【作者】 沈英；

【导师】 张萍；

【作者基本信息】 浙江大学 ， 内科学（肾脏病）， 2019， 硕士

【摘要】 目的:探讨甲状旁腺切除术(parathyroidectomy,PTX)对继发性甲状旁腺功能亢进(secondary hyperparathyroidism,SHPT)的尿毒症患者贫血及心功能的影响。方法:回顾性分析浙江大学附属第一医院2010年1月～2015年12月行甲状旁腺切除术(主要采用PTX加前臂移植术)的尿毒症SHPT患者,收集他们的一般资料及临床资料,至少随访1年,最长3年。应用配对T检验及非参数秩和检验方法比较手术前后贫血、超声心动图指标、干体重、血钙、血磷、白蛋白(ALb)、甲状旁腺激素(iPTH)等变化情况。根据患者术前是否存在左心室肥厚(LVH)分为LVH组和非LVH组,根据年龄分为老年组(≥60岁)和非老年组(<60岁),及术前EF值<60%组,分别比较各亚组患者手术前后超声心动图指标变化。结果:1.完成1年随访的患者共130例,其中血液透析(hemodialysis,HD)患者119例,腹膜透析(peritoneal dialysis,PD)患者11例,男性78例,女性52例。(1)与术前比较,术后1周、1个月、3个月、1年患者iPTH、血钙、磷明显下降(均P<0.01)。术后1周血ALb水平较术前下降,术后3个月、1年血ALb较术前升高,差异有统计学意义(P<0.01)。(2)与术前比较,术后1周、1个月患者血红蛋白(Hb)、红细胞比容(Hct)下降(P<0.01),术后3个月、1年Hb、Hct较术前、术后1个月显著升高(P<0.01)。术后3个月、1年患者促红细胞生成素(EPO)用量较术前、术后1个月减少,差异有统计学意义(P<0.01)。Mann-Kendall检验结果提示,EPO用量呈下降趋势(P<0.05)。(3)与术前比较,术后1年心超指标左室舒张末内径(LVDd)、室间隔舒张末厚度(IVSd)、左室后壁舒张末厚度(LVPWd)、室间隔收缩期厚度(IVSs)、左室收缩期内径(LVDs)、左心室心肌质量(LVM)、左心室心肌质量指数(LVMI)值均明显下降,干体重升高,差异有统计学意义(P<0.05或0.01),左室射血分数(EF)、左室短轴缩短率(FS)、左房内径(LA)、左室后壁收缩期厚度(PWS)与术前比较差异无统计学意义(p>0.05)。非LVH亚组患者术后1年IVSs较术前下降(P<0.05);LVH 亚组患者术后 1 年 LVDs、LVDd、LVPWd、LVM、LVMI、IVSs较术前下降,差异有统计学意义(P<0.05或0.01)。老年亚组患者术后1年LVPWd、LA、LVM、LVMI较术前下降(P<0.05);非老年亚组患者术后1年LVDd、LVPWd、LVDs、IVSs、LVM、LVMI较术前下降,差异有统计学意义(P<0.05或0.01)。EF<60%亚组患者术后1年EF、FS值较术前升高,LVDs、LVM、LVMI值下降,差异有统计学意义(P<0.05或0.01),其余指标与术前比较差异无统计学意义(P>0.05)。2.完成2年随访的患者共91例。与术前比较,术后1年心超指标LVDd、IVSs、LVDs、LVM、LVMI 显著下降,EF 升高(P<0.05 或 0.01),术后 2 年 LVDd、LVPWd、IVSs、LVDs、IVSd、LVM、LVMI 较术前显著下降(P<0.05 或 0.01);与术后 1 年比较,术后2年EF、FS下降,差异有统计学意义(P<0.05),余指标无统计学差异。非LVH亚组患者术后2年仅IVSs较术前下降(P<0.05);LVH亚组患者术后1年LVDs、LVDd、LVPWd、LVM、LVMI 较术前下降(P<0.05 或 0.01),术后 2 年LVDs、LVDd、LVPWd、IVSd、IVSs、LVM、LVMI 较术前下降,差异有统计学意义(P<0.05)。EF<60%亚组患者20例,与术前比较,术后1年EF、FS升高,LVDd、LVDs值下降,差异有统计学意义(P<0.01或0.05);与术前比较,术后2年 EF、FS 值升高,IVSd、LVDd、LVDs、LVM、LVMI 值下降(P<0.01 或 0.05);术后2年干体重较术后1年升高,IVSd值下降,差异有统计学意义(P<0.01或0.05)。3.完成3年随访的患者共14例。与术前比较,术后2年LVDd、LVDs、PWs、LVM、LVMI 值明显下降(P<0.01 或 0.05);术后 3 年 LVDd、LVDs、LVM、LVMI值较术前下降,差异有统计学意义(P<0.01或0.05)。结论:1.甲状旁腺切除加前臂移植术对难治性SHPT是一种安全有效的治疗手段,降低血钙、磷、PTH疗效确切,能明显改善患者贫血情况。2.PTX对患者左心室肥厚有较好改善作用,尤其对术前已存在心室肥厚的患者,能减轻心室重构的程度,对老年患者手术同样能带来显著的临床获益。另外,心脏收缩功能较低下的患者不仅能顺利渡过围手术期,而且术后EF等相关心超指标好转,有利于减少尿毒症SHPT患者心血管事件的发生。更多还原

