macrophage colony-stimulating factor M-CSF c-fms osteoprotegerin OPG RANKL RANK RANKL RANKL /OPG 2/3 parathyroid hormone 1 /4 18

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1 413 DOI /j. issn osteoporosis OP National Institutes of 7 Health NIH 50 15% % Ⅰ Ⅱ / / ~ / / / % % % % % 50% % 14. 4%

2 macrophage colony-stimulating factor M-CSF c-fms osteoprotegerin OPG RANKL RANK RANKL RANKL /OPG 2/3 parathyroid hormone 1 /4 18 PTH 1 25 D 1 25-dihydroxyvitamin D 1 25 OH 2 D β1 transforming growth factor-β1 TGF-β1 Ⅰ Ⅰ 22 basic multicellular unit BMU RANK NF-κB 23 90% ~ 95% / 19 α tumor necrosis factor-α TNF-α interleukin IL -1 IL-6 IL-7 IL-17 E2 prostaglandin E2 PGE2 1% ~2% M-CSF RANKL -κb receptor activator of nuclear factor-κb NF-κB ligand RANKL

3 415 reactive oxidative species ROS D % 80%

4 / D < A 5-2. / D International Osteoporosis Foundation IOF 27

5 417 osteoporosis self-assessment tool for Asians OSTA IOF IOF OSTA = kg OSTA 2 OSTA OSTA IOF cm 7 BMI 19 kg /m / min min D FRAX BMI FRAX 3 OSTA 3. OSTA World Health Organization >-1 WHO fracture risk assessment tool FRAX ~ -4 <-4 OSTA

6 418 2 OSTA OSTA 10 1 FRAX FRAX http / / T www. sheffield. ac. uk /FRAX /tool. aspx country = 2 FRAX FRAX 29 4 FRAX FRAX 4 FRAX 40~ kg cm >5 mg /d 3 1 <45 3 /d 8~ 10 g 285 ml 120 ml 30 ml FRAX g /cm 2 FRAX 3% 20% FRAX 10% ~ 20% FRAX <10%

7 419 T ~ FRAX 10 FRAX D 31 FRAX 2 FRAX FRAX 32 3 FRAX FRAX 3% 20% FRAX 5% FRAX FRAX 3% 20% 4 FRAX FRAX FRAX FRAX FRAX FRAX

8 /3 33% DXA DXA Wards DXA DXA X dual energy X-ray absorptiometry DXA vertebral fracture assessment VFA X IOF OSTA -1 IOF OSTA 1. DXA 2. CT QCT CT quantitative computed tomography QCT QCT peripheral quantitative computed tomography pqct phantom quantitative ultrasound QUS DXA 40 QCT / 41 QCT DXA QCT CT pqct pqct QUS QUS DXA

9 421 QUS QUS DXA 20% ~ 25% 25% ~ 40% X 40% DXA CT X X X X X Genant 44 3 Ⅰ Ⅱ Ⅲ X DXA VFA Genant 6 X T ~ ~ 79 T cm -1 2 cm - >3 bone turnover markers BTMs

10 422 7 alkaline phosphatase ALP osteocalcin OC bone alkaline phosphatase BALP Ⅰ C- procollagen type 1 C-peptide P1CP Ⅰ N- procollagen type 1 N-peptide P1NP 2 h / ratio of urinary calcium to creatinine UCa /Cr tartrate-resistant acid phosphatase TRACP Ⅰ C- serum C-terminal telopeptide of type 1 collagen S-CTX urinary pyridinoline Pyr urinary deoxypyridinoline D-Pyr Ⅰ C- urinary C-terminal telopeptide of type 1 collagen U-CTX Ⅰ N- urinary N-terminal telopeptide of type 1 collagen U-NTX / DXA 1-4 1/3 T DXA T- Ⅰ N- procollagen type 1 N-peptide P1NP Ⅰ C- serum C- terminal telopeptide of type 1 collagen S-CTX DXA 50 / T <T- <-1. 0 T T T- = - / DXA X Z Z- 1. = - DXA / Z WHO DXA ~ <T- < T T-Score T- = - 9 4

