Efficacy of Ultrasound-Guided Percutaneous Ethanol Injection Therapy in Hemodialysis Patients with Secondary Hyperparathyroidism

血液透析患者副甲狀腺腫瘤的手提式超音波診斷和經皮酒精注射療法之效果

許順傑(Sun-Chieh Hsu) ； 蔡明哲(Ming-Che Tsai) ； 阮明昆(Mirng-Kuhn Ruaan) ； 黃建鐘(Jeng-Jong Huang)

《Acta Nephrologica》 17卷1期 (2003/03) Pp. 25-32

摘要

一血液透析診所接受規則血液透析治療的全部171位尿毒症患者，於透析過程中接受手提式超音波篩檢，發現44位（26%）患者有副甲狀腺腫瘤（parathyroid tumor）存在，且大多數其血清完整型副甲狀腺素（i-PTH）值＞250 pg/ml。一共有45位（26%）患者的血清i-PTH值＞250 pg/ml，其中的39位（87%）發現有副甲狀腺腫瘤；而血清i-PTH值呈250 pg/ml，且超音波發現有副甲狀腺腫瘤的22位血液透析患者，同意接受經皮酒精注射治療（percuantous ethanol injection therapy, PEIT）。PEIT的治療效果，於接受注射後0星期（942±493 pg/ml）、4星期、6個月和12個月後，發現i-PTH值有明顯下降；但24個月後，大多數患者復發（950±534 pg/ml）。此外，也發現台灣人的內頸靜脈（internal jugular rein）位於總頸動脈（common carotid artery）的外側和外前側位置者，在右側頸部為88.3%，而左側頸部為83.7%，明顯高於外國人所佔的比例（72%）。

關鍵字

末期腎病 ； 血液透析 ； 副甲狀腺高能症 ； 超音波 ； 酒精注射 ； 內頸靜脈

並列摘要

The presence of ultrasound detectable parathyroid glands in secondary hyperparathyroidism is usually a reflection of poor response to calcitriol treatment and usually indicates an eligible candidate for percutaneous ethanol injection therapy (PEIT). However, the prevalence of ultrasound detectable parathyroid glands in hemodialysis (HD) patients has rarely been surveyed in Taiwan. Also, ideal targets of injection and optimum amounts of ethanol for PEIT have yet to be clearly ascertained. A prospective study was conducted using a hand-carried ultrasound device (SonoSite 180) to survey the prevalence of parathyroid tumor and space- relationship of carotid artery and internal jugular vein in 171 chronic HD patients in Taiwan. These patients with detectable parathyroid glands and secondary hyperparathyroidism underwent PEIT for all detectable glands, regardless of size, which were then destroyed by injecting absolute ethanol in amount equal to the volume of the parathyroid gland. The prevalence rate of ultrasound detectable parathyroid gland is 26% (44/ 171), and the lowest serum level of intact parathyroid hormone (i-PTH) for the detection of parathyroid glands is 107 pg/mi. Linear correlation was noted between the volume of detectable parathyroid glands and serum i-PTH levels (r0.279, P＜0.0001). The conventional space-relationship (i.e., internal jugular vein mainly lay anteriolateral and lateral to common carotid artery) was noted in 88.3% and 83.7% of patients (right and left neck, respectively). Among 45 patients with an i-PTH level ≧ 250 pg/ml, 39 (87%) patients had ultrasound detectable parathyroid glands. Twenty-two of those patients agreed to aggressive PEIT and were followed up for at least two years. The mean i-PTH level to after PEIT decreased significantly from 942±493 pg/mi to 495±368 pg/mi (4 weeks, P＜0.0001), 616±426 pg/mi (6 months, P＜0.0001) and 812±583 pg/mi (12 months, P=0.01), but elevated to 950±534 pg/ml (24 months, P=0.8). After PEIT, two cases had symptoms of transient hoarseness from recurrent laryngeal nerve palsy, and one suffered transient respiratory failure related to neck hematoma and upper airway obstruction. Marked adhesion with adjacent tissue and residual parathyroid gland scattered among fibrotic parathyroid glands were found in three cases receiving parathyroidectomy for unsuccessful PEIT. In brief hand-carried ultrasound is a simple and effective tool for surveying anatomical variation in internal jugular veins and for detecting the presence of hyperplastic parathyroid glands, which are prevalent in Taiwanese on HD at a rate of 26%. Aggressive PEIT showed good short-term effects, but follow-up after 2 years indicated reduced efficacy. In addition, the precise targets of injection and optimum doses of ethanol for PEIT require further study.

並列關鍵字

End-stage renal disease ； hemodialysis ； hyperparathyroidism ； ultrasound ； ethanol injection ； internal jugular vein