Hawley Carmel M, Holt Stephen G
Department Renal Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
Department Renal Medicine, University of Queensland, Brisbane, Queensland, Australia.
Nephrology (Carlton). 2017 Mar;22 Suppl 2:47-50. doi: 10.1111/nep.13029.
Appropriate targets for parathyroid hormone (PTH) in patients with chronic kidney disease (CKD) stages 3-5D are controversial, as are the means by which these targets might be achieved. Secondary hyperparathyroidism is linked to symptoms like bone pain and itch, in addition to less clinically overt issues like bone fragility as well as vascular and soft tissue calcification which may lead to adverse hard endpoints, particularly fracture and death. Recognized therapies for managing a rising PTH include vitamin D analogues, with or without calcimimetic (where available), in addition to management of serum mineral concentrations with diet, binders and dialysis. Despite these interventions, many patients eventually develop refractory metabolic abnormalities of severe hyperparathyroidism (HPT). Treatment decisions in severe HPT in Australia previously centred around whether to perform parathyroidectomy or use calcimimetics in combination with calcitriol (or its analogues) with goals of symptom relief, fracture reduction and reducing vascular risk. The decision to remove Pharmaceutical Benefits Scheme reimbursement for the calcimimetic cinacalcet during 2015, means that parathyroidectomy has now become the only treatment likely to benefit most patients with severe HPT who are medically fit for operative intervention. Although improvements in care are apparent for patients with CKD, there remains an urgent need for basic science and large international trials to inform better ways to manage HPT.
慢性肾脏病（CKD）3 - 5D期患者甲状旁腺激素（PTH）的合适目标存在争议，实现这些目标的方法同样如此。继发性甲状旁腺功能亢进与骨痛、瘙痒等症状有关，此外还与一些临床症状不那么明显的问题有关，如骨质脆弱以及血管和软组织钙化，这些可能导致不良的严重结局，尤其是骨折和死亡。公认的治疗PTH升高的方法包括使用维生素D类似物，可单独使用或联合拟钙剂（若有可用的），此外还包括通过饮食、结合剂和透析来控制血清矿物质浓度。尽管采取了这些干预措施，许多患者最终仍会出现严重甲状旁腺功能亢进（HPT）的难治性代谢异常。在澳大利亚，重度HPT的治疗决策以前主要围绕是否进行甲状旁腺切除术，或使用拟钙剂联合骨化三醇（或其类似物），目标是缓解症状、减少骨折和降低血管风险。2015年取消了拟钙剂西那卡塞的药品福利计划报销，这意味着甲状旁腺切除术现在已成为唯一可能使大多数适合手术干预的重度HPT患者受益的治疗方法。尽管CKD患者的护理有了明显改善，但仍迫切需要基础科学研究和大型国际试验，以找到更好的HPT管理方法。
