甲状旁腺切除术后维持性血液透析患者腹主动脉钙化及骨代谢指标改变
|
摘要
目的观察维持性血液透析(maintenance hemodialysis,MHD)患者甲状旁腺切除术(parathyroidectomy,PTX)后腹主动脉钙化及骨代谢指标的改变并对相关因素进行分析。方法回顾性分析12例PTX后完成1年随访的MHD患者,满足PTX后1周血全段甲状旁腺素(intact parathyroid hormone,iPTH)≤600pg/ml,随访期间继发性甲状旁腺功能亢进未复发。收集患者的基线资料及术前、术后6、术后12月的腹主动脉钙化评分(abdominal aortic calcification score,AACS)、血清钙、血清磷、血清碱性磷酸酶、iPTH及血清骨代谢指标。结果 12例MHD患者年龄(51.33±13.28)岁,透析龄(138.58±57.61)月,男性(4/12,33.3%),女性(8/12,66.7%)。比较术前、术后6月、术后12月之间AACS无显著差异(χ~2=1.529,P=0.465)。术后充足补钙的结果是血清钙在术后6月较术前无显著差异(P=0.307),术后12月较术前明显降低(P=0.003)。血清磷在术后6月、12月较术前明显降低(P值均为0.043)。ALP在术后12月较术前明显降低(P=0.003)。iPTH在术后6月、12月较术前明显降低(P值分别为<0.001,0.003)。血清学骨代谢标志物与术前相比,TRACP、CTX、BAP在术后6月明显下降(P值分别为0.013,<0.001,0.002),在术后12月亦明显下降(P值分别为<0.001,0.001,<0.001)。P1NP、N-MID-OC在术后6月较术前下降,但无统计学差异(P值分别为0.124,0.307),在术后12月较术前明显下降(P值分别为<0.001,0.003)。结论小样本资料显示PTX可纠正钙、磷、ALP代谢紊乱,改善紊乱的血清骨代谢指标,减慢骨转运速度,阻止腹主动脉钙化进展,但对已发生的腹主动脉钙化可能无减轻作用。
Objective To investigate the changes of cardiovascular calcification and bone metabolism and their related factors after parathyroidectomy(PTX) in maintenance hemodialysis(MHD) patients. Methods Twelve MHD patients undergoing PTX operation and follow-up for one year were retrospectively analyzed. Intact parathyroid hormone(iPTH) of these patients was <600pg/ml after PTX for one week, and recurrence of secondary hyperparathyroidism was not found during the follow-up period. Baseline information, abdominal aortic calcification score(AACS), and serum calcium, phosphate, serum alkaline phosphatase(ALP),i PTH and bone metabolism markers were recruited before PTX and after PTX for 6 and 12 months. Results A total of 12 MHD patients after PTX(4 males and 8 females, 51.33 ±13.28 years of age, and 138.58±57.61 months of dialysis vintage) were enrolled in this study. There was no significant difference in AACS between baseline and after PTX for 6 and 12 months(χ~2=1.529,P=0.465). Adequate calcium supplement after PTX resulted in no significant difference in serum calcium between baseline and after PTX for 6 months. However,serum calcium was significantly lower after PTX for 12 months as compared to that of baseline(P=0.003). Serum phosphate levels after PTX for 6 and 12 months were significantly lower than the baseline value(P=0.043). ALP after PTX for 12 months was significantly lower than that of baseline(P=0.003). i PTH levels after PTX for 6 and 12 months were also significantly lower than the baseline value(P<0.001 and P=0.003 respectively). For serum bone metabolism markers, TRACP, CTX and BAP decreased significantly after PTX for 6 months(P=0.013, P<0.001 and P=0.002 respectively) and 12 months(P<0.001, P=0.001 and P<0.001 respectively); P1NP and N-MID-OC after PTX for 6 months were lower than those of baseline but without statistical significance(P=0.124 and 0.307 respectively). P1NP and N-MID-OC after PTX for 12 months were significantly lower those of baseline(P<0.001 and P=0.003 respectively). Conclusion PTX can improve the disorders of calcium, phosphate and ALP as well as bone metabolism, decrease the rate of bone metabolism turnover, and prevent the progression of cardiovascular calcification. However, PTX may not ameliorate the existed cardiovascular calcification.
