自体甲状旁腺异位移植治疗肾性甲状旁腺功能亢进

Treatment of Secondary Hyperparathyroidism in Patients with Chronic Renal Failure by Total Parathyroidectomy and Parathyroid autograft

目的 :为了探讨慢性肾功能衰竭继发性甲状旁腺功能亢进的外科治疗 ,对 2例慢性肾衰出现典型甲旁亢症状的女性患者行甲状旁腺全切除加自体左前臂肌肉内移植。方法 :切除所有旁腺组织 ,冰冻证实旁腺组织增生。切取旁腺中心部分2 0 0mg左右 ,切成 1mm× 1mm× 1mm碎片置于冰盐水中 ,于左前臂桡侧肱桡肌分 3排多处再植 ,每处 4～ 5粒旁腺碎片 ,丝线缝合肌纤维。结果 :术后 1周患者面部胀痛、张口困难、骨关节疼痛等症状开始减轻 ,胃纳好转。外周血PTH明显下降 :例 1的PTH由 2 5 0 0 pg/ml渐降到 37.2pg/ml,例 2的PTH由 2 82 4 pg/ml降到 10 pg/ml。例 1的血钙由 2 .5mmol/L降至1.6mmol/L ;例 2由 3.0mmol/L降至 1.0mmol/L。例 1的血磷由 1.4mmol/L降至 0 .8mmol/L ;例 2由 1.6mmol/L降至 0 .7mmol/L。例1的ALP由 880IU/L降至 6 5 1IU/L ;例 2由 10 6 8IU/L降至 92 8IU/L。以后每月监测PTH 1次 ,例 1随访 10个月 ,PTH平均值为 333.3pg/ml;例 2随访 4个月PTH平均值为 10 8.0 pg/ml。 2例的血钙维持在 1.6mmol/L～ 2 .1mmol/L ,血磷为 0 .8mmol/L～ 1.1mmol/L ,ALP为 4 0 0IU/L～ 4 4 0IU/L。MIBI显示左前臂同位素浓聚。测定移植侧与非移植侧上肢近心端血中PTH的比值分别为 1.5 7和 1.6 9。 2例于术后 3～

Objective: To investigate the surgical treatment of secondary hyperparathyroidism in patients with chronic renal failure.Methods: Two female patients with typical symptoms of hyperparathyroidism who suffered from chronic renal failure and more than ten-year's hemodialysis were performed parathyroidectomy and autotransplantation. The central parts of the freshly removed parathyroid glands (about 200mg) were cut into pieces approximately 1mm by 1mm by1mm in size and placed in sterile iced saline. Many separate intramuscular beds are created for each patient by spreading left brachioradialis muscle and four to five parathyroid pieces are placed in each site.Results: A week after surgery, the patients' symptoms such as face pain, difficulty in opening mouth, bone pain and anorexia were relieved. The levels of serum PTH were decreased from 2500pg/ml and 2824pg/ml(before operation) to 37.2pg/ml and 10pg/ml after surgery. Serum calcium were decreased from 2.5mmol/L and 3mmol/L(before operation) to 37.2pg/ml and 1.0mmol/L after surgery. Serum phosphorum were decreased from 1.4mmol/L and 1.6mmol/L(before operation) to 0.8mmol/L and 0.7mmol/L after surgery. Serum ALP were decreased from 888IU/L and 1068IU/L(before operation) to 651IU/L and 928IU/L after surgery Serum PTH level were followed-up monthly for 10 and 4 months for two patients whose average levels were 333.3pg/ml and 150.0pg/ml respectively. And the levels of serum calcium were 1.6～2.1mmol/l and 0.9～1.6mmol/l. We determined the function of graft glands with MIBI which showed isotope aggregation in patients' left forearms. The serum PTH levels of bilateral upper arm were also determined and the two patients' PTH ratio of graft side to nongraft side were 1.57 and 1.69 respectively.Conclusion:Total parathyroidectomy and parathyroid autotransplatation is a safe and feasible operation used to treat secondary hyperparathyroidism in patients with chronic renal failure. Its short-term effect is satisfactory while the evaluation of long-term effect still need more time to follow-up.