Эффективность терапевтического и хирургического лечения вторичного гиперпаратиреоза у пациентов, получающих заместительную почечную терапию программным гемодиализом

Выводы:

1. Пациенты с вторичным гиперпаратиреозом, рефрактерным к терапии альфакальцидолом, характеризуются как умеренно выраженным (23,6%), так и тяжелым течением заболевания (76,4%). При тяжелой форме вторичного гиперпаратиреоза степень субпериостальной резорбции коррелирует со снижением минеральной плотности костей и уровнем иПТГа уровень иПТГ — с маркерами костного метаболизма и объемом околощитовидных желез. Пациенты, получающие лечение гемодиализом более 10 лет, и лица женского пола представляют группу наибольшего риска по осложнениям вторичного гиперпаратиреоза.

2. Выявлена высокая чувствительность ультразвукового исследования (94,7%) при сравнении со сцинтиграфией (41,3%) и 100% специфичность каждого метода в визуализации околощитовидных желез у диализных пациентов с тяжелым течением вторичного гиперпаратиреоза. Обосновано использование ультразвукового исследования, как базового метода визуализации перед первичным хирургическим вмешательством.

3. Распространенность рецидива вторичного гиперпаратиреоза после паратиреоидэктомии составила 55,9%. У 25% пациентов рецидив наступает в течение года, у 50% - через 3,6 лет. Высокая частота и ранний рецидив связаны с недостаточным объемом операции (удаление менее 4-х желез) в сравнении с тотальной паратиреоидэктомией. Безрецидивная выживаемость не зависит от исходных уровней иПТГ, ЩФ и длительности гемодиализаона выше у пациентов с диффузной и диффузно-узловой гиперплазией (медиана безрецидивной выживаемости — 3 года, рецидив у 47%), по сравнению с узловой гиперплазией и аденомой желез (медиана — 1 год, рецидив у 85%).

4. Предоперационное однократное назначение больших доз активных метаболитов витамина В не компенсирует послеоперационную гипокальциемию и не влечет за собой риск гиперкальциемии. Интраоперационное определение уровня иПТГ при вторичном гиперпаратиреозе нецелесообразно, так как не отражает радикальность проведенной операции. В послеоперационном периоде 96,2% пациентов нуждались в препаратах кальция и витамина О, дозы которых, коррелировали с уровнем щелочной фосфатазы. Пациенты с персистенцией заболевания нуждались в более низких дозах кальция и витамина О.

5. При тяжелом течении вторичного гиперпаратиреоза наиболее эффективна тотальная паратиреоидэктомия с аутотрансплантацией, позволяющая существенно снизить уровни иПТГ, фосфора, кальция, показателей костного метаболизма и повысить минеральную плотность костей.

6. На фоне терапии цинакалцетом отмечено снижение иПТГ более чем на 30% у 88% пациентов, фосфорно-кальциевого произведения более чем на 32% у 97,6% больных с вторичным гиперпаратиреозом, а также сохранение минеральной плотности костей на исходном уровне. В связи с этим, применение цинакалцета может стать альтернативой паратиреоидэктомии при наличии противопоказаний к хирургическому лечению, рецидиве или отказе пациента от операции. При умеренно выраженном вторичном гиперпаратиреозе назначение цинакалцета может быть как самостоятельным методом лечения, так и входить в комплексную терапию совместно с активными метаболитами витамина О.

7. Выявлена положительная корреляция между дозой цинакалцета и степенью снижения фосфорно-кальциевого произведения при умеренно выраженном гиперпаратиреозе. Чем выше исходный иПТГ, тем значительнее гипокальциемический эффект препарата. Среднесуточная доза цинакалцета зависит от тяжести заболевания: при умеренной выраженности ВГПТ она составила 61,8 мг, при тяжелой форме — 96,3 мг. Достоверного влияния цинакалцета на объем околощитовидных желез не обнаружено.

Практические рекомендации:

1. У пациентов с вторичным гиперпаратиреозом, рефрактерным к терапии активными метаболитами витамина Б (или их аналогами), наряду с рутинным определением иПТГ, кальция (скорректированного!), фосфора и щелочной фосфатазы, рекомендовано измерение минеральной плотности средней трети лучевой кости, проведение ультразвукового исследования околощитовидных желез, рентгенологического исследования для диагностики сосудистой, мягкотканой кальцификации и кальцификации внутренних органов.

2. У гемодиализных пациентов с вторичным гиперпаратиреозом перед хирургическим вмешательством в качестве базового метода топической диагностики околощитовидных желез рекомендовано проведение ультразвукового исследования (при высокой квалификации специалиста), в качестве дополнительного — сцинтиграфии.

3. При выявлении пациентов с вторичным гиперпаратиреозом, рефрактерным к стандартной терапии активными метаболитами витамина Б (или имеющих противопоказания к их назначению в связи с гиперкальциемией и/или гиперфосфатемией), необходимо своевременное назначение кальцимиметиков или проведение паратиреоидэктомии.

4. После проведения паратиреоидэктомии происходит активное восстановление (особенно в течение первого месяца) минерализации костей, следовательно, необходим контроль уровня сывороточного кальция через 1,3,7,14,30 дней (далее по необходимости), для коррекции гипокальциемии. В течение первого месяца после паратиреоидэктомии среднесуточная доза элементарного кальция может составлять 3−4гактивных метаболитов витамина Б — 2−4 мкгчерез 1 год — элементарного кальция 2,0гактивных метаболитов витамина Б — 0,5−0,1 мкг.

5. Степень повышения активности щелочной фосфатазы в послеоперационном периоде может быть надежным индикатором снижения сывороточного кальция и потребности пациентов в больших дозах препаратов кальция и активных метаболитов витамина Т). Динамика щелочной фосфатазы может быть предиктором потребности пациентов в препаратах кальция и активных метаболитах витамина Б.

6. Лечение цинакалцетом целесообразно у пациентов с умеренно выраженном вторичным гиперпаратиреозом, при гиперплазии менее четырех околощитовидных желез, рецидиве после паратиреоидэктомии, отсутствии абсолютных показаний к паратиреоидэктомиитакже при тяжелом гиперпаратиреозе и наличии противопоказаний к проведению хирургического лечения. Лечение рекомендовано проводить с ежемесячной титрацией дозы до достижения рекомендуемых значений иПТГ, не допуская развития гипокальциемии.

7. У пациентов с ожидаемой длительной продолжительностью гемодиализа, тяжелой ренальной остеодистрофией, резистентных к терапии или непереносящих увеличенные дозы цинакалцета, также не соблюдающих рекомендаций врачей, методом выбора должна стать паратиреоидэктомия.

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