The Ultrasound Features Of Hemodialysis Patients With Secondary Hyperparathyroidism

Hypocalcemia,phosphate retention and 1,25-dihydroxycholecalciferol(1,25(OH)2D3)deficiency will lead to the synthesis and release of parathyroid hormone(PTH)and the persistent over stimulation of parathyroid gland(PTG),which cause secondary hyperparathyroidism(SHPT).In recent years,with the development of dialysis technique,lifetime of end-stage chronic renal failure(CRF)patients is obviously extended.On the other hand,incidence of SHPT also occurs remarkable increase.It is a kind of systemic disease,featuring disabling and lethal,having a strong negative impact on patients' quality of life.But because of the low awareness of the disease,many patients have been delayed,so the clinical need to diagnose SHPT timely and accurately.As a simple,accurate,noninvasive and reproducible imaging method,ultrasound examination has become the first choice for SHPT detection and has been widely used in clinical.This study intends to obtain the ultrasound features of hemodialysis patients with SHPT(including conventional ultrasound features,Contrast-enhanced ultrasonography(CEUS)features and elastography features)and investigate the value of the three ultrasound techniques in the assessment of the severity of SHPT.Part one: Study on ultrasonographic features of normal parathyroidsObjective: Investigating the value of high frequency ultrasound,contrast-enhanced ultrasound and elastography in the check-up of the normal parathyroid.Methods: 200 patients who had performed health examination were carried out parathyroid ultrasonography and the ultrasonographic findings were observed and analyzed.Results: Of the 200 subjects,120 cases were detected to have normal parathyroid glands,the rate is 60.00%(120/200),which all characterized hyperechoic nodules with clear boundary,delicate uniform and morphological diversity.A total of 233 parathyroid glands were detected.176 inferior parathyroid glands were detected,accounting for 75.54%(176/233),57 upper parathyroid glands were detected,accounting for 24.46%(57/233).The contrast-enhanced ultrasound showed that normal parathyroid's perfusion pattern was consistent with adjacent thyroid.The elastography showed that normal parathyroid texture was softer than that of the adjacent thyroid.Conclusion: High frequency ultrasound can clearly identify the normal parathyroid glands,the contrast-enhanced ultrasound is homogeneous perfusion,the elastic scintigraphy shows slightly softer than thyroid hardness.Part two: Investigate the relationship between recurrent urinary calculi With primary hyperparathyroidism through high frequency ultrasound screening for parathyroidObjective: To explore the relationship between urinary calculi with primary hyperparathyroidism(PHPT)through comparing the parathyroid ultrasound images of the stone group and that of the control group.Methods: 200 cases who came from the Department of Urology were selected as stone group and 200 cases who were excluded urinary calculi and came from the MEC were selected as the control group;They all carried out ultrasound screening for parathyroid and those whose ultrasound images were abnormal had to test parathyroid hormone(PTH),calcium and phosphorus.Results: 28 cases of stone group were found parathyroid tumor,in them,12 cases had increased PTH,increased calcium and decreased phosphorus which conformed to PHPT,while 16 cases had normal PTH,calcium and phosphorus.4 cases of the control group were found parathyroid tumor and PTH,calcium,phosphorus were normal.Among the two groups,the differences between the display rate of parathyroid tumor,the size of tumor and the incidence of PHPT were statistically significant(P<0.05).7 cases of PHPT patients had broken out more than 3 times urinary calculi(58.33%).Conclusion: PHPT is an important and easily overlooked cause of recurrent urinary calculus,and high frequency ultrasound can be used as a routine method to screenparathyroid for recurrent urinary calculus patientsPart three: The clinical value of conventional ultrasound in assessing the severity of secondary hyperparathyroidismObjective: To investigate the conventional ultrasound features of secondary hyperparathyroidism(SHPT)with