案例討論──探討慢性腎臟病瀰漫性骨攝取在副甲狀腺檢查之現象

Diffuse Bone Uptake in the Parathyroid Scan of Chronic Kidney Disease: A Case Report

腎臟是個沉默器官，多數患者初期症狀並不明顯，等到發現異狀時已經有相當程度的受損。人口老化、三高和飲食習慣的改變，讓腎臟疾病和洗腎人數有逐年增加趨勢。一名52歲男性患者，慢性腎臟病（CKD）第5期，生化檢驗ALP（Alkaline Phosphatase）和副甲狀腺指數（I-PTH）數值異常懷疑副甲狀腺亢進。核醫報告指出在副甲狀腺床有放射性同位素攝取增加現象，除此外患者骨骼有瀰漫性攝取增加現象。在影像學上骨骼並不會對鎝-99m MIBI有瀰漫性攝取增加現象，我們回顧了許多參考文獻，此現象為慢性腎臟病礦物質與骨病變（Chronic Kidney Disease-Mineral and Bone Disorders, CKD-MBD）且正處於噬骨細胞活化階段。發生通常與慢性腎疾病患者生化檢驗的高副甲狀腺指數（I-PTH）和高鹼性磷酸酶（ALP）相關。本文主要介紹利用核子醫學副甲狀腺功能檢查（Parathyroid Scan）偵測是否副甲狀腺機能亢進或增生並探討慢性腎臟病瀰漫性骨攝取在副甲狀腺檢查之現象。

Chronic kidney disease (CKD) is silent, with most patients experiencing no obvious symptoms in early stages. At the time of diagnosis, renal damage is usually extensive. The number of patients with CKD and on dialysis has been increasing every year owing to aging, metabolic disorders (hypertension, hyperlipidemia, hyperglycemia), and dietary habits in the population. A 52-year-old man with stage 5 CKD was suspected with hyperparathyroidism, due to abnormal biochemical assay levels of alkaline phosphatase and intact parathyroid hormone. A nuclear medicine study reported increased uptake of radioisotopes in the parathyroid bed as well as increased diffuse bone uptake. Normal parathyroid scintigraphy did not show increased diffuse bone uptake of technetium-99m methoxyisobutylisonitrile. Mineral and bone disorders concurrent with CKD have been reported to occur in the osteoclast activation stage. Their incidence is typically associated with elevated intact parathyroid hormone and alkaline phosphatase levels in biochemical assays of patients with CKD. Here, we report a case of CKD in which parathyroid scanning revealed hyperparathyroidism and hyperplasia. Further, we discuss the phenomenon of diffuse bone uptake in the parathyroid scan of patients with CKD.