摘要

作品简介:CKD-MBD由磷酸钙代代谢的紊乱及其对骨骼的后果（骨质脑膜炎的脆弱性）和软组织的影响定义。在非洲在这个主题中已经完成了很少的研究。只有一项限于达喀尔市的一项学习，于2014年在塞内加尔进行了。这就是为什么我们为所有塞内加尔采取了这项研究，以改善患者更好地照顾指标。

方法:这是一项横断面、回顾性、描述性和分析性研究，在塞内加尔的七个血液透析中心进行了七年（2010年6月30日至2017年7月1日）所有年龄超过15岁且血液透析至少6个月的患者均纳入本研究。目的是确定慢性血液透析患者磷钙紊乱的流行病学、临床和临床旁数据。

结果：纳入患者315例。平均年龄5065±13.84岁。男性占49.8%，女性占50.2%(性别比0.99)。血液透析患者的平均年龄为47,78±32.88个月。58.1%的患者原籍为达喀尔。值得注意的是，91.1%的患者接受了4小时的透析治疗，84.8%的患者每周接受3次透析治疗。主要病因为血管性肾病(43.8%)和不确定性肾病(20.3%)。骨痛15.2%，关节痛10.2%，自发性骨折2.86%。低钙血症占27.6%，高磷血症占53.1%，甲状旁腺功能亢进占48.8%，维生素D缺乏占80.2%，总碱性磷酸酶高占62.2%。在KDIGO规范的患者中，66.70%为钙血症; 40.20% for phosphatemia; 49.80% for the PTHi; 19.80% for vitamin D 25OH and 37.80% for total alkaline phosphatase. According to KDIGO standards, the average frequency of achievement of these phosphocalcic parameters was respected in 11.10% of patients for calcemia; 8.70% for phosphatemia; 8.80% for the iPTH and 15% for the total alkaline phosphatase. Standard radiography showed 62% bone demineralization and 12.1% vascular calcification. Regarding the types of bone involvement, 39.7% was indeterminate; 30.8% fibrous osteitis; 27.6% without bone involvement; 1.3% dynamic osteopathy; 0.6% osteomalacia.

结论:CKD-MBD在塞内加尔的慢性血液透析患者中很常见。普通血症，磷血症和IPTH的常态率为11.75％。在我们的研究中，平均甲状旁腺功能亢进为718 pg/ml，因此导致了47例死亡患者的高死亡率。这些结果鼓励遵守KDIGO建议。

缩写

CKD-MBD：与矿物质骨疾病相关的慢性肾脏疾病；KDIGO：改善全球预后的肾脏疾病；iPTH：完整的甲状旁腺激素；CKD：慢性肾脏疾病

关键词

CKD-MBD;血液透析;塞内加尔

介绍

与矿物骨紊乱（CKDMBD）相关的慢性肾脏疾病在慢性血液透析患者中​​几乎是恒定的并发症。它们造成生命质量和心血管发病率和死亡率增加的损害。BMD在血液透析患者中​​的患病率为66.9％，具有继发性甲状旁腺功能亢进的优势[1]。由于继发性甲状旁腺功能亢进症[2,3]，它们的整体死亡率增加。CKD患者具有高风险的心血管疾病，透析患者的心血管死亡率率高于一般人群[4]。这种患病率主要是由于高磷血症及其骨骼后果以及血管钙化，特别是冠状动脉和瓣膜钙化，其风险较高了5倍[2]。这项工作是在塞内加尔第二次进行的。2014年的第一项研究仅限于达喀尔市的三个血液透析中心。第二项研究更详尽无遗，涉及全国。目标是改善结果，改善塞内加尔全人口报告的统计数据。 The objective in this study was to determine the mineralo-osseous and phosphocalcic status and the prevalence of secondary hyperparathyroidism, to evaluate the prescribed treatment and then to make a comparison with the 2009 KDIGO recommendations.

