
Effects of different dialysis modalities on long-term prognosis after parathyroidectomy in patients with secondary hyperparathyroidism
Liu Xiaoyi, Zhang Zhe, Xie Chao, Hou Aizhen, Ye Peiyi, Kong Yaozhong
Effects of different dialysis modalities on long-term prognosis after parathyroidectomy in patients with secondary hyperparathyroidism
Objective To compare the survival rate of secondary hyperparathyroidism (SHPT) patients with different dialysis modalities after parathyroidectomy (PTX), and analyze the influencing factors of survival prognosis. Methods Clinical data of dialysis patients diagnosed with SHPT and treated with PTX in the First People′s Hospital of Foshan from April 2014 to May 2019 were retrospectively collected and analyzed. The patients were divided into hemodialysis (HD) group and peritoneal dialysis (PD) group according to preoperative dialysis modalities, and the differences in baseline clinical data and cardiac ultrasound results were compared between the two groups. Kaplan-Meier survival analysis was used to compare the difference in cumulative survival rate between the two groups. Multivariate Cox regression model was used to analyze the influencing factors of all-cause death. Receiver operating characteristic curve (ROC curve) was used to predict the risk of all-cause death. Results A total of 99 patients were enrolled in this study, and 94 patients completed follow-up, including 23 patients who died. Compared with PD group (n=45), HD group (n=54) had higher dialysis age, blood pressure, intact parathyroid hormone, alkaline phosphatase, total heart valve calcification rate, mitral valve calcification proportion, interventricular septal thickness (IVST) and left ventricular mass index (all P<0.05). The median follow-up time was 46.00(32.75, 60.25) months. Kaplan-Meier survival analysis showed that there was no significant difference in cumulative survival rate between HD group and PD group (Log-rank test χ2=0.414, P=0.520). Multivariate Cox regression analysis showed that increasing age (HR=1.066, 95%CI 1.017-1.118, P=0.008), systolic blood pressure>140 mmHg (HR=2.601, 95%CI 1.002-6.752, P=0.049) and increasing IVST (HR=1.269, 95%CI 1.036-1.554, P=0.021) were independent influencing factors for all-cause death in dialysis patients after PTX. ROC curve analysis results showed that the cut-off values of age, dialysis age and IVST for predicting all-cause death after PTX were 51.5 years old (AUC=0.673, 95%CI 0.545-0.802, P=0.013) and 75.0 months (AUC=0.654, 95%CI 0.528-0.780, P=0.027) and 13.5 mm (AUC=0.680, 95%CI 0.557-0.803, P=0.010) respectively. The area under the ROC curve for age, dialysis age, IVST, left ventricular hypertrophy in combination with systolic blood pressure>140 mmHg in the prediction of all-cause death after PTX was 0.776(95%CI 0.677-0.875, P<0.001). Conclusions There is no significant difference in cumulative survival rate between HD and PD patients with SHPT after PTX. Increasing age, systolic blood pressure>140 mmHg and increasing IVST are independent risk factors for all-cause death in dialysis patients with SHPT after PTX.
