| Objective: Chronic kidney disease-mineral bone disorder(CKD-MBD) is an important complication for the patients who have chronic kidney disease especially in CKD stage 5. It is mainly manifested as disorders of calcium and phosphorus metabolism, parathyroid hormone and vitamin D and other laboratory abnormalities; secondary hyperparathyroidism caused by bone mineralization, bone turn over, bone volume and intensity abnormal; calcification of vascular or muscle connective tissue. Serum calcium, phosphorus and 1,25(OH) 2D3 on intact parathyroid hormone( i PTH) have a role in the regulation of i PTH, as one of the core links of minerals and abnormal bone metabolism, promote osteoclastic activity, leading to bone in vivo calcium into the blood circulation, osteoporosis, such as vascular calcification; fibroblast growth factor-23( FGF-23) inhibits sodium phosphate cotransporter, and phosphorus uptake and inhibit of 1,25(OH) 2D3 function to adjust the body phosphorus levels; high i PTH hyperlipidemia and high bone alkaline phosphatase(BALP) in parallel, BALP and i PTH can be irritating effect onosteoblast activity, osteoblast activity leads to the increase of BLAP, BLAP can mediate vascular smooth muscle cell( VSMC) plays transformation a very important role, osteoblasts and VSMC originated from similar mesenchymal stem cells, can induce calcification and mineralization of VSMC; Osteoprotegerin(OPG) on bone metabolism and vascular calcification are affected, it as the adjustment factor of bone transformation and calcification, can inhibit vascular endothelial cell apoptosis, strengthen blood vessels of various loss factors of resistance, promoting blood phosphorus and increase of BALP; i PTH, FGF-23, BALP, OPG, Ca2+, P3+ have a synergistic effect to promote calcification, mineral and bone metabolism in vascular abnormalities, thus decrease the level of serum i PTH, FGF-23, BALP, OPG, substance P3+ level can improve the CKD-MBD. At present, the main treatment for the metabolic disorder of calcium and phosphorus is the application of calcium phosphate binders, including calcium phosphate binder such as calcium carbonate, calcium acetate, non-calcium phosphate binder such as lanthanum carbonate, Si Wei Rahm. There are many modes for the treatment of secondary hyperparathyroidism, such as the shock therapy of vitamin D and its derivatives, the calcimimetic agent ultrasound guided percutaneous ethanol injection, parathyroidectomy or parathyroid subtotal, kidney transplantation. Blood purification therapy has a certain role for CKD-MBD; blood purification of conventionalor high-through put blood dialysis treatment model using diffusion principle 3 times a week to remove phosphorus removal treatment for 1800-3600mg/weeks, each time delay dialysis on blood levels of phosphorus can decrease 0.46-1.24mg/dl, Peritoneal dialysis peritoneal dialysate utilization, and the principle of, peritoneal dialysate, through abdominal membrane, by using the principle of diffusion convection, osmotic ultrafiltration removal phosphorus by peritoneal dialysis fluid, phosphorus removal for2100-2520mg/ weeks; but in maintenance hemodialysis(maintenance hemodialysis, MHD) removal or delay dialysis on phosphorus is not ideal, and MHD to PTH, FGF-23 removal is poor or basic does not clear, and hemodia filtration(hemodiafiltration, HDF) by using diffusion and convection through the principle of membrane pore size increased, the convection is strengthening, so on small molecules such as PTH, FGF-23, P removal was better than that of MHD; Hemoperfusion(hemoperfusion, HP) clear the blood of PTH, FGF-23, P by adsorption, and to combined with hemodialysis, make up for the removal of the problem of the poor effect of hemodialysis on PTH alone, FGF-23. As stated above,in the treatment of CKD-MBD there are still some problems of unsatisfied curative effect or problems to varying degrees. In order to remove blood phosphorus, PTH and FGF-23, so as to improve the CKD-MBD, this study adopts HP series HDF to carry on the treatment, and compared with HDF combined with MHD, observe the effect of scavenging effect of the therapy on serum phosphorus, PTH, FGF-23 etc, the control effect of uremia patients complicated with mineral and bone metabolic abnormal, and provide the basis for the treatment and prognosis of uremic complications. After the novelty, in domestic there are no applications of this treatment mode reports.Methods: 60 cases of