维持性血液透析继发性甲状旁腺功能亢进术后复发再处理1例并文献复习

Re-Treatment of Recurrent Secondary Hyperparathyroidism after Surgery in a Maintenance Hemodialysis Patient: A Case Report and Literature Review

摘要: 目的：探讨维持性血液透析合并难治性继发性甲状旁腺功能亢进(secondary hyperparathyroidism, SHPT)的临床特点、诊疗难点、手术方式选择及长期管理策略，提高临床对该病的规范化诊疗水平。方法：回顾性分析1例40岁维持性血液透析12年合并难治性SHPT患者的临床资料、辅助检查、两次手术过程及随访结果，并结合国内外相关文献进行系统复习。结果：患者因左前臂动静脉内瘘功能不良入院，同时合并难治性SHPT，既往2016年曾行甲状旁腺次全切除 + 右前臂自体移植术，近2年骨痛症状反复加重。入院后完善检查提示iPTH显著升高、高磷血症、全身多部位血管及软组织钙化，先后行左侧甲状旁腺全部切除术、右前臂移植甲状旁腺切除术。术后甲状旁腺激素(parathyroid hormone, PTH)从峰值>5000 pg/mL降至375 pg/mL，全身骨痛症状明显缓解，随访期间内瘘功能良好，予碳酸镧联合骨化三醇维持治疗，病情稳定。结论：难治性SHPT药物治疗效果不佳时应及时行外科手术干预，甲状旁腺全切除术(total parathyroidectomy, TPTX)术后复发率显著低于全切除 + 自体移植术(TPTX + autotransplantation, TPTX + AT)。对于TPTX + AT术后复发患者，优先考虑切除前臂移植甲状旁腺，具有创伤小、恢复快、患者接受度高等优势，术后长期监测钙磷代谢及PTH水平并配合药物治疗，可有效改善患者的生活质量及预后。

Abstract: Objective: To explore the clinical characteristics, diagnostic and therapeutic difficulties, surgical options and long-term management strategies of refractory secondary hyperparathyroidism (SHPT) in maintenance hemodialysis patients, and to improve the standardized diagnosis and treatment level of this disease in clinical practice. Methods: The clinical data, auxiliary examinations, two surgical procedures and 2-year follow-up results of a 40-year-old patient with 12 years of maintenance hemodialysis complicated with refractory SHPT were retrospectively analyzed, and relevant domestic and foreign literature was systematically reviewed. Results: The patient was admitted to hospital due to dysfunction of left forearm arteriovenous fistula, complicated with refractory SHPT. He had undergone subtotal parathyroidectomy + right forearm autotransplantation in 2016, and his bone pain symptoms had recurred and aggravated in the past 2 years. After admission, complete examinations showed significantly elevated iPTH, hyperphosphatemia, and systemic vascular and soft tissue calcification. He successively underwent total left parathyroidectomy and right forearm transplanted parathyroidectomy. Postoperatively, parathyroid hormone (PTH) decreased from a peak of >5000 pg/mL to 375 pg/mL, and systemic bone pain symptoms were significantly relieved. During the follow-up period, the internal fistula function was good, and the patient was maintained on lanthanum carbonate combined with calcitriol with stable condition. Conclusion: Surgical intervention should be performed in time when drug treatment is ineffective for refractory SHPT. The recurrence rate after total parathyroidectomy (TPTX) is significantly lower than that after total parathyroidectomy with autotransplantation (TPTX + AT). For patients with recurrence after TPTX + AT, priority should be given to resection of forearm transplanted parathyroid glands, which has the advantages of less trauma, faster recovery and higher patient acceptance. Long-term postoperative monitoring of calcium and phosphorus metabolism and PTH levels combined with drug treatment can effectively improve the quality of life and prognosis of patients.