Objective To investigate the changes of cardiovascular calcification and bone metabolism and their related factors after parathyroidectomy(PTX) in maintenance hemodialysis(MHD) patients. Methods Twelve MHD patients undergoing PTX operation and follow-up for one year were retrospectively analyzed. Intact parathyroid hormone(iPTH) of these patients was <600pg/ml after PTX for one week, and recurrence of secondary hyperparathyroidism was not found during the follow-up period. Baseline information, abdominal aortic calcification score(AACS), and serum calcium, phosphate, serum alkaline phosphatase(ALP),i PTH and bone metabolism markers were recruited before PTX and after PTX for 6 and 12 months. Results A total of 12 MHD patients after PTX(4 males and 8 females, 51.33 ±13.28 years of age, and 138.58±57.61 months of dialysis vintage) were enrolled in this study. There was no significant difference in AACS between baseline and after PTX for 6 and 12 months(χ~2=1.529,P=0.465). Adequate calcium supplement after PTX resulted in no significant difference in serum calcium between baseline and after PTX for 6 months. However,serum calcium was significantly lower after PTX for 12 months as compared to that of baseline(P=0.003). Serum phosphate levels after PTX for 6 and 12 months were significantly lower than the baseline value(P=0.043). ALP after PTX for 12 months was significantly lower than that of baseline(P=0.003). i PTH levels after PTX for 6 and 12 months were also significantly lower than the baseline value(P<0.001 and P=0.003 respectively). For serum bone metabolism markers, TRACP, CTX and BAP decreased significantly after PTX for 6 months(P=0.013, P<0.001 and P=0.002 respectively) and 12 months(P<0.001, P=0.001 and P<0.001 respectively); P1NP and N-MID-OC after PTX for 6 months were lower than those of baseline but without statistical significance(P=0.124 and 0.307 respectively). P1NP and N-MID-OC after PTX for 12 months were significantly lower those of baseline(P<0.001 and P=0.003 respectively). Conclusion PTX can improve the disorders of calcium, phosphate and ALP as well as bone metabolism, decrease the rate of bone metabolism turnover, and prevent the progression of cardiovascular calcification. However, PTX may not ameliorate the existed cardiovascular calcification.
引文
[1]Blacher J,Guerin AP,Pannier B,et al.Arterial Calcifications,Arterial Stiffness,and Cardiovascular Risk in End-Stage Renal Disease[J].Hypertension,2001,38(4):938-942.
[2]姚力,张凌,刘鹏,等.甲状旁腺切除术治疗难治性甲状旁腺功能亢进症89例疗效评价[J].中国血液净化,2009,8(8):431-436.
[3]Kauppila LI,Polak JF,Cupples LA,et al.New indices to classify location,severity and progression of calcific lesions in the abdominal aorta:a 25-year followup study[J].Atherosclerosis,1997,132(2):245-250.
[4]Honkanen E,Kauppila L,Wikstr?m B,et al.Abdominal aortic calcification in dialysis patients:results of the CORD study[J].Nephrol Dial Transplant,2008,23(12):4009-4015.
[5]陈丽平.慢性肾脏病血管异位钙化的药物治疗进展[J].临床合理用药杂志,2016,9(23):180-181.
[6]侯金花,蒋琦,刘志红.2017 KDIGO临床实践指南更新:慢性肾脏病矿物质与骨异常诊断、评估、预防和治疗[J].肾脏病与透析肾移植杂志,2017,26(5):462-466.
[7]Young-Ki L,Ryoung CS,Ajin C,et al.Predictors of vascular calcification progression in maintenance hemodialysis patients[J].Nephrology,2014,19(2),130.
[8]Kim HG,Song SW,Kim TY,et al.Risk factors for progression of aortic arch calcification in patients on maintenance hemodialysis and peritoneal dialysis[J].Hemodial Int,2011,15(4):460-467.
