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Impact of Parathyroidectomy on Left Ventricular Function in End Stage

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Impact of Parathyroidectomy on Left Ventricular Function in End Stage Chen et al. BMC Nephrology (2020) 21:479 https://doi.org/10.1186/s12882-020-02139-3 RESEARCH ARTICLE Open Access Impact of parathyroidectomy on left ventricular function in end stage renal disease patients Shaohua Chen1,2, Kaixiang Sheng1,2, Ying Shen1,2, Hua Jiang1,2, Xin Lei1,2, Lihui Qu1,2, Chunping Xu1,2, Jianghua Chen1,2 and Ping Zhang1,2* Abstract Background: Secondary hyperparathyroidism (SHPT) is a common complication in end-stage renal disease (ESRD) patients, and parathyroidectomy (PTX) is an effective treatment intervention of SHPT. However, the curative impact of PTX on left ventricular function still remains incompletely understood. To evaluate the impact of parathyroidectomy on left ventricular function in ESRD patients, we conducted this retrospective study. Methods: Between Oct 1, 2010 and Oct 1, 2016, ESRD patients presented with SHPT who underwent parathyroidectomy were enrolled. We retrospectively collected the ultrasonic cardiogram parameter pre- and 1-year post-PTX, and analyzed the influence factor for the overturn of left ventricular hypertrophy (LVH) and the improvement of ejection fraction% (EF%). Results: In all the patients (135), the main ultrasonic cardiogram parameter dramatically improved after PTX. Compared with pre-PTX, the left ventricular mass (LVM) (172.82 (135.90, 212.91) g vs. 192.76 (157.56, 237.97) g, p<0.001) and the left ventricular mass index (LVMI) (107.01 (86.79, 128.42) g/m2 vs. 123.54 (105.49, 146.64) g/m2, p<0.001) significantly declined after 1 year of the PTX. Further, 43.75% patients diagnosed with LVH before the PTX have recovered from LVH. In the subgroup analysis of 35 patients with EF% ≤ 60% pre-PTX, EF% and fractional shortening% (FS%) significantly improved after 1 year of the PTX compared with pre-PTX (EF%: 64.90 ± 7.90% vs. 55.71 ± 4.78%, p<0.001; FS% 35.48 ± 6.34% vs. 29.54 ± 2.88%, p<0.001), and 82.86% patients underwent an improvement of left ventricular systolic function post 1year of the PTX. Conclusions: tPTX+AT is an effective curative intervention of secondaryhyperparathyroidismandcan significantly overturn the LVH and increase the left ventricular systolic function. Keywords: ESRD, Left ventricular function, Secondary hyperparathyroidism, Parathyroidectomy Background [1]. While secondary hyperparathyroidism is an import- The morbidity of secondary hyperparathyroidism is high ant risk factor of CVD in ESRD, PTX is an effective in ESRD patients. Among all the complications, cardio- therapeutic method for severe SHPT unmitigated by vascular events are the leading causes of death, and the medicine therapy. It has been reported that the cardio- mortality caused by cardiovascular disease (CVD) is 10 vascular mortality of patients who underwent successful to 100 times higher than that in the general population PTX, registered 37–41% reduction [2, 3]. However, the impact of PTX on left ventricular function remains ob- * Correspondence: [email protected] scure. Case report and small sample size studies have 1 Kidney Disease Center, the First Affiliated Hospital, Zhejiang University shown that the EF% and FS% of hemodialysis patients School of Medicine, Hangzhou, Zhejiang, China 2Key Laboratory of Kidney Disease Prevention and Control Technology, were significantly improved after the PTX [4, 5]. This Zhejiang, Hangzhou, China study was conducted retrospectively to fully explore the © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Chen et al. BMC Nephrology (2020) 21:479 Page 2 of 8 impact of PTX on the left ventricular function of dialysis The ultrasonic cardiogram patients. We also collected the ultrasonic cardiogram parameter pre- and 1- year post-PTX, including ejection fraction% Methods (EF%), fractional shortening% (FS%), left ventricular end- Patients diastolic diameter (LVDd), interventricular septum thick- The cohort of this retrospective study consisted of ESRD ness (IVST), left ventricular posterior wall end-diastolic patients with SHPT received PTX from Oct 1, 2010, to thickness (LVPWD), left atrial diameter (LA), aorta (AO), Oct 1, 2016, at the First Affiliated Hospital, Zhejiang Uni- left ventricular end-systolic dimension (LVDs), left ven- versity School of Medicine. The inclusion criteria of PTX tricular posterior wall end-systolic thickness (LVPWs), were according to Kidney Disease Improving Global Out- ventricular septal end-systolic thickness (IVSs). comes (KDIGO) 2009 guidelines [6]. Accordingly, follow- We used the Devereux correction formula to calculate