原发性甲状旁腺功能亢进症患者术后血钙纵向变化规律及其影响因素分析北大核心CSCD

目的比较原发性甲状旁腺功能亢进症患者手术切除治疗前后血钙的变化规律。方法连续入选自1992年12月至2020年12月在北京积水潭医院手术治疗原发性甲状旁腺功能亢进症的271例患者,所有患者分别于术前、术中20 min、术后2周、术后1~6个月、术后7~12个月及术后1年后测量血钙浓度,并分析患者的性别、年龄、是否合并其他遗传性内分泌腺疾病、是否合并骨病变、是否合并肾结石等可能影响术后血钙水平的因素,利用广义估计方程分析不同类型患者手术前后血钙的变化规律。结果术后低钙血症最常发生在2周内,术后半年均为好发时期;男性、合并骨病变患者术后1~6个月与术后2周血钙值差异均无统计学意义(t=0.875,P=1.000;t=0.034,P=3.049);15~35岁年龄段患者术后1~6个月(t=0.239,P=1.000)和7~12个月(t=1.380,P=0.935)与术后2周血钙值差异均无统计学意义;骨密度变化值与术后血钙变化值相关(F=6.895,P=0.004)。结论甲状旁腺功能亢进症患者术后2周时低钙血症发生率最高,1年后血钙水平可能稳定在正常范围内;男性患者相较于女性患者在术后半年内血钙值仍处于较低水平;合并骨病变患者术后2周时血钙值更低并且回升较为缓慢;15~35岁患者术后1年内血钙值均处于较低水平。     

维持性血液透析继发性甲状旁腺功能亢进患者甲状旁腺切除术后低钙血症的危险因素分析

目的:探讨继发性甲状旁腺功能亢进（secondary hyperparathyroidism,SHPT）维持性血液透析患者接受甲状旁腺切除术（parathyroidectomy,PTX）后补钙量与临床指标的相关性、术后发生低钙血症的危险因素以及PTX术后补钙量对患者远期预后的影响。方法:本研究为单中心回顾性研究,入选2...     

原发性甲状旁腺功能亢进症患者术后低钙血症的发病率及其临床特点

目的 探讨原发性甲状旁腺功能亢症进患者术后低钙血症的发生及与其发生有关的相关因素.方法 回顾性分析2012年1月-2016年9月中国医科大学附属盛京医院普通外科收治的37例原发性甲状旁腺功能亢进症患者的病例资料,按症状将其分为4组,统计各临床症状组术后低钙血症的发病率,以及术后住院时间.用SPSS20.0统计软件进行分析,计量资料以均数±标准差((x)±s)表示,组间比较采用Kruskal-Wallis多组秩和检验;计数资料比较样本量小于40时,采用Fisher精确概率法进行检验;样本量较大时采用x2检验.结果 共26例术后出现低钙血症,发病率为70.2％,平均术后住院时间为7.2 d;骨型组7例出现术后低钙血症,发病率为87.5％,平均术后住院时间为11.6d;肾型组6例出现术后低钙血症,发病率为46.1％,平均术后住院时间为5.5 d;无症状组患者10例出现术后低钙血症,发生率为76.9％,术后平均住院时间为4.8d;混合型、消化系统症状患者、神经精神症状患者各1例,均发生术后低钙血症.骨型组、肾型组和无症状组患者低钙血症发病率差异无统计学意义(P =0.147),三组间术后住院天数差异有统计学意义(x2=11.202,P=0.004).结论 低钙血症为原发性甲状旁腺功能亢进术后的常见并发症,各型患者中骨型患者低钙血症发病率最高,且平均术后住院时间最长,因此骨型患者最应警惕低钙血症的发生;肾及无症状型患者术后低钙血症严重程度较低,术后可酌情尽早出院.     

