【摘要】目的研究难治性继发性甲状旁腺功能亢进症(secondary hyperparathyroidism，SHPT)患者甲状旁腺重量与血生化水平，尤其是血清全段甲状旁腺素水平(intact parathyroid hormone，iPTH)之间的关系。方法收集2018 年1 月～2019 年12 月期间在浙江大学附属邵逸夫医院下沙院区行首次甲状旁腺全切除术(parathyroidectomy，PTX)的43 例难治性SHPT 患者的临床资料，采用多因素线性回归分析切除的甲状旁腺总重量与透析龄、血清校正钙、血磷、iPTH、血碱性磷酸酶(serum alkaline phosphatase，ALP)水平的相关性；并通过Spearman 秩相关分析甲状旁腺重量与甲状旁腺体积、甲状旁腺最大长径、iPTH 之间的相关性。结果43 例患者术中探查发现并切除甲状旁腺共169 枚。Spearman 秩相关分析显示甲状旁腺重量与甲状旁腺体积、甲状旁腺最大长径呈正相关性(r 值分别为0.915、0.778，P 值均＜0.001),iPTH 与甲状旁腺重量和体积均无相关性(r 值分别为0.143、0.080，P 值分别为0.361、0.611)。结论在难治性SHPT 患者中，术前血生化水平包括iPTH，不一定能反应出患者甲状旁腺实际的增生情况，无法完全代表甲状旁腺的功能。
【Abstract】Objective To evaluate the relationship between parathyroid weight and pre-operative blood biochemical levels, especially pre-operative serum total parathyroid hormone level (iPTH), in patients with refractory secondary hyperparathyroidism (SHPT). Methods Clinical data of the 43 patients with refractory SHPT and undergoing the first parathyroidectomy (PTX) in Sir Run Run Shaw Hospital from January 2018 to December 2019 were retrospectively reviewed. Multivariate linear regression was used to analyze the relationship between the total weight of parathyroid glands and the biochemical levels of corrected serum calcium,
blood phosphorus, alkaline phosphatase (ALP) and iPTH before PTX as well as dialysis age of the patients. The relationship between the weight, volume and maximum diameter of parathyroid gland and the iPTH level was investigated by Spearman’s rank correlation coefficient. Results A total of 169 parathyroid glands were found and resected during operation in the 43 patients. Spearman’s rank correlation showed that parathyroid weight was positively correlated with parathyroid volume (r=0.915, P＜0.001) and maximum length diameter (r=0.778, P＜0.001), but iPTH had no correlation with parathyroid weight (r=0.143, P= 0.361) and volume (r=0.080, P=0.611). Conclusion In patients with refractory SHPT, the pre-operative blood biochemical levels including iPTH may not reflect the actual hyperplasia of parathyroid gland and cannot fully represent the function of parathyroid gland.
[1] JOHAL M, LEVIN A. Vitamin D and parathyroid hormone in general populations: understandings in 2009 and applications to chronic kidney disease [J]. Clinical journal of the American Society of Nephrology : CJASN, 2009, 4(9): 1508-14.
[2] NAVES-DIAZ M, PASSLICK-DEETJEN J, GUINSBURG A, et al. Calcium, phosphorus, PTH and death rates in a large sample of dialysis patients from Latin America. The CORES Study [J]. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, 2011, 26(6): 1938-47.
[3] LAU W L, OBI Y A-O, KALANTAR-ZADEH K A-O. Parathyroidectomy in the Management of Secondary Hyperparathyroidism [J]. Clin J Am Soc Nephrol. 2018, 13(6):952-961.
[4] MALBERTI F, MARCELLI D FAU - CONTE F, CONTE F FAU - LIMIDO A, et al. Parathyroidectomy in patients on renal replacement therapy: an epidemiologic study [J]. J Am Soc Nephrol. 2001, 12(6):1242-8.
[5] IVARSSON K M, AKABERI S, ISAKSSON E, et al. The effect of parathyroidectomy on patient survival in secondary hyperparathyroidism [J]. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, 2015, 30(12): 2027-33.
[6] Erratum: Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl. 2017;7:1-59 [J]. Kidney international supplements, 2017, 7(3): e1.
[7] 国家肾脏疾病临床医学研究中心. 中国慢性肾脏病矿物质和骨异常诊治指南概要 [J]. 肾脏病与透析肾移植杂志, 2019, 28(1): 52-7.
