尿毒症继发甲状旁腺功能亢进症患者甲状旁腺切除术后骨转换标志物的短期变化  

Postoperative variations of bone turnover markers in uremic patients with secondary hyperparathyroidism after parathyroidectomy

作　　者：杨光[1] 王宁宁[1] 葛益飞[1] 查小明 毛慧娟[1] 张波[1] 孙彬[1] 俞香宝[1] 曾鸣[1] 邢昌赢[1] 

机构地区：[1]南京医科大学第一附属医院江苏省人民医院肾内科,210029 [2]南京医科大学第一附属医院江苏省人民医院普外科,210029

出　　处：《中华肾脏病杂志》2017年第10期750-756,共7页Chinese Journal of Nephrology

基　　金：江苏省临床医学科技专项基金（BL2014080）

摘　　要：目的研究尿毒症继发甲状旁腺功能亢进症（SHPT）患者接受甲状旁腺切除术（PTX）术后血清骨转换标志物（BTMs）的短期变化情况，为探讨PTX治疗高转换性肾性骨营养不良的发病机制，评估疗效提供理论依据。方法回顾性分析2017年1月至2017年4月期间，在南京医科大学第一附属医院接受PTX的尿毒症SHPT患者的临床资料。手术方式均为甲状旁腺全切联合前臂移植术。收集人选患者PTX术前基线资料和术后第1、3、7天的血全段甲状旁腺激素（iPTH）、BTMs等资料。采用Spearman法分析患者手术前血iPTH和BTMs的相关性，及PTX手术前后BTMs的变化趋势。结果共纳入PTX患者19例。患者术前血iPTH、碱性磷酸酶（ALP）、I型胶原交联羧基端肽区（CTX）及抗酒石酸酸性磷酸酶5b（TRACP-5b）水平均高于正常值范围，分别为（1512．4±612．0）ng／L、267．4（153．1，424．2）U／L、（5．78±1．15）μg／L和（8．79±4．61）IU／L。相关分析结果显示：患者术前基线ALP水平与iPTH（r=0．577，P=0．010），TRACP-5b与iPTH（r=0．640，P=0．003），及ALP与TRACP-5b（r=0．698，P=0．001）之间均呈正相关。提示高转换性肾性骨营养不良的骨转换水平与iPTH呈正相关，且成骨细胞一破骨细胞功能具有偶联上调的特征。PTX术后第1、3、7天BTMs检测结果显示：（1）ALP呈现逐渐升高趋势，提示成骨细胞活性增强；（2）CTX和TRACP-5b呈逐渐降低趋势，提示破骨细胞活性减弱。结论病情严重的SHPT患者PTX术后易表现为高转换性肾性骨营养不良，成骨细胞和破骨细胞活性具有偶联上调的特点，且骨转换水平与iPTH呈正相关。PTX术后短期内成骨细胞活性增强，破骨细胞活性减弱。Objective To study shortdated postoperative variation characteristics of bone turnover markers （BTMs） in uremic patients with secondary hyperparathyroidism （SHPT） underwent parathyroideetomy （PTX）. Methods A total of 19 uremic patients with SHPT underwent successful PTX, hospitalized in the Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University from January 2017 to April 2017, were enrolled in the study. The operative model for all enrolled patients was total parathyroidectomy with forearm autotransplantation. The baseline epidemiological and clinical data before PTX and the levels of serum intact parathyroid hormone （iPTH） and serum BTMs after PTX （in the 1^st, 34 and 7^th postoperative day） were collected. The correlations between serum iPTH and serum BTMs before PTX and the trend analysis of serum BTMs after PTX were studied. Results The levels of serum iPTH, serum alkaline phosphatase （ALP）, serum type I collagen cross-linked C-telopeptides （CTX） and serum tartrate-resistant acid phosphatase 5b （TRACP- 5b） before PTX were increased, in turn, （1512.4±612.0） ng/L, 267.4（153.1,424.2） U/L, （5.78±1.15） μg/ L and （8.79±4.61） IU/L. Positive correlations between ALP and iPTH （r=0.577, P=0.010）, TRACP-5b and iPTH （r=0.640, P=0.003）, and ALP and TRACP- 5b （r=0.698, P=0.001） were found. The serum levels of ALP increased, while the serum levels of CTX and TRACP-5b decreased within 7 days after PTX. Conclusions Renal osteodystrophy （ROD） with high bone turnover rate is common in uremic patients with severe SHPT. The activities of osteoblast and osteoclast are up-regulated in coupling with positive correlations to serum levels of iPTH. Increased activities of osteoblast and decreased activities of osteoclast were found shortdated postoperatively.

关 键 词：甲状旁腺功能亢进症 继发性 甲状旁腺切除术 成骨细胞 破骨细胞 慢性肾脏病矿物质与骨异常 

分 类 号：R582.1[医药卫生—内分泌]