患者和方法

这是一项横断面、回顾性、描述性和分析性研究，在塞内加尔的7个血液透析中心进行了七年（2010年6月30日至2017年7月1日）。所有年龄在15岁以上，因慢性肾功能衰竭和血液透析随访至少6个月的患者均纳入本研究。这些公共和私人中心位于达喀尔（丹特克、ABC、霍吉）、圣路易斯、考拉克、齐金索和图巴。对于每个包含的文件，流行病学参数（年龄、性别、职业）、临床（骨痛、关节痛、行走困难和功能性阳痿、鼓槌指、运动受限和骨变形）、生物学参数（血钙、磷血症、iPTH、25 OH维生素D、碱性细胞磷酸酶、铝血症、血红蛋白血症、CRP、白蛋白血症）、X射线（标准X射线、甲状旁腺颈部超声、甲状旁腺成像、心脏和血管超声、胸腹CT骨盆）和治疗（口服钙、磷酸钙螯合剂、非磷酸钙螯合剂、天然和/或活性维生素D、拟钙剂、甲状旁腺切除术）。使用开发表收集数据，并在治疗干预前后进行分析。

结果

收集了315份患者档案。平均年龄为50.65±13.84岁[17和87岁]。男性占49.8%，女性占50.2%（性别比为0.99）。138名患者（43.8%）出现血管性肾病.不明原因肾病和慢性肾小球肾炎分别出现在20.3%和15.6%的病例中。透析资历为47.78个月，极端值为6个月至202个月。值得注意的是，84.8%（n=267）例患者每周进行3次持续4小时的透析；81%的患者对动静脉瘘进行透析；60名患者（19%）使用导管。在这些导管中，46名（76.7%）使用隧道导管，14名（23.3%）使用临时导管（颈静脉导管）。11名患者（3.5%）有铝中毒治疗史。

临床上有功能症状60例(19.04%)。在体检中，2.9%的患者出现异常。骨痛48例(15.2%)，关节痛32例(10.2%)，行走困难16例(5.08%)，功能性阳痿13例(4.13%)，自发性骨折9例(2.86%)，瘙痒5例(1.6%)。在生物学中，平均血清钙为88.66 mg/l[28和128 mg/l]。根据KDIGO标准，86例(66.7%)患者出现钙血症。平均完成频率为6.10个月。11.1%的患者达到标准的频率。平均磷血症为51.92 mg/l[7和304 mg/l]。81例患者(40.2%)达到了KDIGO靶点。磷酸盐的平均完成频率为6.66个月，其中8.7%的患者尊重实现KDIGO的频率。 Twenty-nine patients (9.2%) had benefited from the determination of aluminum oxide and 52% had normal aluminum level (<20 µg/l). The other characteristics of the phosphocalcic parameters are summarized in table 1. Standard radiography performed in 34 patients (10.8%) objectified: demineralization (61.3%), fractures (32.3%), resorption of phalangeal tussles (3.2%) and geodes (3.2%). 207 patients (65.7%) had undergone echocardiography; 12.1% had valvular calcifications: aortic (48%), mitral (26%) and tricuspid (26%). Supra-aortic trunk ultrasonography and thoraco-abdominal computed tomography respectively showed carotid calcification and coronary calcification. The type of bone involvement was indeterminate in 125 patients (39.7%); the diagnosis of fibrous osteitis was retained in 97 patients (30.8%), adynamic osteopathy in 4 patients (1.3%) and osteomalacia in 2 patients (0.6%). Therapeutically, phosphocalcic disorders have been corrected over a period of one year by regular medication at the recommended dose. So, 132 patients (41.9%) had benefited from calcium supplementation (1g 2-3 times/day) because of chronic hypocalcaemia. The other characteristics of phosphocalcic treatment are summarized in table 2.

特征		我们的研究	KDIGO 2009
钙	剂量（mg/l）	88.66	88-104
	实现的频率	6.10个月	1 - 3个月
磷酸盐	剂量（mg/l）	51.92	24-46
	实现的频率	6.66个月	1 - 3个月
iPTH	剂量（pg / ml）	718.35微克/毫升	150-500
	实现的频率	21.72个月	3-6个月
碱性磷酸酶（UI / L）	剂量	368,86	30 - 130
	实现的频率		一年一次
维生素D	剂量(ng / l)	23.74纳克/升	一年一次

