| Backgrond:Secondary hyperparathyroidism(SHPT) is a common complication in patients with chronic renal failure (CRF) ,SHPT can make many systems injured ,such as renal osteodystrophy,metastatic calcification,skin itching,central and peripheral nervous system diseases, blood diseases,etc,seriously affecting the quality of life and survival of hemodialysis patients. It is reported at home and abroad that the incidence of SHPT in hemodialysis patients was more than 50% , it can be seen that the incidence rate is very high. SHPT is an early-onset, common, multi-system damaged,,treating difficult complication. Therefore, it is especially important for monitoring blood calcium,blood phosphorus intact parathyroid hormone (iPTH) levels of patients with CRF and improving calcium-phosphorus metabolism disorders and clinical symptoms . Hyperphosphatemia,hypocalcemia and down reduction of calcium receptor (CaSR) , the lack of active vitamin D3, reduceing of vitamin D3 receptor(VDR)density ,the resistance of 1,25(OH)2D3, metabolic acidosis are involved in the Pathogenesis of SHPT by stimulating parathyroid cell proliferation to increase PTH. High levels of PTH accelerate the proliferation of osteoblasts and increase transf- ormation efficiency of bone .At present , the main therapy of SHPT include reducing phosphorus ,treating hypocalcemia, the application of active vitamin D, parathyroidectomy, percutaneous ethanol injection therapy,blood purification and so on. 1,25(OH)2D3 is a classic drug that can work on the various aspects of SHPT pathogenesy . First,1,25(OH)2D3 can inhibit the synthesis and secretion of PTH by inhibiting the transcription of preproparathyroid hormone mRNA to reduce parathyroid cell proliferation. At the same time, the activity of vitamin D can promote VDR phosphorylation and attract ratinoic acid X receptor(RXR) of cell nuclear by combing to the specifi receptor VDR of parathyroid cell nuclear,then VDR-RXR dimer combine to vitamin D response element(VDRE)closely,the composite can inhibit the trancecription of PTH gene and synthesis of protein,therefore,1,25(OH)2D3 can make PTH to reduce by incrasing the express of VDR;in addition,1,25(OH)2D3 can incrase the absorption of calcium in intestine,that is to say,1,25 (OH)2D3 can inhibit the synthesis of PTH by increasing blood calcium. Anyway,1,25(OH)2D3 can inhibit various elements of SHPT pathogenesy. dihydroxyvitamin D3 Rocaltrol is of the strongest biological activity,Rocaltrol can work efficiently in vivo not following the hydroxylation of liver and kidney.The present project is to investgate the effects and safety of Rocaltrol in the treatment of SHPT by adopting a single center self- control clinical trial,to invest the clinical value of ultrasonography for the detection of parathyroid glands.Objective:To invest the efficiency and security of Rocaltrol on treating secondary hyperparathyroidism(SHPT) in maintenance hemodialysis (MHD)patients,to invest the clinical value of ultrasonography for the detection of parathyroid glands.Method:1. Clinical resourses :We had chose 30 HD patients with SHPT in the first affiliated hospital of Jilin University from June 2007 to June 2008. 16 cases are male,14 cases are female,the age is among 21 to 73,the age of dialysis is among 1 month to 5 years.For the primary disease,22 cases are chronic glomerulonephritis,4 cases are hypertension nephropathy,4 cases are diabetic nephropathy. We observed the effects for six months, all patients had not ever take Rocaltrol . The iPTH level of all patients is above 300pg/ml and calcium-phosphorus product is under 55mg2/dl2.2 Treatment methods:Rocaltrol,made in Shanghai pharmaceutical limited company, single dose is 0.25ug. Therapeutical dose of Rocaltrol was begun according to the level of iPTH:①If the patient,s iPTH was between 300 to 600 pg/ml,Rocaltrol was applied at a dose of 0.5 to 1.5μg,twice a week,the pills were taken in the evening after HD;②If the patient,s iPTH was between 600 to 1000 pg/ml,Rocaltrol was applied at a dose of 1.0 to 2.0μg,twice a week;③If the patient,s iPTH was above 1000 pg/ml,Rocaltrol was applied at a dose of 2.0 to 4.0μg,twice a week;④If serum calcium was above 10.2mg/ml(2.54mmol/L),serum phosphorus was above 6.0mg/ml (1.94mmol/L) during the treatment period,Rocaltrol was forbidden to use;if serum calcium was between 9.5 to 10.2mg/ml(2.37-2.54 mmol/L),the amount of calcium-containing phosphorus binders was reduced;if serum phosphorus was between 5.5 to 6.0mg/m(l1.78-1.94 mmol/L),calcium carbonate was taken during the meals;If the patient,s iPTH was under 150 pg/ml,Rocaltrol was forbidden to use;If the patient,s iPTH was between 150 to 300 pg/ml,the amount of Rocaltrol was maintained or gradually reduced,even Rocaltrol was forbidden to use.3 Examination contents: Serum calcium,phosphorus,calcium-phosphorus product,iPTH,AKP,ALB of all patients were monitered before the treatment and at the 4th,8th,12th,16 th,20th,24th week after the treatment strated, we observed the effscts for 24 weeks. If the concentration of ALB was under normol level,we conpute the number of corrected calcium instead of serum calcium,the formula is :corrected calcium = serum calcium(mg/dl)+0.8X[4一ALB(g/d1) ]4 the examination of parathyroid ultrasonography:Thirty patients accompanied with SHPT underwent parathyroid ultrasonography,the size and number of enlarged parathyroid glands were noted.5 statistic analysis:All data were processed statistically using software SPSS 11.5,measurement data were shown in the format of x±s,t test was applied,a difference was considered to be significant if P<0.05.Result:(1) After 6 months of treatment, the iPTH significantly declined(P<0.05),21 patients reached targe;(2)There were 7patients with hypercalcemia and 5 patients with hyperphosphataemia,no one caught persistent hypercalcemia;(3)Enlarged parathyroid glands was detected in 12 patients with detection rate of 40%,the size of enlarged parathyroid glands related well with the serum iPTH level (r=0.712).Conclusion:Rocaltrol pulse therapy with reasonably adjusted dosage are effective and safe therapy for SHPT,the effect are better for earlier period of SHPT;ultrasonography is a useful tool for the detection of enlarged parathyroid glands in patients with SHPT,and this method can assess preliminary the severity of SHPT。...
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