血液透析患者甲状旁腺全切除加上臂移植术后低钙血症的防治

目的 观察因继发性甲状旁腺功能亢进症（secondary hyperparathyroidism,SHPT）进行甲状旁腺全切除加上臂移植术（total parathyroidectomy with upper arm autograft,TPTX＋AT）的血液透析患者,术后使用不同钙离子浓度的透析液行透析治疗低钙血症的效果,探讨如何更有效防治术后低钙血症.方法 选择2011年3月至2013年6月在我院接受TPTX＋AT的血液透析患者29例,按照手术时间的先后顺序进行编号,随机将偶数分在A组14例,奇数分在B组15例.术前B组补钙及骨化三醇;术后2组均予补钙及骨化三醇.A组使用钙浓度1.50 mmol/L透析液,B组使用钙浓度1.75 mmol/L高钙透析液.观察术后8 h、24 h、48 h、1周、2周及4周的血钙、血磷及甲状旁腺素（intact parathyroid hormone,iPTH）的变化,记录低钙血症的临床症状,术后达到治疗目标所需要的时间及静脉补钙量.结果 术后血钙、血磷、iPTH均明显下降.术后低钙血症主要表现四肢末端发麻,全身无力,焦虑、烦躁;少数患者表现为心悸、多汗、肌肉痉挛、四肢抽搐,血压低、腹痛或腹泻.A组低钙血症发生率为 85.7%（12/14）、B组为 73.3%（11/15）.术后1周B组血钙水平[（1.95±0.18）mmol/L]明显高于A组[（1.76±0.21）mmol/L].B组术后达到治疗目标所需要的时间为[（7.56±2.25）d],少于A组[（10.54±3.12）d];而B组所需静脉补钙量[（6.86±2.13）g]少于A组[（9.28±2.81）g],差异均有统计学意义（P＜0.05）.结论 并发SHPT的血液透析患者在TPTX＋AT术后常会出现低钙血症,术前、术后足量补充钙剂和骨化三醇,术后使用高钙透析液透析能更加有效防治低钙血症.     

甲状腺手术中甲状旁腺误切和术后低钙血症

目的分析常见甲状腺手术时甲状旁腺误切和术后患者发现低钙血症之间的关系。方法回顾性分析126例甲状腺手术患者的临床资料,其中双侧腺叶大部切除术18例,一侧或双侧腺叶全切术74例和六区清扫术34例。结果 126例患者中,共有25例（19.8%）病理证实存在旁腺误切,有30例（23.8%）术后出现低钙血症,25例（19.8%）出现低钙临床表现,经治疗后症状在2 d内消失。低钙血症的发生（23.8%）和旁腺误切（19.8%）之间是相关的（r=0.87,P=0.0333）。随访6个月,低钙血症消失时间平均为4.25（1-12）周,没有患者出现永久性低钙血症。六区清扫术的总体旁腺误切率为41.2%（14/34）,高于大部切除术的5.6%（1/18）（P〈0.01）,亦高于腺叶全切除术的13.5%（10/74）（P=0.0013）。结论甲状腺腺叶切除及六区清扫术后短暂的低钙血症是比较常见的并发症;旁腺误切可以导致术后低钙血症的发生;六区清扫术有很高的旁腺误切风险。     

原发性甲状旁腺功能亢进术后低钙血症相关因素分析

目的 探讨原发性甲状旁腺功能亢进术后出现低钙血症及其症状的相关因素。方法 收集2009年1月至2015年3月北京协和医院行手术治疗的原发性甲状旁腺功能亢进病人临床资料,分析与术后低钙血症及其症状相关的临床因素。 结果 641例原发性甲状旁腺功能亢进病人成功接受甲状旁腺切除术治疗,并得到术后病理学诊断及长期随访证实。118例（18.4%）术后第一日血清总钙低于正常值下限,210例（32.8%）出现低钙血症相关的临床症状。多因素相关分析发现：原发性甲状旁腺病人术后出现低钙血症相关症状,与病人年龄、术前血清无机磷及碱性磷酸酶（ALP）相关;术后第一日血清总钙水平低于正常与术前血清全片段甲状旁腺激素（iPTH）水平相关。 结论 青年病人、术前血清iPTH和ALP水平增高、血清无机磷水平低可能是原发性甲状旁腺功能亢进术后低钙的相关因素。     

