肾移植术后继发性甲状旁腺功能亢进的临床分析

doi:10.3877/cma.j.issn.1674-3903.2018.02.003

目的

研究肾移植术后合并甲状旁腺功能亢进的受者血清钙、磷代谢及免疫反应性甲状旁腺激素(iPTH)水平的变化趋势，探讨治疗方式的选择。

方法

回顾性分析2012年1月至2014年6月在解放军第三〇九医院全军器官移植研究所泌尿外科因尿毒症行肾移植、且术前并发继发性甲状旁腺功能亢进(SHPT)、术后移植肾功能恢复至估算肾小球滤过率(eGFR)>60 mL·min^－1·(1.73 m²)^－1的受者资料。共179例受者纳入研究，平均年龄(34±6)岁(18～61岁)，术前慢性肾脏病分级均为5级。肾移植术后常规应用骨化三醇治疗(0.25 μg，1次/d)，维持正常血清钙、磷水平。记录肾移植前后受者血清钙、磷及iPTH水平。采用单因素重复测量资料方差分析比较肾移植前和移植后1周、1个月、6个月、12个月和24个月受者血清钙、磷、iPTH水平，采用χ²检验比较低磷血症和高钙血症发生率以及iPTH分布情况。

结果

肾移植术后1个月受者血清钙上升至稳定期，同时血清磷下降至稳定期；术后6个月高钙血症和低磷血症发生率最高，分别为8.4%(15/179)和9.5%(17/179)。术后1～6个月受者iPTH下降明显，随后无明显变化，术后24个月仅有27%(48/179)的受者iPTH水平降至完全正常。

结论

尿毒症患者行肾移植术后，SHPT均有所缓解，但大部分无法恢复至正常水平，术后需要进行积极的针对性治疗。

关键词: 甲状旁腺功能亢进, 肾移植, 钙磷代谢

Objective

To explore the calcium-phosphorus metabolism and variation trend of immunoreactive parathyroid hormone (iPTH) of renal transplantation recipients after transplantation, and correct choice of treatment.

Methods

We retrospectively analyzed the clinical data of 179 recipients who got renal transplantation because of uremia between January 2012 to June 2014 in 309th Hospital of Chinese People′s Liberation Army. All the recipients suffered from secondary hyperparathyroidism (SHPT) and the renal function recoved to the estimated glomerular filtration rate (eGFR) >60 mL·min^-1·(1.73 m²)^-1 after transplantation. The average age of recipients was (34±6) years (18-61 years) and chronic kidney disease function were graded as 5T. Calcitriol (0.25 μg/d) was regularly used after transplantation to maintain normal serum levels of calcium and phosphate. Indexes like eGFR and serum calcium, phosphate and iPTH of recipients before and after transplantation were recorded. One-way analysis of variance for repeated measurement data was used to compare serum calcium, phosphate and iPTH of recipients before and 1 week, 1 month, 6 months, 12 months and 24 months after transplantation. Occurrence rate of hypophosphatemia and hypercalcemia, and distribution of iPTH were compared by Chi-square test.

Results

Serum calcium of recipients after renal transplantation rised to stationary phase, meanwhile, serum phosphate fallen to stationary phase. Recipients had the highest occurrence rate of hypophosphatemia (9.5%, 17/179) and hypercalcemia (8.4%, 15/179) 6 months after transplantation. Serum iPTH declined significantly during 1 to 6 months after transplantation with no significant change later. For serum iPTH, only 24% (48/179) of recipients returned to more normal levels 24 months after transplantation.

Conclusions

Symptoms of SHPT of uremia patients were all alleviated, but most of them couldn′t return to normal level, which needed active and specific treatment after renal transplantation.

Key words: Hyperparathyroidism, Renal transplantation, Mineral metabolism

表1 179例受者肾移植前后血清钙、磷变化情况

时间	血清钙(±s, mmol/L)	高钙血症发生率[例(%)]	血清磷(±s, mmol/L)	低磷血症发生率[例(%)]
术前	2.15±0.21	3 (1.7)	1.92±0.28	4 (2.2)
术后1周	2.14±0.19	2 (1.1)	1.89±0.24	2 (1.1)
术后1个月	2.32±0.14^ab	4 (2.2)	1.03±0.14^ab	13 (7.3)
术后6个月	2.31±0.13^ab	15 (8.4)	0.98±0.16^ab	17 (9.5)
术后12个月	2.34±0.12^ab	9 (5.0)	0.79±0.21^ab	11 (6.1)
术后24个月	2.33±0.17^ab	9 (5.0)	0.75±0.16^ab	6 (3.4)