【Abstract】 Objective:To explore the effect of parathyroidectomy(PTX)on the anemia and cardiac function in uremic patients with secondary hyperparathyroidism(SHPT).Methods:The uremic patients who undergoing PTX in first affiliated hospital of zhejiang university from January 2010 to December 2015 were included in this study.Their general data and clinical data were collected,then all patients were followed up for 1～3 years.Paired T test and non parametric rank sum test were used to compare the changes of anemia indicators,cardiac function indicators determined by echocardiography,dry weight,calcium,phosphorus,albumin(ALb)and parathyroid hormone(PTH)before and after operation.The patients were divided into LVH group and non-LVH group,elderly group(≥60 years old)and non-elderly group(<60 years old),and EF<60%group.The changes of echocardiographic parameters in each subgroup before and after operation were compared.Results:1.A total of 130 patients were followed up for 1 year,including 119 cases of hemodialysis(HD),11 cases of peritoneal dialysis(PD),78 cases of male and 52 cases of female.(1)Compared with preoperative period,iPTH,calcium and phosphorus decreased significantly 1 week,1 month,3 months and 1 year after operation(P<0.01).The serum ALb level decreased 1 week after operation,and increased 3 months,1 year after operation,the difference was statistically significant(P<0.01).(2)Compared with preoperative period,hemoglobin(Hb),hematocrit(Hct)decreased 1 week and 1 month after operation(P<0.01).The levels of Hb and Hct at 3 months and 1 year after operation were significantly higher than those before operation and 1 month after operation(P<0.01).Compared with pre-operation and 1 month after operation,erythropoietin average usage decreased significantly 3 months and 1 year after operation(P<0.01).Mann-Kendall test results indicate that the dosage of EPO showed a downward trend(P<0.05).(3)Compared with preoperative period,the cardiac function indexes(left ventricular end-diastolic diameter(LVDd),interventricular septum end-systolic thickness(IVSs),left ventricular end-systolic diameter(LVDs),left ventricular myocardial mass(LVM),left ventricular myocardial mass index(LVMI),interventricular septum end-diastolic thickness(IVSd),left ventricular posterior wall end-diastolic thickness(LVPWd))decreased significantly 1 year after operation,and dry weight increased(P<0.05 or 0.01);There was no significant difference in left ventricular ejection fraction(EF),left ventricular short axis shortening rate(FS),left atrial diameter(LA)and left ventricular posterior wall end-systolic thickness(PWS)(P>0.05).In the non-LVH group,only IVSs decreased 1 year after operation(P<0.05);In the LVH group,LVDs,LVDd,LVPWd,LVM,LVMI and IVSs decreased significantly 1 year after operation than those in preoperative period(P<0.05 or 0.01).In the elderly group,LVPWd,LA,LVM and LVMI decreased 1 year after operation(P<0.05);The levels of LVDd,LVPWd,LVDs,IVSs,LVM and LVMI in the non-elderly group at 1 year after operation were significantly lower than those before operation(P<0.05 or 0.01).EF and FS increased 1 year after operation in EF<60%group,while LVDs,LVM and LVMI decreased significantly(P<0.05 or 0.01),other indicators showed no significant difference compared with those before operation(P>0.05).2.A total of 91 patients were followed up for 2 years.Compared with preoperative period,LVDd,IVSs,LVDs,LVM and LVMI significantly decreased,EF increased 1 year after the operation(P<0.05 or 0.01);LVDd,LVPWd,IVSs,LVDs,IVSd,LVM and LVMI significantly decreased 2 years after the operation(P<0.05 or 0.01).Compared with 1 year after operation,EF and FS decreased significantly 2 years after operation(P<0.05).In non-LVH group,compared with preoperative period,only IVSs decreased 2 years after operation(P<0.05);In LVH group,compared with preoperative period,LVDs,LVDd,LVPWd,LVM and LVMI decreased 1 year after operation(P<0.05 or 0.01),LVDs,LVDd,LVPWd,IVSd,IVSs,LVM,LVMI decreased 2 years after the operation,the difference was statistically significant(P<0.05).There were 20 patients with EF<60%.Compared with pre-operation,EF and FS increased one year after operation,while LVDd and LVDs decreased(P<0.01 or 0.05).Compared with pre-operation,EF and FS increased two years after operation,while IVSd,LVDd,LVDs,LVM and LVMI decreased(P<0.01 or 0.05).Compared with one year after operation,dry weight increased two years after operation and IVSd decreased,the difference was statistically significant(P<0.01 or 0.05).3.A total of 14 patients completed the 3 years follow-up.Compared with preoperative period,LVDd,LVDs,PWs,LVM,LVMI decreased significantly 2 years after operation(P<0.01 or 0.05);LVDd,LVDs,LVM,LVMI decreased significantly 3 years after operation(P<0.01 or 0.05).Conclusions:PTX with forearm transplantation is a safe and effective treatment for uremic patients with SHPT.The reduction of calcium,phosphorus and PTH is effective and the situation of anemia is obviously improved after the operation.PTX has a good effect on improving left ventricular hypertrophy in patients,especially in patients with ventricular hypertrophy before operation,which can reduce the degree of ventricular remodeling,it can also bring significant clinical benefits to elderly patients.In addition,Patients with lower systolic function can not only successfully get through the perioperative period,but also their related echocardiographic indexes such as EF after operation are improved,PTX helps to reduce the incidence of cardiovascular events in uremic patients with SHPT.更多还原