Current status of diagnosis and treatment of renal osteodystrophy

In patients with chronic kidney disease due to calcium, phosphorus, vitamin D metabolism, secondary hyperparathyroidism and other factors lead to renal osteodystrophy. Current status of diagnosis and treatment of renal osteodystrophyClinically by combining traditional Chinese and Western medicine treatment can improve the curative effect, can improve the results of laboratory test were negative rate, is conducive to their clinical symptoms, that effectively control diet, drug therapy inpidualized, dynamic test parameters, suitable for dialysis method strong can improve the quality of life of patients. The author of the 2008 ~ 2011 at home and abroad for chronic kidney disease mineral and bone metabolic diseases (chronic kidney disease-mineral and bone disorder, CKD-MBD) of the laboratory examination, diagnosis, treatment, and dialysis methods of the related review.

 

Renal osteodystrophy (renal osteodystrophy ROD) has been renamed "chronic kidney disease mineral and bone metabolism diseases (CKD-MBD), is associated with chronic kidney disease (chronic kidney, disease, CKD) with calcium, phosphorus metabolism and bone turnover, mineralization, growth and abnormal blood vessels and soft tissue calcification, pided into high turnover renal osteodystrophy, low turnover renal osteodystrophy (osteomalacia and adynamic bone disease) and mixed osteodystrophy in 3 different types. Now it is believed that secondary hyperparathyroidism (secondary hyperparathyroidism, SHTP) in patients with CKD CKD-MBD, has an important role in the development of SHPT features the level of serum 1,25 (OH) and 2D3 level decreased disorder of calcium and phosphorus metabolism, resulting in parathyroid hyperplasia, secretion of parathyroid hormone (parathyroidhormone, PTH) level increased. Renal osteodystrophy should be in accordance with the systemic disease to treat, put forward the concept of CKD-MBD. At present, CKD-MBD The treatment methods, including limiting phosphorus diet, dialysis, use of phosphate binders, vitamin D receptor agonist (Vitamin D receputor activators, VDRAs) and calcium (calcimimetics) and other quasi drugs. In order to improve the quality of life of patients with kidney disease, the diagnosis of CKD-MBD related factors, analysis of drug treatment and the choice of dialysis modality are as follows:

 

1 diagnosis related factors analysis

1.1 determination of bone mineral density of bone mineral density can reflect the changes of bone mass, is a sensitive index for diagnosis of osteoporosis, bone density can not distinguish between types of renal osteodystrophy, but to reduce bone, bone calcification lack diagnostic value. The diagnostic criteria of osteoporosis based on the 1998 WHO (World Health Organization, WHO standard) the.T value of N measured bone mineral density (bone mineral density values-BMD) - the normal population normal young population mean BMD]/ standard deviation of BMD (standard deviation-SD).T value is more than -1SD -1 SD>T>-2.5 SD is normal, the bone volume decreased, the T value is less than or equal to -2.5 SD for osteoporosis, osteoporotic fracture with serious osteoporosis [4] in the International Osteoporosis Foundation (International Osteoporosis, Foundation, IFO) 2004 World Osteoporosis Conference, University of Sheffield WHO metabolic bone disease research center Johnell After a meta-analysis of 12 clinical studies, BMD was considered a good predictor of fractures (especially hip fractures)

The physiological function of parathyroid hormone 1.2 parathyroid hormone levels is elevated blood calcium levels, reduce serum phosphorus, promote intestinal absorption of calcium. The direct function of the kidney is promoting heavy calcium ions on renal tubular calcium absorption, reduce the urinary excretion in urine, promote phosphate excretion regulation very quickly. The main plasma calcium parathyroid hormone secretion.

1.3 parameters of serum calcium determination in patients with chronic renal failure complicated with renal osteodystrophy often have hypercalcemia or hypocalcemia, combined with parathyroid hormone level index has significance for the diagnosis of renal osteodystrophy. Types of calcium rise tip osteolysis increased, serum calcium decreased indicating parathyroid function low, vitamin D deficiency, uremia.

