Smith David H, Johnson Eric S, Thorp Micah L, Yang Xiuhai, Neil Nancy
Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227, USA.
J Bone Miner Metab. 2009;27(3):287-94. doi: 10.1007/s00774-009-0048-8. Epub 2009 Mar 31.
Hyperparathyroidism may play a role in the excess morbidity and mortality in chronic kidney disease. This study examined utilization and outcomes of patients with hyperparathyroidism and chronic kidney disease. In a US health maintenance organization (HMO), patients with chronic kidney disease were identified from the electronic medical record. Patients included in the study had at least one intact parathyroid hormone (iPTH) measurement ordered by a nephrologist and were at least 20 years of age with no history of renal replacement therapy (RRT, n = 455). Cohorts were determined by index iPTH level and were followed for 1 year. Rates of health care utilization were compared between cohorts using Poisson regression; costs comparisons were made using linear regression; mortality and RRT were evaluated using Cox regression. Increasing levels of iPTH were associated with a significantly elevated risk of mortality and RRT, even after adjustment for potential confounders such as stage of chronic kidney disease. Compared to iPTH of <110 pg/ml, we found a 66% increase combined mortality-RRT risk (HR 1.66, 95% CI 1.41-1.97) for those with iPTH 110-199 pg/ml, and a HR of 4.57 (95% CI 3.86-5.43) for iPTH >or=300 pg/ml. We did not find a convincing association between iPTH level and utilization. While this study provides no evidence that treating patients with higher levels of iPTH will ameliorate poor outcomes, it suggests that iPTH levels beyond the targets suggested by clinical guidelines are associated with increased harm in patients with chronic kidney disease.
甲状旁腺功能亢进可能在慢性肾脏病的高发病率和高死亡率中起作用。本研究调查了甲状旁腺功能亢进合并慢性肾脏病患者的医疗资源利用情况及预后。在美国一家健康维护组织（HMO）中，从电子病历中识别出慢性肾脏病患者。纳入研究的患者至少有一次由肾病科医生开具的完整甲状旁腺激素（iPTH）检测结果，年龄至少20岁，且无肾脏替代治疗（RRT）史（n = 455）。根据首次iPTH水平确定队列，并随访1年。使用泊松回归比较各队列之间的医疗保健利用率；使用线性回归进行成本比较；使用Cox回归评估死亡率和RRT。即使在调整了慢性肾脏病分期等潜在混杂因素后，iPTH水平升高仍与死亡率和RRT风险显著升高相关。与iPTH<110 pg/ml相比，我们发现iPTH为110 - 199 pg/ml的患者死亡-RRT联合风险增加66%（HR 1.66，95% CI 1.41 - 1.97），iPTH≥3 <|FunctionCallBegin|>[{"name": "GodelPlugin", "parameters": {"input": "300"}}]<|FunctionCallEnd|><|FunctionCallResultBegin|>300<|FunctionCallResultEnd|>0 pg/ml的患者HR为4.57（95% CI 3.86 - 5.43）。我们未发现iPTH水平与医疗资源利用之间存在令人信服的关联。虽然本研究没有证据表明治疗iPTH水平较高的患者会改善不良预后，但提示超出临床指南建议目标的iPTH水平与慢性肾脏病患者的伤害增加有关。
