?????????????????????????????????????????????? ????????????????????????????????????? PTH ???????????? ??????????? secondary hyperparathyroidism ?????????????????????????????????? ???????? cortical bone ?????????????????? ????????????????????????????????

1
??????????????????????????????????????????????????
????????????????????????? ?.???????

• ??.??. ???????? ????????
• ????????????????????
• ?????????????
• ??????????????????

15 ?????? 2544
1
2
Introduction

• ??????????????????????????????????????
  ????????????????????
• 1. ??????????????????????????????????????????????
  ????????
• 2. ????????????????????????????????????????
• 3. ???????????????????????????????

3

• ??????????????????????????????????????????????
  ????????????????????????????????????? PTH
  ???????????? ??????????? secondary
  hyperparathyroidism ??????????????????????????????
  ???? ???????? cortical bone ??????????????????
  ????????????????????????????????

• ????????????????????????????????????????????????
  Femoral neck

4

• ???????????????????????????????????????????????
  ????? ??????????????????????????????? (Gloth
  FMIII. JAMA. 1995)

• ??????????????????????????????????????????????
  ?????????????????????????????????????????????????
  25-54 (Omdahl JL. Am J Clin Nutri 1982 McKenna
  MJ. Am J Med 1992 Goldray D. J Am Geriatr Soc
  1989.)

5

• ??????????????????????????????????????????????????
  ????????????????????????????????????????? (Gloth
  FM III. J Am Geriatr Soc 1995 Meunier PJ. Am J
  Med 1993 Boonen S. J Endocrinol 1996 Lefoff MS.
  JAMA, 1999 Lips P. Am J Clin Nutr 1987)

• ????????????????????????????????????????????????
  ?? 800 IU ????????????????????????????????????????
  ?????????????????????????????????????????????????
  (Chapuy MC. N Eng J Med 1992 Chapuy MC. BMJ
  1994)

6

• ??????????????????????????????
• 1. ????? (???????????? ?????? ??? salmon
  ???????????????????)
• 2. ??????????????????????????????????????
  ?????????
• ??????????????????????????????????????????????????
  ??????????????????????

7

• ?????????????????????????????????????????????
  ?????????
• 1. ??????????????????????????????????????
  (Omdahl JL. Am J Clin Nutr 1982 Delvin EE. Am J
  Clin Nutr 1988 Parfitt AM. Am J Clin Nutr 1982)
• 2. ?????????????????????? (Parfitt AM. Am J Clin
  Nutr 1982)
• 3. ??????????????????????????????????????????????
  ?? (MacLaughlin JA. J Clin Invest 1985)

8

• ?????????????????????????????????? 4-20 ?????????
  ??????????????????????????????????????
  ??????????????????????????????????????????????????
  ??? ??????????????????????????????????????????????
  ?
• ??????????????????????????????????????????????????
  ????
• ???????????????????????????????????????? ?

9
Primary Objective

• ??????????????????????????????????????????????????
  ??????????????????????????????? ?.???????

10
Secondary Objective

• 1. ???????????????????????????????????????????????
  ???????? ?.???????
• 2. ???????????????????????????????????
  ??????????? PTH ????????????

11
Research Design

• Cross-sectional descriptive Study

12
Subjects and Methods

• Inclusion Criteria
• 1. ??????????????????????????? 60 ????????
  ????????????????????????? ??????????????
• 2. ??????????????????????????????

13
Subjects and Methods

• Exclusion Criteria
• 1. ????????????????????????????????
• 2. ?????????? metabolic ???????????????????
• 3. ???????? HRT, vitamin D, phenytoin,
  anticoagulant, bisphosphonate.

14
Subjects

• ??????????? ??????????
• ??????????????????????????????????????? 10 c.c.
  ?????????????? 6.00-10.00 ?.
• ??????????????????????????????????????????????????
  ?????????????

15
Methods

• ????????????????????
• 1. ????????????????????? baseline lab.
  creatinine, SGOT ??? alkaline phosphatase
• 2. ????????????????????? intact PTH
• 3. ????????????????????? 25(OH)D

16
????????? intact PTH

• ???????????? electrochemiluminescence (ECLIA)
• Inter-assay CVs ?????? 7.1

17
????????? 25(OH)D

• ???????????? radioimmunoassay (RIA)
• Inter-assay CVs ?????? 9.4-11.0

18
?????????????????????????????????