[9]Qiu PX,Xi SX,Ling Z,et al.Impact of Different Levels of iPTH on All-Cause Mortality in Dialysis Patients with Secondary Hyperparathyroidism after Parathyroidectomy[J].Biomed Res Int,2017,2017(4):1-7.
[10]Daniel WT,Weber C,Bailey JA,et al.Prospective analysis of coronary calcium in patients on dialysis undergoing a near-total parathyroidectomy[J].Surgery,2013,154(6):1315-1321.
[11]Neven E,De Schutter TM,De Broe ME,et al.Cell biological and physicochemical aspects of arterial calcification[J].Kidney Int,2011,79(11):1166-1177.
[12]Salam S,Gallagher O,Gossiel F,et al.Diagnostic Accuracy of Biomarkers and Imaging for Bone Turnover in Renal Osteodystrophy[J].J Am Soc Nephrol,2018,29(5):1557-1565.
[13]Hernandes FR,Canziani ME,Barreto FC,et al.The shift from high to low turnover bone disease after parathyroidectomy is associated with the progression of vascular calcification in hemodialysis patients:A12-month follow-up study[J].PloS One,2017,12(4):1-10.
[14]阚森,张倩,王梦婧,等.甲状旁腺切除术对血液透析患者冠状动脉钙化进展的影响[J].中国血液净化,2015,14(7):408-411.
[15]DiIorio B,Nargi O,Cucciniello E,et al.Coronary artery calcification progression is associated with arterial stiffness and cardiac repolarization deterioration in hemodialysis patients[J].Kidney Blood Press Res,2011,34(3):180-187.
[16]白建梅,张凌,金承刚,等.规律血液透析患者甲状旁腺激素水平对腹主动脉钙化的效应分析[J].中国动脉硬化杂志,2015,23(5):448-452.
[17]李晓琴,冉玉力,粟珏佳.甲状旁腺切除对血液透析患者冠状动脉钙化和心血管事件的影响[J].吉林医学,2016,37(7):1584-1586.
[18]高卓,刘东,张凌,等.甲状旁腺切除对血液透析患者心血管钙化影响的初步探讨[J].中国血液净化,2014,13(11):759-762.
[19]郑学,缪蕙,张欣洲,等.甲状旁腺切除术对终末期肾脏疾病患者冠状动脉钙化的影响[J].临床肾脏病杂志,2011,11(2):68-70.
[20]马丽洁,赵素梅,刘婧,等.甲状旁腺切除术对血液透析患者合并继发性甲状旁腺功能亢进骨代谢及骨密度的影响[J].中华肾脏病杂志,2015,31(1):13-18.
[21]Ishimura E,Okuno S,Okazaki H,et al.Significant association between bone-specific alkaline phosphatase and vascular calcification of the hand arteries in male hemodialysis patients[J].Kidney Blood Press Rese,2014,39(4):299-307.
[22]李璐瑶.骨特异性碱性磷酸酶与维持性血液透析患者心血管钙化的关系[D].上海交通大学,2016.
[23]张蕊,张念荣,席秋萍,等.维持性血液透析合并难治性继发性甲状旁腺功能亢进患者腹主动脉钙化相关因素分析[J].肾脏病与透析肾移植杂志,2017,26(5):432-437.
[2]姚力,张凌,刘鹏,等.甲状旁腺切除术治疗难治性甲状旁腺功能亢进症89例疗效评价[J].中国血液净化,2009,8(8):431-436.
[3]Kauppila LI,Polak JF,Cupples LA,et al.New indices to classify location,severity and progression of calcific lesions in the abdominal aorta:a 25-year followup study[J].Atherosclerosis,1997,132(2):245-250.
[4]Honkanen E,Kauppila L,Wikstr?m B,et al.Abdominal aortic calcification in dialysis patients:results of the CORD study[J].Nephrol Dial Transplant,2008,23(12):4009-4015.