Hyperparathyroidism, secondary / Parathyroidectomy / Renal dialysis / Peritoneal dialysis / Prognosis {{custom_keyword}} /
表1 HD组与PD组患者基线临床资料的比较 |
项目 | 总体(n=99) | HD组(n=54) | PD组(n=45) | 统计值(t/χ2/Z) | P值 |
---|---|---|---|---|---|
年龄(岁) | 50.03±11.48 | 49.02±12.67 | 51.24±9.85 | -1.157 | 0.247 |
男/女(例) | 47/52 | 27/27 | 20/25 | 0.304 | 0.582 |
体重指数(kg/m2) | 21.45(19.74,23.71) | 20.46(18.68,23.30) | 22.04(20.37,24.22) | -2.410 | 0.016 |
收缩压(mmHg) | 136.92±26.38 | 141.50(124.00,154.50) | 132.00(112.50,141.50) | -2.407 | 0.016 |
舒张压(mmHg) | 84.65±14.31 | 87.43±14.38 | 81.31±13.66 | 2.155 | 0.034 |
透析龄(月) | 72.00(60.00,96.00) | 84.00(69.25,108.00) | 60.00(51.00,85.00) | -3.187 | 0.001 |
原发病[例(%)] | 5.391 | 0.139 | |||
慢性肾小球肾炎 | 73(73.74) | 36(66.67) | 37(82.22) | ||
梗阻性肾病 | 13(13.13) | 7(12.96) | 6(13.33) | ||
糖尿病肾病 | 5(5.05) | 4(7.41) | 1(2.22) | ||
其他 | 8(8.08) | 7(12.96) | 1(2.22) | ||
血红蛋白(g/L) | 109.66±20.06 | 113.74±19.67 | 104.76±19.64 | 2.265 | 0.026 |
血清白蛋白(g/L) | 38.28±4.39 | 39.92±3.91 | 36.33±4.16 | 4.421 | <0.001 |
ALP(U/L) | 330.00(172.00,530.00) | 384.00(211.25,704.00) | 198.00(111.50,404.00) | 3.377 | 0.001 |
血钙(mmol/L) | 2.45±0.22 | 2.44±0.23 | 2.46±0.21 | -0.240 | 0.811 |
血磷(mmol/L) | 2.27(1.90,2.63) | 2.23(1.85,2.62) | 2.30(1.93,2.67) | -0.727 | 0.467 |
钙磷乘积 | 5.70±1.50 | 5.41(4.54,6.52) | 5.76(4.86,6.38) | -0.791 | 0.429 |
血清iPTH(ng/L) | 2 056.0(1 426.0,2 500.0) | 2 174.5(1 767.5,2 500.0) | 1 587.0(1 163.0,2 406.5) | -2.943 | 0.003 |
eGFR | 4.33(3.12,5.50) | 4.27(3.31,5.43) | 4.50(2.91,5.54) | -0.337 | 0.736 |
有残余肾功能[例(%)] | 17(17.17) | 3(5.56) | 14(31.11) | 11.271 | 0.001 |
血肌酐(μmol/L) | 981.52±237.31 | 964.85±224.06 | 1 001.51±253.41 | -0.764 | 0.447 |
血尿酸(μmol/L) | 434.62±134.57 | 424.50(335.75,550.50) | 432.00(392.00,493.00) | -0.355 | 0.723 |
血清铁蛋白(μg/L) | 199.20(89.80,483.10) | 413.90(86.35,831.78) | 145.50(91.30,229.75) | -3.046 | 0.002 |
甲状旁腺增生结节数目[枚(%)] | 11.685 | 0.001 | |||
直径<2 cm | 235(83.63)(n=281) | 125(77.16)(n=162) | 110(92.44)(n=119) | ||
直径≥2 cm | 46(16.37)(n=281) | 37(22.84)(n=162) | 9(7.56)(n=119) | ||
服用活性维生素D[例(%)] | 58(58.59) | 32(59.26) | 26(57.78) | 0.022 | 0.882 |
服用磷结合剂[例(%)] | 72(72.73) | 42(77.78) | 30(66.67) | 1.528 | 0.216 |
术后7 d血钙(mmol/L) | 2.16±0.28 | 2.15±0.28 | 2.16±0.28 | -0.177 | 0.860 |
