DTC患者术后继发性甲状旁腺功能减退对骨代谢的影响及其健康管理

Secondary hypoparathyroidism after DTC effects on bone metabolism and health management

    摘要
  • 摘要:
    目的 探讨分化型甲状腺癌（DTC）患者术后继发性甲状旁腺功能减退对骨代谢的影响及其健康管理。
    方法 选取2017年1月至2018年5月行甲状腺全切或次全切术的DTC患者60例。其中30例患者术后出现继发性甲状旁腺功能减退合并低血钙（甲旁减组）；另外30例患者术后甲状旁腺功能正常（对照组）。2组患者分别于术后1个月、6个月以及12个月常规检查甲状旁腺素（PTH）、维生素D、血清钙、血清磷、碱性磷酸酶（ALP）、游离三碘甲状腺原氨酸（FT3）、游离甲状腺素（FT4）、促甲状腺激素（TSH），并进行双能X线骨密度（BMD）的测定与健康管理相关指标检测。甲旁减组的PTH、维生素D、血清钙、血清磷、ALP采用配对t检验；甲旁减组及对照组之间的组间比较（FT3、FT4、TSH及L2～L4、股骨颈、股骨粗隆 、华氏三角的BMD值）采用独立样本t检验。
    结果 ①甲旁减组患者在甲状腺全切或次全切术后1个月与术后6个月、术后6个月与术后12个月的PTH、血清钙、血清磷的比较，差异有统计学意义（PTH：t=−2.467、−2.753 ，P=0.021、0.033；血清钙：t=−2.941、−3.652，P=0.007、0.002；血清磷：t=4.550、4.167，P=0.000、0.004)，维生素D、ALP的比较，差异无统计学意义（维生素D：t=2.153、1.965，P=0.062、0.074；ALP：t=1.970、1.672，P=0.061、0.066）；②术后12个月时，甲旁减组患者股骨颈的BMD下降，与对照组比较，差异有统计学意义（t=1.08，P＝0.002）；术后1个月、6个月及12个月，甲旁减组患者与对照组比较，甲状腺功能水平（FT3、FT4、TSH）及腰椎（L2~L4）、华氏三角、股骨粗隆的BMD差异均无统计学意义（t=0.60~1.82，均P＞0.05）；③随着钙剂及维生素D的服用，甲旁减组患者低血钙的临床症状明显改善，至术后12个月时，以手足麻木、肌肉痉挛为主要表现的患者占6.67%，但服用钙剂及维生素D的依从性下降至80%。
    结论 ①甲旁减组患者股骨颈的BMD在术后12个月时出现降低，腰椎（L2～L4）、华氏三角、股骨粗隆的BMD影响不显著；②DTC术后合并甲旁减组患者多有低血钙的临床表现，在给予钙剂和活性维生素D治疗后症状明显缓解，但患者服药依从性逐渐下降，因此应进一步加强健康教育和管理。

     

    Abstract:
    Objective To investigate the effects of secondary hypoparathyroidism on bone metabolism and health management in patients with differentiated thyroid carcinoma(DTC).
    Methods Sixty patients with DTC who underwent total or subtotal thyroidectomy from January 2017 to May 2018 were enrolled. Among them, 30 patients had secondary hypoparathyroidism and hypocalcemia(hypothyroidism), while the other 30 patients had normal parathyroid function(control group). These two groups of patients were routinely examined for their parathyroid hormone(PTH), vitamin D, serum calcium, serum phosphorus, alkaline phosphatase(ALP), free triiodothyronine(FT3), free thyroxine(FT4), and thyroid stimulating hormone(TSH) at 1, 6, and 12 months after surgery and to determine dual-energy X-ray bone mineral density(BMD) and health-management-related indicators. PTH, vitamin D, serum calcium, serum phosphorus, and ALP in the parathyroid group were tested by conducting a paired t-test, and the indicators for the parathyroid and control groups(FT3, FT4, TSH, and L2 to L4, neck of femoral, femur trochanter, Ward’s triangle BMD value) were compared by conducting an independent sample t-test.
    Results 1. A statistically significant difference in PTH, serum calcium, and serum phosphorus was observed among patients with hypothyroidism at 1 and 6 months after surgery, 6 months after surgery, and 12 months after surgery(PTH: t=–2.467, –2.753, P=0.021, 0.033; serum calcium: t=–2.941, –3.652, P=0.007, 0.002; serum phosphorus: t=4.550, 4.167, P=0.000, 0.004), but no significant difference was observed in terms of vitamin D and ALP(vitamin D: t=2.153, 1.965, P=0.062, 0.074; ALP: t=1.970, 1.672, P=0.061, 0.066); 2. At 12 months after surgery, the BMD of the neck of femoral decreased in the parathyroid group, showing a statistically significant difference from the control group(t=1.08, P=0.002). At 1, 6, and 12 months after surgery, the patients with hypothyroidism showed no significant differences from the control group in terms of thyroid function level(FT3, FT4, and TSH), lumbar vertebrae(L2 to L4), Ward’s triangle, and femur trochanter BMD(t=0.606 to 1.82, all P>0.05). 3. After taking calcium and vitamin D, the clinical symptoms of hypocalcemia in patients with hypothyroidism were significantly improved. Twelve months after surgery, hand and foot numbness and muscle spasms accounted for 6.67% of the symptoms, and after taking calcium and vitamin D, the medication compliance of the patients decreased to 80%.
    Conclusions 1.The BMD of neck of femoral in patients with hypothyroidism decreased at 12 months after surgery, and the BMD of lumbar vertebrae(L2~L4), Ward’s triangle and femur trochanter was not significant; 2.Most patients with parathyroid hypofunction showed clinical manifestations of hypocalcemia after DTC, and their symptoms were significantly relieved after the calcium and active vitamin D treatment. However, the medication compliance of these patients gradually declined. Therefore, health education and management should be further strengthened.

     

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