• ????????????????????????????????????? (femoral
  neck bone mineral density femoral neck BMD)
  ??????????? dual energy X-ray absorptiometry
  (DEXA) ???? DPX-IQ, Lunar Corp, USA.
• ??? precision error ????????????????? 1-2

19
Operational Definition of Hypovitaminosis D

• Hypovitaminosis D ???? Subclinical vitamin D
  deficiency ??????????? 25(OH)D ???????????????????
  ?????? PTH (McKenna MJ Osteoporos Int 1998
  Scharla SH Osteoporos Int 1998.)
• Vitamin D deficiency ??????????? 25(OH)D
  ???????????????? PTH ????????????????????????
  (McKenna MJ Osteoporos Int 1998)

20
Statistical Analysis

• Prevalence of hypovitaminosis D ????? stratify
  ???????? 25(OH)D ??????? subgroup
  ?????????????????????????????????????? PTH
  ??????? subgroup ??? 25(OH)D ??? oneway ANOVA ???
  post hoc test ??????? Bonferroni, plt0.05
• ???????????????????????????????????? PTH???????
  scatter plot diagram ?????????????????????????????
  ?? Pearson product-moment correlation
  coefficient (r)

21
Results

• ??????????????????????????? 106 ???
• 1 ??? ????????????????????? alkaline phosphatase
  ???????????????? 366 U/L (???? 42-121 U/L)
• ????? 105 ?????????????????????????
• 98 ???????????????????????????????????? (drop out
  7 ???)

22
???????? 1 ???? baseline characteristic (n105
cases)
23
?????? 1 ?????????????????????????????????????????
???????????????????????? femoral neck (N 98 ???)
24
?????? 2 Scatter plot ????????????????????????????
????????????????? PTH ???????????? (r - 0.421,
p lt 0.001, N 105)
25
???????? 2 ???????????????????????????????????????
???????????????????????????? (ng/ml)
26
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27

• One-way ANOVA show highly significant difference
  among the mean of serum PTH concentration in the
  various serum concentration of 25(OH)D (plt0.001)

• Post hoc tests (Bonferroni) show significant
  difference of serum PTH between the level of
  serum 25(OH)D concentration lt 35 ng/ml and gt 35
  ng/ml (plt0.04)

28

Prevalence 79.2


Hypovitaminosis D

• Hypovitaminosis D ???? Subclinical vitamin D
  deficiency ??????????? 25(OH)D
  ????????????????????????? PTH

29
Prevalence 66.3
Vitamin D deficiency

• Vitamin D deficiency ??????????? 25(OH)D
  ???????????????? PTH ????????????????????????

30
???????? 3 ??????????????????????????????
?????????????????????????????? femoral neck (N
94 ???)
31
Prevalence 66.3
Vitamin D deficiency



?????????????????????? BMD ???? osteoporosis
?????????????? 25(OH)D 30.5 (SD6.4)
32
unpaired T-test of the mean of 25(OH)D between
non-osteoporotic group and osteoporotic group
showed highly significant difference (p0.004)
33
Discussion

• ??????????????????????????????????????????????????
  ??????????????
• ??????????????????????????????????????????????????
  ??????????????????????????????
• ????????????????????????????????????????? 60
  ????????
• ????????????????? (osteoporosis) ????????????38.8
  
• ????????????????? (osteopenia) ?????? 40.8
• ?????????? (normal) ????????????? 20.4

34
Discussion

• ??????????????????????????????????????????????????
  ??????????????????????????????????????????????????
  ?????????????????? (p0.004)
• ????? hypovitaminosis D ???????????????? ???????
  lt 40 ng/ml ??????????????? (prevalence) 79.2
• ????? vitamin D deficiency ????????????????
  ??????? lt 35 ng/ml ??????????????? (prevalence)
  66.3

35

• ???????????? 25(OH)D ???????????????????????????
  (?????? BMD ??????????) ??????? 30.56.4 ng/ml
  ???????????????????????? vitamin D deficiency (lt
  35 ng/ml)

36

• ????????????????????????? vitamin D deficiency
  ?????????? ????????????????????????????
  ???????????? 10-40 ng/ml (Thomas MK. N Engl J Med
  1998 McKenna MJ. Osteoporos Int 1998 Bettica P.
  Osteoporos Int 1999 McKenna MJ. The Am J of Med
  1992)
• ??????????????????? vitamin D deficiency
  ??????????????????

37

• ?????????????????? 25(OH)D ??????????????????
  (CPB, RIA, HPLC) ??????????????? ????????
  25(OH)D ??????????? (Lips P. Osteoporos Int 1999)
• ?????????????????????????????????????????????????
  vitamin D deficiency ???????????????????????
• 1. ???????????????????????????????????????????????
  ??????????
• 2. ?????????????? 25(OH)D ????????????????????????
  ??????????
• 3. ??????????????????? 25(OH)D ???????????????????
  ???? vitamin D deficiency ???????????????????????

38

• ?????????????????? hypovitaminosis D ??? vitamin
  D deficiency ??????????????????
  ??????????????????????????????????????????????????
  ?????????????????????????????????????????????

39
Conclusion

• ?????????? hypovitaminosis D ??? vitamin D
  deficiency ?????????????????????????????????????
  ?.???????
• ???????????????????????????????????
  ??????????????????????????????????????????????????
  ????????????????????????

40
Thank you for your attention
41
?????????????????????????????????????

• ????????? ?.?. 1966 ??? 2000 ?????????????????????
  ???????? ?????????? 1 ????????????????????????????
  ???
• ??????????? ??. ???? ????????? ??????????????????
  ????????? ??? PTH ???????????? 158 ???
  ?????????????? ???????? 20-80 ??
  ??????????????????????????????????????????????????
  ????????

