甲状旁腺全切术后低iPTH与骨代谢指标及钙化防御相关性研究

Study on the correlation between low-level iPTH after total parathyroidectomy and bone metabolism indexes and Calciphylaxis

目的探讨甲状旁腺全切术后低甲状旁腺素水平与骨代谢标志物及钙化防御相关性研究,关注术后iPTH合理的控制范围。方法选取我院240例行甲状旁腺全切术的透析患者,根据iPTH水平分为:0~49、50~149、150~300pg/mL三组,统计分析相关生化指标,骨代谢标志物及钙化防御发病情况。结果PTX术后三个月患者Hb、Cr水平较术前无显著改变(P>0.05),患者Ca、P、iPTH、TRACP-5b、CTX较治疗前显著下降,B-ALP及钙化防御发生较治疗前明显升高(P<0.05);随着iPTH逐渐降低,三组患者β-CTX及RACP-5b改变无统计学意义(P>0.05),iPTH 50~149pg/mL组与iPTH 150~300pg/mL相比,B-ALP改变及钙化防御发生比例差异无统计学意义(P>0.05),iPTH 0~49pg/mL组B-ALP及钙化防御比例明显高于上述两组,差异具有统计学意义(P<0.05)。结论术后患者短期内成骨细胞功能上调,破骨细胞活性降低,临床症状缓解确切,iPTH进一步降低,过低iPTH患者B-ALP显著升高,游离血钙大量参与骨骼钙化及异位矿化,成骨-破骨细胞耦联活化机制破坏,导致钙化防御例数短期明显升高,因此甲状旁腺全切+前臂移植亦或甲状旁腺次全切,可避免术后iPTH水平剧烈波动,是应该推荐的合理手术方案。

Objective To investigate the correlation between low-level of intact parathyroid hormone(iPTH)after total parathyroidectomy,bone metabolism markers and calciphylaxis,and discuss the reasonable control range of postoperative iPTH level.Methods A total of 240 hemodialysis patients with total parathyroidectomy(TPTX)treated in our hospital were enrolled in this study.The patients were divided into three groups:iPTH<49 pg/mL,50≤iPTH<149 pg/mL,150≤iPTH≤300 pg/mL.The biochemical indexes,bone metabolism markers and calciphylaxis of the three groups were analyzed.Results The levels of Hb and Cr in patients three months after PTX had no significant changes compared with those before surgery(P>0.05).The levels of Ca,P,IPH,tracp-5b and CTX in patients were significantly lower than those before operation.The B-ALP and the occurrence of calciphylaxis was significantly higher than those before treatment(P<0.05).There was no significant difference inβ-CTX and racp-5b among the three groups,(P>0.05).There was no significant difference in the level of B-ALP and the proportion of calciphylaxis between the iPTH:50-149 pg/mL group and the iPTH:150-300 pg/mL group,(P>0.05).The level of B-ALP and the proportion of calciphylaxis in the iPTH:0-49 pg/mL group were significantly higher than those in the other two groups,the difference had statistical significance(P<0.05).Conclusion In short term,the function of osteoblasts was up-regulated,the activity of osteoclasts was decreased and the clinical symptoms were relieved obviously in patients after operation.With the further decreased of iPTH,the level of B-ALP increased significantly in patients with low level of iPTH.A large amount of serum ionized calcium participated in bone calcification and ectopic mineralization,leading to a significant increase in the number of patients with calciphylaxis in a short period of time.Therefore,total parathyroidectomy with forearm autotransplantation or subtotal parathyroidectomy can avoid the sharp fluctuation of the postoperative iPTH level,which is a more reasonable operation.