血液透析患者行甲状旁腺切除术的前瞻性队列研究

Uremic patients with secondary hyperparathyroidism after parathyroidectomy:a prospective cohort study

目的:调查因继发性甲状旁腺功能亢进(SHPT)行甲状旁腺切除术(PTX)的尿毒症血液透析患者的基线情况,并评价PTX的有效性与安全性,分析术后不同全段甲状旁腺激素(iPTH)水平对患者的长期预后的影响。方法:选取自2014年1月至2024年12月行维持性血液透析,药物治疗无效且符合手术指征的SHPT,并在华山医院普外科行PTX的患者入组形成动态队列,将PTX后1周iPTH水平≤20 pg/mL的人群设置为暴露组,术后1周iPTH>20 pg/mL的人群则为对照组。进行基线和随访调查,随访结束时间为2029年12月,收集相关数据开展前瞻性队列研究。结果:自2014年1月至2021年7月符合入选标准的患者共计124例,术前血钙为2.58±0.26 mmol/L,血磷为2.08±0.64 mmol/L,iPTH 1 900.0(1 392.0,2 433.5) pg/mL。术后血钙、血磷、钙磷乘积及iPTH水平较术前显著降低(P<0.05)。围手术期暴露组及对照组之间的血钙、血磷、钙磷乘积无统计学差异,术后两组之间iPTH水平有统计学差异(P<0.05)。随访期间血钙、 iPTH水平趋于稳定,血磷和钙磷乘积在手术1年后缓慢上升。在平均2.4年随访期间,复发率为2.6/100人年,死亡率为4.1/100(人·年)。暴露组与对照组的累积生存率比较,暂无统计学意义。结论:PTX可改善钙磷代谢紊乱,显著降低iPTH,是缓解难治性SHPT的安全且有效的方法。

Objective:To evaluate the effectiveness and safety of parathyroidectomy and analyze the impact of different levels of intact parathyroid hormone(iPTH) on long-term prognosis. Methodology:Our study includes uremic patients with secondary hyperparathyroidism who undergo parathyroidectomy in general surgery of Huashan Hospital from January 2014 to December 2024. The exposure group is the patients with iPTH level≤20 pg/ml one week after parathyroidectomy and the control group is the patients with iPTH level> 20 pg/ml. All the patients are enrolled to form a prospective cohort design for baseline and follow-up investigation. The end time of follow-up is December 2029. Results:124 patients were enrolled between January 2014 and July 2021. The mean level of preoperative serum calcium and phosphorus were(2.58±0.26) mmol/L and(2.08±0.64) mmol/L. The level of preoperative iPTH were 1900.0(1392.0,2433.5) pg/mL. After the operation, the levels of serum calcium, phosphorus, calcium-phosphorus product, and iPTH decreased significantly. There was no significant difference in serum calcium, phosphorus, calcium-phosphorus between the exposure group and the control group. Postoperative iPTH was statistically significant between the two groups. The level of calcium and iPTH remained stable but phosphorus and calcium-phosphorus product rose slowly one year after surgery. The rate of recurrence and death events of these patients was 2.6/100 person-years and 4.1/100 person-years, respectively, during a median follow-up of 2.4 years. Conclusion:The cumulative survival rate between the exposure group and the control group was not statistical different. Parathyroidectomy is a safe and effective therapeutic method to improve the metabolism of calcium and phosphorus and reduce the level of iPTH.