术后7 d血磷(mmol/L) | 0.89(0.68,1.20) | 0.84(0.68,1.20) | 0.91(0.67,1.20) | -0.295 | 0.768 |
术后严重低钙血症[例(%)] | 30(30.30) | 20(37.04) | 10(22.22) | 2.551 | 0.110 |
注:HD:血液透析;PD:腹膜透析;ALP:碱性磷酸酶;iPTH:全段甲状旁腺素;eGFR:估算肾小球滤过率,单位为ml∙min-1∙(1.73 m2)-1;术后严重低钙血症:术后72 h内血清总钙≤1.85 mmol/L;1 mmHg=0.133 kPa;呈正态分布的计量资料用 |
表2 HD组与PD组患者PTX术前心脏彩超检查结果的比较 |
项目 | 总体(n=99) | HD组(n=54) | PD组(n=45) | 统计值(t/χ2/Z) | P值 |
---|---|---|---|---|---|
LVEF(%) | 61.94±7.16 | 62.41±7.18 | 61.38±7.39 | 0.701 | 0.485 |
LVED(mm) | 45.00(41.00,49.00) | 45.00(41.75,49.00) | 43.00(39.00,48.00) | -1.214 | 0.225 |
LVDs(mm) | 30.00(26.00,33.00) | 30.00(26.50,33.25) | 29.00(25.50,33.00) | -0.807 | 0.420 |
IVST(mm) | 13.00(12.00,15.00) | 14.00(12.00,16.00) | 13.00(12.00,14.00) | -2.289 | 0.022 |
IVSs(mm) | 18.00(16.00,19.00) | 18.00(16.00,19.00) | 17.00(16.00,19.00) | -1.409 | 0.159 |
LVPWT(mm) | 12.00(11.00,13.00) | 12.00(11.00,14.00) | 12.00(11.00,13.00) | -2.164 | 0.030 |
LVMI(g/m2) | 132.40(98.40,159.62) | 147.59(114.42,170.89) | 113.78(94.85,136.55) | -3.008 | 0.003 |
左心室肥厚[例(%)] | 62(62.63) | 41(75.93) | 21(46.67) | 8.978 | 0.003 |
心脏瓣膜钙化[例(%)] | 63(63.64) | 37(68.52) | 26(57.78) | 1.224 | 0.269 |
主动脉瓣钙化[例(%)] | 52(52.53) | 30(55.56) | 22(48.89) | 0.437 | 0.508 |
二尖瓣钙化[例(%)] | 41(41.41) | 29(53.70) | 12(26.67) | 7.395 | 0.007 |
总心脏瓣膜钙化率[瓣(%)] | 93(23.48)(n=396) | 59(27.31)(n=216) | 34(18.89)(n=180) | 3.879 | 0.049 |
注:HD:血液透析;PD:腹膜透析;PTX:甲状旁腺切除术;LVEF:左心室射血分数;LVED:舒张末期左心室内径;LVDs:收缩末期左心室内径;IVST:舒张末期室间隔厚度;IVSs:收缩末期室间隔厚度;LVPWT:左心室后壁厚度;LVMI:左心室质量指数;呈正态分布的计量资料用 |
表3 甲状旁腺切除术患者全因死亡的影响因素分析(Cox回归模型,n=94) |
影响因素 | 单因素分析 | 多因素分析 | ||
---|---|---|---|---|
HR(95%CI) | P值 | HR(95%CI) | P值 | |
男性(是/否) | 1.081(0.476~2.451) | 0.853 | ||
年龄(岁) | 1.051(1.013~1.090) | 0.008 | 1.066(1.017~1.118) | 0.008 |
血液透析(是/否) | 1.311(0.573~2.997) | 0.522 | ||
透析龄(月) | 1.011(0.998~1.023) | 0.097 | ||
收缩压>140 mmHg(是/否) | 2.307(1.009~5.272) | 0.047 | 2.601(1.002~6.752) | 0.049 |
iPTH(ng/L) | 1.000(1.000~1.000) | 0.962 | ||
残余肾功能(有/无) | 0.382(0.089~1.637) | 0.195 | ||
IVST(mm) | 1.163(1.009~1.340) | 0.038 | 1.269(1.036~1.554) | 0.021 |
左心室肥厚(有/无) | 2.579(0.957~6.953) | 0.061 | ||
心脏瓣膜钙化(有/无) | 1.437(0.590~3.503) | 0.425 | ||
术后7 d血钙(mmol/L) | 0.349(0.080~1.518) | 0.161 | ||
术后7 d血磷(mmol/L) | 0.919(0.364~2.320) | 0.858 | ||
术后严重低钙血症(有/无) | 0.953(0.392~2.317) | 0.915 |
