Kev Tswj Xyuas Cov Khoom Siv Hluav Taws Xob Thiab Cov Pob Txha Tom Qab Hloov Raum
Feb 20, 2022
Kamyar Kalantar-Zadeh, MD, MPH, PhD1,2,3,4,*ua al
Abstract
Lub hom phiaj ntawm kev tshuaj xyuas- Cov kab mob tsis xws luag thiab pob txha (MBD), cov teeb meem hauv nruab nrab thiab qib siabmob raum mob(CKD), feem ntau tshwm sim hauvraumhloov pauvcov neeg txais. Txawm li cas los xij, muaj ntau qhov tsis meej pem txog kev siv tshuaj ntsuam xyuas cov cuab yeej kuaj mob thiab cov tswv yim tiv thaiv lossis kev kho mob los kho cov pob txha los yog cov pob zeb tsis zoo hauv cov neeg mob hloov chaw. Peb tau tshuaj xyuas cov pov thawj tsis ntev los no hais txog kev nthuav dav thiab qhov tshwm sim ntawm MBD hauvraumhloov pauvcov neeg tau txais kev pab thiab tshuaj ntsuam xyuas, kev tiv thaiv, thiab kev kho mob rau qhov kawg no.
Kev tshawb pom tsis ntev los no- Cov kab mob pob txha qis qis tshwm sim ntau dua tom qabraumtransplantation raws li kev tshawb fawb ntawm pob txha biopsy. Qhov kev pheej hmoo ntawm pob txha yog siab, tshwj xeeb tshaj yog nyob rau thawj ob peb lub hlis tom qab hloov lub raum. Kev hloov pauv hauv cov zaub mov (calcium, phosphorus, thiab magnesium) thiab biomarkers ntawm cov pob txha metabolism (PTH, alkaline phosphatase, vitamin D, thiab FGF-23) raug soj ntsuam nrog ntau yam cuam tshuam rau cov txiaj ntsig tom qab hloov pauv. Calcineurin inhibitors yog txuas rau osteoporosis, qhov kev kho steroid tuaj yeem ua rau ob qho tib si osteoporosis thiab ntau qib ntawm osteonecrosis. Sirolimus thiab everolimus tej zaum yuav muaj kev cuam tshuam ntawm osteoblasts 'kev loj hlob thiab kev sib txawv los yog txo cov pob txha osteoclast-mediated resorption. Cov kev xaiv kws tshuaj rau kev kho mob MBD hauv cov neeg mob hloov pauv suav nrog kev tshem tawm steroid, kev siv bisphosphonates, vitamin D derivatives, calcimimetics, teriparatide, calcitonin, thiab denosumab.
Cov ntsiab lus-MBD tom qabraumKev hloov pauv yog ib txwm muaj thiab pom los ntawm kev poob ntawm cov pob txha ntim thiab cov ntxhia pob zeb txawv txav feem ntau ua rau cov pob txha tsis tshua muaj kab mob. Txawm hais tias tsis muaj cov txheej txheem kho mob zoo rau kev tswj hwm ntawm MBD hauvlub raumCov neeg tau txais kev hloov pauv, cov kws kho mob yuav tsum txuas ntxiv kev kho tus kheej raws li xav tau.
Ntsiab lus:Lub raumosteodystrophy; bisphosphonates; pob txha; calcineurin inhibitor; adynamic pob txha
Hu rau:joanna.jia@wecistanche.com/ WhatsApp: 008618081934791
Cistanchedeserticola tiv thaivraumkab mob
Taw qhia
Kev hloov pauv ntawm cov khoom nruab nrog cev yog ib qho kev kho mob uas muaj txiaj ntsig zoo rau qhov kawg-theem tsis ua haujlwm ntawm cov kabmob no. Covraumyog nyob deb ntawm qhov feem ntau hloov cov khoom nruab nrog cev ob qho tib si hauv Teb Chaws Asmeskas thiab thoob plaws ntiaj teb.1 Ua ntej hauv kev kho cov tshuaj tiv thaiv kab mob thiab cov kev hloov pauv hauv lub xyoo dhau los tau txhim kho allograft thiab cov neeg mob muaj sia nyob, txawm hais tias muaj sia nyob ntev ntawm qee cov neeg ua haujlwm tseem tseem yuav ua kom pom.2 Kev hloov pauv tau zoo muaj peev xwm thim rov qab ntau yam teeb meem ntawm theem kawgraumkab mob; Txawm li cas los xij, kev cuam tshuam ntawm cov pob txha thiab cov ntxhia hauv cov metabolism, tseem hu ua "mineral thiab pob txha tsis zoo" (MBD), tuaj yeem tshwm sim, thaum cov pob txha tshiab kuj tuaj yeem tshwm sim los ntawm kev hloov tshuaj cuam tshuam. MBD yog qhov tshwm sim ntawm tus kab mob raum ntev (CKD) thiab feem ntau pom ob qho tib si hauv cov neeg mob uas tsis yog lim ntshav CKD3 thiab tu cov neeg mob lim ntshav.4 Txawm hais tias cov kab mob pob txha tau raug lees paub tias yog ib qho teeb meem tshwm sim hauv cov neeg tau txais kev hloov hauv lub raum, kev siv niaj hnub siv. Cov cuab yeej kuaj mob txaus thiab cov tswv yim tiv thaiv lossis kev kho mob los kho cov pob txha tsis zoo lossis cov pob zeb hauv av feem ntau yuav yog qhov zoo. Hauv kev tshuaj xyuas no, peb sau cov ntaub ntawv tshiab hais txog qhov tshwm sim thiab qhov tshwm sim ntawm cov kab mob pob txha thiab pob txha (MBD) hauv cov neeg tau txais kev hloov hauv lub raum thiab tshuaj xyuas kev kuaj mob, kev tiv thaiv, thiab kev kho mob rau cov mob no.
