甲状旁腺切除术治疗尿毒症继发性甲状旁腺功能亢进的疗效评价

发布时间：2018-04-30 10:38

本文选题：继发性甲状旁腺功能亢进 + 尿毒症　；参考：《吉林大学》2017年硕士论文

【摘要】：背景:继发性甲状旁腺功能亢进(secondary hyperparathyroidism,SHPT)是慢性肾脏病(chronic kidney disease,CKD)的常见并发症,主要是由钙磷代谢异常及活性维生素D抵抗等因素所致。其主要临床表现有骨痛、皮肤瘙痒、异位钙化等,并可增加心脑血管事件发生率,严重影响患者的生存质量。早期纠正钙磷紊乱是治疗的关键。随着SHPT病程进展,甲状旁腺细胞呈腺瘤样增生,可自主分泌大量PT H(parathyroid hormone,PTH),且Vit D受体、钙受体表达明显下调,钙剂、磷结合剂及活性Vit D疗效差,即发展为难治性SHPT。甲状旁腺切除术(parathyroidect omy PTX)为治疗SHPT的有效手段,目前有甲状旁腺部分切除术(subotal parat hyroidectomy,S-PTX),甲状旁腺全切术(totalparathyroidectomy,T-PTX),甲状旁腺全切+自体移植(parathyroidectomy with autotransplantation,PTX+AT)三种术式,三种术式各有优缺点,关于其在缓解症状、术后并发症、复发率、远期疗效等方面孰优孰劣尚无定论,对此进行研究分析有利于指导临床术式的选择。目的:研究甲状旁腺次全切术、全切术及全切加前臂移植术对尿毒症继发性甲状旁腺功能亢进患者的临床疗效及术后并发症、复发率情况,为临床合适的术式选择提供依据。方法:回顾性分析2014年4月至2016年10月在吉林大学第一医院接受甲状旁腺切除术治疗的72例尿毒症SHPT患者,其中S-PTX组40例,T-PTX组16例,PT X+AT组16例,对各组术前血清钙(calcium,Ca)、磷(phosphorus,P)、全段甲状旁腺激素(intact Parathyroid Hormone,i PTH)、碱性磷酸酶(alkaline phos phatase,ALP)、血红蛋白(haemoglobin,Hb)、白蛋白(albulmin,Alb)及术后1周、1月、6月血清钙、磷、i PTH等一般临床资料和生化指标进行分析,比较各组治愈率、疗效及术后复发率、并发症情况。采用SPSS17.0软件进行资料数据统计。正态或近似正态分布的计量资料以(x±s)表示,组内均数比较采用配对样本的t检验,三组间均数比较采用单因素方差分析,有差异者用LSD-t检验进行两两比较;偏态分布的计量资料采用中位数(下四分位数-上四分位数)表示,组内比较采用Wilcoxon带符号秩检验,组间比较采用Kruskal wallis秩和检验,有差异者用Mann-Whitney检验进行两两比较;计数资料采用例数(百分比),即n(%)表示,用χ2检验进行比较。以P0.05为有统计学意义,P0.01为有显著性统计学意义。结果:1、手术成功71例。三组术后骨痛、皮肤瘙痒、钙化防御等症状均不同程度缓解,以骨关节痛缓解最明显。且全切组缓解率最高,各症状缓解率均达100%。2、各组术后3个时间点血清钙、磷、i PTH较术前相比均下降,差异具有统计学意义(P0.05)。3、三组术后3个时间点血清钙、磷差异无统计学意义(P0.05);S-PTX组及PTX+AT组术后3个时间点i PTH差异无统计学意义(P0.05),但均较T-PTX组高,差异具有统计学意义(P0.05)。4、三种术式成功率无差别(P0.05);T-PTX组、PTX+AT组治愈率较S-PTX组高,差异具有统计学意义(P0.05);三组术后并发声嘶比率无差别(P0.05),声嘶均逐渐自行缓解;三组术后1周低钙血症发生率无差别(P0.05),无肢体搐搦等症状;随访6个月内,三组术后复发率无区别(P0.05)。结论:1、三种术式的PTX均可安全、有效治疗尿毒症SHPT、缓解临床症状,三组中以T-PTX症状缓解率最高。与S-PTX相比,T-PTX、PTX+AT治愈率更高。三种术式对血清钙、磷影响无区别。T-PTX组术后i PTH下降更明显。术后声嘶发生率三者无区别。随访的6个月内,三组术后复发率无区别。2、术后三个时间点S-PTX组、PTX+AT组i PTH均高于T-PTX组,其长期复发率可能更高,二次手术机率增加。故对于难治性SHPT且无肾移植意愿的患者,我们主张T-PTX,可安全且最有效地缓解临床症状,降低二次手术的风险。
[Abstract]:Background: secondary hyperparathyroidism (secondary hyperparathyroidism, SHPT) is a common complication of chronic renal disease (chronic kidney disease, CKD). It is mainly caused by abnormal calcium and phosphorus metabolism and active vitamin D resistance. The main clinical manifestations are bone pain, skin itching, ectopic calcification and so on, and can increase cardiovascular and cerebrovascular events. Early correction of calcium and phosphorus disorder is the key to treatment. With the progress of SHPT, parathyroid cells are adenomatoid hyperplasia, which can independently secrete a large number of PT H (parathyroid hormone, PTH), and Vit D receptor, the expression of calcium receptor is obviously down, calcium, phosphorus binder and active Vit D are poor, that is, the development is Intractable SHPT. parathyroidectomy (parathyroidect omy PTX) is an effective means for the treatment of SHPT. There are three kinds of parathyroidectomy (subotal parat hyroidectomy, S-PTX), parathyroid total resection (totalparathyroidectomy, T-PTX), and parathyroid autologous transplantation (parathyroidectomy). The three kinds of surgical methods have advantages and disadvantages. It is not conclusive about the advantages and disadvantages in alleviating symptoms, postoperative complications, recurrence rate and long-term effect. This study is helpful to guide the selection of clinical operation. The clinical efficacy, postoperative complications and recurrence rates of hyperhyperthyroidism provided a basis for clinical selection. Methods: retrospective analysis of 72 SHPT patients with Uremia Treated in No.1 Hospital of Jilin University from April 2014 to October 2016, including 40 cases in group S-PTX, 16 in group T-PTX and 16 in group