New a sight at group D vitamins
| N.À.
Korovina I.N.Zaharova of A.V.Cheburkin
the Russian medical academy poslediplomnogo educations MZ the Russian Federation, Moscow
Vitamin D (kaltsiferol, antirachitic vitamin) concerns vitamins. Now vitamins D2 (ergokaltsiferol) i D3 (holekaltsiferol) are known, and also active metabolity p`s vitamin that rahit is known very much for a long time and is mentioned even in works Sorana Efessky (98-138 AD) and Galena (131-211 AD) Its clinical and pathoanatomical description was given by English ortoped F.Glisson to 1650. For the first time vitamin D1 (ergosterin) is received only in 1924 by A.Gess and its M.Vejnshtok poluchili from vegetable oils after influence of ultra-violet beams in length volny of 280-310 nanometers. In 1937 A.Vindaus has allocated from blankets of a skin of a pig 7-degidroholesterin which at UFO turns to active vitamin D3. Other by a source vitamin D in an organism vitamin D2 arriving with food I am. In last years it became known, that about 50 % of vitamin D it is synthesised in kozhe. Nedostatochnaja insoljatsija or infringement vsasyvanija vitamin D in intestines result to narusheniju fosforno-kaltsievogo an exchange (a rickets at babies or osteomaljatsija at teenagers and vzroslyh). the Rickets the Rickets meets in all countries, but is especially frequent, where light lack solnechnogo is marked. Children born in the autumn and the winter, are ill with a rickets more often and more hard. At insufficient insoljatsii, the caused climatic features (frequent fogs, oblachnost, smoke content of atmospheric air) or a conditions of life, intensity sinteza of vitamin D decreases. Therefore disease of a rickets above in industrial rajonah, than in the rural. last years frequency of a rickets in Russia among children early vozrasta kolebletsja from 54 to 66 %. By N.F.Filatova`s definition, 1891, the rickets is the general disease organizma shown, mainly, by original change of bones. According to modern representations, a rickets - the disease which has been caused vremennym by discrepancy between requirements of the growing organism in phosphorus and kaltsii and nedostatochnostju the systems providing their delivery in an organism of the child (Spirichev V. B, 1980). the Rickets concerns exchange diseases with primary infringement fosforno-kaltsievogo of an exchange. However, along with it, changes of processes perekisnogo of oxidation lipidov are marked, a metabolism of fibers, microcells, including iron, copper i other Key mechanism of development of a rickets is insufficient receipt of vitamin D an by food and its education in a skin, and also infringement of its synthesis in a liver and kidneys (Spirichev V.B., 1980). The rickets develops usually at children having those or other factors predraspolozhennosti which spectrum at each child is individual (table 1). Combination exogenous and endogennyh factors defines terms of demonstration and weight of a current rahita. Regulation fosforno-kaltsievogo an exchange Vitamin D and its active metabolity are structural units gormonalnoj of the system regulating fosforno-kaltsievyj an exchange. In an organism by difficult prevrashcheny in a liver and kidneys, holekaltsiferol it will be transformed in more active metabolity, capable to regulate vsasyvanie calcium and phosphorus salts in thin kishechnike, reabsorbtsiju in kidneys and their adjournment in bones. It is known, that multicomponent reguljatsiju fosforno-kaltsievogo a homeostasis basically, carry out paratgormon, vitamin D and kaltsitonin . At infringements of a homeostasis of calcium and phosphorus action perechislennyh of substances on cages-targets of various bodies (a bone brain, zheludochno-kishechnyj the path, a liver, kidneys) promotes fast restoration optimalnogo of level of calcium out of and in organism cages. Infringement of structure and function nazvannyh of bodies and biochemical systems calls various gipokaltsiemicheskie sostojanija. Physiological fluctuations Sa and R occur in enough narrow borders: The bottom normativnyj level of the general Sa is equal to blood 2, top - 2,8 mmol/l. gipokaltsiemija nemedlenno activates synthesis paratireoidnogo a hormone which strengthens vyvedenie Sa from a bone fabric in blood, and also ekskretsiju R kidneys in its result umenshenija reabsorbtsii in nephritic kanaltsah. Thus it is saved normal sootnoshenie between Sa and R (product Sa h R is a constant). the Second basic regulator of homeostasis Sa - vitamin D . Ego gomeostatichesky action is directed on restoration of lowered level Sa in blood i realizuetsja more slowly, in comparison with paratgormonom. If last is the factor bystrogo of reaction on menacing to an organism gipokaltsiemiju, and restoration level Sa occurs by destruktsii a bone fabric to development of the expressed osteoporosis D carries out more thin regulation fosforno-kaltsievogo an exchange at level mnogih of bodies. 