超声引导经皮热消融与甲状旁腺切除术治疗继发性甲状旁腺功能亢进疗效与安全性比较的Meta分析

背景与目的 继发性甲状旁腺功能亢进（SHPT）是慢性肾病（CKD）常见的一种并发症，体内钙磷平衡紊乱导致甲状旁腺激素（PTH）代偿性过度分泌。药物治疗效果不佳的患者进展成为难治性SHPT，外科切除增生的甲状旁腺是目前治疗SHPT的有效方法，但手术治疗存在一定的局限性，如手术、麻醉双重风险较高，术后可发生感染、永久性甲状旁腺功能减退、瘢痕增生等潜在风险。随着科学技术的进步，热消融治疗SHPT成为研究热点，但尚缺乏统一诊疗规范，需要更多的循证医学证据促进诊疗标准化的制定。因此，本文通过比较超声引导下热消融与传统甲状旁腺切除术（PTX）治疗SHPT的临床有效性和安全性，探讨热消融术在难治性SHPT治疗中的临床应用前景。方法 检索多个国内外数据库，收集比较超声介导的热消融与传统开放式PTX治疗CKD继发的难治性SHPT的临床对照研究，检索时间为建库至2022年11月30日。根据纳入与排除标准筛选文献后。使用ReveMan 5.3软件行Meta分析。评价指标为术后3、6个月的血清PTH与血清钙水平、住院时间、低钙血症与声音嘶哑的发生率。结果 最终纳入12项研究，共1 060例患者，其中热消融组510例，PTX组550例。与PTX比较，热消融组术后3、6个月PTH水平（MD=18.18，95% CI=-21.19~57.55，P=0.37；MD=-5.35，95% CI=-32.59~21.90，P=0.70）、血钙水平（MD=-0.09，95% CI=-0.28~0.10，P=0.35；MD=-0.10，95% CI=-0.29~0.10，P=0.34）差异均无统计学意义。热消融组低钙血症发生率低于PTX组（18.5% vs. 27.3%），差异有统计学意义（OR=0.57，95% CI=0.38~0.84，P=0.005），两组声音嘶哑发生率差异无统计学意义（OR=0.89，95% CI=0.55~1.45，P=0.64）。热消融组住院时间明显短于PTX组（MD=-3.97，95% CI=-5.68~-2.27，P<0.000 1）。结论 超声引导经皮热消融治疗SHPT可能是PTX的一种替代技术，具备安全、有效、可重复性高、并发症少等特点，但其最终的优越性需要大样本、多中心前瞻性随机对照试验来证明。

Comparison of clinical efficacy and safety between ultrasound-guided thermal ablation and traditional parathyroidectomy for secondary hyperparathyroidism: a Meta-analysis

Background and Aims Secondary hyperparathyroidism (SHPT) is a common complication of chronic kidney disease (CKD), characterized by imbalances in calcium and phosphorus homeostasis leading to compensatory overproduction of parathyroid hormone (PTH). Patients with poor response to medical treatment progress to refractory SHPT, and surgical removal of hypertrophic parathyroid glands is currently an effective method. However, surgical treatment has limitations, including high risks associated with surgery and anesthesia, as well as potential postoperative complications such as infection, permanent parathyroid dysfunction, and scar formation. With advancements in medical technology, thermal ablation has become a research focus for SHPT treatment, but standardized diagnostic and therapeutic protocols are lacking, necessitating more evidence from evidence-based medicine to facilitate the development of standardized guidelines. Therefore, this study was conducted to compare the clinical effectiveness and safety of ultrasound-guided thermal ablation with traditional parathyroidectomy (PTX) in the treatment of refractory SHPT and explore the clinical prospects of thermal ablation in the management of refractory SHPT.Methods Multiple domestic and international databases were searched to collect clinical controlled studies comparing ultrasound-guided thermal ablation with traditional open PTX in the treatment of refractory SHPT of CKD. The search period extended from the inception of each database to November 31, 2022. After applying inclusion and exclusion criteria, literature screening was conducted, and Meta-analysis was performed using RevMan 5.3 software. Evaluation indicators included serum PTH and calcium levels at 3 and 6 months postoperatively, hospitalization duration, and the incidence of hypocalcemia and hoarseness.Results A total of 12 studies involving 1 060 patients were included, with 510 in the thermal ablation group and 550 in the PTX group. Compared to the PTX group, the thermal ablation group showed no statistically significant differences in postoperative 3- and 6-month PTH levels (MD=18.18, 95% CI=-21.19-57.55, P=0.37; MD=-5.35, 95% CI=-32.59-21.90, P=0.70) and calcium levels (MD=-0.09, 95% CI=-0.28-0.10, P=0.35; MD=-0.10, 95% CI=-0.29-0.10, P=0.34). The incidence of hypocalcemia in the thermal ablation group was lower than that in the PTX group (18.5% vs. 27.3%), with a statistical difference (OR=0.57, 95% CI=0.38-0.84, P=0.005), while the incidence of hoarseness showed no significant difference between the two groups (OR=0.89, 95% CI=0.55-1.45, P=0.64). The thermal ablation group had a significantly shorter hospitalization duration than the PTX group (MD=-3.97, 95% CI=-5.68--2.27, P<0.000 1).Conclusion Ultrasound-guided percutaneous thermal ablation for SHPT may be a potential alternative to PTX, demonstrating safety, effectiveness, high repeatability, and fewer complications. However, its ultimate superiority requires confirmation through large-sample, multicenter, prospective, randomized controlled studies.