肾性继发性甲状旁腺功能亢进患者甲状旁腺切除术后复发的预测模型

韩雨辛; 王春晖

doi:10.13201/j.issn.2096-7993.2023.04.009

肾性继发性甲状旁腺功能亢进患者甲状旁腺切除术后复发的预测模型

韩雨辛¹,
王春晖^2, ,

- 1.
  锦州医科大学北部战区总医院研究生培养基地(沈阳，110016)
- 2.
  中国人民解放军北部战区总医院肝胆胰甲状腺外科

详细信息

通讯作者: 王春晖，E-mail: wangchh_2013@163.com

中图分类号: R582.1;R653

收稿日期: 2022-11-22

刊出日期: 2023-04-03

Prediction model of recurrence after parathyroidectomy in secondary hyperparathyroidism

HAN Yuxin¹,
WANG Chunhui^2, ,

- 1.
  Postgraduate Training Base of General Hospital of Northern Theater Command, Jinzhou Medical University, Shenyang, 110016, China
- 2.
  Department of Hepatobiliary Pancreatic thyroid Surgery, General Hospital of Northern Theater Command

More Information

Corresponding author: WANG Chunhui, E-mail: wangchh_2013@163.com

Received Date: 22 November 2022

Publish Date: 03 April 2023

摘要

摘要: 目的定量评估肾性继发性甲状旁腺功能亢进症(SHPT)患者接受甲状旁腺切除术(parathyroidectomy，PTX)治疗后复发的风险。方法收集中国人民解放军北部战区总医院2017年6月—2019年5月期间接受PTX的168例患者的临床资料，通过赤池信息准则(Akaike information criterion，AIC)筛选因素、列线图的形式构建预测模型，由2019年6月—2021年9月期间接受PTX治疗的158例患者组成验证集，在区分度、一致性和临床实用性3个方面对该模型进行外部验证。结果本研究构建的预测模型包含6个变量，分别是透析方式、异位甲状旁腺、术后1 d及术后1个月的全段甲状旁腺激素水平(iPTH)、切除甲状旁腺数目以及术后1 d的血磷，该模型外部验证的C指数为0.992，Calibration曲线的P值为0.886 1，决策曲线也显示该模型评估效果良好。结论本研究构建的预测模型有助于判断SHPT患者行PTX术后是否复发，对其进行个体化预测。
- 继发性甲状旁腺功能亢进症 /
- 甲状旁腺切除术 /
- 复发
Abstract: Objective To quantitatively evaluate the risk of recurrence in patients with secondary hyperparathyroidism after parathyroidectomy.Methods The clinical data of 168 patients who underwent parathyroidectomy(PTX) from June 2017 to May 2019 were collected. The prediction model was constructed by using Akaike information criterion(AIC) to screen factors. A total of 158 patients treated with PTX from June 2019 to September 2021 were included in the validation set to conduct external validation of the model in three aspects of differentiation, consistency and clinical utility.Results The prediction model we constructed includes different dialysis methods, ectopic parathyroid gland, the iPTH level at one day and one month after surgery, the number of excisional parathyroid and postoperative blood phosphorus. The C index of external validation of this model is 0.992 and the P value of the Calibration curve is 0.886 1. The decision curve analysis also shows that the evaluation effect of this model is perfect.Conclusion The prediction model constructed in this study is useful for individualized prediction of recurrence after PTX in patients with secondary hyperparathyroidism.
- secondary hyperparathyroidism /
- parathyroidectomy /
- recurrence

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图 1 列线图

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图 2 建模集(2a)和验证集(2b)的ROC曲线

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图 3 Calibration曲线

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图 4 决策曲线

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表 1 建模集和验证集中患者基线临床资料的比较(n=326)

