改善全球肾脏病预后组织（KDIGO）指南与肾性甲状旁腺功能亢进的甲状旁腺切除术
Kidney Disease Improving Global Outcomes guidelines and parathyroidectomy for renal hyperparathyroidism.
作者信息
Oltmann Sarah C, Madkhali Tariq M, Sippel Rebecca S, Chen Herbert, Schneider David F
机构信息
Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
Department of Surgery, University of Wisconsin, Madison, Wisconsin.
出版信息
J Surg Res. 2015 Nov;199(1):115-20. doi: 10.1016/j.jss.2015.04.046. Epub 2015 Apr 18.
BACKGROUND
Patients with end-stage renal disease develop hypocalcemia, resulting in secondary hyperparathyroidism (SHPT). No clear criterions exist to aid in surgical decision making for SHPT. The 2009 Kidney Disease Improving Global Outcomes (KDIGO) guidelines provide target ranges for serum calcium, phosphate, and parathyroid hormone (PTH) levels in patients with end-stage renal disease. Parathyroidectomy can help achieve these targets. The study purpose was to examine how parathyroidectomy for SHPT impacts KDIGO targets during immediate and long-term follow-up and to evaluate KDIGO categorization with receipt of additional surgical intervention.
METHODS
A retrospective review of a prospective parathyroidectomy database was performed. Included patients had SHPT, were on dialysis, and underwent parathyroidectomy. Calcium, phosphate, and PTH values were classified as below, within, or above KDIGO targets.
RESULTS
Between 2000 and 2013, 36 patients with SHPT met criteria. Subtotal parathyroidectomy was performed in 89%, total parathyroidectomy in 11%. Follow-up time was 54 ± 7 mo. Eight patients (22%) required additional surgery. Twenty-eight patients (76%) were alive at the last follow-up. At the last-follow up, patients had phosphate (46%), and PTH (17%) above KDIGO ranges. Factors associated with reoperation were assessed. Patient PTH within or above target immediately postoperative had a higher rate of reoperation (P < 0.01). At the last follow-up, higher phosphate (P = 0.054) and PTH (P < 0.001) were associated with higher reoperation rates, but calcium (P = 0.33) was not.
CONCLUSIONS
PTH and phosphate levels above KDIGO indices were associated with additional surgical intervention. Many patients had laboratory indices above range at the last follow up, suggesting more patients had persistent or recurrent disease than those who underwent reoperation. Patients may benefit from more aggressive medical and/or surgical management.
背景
终末期肾病患者会出现低钙血症，进而导致继发性甲状旁腺功能亢进（SHPT）。目前尚无明确标准可辅助SHPT的手术决策。2009年改善全球肾脏病预后组织（KDIGO）指南给出了终末期肾病患者血清钙、磷和甲状旁腺激素（PTH）水平的目标范围。甲状旁腺切除术有助于实现这些目标。本研究旨在探讨SHPT甲状旁腺切除术在近期和长期随访期间对KDIGO目标的影响，并评估接受额外手术干预后的KDIGO分类情况。
方法
对一个前瞻性甲状旁腺切除术数据库进行回顾性分析。纳入的患者患有SHPT，正在接受透析，并接受了甲状旁腺切除术。钙、磷和PTH值被分类为低于、处于或高于KDIGO目标范围。
结果
2000年至2013年期间，36例SHPT患者符合标准。89%的患者接受了甲状旁腺次全切除术，11%的患者接受了甲状旁腺全切除术。随访时间为54±7个月。8例患者（22%）需要再次手术。28例患者（76%）在最后一次随访时仍存活。在最后一次随访时，患者的磷（46%）和PTH（17%）高于KDIGO范围。对与再次手术相关的因素进行了评估。术后即刻PTH处于或高于目标范围的患者再次手术率更高（P<0.01）。在最后一次随访时，较高的磷（P=0.054）和PTH（P<0.001）与较高的再次手术率相关，但钙（P=0.33）无关。
结论
PTH和磷水平高于KDIGO指标与额外的手术干预相关。许多患者在最后一次随访时实验室指标超出范围，这表明持续性或复发性疾病的患者比接受再次手术的患者更多。患者可能会从更积极的药物和/或手术治疗中获益。
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