甲状旁腺切除术后维持性血液透析患者腹主动脉钙化的改变

目的 观察维持性血液透析(maintenance hemodialysis,MHD)合并继发性甲状旁腺功能亢进(secondary hyperparathyroidism,SHPT)患者行甲状旁腺切除术(parathyroidectomy,PTX)后腹主动脉钙化及生化指标的发展变化.方法 回顾性分析完成2年随访的严重SHPT患者,按是否行PTX分成PTX手术组和非手术组,观察术后2年腹主动脉钙化评分(abdominal aortic calcification score,AACS)、血清全段甲状旁腺素(iPTH)、血钙、血磷等变化.PTX手术组按照术后2年腹主动脉钙化有无进展分为进展组和非进展组,对比两组的年龄、透析龄、iPTH、血钙、血磷、钙磷乘积等指标,分析腹主动脉钙化进展的相关因素.结果 共纳入44例MHD合并SHPT患者,PTX手术组26例,非手术组18例.PTX手术组与非手术组基线资料比较,透析龄差异有统计学意义(P<0.05),而性别、年龄、高血压史等差异均无统计学意义.与术前比较,PTX手术组患者术后2年血iPTH、血钙、血磷均降低(均P<0.05),AACS前后差异无统计学意义.患者术后2年有8例(30.77%)腹主动脉钙化加速进展,8例(30.77%)腹主动脉钙化好转,10例(38.46%)腹主动脉钙化稳定.患者术后2年腹主动脉钙化非进展组iPTH值低于进展组(20.62+6.44) ng/L比(132.72±76.83) ng/L,P<0.05],而非进展组术前AACS高于进展组(13.11±2.71)分比(2.00±1.41)分,P<0.05].非手术组患者2年后AACS高于基线水平(10.44±1.65)分比(8.05±1.26)分,P<0.05],血磷及钙磷乘积显著下降(均P<0.05),iPTH、血钙等水平无明显变化(均P>0.05).Pearson相关分析结果显示,PTX手术组术后2年AACS相对于术前的下降值与iPTH下降值(r=0.534,P=0.012)、血钙下降值(r=0.643,P=0.004)、血磷下降值(r=0.897,P<0.001)、钙磷乘积的下降值(r=0.568,P=0.021)呈正相关,与术前AACS值呈负相关(r=-0.647,P=0.014).结论 小样本资料显示,相比非手术治疗,PTX可长期纠正甲状旁腺素、钙、磷代谢紊乱,并有阻止腹主动脉钙化进展甚至逆转血管钙化的可能,而腹主动脉钙化逆转可能与iPTH、血Ca、血P、钙磷乘积的下降程度相关.

Changes of abdominal aortic calcification after parathyroidectomy in maintenance hemodialysis patients

Objective To observe the changes of abdominal aortic calcification and biochemical indicators after parathyroidectomy (PTX) in the maintenance hemodialysis (MHD) patients with secondary hyperparathyroidism (SHPT). Methods The MHD patients with SHPT who were followed up for 2 years were analyzed retrospectively and divided into PTX surgery group (n=26) and non-surgery group (n=18) according to whether they underwent PTX，and then the abdominal aortic calcification score (AACS), intact parathyroid hormone (iPTH), blood calcium and phosphorus after 2 years were observed in the two groups. The PTX surgery group was divided into advanced group and non-advanced group according to whether abdominal aortic calcification had progressed or not 2 years after the operation. Indicators such as age, dialysis age, iPTH, blood calcium, blood phosphorus, calcium and phosphorus product were compared between the two groups to analyze the possible factors related to the development of abdominal aortic calcification. Results A total of 44 patients meeting the inclusion criteria were included, with 26 in the PTX surgery group and 18 in the non-surgery group. The baseline data of the PTX surgery group and the non-surgery group showed statistical difference in the age of dialysis (P＜0.05), but no statistical differences in gender, age and history of hypertension. Compared with preoperative indicators, postoperative iPTH, blood calcium and phosphorus significantly reduced (all P＜0.05), and there was no significant difference in AACS. There were 8 cases (30.77%) of accelerating progress of calcification, 8 cases (30.77%) of improvement in calcification, 10 cases (38.46%) of calcification stability. After 2 years, iPTH value of non-advanced group was significantly lower than advanced group (20.62±6.44) ng/L vs (132.72±76.83) ng/L], while the preoperative AACS progress was higher in non-advanced group (13.11±2.71) vs (2.00±1.41)] (all P＜0.05). In non-surgery group, AACS was significantly higher after 2 years (10.44±1.65) vs (8.05±1.26)], blood phosphorus and the product of blood calcium and phosphorus significantly decreased (all P＜0.05) , and the levels of iPTH and blood calcium did not significantly change. Pearson correlation analysis showed that the decreased value between preoperative AACS and 2-year postoperative AACS was positively correlated with the decreased value of iPTH (r=0.534, P=0.012), blood calcium (r=0.643, P=0.004), blood phosphorus (r=0.897, P＜0.001) and calcium-phosphorus product (r=0.568, P=0.021）, and negatively correlated with preoperative AACS (r=-0.647，P=0.014). Conclusions Small sample data shows that PTX can correct parathyroid hormone, calcium and phosphorus for long term, and prevent abdominal aortic calcification progression, even reverse vascular calcification. Whether abdominal aortic calcification improves or not may be associated with the decrease of iPTH, calcium, phosphorus and the product of blood calcium and phosphorus.