维持性血液透析继发性甲状旁腺功能亢进患者甲状旁腺切除术后低钙血症的危险因素分析

目的:探讨继发性甲状旁腺功能亢进（secondary hyperparathyroidism,SHPT）维持性血液透析患者接受甲状旁腺切除术（parathyroidectomy,PTX）后补钙量与临床指标的相关性、术后发生低钙血症的危险因素以及PTX术后补钙量对患者远期预后的影响。方法:本研究为单中心回顾性研究,入选2...     

甲状腺术后不同时间检测甲状旁腺激素预测低钙血症发生的系统评价

目的探讨甲状腺术后不同时间段检测甲状旁腺激素（PTH）对术后低钙血症的预测价值。方法检索中国生物医学文献库、万方数据库、同方数据库及维普中国科技期刊数据库的中文文献,同时检索MEDLINE、OVID、PUBMED、EMBASE等外文数据库,纳入以甲状腺术后发生低钙血症为参考标准,对比不同时间段检测的PTH值预测术后低钙血症的价值。根据检测时间不同分为2组,并分别对纳入文献进行质量评价及偏倚分析,提取相关信息后通过STATA12及Meta-Disc软件进行合并分析,计算合并的敏感度（SEN）、特异度（SPE）、阳性似然比（LR＋）、阴性似然比（LR-）及SROC曲线下面积（AUC）,并对2组指标进行对比分析。结果共纳入23篇文献,其中前瞻性队列研究15篇,回顾性研究8篇;英文文献21篇,中文文献2篇。按不同时间段分为2组,第1组（术后1h内检测PTH值）共纳入患者2012例,其中术后发生低钙血症患者494例,未发生低钙血症患者1518例;第2组（术后4-12h内检测PTH值）共纳入患者693例,其中术后发生低钙血症患者266例,未发生低钙血症患者427例。通过纳入文献漏斗图发现2组文献的发表偏倚均较小。Meta分析结果显示,除合并的SEN外,2组间合并的SPE、朋＋、LR-及AUC的差异均有统计学意义（P〈0．01）;第1组的预测效果好于第2组,术后1h内检测的PTH值〈16ng／L时其AUC面积最大。结论甲状腺术后检测PTH值是一种有效预测术后发生低钙血症的方法,其中术后1h内检测PTH值低于16ng／L对术后低钙血症的预测效果最佳。     

慢性肾脏病患者甲状旁腺切除术后低钙血症的处理

继发性甲状旁腺功能亢进（secondary hyperparathyroidism,SHPT）是慢性肾脏病（chronic kidney disease,CKD）发展至中晚期常见的一种严重影响患者生活质量的并发症,发病机制主要是CKD进展导致肾脏产生的1,25（OH）2D3分泌不足,导致低钙、高磷刺激甲状旁腺增生,导致血甲状旁腺激素（parathyroid hormone,PTH）增高,SHPT患者不仅表现为钙磷代谢紊乱、转移性钙化,还会导致骨骼、关节疼痛、骨骼畸形（如退缩人综合征）。     

甲状腺术后症状性低钙血症与甲状旁腺激素及血钙关系的探讨

目的 检测甲状腺术后患者甲状旁腺激素(PTH)及血钙水平,并探讨其与术后症状性低钙血症发生的关系.方法 手术治疗的351例甲状腺疾病患者,对其术后14～16h血钙和PTH水平进行检测.观察发生轻微症状及严重症状的两组患者术后PTH及血钙情况.结果 本组351例患者术前血钙均>2.0mmol/L,肾功能均正常.58例患者术后出现低钙症状,其中严重症状16例,轻微症状42例.比较血钙<2.0mmol/L是否产生严重症状时其特异度为83%,敏感度为30%,差异无统计学意义.比较PTH<0.8pmol/L是否产生严重症状时其特异度为82.0%,敏感度为87.5%,差异有统计学意义.当应用血钙<2.0mmol/L与PTH<0.8pmol/L联合检测时其特异度为80.5%,敏感度为85.7%,差异有统计学意义.结论 术后14～16h PTH在预测术后症状性低钙血症方面比血钙敏感,PTH<0.8pmol/L可作为严重症状性低钙血症的预测指标,临床应用方便.     

