El-Husseini Amr, Wang Kevin, Edon Annick, Saxon David, Lima Florence, Sloan David, Sawaya B Peter
Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA.
Division of Nephrology, Mansoura University, Mansoura, Egypt.
Nephron. 2018;138(2):119-128. doi: 10.1159/000482016. Epub 2017 Nov 9.
In dialysis and renal transplant patients with secondary and tertiary hyperparathyroidism (HPT), the value of intraoperative parathyroid hormone (ioPTH) during parathyroidectomy (PTX) and its association with long-term PTH levels are unknown. The present study aims at evaluating the relationship of ioPTH with long-term PTH levels post-PTX in dialysis and renal transplant patients in a single-center study.
The ioPTH was measured in 57 dialysis patients (33 females and 24 males) and 18 renal transplant recipients (12 males and 6 females) who underwent PTX from 2005 to 2015 for refractory HPT. Near-total PTX was performed in 56 patients and total PTX with autotransplantation in 20 patients. The PTH monitoring included 3 samples: pre-intubation, 10- and 20-min (pre-ioPTH, 10-ioPTH, and 20-ioPTH) post parathyroid gland excision. Patients were followed up for up to 5 years.
In the dialysis group, the median (25th-75th percentile) pre-, 10-, and 20-ioPTH levels were 1,447 pg/mL (938-2,176), 143 pg/mL (78-244) and 112 pg/mL (59-153) respectively. In the renal transplant group, pre-, 10-, and 20-ioPTH levels were 273 pg/mL (180-403), 42 pg/mL (25-72), and 34 pg/mL (23-45) respectively. All patients in the transplant group had a functional kidney transplant at the time of PTX with a median serum creatinine of 1.3 mg/dL (1.2-1.7) and estimated glomerular filtration rate of 55 mL/min (40-60). The median time between renal transplant and PTX surgeries was 22 months (7-81). The last median follow-up PTH level was 66 pg/mL (15-201) in the dialysis group and 54 pg/mL (17-72) in the transplant group (p = 0.438). The mean time for last PTH post-PTX was 2.3 ± 2.0 years. In both groups, there was no significant difference between 20-ioPTH and any-time post-PTX PTH levels (p = 0.6 and p = 0.9). Nineteen patients (25%) were readmitted within 90 days because of hypocalcemia. One patient in the dialysis group was readmitted for post-PTX hematoma evacuation. No patient required repeat PTX because of recurrent HPT that was refractory to medical therapy. Only one dialysis patient required repeat PTX because the first procedure failed.
The 20-ioPTH is a good indicator of long-term PTH levels in dialysis and renal transplant patients. Hypocalcemia is a common complication, particularly in dialysis patients, and it is the main reason for readmission after PTX. Hypoparathyroidism is a potential concern after PTX in dialysis patients.
在患有继发性和三发性甲状旁腺功能亢进（HPT）的透析及肾移植患者中，甲状旁腺切除术（PTX）期间术中甲状旁腺激素（ioPTH）的价值及其与长期甲状旁腺激素水平的关联尚不清楚。本单中心研究旨在评估透析及肾移植患者中ioPTH与PTX术后长期甲状旁腺激素水平的关系。
对2005年至2015年因难治性HPT接受PTX的57例透析患者（33例女性和24例男性）和18例肾移植受者（12例男性和6例女性）测量ioPTH。56例患者接受了近全甲状旁腺切除术，20例患者接受了甲状旁腺全切加自体移植术。甲状旁腺激素监测包括3个样本：插管前、甲状旁腺切除后10分钟和20分钟（术前ioPTH、10分钟ioPTH和20分钟ioPTH）。对患者进行了长达5年的随访。
在透析组中，术前、10分钟和20分钟ioPTH水平的中位数（第25 - 75百分位数）分别为1447 pg/mL（938 - 2176）、143 pg/mL（78 - 244）和112 pg/mL（59 - 153）。在肾移植组中，术前、10分钟和20分钟ioPTH水平分别为273 pg/mL（180 - 403）、42 pg/mL（25 - 72）和34 pg/mL（23 - 45）。移植组的所有患者在PTX时均有功能良好的肾移植，血清肌酐中位数为1.3 mg/dL（1.2 - 1.7），估计肾小球滤过率为55 mL/min（40 - 60）。肾移植与PTX手术之间的中位时间为22个月（7 - 81）。透析组末次随访时甲状旁腺激素水平的中位数为66 pg/mL（15 - 201），移植组为54 pg/mL（17 - 72）（p = 0.438）。PTX后末次甲状旁腺激素水平的平均时间为2.3±2.0年。在两组中，20分钟ioPTH与PTX后任何时间的甲状旁腺激素水平之间均无显著差异（p = 0.6和p = 0.9）。19例患者（25%）因低钙血症在90天内再次入院。透析组有1例患者因PTX后血肿清除再次入院。没有患者因药物治疗难治的复发性HPT而需要再次进行PTX。只有1例透析患者因首次手术失败而需要再次进行PTX。
20分钟ioPTH是透析及肾移植患者长期甲状旁腺激素水平的良好指标。低钙血症是一种常见并发症，尤其是在透析患者中，它是PTX后再次入院的主要原因。甲状旁腺功能减退是透析患者PTX后一个潜在的问题。