因素	建模集(n=168)			验证集(n=158)
因素	非复发组(n=129)	复发组(n=39)	P值	非复发组(n=122)	复发组(n=36)	P值
年龄/岁	47.6±11.1	47.1±10.2	0.805	46.9±11.0	47.1±9.4	0.933
性别/例(%)			0.100			< 0.001
女	69(53.5)	15(38.5)		51(41.8)	17(47.2)
男	60(46.5)	24(61.5)		71(58.2)	19(52.8)
BMI/(kg/m²)	22.5(20.2，24.0)	22.5(20.6，23.5)	0.784	22.2(20.2，25.7)	22.3(21.0，23.6)	0.729
原发病/肾病类型/例(%)			0.580			0.271
不明原因	34(26.4)	10(25.6)		34(27.9)	15(41.7)
IgA肾病	3(2.3)	1(2.6)		4(3.3)	0
高血压肾病	25(19.4)	14(35.9)		17(13.9)	6(16.7)
慢性肾小球肾炎	39(30.2)	8(20.5)		29(23.8)	8(22.2)
糖尿病	3(2.3)	1(2.6)		4(3.3)	1(2.8)
其他	25(19.4)	5(12.8)		34(27.9)	6(16.7)
透析方式/例(%)			0.042			0.467
腹膜透析	2(1.6)	2(5.1)		10(8.2)	0
血液透析(2/周)	1(0.8)	5(12.8)		6(4.9)	2(5.6)
血液透析(5/2周)	23(17.8)	6(15.4)		23(18.9)	8(22.2)
血液透析(3/周)	103(79.8)	26(66.7)		83(68.0)	26(72.2)
异位甲状旁腺/例(%)			< 0.001			< 0.001
无异位甲状旁腺	121(93.8)	20(51.3)		117(95.9)	26(72.2)
有异位甲状旁腺	8(6.2)	19(48.7)		5(4.1)	10(27.8)
术前iPTH/(pg/mL)	1746.0(1368.0，2134.5)	1835.0(1250.0，2650.0)	0.272	1580.0(1277.5，1852.0)	1609.5(1105.0，2131.8)	0.751
术后10 min iPTH/(pg/mL)	311.0(179.0，483.5)	175.0(117.0，320.0)	< 0.001	314.0(184.8，383.3)	353.3(205.0，420.3)	0.016
术后1 d iPTH/(pg/mL)	12.7 (7.2，19.3)	41.3 (21.7，146.0)	< 0.001	9.4 (5.3，14.3)	122.9 (42.1，200.0)	< 0.001
术后1个月iPTH/(pg/mL)	11.7 (5.4~33.0)	35.7 (35.7~101.7)	< 0.001	8.0 (4.9，16.3)	127.5 (107.6，200.0)	< 0.001
术后3个月iPTH/(pg/mL)	30.7 (10.1~50.8)	50.8 (50.8~93.0)	< 0.001	78.4 (9.6，78.4)	107.0 (78.4，218.5)	< 0.001
切除甲状旁腺数/例(%)			< 0.001			< 0.001
6枚	1(0.8)	1(2.6)		0	1(2.8)
3枚	2(1.6)	7(17.9)		1(0.8)	4(11.1)
5枚	7(5.4)	7(17.9)		4(3.3)	14(38.9)
4枚	119(92.2)	24(61.5)		117(95.9)	17(47.2)
病理类型/例(%)			0.326			0.805
结节样增生	95(73.6)	27(69.2)		107(87.7)	31(86.1)
腺瘤样增生	34(26.4)	12(30.8)		15(12.3)	5(13.9)
术前
血钙/(mmol/L)	2.5(2.3，2.6)	2.5(2.3，2.6)	0.686	2.4±0.2	2.4±0.2	0.845
血磷/(mmol/L)	2.4±0.5	2.5±0.5	0.305	2.4(2.0，2.8)	2.6(2.2，3.1)	0.136
术后1 d
血钙/(mmol/L)	2.2±0.3	2.2±0.3	0.817	2.1(1.9，2.3)	2.2(2.0，2.3)	0.397
血磷/(mmol/L)	1.9(1.4，2.1)	2.1(1.7，2.5)	< 0.001	2.0(1.6，2.2)	2.0(1.7，2.4)	0.220
出院当日
血钙/(mmol/L)	2.1±0.2	2.0±0.3	0.122	2.1±0.2	2.2±0.3	0.730
血磷/(mmol/L)	1.3±0.5	1.2±0.4	0.136		1.4±0.5	1.5±0.6	0.290

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表 2 根据AIC筛选变量结果

变量	β	β的95%CI		OR	OR的95%CI		P值
变量	β	下限	上限	OR	下限	上限	P值
透析方式	-0.054	-0.104	-0.003	0.947	0.901	0.997	0.040
异位甲状旁腺	0.381	0.262	0.499	1.464	1.300	1.647	< 0.001
术后1 d iPTH/(pg/mL)	0.003	0.002	0.004	1.003	1.002	1.004	< 0.001
术后1个月iPTH/(pg/mL)	0.002	0.001	0.003	1.002	1.001	1.003	< 0.001
切除旁腺数目	-0.108	-0.183	-0.033	0.898	0.833	0.968	0.005
术后1 d血磷/(mmol/L)	0.083	0.002	0.163	1.087	1.002	1.177	0.045

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表 3 PTX术后预测复发的各个预测因子截止点

变量	敏感性	特异性	最佳约登指数	截止点
术后1 d iPTH/(pg/mL)	0.897	0.736	0.633	18.675
术后1个月iPTH/(pg/mL)	1	0.806	0.806	65.220
术后1 d血磷/(mmol/L)	0.410	0.915	0.325	2.270

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