透析患者甲状旁腺切除术后低钙血症的发生及处理

目的 分析血液透析患者因继发性甲状旁腺机能亢进症行甲状旁腺切除术(parathyroidectomy,PTX)后低钙血症的发生及相关影响因素,总结处理经验.方法 回顾近10年行PTX的117例透析患者,观察术后血清钙的变化,分析术后1月内最低的血钙水平与术前血清全段甲状旁腺激素(intact parathyroid hormone,iPTH)、碱性磷酸酶(alkaline phosphatase,ALP)、钙及切除的甲状旁腺数量和病理类型等因素的关系,收集低钙血症的临床表现,统计补充元素钙和骨化三醇的用量.结果 在117例患者中,低钙血症的发生率为61.5%(72/117),一般发生在术后1天,少数在术后1～4周.主要表现为烦躁、多汗、四肢末梢发麻;少数表现为心悸、低血压、肌肉痉挛、肺水肿甚或腹泻.术后1天的血钙为(1.92±0.38)mmol/L.术后血钙与术前血iPTH负相关(r=-0.416,P<0.01),与术前血钙负相关(r=-0.756,P<0.01),与术前血ALP及甲状旁腺切除的数量和病理类型(甲状旁腺腺瘤)无关.大部分患者在术后1周口服元素钙(2.55±1.68)g/d和骨化三醇(1.42±0.75)μg/d即能维持血钙在(2.08±0.53)mmol/L.结论 成功的PTX后都有血钙下降,术前更高的血iPTH和钙是导致术后低钙血症发生的危险因素.低钙血症的临床表现各异,足量补充钙制剂和骨化三醇,可以避免和迅速缓解其发生.

Hypocalcemia and its management in dialysis patients after parathyroidectomy

Objective To retrospectively analyze the clinical situation of hypocalcemia after parathyroidectomy（PTX） in hemodialysis patients with refractory secondary hyperparathyroidism（SHPT）.Methods A total of 117 hemodialyis patients with SHPT（average dialysis age 113.8±50.2 months,and 51.3±10.7 years old） treated with PTX in the recent 10 years were retrospectively analyzed.Changes of serum Calcium（Ca） after PTX were evaluated.The relationship between minimum serum Ca within one month after PTX and the factors including serum intact parathyroid hormone（iPTH）,Ca,alkaline phosphatase（ALP） before PTX,the number of parathyroid glands removed,and the pathology of surgical parathyroid samples were analyzed.The symptoms of hypocalcemia and the supplement doses of calcium and active vitamin D（VitD） were recorded.Results Hypocalcemia occurred postoperatively in 72/117 patients（61.5%）,and hypocalcemia symptoms were found in 23 of the 72 hypocalcemia patients（31.9%）.Postoperative hypocalcemia usually occurred in the second day after PTX.The average serum Ca in the second day after PTX was 1.92±0.38mmol/L.The symptoms of hypocalcemia were fidget,low blood pressure,numbness in the ends of extremities,palpitation,hidrosis,pulmonary edema,seizures,diarrhea,etc.Minimum serum calcium after PTX correlated negatively with the preoperative iPTH level（r =-0.416,P=0.000） and serum Ca（r =-0.756,P=0.001）.Most patients were given oral calcium 2.55±1.68g/day and cacitriol 1.42±0.75μ/day within a week after PTX to maintain normal serum Ca.Conclusion Hypocalcemia occurs frequently in patients after successful PTX.The risk factors leading to hypocalcemia after PTX are higher serum iPTH level and serum Ca before PTX.Hypocalcemia symptoms vary in patients.Supplement of sufficient Ca and active VitD is helpful for the prevention of hypocalcemia.