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Нишкумай О.И. Тактика лечения пациентов с остеопенией и мочекаменной болезнью
29.05.2014, 09:40

Резюме
Нішкумай О.І. Тактика лікування пацієнтів з остеопенією та сечокам`яною хворобою.
Сечокам’яна хвороба та остеопороз є не лише медичною, а й соціальною проблемою. Є загальні патогенетичні механізми розвитку цих захворювань, одним з яких є виникнення вторинного гіперпаратиреозу на тлі гіпокальціємії і дефіциту вітаміну Д, що призводить до посилення кісткової резорбції та, як наслідок, порушень структурно-функціонального стану кісткової тканини та розвитку сечокам’яної хвороби. У статті наводиться клінічний приклад тактики лікування пацієнтів з остеопенією при поєднанні з сечокам’яною хворобою.
Ключові слова: сечокам’яна хвороба, остеопороз, гіперпаратиреоз.
Резюме
Нишкумай О.И. Тактика лечения пациентов с остеопенией и мочекаменной болезнью.
Мочекаменная болезнь и остеопороз являются не только медицинской, но и социальной проблемой. Имеются общие патогенетические механизмы развития этих заболеваний, одним из которых является возникновение вторичного гиперпаратиреоза на фоне гипокальциемии и дефицита витамина Д, приводящий к усилению костной резорбции и, как следствие, нарушениям структурно-функционального состояния костной ткани и развитию мочекаменной болезни. В статье приводится клинический пример тактики лечения пациентов с остеопенией при сочетании с мочекаменной болезнью.
Ключевые слова: мочекаменная болезнь, остеопороз, гиперпаратиреоз.
Summary
Nishkumay O.I. Clinical management of osteopenia and urolithiasis.
Urolithiasis and osteoporosis are not only medical but also social problems. Share common pathogenetic mechanisms of these diseases, one of which is the occurrence of secondary hyperparathyroidism against hypocalcemia and vitamin D deficiency, leading to increased bone resorption and, consequently, violations of the structural-functional state of bone and kidney stones disease. The article gives examples of various clinical patient management depending on the degree of change in bone mineral density, and history of the risk of fractures in combination with urolithiasis.
Key words: urolithiasis, osteoporosis, hyperparathyroidism.
Рецензент: д.мед.н., проф. В.І. Коломієць

УДК 616.62-003.7-06:616.61-002.3-092+612.015.31:612.392.63

 

ГЗ «Луганский государственный медицинский университет»

91045, кв. 50-летия Обороны Луганска, 1 г, Луганск, Украина

State Establishment "Lugansk State Medical University"

91045,50 Rokyv Oborony Luganska Block, 1G, Lugansk,Ukraine

nishkumay@ukr.net

The problem of osteoporosis (OP) in recent years has become extremely relevant as a result of a significant increase in the general population of older people. [6] According to WHO experts, OP ranks third after cardiovascular disease and diabetes in the overall ranking of medical and social problems of our time, which is primarily due to its complications - fractures that negatively affect not only the quality but also often on the duration of life, leading to disability or sudden death [5]. It is proved that today the prevalence of OP has reached the nature of the global epidemic [9]. In Ukraine, according to medical statistics and epidemiological studies, the prevalence of systemic osteoporosis in older women is 20-39%, men - 9-23%. In the prevention of osteoporosis great importance is the use of a sufficient amount of calcium-containing foods in the daily diet, as well as the use of calcium, vitamin D, however, is actually a preventive treatment is less than 30% of those who need it. [4] One of the reasons underlying this attitude to the problem of preventing not only patients, but also doctors, is the presence of kidney stone disease (KSD) or fear of provoking her appearance. This has serious justification as nephrolithiasis occurs in about 5% of the population, and the risk of kidney stones in their lifetime is 8-10% [10]. The increased prevalence of kidney stone disease among residents of industrialized countries due to the improvement of living and are closely correlated with race-ethnicity, and geographic region of residence. Also recorded and seasonal fluctuations increased frequency of cases of the disease, associated with high urinary calcium oxalate saturation in men in the summer and for women - early winter. The men in the kidney stone formation occurs in 2 times more often than women. The age at which most often cited nephrolithiasis in men is 30 years for women is characterized by a bimodal age distribution with peaks of incidence of 35 and 55 years. If a kidney stone has formed, the probability of a second of the stone for 5-7 years old is about 50% [7].

Results of recent studies suggest the existence of common pathogenic mechanisms that lead to the development of the KSD and the OP. This is not due to the use of prophylactic calcium supplementation, and vice versa, resulting in inadequate calcium and vitamin D in the blood. Hypocalcemia due to vitamin D deficiency, or the activation of production of parathyroid hormone (PTH). PTH receptors are present on osteoblasts and osteocytes, but not on osteoclasts. However, with an increase in PTH levels is enhanced by activation of osteoclasts and bone resorption. With constantly elevated PTH (hyperparathyroidism), bone resorption predominates over her education, which leads to disruption of bone mineral density [8] and the formation of the matrix with the subsequent formation of stone. Thus, without calcium supplementation and hypocalcemia in most cases lead to secondary hyperparathyroidism stone formation and increases the risk. [3]

On the other hand, the conditions which lead to chronic kidney disease, including stone KSD leads to a decrease in glomerular filtration speed, which reduces the conversion processes of vitamin D to its active form - D-hormone, activating PTH production, which in turn leads to accelerate the development of bone resorption renal osteopathy [2].