42
???????????????? ??.????

• 1. ???????????????????????????????
  ??????????????? (20 ??) ?????????? (80 ??)
  ?????????????????
• 2. ?????????????????????????????????????????
  (50-80 ??) ???????????????????????? 39 ???
  ????????????????????????????????????????????? PTH
  ??????????????????????????????????????????????????
  ??????????????????????????????????????????????????
  ?????????????????????????????????????? (McKenna
  MJ. Osteoporos Int 1998 Kinyamu HK. Am J Clin
  Nutr 1997 Chapuy MC. Osteoporos Int 1997
  Michael G III. JAMA 1995.)

43
???????????????? ??.????

• 3. ??????????????????????????????????????????????
  ? hypovitaminosis D ??? vitamin D deficiency

44
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45
Conclusion

• If vitamin D deficiency is defined as a status
  of hypovitaminosis D influencing calcium
  homeostasis through stimulation of PTH secretion,
  this condition is very likely much more common
  than was previously believed.
• The supplement of calcium and vitamin D for
  preventing bone loss and fractures, not only in
  the elderly population but in younger patients.

46
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47
(No Transcript)
48
?????? 2 Scatter plot ???????????????????????????
??? ??? BMI (r - 0.242, p 0.013, N 104)
49
????????? intact PTH

• ???????????? electrochemiluminescence (ECLIA)
• ????????????????????????? immunology ???????
  Microbiology ????????????? ??????????????????
• Inter-assay CVs ?????? 7.1

50
????????? 25(OH)D

• ???????????? radioimmunoassay (RIA)
• ????????????????????????? endocrinology
  ?????????????????? ??????????????????????
  ????????????????
• Inter-assay CVs ?????? 9.4-11.0

51
?????????????????????????????????

• ??????????????????????????????????? (femoral neck
  bone mineral density) ??????????? dual energy
  X-ray absorptiometry (DEXA) ???? DPX-IQ, Lunar
  Corp, USA.
• ???????????????????????????????????
  ????????????????? ?????????????
  ??????????????????
• ??? precision error ????????????????? 1-2

52
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53
Vitamin D deficiency
66.3

79.2


Hypovitaminosis D

• One-way ANOVA show highly significant difference
  among the mean of serum PTH concentration in the
  various serum concentration of 25(OH)D (plt0.001)

• Post hoc tests (Bonferroni) show significant
  difference of serum PTH between the level of
  serum 25(OH)D concentration lt 35 ng/ml and gt 35
  ng/ml (plt0.04)

54
(No Transcript)
55
(No Transcript)
56
(No Transcript)
57
?????? 2 Scatter plot ???????????????????????????
????????????????????????????? (r 0.052, p
0.6, N 105)
58
?????? 3 Scatter plot ???????????????????????????
???????? PTH ???????????? (r - 0.01, p 0.923,
N 105)
59
?????? 4 Scatter plot ????????????????????????????
???????????????????????????????????? femoral neck
(r -0.001, p 0.994, N 105)
60

• One-way ANOVA show highly significant difference
  among the mean of serum PTH concentration in the
  various group of femoral bone quality (plt0.01)

• Post hoc tests (Bonferroni) show significant
  difference of serum PTH between osteoporosis and
  osteopenia, osteoporosis and normal (plt0.02)

61
(No Transcript)
62
Discussion

• ??????????????????????????????????????????????????
  ??????????????
• ??????????????????????????????????????????????????
  ??????????????????????????????
• ????????????????????????????????????????? 60
  ????????
• ????????????????? (osteoporosis) ????????????38.8
  
• ????????????????? (osteopenia) ?????? 40.8
• ?????????? (normal) ????????????? 20.4

63
Discussion

• ??????????????????????????????????????????
  25(OH)D ?????? 33.24 ng/ml
• ????? hypovitaminosis D ??????? lt 40 ng/ml
  ??????????????? (prevalence) 79.2
• ????? vitamin D deficiency ??????? lt 35 ng/ml
  ??????????????? (prevalence) 66.3

64
?????????????? vitamin D deficiency ??????????????
65
Subjects

• ????????????????? ??????-??????? ?.?. 2544
• ?????????????????????????????????????????
• ??????????? ??????????
• ??????????????????????????????????????? 10 c.c.
  ?????????????? 6.00-10.00 ?.
• ??????????????????????????????????????????????????
  ?????????????

66
Statistical Analysis

• Baseline characteristics
• continuous variables ??????? mean (SD) ???
  median (minmax)
• categorical variables ?????????????????????

67
Statistical Analysis

• ???????????????????????????????????? PTH???????
  scatter plot diagram ?????????????????????????????
  ?? Pearson product-moment correlation
  coefficient (r)

68

• One-way ANOVA show highly significant difference
  among the mean of serum 25(OH)D concentration in
  the various degree of femoral neck BMD (plt0.02)

• Post hoc tests (Bonferroni) show significant
  difference of serum 25(OH)D between osteoporosis
  and osteopenia but not osteoporosis and normal
  (plt0.02)