Jain Nishank, Reilly Robert F
aDivision of Nephrology, University of Arkansas for Medical Sciences bCentral Arkansas Veterans Affairs Healthcare System, Little Rock, Arkansas cOffice of Education, Central Alabama Veterans Healthcare System, Montgomery, Alabama, USA.
Curr Opin Nephrol Hypertens. 2017 Jul;26(4):250-255. doi: 10.1097/MNH.0000000000000327.
In the United States, the number of parathyroidectomies among patients with chronic dialysis has remained stable in the last decade. A fall in serum calcium concentration is common postparathyroidectomy in patients with hyperparathyroidism, which usually resolves in 2-4 days. A severe drop in serum total calcium concentration less than 2.1 mmol/L and/or prolonged hypocalcemia for more than 4 days postparathyroidectomy is called hungry bone syndrome (HBS). Concomitant hypophosphatemia, hypomagnesemia, and hyperkalemia can be seen. Hypocalcemia and hypophosphatemia can persist for months to years. In contemporary clinical practice, HBS may be more commonly seen in patients with secondary compared to primary hyperparathyroidism. Preoperative radiological changes in bone, elevated serum alkaline phosphatase and parathyroid hormone (PTH) levels, and high numbers of osteoclasts on bone biopsy may identify patients at risk. Treatment consists of high-dose oral calcium and calcitriol supplementation. A low-dose pamidronate infusion 1-2 days prior to surgery may prevent HBS.
Recent in-vitro studies reported net calcium movement into bone because of a sudden fall in serum PTH level after a prolonged period of elevation. This supports a previous hypothesis that a sudden drop in serum PTH level after surgery results in the unopposed action of osteoblasts and influx of calcium into bone.
Incidence of HBS and its association with morbidity and mortality remains unclear in contemporary clinical practice. It is more common to encounter HBS in chronic dialysis patients with secondary hyperparathyroidism than those with primary hyperparathyroidism that undergo parathyroidectomies. Use of bisphosphonates to prevent HBS should be explored in future studies.
在美国，过去十年中慢性透析患者的甲状旁腺切除术数量保持稳定。甲状旁腺功能亢进患者甲状旁腺切除术后血清钙浓度下降很常见，通常在2 - 4天内恢复。甲状旁腺切除术后血清总钙浓度严重下降至低于2.1 mmol/L和/或低钙血症持续超过4天被称为饥饿骨综合征（HBS）。可出现伴随的低磷血症、低镁血症和高钾血症。低钙血症和低磷血症可持续数月至数年。在当代临床实践中，与原发性甲状旁腺功能亢进患者相比，继发性甲状旁腺功能亢进患者中HBS可能更常见。术前骨骼的放射学改变、血清碱性磷酸酶和甲状旁腺激素（PTH）水平升高以及骨活检中破骨细胞数量增多可能识别出有风险的患者。治疗包括高剂量口服钙剂和骨化三醇补充。术前1 - 2天低剂量静脉输注帕米膦酸盐可能预防HBS。
近期的体外研究报道，由于血清PTH水平在长期升高后突然下降，导致净钙向骨内移动。这支持了先前的假设，即手术后血清PTH水平突然下降导致成骨细胞的无对抗作用以及钙流入骨内。
在当代临床实践中，HBS的发生率及其与发病率和死亡率的关联仍不清楚。慢性透析继发性甲状旁腺功能亢进患者行甲状旁腺切除术后比原发性甲状旁腺功能亢进患者更易出现HBS。未来研究应探索使用双膦酸盐预防HBS。
