Kitagawa Wataru, Shimizu Kazuo, Akasu Haruki
Department of Surgery II, Nippon Medical School, Tokyo, Japan.
J Nippon Med Sch. 2003 Jun;70(3):278-82. doi: 10.1272/jnms.70.278.
In Japan, there are many dialysis patients because of the successful development and wide application of dialysis techniques. Almost all patients require long-term hemodialysis treatment because kidney transplantation is performed rarely. Renal hyperparathyroidism is one of the serious complications for hemodialysis patients. According to the overview of regular dialysis treatment reported by the Japanese Society for Dialysis Therapy, parathyroidectomy is required in 9.2%of patients who remain on hemodialysis more than 10 years and in 33.5%of those who so remain for more than 25 years. In this paper, we will describe the diagnosis, surgical indications, and operative strategy of renal hyperparathyroidism. The symptoms and biochemical variables were high serum parathyroid hormone (PTH) level, hyperphosphatemia, bone and joints pain, itching, irritability, muscle weakness, severe skeletal deformity, progression of ectopic calcification, and anemia. The clinical indications for performing parathyroidectomy to treat renal hyperparathyroidism in our institute are based on the indications reported by Tominaga et al. These are 1) high serum PTH level, 2) detection of enlarged parathyroid glands, 3) detection of osteitis fibrosa cystica on radiography or detection of high bone turnover by bone metabolic markers or bone scintigram, 4) resistance of symptoms to medical treatment. The routine operative procedure for renal hyperparathyroidism is total parathyroidectomy with forearm autograft. For autotransplantation, 30 pieces sliced 1x1x3 mm of diffuse hyperplasia are implanted into 30 pockets in the forearm without arteriorvenous (A-V) fistula for hemodialysis. In any surgical procedure for renal hyperparathyroidism, it is crucial to identify all parathyroid glands, including supernumerary glands and ectopic glands. At the initial operation for renal hyperparathyroidism, the surgeon must remove all parathyroid glands to avoid persistent and recurrent hyperparathyroidism and choose proper and adequate parathyroid tissue for autograft.
在日本，由于透析技术的成功研发和广泛应用，有许多透析患者。几乎所有患者都需要长期血液透析治疗，因为肾移植很少进行。肾性甲状旁腺功能亢进是血液透析患者的严重并发症之一。根据日本透析治疗学会报告的定期透析治疗概况，在维持血液透析超过10年的患者中，9.2%需要进行甲状旁腺切除术，而在维持血液透析超过25年的患者中，这一比例为33.5%。在本文中，我们将描述肾性甲状旁腺功能亢进的诊断、手术指征和手术策略。症状和生化指标包括血清甲状旁腺激素（PTH）水平升高、高磷血症、骨和关节疼痛、瘙痒、易怒、肌肉无力、严重骨骼畸形、异位钙化进展和贫血。在我们研究所，进行甲状旁腺切除术治疗肾性甲状旁腺功能亢进的临床指征基于富永等人报告的指征。这些指征是：1）血清PTH水平升高；2）检测到甲状旁腺增大；3）X线检查发现纤维囊性骨炎，或通过骨代谢标志物或骨闪烁显像检测到高骨转换；4）症状对药物治疗有抵抗性。肾性甲状旁腺功能亢进的常规手术方法是甲状旁腺全切术加前臂自体移植。对于自体移植，将30片1×1×3毫米的弥漫性增生组织植入前臂无血液透析动静脉（A-V）内瘘的30个囊袋中。在任何肾性甲状旁腺功能亢进的手术中，识别所有甲状旁腺，包括额外的甲状旁腺和异位甲状旁腺至关重要。在肾性甲状旁腺功能亢进的初次手术中，外科医生必须切除所有甲状旁腺，以避免持续性和复发性甲状旁腺功能亢进，并选择合适且足够的甲状旁腺组织进行自体移植。