注:iPTH:全段甲状旁腺素;IVST:舒张末期室间隔厚度;1 mmHg=0.133 kPa |
表4 透析患者甲状旁腺切除术后全因死亡的风险预测分析(ROC曲线) |
因素 | 截断值 | AUC | 敏感度(%) | 特异度(%) | 95%CI | P值 |
---|---|---|---|---|---|---|
年龄 | 51.5岁 | 0.673 | 65.22 | 63.38 | 0.545~0.802 | 0.013 |
透析方式(HD/PD) | 0.485 | 43.48 | 53.52 | 0.349~0.621 | 0.829 | |
透析龄 | 75.0个月 | 0.654 | 73.91 | 66.20 | 0.528~0.780 | 0.027 |
IVST | 13.5 mm | 0.680 | 69.57 | 61.97 | 0.557~0.803 | 0.010 |
左心室肥厚 | 0.617 | 78.26 | 45.07 | 0.490~0.744 | 0.094 | |
收缩压>140 mmHg | 0.600 | 56.52 | 63.38 | 0.465~0.734 | 0.153 | |
联合预测模型1 | 0.764 | 95.65 | 50.70 | 0.666~0.862 | <0.001 | |
联合预测模型2 | 0.776 | 91.30 | 63.38 | 0.677~0.875 | <0.001 |
注:AUC:曲线下面积;HD:血液透析;PD:腹膜透析;IVST:舒张末期室间隔厚度;联合预测模型1:年龄+透析龄+IVST+左心室肥厚;联合预测模型2:年龄+透析龄+IVST+左心室肥厚+收缩压>140 mmHg;1 mmHg=0.133 kPa |
[1] |
Parathyroidectomy (PTx) drastically improves biochemical parameters and clinical symptoms related to severe secondary hyperparathyroidism (SHPT) but the effect of PTx on survival has not been adequately investigated. Here we analyzed data on 114,064 maintenance hemodialysis patients from a nationwide registry of the Japanese Society for Dialysis Therapy to evaluate the associations of severity of SHPT and history of PTx with 1-year all-cause and cardiovascular mortality. We then compared the mortality rate between 4428 patients who had undergone PTx and 4428 propensity score-matched patients who had not despite severe SHPT. During a 1-year follow-up, 7926 patients of the entire study population died, of whom 3607 died from cardiovascular disease. Among patients without a history of PTx, severe SHPT was associated with an increased risk for all-cause and cardiovascular mortality. However, such an increased risk of mortality was not observed among patients with a history of PTx. In the propensity score-matched analysis, patients who had undergone PTx had a 34% and 41% lower risk for all-cause and cardiovascular mortality, respectively, compared to the matched controls. The survival benefit associated with PTx was robust in several sensitivity analyses and consistent across subgroups, except for those who had persistent postoperative SHPT. Thus, successful PTx may reduce the risk for all-cause and cardiovascular mortality in hemodialysis patients with severe, uncontrolled SHPT.
