Risk Factors Of Early Hypocalcemia After Total Parathyroidectomy With Auto-transplantation In Patients With Uremic Secondary Hyperparathyroidism

Objective:Secondary hyperparathyroidism(SHPT)is a disease harming multiple organs such as kidney,parathyroid glands(PT),bone,etc.Clinically,SHPT is manifested by refractory skin itch,muscle pain,bone pain,palpitation,shortness of breath and so on,which can also lead to disabilities and physical deformities.Since the patients with SHPT are difficult to take care of themselves,combined with the long delay and the long treatment period of the disease,in addition to the increased corresponding medical costs,the patients and their families are under enormous financial and psychological burden.The treatment of SHPT mainly includes medication and surgery.As for patients with severe SHPT who are in CKD3-5 stages(severe decline in renal function,eGFR<60 ml/(min · 1.73m2)or the need for dialysis),complicated with drug refractory,there is strong evidence-based medical evidence in support of parathyroidectomy(PTX).There are three options for PTX:total PTX(tPTX),subtotal PTX(sPTX)and total PTX with auto-transplantation(PTX+AT).This research is to identify the risk factors of early hypocalcemia(CVH)after PTX+AT in patients with uremic SHPT,and predict the high-risk populations with CVH after PTX,for easy of clinical intervention earlier.Methods:One hundred and sixteen uremic patients with SHPT and underwent PTX+AT in the Qianfoshan Hospital and General Hospital of Jinan Military Command from July 2013 to August 2016 were enrolled in the study.According to the post-operative serum calcium(Ca)levels within 24 hours,the patients were divided into two groups:the normocalcemia group(33 patients)with the serum Ca levels>2 mmol/L,and the hypocalcemia group(83 patients)with the serum Ca levels≤2 mmol/L.1.The patients’ clinical data were collected,including general information such as age,gender,and major symptoms,major signs,primary kidney disease,dialysis duration,relevant medical history,examination,and so on.2.Variables associated with early hypocalcemia on univariate analysis,including age,gender,dialysis duration,preoperative biochemical indexes and pathological examination.3.A stepwise logistic regression analysis was used to determine the independent risk factors for early hypocalcemia after PTX+AT.4.We analyzed the trends of the average serum calcium concentration in preoperative and the first,third,seventh day after PTX in the hypocalcemia group and the normocalcemia group,and compared the recovery of serum calcium levels between two groups after PTX+AT to explore the rationality of the grouping method and the clinical significance of this research.Results:1.One hundred and sixteen patients were in uremic dialysis stage.The mean age of the patients was 44±11 years,38.8%of whom were female.The vast majority of patients(78.4%)had different degrees of bone disease-related symptoms and signs like bone pain,fractures,becoming shorter.etc.16(13.8%)patients’ skin were itchy,rough or gloomy.20(17.2%)patients had myasthenia,and 4(3.4%)patients with epilepsy or other neurological symptoms.50(50%)patients’ echocardiography showed decreased ventricular systolic or diastolic function.27(23.3%)patients had cardiac valvular calcification.Weekly,all patients’ dialysis time is 12 hours.2.Variables associated with early hypocalcemia on univariate analysis.Compared with the normocalcemia group,patients in the hypocalcemia group were younger(42.1± 10.8 vs 48.4± 11.3 years;P=0.02),and had shorter dialysis time(6 vs 8 years;P=0.02),lower levels of preoperative serum calcium(2.28±0.22 vs 2.50±0.22 mmol/L;P<0.001)and preoperative hemoglobin(103.30±18.04 vs 117.58±17.06 g/dL;P=0.001),higher levels of preoperative alkaline phosphatase(ALP)(843 vs 293 IU/L;P<0.001)and preoperative parathyroid hormone(PTH)(2168 vs 1160 pg/mL;P=0.002).3.By using a stepwise logistic regression analysis,lower levels of preoperative Ca(odds ratio 0.01,95%CI 0.11-0.37,P=0.001),higher levels of preoperative ALP(odds ratio 1.01,95%Cl 0.71-0.93,P<0.001)and higher levels of preoperative PTH(odds ratio 1.01,95%CI 0.58-0.85,P=0.003)were independent risk factors of early hypocalcemia after PTX.4.The trends of the average serum calcium concentration in preoperative and one week after PTX between the two groups showed that in the normocalcemia group,the average serum calcium concentration within postoperative 1 week was less volatile.In addition,after drug therapy,the serum calcium levels could be relatively quickly recovered to the normal range.However,in the hypocalcemia group,the serum calcium levels on the third day after PTX fell sharply,and were not picked up until drug therapy for one week.Conclusion:1.Compared with the normocalcemia group,patients in the hypocalcemia group were younger,and had shorter dialysis time,lower levels of preoperative serum calcium and preoperative hemoglobin,higher levels of preoperative ALP and preoperative PTH.2.Pre-operative hypocalcemia,higher levels of ALP and PTH are closely related to early hypocalcemia after PTX.The serum Ca levels of the patients with one of above risk factors should be monitored more closely to prevent and treat the hypocalcemia after PTX in the early stages.