继发性甲状旁腺功能亢进的治疗策略
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摘要
继发性甲状旁腺功能亢进(SHPT)已成为慢性肾脏病(CKD)常见的并发症之一,严重影响患者生活质量。其治疗策略包括药物、手术和介入。药物包括非选择性和选择性活性维生素D、拟钙剂(西那卡塞),药物治疗期间强调动态观察血清全段甲状旁腺激素(i PTH)和血清钙、磷的变化,以及时调整药物剂量。药物治疗无效且具备手术指征者,可考虑甲状旁腺切除手术(PTX)或超声介入治疗。PTX前需要高频彩超和(或)99Tcm-MIBI双时相显像用于甲状旁腺的定位诊断。PTX有三种术式,其中甲状旁腺全切除加移植是目前最常用的术式。对于不能耐受手术和需要再次PTX的患者可以选择一种新的治疗策略,即彩色超声介导下甲状旁腺热消融术。
Secondary hyperparathyroidism( SHPT) has become one of the most common complications of chronic kidney disease( CKD),and seriously affects the patients' quality of life,whose treatment strategy consists of medication,surgery,and intervention. Its medications include non-selective and selective active vitamin D and cinacalcet,during which the changes of serum intact parathyroid hormone( i PTH),calcium,and phosphorus are monitored,so that the doses of drugs can be timely adjusted. When medical treatment is ineffective and the patient has the indication for surgery,parathyroidectomy( PTX) or ultrasound interventional therapy can be considered. High frequency color ultrasound and / or99Tcm-MIBI dual-phase scintigraphy are / is required for the preoperative localization diagnosis of parathyroid. There are three parathyroidectomy methods,among which total parathyroidectomy plus autotransplantation is currently the most-used surgical method. Color ultrasound-guided thermal ablation of parathyroid gland may be used as a new treatment strategy for patients who can't tolerate PTX or requires a second PTX.
Secondary hyperparathyroidism( SHPT) has become one of the most common complications of chronic kidney disease( CKD),and seriously affects the patients' quality of life,whose treatment strategy consists of medication,surgery,and intervention. Its medications include non-selective and selective active vitamin D and cinacalcet,during which the changes of serum intact parathyroid hormone( i PTH),calcium,and phosphorus are monitored,so that the doses of drugs can be timely adjusted. When medical treatment is ineffective and the patient has the indication for surgery,parathyroidectomy( PTX) or ultrasound interventional therapy can be considered. High frequency color ultrasound and / or99Tcm-MIBI dual-phase scintigraphy are / is required for the preoperative localization diagnosis of parathyroid. There are three parathyroidectomy methods,among which total parathyroidectomy plus autotransplantation is currently the most-used surgical method. Color ultrasound-guided thermal ablation of parathyroid gland may be used as a new treatment strategy for patients who can't tolerate PTX or requires a second PTX.
引文
1 Young EW,Albert JM,Satayathum S,et al.Predictors and consequences of altered mineral metabolism:the Dialysis Outcomes and Practice Patterns Study[J].Kidney Int,2005,67(3):1179-1187.
2 Kidney Disease:Improving Global Outcomes(KDIGO)CKD-MBD Work Group.KDIGO clinical practice guideline for the diagnosis,evaluation,prevention and treatment of chronic kidney diseasemineral and bone disorder(CKD-MBD)[J].Kidney Int,2009,76(1):S1-S130.
3 Fukagawa M,Yokoyama K,Koiwa F,et al.Clinical practiceguideline for the management of chronic kidney disease-mineral and bone disorder[J].Ther Apher Dial,2013,17(3):247-288.
4 K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease[J].Am J Kidney Dis,2003,42(4 Suppl3 ):S1-S201.
5 Yan Y,Qian J,Chen N,et al.Efficacy and initial dose determination of paricalcitol for treatment of secondary hyperparathyroidism in Chinese subjects[J].Clin Nephrol,2014,81(1):20-29.
6 Teng M,Wolf M,Lowrie E,et al.Survival of patients undergoing hemodialysis with paricalcitol or calcitriol therapy[J].N Engl J Med,2003,349(5):446-456.
7 Fukagawa M,Yumita S,Akizawa T,et al.Cinacalcet(KRN1493)effectively decreases the serum intact PTH level with favorable control of the serum phosphorous and calcium level in Japanese patients[J].Nephrol Dial Transplant,2008,23(1):328-335.
8 Block GA,Martin KJ,Francisco AL,et al.Cinacalcet for secondary hyperparathyroidism patients receiving hemodialysis[J].N Eng1 J Med,2004,350(15):1516-1525.
9 Zitt E,Rix M,Fouque D,et al.Effectiveness of cinacalcet in patients with recurrent/persistent secondary hyperparathyroidism following parathyroidectomy:results of the ECHO study[J].Nephrol Dial Transplant,2011,26(6):1956-1961.
10 Ghani A,Baxter P.Surgical parathyroidectomy versus cinacalcet therapy:In the management of secondary hyperparathyroidism[J].Otolaryngol Head Neck Surg,2012,146(2):220-225.
11 Schneider R,Kolios G,Koch BM,et al.An economic comparison of surgical and medical therapy in patient with secondary hyperparathyroidism-the German perspective[J].Surgery,2010,148(6):1091-1099.