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[2] |
Parathyroidectomy (PTX) is done in cases of secondary hyperparathyroidism from chronic kidney disease to improve renal osteodystrophy. Despite this widespread practice, clinical outcomes regarding the benefits of this procedure are still lacking. Most studies in the literature have opted to report the laboratory outcome instead. Our study aimed to evaluate the postoperative clinical course for patients who had undergone total PTX without autoimplantation.All patients who underwent PTX between January 2010 and February 2014 in a tertiary referral center were included in this study and followed up for 12 months. Laboratory outcome parameters include various preoperative and postoperative serial measurements of laboratory parameters. Patients' hospitalizations and mortality records post-PTX were also retrieved and recorded. In all, 90 patients were included in this study. The mean age was 48 ± 18 years. The majority of the patients (54.4%) were male and 90% were on hemodialysis. The mean duration of dialysis was 8.0 ± 5.0 years. Indications for PTX were symptomatic bone pain (95.6%), fractures (3.3%) and calciphylaxis (1.1%). Mean preoperative values for serum calcium, phosphate, alkaline phosphatase and intact parathyroid hormone (iPTH) were 2.40 ± 0.23mmol/L, 1.92 ± 0.51 mmol/L, 689.60 ± 708.50 U/L and 311.90 ± 171.94 pmol/L, respectively. The majority (92.2%) had all four glands removed and 92.2% of the glands showed hyperplasic changes. One year after PTX, 90 patients (100%) had serum iPTH <8 pmol/L and 28 patients (31%) had unmeasurable iPTH levels. A total of 15% of patients had hospitalizations for various reasons and of these, 50% were within 90 days. The mean hospital stay was 14.4 ± 18.6 days. The mortality rate was 4.4% and of these, 25% were in first 30 days. Causes of death were mainly from sepsis (75%) and acute coronary syndrome (25%). One patient (1.1%) had a relapse.Even though PTX markedly reduces postoperative serum iPTH levels, it carries with it significant risk of morbidity and mortality.
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[3] |
It is unclear whether clinical courses of hungry bone syndrome (HBS) after parathyroidectomy (PTX) in peritoneal dialysis (PD) and hemodialysis (HD) patients are different. The present study aimed to investigate the possible differences of postoperative hypocalcemia and hyperkalemia between PD and HD patients.We performed retrospectively 29 PD patients as the PD group and 169 HD patients as the HD group undergoing successful total PTX with autotransplantation. Calcium supplement after surgery was recorded. Higher levels of serum potassium during and immediately after surgery were recorded as K. K was recorded as peak pre-dialysis serum potassium level 3 days post-surgery.There were 157 (92.90%) patients in HD group and 22 (75.86%) patients in PD group suffered from HBS after surgery, with significant difference between the groups (P = 0.004). Patients in PD group had significantly shorter intravenous calcium supplement duration (P = 0.037) and significantly smaller intravenous calcium supplement dosage (P = 0.042) and total calcium supplement dosage during hospitalization (P = 0.012) than patients in HD group. The levels of serum K (P < 0.001) and K (P < 0.001) were both significantly lower in PD group than those in HD group. Peritoneal dialysis was one of the independent influencing factors with negative correlation for calcium supplement, serum K and serum K.Compared with HD patients, the clinical course of HBS after PTX in PD patients was alleviated. Efforts should be devoted to individual perioperative management for PD patients undergoing PTX.
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[4] |
赵沙沙, 闻萍, 甘巍, 等. 甲状旁腺全切术患者术后严重低钙血症危险因素分析[J]. 中华肾脏病杂志, 2019, 35(7):494-498. DOI: 10.3760/cma.j.issn.1001-7097.2019.07.003.
目的 探讨甲状旁腺全切术(total parathyroidectomy without autotransplantation,TPTX)患者术后严重低钙血症的发生率,并分析其危险因素。 方法 病例来自2008年9月至2017年9月期间在南京医科大学第二附属医院接受TPTX的患者。收集患者手术前后血生化检查和术前全段甲状旁腺素(iPTH)等资料,以及手术切除甲状旁腺总质量(切除腺体质量)等。二元Logistic回归模型法分析TPTX患者术后发生严重低钙血症的危险因素。 结果 783例TPTX患者年龄(46.90±10.78)岁,平均透析龄(91.36±41.75)个月,术后发生严重低钙血症者235例,发生率为30.01%。二元Logistic回归分析结果显示,术前血iPTH(OR=7.56,95%CI:1.55~36.79,P=0.01)、血碱性磷酸酶(OR=36.71,95%CI:14.75~91.36,P<0.01)、血磷(OR=1.74,95% CI:1.11~2.71,P=0.02)水平高,切除腺体质量大(OR=1.18,95%CI:1.06~1.31,P<0.01)是患者术后发生低钙血症的危险因素;术前血钙水平高是术后低钙血症(OR=0.02,95%CI:0.01~0.07,P<0.01)的保护因素。 结论 TPTX治疗继发性甲状旁腺功能亢进症术后低钙血症发生率高。术前血iPTH、血碱性磷酸酶、血磷水平高,术中切除腺体总质量大是术后发生严重低钙血症的独立危险因素。
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[5] |
Residual kidney function can be assessed by simply measuring urine volume, calculating GFR using 24-hour urine collection, or estimating GFR using the proposed equation (eGFR). We aimed to investigate the relative prognostic value of these residual kidney function parameters in patients on dialysis.