1.4 serum phosphorus index determination of CKD 3 ~ 4 patients, serum phosphorus level should be maintained at more than 2.7 mg/d (0.87 mol/L) and <4.6 mg/dL evidence (1.4 mol/L) of renal failure in patients with CKD (5) patients with serum phosphorus level and hemodialysis peritoneal dialysis should be maintained at 3.5 ~ 5.5 mg/dL (1.13 1.5 ~ 1.78 mol/L). The serum alkaline phosphatase assay of serum alkaline phosphatase is a group specific phosphatase. This enzyme is widely distributed in tissues and fluids, with bone, liver, breast, intestine, kidney were higher in the most produced by bone cells, small part from the liver bile into the intestines, normal value adults: 3 ~ 13 u, children 5 ~ 28 u, continuous monitoring method, 37 C, 1 ~ 12 years old female <500 U/L; >15 was 40 ~ 150 years old to 12 years old male U/L. 1 <750 U/L; >25 years old was 40 ~ 150 U/L, mainly used for diagnosis of hepatobiliary system and bone disease. Obstructive jaundice Jaundice, jaundice hepatitis, liver cirrhosis, liver necrosis, bone diseases, osteomalacia, rickets, ALP activity recovery increased fracture. 1.6 determination of tartrate resistant acid phosphatase (tartrate resistant acid phosphatase, TRACP TRACP) is a good indicator of bone resorption and osteoclast activity, determination of serum TRACP the concentration of TRACP-5b was.TRACP-5b, the bone metabolism is helpful to understand the physiological conditions and various pathological conditions as the main source of osteoclasts, parathyroid hormone can stimulate bone cells to secrete TRACP, TRACP-5b increased in primary osteoporosis, bone metabolism, bone metastases, chronic renal failure. Reports through the menopause after type 2 diabetes mellitus (type 2 diabetes mellitus, T2DM, T2DM) with osteoporosis (osteoporosis, OP), bone mineral density in patients with OP (bone mineral density, BMD) and the changes of serum 25 hydroxy vitamin D3, bone alkaline phosphatase (bone alkaline, phosphate, BALP), TRACP correlation analysis showed that T2DM patients with BMD and HbA1c patients, FPG was negatively related to serum TRACP, BALP and OT in serum, and 25 hydroxyvitamin D3, BMI showed a significant positive correlation. The serum levels of BALP, OT, TrACP and 25 hydroxy vitamin D3 T2DM and OP considered as the early diagnosis of biochemical indicators.

2 western medicine treatment

 

2.1 drugs to inhibit bone absorption

2.1.1 bisphosphonates (Bisphosphonates, BPs) is currently the most effective inhibitors of bone resorption, as a new generation of bisphosphonates alendronate, bone matrix it is absorbed by the body quickly and mineralization in the combination of inhibit bone resorption, reduce bone metastasis, reduce slow down the speed of bone resorption and bone loss, the bone formation rate than bone resorption rate, bone mass increased to reach. Alendronate is the most commonly used potent inhibitors of bone resorption, can promote calcium balance and increase bone mineral content, is the only way to increase the drug of male osteoporosis bone quality, ibandronate phosphate is currently the only direct intravenous injection and not easy to cause renal damage bisphosphonate ibandronate phosphate inhibition ability of bone resorption is strong, low dose and can produce the corresponding effect.
2.1.2 calcitonin calcitonin (Caicitonin) the main role is to directly inhibit osteoclast activity, reduce the number of indirect regulation; the activity of osteoblasts and promote its proliferation, promote bone formation, central analgesic effect. Calcitonin can increase bone strength, significantly reduce the incidence of lumbar and hip osteoporotic fractures. The clinical commonly used with salmon calcitonin (Miacalcic) and eel calcitonin (elcitonin).

