甲状旁腺切除术治疗继发性甲状旁腺功能亢进症的争议与进展

doi:10.16139/j.1007-9610.2023.06.14

摘要/Abstract

摘要：

继发性甲状旁腺功能亢进症是长期透析病人的常见并发症之一。虽然可以选择拟钙剂、维生素D类似物等药物内科治疗方案，但对于药物治疗反应较差的难治性病人仍可选择甲状旁腺切除术作为治疗手段。目前相关术式包括甲状旁腺次全切除术、甲状旁腺全切除术、甲状旁腺全切除术联合自体移植和甲状旁腺肃清术。由于本病是透析病人体内钙磷和维生素D代谢紊乱刺激甲状旁腺增生所致，因此手术切除甲状旁腺的临床目标参数具有一定的不可控性，外科治疗策略也存在争议。但随着临床数据的积累、新观念的涌现和新技术的更新，合理的药物选择和恰当的手术干预将进一步提升治疗效果和安全性。

关键词: 继发性甲状旁腺功能亢进, 甲状旁腺切除术, 钙磷代谢紊乱

Abstract:

Secondary hyperparathyroidism is one of common complications of long-term dialysis patients. Although medical treatment schemes such as calcimimetics and vitamin D analogues can be selected, patients refractory to drug treatment can still refer to parathyroidectomy as a treatment choice. At present, the surgical treatment include subtotal parathyroidectomy, total parathyroidectomy with or without auto-transplantation and purge parathyroidectomy. Because the etiology of this disease is related to hyperplasia of parathyroid tissue stimulated with metabolic disorder of calcium, phosphorus and vitamin D in dialysis patients, the course of disease and target indexes of surgical treatment might still be difficult to control, and there still lies controversies in surgical therapeutic strategy. However, with updating of clinical data, the emergence of new concepts and the introduction of new technologies, reasonable drug selection and appropriate timing of surgical intervention will further improve the treatment efficacy and safety.

Key words: Secondary hyperparathyroidism, Parathyroidectomy, Metabolic disorder of calcium and phosphorus

中图分类号:

R653
R582.1

王强, 查斯洛, 张伟. 甲状旁腺切除术治疗继发性甲状旁腺功能亢进症的争议与进展[J]. 外科理论与实践, 2023, 28(06): 568-573.

WANG Qiang, ZHA Siluo, ZHANG Wei. Controversy and progress in parathyroidectomy for the treatment of secondary hyperparathyroidism[J]. Journal of Surgery Concepts & Practice, 2023, 28(06): 568-573.

