原发性甲状旁腺功能亢进症术后甲状旁腺激素升高9例并文献复习  

Normocalcemic with elevated post-operative parathormone in primary hyperpara-thyroidism:9 case reports and literature review

作　　者：谢玲玎[1] 王娜[1] 张金苹[1] 王昕[1] 陈晓平[1] 张波[1] 卜石[1] XIE Ling-ding;WANG Na;ZHANG Jin-ping;WANG Xin;CHEN Xiao-ping;ZHANG Bo;BU Shi(Department of Endocrinology, China-Japanese Friendship Hospital, Beijing 100029, China)

机构地区：[1]中日友好医院内分泌科,北京100029

出　　处：《北京大学学报（医学版）》2021年第3期573-579,共7页Journal of Peking University:Health Sciences

摘　　要：目的:对经外科治疗后出现甲状旁腺激素(parathyroid hormone,PTH)升高伴正常血钙(normocalcemic parathormone elevation,NPE)的原发性甲状旁腺功能亢进症(primary hyperparathyroidism,PHPT)患者的临床特征进行分析,提高该病的诊治能力,完善PHPT患者的术后管理。方法:选取2017年8月至2019年11月中日友好医院内分泌科诊断为PHPT且术后6个月内出现NPE的9例患者作为研究对象,回顾性分析其临床资料和转归,并进行相关文献总结。结果:临床特点:9例患者中6例为中老年女性,3例为男性。除1例为无症状性PHPT,其余8例主要临床表现为骨痛、肾结石及恶心、乏力。实验室检查:就诊时均血钙升高[(3.33±0.48)mmol/L],血磷降低[0.76(0.74,0.78)mmol/L],24 h尿钙升高[8.1(7.8,12.0)mmol/24 h],全片段甲状旁腺激素(intact parathyroid hormone,iPTH)明显升高[(546.1±257.7)ng/L],维生素D缺乏[25羟维生素D3水平(21.0±5.7)nmol/L],骨源性碱性磷酸酶[7例41.3(38.6,68.4)μg/L,2例>90μg/L]及N端中段骨钙素(>71.4μg/L)明显升高,2例患者存在肾功能异常。影像学检查:7例骨质疏松,3例患者肾脏超声见肾结石。所有患者甲状旁腺影像学检查均发现明确病灶,其中2例为多发病灶,7例为单发病灶。治疗及转归:2例患者行甲状旁腺切除术治疗,其余患者予甲状旁腺微波热消融治疗;术后1个月患者均出现PTH升高[(255.0±101.4)ng/L],血钙正常,甲状旁腺超声未发现复发病灶。给予钙剂及维生素D联合治疗至术后6个月,PTH均显著下降,术后血钙水平始终正常。结论:PHPT术后发生NPE与术前PTH高水平、维生素D缺乏及肾功能受损可能相关,但并不意味着PHPT的复发或者存在残余病灶;术后充足的钙剂及维生素D的补充可能使患者获益;应规范对PHPT患者的术后随访,以预防和治疗术后NPE。Objective:To summarize and analyze the clinical characteristics of primary hyperpara-thyroidism(PHPT)with normocalcemic parathormone elevation(NPE)after surgical treatment,so as to improve the therapeutic ability and standardized post-operative follow-up of PHPT patients.Methods:Nine patients who were diagnosed with PHPT in the Department of Endocrinology of China-Japan Friendship Hospital from August 2017 to November 2019 were selected as the subjects.They all developed NPE within 6 months after surgical treatment.The clinical features and outcomes were collected and analyzed retrospectively,in addition,the related literature was reviewed.Results:Clinical features:among the 9 patients,6 were middle-aged and elderly females and 3 were male.The main clinical manifestations were bone pain,kidney stones,nausea and fatigue except for one case of asymptomatic PHPT.Pre-operative examination showed high serum calcium[(3.33±0.48)mmol/L],low serum phosphorus[0.76(0.74,0.78)mmol/L],high 24-hour urinary calcium[8.1(7.8,12.0)mmol/24 h],obviously elevated intact PTH[(546.1±257.7)ng/L],vitamin D deficiency[25-hydroxyvitamin D3(21.0±5.7)nmol/L].Serum levels of bone alkaline phosphatase[7 patients 41.3(38.6,68.4)μg/L,2 patients>90μg/L]and N-terminal midcourse osteocalcin(>71.4μg/L)were significantly elevated.The estimated glomerular filtration rate decreased in 2 patients.Imaging examination:7 patients had osteoporosis.Renal calculi were found in 3 patients by renal ultrasound.Imaging examination of parathyroid glands found definite lesions in all the patients,including 2 cases of multiple lesions and 7 cases of single lesions.Treatment and outcome:two patients underwent parathyroidectomy,while other patients were treated with microwave thermal ablation.PTH increased 1 month after therapy[(255.0±101.4)ng/L],and no recurrent lesions were found by parathyroid ultrasound.After combined treatment with cal-cium and vitamin D for six months,PTH decreased significantly and the level of serum calcium remained normal at anytime du

关 键 词：原发性甲状旁腺功能亢进症 甲状旁腺激素 维生素D 

分 类 号：R582.1[医药卫生—内分泌]