With the prolongation of dialysis (peritoneal dialysis or hemodialysis) treatment time for patients with chronic renal failure in uremic stage, the risk of abnormal mineral bone metabolism in chronic kidney disease(CKD-MBD) increased. The Dialysis Outcomes and Practice Pattern Study(DOPPS) research shows that the incidence rate is 40-50%[2]. The secondary changes of parathyroid function are caused by the abnormal metabolism of calcium and phosphorus, the lack of vitamin D and the decrease of its receptor sensitivity, and the rise of the balance point of calcium regulation in the body, then bone pain, myalgia, skeletal deformity, atherosclerotic changes of cardiovascular system and neuropathy occurred[3]. As a safe and effective therapy, surgical treatment has been widely used in clinical practice, but serious postoperative complications have become the difficulty of perioperative treatment, especially hypocalcemia, which has a probability of about 97%. Severe hypocalcemia can be manifested as: respiratory distress, numbness and convulsion of hands and feet, insomnia, headache, acupuncture sensation of lips, palpitation and agitation, fidgety, induced epilepsy, malignant arrhythmia, etc. Intravenous pumping of Portugal Calcium Gluconate is the main treatment [4]. The purpose of this study is to come up with the safe and effective postoperative calcium regulation schemes, and to find that age, preoperative dialysis time, operation method, preoperative calcium value, PTH value, ALP value are closely related to them.
The results of this study show that age is an independent risk factor for postoperative calcium regulation, that is, the younger the patients are, the longer the time of postoperative calcium pumping is. The reason is that young patients need more calcium for their own growth. At the same time, the systemic calcium loss is caused by repeated dialysis treatment, so the perioperative calcium demand is greater. However, some scholars[5] have come to the opposite conclusion. They believe that the absorption of calcium and calcitriol and other drugs in the gastrointestinal tract of the elder patients is more serious, and hypocalcemia is more likely to occur; Therefore, the correlation between age and hypocalcemia needs more data to be confirmed. At the same time, bone density detection and bone biopsy can be used as objective means to evaluate the whole body bone content, but because of their technical requirements and patients' wishes, it can not be widely used in clinical.
As the most important detection index in perioperative period, blood calcium can directly reflect the quality of operation, and is closely related to the occurrence of postoperative symptoms[6]. The key to avoid severe symptoms, especially convulsion caused by hypocalcemia, is to maintain the stability of blood calcium after operation. A rigorous and safe postoperative calcium regulation scheme is directly related to the prognosis of patients. This study confirms that preoperative calcemia value is an independent risk factor of postoperative calcium regulation time, that is, preoperative calcium value is negatively related to postoperative hypocalcemia; Therefore, the blood calcium adjustment should run through the whole treatment process, even before the operation. Routine application of oral calcium before surgery can reduce the incidence of postoperative hypocalcemia and shorten the postoperative calcium regulation time. At the same time, the results of this study confirm that the appropriate use of oral calcium before operation can alleviate bone hunger in varying degrees, so as to shorten the postoperative calcium regulation time, which can be used as a routine treatment in the perioperative period.
Preoperative PTH value reflects parathyroid function. In patients with chronic renal failure in uremic stage undergoing dialysis treatment for a long time, the release of PTH in blood is stimulated by the whole body's osteolysis reflex, so as to promote bone absorption. After surgical removal of the pathological parathyroid gland, PTH value drops sharply, bone resorption is impaired, and then serious hypocalcemia occurs. Some scholars [7] have confirmed that when the preoperative PTH value is more than 1750ng/L, the probability of occurrence of hypocalcemia increased 6.8 times. This study shows that when parathyroid hormone is greater than 1449.30ng/L, it is necessary to strictly implement calcium regulation program to avoid hypocalcemia caused by premature suspension or reduction of calcium pumping. This study also confirms that preoperative PTH value was positively correlated with the postoperative calcium regulation time, that is, the higher preoperative PTH value, the more postoperative calcium demand, and the longer calcium regulation time.
Serum ALP is a key enzyme to promote bone calcification, which will increase in varying degrees for liver disease and bone marrow disease. Serum ALP value in the patients with chronic renal failure in uremic stage can reflect the severity of renal osteodystrophy, that is, the severity of bone hunger syndrome after operation. Kidney Disease: Improving Global Outcomes (KDIGO) suggests that Serum ALP value in blood can be used to evaluate the severity of CKD-MBD [1]. Ho LY and other scholars[8] [9] have confirmed that the higher the preoperative ALP value is, the greater the probability of hypocalcemia is after operation, and the more calcium dose needs to be supplemented. This study combines with preoperative ALP value to determine the degree of bone hunger in the whole body and indirectly guide the time of postoperative calcium regulation, especially the preoperative ALP value is greater than 243.43U/L, that is, the higher the preoperative ALP value is, the greater the degree of bone hunger is, the longer the time of calcium supplementation is, which is an independent risk factor affecting postoperative calcium regulation.
Hypocalcemia is the most serious complication in the perioperative period of surgical treatment of secondary hyperparathyroidism. The measurement and evaluation of preoperative related indicators can better estimate the prognosis, so as to develop a safe and effective calcium regulation therapy. However, the disease situation of patients undergoing dialysis treatment is more complex, and the influencing factors are diverse. The study of double centers and a small sample can not fully cover it. Therefore, more in-depth research still needs big data, especially the widely popularized operation methods and quantitative calcium regulation, etc.