2.2 promoting drug compounds parathyroid hormone and bone formation: low dose of parathyroid hormone can regulate bone metabolism and promote bone remodeling, increase bone strength, improve bone microstructure, high doses can cause bone loss emergence of osteitis fibrosa. Teriparatide (Teriparatide) subcutaneous injection (20 pg/d), is present for osteoporosis drugs into bone for the treatment of the most promising drug to promote bone mineralization.
2.3 A drug that promotes bone mineralization

2.3.1 Selection and treatment of osteoporosis drugs as the most basic, basic organic calcium and calcium amino acid chelate treatment of senile osteoporosis, osteoporosis, calcium is a kind of adjuvant.
2.3.2 of vitamin D and its derivatives with salmon calcitonin 50 IU intramuscular injection, 1 /d, second weeks. 2 to 3 times a week, for 3 months after dialysis, 1 treatment course, alfacalcidol combined with salmon calcitonin can make the patients with bone pain, muscle weakness, skin pruritus incidence was significantly lower than the control group with alfacalcidol, the difference was statistically significant, salmon calcitonin can significantly improve patients hemodialysis patients with renal osteodystrophy symptoms, improve the degree of osteoporosis. A method of ossification in three alcohol as a precursor of drug ossification in three alcohol, the liver mitochondrial hydroxylase by catalytic generation of active vitamin D, promote intestinal absorption of calcium, promote bone formation, salmon calcitonin To reduce the number of osteoclast activity and inhibit bone resorption and stimulate osteoblast formation and activity of slow bone transformation. Ossification in three alcohol: a chemical called 1,25 (OH 2D3) is a kind of more than 40 kinds of vitamin D metabolites have been elucidated the biological effects, so called active vitamin use: treatment. Basic diseases (blood dialysis or peritoneal dialysis), calcium supplement, and oral administration of ossification in three alcohol 0.25 g/d (CA three alcohol), the best sleep intestinal calcium load minimum medication. Luo Gaiquan is an important means of treatment of chronic renal failure secondary hyperparathyroidism, elevated thyroid mechanism: calcium parathormone decreased, 1,25 (OH) 2D3 on thyroid receptor binding, can inhibit the synthesis of parathyroid hormone mRNA, and parathyroid hormone synthesis decreased; Martha ossification in three alcohol with ossification in three alcohol can obviously improve the renal weight increased. Glomerulosclerosis, tubular atrophy and interstitial calcium deposition phenomenon.
2.3.3 strontium strontium salt (Strontium) is a dual role of the bone forming agent (double action of the bone forming agents-DABA), can maintain the bone turnover rate, is a two-way regulating effect on bone metabolism drugs, ranelate strontium (St rontiumranlate SR) is the only dual mechanism of a new class of anti osteoporosis drugs, can stimulate bone formation, inhibit the dual role of bone resorption, enhance bone strength and bone mineral density. Clinical efficacy, tolerability, adverse reactions, and has good application prospect. Accept ranelate strontium 3 years of treatment, the bone density in the spine and hip. Vertebral and non vertebral fractures decreased 41% and 31%.

