Research progress on the treatment of osteoporosis in patients with advanced chronic kidney disease

doi:10.3877/cma.j.issn.2095-3216.2024.02.006

Abstract

Abstract:

Osteoporosis is one of the common complications of patients with chronic kidney disease (CKD), and can seriously affect the patients’ quality of life and increase the mortality. According to their mechanisms of action, the anti-osteoporosis drugs are mainly divided into bone resorption inhibitors and osteoanabolic agents. Patients with advanced CKD are more likely to experience adverse effects of anti-osteoporosis drugs, and may have an increased risk of CKD progression. This article reviewed the progress of research on the treatment of osteoporosis in patients with advanced CKD, aiming to provide assistance for clinical work.

Key words: Advanced chronic kidney disease, Osteoporosis, Treatment

Wuhao Xiao, Kanghan Liu. Research progress on the treatment of osteoporosis in patients with advanced chronic kidney disease[J]. Chinese Journal of Kidney Disease Investigation(Electronic Edition), 2024, 13(02): 92-96.

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References 40

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骨代谢类型	钙	磷	碱性磷酸酶	甲状旁腺素	成骨、破骨细胞活性	骨转化率
高转换型	↓	↑	↑	↑	↑	↑
低转换型	正常或↓	↑	正常或↓	正常或↓	↓	↓

骨代谢类型	钙	磷	碱性磷酸酶	甲状旁腺素	成骨、破骨细胞活性	骨转化率
高转换型	↓	↑	↑	↑	↑	↑
低转换型	正常或↓	↑	正常或↓	正常或↓	↓	↓

指南或共识来源	CKD分期	钙	磷	甲状旁腺素	维生素D或拟钙剂
2015年RA临床实践指南：慢性肾脏病矿物质及骨代谢紊乱^[8]	3-5	控制在正常范围(2D)	0.9～1.5 mmol/L(2C)	进行性升高，且持续高于正常值上限，需考虑治疗(2C)	25(OH)D水平：>75 nmol/L(充足)；37.5～75 nmol/L(不足)；<37.5 nmol/L(缺乏)
	5D	2.2～2.5 mmol/L，避免高钙血症(2C)	1.1～1.7 mmol/L(2C)	维持在正常值上限2～9倍(2C)
2017年KDIGO指南：慢性肾脏病矿物质与骨异常诊断、评估、预防和治疗^[6]	3a-5	避免高钙血症(2C)	控制正常范围(2C)	最佳水平尚不明确	不建议常规使用，伴严重、进行性甲旁亢的CKD4-5期，可使用维生素D及其类似物
	5D			维持在正常值上限2～9倍(2C)	需要降PTH治疗的患者，建议使用维生素D及其类似物、拟钙剂，或联合治疗(2B)
2019年中国慢性肾脏病矿物质和骨异常诊治指南^[5]	3a-5	避免高钙血症(2C)	控制正常范围(2C)	最佳水平尚不明确	不建议常规使用，伴严重、进行性甲旁亢的CKD4-5期，可使用维生素D及其类似物
	5D			维持在正常值上限2～9倍(2C)	需要降PTH治疗的患者，建议使用维生素D及其类似物、拟钙剂，或联合治疗(2B)
2021欧洲共同声明：慢性肾脏病G4-G5D期骨质疏松症诊断和管理^[9]	4-5D	总外源性钙摄入<1 200 mg/d			建议25(OH)D水平维持在50～75 nmol/L

指南或共识来源	CKD分期	钙	磷	甲状旁腺素	维生素D或拟钙剂
2015年RA临床实践指南：慢性肾脏病矿物质及骨代谢紊乱^[8]	3-5	控制在正常范围(2D)	0.9～1.5 mmol/L(2C)	进行性升高，且持续高于正常值上限，需考虑治疗(2C)	25(OH)D水平：>75 nmol/L(充足)；37.5～75 nmol/L(不足)；<37.5 nmol/L(缺乏)
	5D	2.2～2.5 mmol/L，避免高钙血症(2C)	1.1～1.7 mmol/L(2C)	维持在正常值上限2～9倍(2C)
2017年KDIGO指南：慢性肾脏病矿物质与骨异常诊断、评估、预防和治疗^[6]	3a-5	避免高钙血症(2C)	控制正常范围(2C)	最佳水平尚不明确	不建议常规使用，伴严重、进行性甲旁亢的CKD4-5期，可使用维生素D及其类似物
	5D			维持在正常值上限2～9倍(2C)	需要降PTH治疗的患者，建议使用维生素D及其类似物、拟钙剂，或联合治疗(2B)
2019年中国慢性肾脏病矿物质和骨异常诊治指南^[5]	3a-5	避免高钙血症(2C)	控制正常范围(2C)	最佳水平尚不明确	不建议常规使用，伴严重、进行性甲旁亢的CKD4-5期，可使用维生素D及其类似物
	5D			维持在正常值上限2～9倍(2C)	需要降PTH治疗的患者，建议使用维生素D及其类似物、拟钙剂，或联合治疗(2B)
2021欧洲共同声明：慢性肾脏病G4-G5D期骨质疏松症诊断和管理^[9]	4-5D	总外源性钙摄入<1 200 mg/d			建议25(OH)D水平维持在50～75 nmol/L

作用机制	药物	适用范围	不良反应
骨吸收抑制剂	双膦酸盐	eGFR<35 ml/(min·1.73 m²)时不推荐使用；无动力性骨病患者禁用	急性肾损伤；低钙血症；颌骨坏死
	地舒单抗	不经肾脏代谢，适用于晚期CKD患者	严重低钙血症；破骨细胞活性反弹；颌骨坏死
	雌激素及选择性雌激素受体调节剂	绝经后女性	血栓形成风险
	降钙素	适用于伴有骨痛症状或高钙血症患者	胃肠道反应
骨形成促进剂	甲状旁腺素相关肽		高钙血症；短暂性低血压
其他	抗骨硬化蛋白单克隆抗体		低钙血症；心血管不良事件

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