Kitaoka M, Fukagawa M, Ogata E, Kurokawa K
Division of Endocrinology and Metabolism, Showa General Hospital, Tokyo, Japan.
Kidney Int. 1994 Oct;46(4):1110-7. doi: 10.1038/ki.1994.373.
Recent data suggest that the larger parathyroid glands are more resistant to calcitriol therapy than the smaller glands due to more severe reduction of calcitriol receptor number. To control severe secondary hyperparathyroidism resistant to calcitriol pulse therapy in chronic dialysis patients, we introduced repeatable and quantitative ethanol injection(s) into the largest parathyroid gland under ultrasonographic guidance with a specifically modified needle. Efficacy of each injection and the recurrence of hyperparathyroidism were confirmed by color Doppler ultrasonography and could undergo additional ethanol injection(s) into the optimal site. When the ethanol injection(s) into the largest gland was not sufficient to control PTH hypersecretion, we injected ethanol into the next largest gland. We performed 32 injections into 16 parathyroid glands in nine dialysis patients. PTH decreased to less than 200 pg/ml after the final injection in seven patients and they remained controlled either by the following conventional oral active vitamin D or calcitriol pulse therapy. The other two patients, whose PTH decreased but not to less than 200 pg/ml, also became controllable with the following calcitriol pulse therapy. Recurrent nerve palsy was encountered in 2 out of 32 injections, but only transiently. Our data suggest that the measurement of the size of parathyroid glands is an important factor in the management strategy of secondary hyperparathyroidism in chronic dialysis patients, and that ethanol injection(s) into the largest parathyroid gland(s) could be an effective and safe strategy to restore the responsiveness to calcitriol therapy, by reducing the functioning parathyroid cell mass most resistant to calcitriol.
近期数据表明，由于维生素D受体数量减少更为严重，较大的甲状旁腺对骨化三醇治疗的抵抗性比小甲状旁腺更强。为控制慢性透析患者中对骨化三醇脉冲治疗耐药的严重继发性甲状旁腺功能亢进，我们在超声引导下，使用特制改良针，对最大的甲状旁腺进行可重复的定量乙醇注射。每次注射的疗效以及甲状旁腺功能亢进的复发情况通过彩色多普勒超声确认，必要时可在最佳部位再次注射乙醇。当对最大甲状旁腺的乙醇注射不足以控制甲状旁腺激素（PTH）分泌过多时，我们会对次大的甲状旁腺注射乙醇。我们对9名透析患者的16个甲状旁腺进行了32次注射。7名患者在最后一次注射后PTH降至200 pg/ml以下，随后通过常规口服活性维生素D或骨化三醇脉冲治疗得以维持控制。另外两名患者的PTH虽有下降但未降至200 pg/ml以下，后续通过骨化三醇脉冲治疗也实现了可控。32次注射中有2次出现了暂时性的喉返神经麻痹。我们的数据表明，甲状旁腺大小的测量是慢性透析患者继发性甲状旁腺功能亢进管理策略中的一个重要因素，对最大的甲状旁腺进行乙醇注射可能是一种有效且安全的策略，通过减少对骨化三醇最具抵抗性的有功能甲状旁腺细胞数量，恢复对骨化三醇治疗的反应性。