12 姚力,张凌等.甲状旁腺切除术治疗难治性甲状旁腺功能亢进症89 例疗效评价[J].中国血液净化,2009,8(8):431-436.
13 花瞻,姚力,张凌,等.肾性甲状旁腺功能亢进外科治疗术前高频彩超和99Tcm-MIBI双时相显像的应用[J].中国骨质疏松杂志,2010,16(8):580-583.
14 Shih ML,Duh QY,Hsieh CB,et al.Total parathyroidectomy without autotransplantation for secondary hyperparathyroidism[J].World J Surg,2009,33(2):248-254.
15 Milas M,Weber C.Near-total parathyroidectomy is beneficial for patients with secondary and tertiary hyperparathyroidism[J].Surgery,2004,136(6):1252-1260.
16 Dotzenrath C,Cupisti K,Goretzki E,et al.Operative treatment of renal autonomous hyperparathyroidism:cause of persistent or recurrent disease in 304 patients[J].Langenbecks Arch Surg,2003,387(9-10):348-354.
17 张凌,刘亚绵,卞维静,等.超声引导下甲状旁腺无水酒精注射治疗继发性甲状旁腺功能亢进[J].中华内科杂志,2001,16(12):914-916.
18 章建全,仇明,盛建国,等.超声引导下经皮穿刺热消融治疗甲状旁腺结节[J].第二军医大学学报,2013,34(4):362-370.
19 中华医学会肾脏病学分会工作组.慢性肾脏病矿物质与骨异常诊治指导[J].中华肾脏病杂志,2014,2(30):S1-S69.
2 Kidney Disease:Improving Global Outcomes(KDIGO)CKD-MBD Work Group.KDIGO clinical practice guideline for the diagnosis,evaluation,prevention and treatment of chronic kidney diseasemineral and bone disorder(CKD-MBD)[J].Kidney Int,2009,76(1):S1-S130.
3 Fukagawa M,Yokoyama K,Koiwa F,et al.Clinical practiceguideline for the management of chronic kidney disease-mineral and bone disorder[J].Ther Apher Dial,2013,17(3):247-288.
4 K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease[J].Am J Kidney Dis,2003,42(4 Suppl3 ):S1-S201.
5 Yan Y,Qian J,Chen N,et al.Efficacy and initial dose determination of paricalcitol for treatment of secondary hyperparathyroidism in Chinese subjects[J].Clin Nephrol,2014,81(1):20-29.
6 Teng M,Wolf M,Lowrie E,et al.Survival of patients undergoing hemodialysis with paricalcitol or calcitriol therapy[J].N Engl J Med,2003,349(5):446-456.
7 Fukagawa M,Yumita S,Akizawa T,et al.Cinacalcet(KRN1493)effectively decreases the serum intact PTH level with favorable control of the serum phosphorous and calcium level in Japanese patients[J].Nephrol Dial Transplant,2008,23(1):328-335.
8 Block GA,Martin KJ,Francisco AL,et al.Cinacalcet for secondary hyperparathyroidism patients receiving hemodialysis[J].N Eng1 J Med,2004,350(15):1516-1525.
9 Zitt E,Rix M,Fouque D,et al.Effectiveness of cinacalcet in patients with recurrent/persistent secondary hyperparathyroidism following parathyroidectomy:results of the ECHO study[J].Nephrol Dial Transplant,2011,26(6):1956-1961.
10 Ghani A,Baxter P.Surgical parathyroidectomy versus cinacalcet therapy:In the management of secondary hyperparathyroidism[J].Otolaryngol Head Neck Surg,2012,146(2):220-225.
11 Schneider R,Kolios G,Koch BM,et al.An economic comparison of surgical and medical therapy in patient with secondary hyperparathyroidism-the German perspective[J].Surgery,2010,148(6):1091-1099.
12 姚力,张凌等.甲状旁腺切除术治疗难治性甲状旁腺功能亢进症89 例疗效评价[J].中国血液净化,2009,8(8):431-436.
13 花瞻,姚力,张凌,等.肾性甲状旁腺功能亢进外科治疗术前高频彩超和99Tcm-MIBI双时相显像的应用[J].中国骨质疏松杂志,2010,16(8):580-583.
14 Shih ML,Duh QY,Hsieh CB,et al.Total parathyroidectomy without autotransplantation for secondary hyperparathyroidism[J].World J Surg,2009,33(2):248-254.
15 Milas M,Weber C.Near-total parathyroidectomy is beneficial for patients with secondary and tertiary hyperparathyroidism[J].Surgery,2004,136(6):1252-1260.
16 Dotzenrath C,Cupisti K,Goretzki E,et al.Operative treatment of renal autonomous hyperparathyroidism:cause of persistent or recurrent disease in 304 patients[J].Langenbecks Arch Surg,2003,387(9-10):348-354.
17 张凌,刘亚绵,卞维静,等.超声引导下甲状旁腺无水酒精注射治疗继发性甲状旁腺功能亢进[J].中华内科杂志,2001,16(12):914-916.
18 章建全,仇明,盛建国,等.超声引导下经皮穿刺热消融治疗甲状旁腺结节[J].第二军医大学学报,2013,34(4):362-370.
19 中华医学会肾脏病学分会工作组.慢性肾脏病矿物质与骨异常诊治指导[J].中华肾脏病杂志,2014,2(30):S1-S69.