表1 179例受者肾移植前后血清钙、磷变化情况

时间	血清钙(±s, mmol/L)	高钙血症发生率[例(%)]	血清磷(±s, mmol/L)	低磷血症发生率[例(%)]
术前	2.15±0.21	3 (1.7)	1.92±0.28	4 (2.2)
术后1周	2.14±0.19	2 (1.1)	1.89±0.24	2 (1.1)
术后1个月	2.32±0.14^ab	4 (2.2)	1.03±0.14^ab	13 (7.3)
术后6个月	2.31±0.13^ab	15 (8.4)	0.98±0.16^ab	17 (9.5)
术后12个月	2.34±0.12^ab	9 (5.0)	0.79±0.21^ab	11 (6.1)
术后24个月	2.33±0.17^ab	9 (5.0)	0.75±0.16^ab	6 (3.4)

表2 179例受者肾移植前后血清iPTH变化及分布情况

时间	iPTH(±s, pg/mL)	15～≤65 pg/mL[例(%)]	65～≤130 pg/mL[例(%)]	130～650≤ pg/mL[例(%)]	>650 pg/mL[例(%)]
术前	275±167	－	30 (17)	145 (81)	4 (2)
术后1周	264±175	－	38 (21)	137 (77)	4 (2)
术后1个月	200±194^ab	27 (15)	73 (41)	75 (42)	4 (2)
术后6个月	171±183^ab	40 (22)	71 (40)	66 (37)	2 (1)
术后12个月	166±181^ab	43 (24)	79 (44)	55 (31)	2 (1)
术后24个月	163±182^ab	48 (27)	81 (45)	50 (28)	－

表2 179例受者肾移植前后血清iPTH变化及分布情况

时间	iPTH(±s, pg/mL)	15～≤65 pg/mL[例(%)]	65～≤130 pg/mL[例(%)]	130～650≤ pg/mL[例(%)]	>650 pg/mL[例(%)]
术前	275±167	－	30 (17)	145 (81)	4 (2)
术后1周	264±175	－	38 (21)	137 (77)	4 (2)
术后1个月	200±194^ab	27 (15)	73 (41)	75 (42)	4 (2)
术后6个月	171±183^ab	40 (22)	71 (40)	66 (37)	2 (1)
术后12个月	166±181^ab	43 (24)	79 (44)	55 (31)	2 (1)
术后24个月	163±182^ab	48 (27)	81 (45)	50 (28)	－

表3 肾移植术后血清钙、磷及iPTH检测周期(月)

受者CKD分级	检测周期
受者CKD分级	血清钙	血清磷	iPTH
1～3级	6～12	6～12	根据iPTH基线水平和CKD进展情况
4级	3～ 6	3～ 6	6～12
5级	1～ 3	1～ 3	3～ 6

表3 肾移植术后血清钙、磷及iPTH检测周期(月)

受者CKD分级	检测周期
受者CKD分级	血清钙	血清磷	iPTH
1～3级	6～12	6～12	根据iPTH基线水平和CKD进展情况
4级	3～ 6	3～ 6	6～12
5级	1～ 3	1～ 3	3～ 6

