手术治疗继发性甲状旁腺功能亢进多学科协作中的内科管理
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摘要
目的探讨多学科协作诊疗模式(multiple disciplinary team,MDT)在外科手术治疗肾性继发性甲状旁腺功能亢进(secondary hyperparathyroidism,SHPT)中的作用,并明确在MDT中肾脏内科及内分泌科的管理要点。方法回顾性收集2009年1月—2018年12月于四川大学华西医院因肾性SHPT行外科手术治疗的尿毒症患者临床资料。阐述MDT管理肾性SHPT的手术治疗流程,比较MDT成立前后指标变化。结果共纳入187例患者,其中男101例,女86例;平均年龄(47.60±11.28)岁;中位透龄7年。与MDT成立前相比,MDT成立后年均手术量明显提升[(8.50±5.10)vs.(59.50±2.12)例/年,P<0.001]、术前各项检查完善程度都大大提高(P<0.001),手术成功率较前提高(86.8%vs. 97.5%,P=0.010);由肾脏内科收入院的患者比例明显增高(39.7%vs. 84.9%,P<0.001),术后大部分患者转内分泌科(5.9%vs. 77.3%,P<0.001)继续术后低钙、骨病治疗,规范了手术治疗SHPT流程与管理。结论 MDT有助于肾性SHPT患者的综合管理,值得推广应用。肾脏内科与内分泌科可协助外科完善术前检查,充分做好术前准备及改善术后并发症,故重视手术治疗SHPT多学科协作中的内科管理尤为重要。
Objective To investigate the role of multiple disciplinary team(MDT) during surgical treatment of renal secondary hyperparathyroidism(SHPT), and identify management points of Departments of Nephrology and Endocrinology. Methods The data of patients with chronic kidney disease undergoing surgical treatment for SHPT in West China Hospital of Sichuan University between January 2009 and December 2018 were retrospectively collected. We explained the surgical treatment of MDT in the management of renal SHPT, and compared the changes before and after the establishment of MDT. Results A total of 187 patients including 101 males and 86 females were enrolled, with an average age of(47.60±11.28) years old and median dialysis vintage of 7 years. Under MDT, the number of patients with parathyroidectomy increased [(8.50±5.10) vs.(59.50±2.12) patients/year, P<0.001] and the completion rate of preoperative examinations were greatly improved(P<0.001). The success rate of surgery was also increased(86.8% vs. 97.5%, P=0.010).Proportion of patients who were admitted to the Department of Nephrology was significantly increased(39.7% vs. 84.9%,P<0.001). Most patients after surgery were transferred to the Department of Endocrinology(5.9% vs. 77.3%, P<0.001) to manage postoperative complications and metabolic bone disease, and thus normalized the management of SHPT.Conclusions The MDT contributes to management of renal SHPT, which is worthy of popularization and spreading.The management of internal medicine departments during surgical treatment of SHPT based on MDT is important,because they can be helpful to complete preoperative examinations and preoperative preparation as well as to alleviate postoperative complications.
Objective To investigate the role of multiple disciplinary team(MDT) during surgical treatment of renal secondary hyperparathyroidism(SHPT), and identify management points of Departments of Nephrology and Endocrinology. Methods The data of patients with chronic kidney disease undergoing surgical treatment for SHPT in West China Hospital of Sichuan University between January 2009 and December 2018 were retrospectively collected. We explained the surgical treatment of MDT in the management of renal SHPT, and compared the changes before and after the establishment of MDT. Results A total of 187 patients including 101 males and 86 females were enrolled, with an average age of(47.60±11.28) years old and median dialysis vintage of 7 years. Under MDT, the number of patients with parathyroidectomy increased [(8.50±5.10) vs.(59.50±2.12) patients/year, P<0.001] and the completion rate of preoperative examinations were greatly improved(P<0.001). The success rate of surgery was also increased(86.8% vs. 97.5%, P=0.010).Proportion of patients who were admitted to the Department of Nephrology was significantly increased(39.7% vs. 84.9%,P<0.001). Most patients after surgery were transferred to the Department of Endocrinology(5.9% vs. 77.3%, P<0.001) to manage postoperative complications and metabolic bone disease, and thus normalized the management of SHPT.Conclusions The MDT contributes to management of renal SHPT, which is worthy of popularization and spreading.The management of internal medicine departments during surgical treatment of SHPT based on MDT is important,because they can be helpful to complete preoperative examinations and preoperative preparation as well as to alleviate postoperative complications.