Hom pob txha tsis zoo nyob rau hauv raum hloov cov neeg tau txais kev pab
Lub cim tseem ceeb ntawm MBD yog lub raum osteodystrophy, tseem hu ua "raumCov kab mob pob txha", 4 uas tau muab faib ua plaub pawg loj (Daim duab 1): (1) kab mob siab ntawm pob txha, (2) adynamic lossis qis turnover pob txha kab mob, (3) sib xyaw raum osteodystrophy, thiab (4) osteomalacia.5, 6 Cov pov thawj tsis ntev los no qhia tias lub raum osteodystrophy thiab nws cov laj thawj tseem ceeb suav nrog kev ua haujlwm tsis zoo ntawm parathyroid thiab kev tsis sib haum xeeb hauv cov vitamin D thiab FGF-23 muaj feem xyuam rau cov kab mob plawv thiab kev tuag. Table 1 qhia cov yam ntxwv tseem ceeb ntawm 4 hom kab mob uremic pob txha. .7 Cov kev tshawb pom los ntawm cov ntaub ntawv dhau los ntawm cov pob txha txawv txav hauv cov neeg mob tom qab hloov lub raum yog qhov tsis sib haum xeeb. Kev loj hlob ntawm cov pob txha loj heev cuam tshuam nrog kev pheej hmoo ntawm cov kab mob hyperparathyroidism theem nrab; 8,10,11,16 ib txwm tsim cov pob txha; 9 los yog cov pob txha qis (saib Table 1).14,15 Ntev ntev mineralization tsis muaj osteoid Kev sib sau tau pom nyob rau hauv qee qhov kev tshawb fawb ib yam nkaus, 8,14,15 whereas frank osteomalacia tsis tshua pom nyob rau hauv cov neeg tau txais kev hloov raum.12,13,17
Cov kev tshawb pom los ntawm Bone Biopsy Studies
Hauv kev tshawb fawb los ntawm Monier-Faugere thiab al18 hauv 56 feem ntauraumHloov cov neeg mob uas tau kuaj xyuas cov pob txha, cov pob txha pob txha / cov ntaub so ntswg ntim qis dua li ib txwm nyob hauv cov neeg mob feem ntau piv rau cov hnub nyoog- thiab poj niam txiv neej-match tswj kev kawm. Cov kev tshawb pom pob txha zoo sib xws tau tshaj tawm hauv kev tshawb fawb ntev los ntawm Cruz thiab al19 hauv 20 tus neeg mob ua ntej thiab tom qab ntawd 6 lub hlis tom qab.raumhloov pauv. Pre-transplant pob txha histomorphometric kev kuaj mob yog adynamic pob txha kab mob (n=12); kab mob sib xyaw (n=3); kab mob me (n=3); thiab osteitisfibrosa (n=2). Tom qab hloov pauv cov neeg mob feem ntau (n=11) muaj cov kab mob adynamic pob txha.
19 Rojas et al.20 tau qhia tias osteoid ntim, osteoid thickness, osteoid resorption nto, thiab osteoclasst nto yog saum toj no ntau yam ua ntej hloov thiab tseem nyob li ntawm 35 hnub tom qab transplantation; Txawm li cas los xij, qhov chaw osteoid thiab osteoblast tau txo qis hauv 35 hnub tom qab hloov pauv.20 Tseem muaj kev cuam tshuam ntawm cov pob txha tsim thiab mineralization nrog rau apoptosis, uas cuam tshuam nrog cov koob tshuaj ntawm cov tshuaj glucocorticoids.20 Hauv qhov sib piv rau qhov kev tshawb pom saum toj no, kev tshawb fawb ntev. los ntawm Lehman et al21 tau tshaj tawm ntau qhov kev tshawb pom heterogeneous biopsy.
Ua ke ua ke cov pob txha biopsy kev tshawb fawb hauvraumCov neeg tau txais kev hloov pauv, cov kab mob pob txha tsis tshua muaj xws li cov pob txha dynamic thiab osteomalacia zoo li tshwm sim. Feem ntau cov neeg tau txais kev hloov hauv lub raum pom qhov txo qis ntawm cov pob zeb hauv av thiab ncua kev ua kom tsis muaj zog uas tuaj yeem nrog cov PTH txo qis nrog rau cov neeg mob uas muaj cov kab mob me me ua ntej hloov pauv14 thiab leej twg tau txais cov koob tshuaj ntau ntawm glucocorticoids.18 Ntau cov kev tshawb fawb feem ntau qhia txog kev hloov pauv zoo ib yam. nrog rau cov pob txha dynamic kab mob thiab nce deposition ntawm hlau nyob rau hauv lub mineralization pem hauv ntej; 15 Txawm li cas los xij, qee qhov kev tshawb fawb qhia tias cov pob txha txo qis thiab lub sij hawm ntev mineralization lag nyob rau hauv lub xub ntiag ntawm persisting pob txha resorption.8,22,23 Li no, txawm qhov sib txawv ntawm ntau cov pob txha. Kev tshawb fawb biopsy, qhov kev hloov pauv tseem ceeb hauv cov pob txha hloov kho tom qab hloov lub raum yog qhov txo qis hauv cov pob txha tsim thiab cov ntxhia hauv lub ntsej muag ntawm cov pob txha tsis tu ncua, uas tuaj yeem ua rau muaj qhov tsis txaus ntseeg hauv kev kho kom haum rau resorption. Ib yam li ntawd, kev tsim cov pob txha tsis zoo yuav yog qhov tshwm sim ntawm kev hloov pauv hauv osteoblast muaj nuj nqi, txo osteoblastogenesis, lossis nce osteoblast tuag. Cov kev tshawb fawb ntawm pob txha ntau ntxiv hauv ntau tus neeg tau txais kev hloov hauv lub raum yog xav tau kom nkag siab zoo dua qhov cuam tshuam ntawm cov pob txha ua ntej thiab kev tiv thaiv kev tiv thaiv kab mob ntawm cov pob txha histology hauv cov neeg mob no.