ing patients were excluded: those having severe the Left ventricular mass index (LVMI). malnutrition, infection or inflammation; severe liver dis- Left ventricular mass (LVM, g) = 0.8 × 1.04{[LVDd 3 3 ease and coagulation disorders; complicated with a (cm) + IVST (cm) + LVPWd (cm)] -LVDd } + 0.6; 2 hematological disease or malignant tumors; having a his- Body surface area (BSA) (m , female) = 0.0073 × height tory of acute cardiovascular and cerebrovascular events (cm) + 0.0127 × weight (kg) -0.2106; 2 within 6 months; the parathyroid hormone (PTH)>100 BSA (m , male) = 0.0057 × height (cm) + 0.0121 × ng/L within 1 month post- PTX; those who received the weight (kg) + 0.0882; 2 kidney transplantion during the follow-up; with follow-up LVMI (g/m ) = LVM/BSA. < 1 year; received the PTX because of recurrence and data The diagnostic criteria of left ventricular hypertrophy (LVH) ≥ 2 ≥ 2 missing or insufficiency. Patients enrolled were followed are: LVMI 95 g/m (female), LVMI 115 g/m (male) [7]. for at least 1 year; baseline characteristics including age, The improvement of LV systolic function was defined sex, dialysis duration, dialysis modality, the primary dis- as the improvement of the EF% measured by echocardi- eases of ESRD, the number of parathyroid gland removed, ography to an increase of 10% or greater in its absolute the blood pressure pre- and 1-year post-PTX, the cardio- value 1-year post-PTX. vascular drugs used during the follow-up were collected. This study received approval from the Research and Ethics The primary and the secondary evaluation items Committee of the First Affiliated Hospital, Zhejiang Uni- The primary evaluation items were: the change of ultra- versity School of Medicine. sonic cardiogram parameter pre- and 1-year post-PTX; the influence factor for the overturn of LVH; the influ- ence factor for the improvement of EF%. Surgical methods and perioperative management The secondary evaluation items included the biochem- The surgery method employed was total PTX with forearm ical parameters change pre- and post-PTX. autotransplantation (tPTX+AT). The parathyroid tissues were forwarded for pathological examination intra- and Data analysis post-operatively. Tiny pieces of parathyroid tissues were We used the Statistical Package for the Social Sciences transplanted into patients’ forearms. Post-operatively, all (SPSS) version 23.0 (SPSS Inc., Chicago, IL, USA) for statis- patients were given substantial doses of intravenous cal- tical analyses. We used Kolmogorov-Smirnov (KS) test to de- cium, oral calcium, and calcitriol supplement. termine the normality of the continuous variables. Continuous variables were presented as mean ± SD or inter- The biochemical parameters quartile range, and categorical variables were presented as We collected the biochemical parameters including pre- number and proportion. We used the paired t-test and Wil- operative serum calcium, phosphate, alkaline phosphatase, coxon signed- rank sum test to check the difference between parathyroid hormone, and albumin levels; monitored and ultrasonic cardiogram parameters, LVM and LVMI, pre- observed them at 1 week, 1 month, 3 months and 1 year and at one-year post-PTX. Moreover, We used the multiple after the PTX. logistic regression analysis to determine the influence factor for the overturn of LVH and the improvement of EF% one- The cardiovascular drugs and the blood pressure year post-PTX. P < 0.05 was regarded as statistically We collected the cardiovascular drugs used during the significant. follow-up, including angiotensin-converting enzyme in- hibitors (ACEI), angiotensin-receptor blockers (ARBs), Results calcium blockers, cardiotonic β-blockers, isosorbide Patients’ characteristics mononitrate and trimetazidine during the follow-up, and There were 293 ESRD patients diagnosed with SHPT be- the blood pressure 1-year post-PTX. tween Oct 1, 2010, and Oct 1, 2016 received Chen et al. BMC Nephrology (2020) 21:479 Page 3 of 8 parathyroidectomy. Out of them, following pa- had ≥4 parathyroid glands removed, while 16 patients tients(158) were excluded: 10 patients were excluded (11.9%) had <4 parathyroid glands removed. Further, because of the PTH>100 ng/L within 1 month post- all parathyroid glands turned out to be hyperplasia or PTX, 8 because of receiving the kidney transplant adenoma by pathological examination. The average during the follow-up, 39 because of the follow-up< systolic pressure pre-PTX was 139.4 ± 22.8 mmHg, 1 year, 8 because of receiving the PTX due to recur- while the average diastolic pressure was 88.6 ± 15.4 rence; and 93 because of data missing or insuffi- mmHg; the average systolic pressure 1-year post-PTX ciency.
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