表1:基于KDIGO建议的生物参数不同特征概述。

特征	病人人口(n)	百分比 (%)
口服钙	132.	41.9
磷酸盐螯合剂 钙(1g -3次/天) Sevelamer（800毫克，每天3-6次）	244. 224 12.	77.11 91.8 4.9
维生素D 天然(200.000单位/月)天然(0.5-1µg/天)	129. 88 26.	40.96 68.23 20.15
Cinacalcet（306180μg/天）	12.	3．8
甲状旁腺切除术	18.	5.8

表2:治疗特点总结。

三分之一的患者在临床表现上有所改善。47名患者死亡。感染、心脏和出血的原因分别占53%、8.5%和8.5%。治疗后血清钙、磷、iPTH的平均值分别为90.5 mg/l、38.5 mg/l和718 μ g/ml。在双变量分析中，透析年龄、年龄、甲状旁腺功能亢进、纤维性骨炎、骨痛和病理性骨折之间有密切的相关性，p=0.0000。血管钙化与维生素D显著相关(<30)，p为0.028。

讨论

这种回顾性，描述性，分析和多中心研究概述了塞内加尔315例血液透析患者的磷酸钙状态概述。三个主要磷酸钙参数（钙血症，磷血症和IPTH）的正常性普遍性为11.75％。这种结果低于Mahamat Abderraman等人发现的结果。[5]在达喀尔和Benabdellah等。在摩洛哥[6]患病率约为17.78％。患者的平均年龄年轻，平均为50年。年龄，骨痛和自发性骨折之间存在显着相关（p = 0.000），确认本Salah等人的结果。在突尼斯[7]。在我们的研究中展示了年龄和死亡之间的另一个紧密相关性，在英国和意大利的两项研究中报告了DoPP 2004研究[8]。这些事实将在磷酸钙紊乱的结果中解释透析患者的死亡。 The mean duration of hemodialysis in our series was 47 months, like the results of Mahamat Abderraman [5]. On the other hand, it was higher than that found by Léou S, et al. in France [9] and by Zellama, et al. in Tunisia [10], where it was respectively 24 months and 40 months. This difference could be explained by the accessibility and early use of kidney transplantation in these countries. In univariate analysis, a strong correlation (P=0.000) was noted between dialysis seniority and pathological fractures; this confirms the result of the DOPPSII study; the age of dialysis was a risk factor (Odds ratio: 2.92 between the first and third years of dialysis and 3.74 after the third year of dialysis); another positive correlation (P=0.000) with bone pain was noted. Only 3.5% of patients had a history of aluminum intoxication. Rafi, et al. [11] had objectified 15.5% of cases. Our low numbers could be explained by the improvement of water treatment rooms with double osmosis, adequate water quality control and the eviction of aluminum-based drugs. Nearly 70% of our patients had normal calcemia according to KDIGO. These results corroborate the data from the literature [12,13]. This high prevalence would be due to the fact that almost half of the patients took oral calcium in supplementation and that the dialysate calcium used in our centers was fixed at 1.5mmol/l. The average phosphatemia was 51 mg/l. More than half of our patients had hyperphosphatemia, as the results of Laradi, et al. [13] noted 50% of cases. Calcium and phosphatemia should be performed at least once every 3 months in chronic hemodialysis patients. In our study, it was greater than 6 months. The respect of the prescription of these examinations could contribute to the improvement of the clinical state of the patients and make it possible to anticipate the complications of the CKD-MBD. It is the same for hyperparathyroidism which was noted in 50% of cases. These high figures for phosphate and parathyroid hormone represent a high risk of excess mortality and cardiovascular risk with an increase in vascular calcification [13]. It was noted that 50.01% of patients had not benefited from the dosage of vitamin D certainly due to its expensive cost and low prescription by nephrologists. Its average frequency of implementation was 38.69 months against an annual dosage recommended by KDIGO. Half of the patients who had benefited from the vitamin D dosage, for the most part had low reserves. Since patients with vitamin D deficiency had a higher mortality rate [14], vitamin D supplementation would be desirable. This has been demonstrated by several studies that have reported improved survival in hemodialysis patients who have received active vitamin D [15,16]. A significant correlation (p=0.028) between deficiency (and/or insufficiency) of vitamin D and vascular calcifications was noted; this is consistent with the results found by Moradi M et al. in Iran [17]. Concerning the alkaline phosphatases, few studies have been realized, to date. In our work, it was noted that 38% of patients had a rate in the standards recommended by KDIGO. In contrast, 62% of patients had a high rate. This can be explained by the high bone turnover of secondary hyperparathyroidism (48.8%). These results were difficult to interpret because only 23.49% of patients benefited from this examination. Its average frequency of completion was 112.32 months, more than 9 times the recommended duration of KDIGO [18]. This figure remains to be improved since the alkaline phosphatase values and their evolution must be considered to assess bone turnover. In our series, 6.03% of patients had bone demineralization. This result is much lower than that found by Benabdellah, et al. [6] in Morocco with 57% and in Mauritania, et al. [19] with 33%. This discrepancy is attributable to the fact that only 10.8% of patients received standard X-rays. This also explains the difference noted for fracture traits with 3.17% for our study, 7.5% for Benabdellah, et al. [6] and 6.66% in Mauritania, et al. [19]. Only 8.3% of patients had nodules on cervical ultrasound. Ultrasonography was performed in a few patients in our study. This result contrasted with that noted by Benabdellah, et al. [6] which was 16%. There were 8.57% of valvular calcifications. These results were comparable to those of Mahamat Abderraman et al. [5] in Dakar, of Benabdellah et al. in Morocco [6] who found respectively 11.1% and 9% of cases. This high rate could be explained by the average duration of hemodialysis that was 4 years and the fact that more than half of the patients had hyperphosphatemia. Thus, the interest of a good control of the phosphocalcic metabolism resides, not only in the improvement of the quantity and the bone quality of the patients and thus, in the prevention of the fracture risk; but also, in the fight against the formation of the vascular calcifications and other extra bone calcifications. It is well established that vascular calcification is partly related to mineral disorders in dialysis patients; and they are responsible for worsening cardiovascular morbidity and mortality in this already high-risk population [20]. Lindner et al. had noted in their study a very high morbidity and mortality from cardiovascular complications related to accelerated atherosclerosis [20]. In univariate analysis, there was a significant correlation between vascular calcifications with vitamin D deficiency and/or insufficiency. In bivariate analysis, the iPTH level did not influence the occurrence of vascular calcification (p=0.066). This was consistent with numerous studies by Bellasi, et al. [21], Sayarliogu, et al. [22] and Strozecki, et al. [23] who also found no association between biological parameters including serum calcium, phosphorus, iPTH levels and valvular calcifications.

