Renal osteodystrophy is slow, symptoms are advanced, clinically with bone pain, bone fracture, deformation is the main feature. One of the sudden pain symptoms, often systemic, occur in the lower part of the body parts (discreet waist, back, hip, knee, or compression movement) and heavy walking not even shake up. Moreover, renal osteodystrophy and attention to if not treated, will cause some complications such as rickets or osteomalacia, cystic fibrous osteitis, osteoporosis, bone sclerosis and heterotopic ossification, fracture and so on.
(I) principles of treatment
1. maintain normal blood calcium, blood phosphorus concentration, to avoid the occurrence of hyperparathyroidism and metastatic calcification, reduce the secretion of PTH, and correct the deficiency of 1,25- (OH) 2D3, in which the control of blood PTH levels is particularly important
2. delay the development or development of renal osteodystrophy
3. reduce the deposition of aluminum in the bone
4. promote the growth and development of children
5. correct metabolic acidosis
(2) specific treatment methods
1. general treatment
Protein restriction and dairy foods, low phosphorus diet. Serum phosphorus increased, reducing the phosphorus retention. Hyperphosphatemia can inhibit calcium three alcohol synthesis, when the glomerular filtration rate (CFR) of <35ml/min, often appear hyperphosphatemia, ionized calcium decreased, PTH stimulated bone mineralization. But calcium three alcohol reduction, low calcium, bone mineralization affected.
2. symptomatic treatment
(1) the control of hyperphosphatemia: intake restriction of phosphorus: to low phosphorus, low protein diet, but there are too strict control "dangerous phosphate depletion", must regularly check blood phosphorus; the application of phosphate binder: oxygen such as alumina gel, calcium carbonate, magnesium carbonate.
(2) correction of hypocalcemia: appropriate supplementation of calcium, such as calcium carbonate, calcium lactate, calcium gluconate, is usually given daily with calcium 1~2g, 2~4, g or more per day for patients with bone disease. Vitamin D is more effective
(3) vitamin D and its derivatives of vitamin D and its derivatives activity: 1 alpha (OH alpha) D3,25 (OH) D3,1,25- (OH) 2D3 and a large dose of vitamin D2, vitamin D3 and so on. The 1,25- (OH) 2D3 is used more, and with 25- (OH) D3 of 4~8 treatment week no better. Significant effect, may be appropriate to increase the amount, but each increase of not more than 1.25mg.
(4) the other treatment: pay attention to the restriction of the use of vitamin A to prevent osteoporosis. Stimulation of parathyroid available sodium fluoride treatment, daily 60mg, vitamin D and calcium. As far as possible without barbiturates, phenytoin, Doriden, to prevent the interference of 1,25- (OH) 2D3 synthesis. Correct acidosis did not occur. Obvious bone disease who do dialysis.
(5) surgical treatment:
Renal transplantation: this method restores renal function and restores vitamin D, the production of active products, inhibits PTH, restores blood phosphate, serum calcium, restores normal levels, relieves renal osteodystrophy, and even heals
Percutaneous ethanol injection therapy (PFTT) is one of the surgical treatments for secondary hyperparathyroidism, and the effect of.PEIT is influenced by the maximum diameter of >10mm, the number of:PEIT glands, and the density of the vessels
Parathyroidectomy for biochemical evidence, X-ray and tissue of severe secondary hyperparathyroidism and ruled out the possibility of aluminum bone disease patients, when medical treatment fails, surgical removal of the parathyroid glands, eliminate excessive PTH of bone. The newly reported percutaneous ethanol injection caused by parathyroid damage can also be have a similar effect.
Subtotal parathyroidectomy: this method is mainly used for intractable hypercalcemia, the level of PTH increased (>1pg/L) with severe uncontrolled pruritus, soft tissue calcification significantly (especially cardiovascular calcification), medical treatment is difficult to control and osteitis fibrosa, ulcer and ischemic necrosis with soft tissue injury.