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[6] |
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[7] |
Parathyroidectomy (PTx) and medical treatments are both recommended for reducing serum intact parathyroid hormone (iPTH) and curing secondary hyperparathyroidism (sHPT) in patients with chronic kidney disease (CKD), but their therapeutic effects on long-term mortality are not well-known. Thus, we aim to assess such therapeutic effect of PTx. Electronic literatures published on Pubmed, Embase, and Cochrane Central Register of Controlled Trials in any language until 27 November 2015 were systematically searched. All literatures that compared outcomes (survival rate or mortality rate) between PTx-treated and medically-treated CKD patients with sHPT were included. Finally, 13 cohort studies involving 22053 patients were included. Data were extracted from all included literatures in a standard form. The outcomes of all-cause and cardiovascular mortalities were assessed using DerSimonian and Laird's random effects model. We find PTx-treated versus medically-treated patients had a 28% reduction in all-cause mortality and a 37% reduction in cardiovascular mortality. Thus, PTx versus medical treatments might reduce the risks of all-cause and cardiovascular mortalities in CKD patients with sHPT. Further studies with prospective and large-sample clinical trials are needed to find out the real effect of PTx and to assess whether mortality rates differ among patterns of PTx.
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[8] |
The objective of this study was to assess the effect of parathyroidectomy (PTX) treatment on prolonging overall survival (OS) as well as decreasing levels of intact parathyroid hormone (iPTH), calcium (Ca), and phosphorus (P) in elderly hemodialysis patients with severe secondary hyperparathyroidism (SHPT).
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[9] |
徐庆东, 郭焕开, 陈小荷, 等. 血液透析与腹膜透析患者心脏瓣膜钙化高危因素及对临床预后的影响[J]. 疑难病杂志, 2016, 15(11): 1139-1142. DOI: 10.3969/j.issn.1671-6450.2016.11.011.
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[10] |
We sought to compare survival among incident peritoneal dialysis (PD) patients to matched hemodialysis (HD) patients who received pre-dialysis care, including permanent dialysis access placement. Patients starting PD were propensity matched to those starting HD. HD patients who used a central venous catheter during the first 90 days of dialysis were excluded. Stratified Cox proportional hazards models were used to compare patient survival using both intent-to-treat and as-treated analyses. In the intent-to-treat analysis, patients were followed from the date of first dialysis until death and censored at the earliest of the following: renal transplantation, death, renal recovery, loss to follow-up or study end. In the as-treated analysis, patients were also censored at the time of modality change. A total of 1003 matched pairs were obtained from 11,301 incident patients (10,298 HD and 1003 PD). The cumulative hazard ratio for death at one year was 2.38 (95% CI 1.68-3.40) and 2.10 (1.50-2.94) for HD relative to PD patients in the as-treated and intent-to-treat analyses, respectively. The cumulative risk of death, as estimated by the cumulative hazard ratio, favored PD for almost up to 3 years of follow-up in the as-treated analysis and nearly 2 years of follow-up in the intent-to-treat analysis with no differences thereafter. The higher adjusted rate of death observed for HD patients cannot be attributed to initial use of central venous catheters or lack of pre-dialysis care.
