Management of disturbances of calcium and phosphate metabolism in chronic renal insufficiency, with emphasis on the control of hyperphosphataemia
Management of disturbances of calcium and phosphate metabolism in chronic renal insufficiency, with emphasis on the control of hyperphosphataemia
复制标题
DOI：
10.1093/ndt/17.5.723
复制
发表时间：
2002-05-01
影响因子：
6.1
通讯作者：
Ritz, E
中科院分区：
文献类型：
--
作者：
Locatelli, F;Cannata-Andía, JB;Ritz, E
背景慢性肾功能不全（CRI）患者钙磷（Ca-P）代谢紊乱不仅在骨疾病（肾性骨营养不良）中起重要作用，而且在软组织钙化中也起重要作用，血管钙化、动脉硬化和动脉粥样硬化恶化的风险增加。通过讨论，就透析患者肾性骨营养不良的发病机制、临床评估和治疗等关键问题达成共识。继发性甲状旁腺功能亢进主要是由于肾脏活性维生素D产生减少和磷酸盐潴留，以及高磷酸盐血症、低钙血症和甲状旁腺激素（PTH）水平升高。长期相同的因素会导致甲状旁腺增生和自主PTH产生（三级甲状旁腺功能亢进）。由于高磷血症和CaxP产物增加与透析患者死亡率增加相关，因此应从透析前阶段开始，通过补充钙/维生素D预防和管理甲状旁腺功能亢进。高磷血症通常通过肠磷结合剂治疗，但已使用不同类型的结合剂。传统的基于铝的磷结合剂当然是有效的，但由于铝的吸收而具有副作用（骨软化症、脑病、小细胞性贫血）的缺点。含钙磷酸盐结合剂（碳酸钙或醋酸钙）主要用于过去10 - 15年。然而，它们会加重转移性钙化，特别是如果它们与维生素D类似物和高钙透析液浓度一起服用。最近开发了新的无钙和无铝的磷酸盐结合剂，特别是在转移性钙化和/或高钙血症发作的患者中可能有用，以在没有额外钙负荷的情况下减少磷酸盐负荷。新的维生素D类似物和拟钙药物也正在开发用于PTH抑制，目标是最大限度地减少甚至完全避免高钙血症和/或高磷酸盐血症。适当的透析液钙浓度很重要，必须考虑到药物治疗和个体患者的钙平衡。结论：甲状旁腺切除术是治疗高钙血症性甲状旁腺功能亢进的最佳方法。实现循证共识可以为临床医生提供一个有用的工具，用于治疗CRI中的Ca-P代谢紊乱：这已成为肾脏护理的一个重要目标，特别是随着老龄化和动脉粥样硬化风险增加已成为透析人群的主要问题。
Background. Disturbances of calcium-phosphate (Ca-P) metabolism in chronic renal insufficiency (CRI) play an important role not only in bone disease (renal osteodystrophy) but also in soft tissue calcification, with an increased risk of vascular calcification, arterial stiffness, and worsening of atherosclerosis.Methods. Discussion in order to achieve a consensus on key points relating to pathogenesis, clinical assessment, and management of renal osteodystrophy in dialysis patients.Results. Secondary hyperparathyroidism develops primarily as a consequence of reduced active vitamin D production by the kidneys and phosphate retention, with the development of hyperphosphataemia, hypocalcaemia, and increased parathyroid hormone (PTH) levels. The same factors over the long term cause parathyroid gland hyperplasia and autonomous PTH production (tertiary hyperparathyroidism). As hyperphosphataemia and increased CaxP product have been associated with increased mortality in dialysis patients, hyperparathyroidism should be prevented and managed, starting in the pre-dialysis period, by calcium/vitamin D supplementation. Hyperphosphataemia is usually treated by means of intestinal phosphate binders, but different types of binders have been used. The traditional aluminium-based phosphate binders are certainly effective, but have the drawback of side effects due to aluminium absorption (osteomalacia, encephalopathy, microcytic anaemia). Calcium-containing phosphate binders (calcium carbonate or calcium acetate) have mainly been used for the last 10 15 years. However, they aggravate metastatic calcification, particularly if they are taken together with vitamin D analogues and a high calcium dialysate concentration. New calcium- and aluminium-free phosphate binders have recently been developed and may be useful, particularly in patients with metastatic calcification and/or hypercalcaemic episodes, in order to reduce the phosphate burden in the absence of an additional calcium load. New vitamin D analogues and calcimimetic drugs are also being developed for PTH suppression, with the goal to minimize or even entirely avoid hypercalcaemia and/or hyperphosphataemia. A suitable dialysate calcium concentration is important and must take into consideration the medical therapy and the calcium balance on an individual patient basis. Surgical parathyroidectomy is the ultimate means of treating hypercalcaemic hyperparathyroidism, when medical therapy has failed.Conclusion. Achieving an evidence-based consensus can give clinicians a useful tool for the treatment of disturbances of Ca-P metabolism in CRI: this has become an important objective in nephrological care, particularly as ageing and increased risk of atherosclerosis have become major issues in the dialysis Population.