(6) the treatment of high turnover type bone disease: control of serum phosphorus, calcium based phosphate binders, such as calcium carbonate, calcium acetate, current clinical secondary hyperparathyroidism in first-line therapy, taking meals, can reduce serum phosphorus. The clinical application is the most correct low calcium carbonate. Calcium or calcium supplementation should use active vitamin preparation D. active vitamin as ossification in three alcohol is an important drug for the treatment of secondary hyperparathyroidism, calcium sensitive receptor agonists to reduce secondary hyperparathyroidism in patients with plasma PTH level, without elevated blood calcium and phosphorus levels, and can reduce the calcium and phosphorus product inhibition of parathyroid PTH vitamin D analogues with ossification in three alcohol similar synthesis and secretion.
3. Choice of specific drugs for renal osteopathy
(1): the best effect of liquid oxygen alumina, each 5~10ml, 2~3 tablets, 3 times a day, in order to prevent the low phosphorus lead to rickets, every 2 months for 1 times to control blood phosphorus, phosphorus in the diet intake of less than 2g/d, otherwise the medication is invalid. To prevent excessive aluminum deposition to the brain, bone, and produce irreversible refractory rickets, some people think that this is related to phosphorus deficiency. In order to prevent aluminum poisoning, blood phosphorus in the normal use of calcium carbonate, magnesium containing drugs should not be given, because magnesium can promote PTH osteolysis, prone to cause migration of calcification.
(2) calcium carbonate: reducing dietary phosphorus, proper control of serum phosphate, AKP, PTH. with calcium carbonate. The glomerular filtration rate (GFR) 10~40ml/min, 112~115g/d GFR<10ml/min, 1~2g/d. calcium; calcium calcium and ergocalciferol combination is better, but to regularly measure blood calcium and blood, peritoneal fluid, high blood calcium and phosphorus that will produce more calcium phosphate, caused by soft tissue calcification risk, so the blood phosphorus should be lower than 1178mmol/L when calcium is appropriate. Serum phosphorus below 0.65mmol/L is susceptible to high blood calcium. Calcium carbonate 10~20g/24h, can be combined with intestinal phosphate discharged from the feces; non dialysis patients to 3~6g/24h to correct acidosis, recovery of calcium phosphorus is very high; to use the blood phosphorus to 2.26mmol/L. and aluminum hydroxide calcium carbonate increases, aluminum hydroxide decreased. Increasing serum calcium can reduce the blood AKP and PTH, reduce bone resorption and bone fracture, but calcium alone can not increase the normal bone mineralization in the calcium with three alcohol.
(3) vitamin D and its metabolites: in order to prevent calcium and phosphorus products too high, it is necessary to reduce blood phosphorus to about 1162mmol/L, adding vitamin D metabolites is safer
Two hydrogen tachysterol AT10: increased intestinal calcium absorption, improve osteitis fibrosa 0.25~0.375mg/d, 1~2 weeks after the end of treatment of hypercalcemia automatically corrected.
25-OHD: begin 100 g/d, wait for blood calcium to rise, maintain quantity 50 mu g/d, apply double amount when hemodialysis, tall blood calcium stops drug 1 weeks, correct namely
1- a -OHD3: anti spasticity drugs reduce the activity of g/24h 0.5~4, severe osteitis fibrosa, biological effect on calcium 3~4, but there are reports of kidney damage.
Cimetidine: a parathyroid histamine receptor, the drug can block the histamine stimulation of parathyroid gland, reduce the level of PTH and 0.3g/d intravenous injection or oral 0.6~0.9g/d. Adverse reactions were diarrhea, sinus tachycardia, hypothalamic pituitary gonadal axis disorders, neutrophils and calcitonin secretion.
Growth hormone: recombinant human growth hormone (thGH), GH has significant effect on growth and bone mineralization, improve intestinal calcium absorption, increase bone mass, promote renal tubular reabsorption of phosphate and the proliferation of osteoblasts, improve new bone formation and serum calcium and phosphorus, reduce the effect of PTH.GH on soft bone growth plate cells. Due to cartilage calcification. Three normal bone development calcium alcohol therapy of children with kidney disease is necessary, it should be given to rbGH during calcium three alcohol.
(4) iron amine: Aluminum related osteomalacia, ineffective treatment with calcium three alcohol, hypercalcemia is a toxic reaction, the use of iron removal is effective. This medicine is aluminum complexing agent, can clear bone and aluminum, reduce pain, improve bone mineralization