Chirurgische Therapie kritischer Hyperkalzämien und hyperkalzämischer Krisen

Über 90% der Fälle mit kritischer Hyperkalzämie gehen auf eine malignomassoziierte Hyperkalzämie oder einen primären Hyperparathyreoidismus (PHPT) zurück. Die rein konservative Therapie hat eine hohe Mortalität. Wird ein PHPT hingegen frühzeitig operativ versorgt, ist von einer Überlebenschance von > 95% auszugehen. Dies zeigt die besondere Bedeutung der sofortigen interdisziplinären Behandlung, um die Therapie, die Diagnose der Grundkrankheit und das weitere Vorgehen optimal gestalten zu können.

Kernaussagen

• Die Definition einer kritischen Hyperkalzämie und einer hyperkalzämischen Krise wird nicht einheitlich gebraucht; i. d. R. werden als Grenzwerte für das Serum-Kalzium angegeben:

  • Hyperkalzämie: > 2,6 mmol Ca/l = 10,4 mg Ca/100 ml),

  • kritische Hyperkalzämie: ≥ 3,5 mmol Ca/l = 14 mg Ca/100 ml,

  • hyperkalzämische Krise: > 3,0 mmol Ca/l = 12 mg Ca/100 ml mit Vorliegen klinischer Symptome, die eine stationöre Behandlung erforderlich machen.

• Ursache von über 90% kritischer Hyperkalzämien und hyperkalzämischer Krisen ist ein primärer Hyperparathyreoidismus (PHTP) oder eine maligne Grunderkrankung.

• Die Symptomatik ist gekennzeichnet durch unspezifische Beschwerden (Schwächegefühl/Fatigue, Muskel- und Skelettbeschwerden, Übelkeit, Erbrechen und Bauchschmerzen bis hin zum akuten Abdomen).

• Mittels der zervikalen Ultraschalluntersuchung und der Sestamibi-Szintigrafie sind die meisten pathologischen Nebenschilddrüsen detektierbar.

• Ab einem Serum-Kalziumwert von > 3,0–3,1 mmol/l (12–14 mg%) ist unabhängig von zusätzlichen klinischen Symptomen umgehend eine kalziumsenkende Therapie einzuleiten, jedoch dürfen die Anstrengungen der symptomatischen Serum-Kalziumsenkung auf keinen Fall zu einer Verzögerung möglicher kurativer Therapien führen, besonders bei PHTP.

• Die Operationsindikation besteht bei kritischer Hyperkalzämie und hyperkalzämischer Krise aufgrund eines PHPT auch bei erhöhten Serum-Kalziumwerten innerhalb der ersten 48 h nach stationärer Aufnahme und sollte immer interdisziplinär getroffen werden.

• Ohne Therapie sterben alle Patient*innen mit hyperkalzämischer Krise und bei rein konservativer Therapie 14–40%. Demgegenüber liegt die Mortalitätsrate von operierten Patient*innen im Rahmen eines PHPT bei 2–6,5%.

Schlüsselwörter

primärer Hyperparathyreoidismus - Stoffwechselstörung - Nebenschilddrüse - Knochenstoffwechsel

Publication History

Article published online:
15 May 2024

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