Erlichman M, Holohan T V
Health Technol Assess (Rockv). 1995 Dec(6):1-30.
Many studies document bone loss at diagnosis in patients with PHPT (including mild PHPT) that is greater than would be expected in comparable persons without this condition. However, there is no general agreement regarding the severity of bone mass loss in these patients and the rate at which it progresses. A few studies suggest that such accelerated osteoporosis may be self-limited, with patients showing no further decline in BMD after diagnosis. There is insufficient evidence to conclude that PTH-related bone loss is associated with an increased risk of fracture. The few studies that have evaluated the risk of fracture in these patients are conflicting. Some evidence also suggest that, like bone loss in these patients, fracture risk may change during the course of the disease. One study found that patients with PHPT (including those with mild hypercalcemia) were more likely than matched controls to have a history of fractures prior to diagnosis, but that both groups had similar rates of fractures during followup. Moreover, the studies of fractures suffer from several limitations, such as nonrandomization of patients, different definitions of vertebral fractures, small study populations, and short followup times. There is also insufficient evidence to determine the effect of parathyroidectomy on the incidence of fractures in patients with mild PHPT, partly because the natural history of this condition is incompletely understood. Although studies demonstrate that patients with PHPT gain bone mass following parathyroidectomy, the bone reparation is incomplete and bone mass density remains below normal, even though the hyperparathyroidism is cured. Currently, decisions to perform parathyroidectomy are based on signs and symptoms of bone disease, metabolically active renal stones, decreased renal function, fatigue and/or depression, and high levels of serum calcium. Although the use of bone mass measurements has been advocated to aid clinical decisions regarding the risks and benefits of surgery, specific bone changes that indicate the need for parathyroidectomy have not been clearly established. There are virtually no prospective data that evaluate decisions to operate based upon bone mass measurements nor randomized clinical trials comparing the outcome of surgically treated patients with those who have not had surgery. Based on the literature, bone mass measurements cannot predict who among asymptomatic patients will require parathyroidectomy. There is some evidence that nonsurgically treated patients and those who remained hypercalcemic after unsuccessful surgery lost bone at the same percentage rate as normal control subjects.
许多研究记录了原发性甲状旁腺功能亢进症（包括轻度原发性甲状旁腺功能亢进症）患者在诊断时的骨质流失情况，这种流失程度大于无此病症的可比人群预期的流失程度。然而，对于这些患者骨质流失的严重程度及其进展速度，目前尚无普遍共识。一些研究表明，这种加速性骨质疏松可能是自限性的，患者在诊断后骨密度不再进一步下降。没有足够的证据得出甲状旁腺激素相关的骨质流失与骨折风险增加有关的结论。少数评估这些患者骨折风险的研究结果相互矛盾。一些证据还表明，与这些患者的骨质流失情况类似，骨折风险可能在疾病过程中发生变化。一项研究发现，原发性甲状旁腺功能亢进症患者（包括轻度高钙血症患者）在诊断前有骨折病史的可能性高于匹配的对照组，但两组在随访期间的骨折发生率相似。此外，关于骨折的研究存在一些局限性，如患者未随机分组、椎体骨折的定义不同、研究人群规模小以及随访时间短。也没有足够的证据来确定甲状旁腺切除术对轻度原发性甲状旁腺功能亢进症患者骨折发生率的影响，部分原因是对这种病症的自然病程了解不全面。尽管研究表明原发性甲状旁腺功能亢进症患者在甲状旁腺切除术后骨质增加，但骨质修复并不完全，骨密度仍低于正常水平，即便甲状旁腺功能亢进症已治愈。目前，决定进行甲状旁腺切除术是基于骨病的体征和症状、代谢活跃的肾结石、肾功能下降、疲劳和/或抑郁以及血清钙水平升高。尽管有人主张使用骨量测量来辅助关于手术风险和益处的临床决策，但尚未明确确定表明需要进行甲状旁腺切除术的具体骨变化。实际上，几乎没有前瞻性数据评估基于骨量测量的手术决策情况以及比较手术治疗患者与未手术患者结局的随机临床试验。根据文献，骨量测量无法预测无症状患者中哪些人需要进行甲状旁腺切除术。有一些证据表明，非手术治疗的患者以及手术失败后仍有高钙血症的患者骨质流失的百分比与正常对照组相同。