参考文献 45

[1]	Kidney Disease: Improving Global Outcomes KDIGO CKD-MBD Update Work Group. KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD)[J]. Kidney Int Suppl (2011), 2017, 7(1):1-59.
[2]	中国医师协会外科医师分会甲状腺外科医师委员会, 中国研究型医院学会甲状腺疾病专业委员会. 慢性肾脏病继发甲状旁腺功能亢进外科临床实践中国专家共识(2021版)[J]. 中国实用外科杂志, 2021, 41(8):841-848.
	Committee of Thyroid Surgeons, Chinese Physicians Association of Surgeons, China, Specialized Committee on Thyroid Diseases, Chinese Society of Research Hospitals. Chinese expert consensus on surgical practice of hyperthyroidism in patients with chronic kidney disease(2021 edition)[J]. Chin J Pract Surg, 2021, 41(8):841-848.
[3]	TENTORI F, WANG M, BIEBER B A, et al. Recent changes in therapeutic approaches and association with outcomes among patients with secondary hyperparathyroidism on chronic hemodialysis: the DOPPS study[J]. Clin J Am Soc Nephrol, 2015, 10(1):98-109. doi: 10.2215/CJN.12941213 URL
[4]	ZHANG Y, LU Y, FENG S, et al. Evaluation of laboratory parameters and symptoms after parathyroidectomy in dialysis patients with secondary hyperparathyroidism[J]. Ren Fail, 2019, 41(1):921-929. doi: 10.1080/0886022X.2019.1666724 pmid: 31573378
[5]	KOVACEVIC B, IGNJATOVIC M, ZIVALJEVIC V, et al. Parathyroidectomy for the attainment of NKF-K/DOQI™ and KDIGO recommended values for bone and mineral metabolism in dialysis patients with uncontrollable se-condary hyperparathyroidism[J]. Langenbecks Arch Surg, 2012, 397(3):413-420. doi: 10.1007/s00423-011-0901-9 URL
[6]	KIM M S, KIM G H, LEE C H, et al. Surgical outcomes of subtotal parathyroidectomy for renal hyperparathyroi-dism[J]. Clin Exp Otorhinolaryngol, 2020, 13(2):173-178. doi: 10.21053/ceo.2019.01340 URL
[7]	SCHLOSSER K, BARTSCH D K, DIENER M K, et al. Total parathyroidectomy with routine thymectomy and autotransplantation versus total parathyroidectomy alone for secondary hyperparathyroidism: results of a nonconfirmatory multicenter prospective randomized controlled pilot trial[J]. Ann Surg, 2016, 264(5):745-753. doi: 10.1097/SLA.0000000000001875 URL
[8]	CHEN L, WANG K, YU S, et al. Long-term mortality after parathyroidectomy among chronic kidney disease patients with secondary hyperparathyroidism: a systematic review and meta-analysis[J]. Ren Fail, 2016, 38(7):1050-1058. doi: 10.1080/0886022X.2016.1184924 pmid: 27198474
[9]	WANG L, XIN M H, MA Y, et al. Effect of parathyroidectomy on quality of life among patients undergoing dialysis[J]. Int J Gen Med, 2022, 15:1185-1192. doi: 10.2147/IJGM.S354145 pmid: 35153509
[10]	钱寒阳, 任文凯, 王宁宁. 重视继发性甲状旁腺功能亢进患者术后甲状旁腺激素持续过低状态[J]. 肾脏病与透析肾移植杂志, 2021, 30(4):368-373.
	QIAN H Y, REN W K, WANG N N. Persistent low circulating parathyroid hormone levels after parathyroidectomy for secondary hyperparathyroidism patients with chronic kidney disease[J]. J Nephrol Dialy Transplant, 2021, 30(4):368-373.
[11]	LAU W L, OBI Y, KALANTAR-ZADEH K. Parathyroi-dectomy in the management of secondary hyperparathyroidism[J]. Clin J Am Soc Nephrol, 2018, 13(6):952-961. doi: 10.2215/CJN.10390917 URL
[12]	ZMIJEWSKI P V, STALOFF J A, WOZNIAK M J, et al. Subtotal parathyroidectomy vs. total parathyroidectomy with autotransplantation for secondary hyperparathyroi-dism in dialysis patients: short- and long-term outcomes[J]. J Am Coll Surg, 2019, 228(6):831-838. doi: 10.1016/j.jamcollsurg.2019.01.019 URL
[13]	YUAN Q, LIAO Y, ZHOU R, et al. Subtotal parathyroi-dectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism: an updated systematic review and meta-analysis[J]. Langenbecks Arch Surg, 2019, 404(6):669-679. doi: 10.1007/s00423-019-01809-7
[14]	CHEN J, JIA X, KONG X, et al. Total parathyroidectomy with autotransplantation versus subtotal parathyroidectomy for renal hyperparathyroidism: a systematic review and meta-analysis[J]. Nephrology (Carlton), 2017, 22(5):388-396. doi: 10.1111/nep.2017.22.issue-5 URL
