Department of Nephrology, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan.
J Bone Miner Metab. 2012 Mar;30(2):238-42. doi: 10.1007/s00774-011-0320-6. Epub 2011 Oct 12.
The present report describes a case of a 64-year-old pre-dialysis woman with chronic kidney disease (CKD) stage 5, who developed severe hyperparathyroidism. This patient had been on a very low protein diet (VLPD) to delay the progression of CKD and the need for renal replacement therapy (RRT). Her serum calcium levels were high-normal to slightly high during this time. However, her serum intact parathyroid hormone (PTH) levels increased from 400 to 1160 pg/ml rapidly over a period of 3 months. Serum 1,25-(OH)2D levels were low, and ultrasound of the neck showed three markedly enlarged parathyroid glands exceeding 2 cm. Parathyroidectomy was performed, and all glands showed nodular hyperplasia, which indicated severe secondary hyperparathyroidism leading to tertiary. Severe secondary hyperparathyroidism requiring surgical intervention is usually observed in patients with long-term RRT and is relatively rare in the pre-dialysis patient. In this case, extension of the pre-dialysis period by VLPD may have predisposed this patient to develop severe secondary hyperparathyroidism. Thus, careful monitoring of calcium, phosphorus, and PTH may be necessary in patients treated with VLPD even before renal replacement therapy. Furthermore, initiation of dialysis should not be excessively delayed by strict protein restriction dietary therapy.
本报告描述了一例 64 岁的透析前女性慢性肾脏病（CKD）5 期患者，她患有严重甲状旁腺功能亢进症。该患者一直接受极低蛋白饮食（VLPD）以延缓 CKD 的进展和需要肾脏替代治疗（RRT）。在此期间，她的血清钙水平处于正常高值至稍高范围内。然而，她的血清全段甲状旁腺激素（PTH）水平在 3 个月内迅速从 400 增加到 1160 pg/ml。血清 1,25-（OH）2D 水平较低，颈部超声显示三个明显增大的甲状旁腺腺体超过 2 cm。甲状旁腺切除术，所有腺体均显示结节性增生，提示严重的继发性甲状旁腺功能亢进症导致三发性甲状旁腺功能亢进症。需要手术干预的严重继发性甲状旁腺功能亢进症通常发生在长期接受 RRT 的患者中，在透析前患者中相对罕见。在这种情况下，通过 VLPD 延长透析前阶段可能使该患者易发生严重的继发性甲状旁腺功能亢进症。因此，即使在开始肾脏替代治疗之前，接受 VLPD 治疗的患者也需要仔细监测钙、磷和 PTH。此外，不应通过严格的蛋白质限制饮食疗法过度延迟开始透析的时间。