[5]陈丽平.慢性肾脏病血管异位钙化的药物治疗进展[J].临床合理用药杂志,2016,9(23):180-181.
[6]侯金花,蒋琦,刘志红.2017 KDIGO临床实践指南更新:慢性肾脏病矿物质与骨异常诊断、评估、预防和治疗[J].肾脏病与透析肾移植杂志,2017,26(5):462-466.
[7]Young-Ki L,Ryoung CS,Ajin C,et al.Predictors of vascular calcification progression in maintenance hemodialysis patients[J].Nephrology,2014,19(2),130.
[8]Kim HG,Song SW,Kim TY,et al.Risk factors for progression of aortic arch calcification in patients on maintenance hemodialysis and peritoneal dialysis[J].Hemodial Int,2011,15(4):460-467.
[9]Qiu PX,Xi SX,Ling Z,et al.Impact of Different Levels of iPTH on All-Cause Mortality in Dialysis Patients with Secondary Hyperparathyroidism after Parathyroidectomy[J].Biomed Res Int,2017,2017(4):1-7.
[10]Daniel WT,Weber C,Bailey JA,et al.Prospective analysis of coronary calcium in patients on dialysis undergoing a near-total parathyroidectomy[J].Surgery,2013,154(6):1315-1321.
[11]Neven E,De Schutter TM,De Broe ME,et al.Cell biological and physicochemical aspects of arterial calcification[J].Kidney Int,2011,79(11):1166-1177.
[12]Salam S,Gallagher O,Gossiel F,et al.Diagnostic Accuracy of Biomarkers and Imaging for Bone Turnover in Renal Osteodystrophy[J].J Am Soc Nephrol,2018,29(5):1557-1565.
[13]Hernandes FR,Canziani ME,Barreto FC,et al.The shift from high to low turnover bone disease after parathyroidectomy is associated with the progression of vascular calcification in hemodialysis patients:A12-month follow-up study[J].PloS One,2017,12(4):1-10.
[14]阚森,张倩,王梦婧,等.甲状旁腺切除术对血液透析患者冠状动脉钙化进展的影响[J].中国血液净化,2015,14(7):408-411.
[15]DiIorio B,Nargi O,Cucciniello E,et al.Coronary artery calcification progression is associated with arterial stiffness and cardiac repolarization deterioration in hemodialysis patients[J].Kidney Blood Press Res,2011,34(3):180-187.
[16]白建梅,张凌,金承刚,等.规律血液透析患者甲状旁腺激素水平对腹主动脉钙化的效应分析[J].中国动脉硬化杂志,2015,23(5):448-452.
[17]李晓琴,冉玉力,粟珏佳.甲状旁腺切除对血液透析患者冠状动脉钙化和心血管事件的影响[J].吉林医学,2016,37(7):1584-1586.
[18]高卓,刘东,张凌,等.甲状旁腺切除对血液透析患者心血管钙化影响的初步探讨[J].中国血液净化,2014,13(11):759-762.
[19]郑学,缪蕙,张欣洲,等.甲状旁腺切除术对终末期肾脏疾病患者冠状动脉钙化的影响[J].临床肾脏病杂志,2011,11(2):68-70.
[20]马丽洁,赵素梅,刘婧,等.甲状旁腺切除术对血液透析患者合并继发性甲状旁腺功能亢进骨代谢及骨密度的影响[J].中华肾脏病杂志,2015,31(1):13-18.
[21]Ishimura E,Okuno S,Okazaki H,et al.Significant association between bone-specific alkaline phosphatase and vascular calcification of the hand arteries in male hemodialysis patients[J].Kidney Blood Press Rese,2014,39(4):299-307.
[22]李璐瑶.骨特异性碱性磷酸酶与维持性血液透析患者心血管钙化的关系[D].上海交通大学,2016.
[23]张蕊,张念荣,席秋萍,等.维持性血液透析合并难治性继发性甲状旁腺功能亢进患者腹主动脉钙化相关因素分析[J].肾脏病与透析肾移植杂志,2017,26(5):432-437.