nidНефрология и диализNephrology and Dialysis1680-44222618-9801Российское диализное общество10.28996/2618-9801-2024-1-23-34nid-142Research ArticleОБЗОРЫ И ЛЕКЦИИREVIEWS AND LECTURESВторичный гиперпаратиреоз. Специфика, сложности, особенности лечения. Обзор литературы. Часть II - Хирургическое лечениеSecondary hyperparathyroidism. Specific features, complexity, features of treatment. Literature review. Part II - Surgical treatmentДолидзеД. Д.DolidzeD. D.ddolidzed@mail.ruШабунинА. В.ShabuninA. V.glavbotk@yandex.ruШутовЕ. В.ShutovE. V.shutov_e_v@mail.ruЗахароваЕ. В.ZakharovaE. V.helena.zakharova@gmail.comСлепуховаД. В.SlepukhovaD. V.dia.slepuhova@yandex.ruКованцевС. Д.CovantsevS. D.kovantsev.s.d@gmail.comБольшаковС. А.BolshakovS. A.bolshakoff123@yandex.ruГБУЗ “Городская клиническая больница имени С.П. Боткина” Департамента здравоохранения города Москвы; ФГБОУ ДПО “Российская медицинская академия непрерывного профессионального образования” Министерства здравоохранения Российской ФедерацииРоссияGBUZ «S.P. Botkin City Clinical Hospital» Department of Health of the City of Moscow; FGBOU DPO Russian Medical Academy of Continuing Professional Education of the Ministry of Health of the Russian FederationRussian FederationГБУЗ “Городская клиническая больница имени С.П. Боткина” Департамента здравоохранения города Москвы; ФГБОУ ДПО “Российская медицинская академия непрерывного профессионального образования” Министерства здравоохранения Российской Федерации; афедра нефрологии ФПДО ФГБУ ФГОУ «Московский государственный медико-стоматологический университет им. А.И. Евдокимова»РоссияGBUZ «S.P. Botkin City Clinical Hospital» Department of Health of the City of Moscow; FGBOU DPO Russian Medical Academy of Continuing Professional Education of the Ministry of Health of the Russian Federation; A.I. Evdokimov Moscow State University of Medicine and DentistryRussian FederationГБУЗ “Городская клиническая больница имени С.П. Боткина” Департамента здравоохранения города МосквыРоссияGBUZ «S.P. Botkin City Clinical Hospital» Department of Health of the City of MoscowRussian Federation2024210620242612334Copyright © Долидзе Д.Д., Шабунин А.В., Шутов Е.В., Захарова Е.В., Слепухова Д.В., Кованцев С.Д., Большаков С.А., 20242024Долидзе Д.Д., Шабунин А.В., Шутов Е.В., Захарова Е.В., Слепухова Д.В., Кованцев С.Д., Большаков С.А.Dolidze D.D., Shabunin A.V., Shutov E.V., Zakharova E.V., Slepukhova D.V., Covantsev S.D., Bolshakov S.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://journal.nephro.ru/jour/article/view/142

Вторичный гиперпаратиреоз - частое и серьезное осложнение хронической болезни почек (ХБП) как у пациентов на диализе, так в преддиализной стадии. При прогрессировании хронической болезни почек уменьшение количества действующих нефронов и интерстициальный фиброз вызывают каскад осложнений, включающий дефицит витамина D, гиперфосфатемию, снижение всасывания кальция и увеличение продукции паратиреоидного гормона. Непрерывно совершенствуется лекарственная терапия, направленная на различные звенья патогенеза гиперпаратиреоза (ГПТ). С появлением группы кальцимиметиков резко снизилось количество больных с неконтролируемым ГПТ. Однако при формировании резистентности ГПТ к медикаментозному лечению у данной категории больных появляется необходимость в его хирургической коррекции. По различным данным, паратиреоидэктомия помогает улучшить минеральную плотность костей, снизить риски переломов и повысить качество жизни и выживаемость пациентов на диализе. Обзор посвящен наиболее актуальным и спорным вопросам оперативного лечения вторичного ГПТ. Представлены показания к хирургической коррекции согласно различным клиническим и национальным рекомендациям. Затрагиваются вопросы дооперационной топической диагностики околощитовидных желез и ее влияния на исходы операции. Проведен сравнительный анализ чувствительности и специфичности различных методов визуализации (ультразвуковое исследование, сцинтиграфия, компьютерная томография), в режиме «моно»-метода и при их комбинации. Освещаются спорные вопросы выбора оптимального объема операции. В отечественной и зарубежной литературе нет единого мнения о том, какую операцию необходимо выполнять данной коморбидной группе больных. В данном обзоре представлена информация о современных объемах хирургического лечения, их преимуществах и недостатках. Как правило, выполнение субтотальной паратиреоидэктомии сопряжено с более высокими рисками развития рецидива заболевания, тогда как при выполнении тотальной паратиреоидэктомии чаще наблюдается тяжелая гипокальциемия. Выбор объема оперативного вмешательства рассматривается в аспекте вероятной частоты рецидива ГПТ, прогнозируемой продолжительности жизни и возможной трансплантацией почки. Описаны возможные послеоперационные осложнения. Таким образом остаются актуальными проблемы обследования и лечения больных ХБП 5 стадии и вторичным ГПТ.

Secondary hyperparathyroidism is a common and serious complication of chronic kidney disease (CKD) in both dialysis and predialysis patients. Progression of chronic kidney disease with a loss of active nephrons and interstitial fibrosis lead to a cascade of complications, including vitamin D deficiency, hyperphosphatemia, decreased calcium absorption, and increased production of parathyroid hormone. Advance development of drug therapy, targeting various components of hyperparathyroidism (HPT) pathogenesis, and in particular, the advent of calcimimetics, significantly reduced the number of patients with uncontrolled HPT. However, a substantial proportion of patients are drug-resistant, and therefore need surgical correction of HPT. Parathyroidectomy has been widely reported to improve bone mineral density, reduce the risk of fractures, and improve the quality of life and survival of dialysis patients. The review is devoted to the most pressing and controversial issues of surgical treatment of secondary HPT. The topics addressed in the review are as follows: 1) indications for surgical correction are presented according to various clinical National guidelines; 2) issues of preoperative topical localization of the parathyroid glands and its influence on the surgery outcomes; 3) comparative analysis of the sensitivity and specificity of various imaging technics (ultrasound, scintigraphy, computed tomography) alone or in combination; 4) controversial issues of choosing the most optimal extent of surgery. Current available literature does not provide consensus about optimal for this highly comorbid group of patients. This review provides information on modern surgical treatment options, their advantages and disadvantages. As a rule, subtotal parathyroidectomy is associated with a higher risk of disease relapse, while severe hypocalcemia more often observed after a total parathyroidectomy. The choice of the extent of surgical intervention is considered in view of the HPT recurrence rate, predicted life expectancy, and perspective of kidney transplantation. Possible postoperative complications are described. Thus, the problems of examining and treating patients with CKD stage 5 and secondary HPT remain relevant.

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The authors declare that there are no conflicts of interest present.