3 Chinese medicine treatment 

3.1 to invigorate the kidney method Invigorate the kidney particles (main components in angelica 20 g, 15 g of rhubarb, red sage root, 10 g, radix dipsaci 10 g, malaytea scurfpea fruit, 15 g medlar 10 g), daily 1 agent, 1 time in the morning and night.Mechanism: anti-inflammatory, anti-rheumatism, malaytea scurfpea fruit for Yang of the kidney and commonly used drugs, radix dipsaci could improve microcirculation increased capillary open quantity, three drug combination can strong gluten JianGu, warming Yang.Salvia miltiorrhiza can promoting blood circulation to remove blood stasis, angelica blood tonic, pooling can remove stasis pain, angelica blood can wet material, strong gluten JianGu, improve the clinical symptoms of renal bone disease.
3.2 kidney strong bone method in treatment of renal bone disease on the basis of kidney strong bone, often chosen striding tiger hidden pill load, medicinal: antler glue, fleece-flower root, radix cyathulae, eucommia bark, Chinese cynomorium, angelica, prepared rhizome of rehmannia, codonopsis, radix paeoniae rubra, FuZi, tortoise plastron, radix dipsaci, asarum, etc.Filling bone soup (15 g keel 30 g, eucommia bark, 15 g, malaytea scurfpea fruit, radix dipsaci, 15 g Yin sheep grandiflorum, 15 g, 30 g, raw oysters dog ridge 15 g), research has shown that filling bone soup can significantly improve renal bone disease in patients with calcium phosphorus metabolism and low back pain and other symptoms.Invigorating the spleen method: cover all, plus acupuncture and spleen and kidney party (astragalus root, Chinese yam, atractylodes, white cardamom, salvia miltiorrhiza, raw rhubarb, desertliving cistanche, moxibustion licorice).
3.3 kidney invigorate the xie turbidity method Kidney JianGu soup, malaytea scurfpea fruit, epimedium, desertliving cistanche, radix dipsaci, dog ridge, salvia miltiorrhiza, mulberry parasitism, semen coicis each 20 g, each 10 g atractylodes, poria cocos, rhubarb, qi deficiency and radix astragali 30 g, 15 g yam medicine, Yang deficiency were used 12 g lateral root of aconite, Yin deficiency with raw radix rehmanniae 20 g, yuzhu, 10 g), research has shown that kidney JianGu decoction can improve the patients' clinical symptoms, physical signs, reduce serum creatinine, serum creatinine, Scr), urea nitrogen, blood urea nitrogen, Bun) levels, improve the patients' renal function.3.4 monotherapy on the basis of strict diet, with lower phosphor powder (1.0 g cuttlebone) three meals a day in oral, phosphor powder has significantly reduced the calcium-phosphorus product reduction, the role of blood parathyroid hormone, and treatment of renal osteopathy.

4 the choice of dialysis method

Patients with chronic kidney disease progress to uremia, dialysis method can choose peritoneal dialysis (peritoneal dialysis, PD) and hemodialysis (hemodialysis, HD).Studies have shown that PD for renal bone disease, serum osteoclast activity index and control situation is better than that of HD (density, may with HD long-term use of heparin by inhibiting the X factor to produce polymerase chain reaction, stop the osteoblast formation, inhibit the apoptosis of mature osteoclast effect, has led to an increased number of osteoclast and active.High flux hemodialysis (high - flux hemodialysis) compared with the conventional hemodialysis, the use of high flux dialyzer, through diffusion, convection, adsorption of combination way, in addition to the small molecule toxins, markedly improved its ability to remove large and medium molecular, high flux hemodialysis therapy, parathyroid hormone, and CRP was significantly higher than that of HD, IL - 6 fall after the use of high flux hemodialysis can reduce \"oxidative stress\" and \"inflammatory stress\" complement and leukocyte activation decreased significantly, improving micro inflammation in the body.Clinical application of low calcium dialysis method in order to avoid excessive suppression of parathyroid hormone is important means of renal bone disease prevention and control of weak type, avoid excessive suppression of parathyroid hormone, unable to type of bone disease morbidity factors complex, including parathyroid hormone secreted by the parathyroid absolute or relative deficiency is important reasons.Low parathyroid hormone levels is an important characteristic of weak type of bone disease.The study found that blood parathyroid hormone levels below 100 ng/L, and the blood calcium level is greater than 2.5 tendency for L, diagnostic unable to type of bone disease accuracy of 82%.Low calcium dialysis to improve parathyroid inhibition has a certain effect, and can significantly increase the success rate of patients with parathyroid hormone, parathyroid hormone by need to closely monitor the blood, to prevent secondary hyperparathyroidism.Application of low calcium dialysis at the same time should pay attention to nutrition.Low calcium dialysis can effectively control the patient's level of blood calcium and blood perfusion can obviously reduce the patient's blood phosphorus and parathyroid hormone levels, reduce and eliminate the symptoms, to ease the patients of renal bone disease has a positive role in the occurrence and development.