62例次继发性甲状旁腺功能亢进症行甲状旁腺切除术的临床分析

目的 回顾总结难治性尿毒症继发性甲状旁腺功能亢进症(secondary hyperparathyroidism,SHPT)患者行甲状旁腺切除术(parathyroidectomy,PTX)的临床特点和疗效。方法 2008年9月至2011年7月的60名血液透析患者,平均年龄48.1±9.2岁;平均透析龄102.1±31.0月,共行PTX62例次。对比分析患者手术前后症状、全段甲状旁腺激素(intact parathyroid hormone,iPTH)、钙磷等变化,总结手术并发症、病理结果、SHPT复发及预后等临床特点。结果 62例次手术,甲状旁腺全切加前臂自体移植术(total parathyroidectomy with autotransplantation,tPTX+AT)34例(占54.8%),甲状旁腺全切术(不移植)(total parathyroidectomy without autotransplantation,tPTX)共28例(占45.2%)。合并骨骼改变或异位钙化者达51例(82.3%)。术后绝大部分患者的骨痛及瘙痒症状在数天内缓解,2位患者出现一过性声音嘶哑(3.2%),无吞咽困难、呛咳、窒息等。术后低钙血症发生率较高,1周内需要静脉、口服或高钙透析补钙达60例(96.8%)。术后6个月需要静脉补钙者38例(61.2%),术后12月仍需要少量静脉补钙者12例(19.4%)。所有患者甲状旁腺病理上均有结节增生(100%),有的伴钙化、出血、囊变;合并甲状旁腺腺瘤3例(4.8%);合并弥漫性增生仅2例(3.2%)。术前iPTH为1716±874.1ng/ml,磷2.0±0.3mmol/L,钙2.5±0.2mmol/L,术后iPTH(P<0.05)、血清磷(P<0.05)、血清钙(P<0.05)水平均较术前显著降低,且iPTH、磷较长时间维持正常。术后随访13.7±9.8月,2例为甲状旁腺残留再次行手术;SHPT复发6例,均为全切加前臂自体移植术组,其中2例证实为移植物复发,行移植物切除术后恢复正常;其余经活性维生素D控制正常。3例血管钙化严重者死于术后8周至9月。结论 PTX是治疗难治性尿毒症SHPT的一种安全、有效的手段。长期和不同术式的疗效待进一步观察。

A retrospective analysis of 62 maintenance hemodialysis patients with parathyroidectomy

Objection To investigate the clinical manifestations and the effect of parathyroidectomy (PTX) in maintenance hemodialysis (MHD) patients with secondary hyperparathyroidism (SHPT). Methods We retrospectively reviewed 62 MHD patients treated with PTX cases during the period from September, 2008 to July, 2011. Their average age was 48.1±9.2 years old, and their dialysis age ranged 102.1±31.0 months. Symptoms before and after operation, operation complications, pathological findings of the surgical samples, biochemical parameters, serum iPTH, recurrence of SHPT, and prognosis were analyzed. Results In the 62 PTX cases, 34 cases (54.8%) were subjected to total parathyroidectomy with autotransplantation, and 28 cases (45.2%) were treated with total parathyroidectomy without autotransplantation. Bone pain and pruritus relieved significantly after operation. Two cases had the early operation complication of transient hoarseness. The most prevalent postoperation complication was hypocalcemia, and 96.8% patients required oral or intravenous calcium supplement. All parathyroid samples showed nodular changes on pathological examination, some samples also accompanied with calcification, bleeding or cystic degeneration. Parathyroid adenoma was found in 3 patients (4.8%), and diffuse proliferation of parathyroid gland in 2 patients (3.2%). Serum iPTH, phosphorus and calcium decreased significantly after the operation (P<0.05). In the 35 patients followed up after operation for more than one year, second PTX was required in 2 patients. Recurrent hyperparathyroidism was found in 6 patients treated with parathyroidectomy plus autotransplantation, of which 2 patients were diagnosed as graft-dependent recurrence and were cured by removal of the graft, and the other 4 cases were treated orally with active from of vitamin D Conclusion PTX is a relatively safe and effective method in the treatment of MHD patients with SHPT.