【作者】 赵琦；

【导师】 边学海；

【作者基本信息】 吉林大学 ， 临床医学硕士（专业学位）， 2024， 硕士

【摘要】 目的:收集患有继发性甲状旁腺功能亢进(Secondary hyperparathyroidism,SHPT)的慢性肾脏病病人的临床资料,探究接受甲状旁腺切除术的病人发生低钙血症的可能相关因素,建立术后低钙血症预测模型和术后个体化补钙方案,减少术后低钙血症和骨饥饿综合征的发生。方法:本研究为回顾性研究,收集并分析在2017年2月到2022年2月期间于吉林大学中日联谊医院行手术治疗的SHPT病人101例,所有患者手术由本中心同一位外科医生完成。收集101例病人的临床资料,包括性别、年龄等基本信息,术前及术后血磷、术前及术后血钙、术前甲状旁腺激素等生化指标,术中甲状旁腺切除数目、是否行甲状旁腺移植、甲状旁腺移植量等手术相关资料。利用LASSO分析和单因素、多因素logistic回归分析,筛选出对术后低钙血症发生具有影响的因素,建立术后低钙血症的预测模型。模型建立完成后,根据最佳截断值进行模型预测分组,并评价基于模型的预测结果与基于实际血清学结果的一致性;绘制ROC曲线及校准曲线对模型预测效能进行评价。根据所建立的模型及cut off值,对患者进行术前低钙血症预测分组,并分别进行单因素及多因素回归分析,总结影响术后当日合理补钙量的因素并归纳合理补钙量公式。结果:本研究按照入排标准纳入SHPT病人101例,以7:3的比例划分为训练集(70例)和验证集(31例)。通过筛选最终确定体重、术前PTH、术前Ca为术后低钙血症的潜在预测因素(p<0.05)。纳入以上预测因素建立术后低钙血症预测模型,并分别绘制了训练集和验证集的ROC曲线、校准曲线,用于评价模型的区分度和校准度。结果表明,该模型具有较好的区分度和校准度,可以用于预测SHPT病人行甲状旁腺切除术后低钙血症的发生。将全部101例病人按照该预测模型进行术前分组,分为低钙血症低危组(n=52)及高危组(n=9)。分别对两组中病人的体重、术前PTH、术前Ca、术前P、术前ALP进行单因素分析及多因素线性回归分析,结果表明术前PTH、术前ALP是模型预测低危组术后当日合理补钙量的独立影响因素;术前PTH(p=0.049)与术后当日补钙量呈负相关,术前ALP(p=0.024)与术后当日补钙量呈正相关。最终分别归纳出模型预测低危组和模型预测高危组病人术后当日的合理补钙量公式。结论:1.本研究提示:体重、术前PTH是继发性甲状旁腺功能亢进病人行甲状旁腺切除术后发生低钙血症的独立危险因素;术前血钙是继发性甲状旁腺功能亢进病人行甲状旁腺切除术后发生低钙血症的保护因素。2.本研究建立的列线图预测模型具有较好的预测效能。3.术前预测低危组病人:术后当日合理补钙量公式为:静脉补钙量(g)=6.401+0.000498术前PTH+0.004术前ALP4.术前预测高危组病人术后当日合理补钙公式为静脉补钙量(g)=-9.920-0.005术前PTH+0.033术前ALP更多还原

【Abstract】 Objective: To collect clinical data of patients with secondary hyperparathyroidism(SHPT),screen for factors influencing hypocalcemia after parathyroidectomy,establish a predictive model for postoperative hypocalcemia,and individualized calcium supplementation regimen,aiming to reduce the incidence of postoperative hypocalcemia.Methods:This study is a retrospective analysis,collecting and analyzing data from 101 patients with SHPT who underwent surgery at a certain hospital from February 2017 to February 2022.All surgeries were performed by an experienced surgeon from our center.Clinical data of 101 patients were collected,including basic information such as gender and age,as well as preoperative and postoperative levels of serum phosphate,preoperative and postoperative serum calcium,preoperative parathyroid hormone levels,and other biochemical indicators.Surgical-related data such as the number of parathyroid glands removed during surgery,whether parathyroid transplantation was performed,and the amount of parathyroid transplantation were also collected.Factors influencing postoperative hypocalcemia were screened by LASSO analysis and logistic regression analysis,included in the model,and modeled.After the model was established,the model’s predictive groups were grouped according to the optimal cutoff value,and kappa consistency test was conducted with the test group;receiver operating characteristic curve(ROC)and clinical decision curve(DCA)were generated to assess the predictive performance of the model.According to the predictive model,patients were grouped,and univariate and ultivariable regression analyses were conducted to summarize the factors impacting appropriate calcium supplementation on the surgical day and derive the formula for such supplementation..Results:A total of 101 patients with SHPT were included in this study,divided into a training set(70 cases)and a validation set(31 cases)at a ratio of 7:3.Through screening,weight,preoperative PTH,and preoperative calcium were determined as potential predictive factors for postoperative hypocalcemia(p <0.05).A predictive model for postoperative hypocalcemia was established based on the above predictive factors,and ROC curves and DCA curves were drawn for the training and validation sets to evaluate the model’s discriminative ability,calibration,and clinical effectiveness.The results showed that the model had good discriminative ability and calibration,and could be used to predict the occurrence of postoperative hypocalcemia in patients with SHPT after parathyroidectomy.According to the predictive model,all 101 patients were divided into a low-risk group(n=52)and a high-risk group(n=9)for hypocalcemia.Univariate analysis and multivariate linear regression analysis of weight,preoperative PTH,preoperative calcium,preoperative phosphorus,and preoperative ALP in the two groups of patients showed that preoperative PTH and preoperative ALP were independent influencing factors for reasonable calcium supplementation on the day of surgery in the low-risk group;preoperative PTH(p=0.049)was negatively correlated with the amount of calcium supplementation on the day after surgery,and preoperative ALP(p=0.024)was positively correlated with the amount of calcium supplementation on the day after surgery.Finally,the formulas for reasonable calcium supplementation for the low-risk group and the high-risk group of postoperative hypocalcemia were deduced,respectively.Conclusion:1.This study suggests that weight and preoperative PTH are independent risk factors for hypocalcemia after parathyroidectomy in patients with SHPT;preoperative calcium is a protective factor for hypocalcemia.2.The linear predictive model established in this study has good predictive performance.3.Preoperative prediction of low-risk group patients: Formula for reasonable calcium supplementation on the day after surgery:Intravenous calcium supplementation(g)= 6.401 + 0.000498 preoperative PTH + 0.004 preoperative ALP5.Preoperative prediction of high-risk group patients: Formula for reasonable calcium supplementation on the day after surgery:Intravenous calcium supplementation(g)=-9.920-0.005 preoperative PTH + 0.033 preoperative ALP更多还原