磷结合剂治疗维持性血透患者高磷血症有效性和安全性的系统评价及网络Meta分析

发布时间：2018-04-15 05:31

本文选题：高磷血症 + 磷结合剂　；参考：《浙江大学》2014年博士论文

【摘要】：目的：高磷血症是慢性肾脏病常见的并发症。长期的高磷血症可导致继发性甲状旁腺功能亢进、肾性骨病、血管钙化等,增加ESRD患者全因住院率、心血管事件及全因死亡率。因此有效控制血磷对改善ESRD患者预后具有重要意义。目前临床上常用的磷结合剂主要分为含钙磷结合剂(碳酸钙、醋酸钙)和非含钙非含铝磷结合剂(碳酸镧、司维拉姆)两大类。本研究的主要目的是对碳酸钙、醋酸钙、碳酸镧、司维拉姆及安慰剂这四大类药物治疗终末期肾脏病维持性血液透析患者高磷血症的有效性和安全性进行系统评价。方法：利用计算机检索Pubmed, ISI Web of Science, Cochrane图书馆临床对照试验数据库,同时通过手工检索相关系统评价的参考文献作为补充。检索日期为自建库至2013年12月30日。检索已公开发表的随机对照研究。研究的干预与对照分别为四种降磷药物(碳酸钙、醋酸钙、碳酸镧、司维拉姆)和安慰剂中的一种。观测的结局指标包括：血磷水平、血钙水平、血钙磷乘积、血IPTH、高钙血症的发生率。应用R2WinBUGS软件进行贝叶斯网络Meta分析及药效排序。结果：共纳入25个研究,包括3111例患者。其中碳酸钙与醋酸钙比较的文献3篇,司维拉姆与醋酸钙比较的文献6篇,司维拉姆与碳酸钙比较的文献7篇,司维拉姆与碳酸镧比较的文献1篇,司维拉姆与安慰剂比较的文献1篇,碳酸镧与安慰剂比较的文献4篇,碳酸镧与碳酸钙比较的文献4篇。贝叶斯网络Meta分析结果显示：对于维持性血透病人,碳酸镧、司维拉姆、碳酸钙、醋酸钙四类药物在降磷幅度、血钙磷乘积、血IPTH水平上两两比较均没有显著差异,且显著优于安慰剂；碳酸镧、司维拉姆对血钙的影响与安慰剂比较均无显著差异,且显著低于碳酸钙、醋酸钙；碳酸镧治疗组、司维拉姆治疗组高钙血症的发生率显著低于碳酸钙、醋酸钙；目前还没有足够多的证据针对血透患者住院率、血管钙化、骨病、死亡率等终点事件进行网络Meta分析。结论：非含钙磷结合剂(碳酸镧、司维拉姆)能有效、安全的用于治疗维持性血透病人的高磷血症。与含钙磷结合剂相比,碳酸镧和司维拉姆对血钙的影响较小,能减少血透患者高钙血症的发生率。目前仍需大样本、多中心的高质量研究,为碳酸钙、醋酸钙、司维拉姆、碳酸镧这四类药物对患者全因住院率、心血管事件、全因死亡率等终点提供进一步证据。
[Abstract]:Objective: hyperphosphatemia is a common complication of chronic kidney disease.Long-term hyperphosphatemia can lead to secondary hyperparathyroidism, renal osteopathy, vascular calcification and so on.Therefore, the effective control of blood phosphorus is of great significance in improving the prognosis of patients with ESRD.At present, the commonly used phosphate binders are mainly classified into two categories: calcium carbonate (calcium carbonate, calcium acetate) and non-calcium (lanthanum carbonate, Sveram).The aim of this study was to evaluate the efficacy and safety of calcium carbonate, calcium acetate, lanthanum carbonate, sparviram and placebo in the treatment of hyperphosphatemia in maintenance hemodialysis patients with end-stage renal disease.Methods: Pubmed, ISI Web of Science, Cochrane library clinical controlled trial databases were searched by computer, and the related systematic evaluation references were manually searched as supplement.The retrieval date is from self-built library to December 30, 2013.Search for published randomized controlled studies.The intervention was one of four phosphorus lowering drugs (calcium carbonate, calcium acetate, lanthanum carbonate, Sveram) and placebo.The outcome indicators included: serum phosphorus level, serum calcium level, serum calcium and phosphorus product, serum IPTHs, incidence of hypercalcemia.Bayesian network Meta analysis and pharmacodynamics ordering were carried out with R2WinBUGS software.Results: a total of 25 studies, including 3111 patients, were included.Among them, there were 3 articles comparing calcium carbonate with calcium acetate, 6 articles comparing Sveram with calcium acetate, 7 articles comparing Sveram with calcium carbonate, and one article comparing Sveram with lanthanum carbonate.There were 1 literature comparing Sveram with placebo, 4 articles comparing lanthanum carbonate with placebo, 4 articles comparing lanthanum carbonate with calcium carbonate.The results of Bayesian network Meta analysis showed that for maintenance hemodialysis patients, lanthanum carbonate, Sveram, calcium carbonate and calcium acetate had no significant difference in the range of phosphorus reduction, the product of calcium and phosphorus in blood, and the level of IPTH.The effects of lanthanum carbonate and sparviram on serum calcium were not significantly different from those of placebo, and were significantly lower than those of calcium carbonate and calcium acetate.The incidence of hypercalcemia in Sveram group was significantly lower than that in calcium carbonate and calcium acetate, and there was not enough evidence for network Meta analysis of endpoints such as hospitalization rate, vascular calcification, bone disease, mortality and so on.Conclusion: lanthanum carbonate (Sveram, lanthanum carbonate) is effective and safe in the treatment of hyperphosphatemia in maintenance hemodialysis patients.Lanthanum carbonate and Sveram had less effect on serum calcium than calcium and phosphorus binders, and could reduce the incidence of hypercalcemia in hemodialysis patients.There is still a need for large, multicenter, high-quality studies to provide further evidence for the endpoints of calcium carbonate, calcium acetate, Sveram, and lanthanum carbonate for all hospital admissions, cardiovascular events, and all-cause mortality.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R692.5

【参考文献】