术中及围手术期血清iPTH监测对501例继发性甲状旁腺功能亢进患者手术效果的精准诊断研究——“Diagnostic Accuracy Study of Intraoperative and Perioperative Serum Intact PTH Level for Successful Parathyroidectomy in 501 Secondary Hyperparathyroidism Patients”的二  

Diagnostic accuracy study of preoperative and postoperative serum intact PTH levels for the effects of parathyroidectomy in 501 secondary hyperparathyroidism patients

作　　者：张丽娜[1] 邢昌赢[1] 沈冲[2] 曾鸣[1] 杨光[1] 毛慧娟[1] 张波[1] 俞香宝[1] 孙彬[1] 欧阳春[1] 葛益飞[1] 江瑶[1] 尹彩霞[1] 查小明[3] 王宁宁[1] 

机构地区：[1]南京医科大学第一附属医院肾内科,南京210029 [2]南京医科大学公共卫生学院流行病与统计学系,南京211166 [3]南京医科大学第一附属医院普通外科,南京210029

出　　处：《中国血液净化》2017年第4期227-233,共7页Chinese Journal of Blood Purification

基　　金：国家自然科学基金(81270408,81570666);中华医学会临床科研专项基金首届肾脏病青年研究基金(13030300415);江苏省“医学重点人才”项目(RC201162);江苏省肾脏病临床研究中心(BL2014080)

摘　　要：目的甲状旁腺切除术(parathyroidectomy,PTX)是继发性甲状旁腺功能亢进患者(secondary hyperparathyroidism,SHPT)的有效治疗方式,然而由于甲状旁腺位置和数目异常的存在,部分患者术后SHPT仍持续存在。本研究探讨PTX患者术中及围手术期血清全段甲状旁腺激素(intact parathyroid hormone,iPTH)监测对手术效果精准诊断的意义。方法记录501例行甲状旁腺全切+自体前臂移植术(不伴胸腺切除)的慢性肾脏病患者的术中及围手术期血清iPTH值。术后一周内患者血清iPTH≤50 pg/ml为手术成功;若>50 pg/ml则在6月内进行随访,随访血清iPTH<300 pg/mL即为手术成功,否则为SHPT持续存在。结果 433例(86.4%)患者手术成功,49例(9.8%)患者SHPT持续存在,19例(3.8%)患者缺乏有效随访归为手术效果未知组。肝炎(n=204)与非肝炎(n=297)患者比较,基线血清iPTH水平及术中血清iPTH下降百分比无显著统计学差异(P>0.05)。受试者工作特征(receiver operating characteristic,ROC)曲线结果表明术后20分钟血清iPTH下降≥88.9%提示手术成功(曲线下面积0.909,敏感度78.6%,特异度88.5%)。术后4天血清iPTH≥147.4 pg/ml提示SHPT持续存在(曲线下面积0.998,敏感度100%,特异度99.5%)。结论甲状旁腺切除术中血清iPTH监测能提示甲状旁腺切除是否彻底,避免对患者不必要的探查,降低手术并发症的发生率。围手术期血清iPTH监测提示SHPT是否持续存在,对此类患者需密切随访、及时开始药物治疗或必要时再次手术。Objectives Parathyroidectomy （PTX） is an effective treatment for severe secondary hyperpara- thyroidism （SHPT）. However, persistent SHPT may occur because of the presence of supernumerary and ecto- pic parathyroids. This is a diagnostic accuracy study of preoperative and postoperative serum intact parathyroid hormone （iPTH） to predict the effects of PTX. Methods Intraoperative and perioperative serum iPTH values were recorded in 501 SHPT patients treated with total PTX＋autotransplantation and without thymectomy. Patients with serum iPTH ~〈50 pg/mL in the first week after PTX were classified as successful PTX. Pa- tients with serum iPTH^50 pg/mL in the first week after PTX were followed up for 6 months; successful PTX was defined if the follow-up iPTH level was ~300 pg/mL, and persistent SHPT was considered if the iPTH was 〉300 pg/mL. Results A total of 433 （86.4%） patients were defined as successful PTX, 49 （9.8%） as persistent SHPT, and 19 （3.8%） as undetermined due to the incomplete follow-up. Preoperative and postop- erative serum iPTH levels had no significant differences between patients with chronic hepatitis （n=204） and those without chronic hepatitis （n=297）. Receiver operating characteristic （ROC） curves showed that the decrease of iPTH level by≥88.9% after the surgery for 20 minutes could predict successful PTX, with the area under the curve （AUC） of 0.909, the sensitivity of 78.6% and the specificity of 88.5%. Serum iPTH ≥147.4 pg/mL after the surgery for 4 days could predict persistent SHPT, with the AUC of 0.998, the sensitivity of 100% and the specificity of 99.5%. Conclusion Monitoring of postoperative iPTH level can effectively predict the completeness of PTX, thereby avoiding unnecessary re-operation and its possible complications, Perioperative iPTH monitoring is useful for the prediction of persistent SHPT, for which follow-up study, medical intervention or re-operation may be necessary.

关 键 词：术中 围手术期 甲状旁腺激素 甲状旁腺切除术 继发性甲状旁腺功能亢进 

分 类 号：R318.16[医药卫生—生物医学工程]