原发性甲状旁腺功能亢进症术后甲状旁腺激素升高9例并文献复习

doi:10.19723/j.issn.1671-167X.2021.03.022

Abstract

Abstract:

Objective: To summarize and analyze the clinical characteristics of primary hyperpara-thyroidism (PHPT) with normocalcemic parathormone elevation (NPE) after surgical treatment, so as to improve the therapeutic ability and standardized post-operative follow-up of PHPT patients. Methods: Nine patients who were diagnosed with PHPT in the Department of Endocrinology of China-Japan Friendship Hospital from August 2017 to November 2019 were selected as the subjects. They all developed NPE within 6 months after surgical treatment. The clinical features and outcomes were collected and analyzed retrospectively, in addition, the related literature was reviewed. Results: Clinical features: among the 9 patients, 6 were middle-aged and elderly females and 3 were male. The main clinical manifestations were bone pain, kidney stones, nausea and fatigue except for one case of asymptomatic PHPT. Pre-operative examination showed high serum calcium [(3.33±0.48) mmol/L], low serum phosphorus [0.76 (0.74,0.78) mmol/L], high 24-hour urinary calcium [8.1(7.8,12.0) mmol/24 h], obviously elevated intact PTH [(546.1±257.7) ng/L], vitamin D deficiency [25-hydroxyvitamin D₃ (21.0±5.7) nmol/L]. Serum levels of bone alkaline phosphatase [7 patients 41.3(38.6,68.4) μg/L,2 patients >90 μg/L] and N-terminal midcourse osteocalcin (>71.4 μg/L) were significantly elevated. The estimated glomerular filtration rate decreased in 2 patients. Imaging examination: 7 patients had osteoporosis. Renal calculi were found in 3 patients by renal ultrasound. Imaging examination of parathyroid glands found definite lesions in all the patients, including 2 cases of multiple lesions and 7 cases of single lesions. Treatment and outcome: two patients underwent parathyroidectomy, while other patients were treated with microwave thermal ablation. PTH increased 1 month after therapy [(255.0±101.4) ng/L], and no recurrent lesions were found by parathyroid ultrasound. After combined treatment with cal-cium and vitamin D for six months, PTH decreased significantly and the level of serum calcium remained normal at anytime during the follow-up period. Conclusion: The occurrence of postoperative NPE may be related to the higher pre-operative PTH, vitamin D deficiency and lower creatinine clearance. However, NPE may not predict recurrent hyperthyroidism or incomplete parathyroidectomy. Adequate calcium and vitamin D supplementation after surgery seems to be beneficial for patients with NPE. Post-operative follow-up of PHPT patients should be standardized to prevent and treat post-operative NPE.

Key words: Primary hyperparathyroidism, Parathyroid hormone, Vitamin D

CLC Number:

R582.1

XIE Ling-ding, WANG Na, ZHANG Jin-ping, WANG Xin, CHEN Xiao-ping, ZHANG Bo, BU Shi. Normocalcemic with elevated post-operative parathormone in primary hyperpara-thyroidism: 9 case reports and literature review[J].Journal of Peking University (Health Sciences), 2021, 53(3): 573-579.

Figures/Tables 3

Table 1

Clinical characteristics and laboratory examinations of nine patients with PHPT before operation"