引文
1Wang F, Yang C, Long J, et al. Executive summary for the 2015Annual Data Report of the China Kidney Disease Network(CK-NET). Kidney Int, 2019, 95(3):501-505.
2 Levin A, Bakris GL, Molitch M, et al. Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease:results of the study to evaluate early kidney disease. Kidney Int, 2007, 71(1):31-38.
3Block GA, Klassen PS, Lazarus JM, et al. Mineral metabolism,mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol, 2004, 15(8):2208-2218.
4 Tentori F, Blayney MJ, Albert JM, et al. Mortality risk for dialysis patients with different levels of serum calcium, phosphorus, and PTH:the Dialysis Outcomes and Practice Patterns Study(DOPPS).Am J Kidney Dis, 2008, 52(3):519-530.
5Ketteler M, Block GA, Evenepoel PA, et al. Executive summary ofthe 2017 KDIGO Chronic Kidney Disease-Mineral and Bone Disorder(CKD-MBD)Guideline Update:what’s changed and why it matters. Kidney Int, 2017, 92(1):26-36.
6Kim SM, Long J, Montez-Rath ME, et al. Rates and outcomes of parathyroidectomy for secondary hyperparathyroidism in the United States. Clin J Am Soc Nephrol, 2016, 11(7):1260-1267.
7 Fleissig A, Jenkins V, Catt S, et al. Multidisciplinary teams in cancer care:are they effective in the UK?. Lancet Oncol, 2006,7(11):935-943.
8杨晓春,杨帆,李根,等.手术治疗继发性甲状旁腺功能亢进症的多学科协作探讨.中国临床研究, 2015, 28(6):757-760.
9 廖泉.多科合作诊治甲状旁腺功能亢进症.外科理论与实践,2018, 23(2):7-9.
10Pitt SC, Sippel RS, Chen H. Secondary and tertiary hyperparathyroidism, state of the art surgical management. Surg Clin North Am, 2009, 89(5):1227-1239.
11 Mehanna HM, Jain A, Randeva H, et al. Postoperative hypocalcemia-the difference a definition makes. Head Neck, 2010,32(3):279-283.
12Lamb BW, Wong HW, Vincent C, et al. Teamwork and team performance in multidisciplinary cancer teams:development and evaluation of an observational assessment tool. BMJ Qual Saf, 2011,20(10):849-856.
13 陈海珍,陈曦.肾性继发性甲状旁腺功能亢进症的多学科协作治疗.外科理论与实践, 2018, 23(2):17-21.
14Khosla S, Ebeling PR, Firek AF, et al. Calcium infusion suggests a “set-point” abnormality of parathyroid gland function in familial benign hypercalcemia and more complex disturbances in primary hyperparathyroidism. J Clin Endocrinol Metab, 1993, 76(3):715-720.
15 王新玲,衣巴地古丽·库吐鲁克,张竞,等.静脉钙负荷甲状旁腺功能抑制实验的临床应用及安全性评价.医学研究杂志, 2017,46(10):92-95.
16Rodriguez M, Ure?a-Torres P, Pétavy F, et al. Calcium-mediated parathyroid hormone suppression to assess progression of secondary hyperparathyroidism during treatment among incident dialysis patients. J Clin Endocrinol Metab, 2013, 98(2):618-625.