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[11] |
Although peritoneal dialysis (PD) costs less to the health care system compared to in-center hemodialysis (HD), it is an underused therapy. Neither modality has been consistently shown to confer a clear benefit to patient survival. A key limitation of prior research is that study patients were not restricted to those eligible for both therapies.Retrospective cohort study.All adult patients developing end-stage renal disease from January 2004 to December 2013 at any of 7 regional dialysis centers in Ontario, Canada, who had received at least 1 outpatient dialysis treatment and had completed a multidisciplinary modality assessment.HD or PD.Mortality from any cause.Among all incident patients with end-stage renal disease (1,579 HD and 453 PD), PD was associated with lower risk for death among patients younger than 65 years. However, after excluding approximately one-third of all incident patients deemed to be ineligible for PD, the modalities were associated with similar survival regardless of age. This finding was also observed in analyses that were restricted to patients initiating dialysis therapy electively as outpatients. The impact of modality on survival did not vary over time.The determination of PD eligibility was based on the judgment of the multidisciplinary team at each dialysis center.HD and PD are associated with similar mortality among incident dialysis patients who are eligible for both modalities. The effect of modality on survival does not appear to change over time. Future comparisons of dialysis modality should be restricted to individuals who are deemed eligible for both modalities to reflect the outcomes of patients who have the opportunity to choose between HD and PD in clinical practice.Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
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[12] |
Prior studies have shown peritoneal dialysis (PD) patients to have lower or equivalent mortality to patients who receive in-center hemodialysis (HD). Medicare's 2011 bundled dialysis prospective payment system encouraged expansion of home-based PD with unclear impacts on patient outcomes. This paper revisits the comparative risk of mortality between HD and PD among patients with incident end-stage kidney disease initiating dialysis in 2006-2013.We conducted a retrospective cohort study comparing 2-year all-cause mortality among patients with incident end-stage kidney disease initiating dialysis via HD and PD in 2006-2013, using data from the US Renal Data System and Medicare. Analysis was conducted using Cox proportional hazards models fit with inverse probability of treatment weighting that adjusted for measured patient demographic and clinical characteristics and dialysis market characteristics.Of the 449,652 patients starting dialysis between 2006 and 2013, the rate of PD use in the first 90 days increased from 9.3% of incident patients in 2006 to 14.2% in 2013. Crude 2-year mortality was 27.6% for patients dialyzing via HD and 16.7% for patients on PD. In adjusted models, there was no evidence of mortality differences between PD and HD before and after bundled payment (hazard ratio, 0.96; 95% confidence interval, 0.89-1.04; P=0.33).Overall mortality for HD and PD use was similar and mortality differences between modalities did not change before versus after the 2011 Medicare dialysis bundled payment, suggesting that increased use of home-based PD did not adversely impact patient outcomes.Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
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[13] |
<b><i>Purpose:</i></b> Cardiac valve calcification (CVC) is frequently occurred in maintenance hemodialysis (MHD) patients and is associated with cardiovascular and all-cause mortality. This study aimed to evaluate the relationships between risk factors and extent of CVC and further provide the treatment target in MHD patients. <b><i>Methods:</i></b> One hundred and forty-five patients who received MHD ≥3 months were enrolled. CVC was assessed by an echocardiographic, semi-quantitative manner called global cardiac calcium scoring system (GCCS), and demographic, clinical, and laboratory parameters including mineral metabolism markers were collected. <b><i>Results:</i></b> The average age of the patients was 50 ± 12 years, and 54.5% were men. The mean GCCS was 1.8 ± 2.4; 57.2% of patients had GCCS ≥1. Age, dialysis vintage, serum alkaline phosphatase (ALP), and intact parathyroid hormone levels were positively correlated with CVC, whereas serum albumin levels were negatively related to CVC, based on univariate analysis. With multivariate linear regression analysis, serum ALP was the only bone-derived biomarker that showed significant correlation with CVC. Serum ALP ≥232 U/L was a robust predictor of CVC and was associated with the likelihood of GCCS ≥1 (OR 3.92, 95% CI 1.37–11.2, <i>p</i> = 0.011). The decision tree model was used to identify ALP ≥232 U/L and age ≥60 years as important determinative variables in the prediction of CVC in MHD patients. <b><i>Conclusion:</i></b> Serum ALP level is significantly associated with CVC in MHD patients. ALP is suggested to be a promising interventional target for cardiovascular calcification in MHD patients.