Txo cov pob txha Mineral ntom thiab Osteoporosis
Poob pob txha loj tom qabraumKev hloov pauv ua rau osteopenia lossis osteoporosis tshwm sim feem ntau hauv thawj 12 lub hlis, feem ntau hauv cov pob txha cortical. Qhov txo qis tshaj plaws hauv pob txha pob txha pob txha ntom ntom (BMD) [tsis txhob cuam tshuam nrog MBD] ntsuas los ntawm dual-zog X-ray absorptiometry tshwm sim hauv thawj 6 lub hlis tom qab hloov pauv thiab zoo li qeeb tom qab ntawd, tej zaum yuav cuam tshuam txog kev txo qis corticosteroid koob tshuaj. BMD tau tshaj tawm tias yuav txo qis ntawm qhov nruab nrab ntawm 5.5 feem pua rau 19.5 feem pua thaum thawj 6 lub hlis tom qab hloov pauv, 14,24,25 tab sis tsuas yog 2.6–8.2 feem pua ntawm lub hlis 6 thiab 12,26,27 thiab 0 .4-4.5 feem pua tom qab ntawd.28,29
Risk ntawm Fracture
Qhov kev pheej hmoo tag nrho tom qab hloov lub raum yog 3.6–3.8-faj siab dua hauv cov neeg noj qab haus huv, 30, 31, thiab yog 30 feem pua siab dua hauv thawj 3 xyoos tom qab hloov pauv dua li cov neeg mob ntshav lim ntshav.30 Hauv kev rov qab los txoj kev tshawb fawb nrog lub sijhawm rov qab mus txog 33 xyoo, lub hnub nyoog siab dua thiab keeb kwm ntawm ntshav qab zib nephropathy yog tus kws tshaj lij ntawm kev pheej hmoo ntawm pob txha, qhov kev ua haujlwm siab dua yog kev tiv thaiv.31 Ntxiv cov kev pheej hmoo rau pob txha hauvraumCov neeg tau txais kev hloov pauv muaj xws li poj niam txiv neej thiab ua keraum-pancreas transplantation.32-35 Zoo ib yam li muaj kev pheej hmoo tuag ntxiv rau thawj ob peb lub lis piam tom qabraumKev hloov pauv ua raws li kev poob qis hauv kev tuag tom qab ntawd thaum piv rau cov neeg mob ntshav qab zib uas tau tos, cov txheeb ze ntawm kev pheej hmoo ntawm pob txha pob txha yog 34 feem pua ntau dua hauv thawj ob peb lub lis piam tom qab hloov pauv hloov pauv piv rau cov neeg mob lim ntshav tab sis txo qis tsawg kawg yog 1 feem pua ntawm ib hlis kom txog rau thaum kwv yees. Kev pheej hmoo tau sib npaug rau cov neeg tau txais kev lim ntshav thiab hloov pauv li ntawm 630 hnub tom qab hloov pauv.30 Nws yog ib qho tseem ceeb uas yuav tsum nco ntsoov tias cov neeg tau txais kev hloov pauv lub raum yog qhov muaj feem cuam tshuam ntawm vertebral pob txha thiab qhov kev pheej hmoo no ntau dua li lawv txoj kev pheej hmoo ntawm qis qis qis.31
Mineral Metabolism tom qab hloov raum
Kev hloov pauv hauv cov metabolism hauv cov ntxhia xws li cov cim biomarkers ntawm cov pob txha kab mob xws li PTH thiab alkaline phosphatase yog ib txwm muaj tom qab ua tiav.raumhloov pauv. Tsis ntev los noLub raumDisease Initiative Global Outcomes (KDIGO) cov lus qhia 36 tau thov kom muaj kev saib xyuas ib ntus ntawm cov ntshav calcium, thiab phosphorus txhua 6–12 lub hlis, 3–6 lub hlis, 1–3 lub hlis, hauv CKD theem 1–3T, 4T, thiab 5T, raws li, thaum PTH yuav tsum. kuj raug ntsuas ntawm 3-12 lub hlis ib ntus raws li qhov hnyav ntawm CKD. Kev ntsuas ntawm alkaline phosphatase yuav tsum tau ua txhua xyoo lossis ntau zaus thaum muaj PTH siab raws li cov lus qhia tib yam.
