中国血液净化

中国血液净化 ›› 2017, Vol. 16 ›› Issue (04): 227-233.doi: 10.3969/j.issn.1671-4091.2017.04.004

• 临床研究 • 上一篇    下一篇

术中及围手术期血清iPTH 监测对501 例继发性甲状旁腺功能亢进患者手术效果的精准诊断研究——“Diagnostic Accuracy Study of Intraoperative and Perioperative Serum Intact PTH Level for Successful Parathyroidectomy in 501 Secondary Hyperparathyroidism Patients”的二次发表

张丽娜1,邢昌赢1,沈冲3,曾鸣1,杨光1,毛慧娟1,张波1,俞香宝1,孙彬1,欧阳春1,葛益飞1,江瑶1,尹彩霞1,查小明2,王宁宁1   

  1. 南京医科大学第一附属医院 1. 肾内科2. 普通外科
  • 收稿日期:2016-08-03 修回日期:2016-12-07 出版日期:2017-04-12 发布日期:2017-04-12
  • 通讯作者: 王宁宁 wangnn@njmu.edu.cn 查小明 2839034476@qq.com E-mail:wangnn@njmu.edu.cn
  • 基金资助:

    国家自然科学基金(81270408,81570666)；中华医学会临床科研专项基金首届肾脏病青年研究基金(13030300415)；江苏省“医学重点人才”项目(RC201162)；江苏省肾脏病临床研究中心(BL2014080) (本文首次发表于“Scientific Reports”杂志, 2016, 6: p26841)

Diagnostic accuracy study of preoperative and postoperative serum intact PTH levels for the effects of parathyroidectomy in 501 secondary hyperparathyroidism patients

  • Received:2016-08-03 Revised:2016-12-07 Online:2017-04-12 Published:2017-04-12

PDF

370

摘要： 目的甲状旁腺切除术(parathyroidectomy,PTX)是继发性甲状旁腺功能亢进患者(secondary hyperparathyroidism,SHPT)的有效治疗方式，然而由于甲状旁腺位置和数目异常的存在，部分患者术后SHPT 仍持续存在。本研究探讨PTX 患者术中及围手术期血清全段甲状旁腺激素(intact parathyroid hormone,iPTH)监测对手术效果精准诊断的意义。方法记录501 例行甲状旁腺全切+自体前臂移植术(不伴胸腺切除)的慢性肾脏病患者的术中及围手术期血清iPTH 值。术后一周内患者血清iPTH≤50 pg/ml 为手术成功；若＞50 pg/ml 则在6 月内进行随访，随访血清iPTH＜300 pg/mL 即为手术成功，否则为SHPT 持续存在。结果433 例(86.4%)患者手术成功，49 例(9.8%)患者SHPT 持续存在，19 例(3.8%)患者缺乏有效随访归为手术效果未知组。肝炎(n=204)与非肝炎(n=297)患者比较，基线血清iPTH 水平及术中血清iPTH 下降百分比无显著统计学差异(P＞0.05)。受试者工作特征(receiver operating characteristic，ROC)曲线结果表明术后20 分钟血清iPTH 下降≥ 88.9%提示手术成功(曲线下面积0.909，敏感度78.6%，特异度88.5%)。术后4 天血清iPTH≥147.4 pg/ml 提示SHPT 持续存在(曲线下面积0.998，敏感度100%，特异度99.5%)。结论甲状旁腺切除术中血清iPTH 监测能提示甲状旁腺切除是否彻底，避免对患者不必要的探查，降低手术并发症的发生率。围手术期血清iPTH 监测提示SHPT 是否持续存在，对此类患者需密切随访、及时开始药物治疗或必要时再次手术。

关键词: 术中, 围手术期, 甲状旁腺激素, 甲状旁腺切除术, 继发性甲状旁腺功能亢进

Abstract: Objectives Parathyroidectomy (PTX) is an effective treatment for severe secondary hyperparathyroidism (SHPT). However, persistent SHPT may occur because of the presence of supernumerary and ectopic parathyroids. This is a diagnostic accuracy study of preoperative and postoperative serum intact parathyroid
hormone (iPTH) to predict the effects of PTX. Methods Intraoperative and perioperative serum iPTH values were recorded in 501 SHPT patients treated with total PTX+autotransplantation and without thymecto-my. Patients with serum iPTH ≤50 pg/mL in the first week after PTX were classified as successful PTX. Patients with serum iPTH＞50 pg/mL in the first week after PTX were followed up for 6 months; successful PTX was defined if the follow-up iPTH level was ＜300 pg/mL, and persistent SHPT was considered if the iPTH was ＞300 pg/mL. Results A total of 433 (86.4%) patients were defined as successful PTX, 49 (9.8%) as persistent SHPT, and 19 (3.8%) as undetermined due to the incomplete follow-up. Preoperative and postoperative serum iPTH levels had no significant differences between patients with chronic hepatitis (n=204) and those without chronic hepatitis (n=297). Receiver operating characteristic (ROC) curves showed that the decrease of iPTH level by≥88.9% after the surgery for 20 minutes could predict successful PTX, with the area under the curve (AUC) of 0.909, the sensitivity of 78.6% and the specificity of 88.5%. Serum iPTH ≥147.4 pg/mL after the surgery for 4 days could predict persistent SHPT, with the AUC of 0.998, the sensitivity of 100% and the specificity of 99.5%. Conclusion Monitoring of postoperative iPTH level can effectively predict the completeness of PTX, thereby avoiding unnecessary re-operation and its possible complications. Perioperative iPTH monitoring is useful for the prediction of persistent SHPT, for which follow-up study, medical intervention or re-operation may be necessary.

Key words: intraoperative, perioperative, parathyroid hormone, parathyroidectomy, secondary hyperparathyroidism