17 Mccarron DA, Muther RS, Lenfesty B, et al. Parathyroid function in persistent hyperparathyroidism:relationship to gland size.Kidney Int, 1982, 22(6):662-670.
18Indridason OS, Heath H, Khosla S, et al. Non-suppressible parathyroid hormone secretion is related to gland size in uremic secondary hyperparathyroidism. Kidney Int, 1996, 50(5):1663-1671.
19 Goodman WG, Veldhuis JD, Belin TR, et al. Calcium-sensing by parathyroid glands in secondary hyperparathyroidism. J Clin Endocrinol Metab, 1998, 83(8):2765-2772.
20田文,贺青卿,姜可伟,等.慢性肾功能衰竭继发甲状旁腺功能亢进外科临床实践专家共识.中国实用外科杂志, 2016, 36(5):481-486.
21 Cheng SP, Liu CL, Chen HH, et al. Prolonged hospital stay after parathyroidectomy for secondary hyperparathyroidism. World J Surg, 2009, 33(1):72-79.
22National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis, 2003, 42(4 Suppl 3):S1-S201.
23 卞维静,张凌,王文博,等.透析患者甲状旁腺切除术后低钙血症的发生及处理.中国血液净化, 2011, 10(5):246-249.
24Isik Y, Goktas U, Yuzkat N, et al. Hungry bone syndrome as a cause of recurrent laryngospasm after parathyroidectomy. Eur J Anaesthesiol, 2011, 28(2):142-143.
25 国家肾脏疾病临床医学研究中心.中国慢性肾脏病矿物质和骨异常诊治指南概要.肾脏病与透析肾移植杂志, 2019, 28(1):52-57.
26Nenonen A, Cheng SL, Ivaska KK, et al. Serum TRACP 5b is a useful marker for monitoring alendronate treatment:comparison with other markers of bone turnover. J Bone Miner Res, 2005,20(10):1804-1812.
27 Glover SJ, Eastell R, McCloskey EV, et al. Rapid and robust response of biochemical markers of bone formation to teriparatide therapy. Bone, 2009, 45(6):1053-1058.
28Lu KC, Ma WY, Yu JC, et al. Bone turnover markers predict changes in bone mineral density after parathyroidectomy in patients with renal hyperparathyroidism. Clin Endocrinol(Oxf),2012, 76(5):634-642.
2 Levin A, Bakris GL, Molitch M, et al. Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease:results of the study to evaluate early kidney disease. Kidney Int, 2007, 71(1):31-38.
3Block GA, Klassen PS, Lazarus JM, et al. Mineral metabolism,mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol, 2004, 15(8):2208-2218.
4 Tentori F, Blayney MJ, Albert JM, et al. Mortality risk for dialysis patients with different levels of serum calcium, phosphorus, and PTH:the Dialysis Outcomes and Practice Patterns Study(DOPPS).Am J Kidney Dis, 2008, 52(3):519-530.
5Ketteler M, Block GA, Evenepoel PA, et al. Executive summary ofthe 2017 KDIGO Chronic Kidney Disease-Mineral and Bone Disorder(CKD-MBD)Guideline Update:what’s changed and why it matters. Kidney Int, 2017, 92(1):26-36.
6Kim SM, Long J, Montez-Rath ME, et al. Rates and outcomes of parathyroidectomy for secondary hyperparathyroidism in the United States. Clin J Am Soc Nephrol, 2016, 11(7):1260-1267.
7 Fleissig A, Jenkins V, Catt S, et al. Multidisciplinary teams in cancer care:are they effective in the UK?. Lancet Oncol, 2006,7(11):935-943.
8杨晓春,杨帆,李根,等.手术治疗继发性甲状旁腺功能亢进症的多学科协作探讨.中国临床研究, 2015, 28(6):757-760.
9 廖泉.多科合作诊治甲状旁腺功能亢进症.外科理论与实践,2018, 23(2):7-9.