低钙透析液对腹膜透析患者钙磷代谢的影响

目的横断面研究腹膜透析患者使用低钙透析液的安全性及其影响因素。方法选择西安交通大学医学院第一附属医院肾脏内科腹膜透析超过6个月的患者共39例，其中男24例，女15例，年龄56．49±19．31岁，其中使用常规（ca 1．75mmol／L）透析液8例，低钙（ca 1．25mmol／L）透析液31例，比较两组血清钙、磷、甲状旁腺激素、血压以及使用碳酸钙的情况。结果两组血钙无明显差异；常规透析液组血磷和钙磷乘积高于低钙组，两组iPTH无明显差异。低钙组服用碳酸钙剂量明显高于常规透析液组。低钙组服用碳酸钙与未服用碳酸钙血钙无明显差异，服用碳酸钙组血磷控制较为理想、钙磷乘积更接近正常，未服用碳酸钙组血PTH明显升高。结论腹膜透析患者使用低钙透析液有利于控制血磷和血压，有效预防钙磷乘积升高。提高对碳酸钙的依从性是预防使用低钙透析液后引起继发性甲状旁腺功能亢进的关键。     

低钙透析液对血液透析伴继发性甲状旁腺功能减退患者的临床研究

目的：探讨应用含钙1.25mmol／L浓度透析液进行血液透析对维持性血液透析（MHD）伴相继发性甲状旁腺功能减退患者的钙磷代谢和甲状旁腺功能的影响。方法：选择MHD6个月以上、病情稳定、连续2次血iPTH〈100pg／ml的患者60例,随机分为对照组（含钙1.5mmol／L透析液）和治疗组（含钙1.25mmol／L透析液）,每组各30例,观察时间6个月。观察并记录研究前、研究后l、3、6个月等不同时期患者血iPTH、血清校正钙、磷、钙磷乘积等指标的变化以及相关不良反应。另外,选择使用含钙浓度1.5mmol／L和1.25mmol／L透析液进行MHD的患者各20例,检测单次透析前、透析结束时以及下次透析前的血清校正钙、磷和iPTH浓度。结果：（1）治疗组单次透析后血清校正钙、磷和钙磷乘积均较透析前明显下降,iPTH浓度较透前明显升高,P〈0.01;而对照组上述血钙和iPTH浓度无明显变化;（2）透析后治疗组血清校正钙和钙磷乘积较对照组明显下降,血iPTH浓度较对照组明显升高,P〈0.01;两组血磷浓度差异无统计学意义。（3）治疗组1个月后血清校正钙、磷和钙磷乘积较治疗前开始下降,3个月后进一步下降,P〈0.05,6个月后各项指标趋于稳定;iPTH水平1个月后较治疗前明显升高,并随着治疗时间的延长,逐渐升高,P〈0.01。（4）对照组治疗后1、3、6个月上述指标与治疗前比较差异无统计学意义。（5）两组透析过程中出现的不良反应差异无统计学意义。结论：对于血iPTH〈100pg／ml MHD患者应用含钙1.25mmol／L透析液进行血液透析能较好地控制其血清校正钙、磷、钙磷乘积水平,有效地改善被过度抑制的甲状旁腺功能,并且安全性良好。     

61例尿毒症患者甲状旁腺全切加前臂移植术后低钙血症的发生与处理

目的针对内科治疗无效的继发性甲状旁腺功能亢进（sHPT）的尿毒症患者行甲状旁腺全切加前臂移植术,分析术后患者低钙血症的发生与处理。方法61例患者术后立即监测血钙浓度,并静脉补充葡萄糖酸钙,使血钙维持在1．8～2．2mmol／L之间,统计手术前、后患者的全段甲状旁腺激素（iPTH）、血清钙磷乘积和碱性磷酸酶（AKP）水平以及手术切除的总的腺体质量。结果56例患者（占91．7％）术后12-24h即出现血钙低于1．8mmol／L,静脉立即补充葡萄糖酸钙,约合元素钙（18±6）g,补钙剂量与术前血iPTH（r=0．621,P〈0．01）、钙磷乘积（r=0．719,P〈0．01）、AKP（r=0．606,P〈0．01）及总的切除腺体质量（r=0．716,P〈0．01）相关。结论低钙血症是患者甲状旁腺术后的常见表现,与SHPT的严重程度有关,术后及早监测血钙和静脉补钙可有效、安全预防严重低钙血症的发生。     

