甲状腺全切除术后iPTH变化与PHP恢复时间的关系及对永久性PHP的预测价值

Correlation between iPTH changes and time to hypoparathyroidism recovery after total thyroidectomy and predictive value of iPTH levels for permanent hypoparathyroidism

摘要:

目的 探讨甲状腺全切除术后血清甲状旁腺激素（iPTH）变化与甲状旁腺功能减退（PHP）恢复时间的关系及对永久性PHP发生的预测价值。方法 回顾性分析2017年1月—2021年9月在承德医学院附属医院行甲状腺全切除术的516例甲状腺癌及甲状腺良性病变患者的临床资料。统计患者术后血清iPTH恢复至正常参考值下限的时间及各时间段患者的分布情况。对比不同恢复时间患者术前、术后24 h血清iPTH水平。随访6个月，统计患者永久性PHP发生情况，并依据是否发生PHP分为发生组和未发生组。对比发生组和未发生组患者的临床资料。多因素一般Logistic回归模型分析甲状腺全切除术后永久性PHP发生的危险因素。制作受试者工作特征（ROC）曲线，以曲线下面积（AUC）分析血清iPTH水平对甲状腺全切除术后永久性PHP发生的预测价值。结果 不同恢复时间甲状腺全切除患者术前iPTH水平比较，差异无统计学意义（P >0.05）。与恢复时间< 1周患者比较，1～4周、1～3个月、4～6个月和> 6个月患者术后24 h血清iPTH水平更低（P <0.05）；与1～4周比较，1～3个月、4～6个月和> 6个月患者术后24 h血清iPTH水平低（P <0.05）；与1～3个月比较，4～6个月和> 6个月患者术后24 h血清iPTH水平低（P <0.05）；与4～6个月比较，>6个月患者术后24 h血清iPTH水平低（P <0.05）。两组患者性别、年龄、BMI、手术时间、结节最大直径、术后病理良恶性结果、是否合并桥本甲状腺炎、是否合并甲状腺功能亢进、是否包膜侵犯、是否行Ⅵ区、颈侧区及喉返神经后方淋巴结清扫、是否甲状旁腺自体移植、术前血磷、术前血钙、术前血清iPTH、术后24 h血磷比较，差异无统计学意义（P >0.05）。发生组¹³¹I治疗占比高于未发生组，术后24 h血钙及血清iPTH水平则低于未发生组（P <0.05）。多因素一般Logistic分析结果显示：术后¹³¹I治疗［O^R=3.108（95% CI：1.415，6.829）］、术后24 h血钙［O^R=2.768（95% CI：1.036，4.072）］、术后24 h血清iPTH［O^R=3.380（95% CI：1.843，8.104）］水平是甲状腺全切除术后发生永久性PHP的危险因素（P <0.05）。ROC曲线分析结果显示，血清iPTH水平对甲状腺全切除术后永久性PHP发生预测的敏感性、特异性及AUC分别为81.48%（95% CI：0.613，0.930）、76.69%（95% CI：0.726，0.803）、0.817（95% CI：0.781，0.850）。结论 甲状腺全切除术后24 h血清iPTH水平与PHP恢复时间有关，术后24 h血清iPTH水平对永久性PHP发生的预测价值较高。

Abstract:

Objective To investigate the correlation between the changes of intact parathyroid hormone (iPTH) and the time to hypoparathyroidism (PHP) recovery after total thyroidectomy and the predictive value of iPTH levels for the occurrence of permanent PHP.Methods The clinical data of 516 patients with thyroid cancer or benign thyroid lesions who underwent total thyroidectomy in our hospital from January 2017 to September 2021 were retrospectively analyzed. The recovery time of the postoperative serum level of iPTH to the lower limit of the normal range and the distribution of the recovery time were determined. The serum levels of iPTH before the surgery and 24 hours after the surgery were compared among patients with different recovery time. After 6 months of follow-up, the occurrence of permanent PHP in the patients was observed, and the patients were subdivided into the occurrence group and the non-occurrence group according to whether PHP occurred or not. The clinical data of the patients in the occurrence group and the non-occurrence group were compared. The multivariable Logistic regression analysis was performed to determine the risk factors for the occurrence of permanent PHP after total thyroidectomy. The receiver operating characteristic (ROC) curve was plotted, and the predictive value of the serum level of iPTH for the occurrence of permanent PHP after total thyroidectomy was analyzed via the area under the ROC curve (AUC).Results There was no significant difference in preoperative iPTH levels in patients undergoing total thyroidectomy with different recovery time (P > 0.05). Compared with patients with recovery time shorter than 1 week, those with recovery time between 1 week to 4 weeks, 1 month to 3 months, 4 to 6 months and that longer than 6 months had lower serum levels of iPTH 24 hours after the surgery (P < 0.05). Compared with patients with recovery time between 1 week to 4 weeks, those with recovery time between 1 month to 3 months, 4 to 6 months and that longer than 6 months had lower serum levels of iPTH 24 hours after the surgery (P < 0.05). Compared with patients with recovery time between 1 month to 3 months, those with recovery time between 4 to 6 months and that longer than 6 months had lower serum levels of iPTH 24 hours after the surgery (P < 0.05). Besides, patients with recovery time longer than 6 months showed even lower serum levels of iPTH 24 hours after the surgery relative to those in patients with recovery time between 4 to 6 months (P < 0.05). The sex composition, age, BMI, the operative duration, the maximal diameter of the nodules, the malignancy of thyroid lesions, the proportion of patients complicating with Hashimoto's thyroiditis, the proportion of patients complicating with hyperthyroidism, the proportion of tumor capsular invasion, the proportions of lymph node dissection in the VI area, the lateral neck, and behind the recurrent laryngeal nerve, the proportion of parathyroid autotransplantation, preoperative serum levels of phosphorus, calcium, and iPTH, and the level of serum phosphorus 24 hours after the surgery were not different between the two groups of patients (P > 0.05). The proportion of patients undergoing I-¹³¹ treatment in the occurrence group was higher than that in the non-occurrence group, and the serum levels of calcium and iPTH 24 hours after the surgery in the occurrence group were lower than those in the non-occurrence group (P < 0.05). The multivariable Logistic regression analysis showed that postoperative I-¹³¹ treatment [O^R = 3.108, (95% CI: 1.415, 6.829) ], the level of serum calcium 24 hours after the surgery [O^R = 2.768, (95% CI: 1.036, 4.072) ], and the level of serum iPTH 24 hours after the surgery [O^R = 3.380, (95% CI: 1.843, 8.104) ] were risk factors for the occurrence of permanent PHP after total thyroidectomy (P < 0.05). The ROC curve analysis revealed that the sensitivity, specificity and AUC of the serum iPTH level for predicting the occurrence of permanent PHP after total thyroidectomy were 81.48% (95% CI: 0.613, 0.930), 76.69% (95% CI: 0.726, 0.803), and 0.817 (95% CI: 0.781, 0.850), respectively.Conclusions The serum iPTH level 24 hours after total thyroidectomy is related to the recovery time of PHP, and exhibits a high predictive value for the occurrence of permanent PHP.