Oka Hideaki, Miishima Nagisa, Yoshitomi Ryota, Mizobuchi Takeshi, Kamimura Taro, Sugawara Koji, Harada Atsumi
Kidney Center, Matsuyama Red Cross Hospital, Ehime, Japan.
Nihon Jinzo Gakkai Shi. 2010;52(5):584-9.
An 80-year-old man was admitted to our hospital because of exacerbation of preexisting chronic kidney disease (CKD). On admission, he showed elevated levels of serum creatinine (6.37 mg/dL) and corrected calcium (13.7 mg/dL). Although the serum levels of intact parathyroid hormone (I-PTH) and parathyroid hormone-related peptide(PTITH-rP)were low, the serum 1,25-dihydroxyvitamin D3 (1,25 (OH)2D3)levels were high. Computed tomography (CT) revealed ascites, and the ascitic fluid was exudative and serous with predominance of lymphocytes. The levels of adenosine deaminase (ADA) in the ascitic fluid were also elevated, and the results of QuantiFERON-TB2G (QFT-2G)assay were positive, indicating tuberculous peritonitits. Ascites resolved rapidly after initiation of the antituberculosis therapy. The elevated levels of serum calcium and 1,25 (OH) 2D3 returned to below-normal levels; however, serum i-PTH levels increased from 8.9 pg/ mL to 432 pg/mL. Diagnosis of extrapulmonary tuberculosis is often difficult in CKD patients. CKD patients show abnormal vitamin D activation, so these patients usually have low levels of serum 1,25(OH)2D3. On the other hand, in our patient, 1,25(OH)2D3 was extrarenally produced from tuberculous granuloma and therefore, he showed high levels of serum 1,25(OH)2D3 and correspondingly, low levels of serum i-PTH. We observed that the ratio of 1,25 (OH) 2D3:i-PTH decreased due to antituberculosis therapy. This ratio facilitated the diagnosis and evaluation of treatment for this condition.
一名80岁男性因原有慢性肾脏病（CKD）病情加重而入住我院。入院时，他的血清肌酐（6.37 mg/dL）和校正钙（13.7 mg/dL）水平升高。尽管血清完整甲状旁腺激素（I-PTH）和甲状旁腺激素相关肽（PTITH-rP）水平较低，但血清1,25-二羟维生素D3（1,25(OH)2D3）水平较高。计算机断层扫描（CT）显示有腹水，腹水为渗出性浆液性，以淋巴细胞为主。腹水中腺苷脱氨酶（ADA）水平也升高，QuantiFERON-TB2G（QFT-2G）检测结果为阳性，提示结核性腹膜炎。抗结核治疗开始后腹水迅速消退。血清钙和1,25(OH)2D3升高的水平恢复到正常以下；然而，血清i-PTH水平从8.9 pg/mL升至432 pg/mL。在CKD患者中，肺外结核的诊断往往很困难。CKD患者维生素D激活异常，因此这些患者血清1,25(OH)2D3水平通常较低。另一方面，在我们的患者中，1,25(OH)2D3是由结核肉芽肿在肾外产生的，因此，他的血清1,25(OH)2D3水平较高，相应地，血清i-PTH水平较低。我们观察到，由于抗结核治疗，1,25(OH)2D3:i-PTH的比值下降。该比值有助于对这种情况进行诊断和治疗评估。
