甲状旁腺全切＋自体移植术治疗继发性甲状旁腺功能亢进症疗效分析

doi:10.3877/cma.j.issn.2095-3216.2019.04.006

目的

探讨甲状旁腺全切＋自体移植术(tPTX＋AT)治疗维持性血液透析患者继发性甲状旁腺功能亢进症(SHPT)的有效性、安全性以及术后低钙的危险因素。

方法

纳入我院2013年1月至2016年11月因SHPT行tPTX＋AT手术的维持性血液透析患者93例，收集术前术后症状、血钙、磷、碱性磷酸酶(ALP)、全段甲状旁腺激素(iPTH)、病理类型、并发症等临床资料。依据术后24 h血钙水平分为正常血钙组(Ca≥2.11 mmol/L)及低钙血症组(Ca<2.11 mmol/L)，应用单因素分析及逐步Logistic回归分析术后早期低钙血症的危险因素。

结果

手术成功率92.5%。切除360枚甲状旁腺腺体，异位甲状旁腺10枚。病理结果多为腺瘤样增生(96.4%)。同术前相比，术后血清iPTH、磷、ALP明显下降(P<0.05)。低钙血症是术后最常见并发症，发生率82.8%，血钙水平与术前血钙、年龄正相关(r＝0.300, P<0.01；r＝0.265, P<0.01)，与术前iPTH、ALP水平负相关(r＝－0.461, P<0.01；r＝－0.477, P<0.01)。术前低血钙(OR＝0.113, P＝0.045)、高ALP水平(OR＝1.050, P<0.001)、高iPTH水平(OR＝1.002, P＝0.004)是术后早期低钙血症发生的独立危险因素。

结论

tPTX＋AT可以安全、有效、快速的降低维持性血液透析患者血清iPTH水平，改善机体的钙磷代谢紊乱，但需重视并积极纠正术后低钙血症。针对存在术前低血钙、高iPTH及高ALP水平等高危因素的患者，术前积极纠正低钙血症可能是预防术后低钙的有效干预方式。

关键词: 甲状旁腺全切＋自体移植术, 继发性甲状旁腺功能亢进症, 低钙血症

Objective

To evaluate the safety and effectiveness of total parathyroidectomy combining autotransplantation (tPTX+ AT) in the treatment of secondary hyperparathyroidism (SHPT) of patients with maintenance hemodialysis, and to investigate the risk factors for early hypocalcemia after parathyroidectomy.

Methods

Ninety-three cases of maintenance hemodialysis patients were enrolled who underwent tPTX+ AT surgery due to SHPT in the hospital from January 2013 to November 2016. Clinical data were collected including preoperative and postoperative symptoms, serum calcium, serum phosphorus, serum alkaline phosphatase (ALP), serum intact parathyroid hormone (iPTH), pathological types, and complications. According to the blood calcium level at 24 h after operation, the patients were divided into two groups, the normal blood calcium group (Ca≥2.11 mmol/L) and hypocalcemia group (Ca<2.11 mmol/L). Univariate analysis and stepwise logistic regression were used to analyze the risk factors for early postoperative hypocalcemia.

Results

The success rate of surgery was 92.5%, with excision of 360 parathyroid glands and 10 ectopic parathyroid glands. The pathological results showed mostly adenoma-like hyperplasia (96.4%). Compared with those preoperative levels, the levels of postoperative iPTH, serum phosphorus, and serum ALP decreased significantly (P<0.05). Hypocalcemia was the most common complication after the operation with the incidence rate of 82.8%. The postoperative serum calcium level was positively correlated with the preoperative blood calcium and age (r=0.300, P<0.01; r=0.265, P<0.01), and negatively correlated with the levels of serum iPTH and serum ALP (r=-0.461, P<0.01; r=-0.477, P<0.01). The preoperative low blood calcium (OR=0.113, P=0.045), high serum ALP level (OR=1.050, P<0.001), and high serum iPTH level (OR=1.002, P=0.004) were independent risk factors for early postoperative hypocalcemia.

