不同剂量左旋肉毒碱对难治性继发性甲状旁腺功能亢进患者心功能的影响

摘要

目的 观察不同剂量左旋肉毒碱对难治性继发性甲状旁腺功能亢进(R-SHPT)患者心功能的影响.方法 选取2013-2016年在航天中心医院就诊拟行甲状旁腺切除术(PTX)治疗的R-SHPT患者43例,采用随机数字表法将患者分为左旋肉毒碱大剂量治疗组(高剂量组,n =22),左旋肉毒碱常规剂量治疗组(常规剂量组,n=21).高剂量组给予左旋肉毒碱2 g加入0.9％氯化钠溶液20 ml静脉注射,1次/d,连续应用2周,使用总量为28 g.常规剂量组在透析结束时予以左旋肉毒碱1g加入0.9％氯化钠溶液20 ml静脉注射,连续应用2周,使用总量为6 g.检测治疗前后脑钠肽(BNP)、肌钙蛋白Ⅰ(cTnI)水平,并于治疗前后测量左心室舒张末期内径(LVEDD)、室间隔舒张末厚度(IVSdT)、左心室后壁舒张末厚度(LVPWdT)、左心室射血分数(LVEF)、舒张早期和舒张晚期左房室瓣口最大血流速度之比(E/A)等指标.结果 两组治疗前BNP、cTnI、LVEDD、IVSdT、LVPWdT、LVEF、E/A比较,差异均无统计学意义(P＞0.05);两组治疗后LVEF、E/A比较,差异无统计学意义(P＞0.05);常规剂量组治疗后BNP、cTnI、LVEDD、IVSdT、LVPWdT高于高剂量组(P＜0.05).常规剂量组治疗前、后LVEF、E/A比较,差异均无统计学意义(P＞0.05);常规剂量组治疗后BNP、cTnI、LVEDD、IVSdT、LVPWdT低于治疗前(P＜0.05).高剂量组治疗后BNP、cTnI、LVEDD、IVSdT、LVPWdT低于治疗前,LVEF、E/A高于治疗前(P＜0.05).治疗后高剂量组手术回归率为63.6％ (14/22),高于常规剂量组的28.6％ (6/21) (x2=5.31,P=0.021).结论 高剂量左旋肉毒碱治疗R-SHPT患者促进心脏功能恢复、改善左心室重构效果更佳,能为患者行PTX治疗创造更好时机.%Objective To investigate the effect of different doses of L-carnitine on the cardiac function in patients with refractory secondary hyperparathyroidism (R-SHPT).Methods We enrolled 43 cases of R-SHPT who needed to undergo the selective parathyroidectomy (PTX) in Aerospace Center Hospital between 2013 and 2016 and divided them into high-dose group (n =22) and conventional-dose group (n =21) by the random number table.The high-dose group received 2-week intravenous injection of 2 g L-carnitine diluted in 20 ml 0.9％ sodium chloride solution,once daily,the total amount of L-carnitine used was 28 g.The conventional-dose group received intravenous injection of 1 g L-carnitine diluted in 20 ml 0.9％ sodium chloride solution at the end of every hemodialysis (three times a week) for two weeks,and the total amount of L-carnitine used was 6 g.The brain natriuretic peptide (BNP),cardiac troponin Ⅰ (cTnI) and left ventricular end-diastolic dimension (LVEDD),interventricular septal thickness at end-diastole (IVSdT),left ventricular posterior wall thickness at end-diastole (LVPWdT),left ventricular ejection fraction (LVEF),and mitral ratio of peak early to late diastolic filling velocity (E/A) were measured in all the patients before and after treatment.Results Before treatment,the values of BNP,cTnI,LVEDD,IVSdT,LVPWdT,LVEF and E/A did not differ significantly between the two groups (P ＞ 0.05).After treatment,the values of LVEF and E/A in the two groups were similar (P ＞ 0.05),but the values of BNP,cTnI,LVEDD,IVSdT and LVPWdT in the conventional-dose group were much higher than those in the high-dose group (P ＜ 0.05);the values of LVEF and E/A in the conventional-dose group did not change significantly as compared with those measured before treatment (P ＞ 0.05),while those of BNP,cTnI,LVEDD,IVSdT and LVPWdT were obviously lower compared with those measured before treatment (P ＜ 0.05);the values of BNP,cTnI,LVEDD,IVSdT and LVPWdT were much lower and those of LVEF and E/A were much higher in the high-dose group compared with those measured before treatment (P ＜ 0.05);the high -dose group had higher proportion of patients meeting the requirements of PTX than the conventional-dose group [63.6％ (14/22) vs.28.6％ (6/21),x2 =5.31,P =0.021].Conclusion High dose of L-carnitine treatment for patients with R-SHPT is better in the aspects of promoting heart function recovery and improving left ventricular remodeling,which could create better opportunity for the patient who would receive PTX.