结论

CKD-MBD在塞内加尔的慢性血液透析患者中很常见。三个主要磷钙参数(钙血症、磷血症和PTHi)正常的患病率为11.75%。CKD-MBD血液透析患者的总死亡率因继发性甲状旁腺功能亢进而增加。在我们的研究中，平均甲状旁腺功能亢进为718 pg/ml，因此导致了47例死亡患者的高死亡率。我们的结果清楚地显示出显著的高磷血症，甲状旁腺功能亢进和维生素D水平非常低。这些检查的频率也是如此，是推荐时间的两倍。在血清钙和磷血症中达到这一目标的频率大于6个月。这项研究考虑了塞内加尔所有的血液透析中心，与我们在2014年进行的研究相比，该研究给出了更精确的磷钙参数，并且仅限于达喀尔地区。这些结果鼓励遵从KDIGO的建议。这包括尊重临床旁检查和纠正磷钙紊乱的常规处方。 But its results remain perfectible because all hemodialysis patients had not benefited from the dosage of all parameters.

利益冲突

作者不会宣布任何兴趣冲突。

工具书类

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文章信息

文章类型:研究文章

引用:Mahamat Abderraman G, Cisse MM, Mouhatta O(2018)评价塞内加尔慢性血液透析患者的磷钙概况。Int J Nephrol Kidney Fail 4(4): dx.doi.org/10.16966/2380-5498.165

版权:©2018 Mahamat Abderraman G，等这是在创意公约归因许可的条款下分发的开放式文章，其允许在任何媒体中不受限制地使用，分发和再现，只要原始作者和来源被记入。

出版历史记录：

收到日期：2018年11月05

接受日期:2018年11月22日

发表日期:2018年11月28日,