血液透析患者低PTH血症与营养不良、炎症及无力性骨病的关系

摘要

目的 研究血液透析患者全段甲状旁腺激素(intact parathyroid hormone,1～84PTH,iPTH)的可能影响因素,探讨低甲状旁腺激素(parathyroid hormone,PTH)血症与营养不良、炎症、无力性骨病的关系. 方法 纳入维持性血液透析患者共162例,分成低PTH血症组(iPTH≤150pg/ml;n-77)和对照组(150 pg/ml＜iPTH≤600 pg/ml;n=85),收集基础资料,测量身体指标肱三头肌皮褶厚度(tri-ceps skin～fold,TSF)、上臂臂围(mid～arm circumference,MAC)、上臂肌围(mid～arm muscle circumference,MAMC)、体质量指数(body mass index,BMI),检测生化指标iPTH、C反应蛋白(e～reactive protein,CRP)、前白蛋白(prealbumin,PA)、血清白蛋白(albumin,ALB)、总铁结合力(total iron binding capacity,TIBC)、血钙、血磷、三酰甘油(triglyceride,TG)、低密度脂蛋白(low densith lipoprotein,LDL)、总胆固醇(total cholesterol,TC)、白细胞介素～1β (interleukin 1β,IL～1β)、白细胞介素～6(interleukin 6,IL～6)、骨源性碱性磷酸酶(bone alkaline phosphatase,BALP),计算校正钙、钙磷乘积(CaxP),使用营养不良炎症评分(malnutrition inflammation score,MIS)评估患者营养状态,并对相关指标进行分析.结果 iPTH与CRP(F～0.297,P＜0.05)、IL～1β (r=～0.334,P＜0.05)、校正钙(r=～0.393,P＜0.01)呈负相关,iPTH与PA (r=0.426,P＜0.01)、血磷(r=0.579,P＜0.01)、CaxP(r=0.432,P＜0.01)呈正相关.低PTH血症组与对照组比较,营养指标PA较低[(349.75±78.29) g/1比(393.47±75.02)g/1,P＜0.05],炎症指标CRP[(4.99±3.40) mg/1比(3.28±1.79)mg/l,P＜0.05]、IL～1β [1476.09(563.63～4020.16)pg/ml比[659.31(466.79～1888.53)]pg/ml,P＜0.05]较高,低PTH血症组MIS评分显著高于对照组[(12.23±5.59)比(9.0±4.23),P＜0.05],提示低PTH血症患者存在营养不良～炎症综合征(malnutrition-inflammation complex syndrome,MICS).2组BALP水平普遍偏低(0.61 u g/L～5 μ g/L),提示血液透析患者骨代谢率普遍偏低.结论 iPTH与CRP、IL～1β、PA、校正钙、血磷、CaxP关系密切,低PTH血症与MICS关系密切.血液透析患者BALP普遍偏低,提示维持性血液透析患者的骨代谢率普遍偏低.通过改善机体营养不良、炎症状态有望减少低PTH血症的发生,对无力性骨病也可能受益.%Objective To investigate the influence factors for serum iPTH (intact parathyroid hormone,1-84 PTH),and the relationship between low serum PTH,malnutrition,inflammation,and adynamic bone disease in hemodialysis patients.Methods A total of 162 maintenance hemodialysis patients were divided into low PTH group (iPTH≤150 pg/ml;n=77) and control PTH group (150 pg/ml＜iPTH ≤600 pg/ml;n=85).Anthropometrical parameters including triceps skin fold (TSF),mid-arm circumference (MAC),mid-arm muscle circumference (MAMC) and body mass index (BMI) were collected.Serological markers including iPTH,C-reactive protein (CRP),prealbumin (PA),albumin (ALB),total iron binding capacity (TIBC),serum calcium,serum phosphorus,triglyceride (TG),low density lipoprotein (LDL),total cholesterol (TC),interleukin 1β (IL-1β),interleukin 6 (IL-6) and bone alkaline phosphatase (BALP) were assayed.Albumin corrected calcium and calcium phosphorus product (Ca×P) were calculated.Malnutrition inflammation score (MIS) was assessed for nutritional status.Results Serum iPTH was negatively correlated with CRP (r=-0.297,P＜0.05),IL-1β (r=-0.334,P＜0.05) and albumin corrected calcium (r=-0.393,P＜0.01),and positively correlated with PA (r=0.426,P＜0.01),serum phosphorus (r=0.579,P＜0.01) and Ca×P (r=0.432,P＜0.01).PA was significantly lower in low PTH group than in control PTH group (349.75±78.29 g/L vs.393.47±75.02 g/L,P＜ 0.05),while CRP,IL-1β and MIS were significantly higher in low PTH group than in control PTH group [4.99±3.40 mg/1 vs.3.28± 1.79 mg/1,P＜0.05 for CRP;1476.09 (563.63～4020.16) pg/ml vs.659.31 (466.79～1888.53) pg/ml,P＜0.05 for IL-1β;12.23±5.59 vs.9.0±4.23,P＜0.05 for MIS],indicating that low serum PTH is associated with malnutrition in □ ammation complex syndrome (MICS).Serum BALP was gener ally low within 0.61～5 μg/L,indicating the lower bone metabolism rate in all hemodiaysis patients.Conclusion Serum iPTH was related to serum CRP,IL-1β,PA,albumin corrected calcium,serum phosphorus and Ca×P product.Low serum PTH was associated with MICS.Low serum BALP found in all hemodiaysis patients indicated lower bone metabolism rate.Appropriate intervention to improve nutritional status and to inhibit inflammation may be helpful in patients with low serum PTH and adynamic bone disease.