Nichols P, Owen J P, Ellis H A, Farndon J R, Kelly P J, Ward M K
Renal Unit, Royal Victoria Infirmary.
Q J Med. 1990 Nov;77(283):1175-93. doi: 10.1093/qjmed/77.2.1175.
Seventy-three patients with chronic renal failure who underwent parathyroidectomy between March 1978 and April 1987 were reviewed. Thirty-four patients had undergone sub-total parathyroidectomy, and 39 patients had undergone total parathyroidectomy with parathyroid autograft into the forearm. Eight patients showed persistent hyperparathyroidism requiring a second surgical procedure. In all other patients there was highly statistical improvement in parathyroid hormone, total calcium, ionized calcium, alkaline phosphatase and a significant reduction in calcium x phosphate product. Histological evidence of osteitis fibrosa was present in 21 of 22 patients before surgery. Postoperatively, four showed complete resolution and improvement. Three patients developed histological evidence of osteomalacia during the study period. Only four of the 39 patients who underwent total parathyroidectomy with autograft had true recurrent hyperparathyroidism and only two of the 34 patients who underwent sub-total parathyroidectomy had recurrent disease, indicating that there is little to choose between the two techniques in the control of secondary hyperparathyroidism and its subsequent recurrence. In one patient with recurrence of hyperparathyroidism from a forearm parathyroid graft the histological picture was different from that of normal hyperplastic parathyroid tissue. Although it is probable that abnormal parathyroid tissue had been implanted there was no evidence of invasive growth into the forearm muscle. The most striking feature of long term follow-up was the difference in calcium x phosphate product in patients in whom vascular calcification increased compared to those patients with no change or regression of calcification. Mean calcium phosphate product in those patients with progressive vascular calcification was 4.93 for small and medium size vessels and 5.38 for large vessels compared to 4.10 for small and medium vessels and 4.09 for large vessels. In the former case the serum phosphate was 2.00 and 2.17 as compared to 1.75 or 1.73, suggesting that the aim in patients with end stage renal failure maintained by dialysis should be to control the serum phosphate concentration to 1.8 mmol or less and the calcium x phosphate product to less than 4.2.
对1978年3月至1987年4月期间接受甲状旁腺切除术的73例慢性肾衰竭患者进行了回顾性研究。34例患者接受了甲状旁腺次全切除术，39例患者接受了甲状旁腺全切除术并将甲状旁腺自体移植至前臂。8例患者出现持续性甲状旁腺功能亢进，需要再次进行手术。在所有其他患者中，甲状旁腺激素、总钙、离子钙、碱性磷酸酶均有高度统计学意义的改善，钙磷乘积显著降低。22例患者中有21例术前存在纤维性骨炎的组织学证据。术后，4例完全缓解并改善。3例患者在研究期间出现骨软化症的组织学证据。在39例接受甲状旁腺全切除术并自体移植的患者中，只有4例出现真正的复发性甲状旁腺功能亢进，在34例接受甲状旁腺次全切除术的患者中，只有2例出现复发性疾病，这表明在控制继发性甲状旁腺功能亢进及其随后的复发方面，这两种技术之间几乎没有差别。1例因前臂甲状旁腺移植导致甲状旁腺功能亢进复发的患者，其组织学表现与正常增生性甲状旁腺组织不同。尽管可能植入了异常的甲状旁腺组织，但没有证据表明其侵入前臂肌肉生长。长期随访最显著的特点是，血管钙化增加的患者与钙化无变化或减轻的患者相比，钙磷乘积存在差异。进行性血管钙化患者中小血管和中血管的平均钙磷乘积为4.93，大血管为5.38，而无变化或减轻的患者中小血管和中血管为4.10，大血管为4.09。在前一种情况下，血清磷分别为2.00和2.17，而后一种情况为1.75或1.73，这表明对于接受透析维持的终末期肾衰竭患者，目标应是将血清磷浓度控制在1.8 mmol或更低，钙磷乘积控制在4.2以下。