Thus, the occurrence of secondary hyperparathyroidism - a significant predictor of violations of structural and functional state of the bone on the one hand, and a significant factor in the development of KSD.

However, the management of patients is the presence of the KSD and disorders of bone mineral density is varied and depends on the risk factors for OP, the degree of change microarchitectonics bone fracture risk (according to the calculator FRAX), history of fractures. Here is a clinical example of the recommendations by the tactics of the patient.

Clinical case.

Patient M, 61 years old, 5 years old MP (physiological). History: IHD. Stabile angina FC II, diffuse and postinfarction (03.2011) myocardialfibrosis. Hypertention III (MI), 2 degree, the risk 4. CH IIA. Diabetes mellitus type II. KSD recurrent stone left kidney. Chr. pyelonephritis in remission. Biochemical studies: ion.calcium 1.1 mmol/l, phosphorus 0.87 mmol / l, PTH 88.2 pmol / L, Creatinine 133 ml / min., SGF 58 ml / min. Ultrasound densitometry: T-score = -2,1 SD. Conclusion: The deviation of the index of bone density in the range of osteopenia. Assessment of risk of fracture: FRAX 1 = 9,4; FRAX2 = 1. Conclusion: The average risk of fractures.

Clinical management of patients is percutaneous pin crushing of the stone. After treatment at the urologist to follow treatment recommendations for patients with osteopenia supplemental calcium and vitamin D, but given the decline in SGF for the correction of secondary hyperparathyroidism requires active metabolites of vitamin D (alfacalcidol dosage of 1 mg per day), followed by monitoring the levels of ionized calcium, phosphorus, parathyroid hormone levels.

Findings

1. There are common pathogenic mechanisms of kidney stones and osteoporosis, one of which is the occurrence of secondary hyperparathyroidism against hypocalcemia and vitamin D deficiency, which leads to increased bone resorption and, consequently, violations of the structural-functional state of bone formation and microlite.

2. Given the different tactics of patients, depending on the degree of change in bone mineral density, the presence of risk and history of fractures in conjunction with urolithiasis requires interdisciplinary integration for safe and effective treatment of comorbid disease.

3. Appointment of active metabolites of vitamin D (alfacalcidol) for the correction of secondary hyperparathyroidism in treatment of osteoporosis is an effective treatment, at the same time, the combination of osteoporosis with urolithiasis require additional correction for the elimination of stones from the urinary system.

Литература

  1. Мазуренко С.О. Ремоделирование костной ткани и патологическая физиология почечных остеодистрофий / С.О. Мазуренко, А.Н. Шишкин, О.Г. Мазуренко // Нефрология. – 2002. – Т. 6, № 2. – С. 15-27.
  2. Мартынюк Л.П. Особливості мінерального обміну та функції пара щитоподібних залоз при хронічній хворобі нирок / Л.П. Мартинюк, Лар.П. Мартинюк, О.О. Ружицька // Боль. Суставы. Позвоночник. – 2012. - № 2 (6). – С. 72-79.
  3. Милованова Л.Ю. Нарушения фосфорно-кальциевого обмена при хронической болезни почек ІІІ-IV стадий / Л.Ю. Милованова, Ю.С. Милованов, Л.С. Козловская // Клиническая нефрология. – 2011. - № 1. – С. 58-68.
  4. Поворознюк В.В. Заболевание костно-мышечной системы и возраст / В.В. Поворознюк // Проблемы старения и долголетия. – 2008. – Т. 17, № 4. – С. 399-412.
  5. Поворознюк В.В. Остеопороз – проблема ХХІ сторіччя / В.В. Поворознюк // Мистецтво лікування. – 2005. – № 10. – С. 37–40.
  6. Рекомендації з діагностики, профілактики та лікування системного остеопорозу у жінок в постменопаузальному періоді: метод. рекомендації / В.М. Коваленко, В.В. Поворознюк [та ін.]. –Український Центр наукової інформації і патентно-ліцензійної роботи. – 2010. – 50с.
  7. Урологія: навчільний посібник / С.М. Шамраєв, О.Г. Кривобок, Ю.О. Віненцов, С.Є. Золотухін. – Донецьк: Каштан, 2010. – 144 с.
  8. Brown E.M. Calcium, magnesium and the control of PTH secretion / E.M. Brown, C.J. Chen // Bone Miner. – 1989. – Vol. 5. – P. 249-267.
  9. Johnell O. Mortality after osteoporotic fractures / O. Johnell, J. Kanis // Osteoporos.Int. – 2004. – Vol. 15. – P.38-42.
  10.  Parks J.H. Gender differences in seasonal variation of urine stone risk factors / J.H. Parks, R. Barsky, F.L. Сое // J. Urol. – 2003. –Vol. 170. – P.384-388.
  11.  Proceedings of the NIH Consensus Development Conference on Diagnosis and Management of Asymptomatic Primary Hyperparathyroidism / J.T. Potts [et al.] // J.Bone Miner Res. – 1991. – Vol. 1, № 6, Suppl. 2. – P. 234-249.
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