[8] PAVLOVIC D, TOMIC BRZAC H. Ultrasonographic evaluation of parathyroid hyperplasia in dialysis patients [J]. Scientific World Journal. 2006, 6:1599-608.
[9] SILVER J, KILAV R FAU - NAVEH-MANY T, NAVEH-MANY T. Mechanisms of secondary hyperparathyroidism [J]. Am J Physiol Renal Physiol. 2002, 283(3):F367-76.
[10] CUNNINGHAM J, LOCATELLI F FAU - RODRIGUEZ M, RODRIGUEZ M. Secondary hyperparathyroidism: pathogenesis, disease progression, and therapeutic options [J]. Clin J Am Soc Nephrol. 2011, 6(4):913-21.
[11] INABA M, OKUNO S FAU - CHOU H, CHOU H FAU - IMANISHI Y, et al. Positive correlation of serum bio-intact PTH(1-84) but not intact PTH with parathyroid gland size in hemodialysis patients [J]. Biomed Pharmacother. 2006, 60(2):62-5.
[12] FANG L, TANG B, HOU D, et al. Relationship between parathyroid mass and parathyroid hormone level in hemodialysis patients with secondary hyperparathyroidism [J]. BMC Nephrol. 2015, 16:82.
[13] 王继伟, 张兵林, 张凌. 甲状旁腺激素与尿毒症继发甲状旁腺功能亢进术后病理的相关性研究 [J]. 中国血液净化, 2015, 14(12): 732-5.
[14] LEONG D C W, LO J, NGUYEN H, et al. The correlation of preoperative biochemical tests with parathyroid adenoma weight. Can we predict expected adenoma weight preoperatively? [J]. Asian J Surg. 2019, S1015-9584(19)30822-X.
[15] SOUBERBIELLE J C, BOUTTEN A FAU - CARLIER M C, CARLIER MC FAU - CHEVENNE D, et al. Inter-method variability in PTH measurement: implication for the care of CKD patients [J]. Kidney Int. 2006, 70(2):345-50.
[16] HOCHER B, ARMBRUSTER FP FAU - STOEVA S, STOEVA S FAU - REICHETZEDER C, et al. Measuring parathyroid hormone (PTH) in patients with oxidative stress--do we need a fourth generation parathyroid hormone assay? [J]. PLoS One. 2012, 7(7):e40242.
[17] HOCHER B, OBERTHUR D FAU - SLOWINSKI T, SLOWINSKI T FAU - QUERFELD U, et al. Modeling of oxidized PTH (oxPTH) and non-oxidized PTH (n-oxPTH) receptor binding and relationship of oxidized to non-oxidized PTH in children with chronic renal failure, adult patients on hemodialysis and kidney transplant recipients [J]. Kidney Blood Press Res. 2013, 37(4-5):240-51.
[18] CAVALIER E, SOUBERBIELLE J C, DELANAYE P. PTH determination in hemodialyzed patients-A laboratory perspective [J]. Semin Dial. 2019, 32(6):490-492.
[19] HOCHER B, ZENG S. Need for better PTH assays for clinical research and patient treatment [J]. Clin Chem Lab Med. 2018, 56(2):183-185.
[20] LEWIN E, OLGAARD K. Influence of parathyroid mass on the regulation of PTH secretion [J]. Kidney Int Suppl. 2006, 102:S16-21.
[21] TOMINAGA Y, TANAKA Y, SATO K, et al. Histopathology, pathophysiology, and indications for surgical treatment of renal hyperparathyroidism [J]. Seminars in surgical oncology, 1997, 13(2): 78-86.
[22] TOMINAGA Y, NUMANO M FAU - TANAKA Y, TANAKA Y FAU - UCHIDA K, et al. Surgical treatment of renal hyperparathyroidism [J]. Semin Surg Oncol. 1997, 13(2):87-96.
[23] FUKAGAWA M, YOKOYAMA K, KOIWA F, et al. Clinical practice guideline for the management of chronic kidney disease-mineral and bone disorder [J]. Therapeutic apheresis and dialysis : official peer-reviewed journal of the International Society for Apheresis, the Japanese Society for Apheresis, the Japanese Society for Dialysis Therapy, 2013, 17(3): 247-88.