25-IT-d3 formed in a liver, possesses enough expressed aktivnostju, its level in a liver is stable and in norm fluctuates from 10 to 100 ng/ml. Most active metabolit vitamin D3 - 25ON-D3 1 alpha-gidroksilazy is synthesised in kidneys in result dejstvija of enzyme. Consider, that this metabolit vitamin D is gormonom, which operates at level of the genetic device of a cage. Except vitamin D and its cores metabolitov, other similar biohimicheskie structures, which action on elektrolitnyj a homeostasis less izucheno. Vazhnym gomeostaticheskim by effect 1,25 (IT) 2-D3 are defined activization transporta Sa in an intercellular liquid from a gastroenteric path by an induction sinteza enterotsitom the Sa-connecting protein is. In conditions gipokaltsiemii vitamin D operates on a bone similarly paratgormonu - temporarily increases rezorbtsiju bone tkani, simultaneously strengthening vsasyvanie Sa from intestines. After restoration Sa in norm blood do, vitamin D improves quality of a bone fabric: promotes quantity osteoblastov increase, reduces kortikalnuju poroznost and rezorbtsiju bones. Receptors to 1,25 (IT) 2-D3 imejut cages of many bodies, providing universal regulation of fermental vnutrikletochnyh systems. The regulation mechanism the following: 1,25 (IT) 2 vitamin D3 activates a corresponding receptor, further in a signal transmission intermediaries- adenilattsiklaza and tsamf, mobilising Sa and its communication with fiber kalmodulinom participate. Eventual effect strengthening of function of a cage and, hence, body. From the above-stated scheme netrudno to present consequences of deficiency of vitamin D that is reflected in tab. 3. the Third basic regulator fosforno-kaltsievogo an exchange is kaltsitonin - a hormone of a thyroid gland which reduces activity and the quantity osteoklastov. Calcitoninum strengthens adjournment Sa in a bone fabric, liquidating all kinds of an osteoporosis. Decrease in level Sa in blood is promoted by glucocorticoids, somatotropnyj a hormone, gljukagon, androgeny and an estrogen, that is in development of a rickets prinimajut participation many endokrinnye systems. Infringements fosforno-kaltsievogo an exchange Infringements of structure and function of the bodies participating in regulation fosforno-kaltsievogo of an exchange, are the reason of various diseases and the syndromes gipokaltsiemii developing during a life of the child. At children`s age bone changes can be the most expressed clinical displays of deficiency Sa in an organism. children of early age in suppressing bolshinstve cases have a rickets called by deficiency of vitamin of D.Eta the form of a rickets (D-scarce, mladenchesky) is considered as independent disease . the Changes of bone system similar to the D-scarce rickets can have a place pri the primary genetically determined and secondary diseases of bodies, uchastvujushchih in a metabolism of vitamin D: Parathyroid glands, a gastroenteric path, pochek, a liver, bone system. In such cases the diagnosis "rickets" loses nozologicheskuju the characteristic and is treated, how rahitopodobnyj a core zabolevanija syndrome (gipoparatireoza, nephritic tubuljarnogo atsidoza, a syndrome De-SINK-debre-fankoni i etc.) . Defeat of a bone fabric medical products . Most can call more often various infringement fosforno-kaltsievogo an exchange with osteoporosis development call glucocorticoids . On the second place on frequency stand osteopatii against application protivosudorozhnyh preparatov (phenobarbital). Development of infringements fosforno-kaltsievogo an exchange pri application tireoidnyh hormones , geparina (is possible at therapy more than 3 mes), long ispolzovanii antatsidov, tsiklosporina, tetratsiklina, gonadotropina, derivatives fenotiazina. Existing forms of vitamin D are presented to tab. 5. Application of vitamin D Indications for purpose active metabolitov vitamin D3: 1. An osteoporosis (congenital and got). 