前一篇,把降磷的三大重點,以及透析清除磷離子的極限,都討論過了,接下來的文章,會把重點放在“磷結合劑”。
歷史的演進,從鋁開始
1970年代,所使用的磷結合劑是鋁片,特點是:便宜、降磷效果很好!
但是在那個年代,人們發現接受透析的患者,會出現一些特別的症狀,包含:失智、語言改變、雙手顫抖、肌跳躍、甚至癲癇發作、昏迷或死亡,這個症候群,稱為“透析腦病變(dialysis encephalopathy)”。
這群患者的腦組織在顯微鏡底下,會看到鋁的沉積。因此,研究認為這種情況,和累積過量的鋁很有關係。在那個透析水質還沒這麼講究的年代,透析液中普遍仍含有鋁,加上都使用鋁片當作磷結合劑,雙重因素的影響之下,導致透析患者的死亡原因中,“透析腦病變”而死亡的比例超過10%。
事情還沒結束,鋁沉積在骨頭上,會造成“骨軟化症(osteomalacia)”,在透析腦病變的患者身上,有時候也會合併看到這種骨頭病變,症狀有:骨頭痛、近端肢體無力、骨折等等,診斷要靠骨頭切片檢查才能知道。鋁還可能有其他的狀況,如:高血鈣(hypercalcemia)、或小血球性貧血(microcytic anemia)等等(from KDOQI guideline 12.)。
目前的進展
1990年代,使用逆滲透方式來製作透析液,以及鋁片的使用大幅減少之後,鋁造成的問題就減少了非常多,現在水質的控制也有嚴格的規範,透析液中鋁的濃度應該在<10 µg/L以下,所以,只有偶而零星的案例會被報導在期刊裡。
由於水質的進步,近年來有一些針對鋁片的研究,在嚴格監控血中鋁濃度的情況下,鋁中毒的情況也沒有發生,但是這個研究是個小規模研究(研究個案只有39個,服用兩年);甚至有些聲音認為,只要水質的控制沒有問題,鋁片沒有想像中可怕,這篇有提到各國家在2007年使用鋁片的比例,在澳洲與紐西蘭,高達32.4%的腎友有使用鋁片,不過這篇的結論裡面,仍然希望要有大規模的研究,才能夠支持鋁片的使用。
我們應該怎麼做?
根據KDOQI治療指引,或者KDIGO指引,或者專門撰寫口服磷結合劑的大師,都是建議如果可以的話,盡量避免使用鋁片,這個建議是專家意見,如果一定得使用,也盡量用短期,以避免不必要的風險,這樣是最安全、最保險的作法。
但是有一種情況一定要避免的,若副甲狀腺機能非常低下,很可能是“無力骨(Adynamic bone disease)狀態”的話,那盡可能不要用鋁片吧。還有一點小提醒,當在腸道中同時有檸檬酸鹽(citrate)時,會促進鋁的吸收,所以,當使用鋁片的時候,也要避免吃到含檸檬酸鹽的東西喔。
參考文獻:
KDOQI guideline 12. Aluminum Overload and Toxicity in CKD
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1.
Pepper R, Campbell N, Yaqoob MM, Roberts NB, Fan SLS. Do oral aluminium phosphate binders cause accumulation of aluminium to toxic levels?
BMC Nephrology. 2011;12(1):55.
http://doi.org/10.1186/1471-2369-12-55 1.
Andrade LGM, Garcia FD, Silva VS, et al. Dialysis encephalopathy secondary to aluminum toxicity, diagnosed by bone biopsy.
Nephrol Dial Transplant. 2005;20(11):2581-2582.
http://doi.org/10.1093/ndt/gfi072 1.
Mudge DW, Johnson DW, Hawley CM, et al. Do aluminium-based phosphate binders continue to have a role in contemporary nephrology practice?
BMC Nephrol. 2011;12:20.
http://doi.org/10.1186/1471-2369-12-20