1	李春红,田洁. 继发性甲状旁腺功能亢进症的药物治疗进展[J]. 医学综述，2016, 22(11): 2171-2174.
2	Moe S,Drueke T,Cunningham J, et al. Definition, evaluation, and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes(KDIGO)[J]. Kidney Int, 2006, 69(11): 1945-1953.
3	Trillini M,Cortinovis M,Ruggenenti P, et al. Paricalcitol for secondary hyperparathyroidism in renal transplantation[J]. J Am Soc Nephrol, 2015, 26(5): 1205-1214.
4	《活性维生素D的合理应用》专家协作组. 活性维生素D在慢性肾脏病继发性甲旁亢中合理应用的专家共识(修订版)[J]. 中华肾脏病杂志，2005, 21(11): 698-699.
5	张建荣，张凌. 慢性肾脏病继发性甲旁亢[M]. 北京：人民军医出版社，2010：143-147.
6	Tiosano D,Hochberg Z. Hypophesphatemia: the common denominator of all rickets[J]. J Bone Miner Metab, 2009, 27(4): 392-401.
7	刘航,张晓东. 肾移植术后甲状旁腺机能亢进症研究进展[J]. 国际移植与血液净化杂志，2015, 13(5): 3-6.
8	Molnar MZ,Kovesdy CP,Mucsi I, et al. Association of prekidney transplant malkels of mineral and bone disorder with post-transplant outcomes[J]. Clin J Am Soc Nephrol, 2012, 7(11): 1859-1871.
9	Ostovan MA,Fazelzadeh A,Mehdizadeh AR, et al. How to decrease cardiovascular mortality in renal transplant recipients[J]. Transplant Proc, 2006, 38(9): 2887-2892.
10	Savaj S,Gbods FJ. Vitamin D, parathyroid hormone, and bone mineral density status in kidney transplant recipients[J]. Iran J Kidney Dis, 2012, 6(4): 295-299.
11	Egbuna OI,Taylor JG,Bushinsky DA, et al. Elevated calcium phosphate product after renal transplantation is a risk factor for graft failure[J]. Clin Transplant, 2007, 21(4): 558-566.
12	Boom H,Mallat MJ,de Fijter JW, et al. Calcium levels as a risk factor for delayed graft function[J]. Transplantation, 2004, 77(6): 868-873.
13	Kurella M,Butterly DW,Smith SR. Post transplant erythrocytosis in hypercalcemic renal transplant recipients[J]. Am J Transplant, 2003, 3(7): 873-877.
14	冯冰,代文琼,尹素凤. 慢性肾脏病继发性甲旁亢的治疗[J]. 中国卫生标准管理，2014, 5(5): 12-13.
15	Roodnat JL,van Gurp EA,Mulder PG, et al. Highpretransplant parathyroid hormone levels increase the risk forgraft failure after renal transplantation[J]. Transplantation, 2006, 82(3): 362-367.
16	王莉,李贵森,刘志红. 中华医学会肾脏病学分会《慢性肾脏病矿物质和骨异常诊治指导》[J]．肾脏病与透析肾移植杂志，2013，22(6): 554-559.
17	中国疾病预防控制中心营养与食品安全所．中国食物成分表(第二版) [M]．北京：北京大学医学出版社，2009.
18	Saliba W,El-Haddad B. Secondary hyperparathyroidism：pathophysiology and treatment[J]. J Am Board Fam Med, 2009, 22(5): 574-581.
19	Di Iorio B,Molony D,Bell C, et al. Sevelamer versus calcium carbonate in incident hemodialysis patients: results of an open-label 24-month randomized clinical trial[J]. Am J Kidney Dis, 2013, 62(4): 771-778.
20	王泰娜,徐斌,贾凤玉，等. 帕立骨化醇治疗血液透析患者伴继发性甲状旁腺功能亢进[J]. 肾脏病与透析肾移植杂志，2015, 24(1): 1-5.
21	Fraz JM,Elangovan L,Maung HM, et al. Intermittent doxercalciferol(1alpha-hydroxyvitamin D(2) ) therapy for secondary hyperparathyroidism[J]. Am J Kidney Dis, 2000, 36(3): 550-561.
22	Kidney Disease: Improving Global Outcomes(KDIGO) CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder(CKD-MBD)[J]. Kidney Int Suppl, 2009, (113): S1-S130.
23	Cunningham J,Locatelli F,Rodriguez M. Secondary hyperparathyroidism: pathogenesis, disease progression, and therapeutic options[J]. Clin J Am Soc Nephrol, 2011, 6(4): 913-921.
24	Raggi P,Chertow GM,Torres PU, et al. The advance study: a randomized study to evaluate the effects of cinacalcet plus low dose vitamin D on vascular calcification in patients on hemodialysis[J]. Nephrol Dial Transplant, 2011, 26(4): 1327-1339.
25	Parikh S,Nagaraja H,Agarwal A, et al. Impact of postkidneytransplant parathyroidectomy on anograf: function[J]. Chn Transplant, 2013, 27(3): 397-402.
26	罗丽花,管保章,黄盛玲，等. 微波消融治疗继发性甲状旁腺功能亢进2例的短期疗效观察[J]. 中华肾脏病杂志，2015, 31(4): 312-313.

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Clinical analysis of secondary hyperparathyroidism after renal transplantation

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Clinical analysis of secondary hyperparathyroidism after renal transplantation