继发性甲状旁腺功能亢进患者术后严重低钙血症风险评分模型的构建与验证

背景与目的 甲状旁腺切除术（PTX）是治疗难治性或进展性继发性甲状旁腺功能亢进（SHPT）的有效方法,严重低钙血症（SH）是术后常见且严重的并发症,术前有效预测SH对SHPT患者的术后管理及针对性干预治疗具有重要的临床价值,但目前尚无SH风险预测评分系统。因此,本研究探讨SHPT患者行PTX后发生SH的危险因素并构建术前风险预测评分模型,以期为临床提供参考。方法 回顾性分析2010年11月—2022年3月在中国人民解放军联勤保障部队第九六〇医院行甲状旁腺全切加自体移植术（tPTX+AT）的513例SHPT患者临床资料,将患者按入院时间分为建模组（404例）,验证组（109例）。根据术后3 d内最低的血钙水平将患者分为SH组和非SH组,进行单因素和多因素分析,以确定术后SH的独立危险因素,利用Logistic回归构建SH风险预测评分模型,分别在建模组和验证组中应用受试者工作特征曲线（ROC）对模型进行内部验证和外部验证。结果 全组513例患者中237例（46.20%）发生术后SH。在建模组中,单因素分析显示,皮肤瘙痒、身高缩短、年龄以及术前血红蛋白、碱性磷酸酶（ALP）、白蛋白、血钙、全段甲状旁腺激素（iPTH）、骨钙素、术前I型胶原C端肽分解片段（β-CTX）与术后SH明显有关（均P<0.05）;多因素分析显示,术前ALP>363.5 U/L、iPTH>2 239 pg/mL、β-CTX>3.305 μg/L和身高缩短是术后SH的独立危险因素,术前血钙>2.50 mmol/L是术后SH的保护因素（均P<0.05）。将ALP>363.5 U/L、iPTH>2 239 pg/mL、β-CTX>3.305 μg/L作为预测因子构建SH风险预测评分模型,阳性时分别赋值7、4、6分,阴性时均为0分。结果显示,10~13分时SH发生率为58.82%、17分时SH发生率为82.93%。该模型在建模组和验证组ROC曲线下的面积（AUC）分别为0.811（95% CI=0.768~0.853）、0.826（95% CI=0.745~0.906）,均有统计学意义（均P<0.05）。结论 构建的SHPT患者行PTX后发生SH的风险预测评分模型预测效能较好,可用于术前识别高风险患者,为临床指导SHPT患者的术后管理和治疗提供重要参考。     

Inadvertent parathyroidectomy during thyroid surgery: the incidence of a complication of thyroidectomy

Background and aims Incidental parathyroidectomy is a complication of thyroid surgery. The aim of this report is to explore the incidence, risk factors, and clinical relevance of inadvertent parathyroidectomy during thyroidectomy.Materials and methods Patients who underwent thyroidectomy between January 1998 and June 2005 were evaluated. Pathology reports were reviewed for the presence of parathyroid tissue in the thyroidectomy specimens. Information regarding diagnosis, operative details, and postoperative hypocalcemia were collected.Results Three hundred and fifteen thyroid procedures were performed: 163 total thyroidectomies, 124 near-total thyroidectomies, and 28 lobectomies. The findings were benign in 240 and malignant in 75 cases. Incidental parathyroidectomy was found in 68 (21.6%) cases: 58 were benign and 10 were malignant. One and two parathyroids were accidentally removed in 46 and 22 patients, respectively. Parathyroid tissue was found in intrathyroidal (33%) and extracapsular (27%) sites. Total/near-total thyroidectomy was not associated with increased risk of incidental parathyroidectomy (P=0.646), and there was no association of inadvertent parathyroidectomy with postoperative hypocalcemia (P=0.859). Thyroid malignancy was associated with decreased incidence of incidental parathyroidectomy (P=0.047).Conclusion Inadvertent parathyroidectomy, although not uncommon, is not associated with postoperative hypocalcemia. The type of surgical procedure does not increase the risk of incidental parathyroidectomy, while thyroid malignancy may reduce the incidence of inadvertent parathyroidectomy.     

