【摘要】目的研究继发性甲状旁腺功能亢进症(secondary hyperparathyroidism，SHPT)患者甲状旁腺切除术(parathyroidectomy，PTX)后高钾血症的危险因素，为减少术后高钾血症提供理论依据。方法回顾性分析2014 年1 月～2019 年10 月期间常州市第一人民医院因SHPT 行PTX 手术患者的临床资料，按照术后血钾水平分为高钾组及非高钾组，比较2 组患者PTX 围手术期血钾、钙、磷、全段甲状旁腺激素(intact parathyroid hormone，iPTH)等指标差异。结果PTX 患者术后血钾高于术前(t=-9.125，P＜0.001)，血钙、磷及iPTH 低于术前(t/Z 值分别为9.853，2.044，6.334；P 值分别为＜0.001，0.046，＜0.001)；有28/53(52.8%)的患者术后发生高钾血症，术前K+水平是SHPT 患者PTX 术后出现高钾血症的独立危险因素(β=-3.054，P=0.008)。根据ROC 曲线分析，术前K+的最佳截定值为4.30mmol/L。结论术前K+水平较高的SHPT 患者PTX 术后出现高钾血症风险较高，积极降低术前K+水平在4.30mmol/L 以下有助于减少术后高钾血症风险。
【Abstract】Objective Parathyroidectomy (PTX) is the main method to treat secondary hyperparathyroidism (SHPT). However, the risk factors for postoperative hyperkalemia are uncertain. This study was to investigate the risk factors for postoperative hyperkalemia after PTX for SHPT. Methods A total of 53 patients with SHPT undergoing PTX in Changzhou First People’s Hospital from January 2013 to August 2019 were involved in this study. Laboratory examinations including serum K+, Ca2+, alkaline phosphatase, phosphorus and intact parathyroid hormone were conducted before and after PTX. Results In PTX patients, postoperative serum K+ was higher than preoperative level (t=-9.125, P<0.001), and postoperative serum Ca2 + (t=-9.853, P<0.001), phosphorus (t=2.044, P=0.046) and iPTH (Z=-6.334, P<0.001) were lower than the preoperative levels. Postoperative hyperkalemia developed in 28 (52.8%) patients. Preoperative serum K+ level was the independent risk factor for hyperkalemia after PTX in SHPT patients (β=-3.054, P=0.008). The ROC curve showed that the optimal cut- off value for preoperative serum K+ was 4.3mmol/L. Conclusion SHPT patients with higher serum K+ before surgery have a higher risk of hyperkalemia after PTX, Lowering serum K+ below 4.3mmol/L before surgery is useful to reduce the risk of postoperative hyperkalemia.
[1]Tentori F, Wang M, Bieber BA, et al.Recent changes in therapeutic approaches and association with outcomes among patients with secondary hyperparathyroidism on chronic hemodialysis：the DOPPS study[J].Clin J Am Soc Nephrol, 2015, 10(1):98-109
[2]Naves-Díaz M, Passlick-Deetjen J, Guinsburg A, al.Calcium,phosphorus,PTH and death rates in a large sample of dialysis patients from Latin AmericaThe CORES Study[J].Nephrol Dial Transplant, 2011, 26(6):1938-1947
[3]Erratum: Kidney Disease: Improving Global Outcomes KDIGO CKD-MBD Update Work Group.KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis,Evaluation,Prevention,and Treatment of Chronic Kidney Disease - Mineral and Bone Disorder (CKD - MBD)[J].Kidney Int Suppl, 2017, 7(3):e1-59
[4]杨光, 邢昌赢, 王宁宁, 等.维持性血液透析患者甲状旁腺切除术后发生骨饥饿综合征的影响因素[J].中华肾脏病杂志, 2019, 38(8):568-574
[5]Ho LY, Wong PN, Sin HK, et al.Risk factors and clinical course of hungry bone syndrome after total parathyroidectomyin dialysis patients with secondary hyperparathyroidism[J].BMC Nephrol, 2017, 18(1):12-22
[6]Goldfarb M, Gondek SS, Lim SM, et al.Postoperative hungry bone syndrome in patients with secondary hyperparathyroidismof renal origin[J].World J Surg, 2012, 36(6):1314-1319
[7]Kidney Disease: Improving Global Outcomes KDIGO CKD-MBD Update Work Group.KDIGO clinical practice guidline for the diagnosis,evaluation,prevention,and treatment of Chronic Kidney Disease—Mineral and Bone Disorder(CKD—MBD)[J].Kidney Int Suppl, 2009, 113(8):S1-130
[8] Daniel J Rosenkrans, Lavinia M Kolarczyk.Intraoperative Hyperkalemia and Ventricular Arrhythmia During Parathyroidectomy: A Case Report .[J].A A Case Rep, 2017, 9(4):105-107
[9]Yang G, Wang J, Sun J, et al.Perioperative hyperkalemia in hemodialysis patients undergoing parathyroidectomy for renal hyperparathyroidism[J].Intern Emerg Med, 2019, 14(7):1065-1071
[10]Bajaj Y, Roberts S, Simon D, et al.Intra-operative hyperkalemia: a serious but under recognised complication of renal parathyroidectomy - a prospective study: how we do it[J].Clin Otolaryngol, 2011, 36(1):69-72
[11]Yang YL, Lu HF, Chung KC, et al.Young age,male sex,and end-stage renal disease with secondary hyperparathyroidism as risk factors for intraoperative hyperkalemia during parathyroid-ectomy[J].J Clin Anesth, 2015, 27(3):195-200
[12]Li S, Liu S, Chen Q, et al.Clinical predictor of postoperative hyperkalemia after parathyroidectomy in patients with hemodialysis[J].Int J Surg, 2018, 53(5):1-4
[13]Lu KC, Ma WY, Yu JC, et al.Bone turnover markers predict changes in bone mineral density after parathyroidectomy in patients with renal hyperparathyroidism[J].Clin Endocrinol (Oxf), 2012, 76(5):634-642
[14]Hayes JF, Gross GF, Schuman ES.Surgical management of renal hyperparathyroidism in the dialysis patient[J].Am J Surg, 1982, 143:569-571
[15]Cruz DN, Perazella MA.Biochemical aberrations in a dialysis patient following parathyroidectomy[J].Am J Kidney Dis, 1997, 29(5):759-762
[16]Yang G, Ge Y, Zha X, et al.Peritoneal dialysis can alleviate the clinical course of hungry bone syndrome after parathyroidectomy in dialysis patients with secondary hyperparathyroidism[J].Int Urol Nephrol, 2019, 51(3):535-542
[17] Racca F, Mongini T, Wolfler A, et al.Recommendations for anesthesia and perioperativemanagement of patients with neuromuscular disorders[J].Minerva Anestesiol, 2013, 79(4):419-433
[18] Chong GC, Choi JDW, Lee TT, et al.Intraoperative and postoperative hyperkalaemia after total parathyroidectomy following exposure to cinacalcet in sixteen patients for renal hyperparathyroidism[J].Clin Otolaryngol, 2017, 42(6):1369-1373
[19]Song YH, Cai GY, Xiao YF, et al.Can we predict who will develop postoperative hyperkalaemia after parathyroidectomy in dialysis patients with secondary hyperparathyroidism[J].BMC Nephrol, 2019, 20(1):225-233