Calcium tshuaj
Muaj ntau ntau yam uas yuav ua rau muaj kev kub ntxhov lossis ua rau hypercalcemia tom qab ua tiavraumhloov pauv: (1) persistently elevated serum PTH, (2) correction of hyperphosphatemia; and (3) improved 1,25(OH)2 vitamin D production from the allograft. Although severe hypercalcemia (>3 mmol/l or >12 mg/dL) is rarely observed, hypercalcemic episodes (defined as total serum calcium >2.62 mmol/l or >10.5 mg / dL) tau tshaj tawm hauv 30 feem pua thiab 12 feem pua ntawm cov neeg tau txais kev hloov pauv raum, 1 xyoo thiab 5 xyoos tom qab hloov pauv, feem.37 Hauv kev tshawb fawb tsis ntev los no, tom qab hloov pauv hypercalcemia tsis cuam tshuam nrog cov pob txha hloov pauv txawv txav.38 Hauv ib txoj kev tshawb nrhiav hyperkalemia tshwm sim los cuam tshuam nrog interstitial micro-calcifications hauv lub raum allograft thiab cov txiaj ntsig tsis zoo rau lub sijhawm ntev graft.39
Cov tshuaj phosphorus
Hyperphosphatemia (phosphorus >4.5 mg / dL) feem ntau tshwm sim hauv cov neeg mob ua ntej hloov pauv, thaum hypophosphatemia (phosphorus)<2.5 mg/dl)="" is="" observed="" much="" more="" frequently="" after="" renal="" transplantation,="" especially="" in="" the="" first="" few="" weeks="" postoperatively.17,40-42="" decreased="" phosphorus="" reabsorption="" in="" the="" proximal="" tubule,="" potentially="" related="" to="" persistently="" elevated="" pth="" or="" fgf-23="" levels,="" and="" a="" quasi="" "hungry="" bone="" syndrome"="" seem="" to="" be="" mechanisms="" responsible="" for="" post-transplantation="" hypophosphatemia.="" hypophosphatemia="" has="" been="" associated="" with="" severe="" alterations="" in="" bone="" turnover="" that="" include="" a="" decrease="" in="" osteoblast="" activity="" that="" leads="" to="" rickets="" and="" osteomalacia.17,43="" several="" recent="" studies="" indicate="" that="" post-transplantation="" hypophosphatemia="" frequently="" is="" independent="" of="" pth,44="" suggesting="">
FGF-23,45-47 los yog tej zaum lwm yam kev lom zem ntxiv (lwm yam phosphating) ua rau phosphaturia nyob rau thaum ntxov tom qab hloov lub sij hawm.41,42 Ob qho tib si pre-transplant48 thiab post-transplant49 serum phosphorous derangements tshwm sim muaj feem xyuam. nrog anemia 50 thiab kev pheej hmoo tuag hauvraumhloov pauvcov neeg txais.
Cov tshuaj Magnesium
Hypomagnesemia, uas yog ib qho mob tshwm sim, tshwj xeeb tshaj yog nyob rau thawj ob peb lub lis piam tom qab hloov lub raum, kuj yog ib qho kev ywj pheej kwv yees ntawm qhov pib mob ntshav qab zib mellitus tshiab (de novo) hauv cov neeg tau txais kev hloov pauv raum.51 Xya caum txog 80 feem pua ntawm cov ntshav magnesium yog lim dawb ntawm. cov glomerulus thiab feem ntau (txog 97 feem pua) yog reabsorbed thoob plaws hauv lub nephron. Calcineurin inhibitors suav nrog cyclosporine A tuaj yeem cuam tshuam nrog magnesium metabolism ua rau txo qis magnesium reabsorption, tso zis magnesium nkos, thiab hypomagnesemia hauv cov neeg mob lub raum hloov pauv tau txais cov tshuaj tiv thaiv kab mob no.52 Txoj kev tshawb fawb tsis ntev los no qhia tias cov tshuaj magnesium qis hauv cov ntshav tau cuam tshuam nrog kev txo qis hauv cov ntshav. lub raum allograft muaj nuj nqi thiab nce nqi ntawm graft poob nyob rau hauv lub raum hloov neeg tau txais kev kho mob nrog cyclosporine nephropathy.52 Seb hypomagnesemia per se pab rau cyclosporine nephropathy, los yog seb magnesium supplementation yuav txo tau lub cyclosporine nephropathy yog tsis meej.
PTH thiab Alkaline Phosphatase
PTH levels usually decline rapidly (>50 feem pua ) thaum thawj 3-6 lub hlis tom qab hloov lub raum vim qhov txo qis hauv cov qog ua haujlwm parathyroid qog, 53 ua raws li kev poob qis dua tej zaum yuav tshwm sim los ntawm kev cuam tshuam qeeb ntawm cov qog no.16,37 Txawm li cas los xij, tsis tu ncua nce qib ntawm cov ntshav. PTH txawm hais tias normalization ntawm lub raum ua haujlwm tau raug tshaj tawm txog li 25 feem pua ntawm cov neeg tau txais kev hloov lub raum 1 xyoo tom qab hloov pauv.
37,54 Cov no hu ua refractory (los yog tertiary) hyperparathyroidism mob tej zaum yuav tshwm sim los ntawm monoclonal glandular hyperplasia.55,56 Muaj ntau yam uas cuam tshuam nrog kev pheej hmoo tom qab hloov pauv hyperparathyroidism xws li cov kab mob hauv lub raum ntev ntev ua ntej hloov pauv. , 37,57,58 txo qis rau lub raum ua haujlwm, 59 qib qis ntawm 1,25(OH)2- thiab 25(OH) vitamin D, thiab txo qis kev qhia ntawm vitamin D thiab calcium-sensing receptors thiab kuj txo cov kev qhia ntawm FGF-23 receptors nyob rau hauv lub caj pas parathyroid. 54,60-62 Ob qho tib si ua ntej hloov pauv 63 thiab tom qab hloov pauv 39 qib ntshav qab zib PTH cuam tshuam nrog cov txiaj ntsig tsis zoo suav nrog kev ua haujlwm tsis zoo. Txawm li cas los xij, nws yog ib qho tseem ceeb uas yuav tsum nco ntsoov tias ob txoj kev tshawb fawb uas ntsuas cov pob txha biopsy hauvraumCov neeg tau txais kev hloov pauv tsis pom qhov sib cuam tshuam ntawm cov ntshav qab zib PTH thiab cov pob txha hloov pauv, 18,38 thiab kev kuaj pom tseeb ntawm PTH tsis yog qhov tseeb.64 Cov kev kho mob rau hyperparathyroidism tau sau tseg hauv qab no. Cov pob txha tshwj xeeb alkaline phosphatase muaj kev sib raug zoo nrog calcitriol thiab txaus qhia txog kev tsim cov pob txha ntxiv tom qab hloov lub raum.65 Cov qib siab ntawm alkaline phosphatase, tab sis tsis yog PTH hauv lub hlis ua ntej hloov lub raum tuaj yeem ua rau tsis zoo tom qab hloov cov txiaj ntsig (Miklos Z. Molnar. thiab cov npoj yaig, kev sib txuas lus ntawm tus kheej).