Influencing factors of hungry bone syndrome in maintenance hemodialysis patients after parathyroidectomy

Objective To investigate the influencing factors of hungry bone syndrome (HBS) in maintenance hemodialysis patients with secondary hyperparathyroidism (SHPT) after parathyroidectomy (PTX). Methods A retrospective study was conducted on maintenance hemodialysis patients with SHPT undergoing successful parathyroidectomy with autotransplantation. Clinical data and perioperative indicators of the selected patients were collected. The enrolled patients were divided into HBS group and non-HBS group based on whether the lowest level of blood calcium less than 2.0 mmol/L after surgery. The difference of general clinical data and perioperative indicators between the two groups were compared. The risk factors of HBS were analyzed by logistic regression analysis. Multiple linear regression method was used to analyze the independent factors affecting the maintenance time of intravenous calcium supplementation, the total amount of calcium supplementation during intravenous calcium supplementation and the highest serum level of potassium within 24 h after surgery. Results A total of 306 patients were included in the study. All patients had low levels of serum calcium after operation. There were 230 patients (75.16%) with the lowest blood calcium＜2.00 mmol/L after PTX (HBS group), and 76(24.84%) cases in the non-HBS group. Predialysis coefficient of serum calcium=(preoperative blood calcium-2.20) mmol/L÷0.01 mmol/L. Logistic regression analysis showed that higher predialysis coefficient of serum calcium (B=-0.063, OR=0.939, 95%CI 0.894-0.987, P=0.013) and lower level of preoperative serum alkaline phosphatase (ALP) (B=0.035, OR=1.033, 95%CI 1.019-1.050, P＜0.001) were independent risk factors for HBS. Multiple linear regression analysis revealed that preoperative blood intact parathyroid hormone (iPTH) (B=0.017, P＜0.001 and B=0.041, P＜0.001), preoperative serum ALP (B=0.052, P＜0.001 and B=0.107, P＜0.001) and preoperative hemoglobin (Hb) (B=-0.453, P=0.041 and B=-1.058, P=0.007) were independent factors affecting the maintenance time of intravenous calcium supplementation and the total amount of calcium supplementation in HBS patients. Preoperative predialysis level of serum potassium (B=0.859, P＜0.001) was the independent influencing factor of the maximum level of serum potassium within 24 hours after surgery. Conclusions Patients with lower levels of preoperative serum calcium and higher levels of serum ALP are prone to HBS after PTX. Postoperative calcium supplementation may need to be strengthened in HBS patients with higher preoperative iPTH and ALP levels and lower preoperative Hb levels. High preoperative basal potassium levels may increase the risk of hyperkalemia after PTX.     

Routine oral calcium and vitamin D supplements for prevention of hypocalcemia after total thyroidectomy

BACKGROUND: The purpose of this study was to evaluate the clinical usefulness of routine oral calcium and vitamin D supplements in the prevention of hypocalcemia after total thyroidectomy. METHODS: Ninety patients who underwent total thyroidectomy were randomly assigned to routinely receive or not receive a supplement containing oral calcium (3 g/d) and vitamin D (1 g/d) for 2 weeks. Hypocalcemic signs and symptoms, serum calcium, and parathyroid hormone (PTH) levels were monitored and compared between the 2 groups. RESULTS: The incidences of symptomatic and laboratory hypocalcemia were significantly lower in the oral calcium/vitamin D group than in the group not receiving the supplement: 3 of 45 patients (7%) versus 11 of 45 (24%) and 6 of 45 (13%) versus 16 of 45 (36%), respectively (P < or = .02). The hypocalcemic symptoms were minimal in the supplement group but more severe in the group not receiving the supplement. Serum calcium levels decreased in both groups after surgery but recovered earlier in the supplement group. No hypercalcemia or PTH inhibition developed in the supplement group. CONCLUSION: Routine administration of a supplement containing oral calcium and vitamin D is effective in reducing the incidence and severity of hypocalcemia after total thyroidectomy.     

