Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California, Irvine, California.
Clin J Am Soc Nephrol. 2018 Jun 7;13(6):952-961. doi: 10.2215/CJN.10390917. Epub 2018 Mar 9.
Secondary hyperparathyroidism develops in CKD due to a combination of vitamin D deficiency, hypocalcemia, and hyperphosphatemia, and it exists in nearly all patients at the time of dialysis initiation. There is insufficient data on whether to prefer vitamin D analogs compared with calcimimetics, but the available evidence suggests advantages with combination therapy. Calcium derangements, patient adherence, side effects, and cost limit the use of these agents. When parathyroid hormone level persists >800 pg/ml for >6 months, despite exhaustive medical interventions, monoclonal proliferation with nodular hyperplasia is likely present along with decreased expression of vitamin D and calcium-sensing receptors. Hence, surgical parathyroidectomy should be considered, especially if concomitant disorders exist, such as persistent hypercalcemia or hyperphosphatemia, tissue or vascular calcification including calciphylaxis, and/or worsening osteodystrophy. Parathyroidectomy is associated with 15%-57% greater survival in patients on dialysis, and it also improves hypercalcemia, hyperphosphatemia, tissue calcification, bone mineral density, and health-related quality of life. The parathyroidectomy rate in the United States declined to approximately seven per 1000 dialysis patient-years between 2002 and 2011 despite an increase in average parathyroid hormone levels, reflecting calcimimetics introduction and uncertainty regarding optimal parathyroid hormone targets. Hospitalization rates are 39% higher in the first postoperative year. Hungry bone syndrome occurs in approximately 25% of patients on dialysis, and profound hypocalcemia requires high doses of oral and intravenous calcium along with calcitriol supplementation. Total parathyroidectomy with autotransplantation carries a higher risk of permanent hypocalcemia, whereas risk of hyperparathyroidism recurrence is higher with subtotal parathyroidectomy. Given favorable long-term outcomes from observational parathyroidectomy cohorts, despite surgical risk and postoperative challenges, it is reasonable to consider parathyroidectomy in more patients with medically refractory secondary hyperparathyroidism.
继发性甲状旁腺功能亢进症（SHPT）是由于维生素 D 缺乏、低钙血症和高磷血症共同作用而在慢性肾脏病（CKD）中发生的，并且几乎在所有开始透析的患者中都存在。目前尚缺乏关于维生素 D 类似物与钙敏感受体激动剂相比是否具有优势的充分数据，但现有证据表明联合治疗具有优势。钙代谢紊乱、患者依从性、副作用和成本限制了这些药物的使用。如果甲状旁腺激素（PTH）水平持续>800 pg/ml 且持续>6 个月，即使进行了全面的药物干预，也可能存在甲状旁腺单克隆增殖伴结节性增生，同时伴有维生素 D 和钙敏感受体表达减少。因此，应考虑手术甲状旁腺切除术，特别是如果存在并存疾病，如持续性高钙血症或高磷血症、组织或血管钙化（包括钙磷灰石沉着症）和/或进行性骨营养不良恶化。甲状旁腺切除术与透析患者 15%-57%的生存率增加相关，也可改善高钙血症、高磷血症、组织钙化、骨密度和健康相关生活质量。尽管平均甲状旁腺激素水平升高，但美国 2002 年至 2011 年期间每 1000 名透析患者的甲状旁腺切除术率下降到约 7 例，反映了钙敏感受体激动剂的引入和对最佳甲状旁腺激素目标的不确定性。术后第一年的住院率增加 39%。在透析患者中，约 25%的患者会发生饥饿骨综合征，严重低钙血症需要大剂量口服和静脉补钙以及骨化三醇补充。甲状旁腺全切加自体移植会导致更高的永久性低钙血症风险，而甲状旁腺次全切除术复发甲状旁腺功能亢进症的风险更高。鉴于观察性甲状旁腺切除术队列的长期预后良好，尽管存在手术风险和术后挑战，但对于药物难治性继发性甲状旁腺功能亢进症患者，考虑甲状旁腺切除术是合理的。