[15]	KANG B H, HWANG S Y, KIM J Y, et al. Predicting postoperative total calcium requirements after parathyroidectomy in secondary hyperparathyroidism[J]. Korean J Intern Med, 2015, 30(6):856-864. doi: 10.3904/kjim.2015.30.6.856 pmid: 26552461
[16]	LIU M E, QIU N C, ZHA S L, et al. To assess the effects of parathyroidectomy (TPTX versus TPTX+AT) for se-condary hyperparathyroidism in chronic renal failure: a systematic review and meta-analysis[J]. Int J Surg, 2017, 44:353-362. doi: 10.1016/j.ijsu.2017.06.029 URL
[17]	HOU J, SHAN H, ZHANG Y, et al. Network meta-analysis of surgical treatment for secondary hyperparathyroi-dism[J]. Am J Otolaryngol, 2020, 41(2):102370. doi: 10.1016/j.amjoto.2019.102370 URL
[18]	NASCIMENTO JUNIOR C P, ARAP S S, CUSTODIO M R, et al. Parathyroid hormone levels after parathyroidectomy for secondary hyperparathyroidism[J]. Rev Assoc Med Bras (1992),2021, 67(2):230-234. doi: 10.1590/1806-9282.67.02.20200609 URL
[19]	SHAN C X, QIU N C, ZHA S L, et al. A novel surgical strategy for secondary hyperparathyroidism: purge parathyroidectomy[J]. Int J Surg, 2017, 43:112-118. doi: 10.1016/j.ijsu.2017.05.062 URL
[20]	OKADA M, TOMINAGA Y, YAMAMOTO T, et al. Location frequency of missed parathyroid glands after parathyroidectomy in patients with persistent or recurrent se-condary hyperparathyroidism[J]. World J Surg, 2016, 40(3):595-599. doi: 10.1007/s00268-015-3312-1 URL
[21]	李伟, 刘冰洋, 单成祥, 等. 甲状旁腺肃清术对继发性甲状旁腺功能亢进的疗效评价[J]. 外科理论与实践, 2019, 24(4):325-329.
	LI W, LIU B Y, SHAN C X, et al. Evaluation of purge parathyroidectomy in treatment of secondary hyperparathyroidism[J]. J Surg Concepts Pract, 2019, 24(4):325-329.
[22]	KAKUTA T, SAWADA K, KANAI G, et al. Parathyroid hormone-producing cells exist in adipose tissues surrounding the parathyroid glands in hemodialysis patients with secondary hyperparathyroidism[J]. Sci Rep, 2020, 10(1):3290. doi: 10.1038/s41598-020-60045-y pmid: 32094398
[23]	TARIM I A, KESICIOGLU T, KARABULUT K, et al. An intraoperative serum parathormone level study in patients with chronic renal failure that underwent subtotal parathyroidectomy what extent of decrease is sufficient at which moment?[J]. Ann Ital Chir, 2021, 92:435-440.
[24]	CHAVEZ K V, MARQUEZ-GONZALEZ H, CHAVEZ-TOSTADO M. The usefulness of intraoperative PTH as a predictor for successful parathyroidectomy in secondary hyperparathyroidism[J]. Front Surg, 2021, 8:696469. doi: 10.3389/fsurg.2021.696469 URL
[25]	VAN BEEK D J, FREDRIKSSON S, HAEGELE S, et al. Use of intraoperative parathyroid hormone measurements during parathyroidectomy to predict postoperative parathyroid hormone levels in patients with renal hyperparathyroidism: meta-analysis[J]. BJS Open, 2022, 6(1):zrab151. doi: 10.1093/bjsopen/zrab151 URL
[26]	XU F, HUANG Y, ZENG M, et al. Diagnostic values of intraoperative (1-84) parathyroid hormone levels are superior to intact parathyroid hormone for successful parathyroidectomy in patients with chronic kidney disease[J]. Endocr Pract, 2021, 27(11):1065-1071. doi: 10.1016/j.eprac.2021.04.006 URL
[27]	SILVEIRA A A, BRESCIA M D G, DO NASCIMENTO C P, et al. PTH spikes during surgical treatment for secon-dary and tertiary hyperparathyroidism: a prospective observational study[J]. World J Surg, 2022, 46(7):1693-1701. doi: 10.1007/s00268-022-06506-z URL
[28]	LI W, LIU B, SHAN C, et al. Application of carbon nanoparticles in localization of parathyroid glands during total parathyroidectomy for secondary hyperparathyroi-dism[J]. Am J Surg, 2020, 220(6):1586-1591. doi: 10.1016/j.amjsurg.2020.04.034 URL
[29]	单成祥, 李伟, 刘冰洋, 等. Tider方法在手术治疗继发性甲状旁腺功能亢进中的应用[J]. 外科理论与实践, 2020, 25(3):234-238.
	SHAN C X, LI W, LIU B Y, et al. Application of Tider process in parathyroidectomy for treatment of secondary hyperparathyroidism[J]. J Surg Concepts Pract, 2020, 25(3):234-238.
[30]	乔楠, 付庆锋, 李鸿博, 等. 继发性甲状旁腺功能亢进外科治疗中甲状旁腺自体移植现状[J]. 中国实用外科杂志, 2019, 39(4):379-381.