patients who was in the 5 stage of chronic kidney disease which is also called uremia period, were randomly divided into A, B two groups; These patients have underwent maintenance hemodialysis for more than 12 months, 3 times weekly for blood purification treatment. A group of 30 cases of Combined Hemoperfusion and hemodiafiltration group, including 20 male cases, 10 female cases, age 21-84 years old, mean age 49.33 ±16.44 years, primary disease was chronic glomerulonephritis in 13 cases, diabetic nephropathy in 7 cases, chronic pyelonephritis in 4 cases, Obstructive nephropathy in 4 cases and polycystic kidney in 2 cases, given once a week treatment for combined hemoperfusion and hemodiafiltration, two times weekly routine hemodialysis; B group of 30 patients with hemodiafiltration group, male 16 cases, female 14 cases, age 18-83 years old, mean age 48.07±16.14 years, primary disease was chronic glomerulonephritis in 11 cases, 9 cases of diabetic nephropathy, chronic pyelonephritis in 6 cases, obstructive nephropathy in 3 cases, 1 cases of polycystic kidney, weekly blood hemodiafiltration, two times weekly routine hemodialysis. Conventional hemodialysis are made of low flux dialyzer underwent conventional F6, bicarbonate hemodialysis, each time last for 4h, 250ml/min blood flow, dialysate flow rate of 500 ml/min; hemodiafiltration room after replacement, using FX60 high flux dialyzer, displacement2000ml/h, 250ml/min blood flow, dialysate flow rate of 500 ml/min; Combined Hemoperfusion and hemodiafiltration with irrigation flow is connected in series FX60 high flux dialyzer before, 0-2h for combined hemoperfusion and hemodiafiltration, blood flow 200ml/min, 2h after the removal of perfusion is abandoned, 2-4h simple hemodiafiltration therapy, blood flow changed to 250ml/min. Two groups of patients were given continuous treatment for 24 weeks, and for the first time in first weeks before and after treatment and before and after the 24 weekend treatment, determination of i PTH, FGF-23, BALP, OPG, Ca2+, P3+; Blood samples were tested i PTH, FGF-23,BALP, OPG using ELISA radioimmunoassay, determination of blood calcium and phosphorus in phosphorus molybdic acid by ion selective electrode method; Analysis of each group before and after treatment in patients with the first and the last time,and analysis in two groups of patients before treatment and after treatment for the first time, before and after the treatment for the last treatment with a comparative analysis of the correlation between indicators; Multivariate Logistic regression analysis of risk factors of mineral and bone metabolism abnormality, performed statistical analysis on income results by using SPSS18.0 analysis software.Results: Changes of laboratory index in two groups of patients: there was no significant difference(P > 0.05) between the two groups of patients with i PTH, FGF-23, BALP, OPG, Ca2+, P3+ for the first time before treatment. two in the group of i PTH, FGF-23, BALP, OPG, P3+ for the first time after treatment compared with before treatment, for the first time after the last treatment and the end times compared to that before treatment, the difference was statistically significant(P < 0.05); between the two groups i PTH, FGF-23, BALP, OPG, P3+ after the first treatment, before the last treatment, after the last treatment comparison, system differences were statistically significant(P< 0.05); Two groups of the Ca2+,for the first time after treatment compared with before treatment, and after the last treatment compared with last treatment before, had no statistically significant difference. Two treatment mode of laboratory detection of serum concentration of material removal rate: comparison of Combined Hemoperfusion and hemodiafiltration group and hemodiafiltration group serum concentrationof substance i PTH, FGF-23, BALP, OPG, P3+ removal rate after the first treatment, after the last treatment comparison, the difference was statistically significant(P<0.05). Multivariate Logistic regression analysis showed that, i PTH, FGF-23, P3+ in serum was the relative risk factors of mineral and bone metabolism abnormality.Conclusion:1 i PTH, FGF-23, BALP, OPG and P can be used as a diagnostic index with mineral and bonemetabolic abnormality in uremia.2 Combined hemoperfusion and hemodiafiltration can effectively improve uremic complications of mineral and bone abnormal metabolism. |
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