Cistanche tuaj yeem txo cov kab mob raum
Vitamin D thiab FGF-23
Cov ntshav qis qis 25-OH-D ntau ntau yog tshwm sim tom qab hloov khoom nruab nrog cev, ob qho tib si thaum lub sijhawm tom qab phais tas li thiab cov neeg tau txais txiaj ntsig mus ntev.66 Raws li KDIGO cov lus qhia36 raum hloov cov neeg mob yuav tsum tau soj ntsuam rau qhov muaj vitamin D. tsis muaj peev xwm los ntawm kev tshuaj xyuas cov theem ntawm 25-(OH) vitamin D (calcidiol), thiab vitamin D deficiency thiab insufficiency yuav tsum raug kho siv cov tswv yim kho mob pom zoo rau cov pej xeem. Txawm hais tias qib ntawm 1,25 (OH) 2 vitamin D (calcitriol) feem ntau nce tom qab ua tiav lub raum engraftment, nws tseem yuav nyob qis dua piv rau cov neeg ib txwm. D qib yog cov tshuaj tiv thaiv kab mob, qib PTH, thiab lub raum tsis ua haujlwm.45 Txoj kev tshawb fawb los ntawm Evenepoel li al. pom qhov nce siab ua ntej hloov pauv PTH thiab qib qis tom qab hloov pauv ntawm FGF23 los ua qhov kev kwv yees ntxiv ntawm kev txhim kho tom qab hloov pauv 1,25 (OH) 2 qib vitamin D, txawm hais tias cov no tsis muaj zog tshaj lub raum graft function.45
FGF-23 per se zoo nkaus li yog qhov muaj zog thiab muaj kev ywj pheej kwv yees ntawm kev tuag hauv cov neeg tau txais kev hloov pauv raum.67
Preexisting Osteodystrophy
Yuav luag txhua tus neeg mob uas tau txais lub raum allograft raug kev txom nyem los ntawm qee qhov kev mob ntawm cov pob txha preexisting. Qhov tshwm sim thiab qhov tshwm sim ntawm cov kab mob uas tsis tshua muaj tshwm sim hauv pob txha tuaj yeem tau nce tsis ntev los no, tej zaum yog vim muaj ntau dua dialysate calcium concentrations (1.75 mmol / L [3.5 mEq / L]), ntau cov calcium uas muaj phosphate binders, thiab muaj peev xwm overzealous. Kev siv cov active vitamin D metabolites. Nws tsis paub meej tias MBD uas twb muaj lawm ua ntej muaj qhov tshwm sim tseem ceeb ntawm cov txiaj ntsig tom qab hloov pauv; Txawm li cas los xij, qee qhov chaw hloov pauv tau txiav txim siab rau cov neeg mob lim ntshav nrog qib PTH siab ua cov neeg sib tw tsis zoo rau kev hloov lub raum, uas zoo ib yam li cov cai cuam tshuam txog lub cev qhov hnyav thiab kev rog uas tsis ntev los no tau raug teeb meem.68
Cov teebmeem ntawm kev hloov pauv-Tshwj xeeb kho rau pob txha
Tom qab hloov cov tshuaj tiv thaiv kab mob tiv thaiv kab mob tuaj yeem muaj feem cuam tshuam loj rau cov kab mob ntawm cov pob txha. 69-72 Lub luag haujlwm ntawm corticosteroids paub zoo. Thaum thawj ob peb lub hlis tom qab hloov pauv, cov pob txha sai sai tom qab hloov mus rau steroid-induced acceleration nyob rau hauv cov pob txha remodeling tshwm sim nyob rau hauv cov pob txha cancellous.14 Ib txoj kev tshawb no uas koom nrog serial pob txha biopsies ntawm 22 hnub thiab 160 hnub tom qab transplantation pom impaired osteoblastogenesis thiab thaum ntxov osteoblast apoptosis tej zaum yuav muaj feem xyuam. mus rau steroid therapy.20 Lub etiology ntawm glucocorticoid-induced pob txha tsis meej yog ntau-factorial.73-75 Steroids tuaj yeem ua rau osteoblasts ncaj qha thiab ua rau muaj zog osteoclast.75 Lwm cov teebmeem steroid suav nrog txo calcium nqus hauv plab, txo gonadal cov tshuaj hormone ntau lawm, txo qis insulin-zoo li kev loj hlob factor-1 (IGF-1) ntau lawm, txo rhiab heev rau PTH, nce receptor activator ntawm NF-kappa beta ligand (RANKL), thiab nce osteoclastogenesis.75-77
Calcineurin inhibitors suav nrog cyclosporine thiab tacrolimus tau txuas rau osteoporosis.78,79 Epidemiologic cov kev tshawb fawb uas tau tshuaj xyuas kev pheej hmoo ntawm pob txha, txawm li cas los xij, tsis tuaj yeem tsim kev koom tes ntawm kev siv calcineurin inhibitors thiab fracture risk.31,80 Txawm hais tias mycophenolate mofetil, sirolimus, thiab azathioprine tsis cuam tshuam rau pob txha ntim hauv cov nas,81-83 kev tshawb fawb hauv vitro tsis ntev los no qhia tias sirolimus tuaj yeem cuam tshuam nrog kev loj hlob thiab kev sib txawv ntawm osteoblasts, 84 thaum everolimus txo cov pob txha poob hauv ovariectomized nas los ntawm kev txo qis osteoclast-mediated pob txha resorption. Calcineurin- inhibitor-induced pain syndrome tej zaum yuav tshwm sim los ntawm kev mob osteonecrosis, nrog rau cov pob txha mos edema ib ntus. intraosseous siab, cuam tshuam vascular mov, mob plab edema, thiab kev loj hlob ntawm 'pob txha compartment syndrome'.