2. Rahitopodobnye diseases. 3. Chronic nephritic insufficiency. 4. A syndrome broken vsasyvanija (primary and secondary, in t.ch. postrezektsionnyj). 5. gipoparatireoidizm (idiopatichesky, postoperative), psevdogipoparatireoidizm. Now there were prospects applications active metabolitov vitamina D for treatment of many somatic diseases , characterised giperproliferatsiej cages, not complete differentiation and superfluous activating Ò-cages. So, there were data about efficiency 1,25 (IT) 2-DZ at psoriaze v a kind of system therapy throughout 4-6 months under the control of calcium of blood, and also ego structural analogues (kaltsipotriol, 22-oksakaltsipotriol), not calling giperkaltsiemii, for local therapy. At the expense of activity increase estestvenyh killers, normalisation supressorov, pojavilas possibility of use active metabolitov vitamin D3 at revmatoidnom artrite, tireoidite, allergic entsefalomielite, a diabetes, transplantation of bodies, sifiliticheskom system eritematoze . last years it became known, that 1,25 (IT) 2-DZ suppresses proliferatsiju and accelerates a considerable quantity differentiation tumoral cages , kotorye call an expression of receptors to vitamin D. The clinical tests spent in To England, show, that in the near future it is possible to expect application of derivatives vitamina D for mono-and the combined therapy of many tumoral diseases. So, 22-oksatriol calls dozozavisimuju supressiju growth of a tumour mice, which implantirovana kartsinoma a mammary gland of the person. Other analogue 1,25 (IT) 2-2 2 2 - geksafljuoro-trigidrovitamin D3 (DD-003) brakes growth of a tumour of a thick gut. So promising therapeutic possibilities active metabolitov vitamin D will be allowed dobit good results in therapy of many heavy somatic diseases. Preventive maintenance and rickets treatment are applied Most often preparations of vitamin D in pediatric practice for profilaktiki and treatments of a rickets at children. Oil forms vitamina DZ existing till now not always are well soaked up. Causes of infringement vsasyvanija masljanogo a solution of vitamin D are: • a syndrome broken vsasyvanija in a thin gut (tseliakija; gastrointestinalnaja the food allergy form, ekssudativnaja enteropatija, etc.) ; • a pancreatitis; • kistofibroz a pancreas (mukovistsidoz); • dizembriogenez enterotsitov; • chronic enterokolity; • illness the Crone. last years there was a water form of vitamin DZ. By advantages water a solution of vitamin DZ are: • the best vsasyvanie from ZHKT (the water solution is soaked up in 5 times faster, and kontsentratsija in a liver in 7 times above); • more long effect at application of a water solution (remains do 3 mes, and oil - to 1-1,5 mes); • the big activity; • fast approach of clinical effect (in 5-7 days after purpose DÇ and of 10-14 days at reception D2); • high efficiency at a rickets and rahitopodobnyh diseases, a path pathology zheludochno-kishechnogo; • convenience and safety of the medicinal form. the Preparation is approved in scientific research institute of pediatrics and children`s surgery MZ the Russian Federation (Novikov P. V and soavt., 1997) at a rickets and rahitopodobnyh diseases. By authors it is shown, that water-soluble forma vitamin DZ is convenient and safe at sick of a rickets and inherited vitamin-D-rezistentnym a rickets . High therapeutic efficiency vodorastvorimoj of the form of vitamin DZ at all patients with sharp and podostroj forms rahita in a daily dose nearby 5000 ME is shown. The preparation also has appeared effective at treatment of children s vitamin-d-resistant a rickets in a daily dose 30 000 ME. In 30-45 days after achievement of therapeutic effect at a rickets neobhodimo to pass to supporting dose - preventive, 500 ME (1 drop vodorastvorimogo of vitamin DZ) which the child should receive daily in a current dvuh of years and during winter time for the third year of a life. Usually we recommend to begin treatment rahita with 2000 ME within 3-5 days, then at good shipping a dose raise to individualnoj medical (more often 3000 ME) under the