超声评估维持性血液透析患者甲状旁腺增生的临床价值和相关因素分析

The clinical significance of hyperparathyroidism detected by ultrasonography and analysis of its related factors in hemodialysis patients

目的研究维持性血液透析患者超声评估甲状旁腺增生的患病率,并结合临床资料分析甲状旁腺增生的影响因素,探讨甲状旁腺激素水平对甲状旁腺增生的预测价值。方法选取2015年7月~2015年12月上海交通大学医学院附属瑞金医院血液净化中心维持性血液透析(maintenance hemodialysis,MHD)患者,收集患者基线时性别、年龄、透析龄、原发疾病、用药情况和血生化指标。使用Philips i E33彩色多普勒超声诊断仪评估甲状旁腺增生,探头频率11MHz。结果 2011年7~12月期间,共有96例MHD患者进入本研究,其中56例(58.3%)原发疾病为慢性肾小球肾炎,60例(62.5%)为男性,年龄(56.2±13.3)岁,透析龄(75.8±55.6)月。96例MHD患者中,54例(57.3%)患者B超可见甲状旁腺增生,其中41例(42.7%)为左侧甲状旁腺增生,44例(45.8%)为右侧甲状旁腺增生,29例(30.2%)为双侧甲状旁腺增生。透析龄<36个月、36~72个月和≥72个月的患者超声诊断甲状旁腺增生的患病率分别为34.6%、54.5%和68.8%,3组间有统计学差异(χ~2=0.018,P=0.018)。比较甲状旁腺增生组(n=54)和无甲状旁腺增生组(n=42)两组间患者临床资料、生化指标和药物治疗情况,发现甲状旁腺增生组透析龄更长(t=-3.507,P=0.001)、血磷(t=-2.591,P=0.011)和全段甲状旁腺激素(intact parathyroid hormone,i PTH)水平更高(Z=-4.328,P<0.001),以及维生素D制剂使用率(χ~2=11.197,P=0.001)更高。受试者工作特征曲线(receiver operating characteristic curve,ROC曲线)显示i PTH水平能有效预测甲状旁腺增生(AUC=0.758,P<0.001,95%CI 0.661~0.855)。当i PTH为456.9pg/ml时,其对甲状旁腺增生预测的敏感性为57.4%,特异性为88.1%。结论甲状旁腺增生是尿毒症患者常见的并发症之一,超声检查是评估尿毒症患者甲状旁腺增生的有效手段。较长的透析龄、高甲状旁腺激素水平、高磷血症和活性维生素D制剂的应用与甲状旁腺增生相关。当i PTH>400pg/ml时,建议常规行甲状旁腺超声评估甲状旁腺增生情况。

Objective We used ultrasonography to investigate the prevalence of hyperparathyroidism, which was used to analyze the related factors of hyperparathyroidism by the correlation to clinical data and to explore the value of intact parathyroid hormone （iPTH） for the prediction of hyperparathyroidism in maintenance hemodialysis （MHD） patients. Method MHD patients treated in Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine in the period from July 1st, 2015 to Dec. 31st, 2015 were recruited. Their clinical data, gender, primary disease, dialysis vintage, biochemical data and medica- tion at baseline were collected. Parathyroid hyperplasia was detected by Philips iE33 color Doppler sonog- raphy system （transducer frequency = 11 MHz）. Results This study enrolled 96 MHD patients treated in the period of Jul. 2011 to Dec. 2011. The primary disease was chronic glomerulonephritis in 56 patients （58.3%）; 60 （62.5%） patients were males; mean age was 56.2- 13.3 years old; and mean dialysis vintage was 75.8-55.6 months. Ultrasonography found parathyroid hyperplasia in 54 （57.3%） patients, of whom 41 （42.7%） patients had left parathyroid hyperplasia, 44 （45.8%） patients had right parathyroid hyperpla- sia, and 29 （30.2%） patients had bilateral parathyroid hyperplasia. The prevalence of parathyroid hyperplasia was 34.6%, 54.5% and 68.8% （Z2=0.018, P=0.018） in patients with dialysis vintage 〈36 months, 36- 72 months and ≥72 months respectively. Patients with parathyroid hyperplasia （n=54） had longer dialysis vintage （t=-3.507, P=0.001）, higher serum phosphorus （t=-2.591, P=-0.011）, higher intact parathyroid hormone （iPTH） （Z=-4.328, P〈 0.001） and more patients taking active vitamin D preparations （X2= 11.197, P= 0.001）, as compared with those without parathyroid hyperplasia （n=42）. Receiver operating characteristic （ROC） curve showed that iPTH level could predict parathyroid hyperplasia （AUC=0.758, P〈0.001, 95% CI 0.661-0.855）. When iPTH level was set at 456.9pg/ml, the sensitivity and specificity for parathyroid hy- perplasia were 57.4% and 88.1%, respectively. Conclusion Parathyroid hyperplasia is one of the common complications in uremic patients. Ultrasonography is one of the efficient methods to evaluate the parathyroid gland size. Longer dialysis vintage, higher iPTH level, hyperphosphatemia and active vitamin D treatment are associated with parathyroid hyperplasia. Routine parathyroid ultrasonography to evaluate parathyroid size should be carried out when the patient had iPTH 〉400pg/ml.