{{12} } Kev kho mob steroid yog lwm qhov kev pheej hmoo rau osteonecrosis nyob rau hauv lub raum hloov cov neeg txais.87 Mechanisms tej zaum yuav muaj xws li kev sib txawv ntawm mesenchymal qia hlwb rau adipocytes ua rau muaj zog intraosseous siab thiab vau ntawm cov pob txha sinusoids, thiab nce osteoblast thiab osteocyte apoptosis. Calcineurin-inhibitors, tshwj xeeb tshaj yog cyclosporine A, tuaj yeem ua rau muaj kev pheej hmoo ntawm osteonecrosis vim yog vasoconstrictive cuam tshuam, thiab sirolimus tuaj yeem cuam tshuam rau kev txhim kho osteonecrosis los ntawm kev ua kom muaj zog ntawm calcineurin inhibitors lossis los ntawm kev cuam tshuam cov lipid profile. 86
Chronic Allograft Nephropathy Associated MBD
Maj mam ua tsis tau allografts tuaj yeem ua rau tom qab hloov pauv CKD theem 3-5T ua rau muaj kev pheej hmoo ntawm kev loj hlob zuj zus lossis de novo kev loj hlob ntawm hyperparathyroidism, active vitamin D tsis txaus thiab tag nrho cov spectrum ntawm "classic" MBD uas tau pom nyob rau hauv kev hloov pauv-naïve. - CKD cov neeg mob.3,59 Hauv kev tshawb fawb ntawm ntau dua 900 tus neeg mob hloov pauv PTH pom qhov cuam tshuam tsis zoo nrog kwv yees GFR hauv CKD theem 3-5T (r=-0.29, P<0.001).59 high="" pth="" values="" correlate="" with="" significant="" bone="" loss="" at="" the="" hip="" and="" other="" areas.88="" given="" recent="" data="" that="" delaying="" the="" return="" to="" dialysis="" therapy="" may="" be="" associated="" with="" better="" survival="" in="" gradually="" failing="" kidney="" transplant="" recipients,89,90="" higher="" rates="" of="" mbd="" are="" to="" be="" expected="" in="" the="" prevalent="" transplant="">
Kev tswj hwm ntawm MBD hauv raum hloov cov neeg tau txais kev pab
Ntau cov kev coj ua thiab kev tshuaj xyuas cov kws tshaj lij tuaj yeem siv los tsim cov lus pom zoo rau kev tiv thaiv, kev kuaj mob, thiab kev tswj cov kab mob pob txha thiab cov kab mob tsis zoo hauv cov neeg tau txais kev hloov pauv raum.36,91,92 Txog rau hnub no, tsis muaj kev sim tshuaj randomized hauv cov neeg tau txais kev hloov hauv lub raum tau kuaj xyuas. Cov txiaj ntsig ntawm kev kho pob txha tshwj xeeb rau cov txiaj ntsig kho mob, suav nrog kev tuag, kev ua neej zoo, lossis kev pheej hmoo ntawm pob txha.36 Hauv cov neeg mob hloov lub plawv alendronate tau zoo li calcitriol los tiv thaiv cov pob txha.93 Table 2
shows a list of selected studies pertaining to MBD management in renal transplant recipients. The KDIGO guidelines36 recommend treatment with active vitamin D (calcitriol or alfacalcidol) or bisphosphonates in the first 12 months after kidney transplant in those with estimated GFR>30 mL / min / 1.73 m2 thiab cov pob txha pob txha tsawg tsawg, thiab kev txiav txim siab ntawm pob txha biopsy los qhia kev kho mob, tshwj xeeb tshaj yog ua ntej siv cov bisphosphonates vim muaj qhov tshwm sim ntawm cov pob txha dynamic. Kev tshuaj xyuas Cochrane Database, txawm li cas los xij, qhia tias tsis muaj hom kev kho mob MBD cuam tshuam nrog kev muaj sia nyob zoo dua hauv cov neeg tau txais kev hloov hauv lub raum, txawm hais tias kev kho mob txo qhov kev pheej hmoo ntawm pob txha.92 Kev xaiv tshuaj kho mob rau kev kho mob MBD hauv cov neeg mob hloov pauv tau teev nyob rau hauv Table 3 thiab suav nrog steroid tshem tawm, bisphosphonates, vitamin D derivatives, calcimimetics, teriparatide, calcitonin, thiab denosumab.
Steroid tshem tawm lossis zam
Qhov laj thawj rau kev txo qis kev raug mob corticosteroid yog qhov nyuaj thiab ua raws li kev pheej hmoo ntawm kev mob pob txha, avascular necrosis, thiab lwm yam kev mob tshwm sim. Qee cov kev tshawb fawb pom tau tias muaj txiaj ntsig zoo ntawm kev ua kom ntxov ntxov ntawm prednisolone ntawm BMD.123,124 Hauv qhov sib piv, txawm li cas los xij, kev sim tshuaj ntsuam xyuas randomized tau pom tias kev tshem tawm steroid, thaum nqa tawm lub lis piam mus rau hli tom qab hloov lub raum, cuam tshuam nrog kev pheej hmoo ntawm kev tsis lees paub.125,126 Li no. , tam sim no KDIGO cov lus qhia 36 tam sim no tsis pom zoo kom tshem tawm cov tshuaj steroid thiab kev zam raws li kev ua haujlwm niaj hnub.
