阿德福韦酯致肾小管酸中毒并低磷骨软化症3例临床分析  

Renal tubular acidosis and secondary hypophosphatemic osteomalacia caused by adefovir dipivoxil:3 cases report

作　　者：吴丹[1,2] 巴建明[1] 谷伟军[1] 金楠[1] 杨国庆[1] 母义明[1] 窦京涛[1] 吕朝晖[1] 

机构地区：[1]解放军总医院内分泌科,北京100853 [2]江苏省省级机关医院内分泌科,南京210024

出　　处：《中国骨质疏松杂志》2012年第11期1058-1061,共4页Chinese Journal of Osteoporosis

摘　　要：目的通过对3例阿德福韦酯致肾小管酸中毒(RTA)并低磷骨软化症病例临床特点及治疗的分析,提高对阿德福韦酯治疗中致肾小管功能障碍的认识。方法总结3例阿德福韦酯致RTA并继发性低磷骨软化症患者的临床资料及治疗。结果 3例患者均因"全身骨痛进行性加重"入院,来院时均卧床、行走困难。检查结果均提示血气偏酸(pH 7.329～7.381)、碱性尿(pH 6.5～8.0)、低磷血症(0.42～0.68mmol/L)、低血钾(3.08～3.5mmol/L)、碱性磷酸酶高(185.1～247.7U/L)、血钙及PTH正常,均有骨质疏松,病例1诊断为肾小管酸中毒,病例2、3有糖尿、蛋白尿、氨基酸尿,诊断为Fanconi综合征,3例患者均合并继发性低磷骨软化症。根据病史及各项检查结果,因患者均有长期使用阿德福韦酯治疗史,考虑肾小管损伤原因与阿德福韦酯有关。治疗上首先停用阿德福韦酯,改为其他抗病毒药物,并针对各自不同生化异常予以中性磷合剂、活性维生素D、枸橼酸钾及碳酸氢钠等相应对症处理,随访发现临床症状显著改善,骨痛减轻,可自行行走,生化指标逐渐恢复正常。结论临床上阿德福韦酯治疗乙型肝炎患者致肾功能损伤者并不少见,应用阿德福韦酯期间应常规进行肾功能和血电解质水平监测。临床上考虑肾小管酸中毒及有低磷血症的患者应考虑到药物性肾损伤的可能。Objective To analyze the clinical characteristics and treatment of 3 patients with renal tubular acidosis （RTA） and secondary hypophosphatemie osteomalacia caused by adefovir dipivoxil, and to raise awareness of renal tubular dysfunction caused by adefovir dipivoxil. Methods The clinical data and treatment of 3 patients with RTA and hypophosphatemie osteomalacia caused by adefovir dipivoxil were reviewed and summarized. Results Three patients were hospitalized with the chief complaint of progressive systemic aggravation of bone pain. When they came to our hospital, they all lied in bed and could hardly walk. Laboratory tests showed acidic blood （ pH = 7. 329 - 7. 381 ） , alkaline urine （ pH = 6. 5 - 8.0） , hypophosphatemia （0.42 - 0. 68 mmol/L） , hypokalemia （3.08 - 3.5mmol/L） , higher level of alkaline phosphatase （185.1 -247.7U/L） , and normal serum calcium and PTH. They all had osteoporosis. Case 1 was diagnosed as renal tubular acidosis, and case 2 and case 3 were diagnosed as Fanconi syndrome because they had glycosuria, proteinuria, and aminoaciduria. All the 3 patients had secondary hypophosphatemic osteomalacia. According to their medical history, laboratory tests, and the history of long-term oral administration of adefovir dipivoxil, we considered that the injury of renal tubular was caused by adefovir dipivoxil. The initial treatment was to withdraw adefovir dipivoxil and to use other antivirals instead.Effective managements including the supplementation of neutral phosphorus mixture, active vitamin D, potassium citrate, and sodium bicarbonate were given according to the different biochemical abnormality. The follow-up showed that their clinical symptoms ameliorated significantly, and bone pain relieved. They could walk without any help. The biochemical indicators gradually returned to normal. Conclusion Impairment of renal function during the treatment of adfovir dipivoxil for patients with hepatitis B is not rare in clinical practice. Renal function and blood electrolyte level

关 键 词：肾小管酸中毒 FANCONI综合征 低磷性骨软化症 阿德福韦酯 药物不良反应 

分 类 号：R589[医药卫生—内分泌] R683[医药卫生—内科学]