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CSE 2014:夏维波教授解读原发性甲状旁腺功能亢进症诊疗指南

2014-09-09 CSE2014 中华医学会内分泌学会

8月28日下午在第十三次全国内分泌学学术会议(CSE2014)的“骨质疏松和钙磷代谢疾病”专题发言上,北京协和医院内分泌科夏维波教授向与会者介绍了即将发布的新版《原发性甲状旁腺功能亢进症诊疗指南》。 原发性甲状旁腺功能亢进症(简称甲旁亢,PHPT)是一种常见的内分泌疾病。随着医疗技术的进步和生活方式的改变,近20~30年来我国PHPT的疾病谱、临床特征和诊疗方案已经发生较大的变化。200

8月28日下午在第十三次全国内分泌学学术会议(CSE2014)的“骨质疏松和钙磷代谢疾病”专题发言上,北京协和医院内分泌科夏维波教授向与会者介绍了即将发布的新版《原发性甲状旁腺功能亢进症诊疗指南》。

原发性甲状旁腺功能亢进症(简称甲旁亢,PHPT)是一种常见的内分泌疾病。随着医疗技术的进步和生活方式的改变,近20~30年来我国PHPT的疾病谱、临床特征和诊疗方案已经发生较大的变化。2006年中华医学会骨质疏松和骨矿盐疾病分会曾发布过《原发性甲旁亢诊疗指南》(2006版讨论稿),但当时由于条件和篇幅所限该版指南较为简单,对甲旁亢诊疗中的诸多问题并未涵盖。

为进一步适应临床诊疗要求、推动我国PHPT诊疗的规范化和提高诊疗水平,中华医学会骨质疏松和骨矿盐疾病分会和中华医学会内分泌学会代谢性骨病学组联合本领域的专家,历时1年修订了新一版《原发性甲状旁腺功能亢进症诊疗指南》,并于今年8月份在《中华骨质疏松和骨矿盐疾病杂志》上发布。

本指南涵盖了PHPT的流行病学特征、发病机制、临床表现、诊断和鉴别诊断、手术指征、长期药物治疗和随诊、PHPT中的特殊问题等多个方面。并具有以下特点:

一、尽管我国 PHPT的患者逐年增多,但是缺乏准确的流行病学资料,此方面需加强研究。

二、在病因和发病机制中,特别强调了家族性或遗传性PHPT的发病机制和致病基因。说明在PHPT的诊疗中需特别重视该病的遗传发病机制和相关的分子诊断。

三、PHPT的临床表现各异、轻重不一,可以为无症状或一些非特异性症状,或发展为累及骨骼、泌尿系、消化系统的多系统表现,严重者甚至出现高钙危象。

四、实验室检查中除了常规的钙、磷、碱性磷酸酶等指标外,还特别详述了不同的PTHT测定方法的意义和其判断标准。另外指出在 PHPT 中检测 25-(OH)D3 的必要性及其价值。

五、在常规的PHPT定位诊断如超声检查和 MIBI 显像的基础上,本指南还指出 MRI 和 CT 检查对判断病变的位置及其与周围组织的关系有参考价值,而选择性经脉采血测定 PTH 亦可作为参考。术后 PTH 的监测对于在微创和小切口手术中判断手术是否成功有益。

六、本指南提出了九条PHPT的诊断线索,特别强调了PHPT与其他类型甲旁亢的鉴别,以及根据临床表现与高钙血症、骨骼病变和泌尿系结石的鉴别诊断思路。

七、无症状甲旁亢的手术指征在本指南中占了一定篇幅,这是由于近年来无症状 PHPT 的患者渐多,是否手术已经成为内外科医师、以及患者关心的重点。因此本指南结合国际主要学术组织的观点,根据血钙水平、年龄、肾功能和骨骼情况综合判断手术的指证。

八、越来越多的 PHPT 患者暂时不需手术或不能手术,因此甲旁亢的长期随访和抗骨质疏松治疗等已经成为常规。双膦酸盐、雌激素、SERMS和拟钙制剂可做为长期药物治疗的选择。

九、高钙危象是甲旁亢的急症,及时合理的处理对于挽救患者生命,为 PHPT的手术治疗或其它治疗会赢得机会。临床上需重视血钙大于3.5mmol/L的患者,予以急诊处理、及时扩容、促尿钙排泄、及时使用双膦酸盐类药物或降钙素类药物,甚至血透或腹透治疗。

十、本指南中特别关注了 PHPT 中的四个特殊问题,如正常血钙的甲旁亢、无症状甲旁亢、家族性或综合征性的甲旁亢、以及合并佝偻病 / 骨软化症的 PHPT。提示在 PHPT 的临床诊疗中需要重视以上情况,予以相应的鉴别诊断和处理。

总之,本版《原发性甲状旁腺功能亢进症诊疗指南》 是在原版指南经典内容的基础上,结合目前国内外的临床和研究进展,针对临床实际问题提出指导性意见或建议,综合了国内多家医院的本领域专家的意见,在多轮修订的基础上完成的。期望本指南能对我国 PHPT的临床治疗实践活动起到指引作用。


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    2014-11-02 仁医06
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