different severity and to explore the clinical value of conventional ultrasound in assessing the severity of SHPT.Methods: Of 212 patients who underwent hemodialysis from June 2015 to November 2015,there were 50 patients having parathyroid hyperplasia in conventional ultrasound.According to the parathyroid hormone(PTH),these 50 patients were divided into four groups(8 cases Group1: PTH<250ng/L,12 cases Group2: PTH250~600ng/L,18 cases Group3: PTH600~800ng/L,12 cases Group4: PTH ?800ng/L).The shape?size?number?internal echo and blood flow of parathyroid glands(PTGs)were observed and compared between the four groups.21 cases SHPT patients underwent parathyroidectomy recently.Results: When PTH<250ng/L,the ultrasound features were:(1)shape was regular;(2)maximum diameter was<10mm;(3)occurred single hyperplasia;(4)the internal echo was homogeneous;(5)the blood flow was grade 0 or grade?.When PTH250~600ng/L,the ultrasound features were:(1)shape was regular;(2)maximum diameter of most PTGs was <10mm;(3)most PTGs occurred single hyperplasia;(4)the internal echo of most PTGs was homogeneous;(5)the blood flow was grade?or grade?and most were grade I.When PTH600 ~ 800ng/L,the ultrasound features were:(1)shape was irregular;(2)maximum diameter of most PTGs was ?10mm;(3)most PTGs occurred multiple hyperplasia;(4)the internal echo of most PTGs was inhomogeneous;(5)the blood flow was grade?or grade?and most were grade?.When PTH ?800 ng/L,the ultrasound features were:(1)shape was irregular;(2)maximum diameter was ?10mm;(3)occurred multiple hyperplasia;(4)the internal echo was inhomogeneous;(5)the blood flow was grade?or grade III.The difference of ultrasound features between the four groups were statistically significant(p<0.05).But some ultrasound features between Group2 and Group3 overlap,reducing the accuracy of assessing the severity of SHPT.The pathological diagnostic accordant rate with the ultrasound ones in Group3 was only 66.7%.Conclusion: Ultrasound is inexpensive,noninvasive,accurate positioning and it can clearly show the shape?size?number?internal echo and blood flow of PTGs,so it has a high clinical value in the diagnosis of SHPT.It also has certain clinical value in assessing the severity of SHPT,but the accuracy rate is not high,so other ultrasound technologies are needed.Part four: The Significance of ultrasound in determining whether SHPT patients are sensitive to calcitriol treatmentObjective: This study was to explore the significance of ultrasound in determining whether the patients with secondary hyperparathyroidism(SHPT)are sensitive to calcitriol treatment.Methods: Of 212 patients who underwent hemodialysis,there were 42 SHPT patients having parathyroid hyperplasia in ultrasound.Sequioa 512(SIMENS,German)and Aixplorer(Supersonic Imagine France)ultrasonic diagnostic apparatus were used.Conventional ultrasound quantitatively or semi-quantitatively analyzed the shape,size,number,blood supply of hyperplasia parathyroid;Contrast enhanced ultrasound(CEUS)quantitatively analyzed the peak intensity of perfusion of hyperplasia parathyroid;Elastrography using shear wave elastrography(SWE)technique to quantitatively assess the hardness of hyperplasia parathyroid.According to the decrease value of Parathyroid hormone(PTH),42 SHPT patients were divided into two groups-susceptible group and drug insusceptible group.These 42 SHPT patients' ultrasound images were retrospectively analyzed.Results: The morphology,size,number,blood flow,elastic modulus and perfusion of the parathyroid glands were correlated with drug therapeutic outcome(oral calcitriol).Most SHPT patients with drug susceptible showed volume<438.50mm3,number?2,with 0~1 structural and vascular patterns,associated with Relative Maximum Intensity(RIMAX)<1.59 and elastic modulus<18.8k Pa,whereas most SHPT patients with drug insusceptible showed volume?438.50mm3,number?3,with 2~3 structural and vascular patterns,associated with Relative Maximum Intensity(RIMAX)?1.59 and elastic modulus ?18.8k Pa.Conclusion: Ultrasonography in SHPT allows an accurate definition of the morphology,size,number,blood flow,elastic modulus and perfusion of the parathyroid glands and is useful in determining whether SHPT patients are sensitive to calcitriol treatment.