Bisphosphonates
Bisphosphonates (tseem hu ua diphosphonates) muaj ob pawg phosphonates (PO3) thiab siv los tiv thaiv pob txha loj thiab kho pob txha thiab lwm yam mob osteopenic. Daim duab 2 qhia txog cov ntsiab lus ntawm cov txiaj ntsig ntawm kev tshawb fawb bisphosphonates hauv cov neeg tau txais kev hloov hauv lub raum. Hauv plaub qhov kev tshawb fawb ntawm ntau koob tshuaj pamidronate thaum pib lub hlis tom qab hloov lub raum, kev tiv thaiv ntawm cov pob txha tsis tau tshwm sim txawm tias tom qab kev kho mob raug txiav tawm lawm. Txawm hais tias cov kab mob pob txha qis qis tuaj yeem txhim kho lossis ua phem rau ntau tus neeg mob.99,100 Cov txiaj ntsig zoo sib xws tau pom thaum alendronate raug tswj hwm.94,105 Intravenous ibandronate tau siv los ntawm Grotz et al.103 hauv 80 randomly muab cov neeg tau txais kev hloov pauv ntawm koob tshuaj 1 mg tam sim ua ntej. kev hloov pauv thiab 2 mg ntawm 3, 6, thiab 9 lub hlis tom qab hloov pauv thiab ua kom pom kev tiv thaiv cov pob txha poob, txha nraub qaum deformation, thiab poob ntawm lub cev qhov siab thaum thawj xyoo tom qab hloov lub raum.103 Lwm randomized tswj kev sim ntawm 20 lub raum hloov pauv tau pom tias zoledronate txhim kho cov calcium cov ntsiab lus ntawm cov pob txha pob txha.97 Raws li seb qhov kev cuam tshuam luv luv no ua rau muaj kev cuam tshuam dab tsi. Kev txhawb nqa pob txha-sparing nyhuv tom qab lub sij hawm, nyob rau hauv lwm txoj kev tshawb fawb zoledronate therapy conferred tsis muaj txiaj ntsig zoo piv rau cov placebo tom qab 3 xyoos tom qab hloov pauv.98 Lub lis piam qhov ncauj nce siab tam sim tom qab hloov lub raum tuaj yeem txhim kho BMD, tshwj xeeb tshaj yog nyob rau hauv caj dab femoral ntawm 6- Lub hlis tom qab, tsis muaj kev phiv loj.104 Li no, kev kho bisphosphonate tuaj yeem txhim kho cov pob txha pob txha pob txha ntawm lub caj dab femoral thiab lumbar qaum thiab txo qhov kev pheej hmoo ntawm kev tsis lees paub, thiab yuav txo tau txoj kev pheej hmoo ntawm pob txha, 127 txawm tias bisphosphonates tsis tshwm sim. kom muaj kev cuam tshuam rau tus neeg mob muaj sia nyob lossis kev poob qis.92
Vitamin D derivatives thiab D-mimetics nrog lossis tsis muaj calcium ntxiv
Ntau hom vitamin D derivatives thiab lawv cov kev faib cov tshuaj muaj nyob rau hauv Table 3. Nyob rau hauv ib tug zoo-tswj, dig muag txoj kev tshawb no, Josephson et al110 qhia tau hais tias raum hloov cov neeg tau txais kev pab uas tau txais calcium thiab calcitriol muaj tsis tshua muaj pob txha poob nyob rau hauv lub lumbar qaum thiab nce. BMD nyob rau hauv lub distal radius thiab femoral caj dab piv nrog cov neeg mob hloov chaw muab calcium ib leeg lossis placebo. Cov neeg mob kho tsis tau hypercalcemia tseem ceeb lossis ua rau lub raum ua haujlwm tsis zoo nyob rau hauv ob xyoos ntawm txoj kev tshawb no.110 Torres li al qhia tias kev kho nrog cov tshuaj calcium uas tsis tshua muaj nyob rau hauv 1 xyoos, ntxiv rau cov calcitriol tsis tu ncua rau 3 lub hlis tom qab hloov pauv tau zoo, txo qis. PTH ntau ntau sai, thiab tiv thaiv cov pob txha poob ntawm proximal femur.109 Piv rau cov placebo, calcidiol thiab qhov ncauj calcium nce BMD ntawm lumbar qaum thiab femoral caj dab. 107,108,128 Paricalcitol, ib qho kev xaiv vitamin D receptor activator, tseem hu ua D-mimetic, 4,129 yog qhia nyob rau hauv kev tiv thaiv thiab kev kho mob ntawm theem nrab hyperparathyroidism.
Cov txiaj ntsig ua ntej ntawm kev sim tshuaj ntsuam xyuas tau pom tias kev hloov pauv ntawm cov zis peptides tshwm sim vim kev kho mob nrog paricalcitol; 111 txawm li cas los xij, tsis muaj kev tshawb fawb tau soj ntsuam kev sib koom ntawm cov pob txha pob txha, BMD lossis cov txiaj ntsig, thiab kev tswj hwm ntawm paricalcitol.