	QIAO N, FU Q F, LI H B, et al. Current status of parathyroid autotransplantation in the surgical management of secondary hyperparathyroidism[J]. Chin J Pract Surg, 2019, 39(4):379-381.
[31]	SUN X, ZHANG X, ZHANG L, et al. Relationship between intraoperative measured parameters of parathyroid gland and pathological patterns in patients with secon-dary hyperparathyroidism[J]. Ann Transl Med, 2021, 9(2):99. doi: 10.21037/atm URL
[32]	ZHAO S, GAN W, XIE W, et al. A single-center experience of parathyroidectomy in 1500 cases for secondary hyperparathyroidism: a retrospective study[J]. Ren Fail, 2022, 44(1):23-29. doi: 10.1080/0886022X.2021.2016445 pmid: 35094636
[33]	AITI A, ROSSI M, ALVIANO F, et al. Parathyroid tissue cryopreservation: does the storage time affect viability and functionality?[J]. Biopreserv Biobank, 2019, 17(5):418-424. doi: 10.1089/bio.2018.0140 pmid: 31025874
[34]	SHEPET K, ALHEFDHI A, USEDOM R, et al. Parathyroid cryopreservation after parathyroidectomy: a worthwhile practice?[J]. Ann Surg Oncol, 2013, 20(7):2256-2260. doi: 10.1245/s10434-013-2941-6 pmid: 23504122
[35]	拟钙剂在慢性肾脏病患者中应用的专家共识[J]. 中华肾脏病杂志, 2018, 34(9):703-707.
	Expert consensus on the application of calcimimetics in patients with chronic kidney disease[J]. Chin J Nephrol, 2018, 34(9):703-707.
[36]	OKUNO S, INABA M, ISHIMURA E, et al. Effects of long-term cinacalcet administration on parathyroid gland in hemodialysis patients with secondary hyperparathyroidism[J]. Nephron, 2019, 142(2):106-113. doi: 10.1159/000496808 URL
[37]	LEE C H, CHEN J Y, KUO P C, et al. Parathyroidectomy for dialysis patients in the era of calcimimetics: the surgeons' point of view[J]. J Chin Med Assoc, 2022, 85(3):279-285. doi: 10.1097/JCMA.0000000000000694 URL
[38]	VAN DER PLAS W Y, DULFER R R, ENGELSMAN A F, et al. Effect of parathyroidectomy and cinacalcet on quality of life in patients with end-stage renal disease-related hyperparathyroidism: a systematic review[J]. Nephrol Dial Transplant, 2017, 32(11):1902-1908. doi: 10.1093/ndt/gfx044 URL
[39]	KOMABA H, HAMANO T, FUJII N, et al. Parathyroidectomy versus cinacalcet among patients undergoing hemodialysis[J]. J Clin Endocrinol Metab, 2022, 107(7):2016-2025. doi: 10.1210/clinem/dgac142 URL
[40]	KOH E Y, VAN DER PLAS W Y, DULFER R R, et al. Outcomes of parathyroidectomy versus calcimimetics for secondary hyperparathyroidism and kidney transplantation: a propensity-matched analysis[J]. Langenbecks Arch Surg, 2020, 405(6):851-859. doi: 10.1007/s00423-020-01953-5
[41]	杨柳, 张凌, 杨莉. 血液透析合并继发性甲状旁腺功能亢进患者PTX手术和西那卡塞药物治疗的成本效果分析[J]. 中华内分泌外科杂志, 2021, 15(6):661-665.
	YANG L, ZHANG L, YANG L. To compare the cost-effectiveness of PTX and cinacalcet for patients with hemodialysis complicated with secondary hyperparathyroi-dism—a study based on real world data[J]. Chin J Endocr Surg, 2021, 15(6):661-665.
[42]	MATHUR A, AHN J B, SUTTON W, et al. Increasing rates of parathyroidectomy to treat secondary hyperparathyroidism in dialysis patients with medicare coverage[J]. Surgery, 2022, 172(1):118-126. doi: 10.1016/j.surg.2022.02.005 URL
[43]	VAN DER PLAS W Y, ENGELSMAN A F, OZYILMAZ A, et al. Impact of the introduction of calcimimetics on timing of parathyroidectomy in secondary and tertiary hyperparathyroidism[J]. Ann Surg Oncol, 2017, 24(1):15-22. doi: 10.1245/s10434-016-5450-6 pmid: 27459979
[44]	VAN DER PLAS W Y, ENGELSMAN A F, UMAKANTHAN M, et al. Treatment strategy of end stage renal disease-related hyperparathyroidism before, during, and after the era of calcimimetics[J]. Surgery, 2019, 165(1):135-141. doi: 10.1016/j.surg.2018.04.092 URL
[45]	FRIEDL C, ZITT E. Role of etelcalcetide in the management of secondary hyperparathyroidism in hemodialysis patients: a review on current data and place in therapy[J]. Drug Des Devel Ther, 2018, 12:1589-1598. doi: 10.2147/DDDT URL