【摘要】目的观察帕立骨化醇联合血液灌流治疗血液透析患者继发性甲状旁腺功能亢进症(secondary hyperparathyroidism，SHPT)的疗效。方法将入组的30 例患者随机分为A 组(帕立骨化醇组)和B 组(帕立骨化醇+血液灌流组)，所有病例随访12 周。患者治疗前、4 周、8 周、12 周分别复查相关生化指标；每2 周监测钙、磷、全段甲状旁腺激素(intact parathyroid hormone，iPTH)。结果①和治疗前比较，2 组iPTH、碱性磷酸酶在4 周后均下降(A 组t=6.048,3.459；P＜0.001,0.004；B 组t=6.776,3.366；P＜0.001,0.005)。和A 组比较，治疗8 周时B 组帕立骨化醇剂量减少(t=3.298,P=0.003)，甲状旁腺激素和碱性磷酸酶水平下降更明显(t=2.635,2.508；P =0.014,0.018)。②iPTH 下降＞30%的例数在4 周、8周、12 周A 组分别为4、7、10 例，B 组分别为6、11、12 例。③和治疗前比较，B 组血磷和钙磷乘积4 周后均下降(t=19.176,4.801；P 均＜0.001)，2 组血钙在2 周后均升高(A 组：t=2.926,P=0.011；B 组t=2.756,P=0.015)。和A 组比较，B 组4 周后血磷和钙磷乘积降低(t=3.889,3.510；P=0.001,0.002)。结论帕立骨化醇治疗可有效降低SHPT 透析患者的iPTH 水平，联合血液灌流治疗效果更佳，且可降低血磷和钙磷乘积及减少帕立骨化醇剂量。
【Abstract】Objectives To observe the efficacy of paricalcitol combined with hemoperfusion on secondary hyperparathyroidism (SHPT) in maintenance hemodialysis (MHD) patients. Methods Thirty MHD patients with SHPT were randomly divided into group A (treated with paricalcitol) and group B (treated with paricalcitol plus hemoperfusion). They were followed up for 12 weeks. During the 12 weeks treatment period, biochemical markers were assayed at baseline and every 4 weeks, and serum intact parathyroid hormone (iPTH), calcium, phosphorus and alkaline phosphatase (ALP) were assayed every 2 weeks. The efficacy parameter was set at the decrease of iPTH more than 30% of baseline value after 12 weeks treatment. The incidence of adverse events was also observed. Results ① Compared to the baseline levels, serum iPTH and ALP were significantly declined after the treatment for 4 weeks in both groups (in group A: t=6.048 and 3.459, P＜0.001 and 0.004; in group B: t=6.776 and 3.366, P＜0.001 and 0.005). After the treatment for 8 weeks, paricalcitol dosage, serum iPTH and serum ALP were markedly declined in group B than in group A (t=3.298, 2.635 and 2.508, P=0.003, 0.014 and 0.018). ②After the treatment for 12 weeks, the number of patients with the decrease of iPTH more than 30% of the baseline value were 10 in group A and 12 in group B. ③Compared with the baseline values, serum phosphorus and calcium-phosphorus product were markedly declined after the treatment for 4 weeks in group B (t=19.176 and 4.801, P＜0.001), and serum calcium was higher after the treatment for 2 weeks in both groups (group A: t=2.926, P=0.011; group B: t=2.756, P=0.015). After the treatment for 4 weeks, serum phosphorus and calcium-phosphorus product were apparently lower in group B than in group A (t=3.889 and 3.510, P=0.001 and 0.002). Conclusions Paricalcitol therapy is effective for lowering serum iPTH in MHD patients with SHPT; paricalcitol combined with hemoperfusion will have better effects in lowering paricalcitol dosage, serum phosphorus and calcium-phosphorus product.
[1]张雪琴,陆晨.帕立骨化醇与骨化三醇治疗继发性甲状旁腺功能亢进症进展［Ｊ］.临床肾脏病杂志，2017,17(12）：761-764．
[2] Zawierucha J1, Malyszko J2, Malyszko JS，etal. Three Therapeutic Strategies: Cinacalcet, Paricalcitol or Both in Secondary Hyperparathyroidism Treatment in Hemodialysed Patients During 1-Year Observational Study-A Comparison[J]. Front Endocrinol (Lausanne). 2019 Feb 5;10:40.
[3] Ve?eri?-Haler ?, Romozi K, Antoni? M, etal. Comparison of the Pharmacological Effects of Paricalcitol Versus Calcitriol on Secondary Hyperparathyroidism in the Dialysis Population[J]. Ther Apher Dial. 2016 Jun;20(3):261-266.
[4]李悦，常靓，蔡俏等。血液透析联合血液灌流对骨化三醇冲击治疗继发性甲旁亢的效果分析[J].标记免疫分析与临床.２０１９,２６(６):949-953.
[5]何琦,梁凌,蒋金玉.血液透析联合血液灌流对尿毒症继发甲状旁腺功能亢进的疗效[J].中国临床研究[J] ,2018,31 (2):189-192.
[6] Lu KC, Wu CC, Yen JF, et al. Vascular calcification and renal bone disorders [J]. Scientific World Journal, 2014, 2014:637065.
[7] 唐学琴,陈泽君,甘华.维持性血液透析患者继发性甲状旁腺功能亢进阿法骨化醇冲击治疗的Meta分析[J].肾脏病与透析肾移植杂志,2014,23(02):128-135.
[8] Garabed Eknoyan, Bertram L. Kasiske, David C. Wheeler, et al. KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis,Evaluation, Prevention, and Treatment of Chronic KidneyDisease–Mineral and Bone Disorder (CKD-MBD) [J]. Kidney Int, 2017,7 (Suppl): 35–36.
[9]李京, 李霞,王怡. 帕立骨化醇治疗血液透析患者伴继发性甲状旁腺功能亢进的疗效观察[J]. 中国血液净化.2019,18(6) :386-389.
[10] Zawierucha J, Ma?yszko J, Ma?yszko JS, etal. Treatment of secondary hyperparathyroidism with paricalcitol with or without cinacalcet in hemodialysis patients[J]. Pol Arch Intern Med. 2017,127(12):840-845.
[11] 王泰娜, 徐斌, 贾凤玉等.帕立骨化醇治疗血液透析患者伴继发性甲状旁腺功能亢进[J].肾脏病与透析肾移植杂志,2015,24（1）：1-5.
[12] 2019. Koc H, Hoser H, Akdag Y ，etal.Treatment of secondary hyperparathyroidism with paricalcitol in patients with end-stage renal disease undergoing hemodialysis in Turkey: an observational study[J]. Int Urol Nephrol. 2019 Jul;51(7):1261-1270.
[13] Olaizola I1, Caorsi H2, Fajardo L，etal.Effectiveness and safety of a 6-month treatment with paricalcitol in patients on hemodialysis with secondary hyperparathyroidism[J]. J Bras Nefrol. 2016,38(3):302-312.
[14] 欧志强，李新伦，张宏等. 血液灌流对维持性血液透析患者蛋白结合类毒素清除及生活质量的影响[J]. 中国血液净化,2018,17(4):229-233.
[15] 谢祖刚, 陈安安, 石相雅等. 不同频率血液灌流治疗对甲状旁腺激素和血清钙磷清除的研究[J]. 中国血液净化.2014,13(5):380-383.
[16] 蒲超，薛痕，杨有京等. 低钙透析联合血液灌流治疗维持性血液透析患者继发性甲状旁腺功能亢进疗效的观察[J]. 中国现代杂志，2010，20（22）：3440-344