11 423 9 D DXA 1 /3 T < T- < DXA X X X 1 X 30% X 4

12 424 D 50 X X 3 X 3. C- 25 D 25-hydroxy-vitamin D 25OHD S1 800 mg ~ mg mg 500 ~ 600 /d ~ 1. 0 g /kg 300 ml S ~ 30 min

13 425 2 D D 10 D DXA 1 /3 T- D <T- < D D OHD 18 μg /L 61. 0% D S3 D 400 IU 10 μg /d 65 D IU 15 μg /d IU 50 μg /d 50 D 800 ~ IU /d D 25OHD D D 25OHD 75 nmol /L 30 μg /L D selected estrogen receptor modulators SERMs D D 1 D FRAX 10 3% 20% DXA X FRAX denosumab RANKL China Food and Drug Administration CFDA 11 D K2 RANKL

14 bisphosphonates P-C-P CFDA 70 mg / mg / mg / mg / 1 1 D 3 70 mg + D IU IU ~ 300 ml 30 min 30 min 35 ml /min CFDA 13 CFDA 5 mg / 1 15 min D D 1~ 3 d 35 ml /min CFDA 14 CFDA 35 mg / mg / ~ 300 ml 30 min 30 min 35 ml /min CFDA

15 CFDA 1 mg /2 mg mg / 1 2 mg 250 ml 0. 9% 2 h 200 ~ 300 ml 30 min D D 1~ 3 d 35 ml/min >5 mg/dl >442 μmol /L CFDA 16 CFDA 0. 2 g / g / D 2 h 35 ml /min CFDA 17 CFDA 200 mg / h 35 ml/min CFDA 2 15 min 2 h 4 osteonecrosis of the jaw 3 d ONJ ONJ 90% 71 3 ONJ 60% 1% ~ 15% ONJ % ~ 0. 01% <35 ml /min <0. 001% ONJ

16 ONJ ~6 3 5 atypical femur fracture AFF 2012 AFF Meta 6 3 X AFF MRI AFF AFF 3. AFF menopausal hormone therapy 3. 2 ~ 50 /10 AFF 78 MHT MHT 2. estrogen therapy ET estrogen plus progestogen therapy EPT calcitonin 18 CFDA 20 U / 20 U 1 10 U / 10 U 2 CFDA 19 CFDA 2 ml IU / 200 IU 1 50 IU / 50 IU 100 IU 1 CFDA

17 / < / selective estro- receptor modulators SERMs SERMs Women's Health Initiative WHI gen SERMs

18 CFDA 1 60 mg / 60 mg 35mL /min CFDA 5. parathyroid hormone analogue PTHa recombinant human parathyroid hormone 1-34 rhpth1-34 PTHa / CFDA <30 ml /min CFDA 20 μg / h 2 35 ml /min 18 CFDA rhpth strontium CFDA 2 g / 2 g 2 h drug rash with eosinophilia and systemic symptoms DRESS 95-96

19 D D vitamin D analogue 1α D 3 α D α menatetrenone D D 1α γ D 24 α- α- CFDA D CFDA D α μg/ 0. 5 μg/ 1. 0 μg/ 0. 25~1. 0 μg 1 CFDA CFDA D D μg / 0. 5 μg / μg μg / 1 CFDA 8. K 26 K2 γ- CFDA 15 mg / 15 mg 3 9. RANKL denosumab 27 kappa-b RANKL RANKL RANKL RANK FDA

20 mg /1 ml 60 mg D D ~5 5 / X fracture liaison service FLS ~5 2 1

21 433 2 PTH 18 ~ CFDA CFDA CFDA D CFDA CFDA CFDA 29 CFDA CFDA CFDA 30 CFDA CFDA

22 DXA 4. 7% ~18% 137 4% % 84% % ~ 41% 140 D precision error 95% least significant change LSC

23 X LSC www. ISCD. org National Osteoporosis 26 Found-ation NOF International Socienty for Clinical Densitometry ISCD NOF 26 ISCD ~ QCT vbmd 26 pdxa pqct QUS BTMs 5 BTMs 143 BTMs BTMs LSC LSC BTMs BTMs cm

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