不同钙离子浓度透析液对单次血液透析钙平衡的影响

目的观察三种不同钙离子浓度透析液对维持性血液透析患者单次透析过程中血钙的影响,为透析液钙离子浓度的个体化选择提供理论参考。方法选择2014年1月在哈尔滨医科大学附属第一医院血液净化中心接受维持性血液透析治疗的患者80例为研究对象,随机分为3组,根据使用不同钙离子浓度分别为1.25 mmol/L(DCa 1.25组)、1.5 mmol/L(DCa 1.50组)和1.75 mmol/L(DCa 1.75组)的透析液进行单次血液透析治疗,每次透析4 h,3组所用透析液除钙离子浓度不同外,其他透析液主要成分组间无差别。分别检测每组透析前、后及下一次透析前的血肌酐(SCr)、尿素氮(BUN)、血白蛋白(albumin,Alb)、血钙、血磷等生化指标,同时监测单次透析前后患者的血压变化。结果对患者透析前基线数据初步分析结果表明,透析前iPTH水平为(458.7±408.2)ng/L、血钙(2.2±0.2)mmol/L、血磷(2.1±0.6)mmol/L、钙磷乘积(57.4±18.9)。iPTH、血钙、血磷达标率分别为53.8%、46.3%,25.0%;透析患者普遍伴有低钙血症(占48.8%)、高磷血症(占71.3%)和高甲状旁腺素血症(占23.8%)。单次透析治疗结束后的血钙水平分别为DCa 1.25组(2.27±0.20)mmol/L、DCa 1.50组(2.53±0.21)mmol/L、DCa 1.75组(2.51±0.20)mmol/L,组间比较差异有统计学意义(F=12.52,P0.01)。与透析前相比较,3组透析后血钙浓度较透析前均有所增加;协方差分析结果表明,在扣除透析前血钙浓度的影响因素后,DCa 1.25组血钙平均增加量最小。单次透析结束后血钙达标率分别为65.4%(DCa 1.25组)、48.1%(DCa 1.50组)、58.8%(DCa1.75组);透析结束后高钙血症的发生率DCa 1.75组(占41.2%)与DCa 1.50组(占51.9%)明显高于DCa 1.25组(占19.2%)。三种透析液对透析患者的血磷、血压影响差异均无统计学意义(P0.05)。结论单次使用钙离子浓度为1.25 mmol/L的透析液治疗,对透析后血钙浓度的影响最小、血钙达标率最高、高钙血症的发生率最低;与钙离子浓度分别为1.50 mmol/L和1.75 mmol/L透析液比较,钙离子浓度1.25 mmol/L更接近人体生理离子钙浓度。     

Care of patients with hypocalcemia after parathyroidectomy.

In this series of 56 patients diagnosed as having hyperparathyroidism, 37 per cent were found to have multiple gland involvement. The data seem to indicate that routine screening has increased the number of patients operated upon each year. Hypocalcemia in the postoperative period may be manifest by a variety of symptoms, but in general does not seem to affect the postoperative course. The postoperative low point of serum calcium seems directly temporally related to the highest preoperative levels-the higher preoperative levels take longer to reach lowest postoperative levels. Several techniques of management are described.     

Hypomagnesemia associated with hypocalcemia after undetected parathyroidectomy]

A case is reported of hypomagnesaemia and hypocalcaemia occurring postoperatively in a 59-year-old man operated on for hypopharyngeal carcinoma which had extended to the upper extremity of the oesophagus. Surgery consisted in total pharyngolaryngectomy, ganglion curage, jejunal transplant, thyroidectomy and tracheostomy. Total parathyroidectomy was not mentioned in the surgical report. Hypocalcaemia was first noticed on the day following the procedure. On the tenth postoperative day, the patient became agitated and had myoclonia and muscle fasciculations. Nystagmus and orthostatic hypotension also occurred. There were no cardiac signs. Treatment with calcium alone was insufficient. These symptoms only disappeared once magnesium sulphate had been added.