甲状旁腺切除术对血液透析患者合并继发性甲状旁腺功能亢进骨代谢及骨密度的影响

目的 观察甲状旁腺切除术(parathyroidectomy,PTX)对继发性甲状旁腺功能亢进(secondary hyperparathyroidism,SHPT)的维持性血液透析患者骨代谢及骨密度(BMD)的影响.方法 26例SHPT患者行PTX.术前及术后1、3、6、12、18、24个月时常规检测血钙、血磷、血清碱性磷酸酶,化学发光法检测血清全段甲状旁腺素(intact parathyroid,iPTH)、骨钙素(OC)、Ⅰ型前胶原氨基末端前肽(PINP)、β胶原蛋白(β-C TX),术前及术后24个月时双能X线法测定腰椎、股骨颈、骨盆各部位骨密度,观察患者甲状旁腺切除术前、术后骨代谢指标及骨密度变化.结果 (1)与术前比较,血清OC水平(104.49±25.42) μg/L比(695.46±355.62) μg/L,P＜ 0.01]、PINP水平(248.36±159.38) μg/L比(809.28±283.50) μg/L,P＜0.01]于手术3个月后明显降低,β-CTX水平于手术1个月后明显降低(1.60±0.64) μg/L比(3.37±1.34) μg/L,P＜0.01].(2)与术前比较,术后24个月时腰椎BMD(0.88±0.23) g/cm2比(0.78±0.23) g/cm2,P＜0.01]、股骨颈BMD(0.96±0.19) g/cm2比(0.84±0.24) g/cm2,P＜ 0.01]及腰椎Z评分(-1.24±0.55)比(-1.66±0.24),P＜0.01]、股骨颈Z评分(-1.51±0.72)比(-1.93±0.40),P＜0.01]均升高.(3)相关分析显示,术前血清iPTH水平与⊿腰椎Z评分(r=0.584,P=0.002)、⊿股骨颈Z评分(r=0.400,P=0.043)呈正相关,术前血清OC水平与⊿腰椎Z评分(r=0.651,P＜0.001)、⊿股骨颈Z评分(r=0.509,P=0.008)呈正相关.结论 PTX术可以降低患者升高的iPTH、OC、PINP及β-CTX水平,增加骨密度,同时改善多项生化指标,提高患者生活质量.

Effects of parathyroidectomy on bone metabolism and bone mineral density in hemodialysis patients with secondary hyperparathyroidism

Objective To observe the effects of parathyroidectomy(PTX) on bone metabolism and bone mineral density(BMD) in maintenance hemodialysis patients with secondary hyperparathyroidism (SHPT). Methods A total of 26 dialysis patients with SHPT were treated with PTX. Serum calcium, phosphorus, alkaline phosphatase(ALP) levels were determined by standard methods. The levels of serum intact parathyroid (iPTH), osteocalcin (OC), procollagen type I amino- terminal propeptide (PINP), β - crosslaps (β - CTX) were measured by chemiluminescence. BMD was measured by dual energy X ray absorptiometry. iPTH, OC, PINP, β-CTX, serum calcium, phosphorus, ALP were measured before parathyroidectomy and 1, 3, 6, 12, 18, 24 months after operation. Lumbar spine (LS) and femoral neck (FN) BMD were measured before and 24 months after PTX. Results Compared with that before operation, serum OC(104.49±25.42) μg/L vs (695.46±355.62) μg/L, P＜ 0.01] and PINP levels (248.36 ± 159.38) μg/L vs (809.28 ± 283.50) μg/L, P＜0.01] progressively decreased 3 months after PTX, and serum β-CTX levels (1.60±0.64) μg/L vs (3.37±1.34) μg/L, P＜ 0.01] decreased 1 month after PTX. Compared with that before operation, BMD levels increased 24 months after PTX in LS(0.88±0.23) g/cm2 vs (0.78±0.23) g/cm2, P＜0.01] and FN(0.96±0.19) g/cm2 vs (0.84±0.24) g/cm2, P＜0.01], and Z-scores were also increased in both LS(-1.24±0.55) vs (-1.66± 0.24), P＜0.01] and FN(-1.51±0.72) vs (-1.93±0.40), P＜0.01]. Correlation analysis showed that baseline iPTH was positively correlated with△Z-score in FN (r=0.584, P=0.002) and LS (r=0.400, P= 0.043), and so did the OC with△Z - score in FN (r=0.651, P＜0.001) and LS (r=0.509, P=0.008). Conclusion The levels of OC, PINP and β-CTX are reduced and BMD is improved in hemodialysis patients with SHPT after PTX.