目的 比较甲状旁腺次全切除术(subtotal parathyroidectomy，STPX)和甲状旁腺全切除并自体移植术(total parathyroidectomy with autotransplantation，TPX-AT)对肾移植术后患者三发性甲状旁腺功能亢进(tertiary hyperparathyroidism, THPT)的治疗效果。 方法 回顾性分析2018年5月～2021年9月肾移植成功后THPT患者接受STPX或TPX-AT治疗的临床资料，包括患者年龄、性别、透析龄、手术类型、最终病理结果、手术前生化检验值[包括血钙、全段甲状旁腺素(iPTH)、磷、碱性磷酸酶(ALP)、肾小球滤过率等]以及手术后定期随访的iPTH值。 结果 共纳入18名患者，男性8人，女性10人，平均年龄(45.56±3.46)岁，平均透析时间(6.70±1.20)年。将患者分为STPX组和TPX-AT组，每组各9例患者。2组患者手术前平均血钙、血磷、ALP、iPTH水平无统计学差异。手术后第1天，STPX组和TPX-AT组iPTH分别降至98.88pg/ml、39.39pg/ml，2组间比较无显著差异(t=-1.423，P=0.181)，2组手术后治愈率分别为55.5%、77.8%；手术后6月2组iPTH分别为105.52pg/ml、151.07pg/ml。2组总有效率为61.1%，STPX组有效率为55.5%，TPX-AT组有效率为66.7%。 结论 TPX-AT手术后治愈率高于STPX，但手术后6个月，STPX和TPX-AT治疗THPT的有效率均不理想。手术后第1天iPTH水平对患者预后具有一定参考价值。
Objective To compare the therapeutic effects of subtotal parathyroidectomy (STPX) and total parathyroidectomy plus autologous transplantation in forearm (TPX-AT) on tertiary hyperparathyroidism (THPT) in patients with successful kidney transplantation. Method The patients with THPT after successful kidney transplantation and receiving STPX or TPX-AT from May 2018 to September 2021 were retrospectively reviewed. Their clinical data including age, sex, dialysis age, type of surgery, final pathological findings, preoperative biochemistry tests (serum calcium, iPTH, phosphorus, alkaline phosphatase, glomerular filtration rate, etc.) and postoperative iPTH at each following time were collected and analyzed. Result A total of 18 patients were included in this study, including 8 males and 10 females, with an average age of (45.56±3.46)years and an average dialysis time of (6.70±1.20)years. The patients were divided into STPX group and TPX-AT group, with 9 patients in each group. There were no significant differences in the preoperative values of mean serum calcium, phosphorus, ALP and iPTH between the two groups. At the first postoperative day, iPTH levels decreased to 98.88pg/ml and 39.39pg/ml in STPX group and TPX-AT group, respectively, but without statistical significance between the two groups (t=-1.423, P=0.181). The postoperative cure rates were 55.5% and 77.8% and the iPTH levels after the operation for 6 months were 105.52pg/ml and 151.07pg/ml in STPX group and TPX-AT group, respectively. The overall effective rate of the two groups was 61.1%; the effective rate was 55.5% in STPX group and was 66.7% in TPX-AT group. Conclusion The postoperative cure rate was higher in TPX-AT group than that in STPX group. However, the effective rates to THPT after the operation for 6 months were unsatisfactory in both groups. The iPTH level at the first postoperative day may be an indicator for prognosis of the THPT patients.
[1] Portillo MR, Rodríguez-Ortiz ME. Secondary Hyperparthyroidism: Pathogenesis, Diagno-sis, Preventive and Therapeutic Strategies[J]. Rev Endocr Metab Disord, 2017,18(1):79-95.
[2] 张妍妍, 王培松, 王雪薇, 等. 三发性甲状旁腺功能亢进症诊治进展[J]. 中华内分泌外科杂志, 2020,14(1):83-86.
[3] Messa P, Alfieri CM. Secondary and Tertiary Hyperparathyroidism[J]. Front Horm Res, 2019,51:91-108.
[4] Palumbo VD, Palumbo VD, Damiano G, et al. Tertiary hyperparathyroidism: a review[J]. Clin Ter, 2021,172(3):241-246.
[5] Gioviale MC, Bellavia M, Damiano G, et al. Post-transplantation tertiary hyperparathy-roidism[J]. Ann Transplant, 2012,17(3):111-9.
[6] Lou I, Schneider DF, Leverson G, et al. Parathyroidectomy is underused in patients with tertiary hyperparathyroidism after renal transplantation[J]. Surgery, 2016,159(1):172-9.
[7] Ozdemir FN, Afsar B, Akgul A, et al. Persistent hypercalcemia is a significant risk factor for graft dysfunction in renal transplantation recipients[J]. Transplant Proc, 2006,38(2):480-2.
[8] Perrin P, Caillard S, Javier RM, et al. Persistent hyperparathyroidism is a major risk factor for fractures in the five years after kidney transplantation[J]. Am J Transplant, 2013,13(10):2653-63.
[9] Dulfer RR, Franssen G, Hesselink DA, et al. Systematic review of surgical and medical treatment for tertiary hyperparathyroidism[J]. Br J Surg, 2017,104(7):804-813.
[10] Nicholson ML, Veitch PS, Feehally J. Parathyroidectomy in chronic renal failure: compar-ison of three operative strategies[J]. J R Coll Surg Edinb, 1996,41(6):382-7.
[11] Hiramitsu T, Hasegawa Y, Futamura K, et al. Intraoperative intact parathyroid hormone monitoring and frozen section diagnosis are essential for successful parathyroidectomy in secondary hyperparathyroidism[J]. Front Med (Lausanne), 2022,9:1007887.
[12] Choi HR, Aboueisha MA, Attia AS, et al. Outcomes of Subtotal Parathyroidectomy Versus Total Parathyroidectomy With Autotransplantation for Tertiary Hyperparathyroidism: Mul-ti-institutional Study[J]. Ann Surg, 2021,274(4):674-679.
[13] Hsieh TM, Sun CK, Chen YT, et al. Total parathyroidectomy versus subtotal parathyroid-ectomy in the treatment of tertiary hyperparathyroidism[J]. Am Surg, 2012,78(5):600-6.
[14] Zmijewski PV, Staloff JA, Wozniak MJ, et al. Subtotal Parathyroidectomy vs Total Para-thyroidectomy with Autotransplantation for Secondary Hyperparathyroidism in Dialysis Patients: Short- and Long-Term Outcomes[J]. J Am Coll Surg, 2019,228(6):831-838.
[15] Kakuta T, Sawada K, Kanai G, et al. Parathyroid hormone-producing cells exist in adipose tissues surrounding the parathyroid glands in hemodialysis patients with secondary hy-perparathyroidism[J]. Sci Rep, 2020,10(1):3290.
