department of Medicine, Queen's University, Kingston, Ontario, Canada.
Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada.
Am J Nephrol. 2024;55(6):638-646. doi: 10.1159/000541109. Epub 2024 Sep 2.
Vitamin D insufficiency is common in patients who receive hemodialysis, yet there is no clear guidance regarding surveillance or treatment. We hypothesized that increasing 25(OH)D3 levels is associated with lower phosphate, parathyroid hormone (PTH), and alkaline phosphatase (ALP).
Baseline 25(OH)D3 level was measured in all patients receiving in-center hemodialysis in June 2017. Laboratory parameters were measured every 6 (phosphate, calcium) or 12 weeks (25(OH)D3, PTH, ALP) until February 2021. In September 2018, a treatment algorithm of 50,000 IU weekly until sufficient followed by 50,000 IU monthly was suggested. Generalized linear mixed regression models including linear spline effects, a log link function, and random effects were used to examine the impact of increasing 25(OH)D3 levels on calcium, phosphate, ALP, and PTH.
Of 697 participants, 15% and 57% had vitamin D deficiency (25(OH)D3 <25 nmol/L) and insufficiency (between 25 and 74 nmol/L). Incorporating up to 7,272 observations, increasing 25(OH)D3 was associated with significantly decreasing PTH for 25(OH)D3 levels between 25 and 75 nmol/L regardless of vitamin D treatment. In an interaction model, the negative slope between 25(OH)D3 and PTH remained significant beyond 75 nmol/L in the absence of calcitriol. Increasing 25(OH)D3 was associated with significantly decreasing phosphate for 25(OH)D3 levels between 25 and 75 nmol/L regardless of vitamin D treatment and below 25 nmol/L in values of untreated patients. Calcium increased across the spectrum of 25(OH)D3 regardless of vitamin D treatment. Overall, 0.2% of 25(OH)D3 levels exceeded 250 nmol/L and 2.1% of calcium levels exceeded the normal range.
Vitamin D treatment in a real-world setting was safe and associated with lower PTH levels. Whether improved biochemical markers translate to a reduction in clinical endpoints warrants further study.
维生素D缺乏在接受血液透析的患者中很常见，但在监测或治疗方面尚无明确指导。我们假设提高25(OH)D3水平与降低磷酸盐、甲状旁腺激素（PTH）和碱性磷酸酶（ALP）有关。
2017年6月对所有接受中心血液透析的患者测量基线25(OH)D3水平。每6周（磷酸盐、钙）或12周（25(OH)D3、PTH、ALP）测量一次实验室参数，直至2021年2月。2018年9月，建议采用每周50,000 IU直至充足然后每月50,000 IU的治疗方案。使用包括线性样条效应、对数链接函数和随机效应的广义线性混合回归模型来检验提高25(OH)D3水平对钙、磷酸盐、ALP和PTH的影响。
在697名参与者中，15%和57%存在维生素D缺乏（25(OH)D3<25 nmol/L）和不足（25至74 nmol/L之间）。纳入多达7272次观察结果，无论维生素D治疗如何，对于25(OH)D3水平在25至75 nmol/L之间，提高25(OH)D3与PTH显著降低相关。在一个交互模型中，在没有骨化三醇的情况下，25(OH)D3与PTH之间的负斜率在超过75 nmol/L时仍然显著。无论维生素D治疗如何，对于25(OH)D3水平在25至75 nmol/L之间以及未治疗患者的值低于25 nmol/L时，提高25(OH)D3与磷酸盐显著降低相关。无论维生素D治疗如何，钙在25(OH)D3的整个范围内均升高。总体而言，25(OH)D3水平的0.2%超过250 nmol/L，钙水平的2.1%超过正常范围。
在实际临床环境中进行维生素D治疗是安全的，并且与较低的PTH水平相关。改善的生化指标是否能转化为临床终点的降低值得进一步研究。
