【摘要】目的探讨维持性血液透析(maintenance hemodialysis，MHD)患者全因死亡和主要不良心脏事件(major cardiovascular events，MACE)的相关因素，特别是甲状旁腺(parathyroid，PT)增生在全因死亡和MACE 中的作用。方法选取首都医科大学附属北京安贞医院2013 年7 月～2019 年7 月的MHD 患者，收集其死亡或MACE 的相关资料，尤其是冠状动脉钙化积分(coronary artery calcium score，CaCS)及PT 增生的数据进行统计学分析。结果共纳入资料较为完整的MHD 患者70 例，中位随访时间71 个月，基线平均年龄(60.07±13.62)岁、透析龄(58.37±50.17)月；男性占61.4%。随访期间全因死亡率44.3%(31/70)，MACE 发生率34.3%(24/70)。死亡组患者的年龄(t=-3.707,P＜0.001)、PT 增生的比例(χ2=8.504,P=0.004)及CaCS 值(Z=-3.536,P＜0.001)明显高于非死亡组；血磷(t=-1.222,P=0.226)、全段甲状旁腺激素(intact parathyroid hormone，iPTH)(t=1.877,P=0.065)在2 组间无显著性差异。多因素COX 回归分析显示PT 增生和高龄是全因死亡(PT 增生HR=2.422，95% CI：1.081～5.427，P=0.032；年龄HR =1.054，95% CI：1.013～1.097，P=0.032)和MACE(PT 增生HR=9.117，95% CI：2.195～37.877，P=0.002；年龄HR=1.055，95% CI：1.003～1.110，P=0.036)的独立危险因素。生存分析显示PT 增生组全因死亡(χ2=5.760，P=0.016)和MACE事件(χ2=6.794，P=0.009)发生率高于PT非增生组。分析PT增生的相关因素发现高血磷(OR=125.805, 95%CI：5.009～3159.418, P=0.003)和长透析龄(OR= 1.023, 95% CI：1.000～1.046, P=0.047)是PT 增生的独立危险因素。结论PT 增生是全因死亡和MACE 的危险因素；血磷水平升高是PT增生的独立危险因素。提示临床早期干预导致PT 增生的危险因素，如高磷血症等，可起到降低MHD 患者的全因死亡率和MACE的作用。
【Abstract】Objective To study the risk factors for all- cause death and major cardiovascular events (MACE) in maintenance hemodialysis (MHD) patients, especially the role of parathyroid (PT) hyperplasia in the death and MACE in MHD patients. Methods We recruited the MHD patients treated in our dialysis center from July 2013 to July 2019. Their prognosis, MACE, coronary artery calcium score (CACS), and PT hyperplasia from ultrasonography were collected and analyzed by statistical methods. Results A total of 70 MHD patients were enrolled in this study. The median follow-up period was 71 months, the mean age of the patients was 60.07±13.62 years, and the mean dialysis duration was 58.37±50.17 months. During the followup period, 44.3% of the patients died, and 34.3% of the patients had MACE. Age (t=-3.707, P<0.001), prevalence of PT hyperplasia (χ2=8.504, P=0.004) and CACS (Z=-3.536, P＜0.001) were significantly higher in the death patients than in the survival patients (P＜0.05); but serum phosphorus (t=- 1.222, P=0.226) and iPTH (t=1.877, P=0.065) were similar between the two groups of patients. Multivariant Cox regression analysis showed that PT hyperplasia and age were the independent risk factors for all-cause death (PT hyperplasia: HR=2.422, 95% CI 1.081~5.427, P=0.032; age: HR=1.054, 95% CI 1.013~1.097, P=0.032) and MACE (PT hyperplasia: HR= 9.117, 95%CI 2.195~37.877, P=0.002; age: HR=1.055, 95%CI 1.003~1.110, P=0.036). Survival analysis showed that the rates of all- cause death (P=0.016) and MACE (P=0.009) were significantly higher in patients with PT hyperplasia than in those without PT hyperplasia. Analysis of the related factors for PT hyperplasia found that higher serum phosphorus (OR=125.805, 95% CI 5.009 ~ 3159.418, P=0.003) and longer duration of dialysis (OR=1.023, 95% CI 1.000~1.046, P=0.047) were the independent risk factors for PT hyperplasia. Conclusion PT hyperplasia is a risk factor for all-cause death and MACE, and higher serum phosphorus is an independent risk factor for PT hyperplasia. These results suggest that early clinical intervention of risk factors for PT hyperplasia, such as hyperphosphatemia, are useful measures for reducing allcause mortality and MACE.
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