Ghazali A, Ben Hamida F, Bouzernidj M, el Esper N, Westeel P F, Fournier A
Centre Hospitalier Universitaire D'Amiens, France.
Curr Opin Nephrol Hypertens. 1993 Jul;2(4):566-79. doi: 10.1097/00041552-199307000-00007.
Phosphate retention plays a major role in the pathogenesis of hyperparathyroidism at all stages of renal insufficiency. Dietary phosphate restriction is mandatory only for adults and is not advised for children because of the recommended diet allowance. Dietary restriction is usually not sufficient, and phosphate binders are almost always necessary when the glomerular filtration rate falls below 40 mL/min. Because long-term administration of aluminum phosphate binders is associated with risk of aluminum intoxication despite the use of so-called "safe doses", alternative phosphate binders should be used. Magnesium hydroxide and carbonate can be used only for dialysis patients because a low dialysate magnesium concentration is necessary to prevent the hazards of hypermagnesemia. Therefore, the major alternative is the use of alkaline salts of calcium. The most recently proposed salt, acetate, has a higher phosphate-binding capacity than carbonate but exposes patients to the same incidence of hypercalcemia despite the use of half the dose of elemental calcium. These salts should be taken with meals in order to complex more dietary phosphate and decrease calcium absorption and therefore the risk of hypercalcemia. Oral calcium alone, without 1 alpha OH-vitamin D3 derivatives, can prevent hyperphosphatemia and hyperparathyroidism in most uremic patients before dialysis and in about half of the patients dialyzed with a dialysate calcium of 1.5 to 1.65 mmol/L. 1 alpha OH-vitamin D3 derivatives, which increase intestinal absorption of phosphate, should be used only when hyperphosphatemia has been prevented by oral calcium and diet and when plasma parathyroid hormone levels increase above three times the upper limit of normal. To decrease hypercalcemic risk, patients should be given 1 alpha OH-vitamin D3 derivatives, preferably at night, as an intermittent bolus (intravenous or oral). In dialysis patients, the dialysate concentration of calcium may have to be further decreased in order to prevent hypercalcemia when high doses of oral calcium are necessary to control hyperphosphatemia.
在肾功能不全的各个阶段，磷酸盐潴留在甲状旁腺功能亢进的发病机制中起主要作用。仅对成年人而言，饮食中限制磷酸盐是必要的，由于推荐的饮食摄入量，不建议儿童这样做。饮食限制通常是不够的，当肾小球滤过率降至40 mL/分钟以下时，几乎总是需要使用磷酸盐结合剂。尽管使用了所谓的“安全剂量”，但长期服用磷酸铝结合剂仍与铝中毒风险相关，因此应使用其他替代磷酸盐结合剂。氢氧化镁和碳酸镁仅可用于透析患者，因为需要低透析液镁浓度以预防高镁血症的危害。因此，主要的替代方法是使用钙的碱性盐。最近提出的盐，醋酸盐，其磷酸盐结合能力高于碳酸盐，但尽管元素钙的用量减半，患者发生高钙血症的发生率相同。这些盐应与餐同服，以便结合更多的饮食中的磷酸盐并减少钙的吸收，从而降低高钙血症的风险。单独口服钙，不使用1α-羟维生素D3衍生物，可预防大多数透析前尿毒症患者以及约一半使用1.5至1.65 mmol/L透析液钙进行透析的患者发生高磷血症和甲状旁腺功能亢进。1α-羟维生素D3衍生物会增加肠道对磷酸盐的吸收，仅在口服钙和饮食已预防高磷血症且血浆甲状旁腺激素水平升高至正常上限的三倍以上时才应使用。为降低高钙血症风险，应给予患者1α-羟维生素D3衍生物，最好在夜间，作为间歇性大剂量给药（静脉内或口服）。在透析患者中，当需要高剂量口服钙来控制高磷血症时，可能必须进一步降低透析液钙浓度以预防高钙血症。
