Shane E, Silverberg S J, Donovan D, Papadopoulos A, Staron R B, Addesso V, Jorgesen B, McGregor C, Schulman L
Department of Medicine, Columbia-Presbyterian Medical Center, New York, New York 10032, USA.
Am J Med. 1996 Sep;101(3):262-9. doi: 10.1016/S0002-9343(96)00155-6.
Fractures, a common complication of cardiac and liver transplantation, have not been reported in association with lung transplantation. However, many patients with end-stage pulmonary disease have multiple risk factors for osteoporosis, and several studies have suggested that osteoporosis before transplantation may increase the risk of fracture after transplantation. Therefore, we evaluated a group of patients with end-stage pulmonary disease who were awaiting lung transplantation to determine the prevalence of osteoporosis.
Seventy patients (aged 18-70 years) were evaluated consecutively with bone densitometry by dual-energy x-ray absorptiometry. The patients were predominantly Caucasian (96%). Bone mass was expressed as bone mineral density (BMD; g/cm2), as the number of standard deviations (SD) below peak bone mass (T score), and as bone mineral apparent density (BMAD; g/cm3), a measurement that minimizes the effects of bone size on BMD. Spine radiographs were obtained in a subset of 50 consecutive patients to detect vertebral compression fractures. Vitamin D status was assessed with serum concentrations of 25-hydroxyvitamin D. The patients were sorted into groups by pulmonary diagnosis: chronic obstructive pulmonary disease (COPD; n = 28); cystic fibrosis (n = 11); idiopathic pulmonary fibrosis; and other lung diseases (Other; n = 31).
In the group as a whole, osteoporosis (T score below -2.5) was present in 30% of the patients at the lumbar spine and 49% at the femoral neck. Osteopenia (T score between -1 and -2.5) was present in an additional 35% at the lumbar spine and 31% at the femoral neck. The average femoral neck T score of patients with COPD and cystic fibrosis fell into the osteoporotic range (-2.7 +/- 0.3 and -2.6 +/- 0.3, respectively), significantly (P < 0.01) below that of the patients in the Other category (-1.5 +/- 0.3). The average lumbar spine T score fell into the osteopenic range in all three groups. Low BMAD in patients with cystic fibrosis confirmed that their low BMD was not due to their smaller body size. The prevalence rate of vertebral fractures was 29% in patients with COPD and 25% in those with cystic fibrosis. Vitamin D deficiency (25-hydroxyvitamin D levels < or = 10 ng/ml) was present in 36% of patients with cystic fibrosis and 20% with COPD and Other lung diseases. Lumbar spine BMD tended to be lower in cystic fibrosis patients with vitamin D deficiency. Patients with exposure to glucocorticoids (n = 46) had significantly more vertebral fractures (P < 0.05) and duration of exposure correlated negatively with lumbar spine BMD (r = -0.398; P = 0.008). COPD and Other patients not on glucocorticoids had mild lumbar spine osteopenia (0.972 +/- 0.06 g/cm2; T = -1.2 +/- 0.6). Very few of the patients on glucocorticoids were on any regimen to prevent osteoporosis.
Osteoporosis and vitamin D deficiency are extremely common in patients with end-stage pulmonary disease. Only 34% of patients had normal lumbar spine BMD and only 22% had normal BMD at the hip. Patients with cystic fibrosis and glucocorticoid-treated patients with COPD were most severely affected. Therapies to prevent bone loss and treat established osteoporosis are uncommonly utilized in glucocorticoid-treated patients with end-stage pulmonary disease. Candidates for lung transplantation should be evaluated for osteoporosis and vitamin D deficiency at the time of acceptance to the transplant waiting list.
骨折是心脏和肝移植常见的并发症，但尚未见与肺移植相关的报道。然而，许多终末期肺病患者有多种骨质疏松的危险因素，并且多项研究提示移植前骨质疏松可能增加移植后骨折的风险。因此，我们评估了一组等待肺移植的终末期肺病患者，以确定骨质疏松的患病率。
连续对70例年龄在18至70岁之间的患者进行双能X线吸收法骨密度测定。患者主要为白种人（96%）。骨量以骨矿物质密度（BMD；g/cm²）、低于峰值骨量的标准差（SD）数（T值）以及骨矿物质表观密度（BMAD；g/cm³）表示，BMAD可将骨大小对BMD的影响降至最低。对连续50例患者的子集进行脊柱X线摄片以检测椎体压缩骨折。用血清25-羟维生素D浓度评估维生素D状态。根据肺部诊断将患者分组：慢性阻塞性肺疾病（COPD；n = 28）；囊性纤维化（n = 11）；特发性肺纤维化；以及其他肺部疾病（其他；n = 31）。
在整个研究组中，腰椎骨质疏松（T值低于 -2.5）的患者占30%，股骨颈骨质疏松的患者占49%。腰椎骨量减少（T值在 -1至 -2.5之间）的患者在腰椎额外占35%，在股骨颈额外占31%。COPD和囊性纤维化患者的平均股骨颈T值处于骨质疏松范围（分别为 -2.7 ± 0.3和 -2.6 ± 0.3），显著低于（P < 0.01）其他组患者（-1.5 ± 0.3）。所有三组患者的平均腰椎T值均处于骨量减少范围。囊性纤维化患者的低BMAD证实其低BMD并非因其体型较小。COPD患者的椎体骨折患病率为29%，囊性纤维化患者为25%。36%的囊性纤维化患者、20%的COPD患者和其他肺部疾病患者存在维生素D缺乏（25-羟维生素D水平≤10 ng/ml）。维生素D缺乏的囊性纤维化患者腰椎BMD往往较低。接受糖皮质激素治疗的患者（n = 46）椎体骨折显著更多（P < 0.05），且暴露时间与腰椎BMD呈负相关（r = -0.398；P = 0.008）。未接受糖皮质激素治疗的COPD和其他患者存在轻度腰椎骨量减少（0.972 ± 0.06 g/cm²；T = -1.2 ± 0.6）。接受糖皮质激素治疗的患者中很少有人采用任何预防骨质疏松的方案。
骨质疏松和维生素D缺乏在终末期肺病患者中极为常见。仅34%的患者腰椎BMD正常，仅22%的患者髋部BMD正常。囊性纤维化患者以及接受糖皮质激素治疗的COPD患者受影响最为严重。在接受糖皮质激素治疗的终末期肺病患者中，很少采用预防骨质流失和治疗已确诊骨质疏松的疗法。肺移植候选者在被列入移植等待名单时应评估是否存在骨质疏松和维生素D缺乏。
