Tominaga Y, Numano M, Tanaka Y, Uchida K, Takagi H
Department of Transplant Surgery, Nagoya Second Red Cross Hospital, Japan.
Semin Surg Oncol. 1997 Mar-Apr;13(2):87-96. doi: 10.1002/(sici)1098-2388(199703/04)13:2<87::aid-ssu4>3.0.co;2-y.
Advanced secondary (renal) hyperparathyroidism induced by chronic renal disturbance is one of the most serious complications for long-term hemodialysis patients. Parathyroidectomy is indicated in patients with severely advanced renal hyperparathyroidism refractory to medical treatment (including calcitriol pulse therapy) and the clinical effect of parathyroidectomy is striking. However, skeletal deformity, vessel calcification, and remarkable reduction of bone content is irreversible, and it is important to perform parathyroidectomy at right time. Based on histopathological and pathophysiological investigations, nodular hyperplasia is monoclonal neoplasia with abnormal parathyroid hormone (PTH) response to extracellular calcium and vitamin D. When parathyroid hyperplasia progresses to nodular hyperplasia, parathyroidectomy should be required. Total parathyroidectomy with forearm autograft is the preferable procedure for renal hyperparathyroidism, especially for patients who need to continue hemodialysis treatment after parathyroidectomy. Removal of all parathyroid glands, including supernumerary glands, at the initial operation, and proper choice of adequate parathyroid tissue for autograft, are important to prevent persistent and recurrent hyperparathyroidism. Preoperative image diagnosis is useful for localization, and routine resection of thymic tissue is necessary to remove supernumerary glands. In our series of 548 patients, graft-dependent recurrent hyperparathyroidism was not negligible and the incidence was about 20% at the 5th year postoperatively. Enlarged autografts of parathyroid tissue could be removed from forearm under local anesthesia with fewer invasions. The function of autografted parathyroid tissue is nearly satisfactory and no re-transplantation of cryopreserved parathyroid tissue was necessary. To avoid adynamic bone disease, relatively high PTH level is required-over-suppression of PTH by excess of vitamin D and calcium salts should be avoided. In our experience, total parathyroidectomy with forearm autograft is very effective and adequate treatment for advanced renal hyperparathyroidism, and parathyroid function can be controlled after parathyroidectomy.
慢性肾脏疾病引起的晚期继发性（肾性）甲状旁腺功能亢进是长期血液透析患者最严重的并发症之一。对于药物治疗（包括骨化三醇冲击疗法）难治的重度晚期肾性甲状旁腺功能亢进患者，甲状旁腺切除术是必要的，且甲状旁腺切除术的临床效果显著。然而，骨骼畸形、血管钙化和骨含量显著降低是不可逆的，适时进行甲状旁腺切除术很重要。基于组织病理学和病理生理学研究，结节性增生是一种单克隆肿瘤，甲状旁腺激素（PTH）对细胞外钙和维生素D有异常反应。当甲状旁腺增生发展为结节性增生时，就需要进行甲状旁腺切除术。甲状旁腺全切加前臂自体移植术是治疗肾性甲状旁腺功能亢进的首选方法，尤其适用于甲状旁腺切除术后仍需继续血液透析治疗的患者。初次手术时切除所有甲状旁腺，包括异位甲状旁腺，并正确选择合适的甲状旁腺组织进行自体移植，对于预防持续性和复发性甲状旁腺功能亢进很重要。术前影像诊断有助于定位，常规切除胸腺组织对于切除异位甲状旁腺是必要的。在我们的548例患者系列中，移植依赖型复发性甲状旁腺功能亢进不可忽视，术后第5年的发生率约为20%。前臂自体移植的甲状旁腺组织增大时，可在局部麻醉下从前臂切除，创伤较小。自体移植甲状旁腺组织的功能基本令人满意，无需再次移植冷冻保存的甲状旁腺组织。为避免动力缺失性骨病，需要相对较高的PTH水平，应避免维生素D和钙盐过量导致PTH过度抑制。根据我们的经验，甲状旁腺全切加前臂自体移植术是治疗晚期肾性甲状旁腺功能亢进非常有效且充分的方法，甲状旁腺切除术后甲状旁腺功能可得到控制。
