Aojula Nivaran, Khan Shahab, Gittoes Neil, Hassan-Smith Zaki
Department of Medicine, Faculty of Medicine, Imperial College London, London, UK.
Department of Endocrine Surgery, John Radcliffe Hospital, Oxford, UK.
Ther Adv Endocrinol Metab. 2021 Feb 27;12:2042018821995370. doi: 10.1177/2042018821995370. eCollection 2021.
Primary hyperparathyroidism (PHPT) is classically associated with both an elevated or 'inappropriately normal' parathyroid hormone (PTH) level and raised serum calcium. However, in clinical practice, increasing numbers of patients present with raised PTH but normal serum calcium, renal function and vitamin D; this is known as normocalcaemic PHPT (nPHPT). Studies investigating the clinical presentation of this condition have shown that patients may present with hypertension, nephrolithiasis, impaired glucose tolerance, osteoporosis and fragility fractures. The prevalence of such complications in nPHPT is similar to that in classical hypercalcaemic PHPT (hPHPT). Although the National Institute for Health and Care Excellence (NICE) have developed guidelines for the management of PHPT generally, a consensus is yet to be reached on the optimal management of nPHPT specifically. A review of the literature on parathyroidectomy in the treatment of nPHPT revealed that nPHPT patients were more likely to present with multi-glandular disease and significantly less nPHPT patients had an intra-operative PTH fall of >50% compared with those with hPHPT. These findings demonstrate that patients with nPHPT are more likely to receive bilateral neck explorations and require remedial surgery compared with hPHPT patients. Following surgery, improvements in bone mineral density (BMD) and renal stones are generally observed in those with nPHPT. Where surgery is not possible, medical management with alendronate has been shown to be effective in nPHPT patients. Given the higher incidence of multi-gland disease and greater possibility of remedial surgery in nPHPT, careful consideration of risks and benefits should be made on an individualised basis and surgery should be performed by surgeons experienced in four gland exploration.
原发性甲状旁腺功能亢进症（PHPT）传统上与甲状旁腺激素（PTH）水平升高或“不适当正常”以及血清钙升高有关。然而，在临床实践中，越来越多的患者表现为PTH升高但血清钙、肾功能和维生素D正常；这被称为血钙正常的PHPT（nPHPT）。对这种情况临床表现的研究表明，患者可能出现高血压、肾结石、糖耐量受损、骨质疏松症和脆性骨折。nPHPT中这些并发症的患病率与经典高钙血症性PHPT（hPHPT）相似。尽管英国国家卫生与临床优化研究所（NICE）已经制定了一般PHPT的管理指南，但对于nPHPT的最佳管理尚未达成共识。对甲状旁腺切除术治疗nPHPT的文献综述显示，与hPHPT患者相比，nPHPT患者更可能出现多腺体疾病，且术中PTH下降>50%的nPHPT患者明显更少。这些发现表明，与hPHPT患者相比，nPHPT患者更可能接受双侧颈部探查并需要补救手术。手术后，nPHPT患者的骨矿物质密度（BMD）和肾结石通常会有所改善。在无法进行手术的情况下，已证明使用阿仑膦酸钠进行药物治疗对nPHPT患者有效。鉴于nPHPT中多腺体疾病的发生率较高且补救手术的可能性较大，应在个体化基础上仔细考虑风险和益处，手术应由有四腺体探查经验的外科医生进行。