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[14] |
何俊伶, 杜晓刚. 甲状旁腺功能亢进症增加慢性肾脏病患者心血管疾病风险的研究进展[J]. 中华临床医师杂志(电子版), 2013, (24): 11585-11588. DOI: 10.3877/cma.j.issn.1674-0785.2013.24.114.
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[15] |
Influence of dialysis modalities on patients undergoing parathyroidectomy for renal hyperparathyroidism[J]. Formosan Journal of Surgery, 2015, 48(5): 151-156. DOI: 10.1016/j.fjs.2015.07.002.
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[16] |
鲁晓涵, 林海霞, 耿明慧, 等. 联合检测血清碱性磷酸酶和甲状旁腺激素对维持性血液透析患者全因及心血管事件死亡风险的预测价值[J]. 中华内科杂志, 2020, 59(8): 634-637. DOI: 10.3760/cma.j.cn112138-20190902-00600.
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[17] |
侯爱珍, 肖观清, 张豫, 等. 甲状旁腺全切除加前臂自体移植术对继发性甲状旁腺功能亢进症患者左心室肥厚的影响[J]. 中国血液净化, 2017, 16(1): 39-43. DOI: 10.3969/j.issn.1671-4091.2017.01.010.
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[18] |
侯爱珍, 肖观清, 叶佩仪, 等. 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[J]. 中华肾脏病杂志, 2020, 36(3): 183-188. DOI: 10.3760/cma.j.cn441217-20190926-00037.
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。
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[19] |
沈英, 张萍, 蒋华, 等. 甲状旁腺切除对尿毒症继发甲状旁腺功能亢进患者贫血和心功能的影响[J]. 中华肾脏病杂志, 2018, 34(5): 321-326. DOI: 10.3760/cma.j.issn.1001-7097.2018.05.001.
目的 探讨甲状旁腺全切(PTX)加前臂种植术对尿毒症继发性甲状旁腺功能亢进(SHPT)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10月至2015年12月接受甲状旁腺全切+前臂种植术的130例尿毒症患者的临床资料,比较手术前后贫血、超声心动图指标等变化。根据术前是否存在左心室肥厚(LVH)分为LVH组和非LVH组,比较两组患者术前及术后1年超声心动图指标变化。 结果 与术前组相比,术后3个月组、1年组患者血红蛋白、红细胞比容显著升高,红细胞生成素用量显著减少(均P<0.01)。与术前组相比,术后1年组患者干体重显著增加,心脏超声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)、左心室心肌重量(LVM)、左心室心肌重量指数(LVMI)显著下降(均P<0.05)。LVH组患者术后1年组LVDs、LVDd、LVPWd、LVM、LVMI、IVSs均较术前组显著下降(均P<0.05);非LVH组患者术后1年组仅IVSs较术前组下降(P<0.05)。 结论 PTX加前臂移植术是难治性SHPT有效的治疗手段,能明显改善贫血及左心室结构和功能,尤其对于术前存在左心室肥厚的患者。
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[20] |
刘文, 于颖娟, 张林, 等. 甲状旁腺全切术对尿毒症继发甲状旁腺功能亢进症患者冠脉钙化及左心室肥厚的影响[J]. 现代医学, 2017, 45(10): 1438-1441. DOI: 10.3969/j.issn.1671-7562.2017.10.012.
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[21] |
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刘晓怡:数据收集、整理、统计学分析及论文撰写;张喆、谢超:研究指导、论文修改;侯爱珍:数据收集及整理;叶佩仪、孔耀中:研究指导、论文修改及经费支持
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