本文選題：繼發(fā)性甲狀旁腺功能亢進(jìn) + 尿毒癥��； 參考：《吉林大學(xué)》2017年碩士論文

【摘要】：背景:繼發(fā)性甲狀旁腺功能亢進(jìn)(secondary hyperparathyroidism,SHPT)是慢性腎臟病(chronic kidney disease,CKD)的常見并發(fā)癥,主要是由鈣磷代謝異常及活性維生素D抵抗等因素所致。其主要臨床表現(xiàn)有骨痛、皮膚瘙癢、異位鈣化等,并可增加心腦血管事件發(fā)生率,嚴(yán)重影響患者的生存質(zhì)量。早期糾正鈣磷紊亂是治療的關(guān)鍵。隨著SHPT病程進(jìn)展,甲狀旁腺細(xì)胞呈腺瘤樣增生,可自主分泌大量PT H(parathyroid hormone,PTH),且Vit D受體、鈣受體表達(dá)明顯下調(diào),鈣劑、磷結(jié)合劑及活性Vit D療效差,即發(fā)展為難治性SHPT。甲狀旁腺切除術(shù)(parathyroidect omy PTX)為治療SHPT的有效手段,目前有甲狀旁腺部分切除術(shù)(subotal parat hyroidectomy,S-PTX),甲狀旁腺全切術(shù)(totalparathyroidectomy,T-PTX),甲狀旁腺全切+自體移植(parathyroidectomy with autotransplantation,PTX+AT)三種術(shù)式,三種術(shù)式各有優(yōu)缺點(diǎn),關(guān)于其在緩解癥狀、術(shù)后并發(fā)癥、復(fù)發(fā)率、遠(yuǎn)期療效等方面孰優(yōu)孰劣尚無定論,對此進(jìn)行研究分析有利于指導(dǎo)臨床術(shù)式的選擇。目的:研究甲狀旁腺次全切術(shù)、全切術(shù)及全切加前臂移植術(shù)對尿毒癥繼發(fā)性甲狀旁腺功能亢進(jìn)患者的臨床療效及術(shù)后并發(fā)癥、復(fù)發(fā)率情況,為臨床合適的術(shù)式選擇提供依據(jù)。方法:回顧性分析2014年4月至2016年10月在吉林大學(xué)第一醫(yī)院接受甲狀旁腺切除術(shù)治療的72例尿毒癥SHPT患者,其中S-PTX組40例,T-PTX組16例,PT X+AT組16例,對各組術(shù)前血清鈣(calcium,Ca)、磷(phosphorus,P)、全段甲狀旁腺激素(intact Parathyroid Hormone,i PTH)、堿性磷酸酶(alkaline phos phatase,ALP)、血紅蛋白(haemoglobin,Hb)、白蛋白(albulmin,Alb)及術(shù)后1周、1月、6月血清鈣、磷、i PTH等一般臨床資料和生化指標(biāo)進(jìn)行分析,比較各組治愈率、療效及術(shù)后復(fù)發(fā)率、并發(fā)癥情況。采用SPSS17.0軟件進(jìn)行資料數(shù)據(jù)統(tǒng)計(jì)。正態(tài)或近似正態(tài)分布的計(jì)量資料以(x±s)表示,組內(nèi)均數(shù)比較采用配對樣本的t檢驗(yàn),三組間均數(shù)比較采用單因素方差分析,有差異者用LSD-t檢驗(yàn)進(jìn)行兩兩比較;偏態(tài)分布的計(jì)量資料采用中位數(shù)(下四分位數(shù)-上四分位數(shù))表示,組內(nèi)比較采用Wilcoxon帶符號(hào)秩檢驗(yàn),組間比較采用Kruskal wallis秩和檢驗(yàn),有差異者用Mann-Whitney檢驗(yàn)進(jìn)行兩兩比較;計(jì)數(shù)資料采用例數(shù)(百分比),即n(%)表示,用χ2檢驗(yàn)進(jìn)行比較。以P0.05為有統(tǒng)計(jì)學(xué)意義,P0.01為有顯著性統(tǒng)計(jì)學(xué)意義。結(jié)果:1、手術(shù)成功71例。三組術(shù)后骨痛、皮膚瘙癢、鈣化防御等癥狀均不同程度緩解,以骨關(guān)節(jié)痛緩解最明顯。且全切組緩解率最高,各癥狀緩解率均達(dá)100%。2、各組術(shù)后3個(gè)時(shí)間點(diǎn)血清鈣、磷、i PTH較術(shù)前相比均下降,差異具有統(tǒng)計(jì)學(xué)意義(P0.05)。3、三組術(shù)后3個(gè)時(shí)間點(diǎn)血清鈣、磷差異無統(tǒng)計(jì)學(xué)意義(P0.05);S-PTX組及PTX+AT組術(shù)后3個(gè)時(shí)間點(diǎn)i PTH差異無統(tǒng)計(jì)學(xué)意義(P0.05),但均較T-PTX組高,差異具有統(tǒng)計(jì)學(xué)意義(P0.05)。4、三種術(shù)式成功率無差別(P0.05);T-PTX組、PTX+AT組治愈率較S-PTX組高,差異具有統(tǒng)計(jì)學(xué)意義(P0.05);三組術(shù)后并發(fā)聲嘶比率無差別(P0.05),聲嘶均逐漸自行緩解;三組術(shù)后1周低鈣血癥發(fā)生率無差別(P0.05),無肢體搐搦等癥狀;隨訪6個(gè)月內(nèi),三組術(shù)后復(fù)發(fā)率無區(qū)別(P0.05)。結(jié)論:1、三種術(shù)式的PTX均可安全、有效治療尿毒癥SHPT、緩解臨床癥狀,三組中以T-PTX癥狀緩解率最高。與S-PTX相比,T-PTX、PTX+AT治愈率更高。三種術(shù)式對血清鈣、磷影響無區(qū)別。T-PTX組術(shù)后i PTH下降更明顯。術(shù)后聲嘶發(fā)生率三者無區(qū)別。隨訪的6個(gè)月內(nèi),三組術(shù)后復(fù)發(fā)率無區(qū)別。2、術(shù)后三個(gè)時(shí)間點(diǎn)S-PTX組、PTX+AT組i PTH均高于T-PTX組,其長期復(fù)發(fā)率可能更高,二次手術(shù)機(jī)率增加。故對于難治性SHPT且無腎移植意愿的患者,我們主張T-PTX,可安全且最有效地緩解臨床癥狀,降低二次手術(shù)的風(fēng)險(xiǎn)。
[Abstract]:Background: secondary hyperparathyroidism (secondary hyperparathyroidism, SHPT) is a common complication of chronic renal disease (chronic kidney disease, CKD). It is mainly caused by abnormal calcium and phosphorus metabolism and active vitamin D resistance. The main clinical manifestations are bone pain, skin itching, ectopic calcification and so on, and can increase cardiovascular and cerebrovascular events. Early correction of calcium and phosphorus disorder is the key to treatment. With the progress of SHPT, parathyroid cells are adenomatoid hyperplasia, which can independently secrete a large number of PT H (parathyroid hormone, PTH), and Vit D receptor, the expression of calcium receptor is obviously down, calcium, phosphorus binder and active Vit D are poor, that is, the development is Intractable SHPT. parathyroidectomy (parathyroidect omy PTX) is an effective means for the treatment of SHPT. There are three kinds of parathyroidectomy (subotal parat hyroidectomy, S-PTX), parathyroid total resection (totalparathyroidectomy, T-PTX), and parathyroid autologous transplantation (parathyroidectomy). The three kinds of surgical methods have advantages and disadvantages. It is not conclusive about the advantages and disadvantages in alleviating symptoms, postoperative complications, recurrence rate and long-term effect. This study is helpful to guide the selection of clinical