继发性甲状旁腺功能亢进患者术后严重低钙血症风险评分模型的构建与验证

背景与目的 甲状旁腺切除术（PTX）是治疗难治性或进展性继发性甲状旁腺功能亢进（SHPT）的有效方法,严重低钙血症（SH）是术后常见且严重的并发症,术前有效预测SH对SHPT患者的术后管理及针对性干预治疗具有重要的临床价值,但目前尚无SH风险预测评分系统。因此,本研究探讨SHPT患者行PTX后发生SH的危险因素并构建术前风险预测评分模型,以期为临床提供参考。方法 回顾性分析2010年11月—2022年3月在中国人民解放军联勤保障部队第九六〇医院行甲状旁腺全切加自体移植术（tPTX+AT）的513例SHPT患者临床资料,将患者按入院时间分为建模组（404例）,验证组（109例）。根据术后3 d内最低的血钙水平将患者分为SH组和非SH组,进行单因素和多因素分析,以确定术后SH的独立危险因素,利用Logistic回归构建SH风险预测评分模型,分别在建模组和验证组中应用受试者工作特征曲线（ROC）对模型进行内部验证和外部验证。结果 全组513例患者中237例（46.20%）发生术后SH。在建模组中,单因素分析显示,皮肤瘙痒、身高缩短、年龄以及术前血红蛋白、碱性磷酸酶（ALP）、白蛋白、血钙、全段甲状旁腺激素（iPTH）、骨钙素、术前I型胶原C端肽分解片段（β-CTX）与术后SH明显有关（均P<0.05）;多因素分析显示,术前ALP>363.5 U/L、iPTH>2 239 pg/mL、β-CTX>3.305 μg/L和身高缩短是术后SH的独立危险因素,术前血钙>2.50 mmol/L是术后SH的保护因素（均P<0.05）。将ALP>363.5 U/L、iPTH>2 239 pg/mL、β-CTX>3.305 μg/L作为预测因子构建SH风险预测评分模型,阳性时分别赋值7、4、6分,阴性时均为0分。结果显示,10~13分时SH发生率为58.82%、17分时SH发生率为82.93%。该模型在建模组和验证组ROC曲线下的面积（AUC）分别为0.811（95% CI=0.768~0.853）、0.826（95% CI=0.745~0.906）,均有统计学意义（均P<0.05）。结论 构建的SHPT患者行PTX后发生SH的风险预测评分模型预测效能较好,可用于术前识别高风险患者,为临床指导SHPT患者的术后管理和治疗提供重要参考。     

甲状腺手术中甲状旁腺误切和术后低钙血症

目的分析常见甲状腺手术时甲状旁腺误切和术后患者发现低钙血症之间的关系。方法回顾性分析126例甲状腺手术患者的临床资料,其中双侧腺叶大部切除术18例,一侧或双侧腺叶全切术74例和六区清扫术34例。结果 126例患者中,共有25例（19.8%）病理证实存在旁腺误切,有30例（23.8%）术后出现低钙血症,25例（19.8%）出现低钙临床表现,经治疗后症状在2 d内消失。低钙血症的发生（23.8%）和旁腺误切（19.8%）之间是相关的（r=0.87,P=0.0333）。随访6个月,低钙血症消失时间平均为4.25（1-12）周,没有患者出现永久性低钙血症。六区清扫术的总体旁腺误切率为41.2%（14/34）,高于大部切除术的5.6%（1/18）（P〈0.01）,亦高于腺叶全切除术的13.5%（10/74）（P=0.0013）。结论甲状腺腺叶切除及六区清扫术后短暂的低钙血症是比较常见的并发症;旁腺误切可以导致术后低钙血症的发生;六区清扫术有很高的旁腺误切风险。     

不同钙浓度透析液治疗甲状旁腺切除术后低钙血症的探讨

目的观察血液透析患者行甲状旁腺切除术后,使用不同钙浓度透析液纠正术后低钙血症的效果。方法回顾性分析2011年10月至2014年5月我院血液透析中心行甲状旁腺切除术的13例患者,根据术后透析治疗时使用的不同钙浓度透析液,分为A组(使用钙浓度1.50 mmol/L透析液)5例,B组(使用钙浓度1.75 mmol/L透析液)8例。分别观察2组患者术后当日、术后第3、6个月透析前后的血压及透析间期的血钙、血磷、全段甲状旁腺素(intact parathyroid hormone,iPTH),比较数值之间的变化;同时统计2组患者口服钙剂的用量,并通过彩色多普勒超声心脏瓣膜评估及胸部多层螺旋电子计算机断层扫描成像(multi-slice computed tomography,MSCT)所示心脏大血管的影像学表现,比较术前及术后第6个月患者冠状动脉钙化评分分值的变化。结果比较2组单次血液透析治疗时透析前与透析结束后4 h的血钙,2组透析结束后4 h的血钙较透析前均升高,差异有统计学意义(P0.05)。同时分别比较2组透析前与术后第3、6个月时血钙变化,差异有统计学意义(P0.05)。而2组之间透析前的血磷、iPTH无统计学差异(P0.05)。通过6个月调整治疗后,血钙较术后当日明显升高(P0.05),血磷明显下降(P0.05)。术后第6个月时,B组较A组口服钙片的剂量明显减少,血压明显上升(P0.05)。同时术前及术后第6个月心脏瓣膜评估及冠状动脉钙化评分分值无明显变化(P0.05)。结论高钙透析液能更好、更快的纠正术后出现的严重低钙血症,减少维持性钙片的服用剂量,但须注意异位钙化的风险及高血压的发生。     

