* ** ** * ** (mineralization) (Renal Bone Disease) (renal osteodystrophy) D (Osteoporosis) (Amyloidosis) ( 1) [1] 1. (high turnover bone disease) 2. (lower turnover bone) 3. (mix type) D [2,3] Calcium, Vitamin D Low turnover Intact PTH High turnover <150 pg/ml 150-300 pg/ml >300-400 pg/ml Adynamic Normal Bone Osteotitis mild Osteomalacia Functions Fibrosa Al 3+ Mixed Lesion 1. [1] 96 19 2 55
trade-off (glomerular filtration rate) 70 ml/min D 25 ml/min [4] D D D (secondary hyperparathyroidism) [3] (osteoblast) (osteoclast) (osteoclast-stimulating factor) (woven bone) (osteoid) (osteotitis fibrosa cystica) D (adynamic bone disease) (osteomalacia) [1] D3 (remodeling) [5] D (mineralization) (unmineralized osteoid) (uncalcified bone) (rickets) ( 1) [18] 1. ( ) D β2 56 96 19 2
(Ca P) (metastatic calcification) X 40 3% 38% 1% 7 70 50 [19] X β2 (amyloid deposit) X (cystic bone lesions) β 2 (MRI) (Alkaline-phosphatase) Intact PTH (ipth) amino-terminal PTH ipth ipth ipth ipth ipth [6,7] (iliac crest bone biopsy with double tetracycline labeling) 1. ( ) 2. Intact PTH 100 500 pg/ml 3. (osteoporosis) DEXA (dual energy X ray absorptionetry) (Bone Mineral Density, BMD) [9] 96 19 2 57
ipth 400 pg/ml ipth 800 1000 ipth ipth 2 [8,9] 2.7 4.6 mg/dl 3.5 5.5 mg/dl ipth 35 70 pg/ml ipth 70 110 pg/ ml ( ) ipth 150 300 pg/ml ( 3) [8] (phosphate binder) 6.5 mg/dl 27% (90 95%) 10.5 mg/dl [20] 2. ( ) D3 3. ( ) (mg/dl) 8.4 10.2 8.4 10.2 8.4 9.5 (mg/dl) 2.7 4.6 2.7 4.6 3.5 5.5 < 55 < 55 < 55 (pg/ml) 35 70 70 110 150 300 58 96 19 2
4 5 1500 2000 ( ) 10.2 mg/dl ipth 150 pg/dl 7.0 mg/dl ( ) Renagel Fosrenol Renagel Fosrenol 5.5 mg/dl [10,11] Renagel Fosrenol 1998 (Food and Drug Administration; FDA) Renagel ( sevelamer hydrochloride) Renagel Renagel Renagel Renagel [12] (Fosrenol Lanthanum carbonate) FDA EMEA (Lanthanum) (B.B.B.), (Ca P) 55 (8.4 9.5 mg/dl) 10.2 mg/dl Renagel Fosrenol D (1.5 to 2.0 meq/l) 96 19 2 59
1998 Black AJKD 6.5 mg/dl 27% 65 34% 60% 55 60 55 ipth 25-hydroxyvitamin D25-hydroxyvitamin D 30 ng/ml D2 (ergocalciferol) 25-hydroxyvitamin D 30 ng/ml ipth 300 pg/ml D D3 Calcitriol D3 Alfacalcidol D2 Paricalcidol (Zemplar) Zemplar 9.5 mg/dl4.6 mg/ dl D3 ipth 9.5 mg/dl4.6 mg/dl ipth D3 9.5 mg/dl 4.6 mg/dl ipth D3 [13,14] D paricalcitol or doxercalciferol (calcium sensing receptor) (calcimimetics) Cinacalcet ipth 300 600 pg/ml D3(Calcitriol) 0.5 2.0 μgd3 D3 ipth 150 pg/ml D3 ipth 600 1200 pg/ml D3 2.0 4.0 μg D ( Paricalcitol Doxercalciferol) D3 ipth 1200~1800 pg/ml D3 4.0 6.0 μg ipth 1800 pg/ml 6.0 8.0 μg D3 D3 60 65 D3 60 ( 2) [8] 60 96 19 2
Ca >10.2 mg/dl 9.5< Ca <10.2 mg/ dl Ca <9.5 mg/ dl D 9.5mg/ dl (1) <5.5 D (2) 5.5< <6.0 (3) >6.0 D ipth ipth <150 pg/ml 150<iPTH <300 pg/ml ipth>300 pg/ml ipth>800 pg/ml D D ipth D D ipth ipth 2. D 96 19 2 61
D3 1500 pg/ml D3 1 0.50.5 (nodular hyperplasia) D3 D ipth 800 pg/ml ipth 48 72 7.2 mg/dl (Calcium gluconate) 1 2 mg/kg/hr 10 90 1 2 D3 0.5 2.0 μg i P T H Chvostek s Trousseau s signs D3 (renal tubular acidosis) D (citrate salts) D 20 μ g/l 60 200 μ g/l deferoxamine (DFO) DFO 5 DFO 50 μg/l 200 μ g/l DFO 5 μ g/l deferoxamine D D ipth [16,17] HCO3 30 ml/min IGF-1 62 96 19 2