Item	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6	Case 7	Case 8	Case 9	Reference (range)
Gender	Female	Female	Female	Female	Male	Female	Male	Female	Male
Age/years	54	55	76	56	55	54	59	58	31
Body mass index/(kg/m²)	18.8	37.1	28.5	22.3	24.5	26.4	25.4	23.8	21.3
Ostealgia	Yes	No	No	Yes	Yes	Yes	Yes	No	Yes
Fatigue	Yes	No	Yes	Yes	Yes	Yes	Yes	No	Yes
Nausea	Yes	No	Yes	Yes	Yes	Yes	Yes	No	Yes
Fracture	No	No	No	No	No	No	No	No	No
Kidney stone	Yes	No	No	Yes	Yes	No	No	Yes	Yes
25OHD₃/(nmol/L)	27.4	17.8	19.5	31.3	11.5	20.3	22.4	19.8	19.0	Lack<25, insufficient 25-74, enough 75-250
Ca/(mmol/L)	3.51	2.96	2.80	3.06	3.43	3.32	3.41	3.09	4.46	2.00-2.75
P/(mmol/L)	0.75	0.74	0.54	0.93	0.76	0.74	0.78	0.78	0.76	0.81-1.78
ALP/(U/L)	295	109	176	112	207	189	207	168	721	40-150
iPTH/(ng/L)	589.4	255.5	571.8	358.6	669.2	522.5	485.6	330.4	1 131.8	12-88
24 h UCa/(mmol/24 h)	14.9	8.1	7.8	7.6	8.0	8.6	9.1	7.7	31	2.7-7.5
Bone-derived alkaline phosphatase/(μg/L)	>90	41.3	40.5	38.6	79.4	60.5	68.4	38.2	>90	8.5-17.9
N-MID OC/(μg/L)	>71.4	>71.4	>71.4	>71.4	>71.4	>71.4	>71.4	>71.4	>71.4	11.7-55.2
TRACP/(U/L)	6.56	3.01	3.97	4.10	2.56	4.23	4.35	3.42	6.42	2.05-4.53
β-CTX/(μg/L)	1.25	1.07	0.80	0.90	0.28	0.82	0.94	0.56	8.56	0.128-1.292
eGFR [mL/(min·1.73m²)]	81.6	111.3	44.4	100.4	111.4	90.3	92.4	88.6	56.4	80-120
Albumin/(g/L)	40.0	41.2	39.6	47.6	42.7	41.5	40.6	40.8	38.5	35.0-55.0
Bone mineral density
T_L2-4	-3.9	-2.7	-2.6	-2.9	-0.8	-2.7	-2.9	-2.1	-0.1(Z)
T_{femoral neck}	-3.7	-2.6	-1.7	-2.6	-1.8	-2.8	-2.4	-2.0	-3.4(Z)
T_{total hip}	-3.5	-2.4	-1.5	-2.7	-1.8	-2.6	-2.5	-2.1	-3.0(Z)
Parathyroid ultrasonography	Single lesion: 2.8 cm× 2.7 cm	Lesion 1: 1.1 cm× 0.6 cm; Lesion 2: 1.1 cm× 0.8 cm	Single lesion: 2.1 cm× 1.2 cm	Single lesion: 2.0 cm× 0.5 cm	Lesion 1: 1.3 cm× 0.8 cm; Lesion 2: 1.5 cm× 0.8 cm; Lesion 3: 1.8 cm× 1.2 cm	Single Lesion: 2.4 cm× 2.5 cm	Single lesion: 2.8 cm× 1.5 cm	Single lesion: 2.1 cm× 0.9 cm	Single lesion: 2.6 cm× 2.1 cm
Technetium-99m sestamibi and computed tomography	Single lesion	Two lesions	Single lesion	Single lesion	Three lesions	Single lesion	Single lesion	Single lesion	Single lesion

Table 1

Figure 1

Table 2

Post-operative treatment of the nine patients"

Items	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6	Case 7	Case 8	Case 9
Post-operative 1-month therapy	Rocaltrol 0.25 μg, 2/d; Calcium carbonate 1.5 g, 2/d	Rocaltrol 0.25 μg, 2/d; Calcium carbonate 1.5 g, 2/d; VitD₃ 800 IU, 1/d	Rocaltrol 0.25 μg, 2/d	Rocaltrol 0.25 μg, 2/d; Calcium carbonate 0.75 g, 2/d	Rocaltrol 0.25 μg, 2/d; Calcium carbonate 0.75 g, 2/d	Rocaltrol 0.25 μg, 2/d; Calcium carbonate 0.75 g, 1/d	Rocaltrol 0.25 μg, 2/d; Calcium carbonate 0.75 g, 1/d	Rocaltrol 0.25 μg, 1/d; Calcium carbonate 0.75 g, 2/d	Rocaltrol 0.25 μg, 3/d; Calcium carbonate 0.75 g, 3/d; VitD₃ 2 000 IU, 1/d
Post-operative 3-month therapy	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg,2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 1.5 g, 2/d; Rocaltrol 0.25 μg,3/d;VitD₃ 2 000 IU,1/d
Post-operative 6-month therapy	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg,2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 750 mg, 2/d; Rocaltrol 0.25 μg, 2/d; VitD₃ 2 000 IU,1/d	Calcium carbonate 1.5 g, 2/d; Rocaltrol 0.25 μg, 3/d; VitD₃ 2 000 IU,1/d

Table 2

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