臨牀透析 Vol.23 No.10(1-5)


特集名 適正透析 -- エビデンスをめぐる課題
題名 適正血液透析とエビデンス (5) リン・カルシウム・骨代謝
発刊年月 2007年 09月
著者 角田 隆俊 東海大学医学部腎代謝内科
著者 斎藤 明 東海大学医学部腎代謝内科
【 要旨 】 透析患者の「Ca・P代謝異常」が,骨代謝ばかりでなく血管病変と重要な関わりがあることが明らかになってきた.最近では,従来から使われているRODという考え方が,全身性疾患と捉えられるようになり,「慢性腎臓病に伴う骨ミネラル代謝異常 (CKD-mineral and bone disorder ; CKD-MBD)」という概念が提唱された.全身性疾患としてCKD-MBDを考えるときに,必要なものは生命予後を第一に考えたガイドラインである.2003年に米国のNational Kidney Foundation (NKF),Kidney Disease Outcomes Quality Initiative (K / DOQI) よリエビデンスをもとに構成された「慢性腎疾患における骨代謝・骨疾患治療ガイドライン (Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease)」が発表された.これを受けて2006年に日本透析医学会のガイドライン作成ワーキンググループより,「透析患者における二次性副甲状腺機能亢進症治療ガイドライン」が提唱された.ポイントとなる数値は,(1) 血清リン (P) 濃度の目標値 : 3.5 - 6.0 mg / dl,血清補正カルシウム (Ca) 濃度の目標値 : 8.4 - 1O.O mg / dl,(2) intact-PTHの管理目標値 : 60 - 180 pg / ml,(3) 副甲状腺インターベンション適応 : P,Caの管理目標値を遵守したうえでintact-PTH > 500 pg / mlである.
Theme Issues of Evidence-based Adequate Dialysis Therapy
Title Management of chronic kidney disease-related mineral and bone disorders (CKD-MBD)
Author Takatoshi Kakuta Division of Nephrology, Department of Medicine, Tokai University
Author Akira Saito Division of Nephrology, Department of Medicine, Tokai University
[ Summary ] Abnormalities of mineral and bone metabolism in patients with chronic kidney disease (CKD) have traditionally been assessed and managed in terms of renal osteodystrophy (ROD). However, it has been demonstrated that abnormal mineral and bone metabolism in CKD not only produces bone lesions, but also influences the prognosis by causing ectopic calcification throughout the body, including the blood vessels, over the long term. In 2003, the K / DOQI guidelines were released by the National Kidney Foundation (NKF) in the United States. In Japan, guidelines for the treatment of secondary hyperparathyroidism in patients on dialysis (JSDT guidelines) were issued in 2006. The JSDT guidelines were drafted on the basis that PTH should be controlled, with serum phosphorus and serum calcium levels remaining under optimal control. Under these circumstances, the regulation of PTH is limited by the range of target values for serum phosphorus and calcium. P : 3.5 - 6.0 mg / dl, Ca : 8.4 - 10.0 mg/dl, intact PTH : 60 - 180 pg / ml. When serum P, Ca and PTH levels can not be maintained within target range, medical treatment including active vitamin D therapy, should not be continued and parathyroid intervention therapy should be considered to avoid progression of ectopic calcification. Parathyroid intervention therapy should be recommended in patients with severe hyperparathyroidism (persistent high serum level of intact PTH level > 500 pg / ml), associated with hyperphosphatemia (serum P > 6.0 mg / dl) and / or hypercalcemia (serum Ca > 10.0 mg / dl) that is refractory to medical therapy.
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