operation. The clinical efficacy, postoperative complications and recurrence rates of hyperhyperthyroidism provided a basis for clinical selection. Methods: retrospective analysis of 72 SHPT patients with Uremia Treated in No.1 Hospital of Jilin University from April 2014 to October 2016, including 40 cases in group S-PTX, 16 in group T-PTX and 16 in group PT X+AT. Serum calcium (calcium, Ca), phosphorus (phosphorus, P), whole segment parathyroid hormone (intact Parathyroid Hormone, I PTH), alkaline phosphatase (alkaline Phos phatase), hemoglobin (alkaline Phos phatase), serum albumin, and 1 weeks after operation, January, June, and other general clinical and biochemical indexes. Analysis, compare the cure rate, curative effect and postoperative recurrence rate and complication. SPSS17.0 software is used to carry out data statistics. The measurement data of normal or approximate normal distribution are expressed by (x + s), and the average number of the group is compared with the paired sample t test. The average number of the three groups is compared with the single factor analysis of variance, and the difference is carried out by the LSD-t test. 22 comparison; the measurement data of the partial distribution are expressed in the median (the lower four digits - the upper four digits), the group comparison uses the Wilcoxon band sign rank test, the group is compared with the Kruskal Wallis rank sum test, and the difference is compared with the Mann-Whitney test. The number of data uses the number of cases (percentage), that is, n (%), and x 2 test Compared with the statistical significance of P0.05, P0.01 had significant statistical significance. Results: 1, the operation was successful in 71 cases. The three groups of postoperative bone pain, skin pruritus, calcification defense and other symptoms were alleviated in different degrees, with the most obvious relief of bone and joint pain. The remission rate of all the total cut groups was the highest and the rate of each symptom was 100%.2, and the blood was at 3 time points after the operation. Calcium, phosphorus, I PTH decreased compared with pre operation, and the difference was statistically significant (P0.05).3. There was no statistically significant difference in serum calcium and phosphorus in three groups at 3 time points after operation (P0.05), and there was no statistical significance (P0.05) at 3 time points after operation in group S-PTX and PTX+AT, but higher than that in T-PTX group (P0.05), three kinds of surgical procedures. There was no difference in power (P0.05), group T-PTX, group PTX+AT was higher than group S-PTX, and the difference was statistically significant (P0.05). There was no difference between the three groups after operation (P0.05), and the hoarseness was gradually relieved, and the incidence of hypocalcemia in the three groups was not different (P0.05) and no tetany, and the recurrence rate of the three groups in the three groups after 6 months of follow-up was no area. (P0.05). Conclusion: 1, three kinds of surgical methods are safe and effective in treating uremia SHPT and alleviating clinical symptoms. The rate of T-PTX symptom remission is the highest in three groups. Compared with S-PTX, T-PTX, PTX+AT has a higher cure rate. Three kinds of surgical methods have no difference in serum calcium and phosphorus from.T-PTX group. The incidence of postoperative hoarseness is three. Within 6 months of the visit, the recurrence rate of the three groups was no different.2, three time after the operation in group S-PTX, and the I PTH in group PTX+AT was higher than that of the T-PTX group. The long-term recurrence rate was higher and the probability of the two operation increased. Therefore, we advocated T-PTX for the patients with refractory SHPT and no renal transplantation, which was safe and effective to alleviate the clinical symptoms and reduce two times of hand. Risk of operation.

【學(xué)位授予單位】：吉林大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R692.5;R653

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