CAJ | 학술논문

目的分析维持性透析患者骨病的组织学改变并探讨非侵入性检测对肾性骨营养不良(ROD)的诊断意义.方法 91例维持性透析患者髂骨活检标本经HE、甲苯胺蓝及Masson染色后光镜下观察进行病理分型.对2004年至2006年骨活检者外周血,以放射免疫法检测免疫反应性甲状旁腺激素(iPTH)水平;ELISA法检测骨保护素(OPG)和可溶性骨保护素配体水平;化学发光法检测骨钙素(OCN)水平.结果 ROD的发生率达100%.依据骨组织学改变特征,分为Ⅰ型高转运型ROD(继发性甲状旁腺功能亢进性骨病)50例(54 .9%);Ⅱ型:低转运型ROD(包括骨软化及无动力型骨病)9例(9 .9%);Ⅲ型混合性ROD(兼有高转运及低转运型骨病)32例(35 .2%).各型ROD患者血浆iPTH水平显著高于健康对照,低转运型ROD组iPTH水平最低,各型ROD间iPTH水平差异无统计学意义.ROD组外周血骨保护素水平明显高于健康对照组[(2176 .58±1576 .08)pmol/L比(1310 .46±1254 .00)pmol/L,P＜0 .05],高转运型ROD患者OPG水平[(2261 .85±1712 .22)pmol/L]显著高于对照组(P＜0 .05).各型ROD间OPG差异无统计学意义.高转运型ROD可溶性骨保护素配体(sRANKL)水平明显高于健康对照组[(0 .328±0 .524)pmol/L比(0 .084±0 .190)pmol/L,P＜0 .05],而各型ROD间差异无统计学意义.各型ROD中骨钙素水平显著高于健康对照组(P＜0 .05).低转运型ROD组OCN水平最低,混合型ROD组OCN明显高于低转运型ROD组[(226 .63±66 .46)pmol/L比(193 .03±104 .27)pmol/L,P＜0 .051.结论 iPTH水平能较好地预测骨组织学改变,但不能完全推测骨病的病理类型.外周血OPG、sRANKL及OCN水平尚不能鉴别ROD各型的区别,其对骨病的诊断意义有待进一步探讨.骨组织学检查仍是ROD诊断的金标准.
목적 분석유지성투석환자골병적조직학개변병탐토비침입성검측대신성골영양불량(ROD)적진단의의.방법 91례유지성투석환자가골활검표본경HE、갑분알람급Masson염색후광경하관찰진행병리분형.대2004년지2006년골활검자외주혈,이방사면역법검측면역반응성갑상방선격소(iPTH)수평;ELISA법검측골보호소(OPG)화가용성골보호소배체수평;화학발광법검측골개소(OCN)수평.결과 ROD적발생솔체100%.의거골조직학개변특정,분위Ⅰ형고전운형ROD(계발성갑상방선공능항진성골병)50례(54 .9%);Ⅱ형:저전운형ROD(포괄골연화급무동력형골병)9례(9 .9%);Ⅲ형혼합성ROD(겸유고전운급저전운형골병)32례(35 .2%).각형ROD환자혈장iPTH수평현저고우건강대조,저전운형ROD조iPTH수평최저,각형ROD간iPTH수평차이무통계학의의.ROD조외주혈골보호소수평명현고우건강대조조[(2176 .58±1576 .08)pmol/L비(1310 .46±1254 .00)pmol/L,P＜0 .05],고전운형ROD환자OPG수평[(2261 .85±1712 .22)pmol/L]현저고우대조조(P＜0 .05).각형ROD간OPG차이무통계학의의.고전운형ROD가용성골보호소배체(sRANKL)수평명현고우건강대조조[(0 .328±0 .524)pmol/L비(0 .084±0 .190)pmol/L,P＜0 .05],이각형ROD간차이무통계학의의.각형ROD중골개소수평현저고우건강대조조(P＜0 .05).저전운형ROD조OCN수평최저,혼합형ROD조OCN명현고우저전운형ROD조[(226 .63±66 .46)pmol/L비(193 .03±104 .27)pmol/L,P＜0 .051.결론 iPTH수평능교호지예측골조직학개변,단불능완전추측골병적병리류형.외주혈OPG、sRANKL급OCN수평상불능감별ROD각형적구별,기대골병적진단의의유대진일보탐토.골조직학검사잉시ROD진단적금표준.
Objective To analyze the histological changes of bone diseases and to investigate the noninvasive measurements for diagnosing renal osteodystrophy (ROD) in maintenance dialysis patients . Methods Ninety-one patients were selected to receive bone biopsy . The bone samples were stained with HE, toluidine blue and Masson, and were examined with light microscopy . The levels of immunoreactive parathyroid hormone (iPTH), osteoprotegerin (OPG),sRANKL and osteocalcin (OCN) were determined in the patients enrolled from 2004 to 2006 . The level of iPTH was measured by radioimmunoassay . OPG and sRANKL were measured by ELISA,and OCN was measured by chemiluminescence . Results The incidence of ROD in the maintenance patients was 100% . According to the histological appearance, 50 cases (54 .9%) were high turnover bone disease (secondary hyperparathyroid bone disease), 9 cases (9 .9%) were low turnover bone diseases(osteomalacia and adynamic bone disease), and 32 cases(35 .2% ) were mixed bone disease . The level of iPTH in patients with ROD was significantly increased compared with healthy controls . It was the lowest in low turnover bone diseases . There was no difference among three types of ROD . OPG level was significantly increased compared with healthy controls [(2176 .58±1576 .08) pmol/L vs (1310 .46±1254 .00) pmol/L, P＜0 .05] . The level in high turnover bone diseases was higher than that of the healthy controls [(2261 .85±1712 .22) pmol/L vs (1310 .46±1254 .00) pmol/L, P＜0 .05] . There was no difference among three types of ROD .sRANKL level in high turnover bone disease was significantly increased compared with healthy controls [(0 .328±0 .524)pmol/L vs (0 .084±0 .190) pmol/L, P＜0 .05] . OCN level was also higher than that of the healthy controls (P＜0 .05), and the OCN level in low turnover ROD was the lowest among three types of ROD . OCN level in mixed ROD was dramatically increased as compared to low turnover ROD [(226 .633±66 .455) pmol/L vs (193 .03±104 .269) pmol/L, P ＜0 .05] .Conclusions The histological changes of bone disease can be indicated by iPTH level, but the types of ROD can not be distinguished according to iPTH level neither be differentiated by the levels of OPG, sRANKL and OCN . Bone histomorphometry is still the golden standard for diagnosing renal osteodystrophy .