1,25(OH) 2 D3 3 4 5 HCO 3 HCO 3 22 meq/l (NaHCO 3 ) [15] 1. Sherrard DJ, Hercz G, Pei Y, Maloney NA, Greenwood C, Manuel A: The spectrum of bone disease in end-stage renal failure- an evolving disorder. Kidney Int 1993; 43: 436-42. 2. Martin KJ, Gonzalez EA: Strategies to minimize bone disease in renal failure. Am J Kidney Dis 2001; 38: 1430-06. 3. Llach F, Forero FV: Secondary hyperparathyroidism in chronic renal failure: Pathogenic and clinical aspects. Am J Kidney Dis 2001; 38: 20-33. 4. Martinez I, Saracho R, Montenegro L, Llach F: A deficit of calcitriol may not be the initial factor in the pathogenesis of secondary hyperparathyroidism. Nephrol Dial Transplant 1996; 11: 22-8. 5. Slausky IB, Goodman WG: Adynamic renal osteodystrophy: Is there a problem. J Am Soc Nephrol 2001; 12: 1978-85. 6. Goodman WG: The evolution of assays for parathyroid hormone. Semin Dial 2005; 18: 296-301. 7. Lindberg JS: Calcimimetics: a new tool for management of hyperparathyroidism and renal osteodystrophy in patients with chronic kidney disease. Kidney Int Suppl 2005; 95: S33-6. 8. National Kidney Foundation: K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42(Suppl 3): S1-201. 9. S Moe, T Drueke, J Cunningham, W Goodman, K Martin, K Olgaard, et al: Definition, evaluation, and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2006; 69: 1945-53. 10. Noordzij M, Korevaar JC, Boeschoten EW, Dekker FW, Bos WJ, Krediet RT: Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) Study Group. The Kidney Disease Outcomes Quality Initiative (K/DOQI) Guideline for Bone Metabolism and Disease in CKD: association with mortality in dialysis patients. Am J Kidney Dis 2005; 46: 925-32. 11. Nolan CR: Phosphate binder therapy for attainment of K/ DOQI bone metabolism guidelines. Kidney Int Suppl 2005; 96: S7-14. 12. Chertow GM, Burke SK, Dillon M, et al: Long-term effects of sevelamer hydrochloride on the calcium? Phosphate product and lipid profile of hemodialysis patients. Nephrol Dial Transplant 1999; 14: 2907-14 13. Hernandez JD, Wesseling K, Salusky IB: Role of parathyroid hormone and therapy with active vitamin D sterols in renal osteodystrophy. Semin Dial 2005; 18: 290-5. 14. Salusky IB: Are new vitamin D analogues in renal bone disease superior to calcitriol? Pediatr Nephrol 2005; 20: 393-8. 15. Kraut JA, Kurtz I: Metabolic acidosis of CKD: diagnosis, clinical characteristics, and treatment. Am J Kidney Dis 2005; 45: 978-93. 16. Coen G: Adynamic bone disease: an update and overview. J Nephrol 2005; 18: 117-22. 17. Levin A, Bakris GL, Molitch M, Smulders M, Tian J, Williams LA, et al: Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: Results of the study to evaluate early kidney disease. Kidney Int 2007; 71: 31-8. 18. keith A. Hruska, Steven L: Teitelbaum. Renal osteodystrophy. NEJM 1995; 333: 166-75. 19. Geoffrey A. Block, Preston S, Klassen J: Michael Lazarus, Norma Ofsthun, Edmund G. Lowrie and Glenn M. Chertow. Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol 2004; 15: 2208-18. 20. 2000 14 139-228 96 19 2 63