| Backgrounds and objective:Secondary hyperparathyroidism(SHPT)is one of the common complications appeared among patients with chronic kidney disease(CKD).At present,the curative effect of medical treatment is limited.There are still some patients whose serum levels of parathyroid hormone(PTH),phosphorus and calcium are not up to standard,or not effectively controlled,so they gradually progress to severe SHPT.It is more frequently in patients who receive maintenance hemodialysis(MHD)for years.The symptoms may include the progressive high turnoverbone disease,vascular calcification,fibrous osteitis,calciphylaxis etc,which may increase the risk of cardiovascular disease and mortality.In this case,parathyroidectomy(PTX)should be performed as soon as possible,otherwise the patient’s quality of life and survival rate will be seriously affected.It is a rapid and effective therapy for severe SHPT.However,these patients often have multiple system diseases,and many complications may occur after PTX.Hypocalcemia was the one of the most common complications,and severe hypocalcemia(SH)in a short period of time can cause malignant arrhythmias,laryngeal spasms,asphyxia,seizures and even cardiac arrest.The perioperative treatment of PTX is difficult and the operative risk is high.Therefore,it requires close collaboration among many collaborators.Due to the diversity of surgery methods and surgical procedures in different hospitals and the lack of standard guidelines,it is hardly possible to perform surgeries for severe SHPT patients in both national and foreign hospitals.At present,the research of PTX in the treatment of severe SHPT is still in the exploratory stage.In view of the current research status of PTX in the treatment of SHPT at home and abroad,the objective of these studies are demonstrated as follows:1.To investigate the safety and efficacy of PTX in the dialysis patients combined with severe SHPT by retrospectively analyzing the clinical data of maintenance hemodialysis patients undergoing PTX.2.To analyze the influencing factors for the early occurrence of SH after PTX,and to predict chance of SH in the early postoperative period,and therefore to provide theoretical support for early intervention of some patients.Methods:1.A total of 303 patients with stage 5 maintenance hemodialysis of chronic kidney disease complicated with severe SHPT who underwent PTX in the 960th Hospital of the PLA Joint Logistics Support Force from November 2010 to December 2018 were selected.Clinical data of all patients(including age,sex,dialysis age,primary disease,number of parathyroid glands removed,etc.)were collected.Observed the improvement of postoperative clinical symptoms and complications.2.Parameters including intact parathyroid hormone(iPTH),calcium,phosphorus,alkaline phosphatase(ALP)in serum of all patients were collected before and after surgery,and changes in indexes before and after surgery,as well as the success rate and cure rate were analyzed.3.SH was defined as the lowest level of serum calcium below 1.875mmol/L within 3 days after surgery.303 patients were divided into SH group and non-SH group,and univariate analysis was conducted to analyze the differences between the two groups.Spearman rank correlation analysis was used to compare the correlation between each univariable with statistically significant difference and postoperative blood calcium,and multivariate binary Logistic regression analysis was conducted to further determine the independent influencing factors of postoperative SH.Receiver operating characteristic(ROC)curve analysis was further performed to delineate the area under the ROC curve(AUC)to help better evaluate the diagnostic value of the selected variables.Results:1.All 303 patients underwent total parathyroid resection and autologous transplantation,including 183 males and 120 females,with an average age of(44.5±11.10)years and an average dialysis age of(6.81±3.44)years.There were 159(52.48%)patients with primary chronic glomerulonephritis,88(29.04%)patients with hypertension,10(3.3%)patients with diabetes,4(1.32%)patients with polycystic kidney disease,and 42(13.86%)patients with unknown etiology.A total of 1204 parathyroid glands were removed.The bone pain and pruritus of 284 patients were significantly relieved on the day of operation,and as of 19 patients were relieved in about 1 week.171 cases(56.44%)had hypocalcemia,106 cases(34.98%)had SH,21 cases(6.93%)had different degrees of mental disorder or personality change,10 cases(3.3%)had subcutaneous hemorrhage and hematoma,2 cases(0.6%)had hypotensive shock,1 case(0.3%)had subcutaneous emphysema,and 1 case(0.3%)had acute cerebral infarction,all of which recovered after symptomatic treatment.2.On the first postoperative day,the median serum iPTH of 25.65(16.00,43.20)pg/mL,the median serum phosphorus of 1.43(1.01,1.94)mmol/L and the median serum calcium of 2.04(1,76,2.29)mmol/L,which were all lower than those before surgery,and the difference was statistically significant(all P<0.001).The standard of iPTH<300pg/mL within 7 days after surgery was considered as surgical cure,and the standard of iPTH decreased by>80%20 minutes after surgery was considered as surgical success.The surgical cure rate and success rate were both 99%.3.Univariate analysis showed that there were statistically significant differences in preoperative serum calcium,osteocalcin,age,alkaline phosphatase and serum iPTH between SH group and non-SH group(all P<0.05).Spearman rank correlation bivariable analysis showed that postoperative serum calcium was positively correlated with age(rs=0.201,P<0.001),preoperative serum calcium(rs=0.264,P<0.001),osteocalcin(rs=0.271,P=0.003),and negatively correlated with preoperative iPTH(rs=-0.268,P<0.001)and ALP(rs=-0.270,P<0.001).Multivariate binary Logistic regression analysis showed that young age(OR=1.698),low preoperative serum calcium(OR=1.831)and high iPTH(OR=0.318)were independent risk factors for the occurrence of postoperative SH.According to ROC curve,preoperative serum calcium(AUC=0.629)and iPTH(AUC=0.652)were more prominent than age(AUC=0.578)as independent influencing factors.Conclusion:1.PTX is a safe and effective treatment for maintenance hemodialysis patients combined with severe SHPT,with fewer fatal complications which are difficult to treat,the success rate and cure rate are high2.Patients with low preoperative serum calcium,younger age and high iPTH are prone to postoperative SH.Patients in the above categories need to be closely monitored by the postoperative serum calcium level and intervene should be performed as soon as possible. |