10Pitt SC, Sippel RS, Chen H. Secondary and tertiary hyperparathyroidism, state of the art surgical management. Surg Clin North Am, 2009, 89(5):1227-1239.
11 Mehanna HM, Jain A, Randeva H, et al. Postoperative hypocalcemia-the difference a definition makes. Head Neck, 2010,32(3):279-283.
12Lamb BW, Wong HW, Vincent C, et al. Teamwork and team performance in multidisciplinary cancer teams:development and evaluation of an observational assessment tool. BMJ Qual Saf, 2011,20(10):849-856.
13 陈海珍,陈曦.肾性继发性甲状旁腺功能亢进症的多学科协作治疗.外科理论与实践, 2018, 23(2):17-21.
14Khosla S, Ebeling PR, Firek AF, et al. Calcium infusion suggests a “set-point” abnormality of parathyroid gland function in familial benign hypercalcemia and more complex disturbances in primary hyperparathyroidism. J Clin Endocrinol Metab, 1993, 76(3):715-720.
15 王新玲,衣巴地古丽·库吐鲁克,张竞,等.静脉钙负荷甲状旁腺功能抑制实验的临床应用及安全性评价.医学研究杂志, 2017,46(10):92-95.
16Rodriguez M, Ure?a-Torres P, Pétavy F, et al. Calcium-mediated parathyroid hormone suppression to assess progression of secondary hyperparathyroidism during treatment among incident dialysis patients. J Clin Endocrinol Metab, 2013, 98(2):618-625.
17 Mccarron DA, Muther RS, Lenfesty B, et al. Parathyroid function in persistent hyperparathyroidism:relationship to gland size.Kidney Int, 1982, 22(6):662-670.
18Indridason OS, Heath H, Khosla S, et al. Non-suppressible parathyroid hormone secretion is related to gland size in uremic secondary hyperparathyroidism. Kidney Int, 1996, 50(5):1663-1671.
19 Goodman WG, Veldhuis JD, Belin TR, et al. Calcium-sensing by parathyroid glands in secondary hyperparathyroidism. J Clin Endocrinol Metab, 1998, 83(8):2765-2772.
20田文,贺青卿,姜可伟,等.慢性肾功能衰竭继发甲状旁腺功能亢进外科临床实践专家共识.中国实用外科杂志, 2016, 36(5):481-486.
21 Cheng SP, Liu CL, Chen HH, et al. Prolonged hospital stay after parathyroidectomy for secondary hyperparathyroidism. World J Surg, 2009, 33(1):72-79.
22National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis, 2003, 42(4 Suppl 3):S1-S201.
23 卞维静,张凌,王文博,等.透析患者甲状旁腺切除术后低钙血症的发生及处理.中国血液净化, 2011, 10(5):246-249.
24Isik Y, Goktas U, Yuzkat N, et al. Hungry bone syndrome as a cause of recurrent laryngospasm after parathyroidectomy. Eur J Anaesthesiol, 2011, 28(2):142-143.
25 国家肾脏疾病临床医学研究中心.中国慢性肾脏病矿物质和骨异常诊治指南概要.肾脏病与透析肾移植杂志, 2019, 28(1):52-57.
26Nenonen A, Cheng SL, Ivaska KK, et al. Serum TRACP 5b is a useful marker for monitoring alendronate treatment:comparison with other markers of bone turnover. J Bone Miner Res, 2005,20(10):1804-1812.
27 Glover SJ, Eastell R, McCloskey EV, et al. Rapid and robust response of biochemical markers of bone formation to teriparatide therapy. Bone, 2009, 45(6):1053-1058.
28Lu KC, Ma WY, Yu JC, et al. Bone turnover markers predict changes in bone mineral density after parathyroidectomy in patients with renal hyperparathyroidism. Clin Endocrinol(Oxf),2012, 76(5):634-642.