control of calcium of blood and urine. A dose 5000 ÌÅ appoint only at the expressed bone changes. protivoretsidivnoe treatment provodjat to children from group of risk vitamin DZ in a dose 2000-5000 ME during 3-4 ned. This course spend through 3 mes after the termination of 1st course (do not spend in the summer), water-soluble vitamin DZ is better ispolzovat. The preparation is well transferred, the collateral effektov and undesirable phenomena at its application is not revealed. last years spirit a solution of vitamin D2 practically ne vypuskaetsja in view of a high dose, in 1 drop - nearby 4000 ME) and overdose possibilities from-for isparenija spirit and increase in concentration of a solution. postnatalnaja specific preventive maintenance of a rickets is spent by vitamin D , the minimum preventive dose makes for healthy donoshennyh children rannego of age 400-500 ME a day (the CART, 1971, the Method, recommendations MZ the USSR, 1990). This doza naznachaetsja from 3-4 week age in osenne-zimne-spring the periods taking into account conditions zhizni of the child and risk factors of development of disease. It is necessary to remember, as in summer period at in sufficient insoljatsii (cloudy, rainy summer), especially in northern regionah Russia, it is expedient to appoint a preventive dose of vitamin D. Specific rickets preventive maintenance donoshennym to children is spent in osenne-zimne-spring periody year on the first and second year of a life. from risk group on a rickets daily purpose vitamina D in a dose 1000 ME during osenne-zimne-spring is recommended to Children The period in techenie first two years of a life. the risk Group on a rickets is made by children : • nedonoshennye, malovesnye; • born with signs of morfo-functional immaturity; • with a syndrome malabsorbtsii (tseliakija, gastrointestinalnaja the form food allergii, ekssudativnaja enteropatija, etc.) ; • with the convulsive syndrome, receiving antikonvulsanty; • with the lowered impellent activity (parezy and paralyses, long immobilizatsija); • with a chronic pathology of a liver, zhelchevyvodjashchih ways; • often ill with sharp respiratory diseases; • the receiving not adapted dairy mixes; • with the burdened heredity on infringements fosforno-kaltsievogo obmena; • from twins or from repeated sorts with small intervals between them. Specific preventive maintenance of a rickets nedonoshennym to children from 1 degree is spent about 10-14 days of a life on 400-500-1000 ME a day daily in techenie first two years, excepting summer months. At nedonoshennosti 2-3 degrees vitamin D appointed about 10-20 days (after an establishment enteralnogo a food) in a dose 1000-2000 ME daily within the first year of a life, and on the second year in a dose 500-1000 ME, excepting summer mesjatsy. Specific preventive maintenance of a rickets is better to spend water solution vitamina DZ, especially at nedonoshennyh children, taking into account immaturity at them fermentativnoj aktivnosti intestines. Contra-indication to purpose of a preventive dose of vitamin D can be: idiopaticheskaja kaltsiurija (Williams-Burne illness), gipofosfatazija, organicheskoe defeat TSNS with symptoms mikrotsefalii and kraniostenoza. Children with the small sizes rodnichka have only relative contra-indications k to purpose of vitamin D . Specific preventive maintenance of a rickets im provoditsja, since 3-4 months of a life. the Literature 1. M.A.Dambaher, E.Shaht the Osteoporosis and active metabolity vitamin D EULAR Publishers.-Basle.-Switzerland.-1996. 2. Diagnostics and treatment rahitopodobnyh diseases at children. Methodical recommendations. ÒÕ., 1988. 3. P.V.Novikov, E.A.Kazi-Ahmetov, A.V.Safonov New (water-soluble) form vitamina D3 for treatment of children about vitamin-d-scarce and inherited vitamin-D-rezistentnym rahitom.//Ross. The bulletin perinatologii and pediatrics 1997; 6. 4. Preventive maintenance and treatment of a rickets at children of early age. Methodical recommendations.-Ì., 1990. 5. A role active metabolitov vitamin D in patogeneze and treatment metabolic osteopaty. Under the editorship of prof. E.I.Marovoj. M, 1997. 6. A.V.Cheburkin. About treatment of a rickets by vitamin D//Paediatrics.1979; 10: 18-21. Applications to article
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