Calciimetics
Hauv ob peb xyoos dhau los, tus neeg sawv cev calcimimetic cinacalcet tau raug tshuaj xyuas ntau zaus rau kev kho mob hypercalcemia hauv cov neeg mob lub raum graft nrog cov tsis tu ncua refractory hyperparathyroidism. Raws li tau pom hauv qee qhov kev sim tom qab hloov pauv cinacalcet tau ua tiav kho cov qib calcium hauv cov ntshav thiab PTH uas tsis muaj kev cuam tshuam rau lub raum ua haujlwm, 114,115,120,121 thiab nws zoo li muaj kev nyab xeeb rau cov neeg txais kev hloov pauv raum.117,122 Ib qho txiaj ntsig zoo ntawm cinacalcet ntawm BMD hauv cov neeg mob lub raum hloov pauv. tshaj tawm los ntawm ntau qhov kev tshawb fawb me me (saib Table 2).116,118,119 Txaus siab, cinacalcet kuj tseem yuav muaj txiaj ntsig zoo rau cov ntshav siab hauv cov neeg tau txais kev hloov hauv lub raum, tab sis tsis yog ntawm cov txiaj ntsig.130
Lwm cov kev kho mob uas muaj peev xwm MBD
Lwm tus kws kho mob tau kawm nyob rau hauv cov neeg mob tom qab hloov lub raum yog teriparatide, ib tug recombinant tib neeg PTH. Ib qho kev sim tsis ntev los no tau pom tias teriparatide muab rau cov neeg mob hloov lub raum rau 6 lub hlis muaj kev nyab xeeb tab sis tsis hloov BMD nyob rau hauv lub lumbar qaum los yog lub vojvoog distal piv nrog cov placebo pawg.131 Txawm li cas los xij, BMD ntawm lub caj dab femoral tseem nyob ruaj khov hauv qhov muab teriparatide, piv rau. nrog kev txo qis hauv pawg placebo. Tsis tas li ntawd, tom qab 6 lub hlis, tsis muaj qhov sib txawv tseem ceeb ntawm ob pawg tau kuaj pom hauv pob txha, pob txha histology, qib vitamin D, PTH qib, lub raum ua haujlwm, lossis cov cim pob txha serologic.131 Teriparatide tuaj yeem suav tias yog lwm txoj kev kho mob ntawm MBD hauv raum. Hloov cov neeg mob uas tsis tshua muaj PTH thiab refractory hypocalcemia.132 Lwm qhov muaj peev xwm kho tau tus neeg sawv cev yog calcitonin; txawm hais tias nws tsis muaj txiaj ntsig rau kev tuag, kev poob qis, thiab kev pheej hmoo ntawm pob txha hauv cov neeg mob tom qab hloov lub raum.92,133,134 Kev cob qhia thiab kev kho hormonal yog lwm yam kev cuam tshuam. Cov txiaj ntsig ntawm kev tawm dag zog ib txwm muaj lossis kev kho tshuaj hormone hloov pauv ntawm cov pob txha poob lossis kev pheej hmoo ntawm pob txha tseem tsis tau kuaj xyuas hauv cov neeg tau txais kev hloov hauv lub raum, txawm tias cov ntaub ntawv los ntawm lwm cov neeg mob hloov pauv hauv nruab nrog cev tau cog lus. 135,136 Denosumab, RANK-ligand inhibitor rau kev kho mob postmenopausal osteoporosis; 4 muaj peev xwm theoretically txo osteoclastic resorption ntawm cov kab mob trabecular thiab, yog li, siv rau kev kho mob osteonecrosis, tab sis tam sim no, tsis muaj tib neeg cov ntaub ntawv. Cov theem thaum ntxov ntawm osteonecrosis feem ntau yog tswj hwm kev saib xyuas lossis nrog cov tub ntxhais decompression nrog rau cov pob txha grafting thiab tsis ntev los no kev txhaj tshuaj ntawm cov pob txha morphogenic protein, thaum iloprost los txhim kho cov ntshav khiav ua ke nrog bisphosphonates tsim nyog tau txais kev kawm ntxiv. 86
Cov lus xaus
Mineral thiab pob txha mob tom qab hloov lub raum yog qhov tshwm sim thiab tshwm sim los ntawm kev poob ntawm cov pob txha ntim thiab mineralization abnormalization ua rau cov pob txha tsis tshua muaj kab mob hauv cov neeg mob feem ntau. Muaj ob peb yam tseem ceeb xws li osteodystrophy ua ntej uas twb muaj lawm, kev hloov pauv kev kho tshwj xeeb, thiab txo lub raum ua haujlwm vim mob ntev.
Allograft nephropathy. Lub sijhawm no tsis muaj cov txheej txheem kho mob zoo uas yuav muab cov pob txha khaws cia lossis cov teebmeem anabolic nrog rau qib siab ntawm qhov tseeb. Txawm li cas los xij, vitamin D analogs thiab bisphosphonates feem ntau siv rau kev kho mob ntawm MBD tom qab hloov lub raum. Txawm hais tias yuav tsum muaj kev tshawb fawb ntau ntxiv los tshuaj xyuas qhov cuam tshuam ntawm kev kho mob sib txawv ntawm cov pob txha mob tom qab hloov lub raum, cov kws kho mob yuav tsum txuas ntxiv kho tus kheej raws li lawv cov kev txawj ntse thiab kev txiav txim siab zoo tshaj plaws.
Cistanche deserticola tiv thaiv kab mob raum, nyem qhov no kom tau txais cov qauv
1Harold Simmons Center for Chronic Disease Research & Epidemiology, Los Angeles Biomedical Research Institute ntawm Harbor-UCLA Medical Center, Torrance, CA
2Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA
3David Geffen Tsev Kawm Ntawv Tshuaj Kho Mob ntawm UCLA, Los Angeles, CA
4Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA 5Institute of Pathophysiology, Semmelweis University, Budapest, Hungary 6Division of Nephrology, University of Virginia, Charlottesville, VA, USA 7Division of Nephrology, Salem VA Medical Center, Salem, Teb chaws USA
8 Kaiser Permanente, CA
9 Lub Tsev Haujlwm Saib Xyuas Kev Coj Tus Cwj Pwm, Semmelweis University, Budapest, Hungary
10 Dept. ntawm Tshuaj, Division of Nephrology, McGill Univ. Health Cntr, Montreal, Quebec, Canada
Cov ntaub ntawv
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