维持性血液透析患者甲状旁腺切除术后发生骨饥饿综合征的影响因素

Influencing factors of hungry bone syndrome in maintenance hemodialysis patients after parathyroidectomy

目的探讨维持性血液透析(MHD)合并继发性甲状旁腺功能亢进症(SHPT)患者接受甲状旁腺切除术(PTX)后发生骨饥饿综合征(HBS)的影响因素.方法回顾性分析2013年1月至2018年6月在江苏省人民医院因SHPT接受PTX的MHD患者的临床资料,PTX手术方式均为甲状旁腺全切除联合自体前臂移植.收集入选患者一般临床资料和围手术期相关指标结果.按照术后最低血钙<2.00 mmol/L与否分为HBS组和非HBS组.比较两组患者一般临床资料和围手术期相关指标的差异;Logistic回归分析法分析影响患者术后发生HBS的危险因素;多元线性回归法分析患者静脉补钙维持时间、静脉补钙期间总补钙量和术后24 h内血钾最高值的影响因素.结果306例患者纳入本研究,所有患者术后均有不同程度的血钙水平降低,PTX术后最低血钙<2.00 mmol/L者230例(75.16%).Logistic回归分析结果显示,术前透析前血钙系数(血钙较正常值下限每增高0.01 mmol/L的倍数值)偏低(B=-0.063,OR=0.939,95%CI 0.894~0.987,P=0.013)和术前血碱性磷酸酶(ALP)水平偏高(B=0.035,OR=1.033,95%CI 1.019~1.050,P<0.001)是发生HBS的独立危险因素.多元线性回归分析结果显示,术前血全段甲状旁腺素(iPTH)(B=0.017,P<0.001和B=0.041,P<0.001)、术前ALP(B=0.052,P<0.001和B=0.107,P<0.001)和术前血红蛋白(Hb)(B=-0.453,P=0.041和B=-1.058,P=0.007)是HBS患者静脉补钙维持时间和静脉补钙期间总补钙量的独立影响因素.术前透析前血钾(B=0.859,P<0.001)是术后24 h内血钾最高值的独立影响因素.结论术前血钙较低和血ALP较高的患者PTX术后易发生HBS;术前血iPTH和ALP水平较高、术前Hb水平较低的HBS患者术后需要加强补钙.术前基础血钾水平较高可增加PTX术后高钾血症风险.

Objective To investigate the influencing factors of hungry bone syndrome(HBS)in maintenance hemodialysis patients with secondary hyperparathyroidism(SHPT)after parathyroidectomy(PTX).Methods A retrospective study was conducted on maintenance hemodialysis patients with SHPT undergoing successful parathyroidectomy with autotransplantation.Clinical data and perioperative indicators of the selected patients were collected.The enrolled patients were divided into HBS group and non-HBS group based on whether the lowest level of blood calcium less than 2.0 mmol/L after surgery.The difference of general clinical data and perioperative indicators between the two groups were compared.The risk factors of HBS were analyzed by logistic regression analysis.Multiple linear regression method was used to analyze the independent factors affecting the maintenance time of intravenous calcium supplementation,the total amount of calcium supplementation during intravenous calcium supplementation and the highest serum level of potassium within 24 h after surgery.Results A total of 306 patients were included in the study.All patients had low levels of serum calcium after operation.There were 230 patients(75.16%)with the lowest blood calcium<2.00 mmol/L after PTX(HBS group),and 76(24.84%)cases in the non-HBS group.Predialysis coefficient of serum calcium=(preoperative blood calcium-2.20)mmol/L÷0.01 mmol/L.Logistic regression analysis showed that higher predialysis coefficient of serum calcium(B=-0.063,OR=0.939,95%CI 0.894-0.987,P=0.013)and lower level of preoperative serum alkaline phosphatase(ALP)(B=0.035,OR=1.033,95%CI 1.019-1.050,P<0.001)were independent risk factors for HBS.Multiple linear regression analysis revealed that preoperative blood intact parathyroid hormone(iPTH)(B=0.017,P<0.001 and B=0.041,P<0.001),preoperative serum ALP(B=0.052,P<0.001 and B=0.107,P<0.001)and preoperative hemoglobin(Hb)(B=-0.453,P=0.041 and B=-1.058,P=0.007)were independent factors affecting the maintenance time of intravenous calcium supplementation and the total amount of calcium supplementation in HBS patients.Preoperative predialysis level of serum potassium(B=0.859,P<0.001)was the independent influencing factor of the maximum level of serum potassium within 24 hours after surgery.Conclusions Patients with lower levels of preoperative serum calcium and higher levels of serum ALP are prone to HBS after PTX.Postoperative calcium supplementation may need to be strengthened in HBS patients with higher preoperative iPTH and ALP levels and lower preoperative Hb levels.High preoperative basal potassium levels may increase the risk of hyperkalemia after PTX.