在有医疗保险覆盖的透析患者中，甲状旁腺切除术治疗继发性甲状旁腺功能亢进症的比例不断增加。
Increasing rates of parathyroidectomy to treat secondary hyperparathyroidism in dialysis patients with Medicare coverage.
机构信息
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD.
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD.
出版信息
Surgery. 2022 Jul;172(1):118-126. doi: 10.1016/j.surg.2022.02.005. Epub 2022 Mar 21.
BACKGROUND
Secondary hyperparathyroidism affects nearly all patients with renal failure on dialysis. Medical treatment of secondary hyperparathyroidism has considerably evolved over the past 2 decades, with parathyroidectomy reserved for severe cases. The primary objective of our study was to understand how trends in medical treatments affected parathyroidectomy rates in patients with secondary hyperparathyroidism on dialysis.
METHODS
We used the United States Renal Data System to identify 379,835 adult patients (age ≥18) who were on maintenance dialysis in the United States between 2006 and 2016 with Medicare as the primary payor and ascertained treatment for secondary hyperparathyroidism. Adjusted rate ratios for rates of parathyroidectomy were calculated using multivariable-adjusted Poisson regression.
RESULTS
Of 379,835 secondary hyperparathyroidism patients, 4,118 (1.1%) underwent parathyroidectomy, 39,835 (10.5%) received cinacalcet, 243,522 (64.1%) received phosphate binders, 17,571 (4.6%) received vitamin D analogs, and 86,899 (22.9%) received no treatment during the 10 years of follow-up. Over the entire study period, there was a 3.5-fold increase in the use of calcimimetics and a 3.4-fold increase in rates of parathyroidectomy. Compared to 2006 through 2009, utilization of parathyroidectomy increased 52% (adjusted rate ratio = 1.52, 95% confidence interval: 1.39-1.65) between 2010 and 2013 and by 106% (adjusted rate ratio = 2.06, 95% confidence interval: 1.90-2.24) between 2014 and 2016. The greatest increase in parathyroidectomy utilization occurred in younger patients (age 18-64 years), Black patients, female patients, those living in higher poverty neighborhoods, those listed for kidney transplant, and those who live in the Southern region of the United States.
CONCLUSION
Despite the evolution of medical treatments and an increase in the use of calcimimetics to treat secondary hyperparathyroidism, parathyroidectomy rates have been steadily increasing among dialysis patients with Medicare coverage.
背景
继发性甲状旁腺功能亢进症几乎影响所有接受透析治疗的肾衰竭患者。在过去的 20 年中，继发性甲状旁腺功能亢进症的治疗方法有了很大的发展，甲状旁腺切除术仅保留用于严重病例。我们研究的主要目的是了解继发性甲状旁腺功能亢进症患者的医学治疗方法的变化趋势如何影响甲状旁腺切除术的比率。
方法
我们使用美国肾脏数据系统确定了 379835 名成年患者（年龄≥18 岁），这些患者在美国接受维持性透析治疗，主要支付者为医疗保险，并确定了继发性甲状旁腺功能亢进症的治疗方法。使用多变量调整泊松回归计算甲状旁腺切除术的调整后率比。
结果
在 379835 例继发性甲状旁腺功能亢进症患者中，4118 例（1.1%）接受了甲状旁腺切除术，39835 例（10.5%）接受了西那卡塞治疗，243522 例（64.1%）接受了磷酸盐结合剂治疗，17571 例（4.6%）接受了维生素 D 类似物治疗，86899 例（22.9%）在 10 年的随访期间未接受任何治疗。在整个研究期间，钙敏感受体激动剂的使用增加了 3.5 倍，甲状旁腺切除术的比率增加了 3.4 倍。与 2006 年至 2009 年相比，2010 年至 2013 年甲状旁腺切除术的使用率增加了 52%（调整后率比为 1.52，95%置信区间：1.39-1.65），2014 年至 2016 年增加了 106%（调整后率比为 2.06，95%置信区间：1.90-2.24）。甲状旁腺切除术使用率的最大增加发生在年龄在 18-64 岁的年轻患者、黑人患者、女性患者、生活在贫困程度较高的社区的患者、等待肾移植的患者和生活在美国南部地区的患者中。
结论
尽管继发性甲状旁腺功能亢进症的治疗方法有所发展，并且钙敏感受体激动剂的使用增加了治疗继发性甲状旁腺功能亢进症，但医疗保险覆盖的透析患者中甲状旁腺切除术的比率仍在稳步上升。
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