Schlosser Katja, Endres Nadine, Celik Ilhan, Fendrich Volker, Rothmund M, Fernández E Domínguez
Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstrasse, 35033, Marburg, Germany.
World J Surg. 2007 Oct;31(10):1947-53. doi: 10.1007/s00268-007-9187-z.
Parathyroid surgery (PTX) in patients with tertiary hyperparathyroidism (tHPT) may endanger the long-term survival of transplanted renal grafts. The mechanism by which graft function deteriorates is unknown. We reviewed our experience in regard to the operative procedures and postoperative outcome.
Sixty-nine patients were operated on for tHPT between 1987 and 2006 at our institution. Serum (s) calcium, s-creatinine, and levels of intact parathyroid hormone (PTH) were measured before and after PTX. The Modification of Diet in Renal Disease (MDRD) equation was used to estimate glomerular filtration rate (GFR).
The entire patient group developed a deterioration of kidney graft function after PTX. Nineteen of 69 patients developed a decrease in GFR of more than 20% during the hospital stay, persisting for more than one year after PTX. Ten of them had to restart dialysis during the first year after PTX. Mean preoperative s-creatinine was 4.4 +/- 0.6 mg/dl in these patients. When divided according to the surgical procedure performed, only the subgroup who underwent total parathyroidectomy showed a significant worsening of graft function when compared to subtotal or reoperative PTX.
PTX is an efficient way to treat tHPT but represents a risk for impairing graft function, especially for patients that already demonstrate poor kidney function at the time of surgery. In the aim to prevent transient hypoparathyroidism, which may provoke reduced graft perfusion, as one possible cause of kidney graft deterioration associated with PTX, one should consider subtotal instead of total parathyroidectomy.
三发性甲状旁腺功能亢进症（tHPT）患者进行甲状旁腺手术（PTX）可能会危及移植肾的长期存活。移植肾功能恶化的机制尚不清楚。我们回顾了我们在手术操作和术后结果方面的经验。
1987年至2006年期间，我们机构对69例tHPT患者进行了手术。在PTX前后测量血清钙、血清肌酐和完整甲状旁腺激素（PTH）水平。采用肾脏病饮食改良（MDRD）方程估算肾小球滤过率（GFR）。
整个患者组在PTX后出现移植肾功能恶化。69例患者中有19例在住院期间GFR下降超过20%，并在PTX后持续一年以上。其中10例患者在PTX后的第一年不得不重新开始透析。这些患者术前平均血清肌酐为4.4±0.6mg/dl。根据所进行的手术方式进行分组时，与次全或再次手术的PTX相比，仅接受甲状旁腺全切除术的亚组显示移植功能显著恶化。
PTX是治疗tHPT的有效方法，但存在损害移植功能的风险，尤其是对于手术时已显示肾功能较差的患者。为了预防可能导致移植肾灌注减少的短暂性甲状旁腺功能减退，这是与PTX相关的移植肾恶化的一个可能原因，应考虑行次全甲状旁腺切除术而非甲状旁腺全切除术。