Risk factors for hypocalcemia in dialysis patients with refractory secondary hyperparathyroidism after parathyroidectomy: a meta-analysis

ObjectiveHypocalcemia after parathyroidectomy (PTX) results in tetany, diarrhea, cardiac arrhythmia, and even sudden death. However, a meta-analysis or systematic evaluation of risk factors with the occurrence and development of hypocalcemia in patients with secondary hyperparathyroidism (SHPT) after PTX has never been performed.MethodsA thorough search of electronic databases, including PubMed, Web of Science, the Cochrane Library, and EMBASE, was performed to retrieve relevant studies from database inception to June 2021. Quality of the included studies was assessed by two independent reviewers using the Newcastle–Ottawa Scale. Review Manager 5.3 and Stata 16.0 were used for meta-analysis. The random-effects model was adopted to calculate the 95% CIs (I²> 50% or p < 0.05) of the combined effect size and the corresponding homogeneous data. Otherwise, a fixed-effects model was used.ResultsThirteen studies including 2990 participants who met the inclusion criteria were enrolled in the present meta-analysis. The overall quality of the enrolled studies had a score of >7 points. Risk factors significantly related to hypocalcemia in patients with SHPT after PTX were preoperative serum calcium (OR 0.19, 95%CI 0.11–0.31), preoperative alkaline phosphatase (ALP) (OR 1.01, 95% CI 1.01–1.02), and preoperative intact parathyroid hormone (iPTH) (OR 1.38, 95%CI 1.20–1.58). Meanwhile, age (OR 0.97, 95%CI 0.87–1.10) was not significantly correlated with hypocalcemia after PTX.ConclusionsBased on the current evidence, preoperative serum calcium, preoperative ALP, and preoperative iPTH were significant predictors of hypocalcemia in patients with SHPT after PTX. More attention should be given to patients with these risk factors for the prevention of postoperative hypocalcemia.     

Factors predictive of critical value of hypocalcemia after total parathyroidectomy without autotransplantation in patients with secondary hyperparathyroidism

Background: Severe hypocalcemia is the most dangerous complication occurring after total parathyroidectomy without autotransplantation (TPTX) for secondary hyperparathyroidism (SHPT). We aim to identify the prevalence and potential risk factors of very severe hypocalcemia in patients with SHPT undergoing TPTX.

Methods: From April 2012 to August 2015, 157 patients with SHPT undergoing TPTX were reviewed. The critical value of hypocalcemia (CVH) was postoperative serum Ca²⁺ levels of ≤1.5?mmol/L.

Results: Univariate analysis showed that patients in the CVH group were significantly younger than those in the non-CVH group. Sex ratio was significantly different between the two groups. The CVH group had significantly higher levels of preoperative PTH and ALP. Male sex and preoperative levels of PTH and ALP were significant independent risk factors by logistic regression analysis.

Conclusions: Male sex, preoperative PTH and ALP were significantly associated with CVH in patients with SHPT undergoing TPTX.     

Bisphosphonate pretreatment attenuates hungry bone syndrome postoperatively in subjects with primary hyperparathyroidism

Primary hyperparathyroidism is characterized by hypercalcemia with loss of bone mass. After parathyroidectomy, hypocalcemia may develop in some patients due to unregulated bone mineralization. Preoperative administration of bisphosphonates, potent inhibitors of osteoclast activity, may prevent postoperative hypocalcemia after parathyroidectomy. We retrospectively reviewed medical records to investigate the effect of bisphosphonate pretreatment on serum calcium level changes after parathyroidectomy. Twenty-three patients with a diagnosis of primary hyperparathyroidism underwent parathyroidectomy between April 1997 and August 2002. Clinical and laboratory data were collected before and after the operation. These patients were divided into two groups; those showing hungry bone syndrome (n = 9) and those not (n = 14). None of the 9 patients with hungry bone syndrome had received bisphosphonate pretreatment. Of the 14 patients without hungry bone syndrome, 6 had received bisphosphonate pretreatment (P < 0.05). Furthermore, preoperative calcium concentration was not related to the occurrence of hypo-calcemia in those without bisphosphonate pretreatment. In conclusion, administration of bisphosphonates in primary hyperparathyroidism can prevent the occurrence of hungry bone syndrome after parathyroidectomy.     