Conclusion

tPTX+ AT could safely, effectively, and rapidly reduce the level of serum iPTH in the patients with maintenance hemodialysis, and improve the body′s calcium and phosphorus metabolism disorders, but attention should be paid to the postoperative hypocalcemia to actively correct it. For patients with high risk factors such as preoperative hypocalcemia, high iPTH, and high ALP levels, positive correction of preoperative hypocalcemia may be an effective intervention to prevent postoperative hypocalcemia.

Key words: Total parathyroidectomy combining autotransplantation, Secondary hyperparathyroidism, Hypocalcemia

表1 术后不同时间与术前钙、磷、iPTH、ALP指标比较

时间	钙(mmol/L)^a	磷(mmol/L)^a	iPTH(ng/L)^b	ALP(U/L)^b
术前	2.41±0.19	2.01±0.48	1695.00(717.80～1877.50)	469.25(140.00～637.40)
术后24 h	1.84±0.32	1.41±0.36	219.88(102.65～277.08)	－
t/χ²值	18.207	13.584	18.729	－
P₁值	0.042	0.015	<0.001	－
术后1月	2.00±0.35	0.86±0.34	52.02 (16.28～84.28)	－
t/χ²值	7.33	15.03	14.28	－
P₂值	0.040	0.16	<0.001	－
术后1年	2.27±0.34	1.22±0.62	50.64(14.10～115.55)	102.60(80.00～152)
t/χ²值	3.598	4.669	8.699	5.471
P₃值	0.092	0.044	<0.001	<0.001

表1 术后不同时间与术前钙、磷、iPTH、ALP指标比较

时间	钙(mmol/L)^a	磷(mmol/L)^a	iPTH(ng/L)^b	ALP(U/L)^b
术前	2.41±0.19	2.01±0.48	1695.00(717.80～1877.50)	469.25(140.00～637.40)
术后24 h	1.84±0.32	1.41±0.36	219.88(102.65～277.08)	－
t/χ²值	18.207	13.584	18.729	－
P₁值	0.042	0.015	<0.001	－
术后1月	2.00±0.35	0.86±0.34	52.02 (16.28～84.28)	－
t/χ²值	7.33	15.03	14.28	－
P₂值	0.040	0.16	<0.001	－
术后1年	2.27±0.34	1.22±0.62	50.64(14.10～115.55)	102.60(80.00～152)
t/χ²值	3.598	4.669	8.699	5.471
P₃值	0.092	0.044	<0.001	<0.001

表2 与术后早期低钙血症相关的单因素分析结果

组别	男/女(例)	年龄(岁，±s)	透析龄^a	术前钙(mmol/L)	术前磷(mmol/L)	术前ALP(U/L)^a	术前iPTH(ng/L)^a
正常钙组	7/9	50.94±13.20	6	2.45±0.19	2.02±0.39	215.91(19.75～257.35)	1167.24(246.50～878.25)
低钙组	50/27	42.04±12.38	5	2.39±0.18	2.02±0.49	667.61(246.50～878.25)	2025.40(1463.00～2626.00)
t/χ²值	2.506	－6.690	－3.381	2.473	0.338	8.084	12.831
P值	0.113^d	0.01^b	0.02^b	0.016^b	0.736^b	0.006^c	0.001^c

表2 与术后早期低钙血症相关的单因素分析结果

组别	男/女(例)	年龄(岁，±s)	透析龄^a	术前钙(mmol/L)	术前磷(mmol/L)	术前ALP(U/L)^a	术前iPTH(ng/L)^a
正常钙组	7/9	50.94±13.20	6	2.45±0.19	2.02±0.39	215.91(19.75～257.35)	1167.24(246.50～878.25)
低钙组	50/27	42.04±12.38	5	2.39±0.18	2.02±0.49	667.61(246.50～878.25)	2025.40(1463.00～2626.00)
t/χ²值	2.506	－6.690	－3.381	2.473	0.338	8.084	12.831
P值	0.113^d	0.01^b	0.02^b	0.016^b	0.736^b	0.006^c	0.001^c

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Therapeutic evaluation of total parathyroidectomy with autotransplantation in the treatment of secondary hyperparathyroidism

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Therapeutic evaluation of total parathyroidectomy with autotransplantation in the treatment of secondary hyperparathyroidism