血液透析患者甲状旁腺全切除加上臂移植术后低钙血症的防治

目的 观察因继发性甲状旁腺功能亢进症（secondary hyperparathyroidism,SHPT）进行甲状旁腺全切除加上臂移植术（total parathyroidectomy with upper arm autograft,TPTX＋AT）的血液透析患者,术后使用不同钙离子浓度的透析液行透析治疗低钙血症的效果,探讨如何更有效防治术后低钙血症.方法 选择2011年3月至2013年6月在我院接受TPTX＋AT的血液透析患者29例,按照手术时间的先后顺序进行编号,随机将偶数分在A组14例,奇数分在B组15例.术前B组补钙及骨化三醇;术后2组均予补钙及骨化三醇.A组使用钙浓度1.50 mmol/L透析液,B组使用钙浓度1.75 mmol/L高钙透析液.观察术后8 h、24 h、48 h、1周、2周及4周的血钙、血磷及甲状旁腺素（intact parathyroid hormone,iPTH）的变化,记录低钙血症的临床症状,术后达到治疗目标所需要的时间及静脉补钙量.结果 术后血钙、血磷、iPTH均明显下降.术后低钙血症主要表现四肢末端发麻,全身无力,焦虑、烦躁;少数患者表现为心悸、多汗、肌肉痉挛、四肢抽搐,血压低、腹痛或腹泻.A组低钙血症发生率为 85.7%（12/14）、B组为 73.3%（11/15）.术后1周B组血钙水平[（1.95±0.18）mmol/L]明显高于A组[（1.76±0.21）mmol/L].B组术后达到治疗目标所需要的时间为[（7.56±2.25）d],少于A组[（10.54±3.12）d];而B组所需静脉补钙量[（6.86±2.13）g]少于A组[（9.28±2.81）g],差异均有统计学意义（P＜0.05）.结论 并发SHPT的血液透析患者在TPTX＋AT术后常会出现低钙血症,术前、术后足量补充钙剂和骨化三醇,术后使用高钙透析液透析能更加有效防治低钙血症.

Prevention of hypocalcemia in dialysis patients after total parathyroidectomy with upper arm autograft

Objective To investigate prevention of hypocalcemia in dialysis patients by using different calcium concentration dialysate after total parathyroidectomy with upper arm autograft （TPTX ＋ AT） with secondary hyperparathyroidism （SHPT）. Methods 29 cases of dialysis patients after TPTX ＋ AT with SHPT from March 2011 to April 2013 were chosen. According to the operating time,29 cases were ordered the number. The cases with even number were randomly divided into group A （14 cases） and those with odd number were divided into group B （15 cases）. Group A was given 1. 50% calcium dialysate-and group B 1. 75% high calcium dialysate after TPTX ＋ AT. Patients in group B were supplemented with calrium and calcitriol before TPTX ＋ AT, and patients in two groups were supplemented with calrium and calcitriol after the operation. The changes of serum calcium, serum phosphorus, and intact parathyroid hormone （iPTH） after TPTX ＋ AT were observed. The clinical symptoms of hypocalcemia, the time and the supplementary doses of calcium reaching the treating target were recorded. Results The postoperative serum calcium, serum phosphorusvand iPTH were lowered significantly. The symptoms of hypocalcemia were numbness of extrernitties , weakness, anxiety, dysphoria, palpitation, hyperidrosis, myospasm, twitching limbs, hypotension, abdominal pain, diarrhea, etc. The incidence rate of hypocalcemia in group A and group B was 85. 7% （12/14） and 73. 3% （11/ 15） ,respectively. The divided difference of serum calcium at the seventh day after TPTX ＋ AT was [（ 1. 95 ± 0. 18）mmol/L] in group B, higher significantly than that [（ 1. 76 ± 0. 20mmol/L] in group A The average time of reaching treating target was [（7.56 ± 2. 25）d] in group B, which was shorter than that [（10.54 ± 3. 12）d] in group A The supplementary doses of calcium was [（6.86 ± 2. 13） g] in group B, less than that [（ 9. 28 ±2. 81） g] in group A There was significant difference between the two groups in all above-mentioned （P〈0. 05）. Conclusions Hypocalcemia occurs frequently in dialysis patients with SPTH after TPTX ＋ AT. It could be prevented effectively by supplementing sufficient calrium and calcitriol before and after the operation, and by dialysing with high calcium dialysate after operation.