Calcium supplement necessary to correct hypocalcemia after total parathyroidectomy for renal osteodystrophy

BACKGROUND: Prediction of the extent of calcium supplement will facilitate safe and efficient management of hypocalcemia in the early postoperative stage of total parathyroidectomy with autotransplantation (PTXa) in patients with renal osteodystrophy. METHODS: The correlation between the extent of calcium deficiency, estimated by the amount of calcium supplement over 48 h after PTXa and using various parameters such as carboxy terminal parathyroid hormone (c-PTH), intact PTH (i-PTH), alkaline phosphatase (ALP), serum calcium, serum phosphorus, duration of hemodialysis, total weight of resected parathyroid glands and degree of subperiosteal resorption of the middle phalanx was examined in 49 patients who underwent PTX with subcutaneous autotransplantation. Bone mineral density (BMD) was also determined before, 3 months and 1 year after PTXa with dual energy X-ray absorptiometry (DEXA) in 13 patients. RESULTS: There was a positive correlation between pre-operative i-PTH level (r=0.56, P<0.0005) or ALP level (r=0.50, P<0.0005) and the amount of calcium supplement over 48 h after PTXa in these patients. Furthermore, the degree of subperiosteal resorption, determined by Jensen's classification, was significantly correlated with the amount of calcium supplement after PTX (P<0.05). Bone mineral density 3 months after (P<0.0005) and 1 year after PTXa (P<0.001) significantly increased compared with BMD before PTXa in all patients examined. CONCLUSION: These findings suggest that the pre-operative determination of i-PTH, ALP levels and degree of subperiosteal resorption allow the management of hypocalcemia safely and efficiently in renal osteodystrophy patients after PTXa.     

Focused versus conventional parathyroidectomy for primary hyperparathyroidism: a prospective,randomized, blinded trial

BACKGROUND: For many years bilateral neck exploration (BNE) was the gold standard operation for primary hyperparathyroidism (pPHP). With advances in preoperative pathological gland localization and intraoperative parathyroid hormone (IPTH) monitoring, minimally invasive approaches have evolved. This study is aimed to compare BNE and focused parathyroidectomy (FP) in a prospective, randomized, blind trial. PATIENTS AND METHODS: Between 2005 and 2007, 48 patients with pPHP were enrolled in our study. Twenty three patients were randomized to the BNE group and 24 to the FP group. Patients in the FP group underwent preoperative localization studies. All parathyroidectomies were guided by intraoperative intact parathyroid hormone (IIPTH) monitoring. In the BNE group, neither IIPTH nor preoperative localization studies were performed. RESULTS: All patients were cured by the primary operation. Overall, the operative time was similar in both groups. In the focused exploration (FE) group, compared to the BNE group, there was lower pain intensity at 4, 8, 16, 24, 36 and 48 h after surgery (p < 0.001), lower consumption of analgesics (p < 0.001), lower analgesia request rate (p < 0.001), shorter scar length (p < 0.001), higher cosmetic satisfaction rate 2 days, 1 month (p < 0.001) and 6 months after surgery (p < 0.05), but after 1 year cosmetic satisfaction rate became not significant (p = 0.38). Focused exploration (FE) was more expensive (p < 0.05). We did not find any difference in quality of life after 1 month and 6 months after surgery in both groups. CONCLUSION: Both methods of parathyroidectomy for PHP are safe and effective. Focused exploration (FE) has several advantages: lower postoperative pain, lower analgesic request rate, lower analgesic consumption, shorter scar length, better cosmetic satisfaction rate in a short time period.     

Minimally invasive endoscopic-assisted parathyroidectomy for primary hyperparathyroidism

Background: Minimally invasive surgery for primary hyperparathyroidism (pHPT) depends on both an accurate preoperative localization and the availability of intraoperative parathyroid hormone monitoring. Methods: Patients with sporadic pHPT and one unequivocally enlarged parathyroid gland on preoperative imaging underwent endoscopic-assisted parathyroidectomy. Intraoperative rapid parathyroid hormone (quick PTH) monitoring was performed, and surgical success was confirmed when there was a >50% decrease in quick PTH level 10 min after excision as compared with the baseline level at induction. The surgical outcome and the use of preoperative localization, together with the role played by quick PTH assay in enhancing the operative success, were evaluated. Results: From 1999 to 2002, 66 of 107 patients (62%) were selected for this approach. The accuracy of ^99mTc-Sestamibi scintigraphy and ultrasonography was 97% and 70%, respectively. Conversion was required in four cases due to technical problems, and four additional patients failed to show a significant decline in quick PTH levels postexcision. Two patients underwent cervical exploration without the finding of any additional pathology, and another two patients had a delayed drop in quick PTH that was confirmed 30 min postexcision. All patients had a solitary adenoma and were cured of hypercalcemia during a median follow-up of 9 months. Conclusions: Minimally invasive endoscopic-assisted parathyroidectomy can be performed expeditiously in a select group of patients based on ^99mTc-Sestamibi scintigraphy. The use of quick PTH assay can ensure surgical success, but careful interpretation of the results is mandatory.