PT X+AT. Serum calcium (calcium, Ca), phosphorus (phosphorus, P), whole segment parathyroid hormone (intact Parathyroid Hormone, I PTH), alkaline phosphatase (alkaline Phos phatase), hemoglobin (alkaline Phos phatase), serum albumin, and 1 weeks after operation, January, June, and other general clinical and biochemical indexes. Analysis, compare the cure rate, curative effect and postoperative recurrence rate and complication. SPSS17.0 software is used to carry out data statistics. The measurement data of normal or approximate normal distribution are expressed by (x + s), and the average number of the group is compared with the paired sample t test. The average number of the three groups is compared with the single factor analysis of variance, and the difference is carried out by the LSD-t test. 22 comparison; the measurement data of the partial distribution are expressed in the median (the lower four digits - the upper four digits), the group comparison uses the Wilcoxon band sign rank test, the group is compared with the Kruskal Wallis rank sum test, and the difference is compared with the Mann-Whitney test. The number of data uses the number of cases (percentage), that is, n (%), and x 2 test Compared with the statistical significance of P0.05, P0.01 had significant statistical significance. Results: 1, the operation was successful in 71 cases. The three groups of postoperative bone pain, skin pruritus, calcification defense and other symptoms were alleviated in different degrees, with the most obvious relief of bone and joint pain. The remission rate of all the total cut groups was the highest and the rate of each symptom was 100%.2, and the blood was at 3 time points after the operation. Calcium, phosphorus, I PTH decreased compared with pre operation, and the difference was statistically significant (P0.05).3. There was no statistically significant difference in serum calcium and phosphorus in three groups at 3 time points after operation (P0.05), and there was no statistical significance (P0.05) at 3 time points after operation in group S-PTX and PTX+AT, but higher than that in T-PTX group (P0.05), three kinds of surgical procedures. There was no difference in power (P0.05), group T-PTX, group PTX+AT was higher than group S-PTX, and the difference was statistically significant (P0.05). There was no difference between the three groups after operation (P0.05), and the hoarseness was gradually relieved, and the incidence of hypocalcemia in the three groups was not different (P0.05) and no tetany, and the recurrence rate of the three groups in the three groups after 6 months of follow-up was no area. (P0.05). Conclusion: 1, three kinds of surgical methods are safe and effective in treating uremia SHPT and alleviating clinical symptoms. The rate of T-PTX symptom remission is the highest in three groups. Compared with S-PTX, T-PTX, PTX+AT has a higher cure rate. Three kinds of surgical methods have no difference in serum calcium and phosphorus from.T-PTX group. The incidence of postoperative hoarseness is three. Within 6 months of the visit, the recurrence rate of the three groups was no different.2, three time after the operation in group S-PTX, and the I PTH in group PTX+AT was higher than that of the T-PTX group. The long-term recurrence rate was higher and the probability of the two operation increased. Therefore, we advocated T-PTX for the patients with refractory SHPT and no renal transplantation, which was safe and effective to alleviate the clinical symptoms and reduce two times of hand. Risk of operation.

【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R692.5;R653

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