The Efficacy Of Surgical Treatment Of Secondary Hyperparathyroidism-Systemic Review

Background and Objective:The number of patients suffering from chronic kidney disease(CKD)worldwide has been increasing year by year,CKD related complications have drawn specially attention.Secondary hyperparathyroidism(SHPT)is one of the most common complications in patients with chronic kidney disease.Its treatments are mainly drug treatment and surgical treatment.It is recommended to use surgical treatments for drug-refractory SHPT by the guidelines.The operation methods include subtotal parathyroidectomy(SPTX),total parathyroidectomy(TPTX),and total parathyroidectomy with autotransplantation(TPTX+AT).Currently,there is no powerful evidence for which one is the best operation method.This systematic review compares the surgical outcomes of three different surgical procedures for the treatment of secondary hyperparathyroidism by using a network meta-analysis.Methods:Databases such as pub-med,web of science,corchrane library,embase,medline,CNKI,Wanfang,etc.are searched to find relevant clinical trials on the treatment of SHPT with three surgical methods from inception to December 31,2016.According to the inclusion and exclusion criteria for document screening,and the extracted literatures are using NOS scale and Cochrane system evaluation manual for quality assessment.Using the R 3.3.1 software for network meta-analysis,through the R software to call the gemtc package quantitative analysis of the data and draw the required graphics,to achieve homogeneity and model consistency analysis,convergence analysis,the sequencing of the efficacy of different surgical methods.Results:A total of 23 literatures are included.Among them,11 articles are compared with SPTX and TPTX+AT,8 articles are compared between TPTX and TPTX+AT,and 4 articles are compared among the three studies.The number of cases is 2653 cases,and the score of the included literature quality NOS scale is basically between 5-8 stars.5 indicators are compared and sorted by the network meta-analysis.(1)All included articles contain the comparison of recurrence rates.There are 4 groups of studies comparing SPTX and TPTX.There are 15 groups of studies comparing SPTX and TPTX+AT,and there are 12 groups of studies comparing TPTX and TPTX+AT.Comparison between TPTX+AT and SPTX is not statistically significant(OR=1.1,95%CI:0.46-2.5);TPTX has a lower recurrence rate than TPTX+AT,and the difference is statistically significant between TPTX+AT and TPTX(OR=0.087,95%CI:0.018-0.27).The order of recurrence rate from high to low is SPTX,TPTX+AT,and TPTX.(2)A total of 16 included articles describe for reoperation because of recurrence or persistence of SHPT.There are 2 groups of studies comparing SPTX and TPTX.While 9 groups of studies comparing SPTX and TPTX+AT,and there are 9 groups of studies comparing TPTX and TPTX+AT.Forest plot results show that the difference is not statistically significant between SPTX and TPTX+AT(OR=0.67,95%CI:0.21-2.3).Comparing with TPTX+AT,TPTX has a lower incidence of reoperation and simultaneously there is a significant difference(OR=0.14,95%CI:0.021-0.60).The reoperation because of recurrence or persistence of SHPT rates from high to low is TPTX+AT,SPTX,and TPTX.(3)There are 6 literatures referring to the patients’symptomatic improvement,including 2groups of SPTX vs TPTX,4 groups of SPTX vs TPTX+AT and 4 groups of TPTX vs TPTX+AT.Forest plot results show that the difference is not statistically significant both between SPTX and TPTX+AT(OR=1.2,95%CI:0.31-8.1)and between TPTX and TPTX+AT(OR=1.1,95%CI:0.22-5.1).The rank of symptomatic improvement from high to low is TPTX+AT,SPTX,and TPTX.(4)There are 9 articles describing the hypocalcemia or hypoparathyroidism.There are 3groups of studies comparing SPTX with TPTX.While 6 groups of studies compare SPTX with TPTX+AT,and comparing TPTX with TPTX+AT are 6 groups of studies.Forest plot results show that SPTX has a lower rates of hypoparathyroidism than TPTX+AT(OR=0.34,95%CI:0.061-1.5)and TPTX has a higher rates of hypoparathyroidism than TPTX+AT(OR=3.8,95%CI:0.97-14.0),but both of the differences have no statistical significance.The incidence rates of hypocalcemia or hypoparathyroidism from high to low is TPTX,TPTX+AT,SPTX.(5)There are 3 literatures referring to surgical complications,of which 2 are for comparison of the 3 surgical methods,the other is TPTX vs TPTX+AT.Forest plot results show that the difference is no statistically significant neither in SPTX vs TPTX+AT(OR=1.1,95%CI:0.19-4.6)nor in TPTX vs TPTX+AT(OR=0.65,95%CI:0.17-2.2).The incidence rates of surgically-related complications from high to low is SPTX,TPTX+AT,and TPTX.Further analysis shows that there is a certain gap between the specifications of the three surgical procedures,especially in the SPTX.The remained pieces of parathyroid tissues are slightly different between the various research teams.It is not clear yet whether it had a decisive significance for outcomes though different surgical implementation details have been found.The gemtc software package is used to test the homogeneity of each articles under the model,the heterogeneity of this model is acceptable because of I~2<75%,and the direct comparison evidence is basically reliable.The nodal splitting method is used to test the consistency of the model by the R software gemtc package.Except for the reoperation because of recurrence/persistence rate P<0.05,indicating that the direct and indirect comparison models have poor consistency,and the results of the meta-analysis are needed to be further verified.The remaining 4 indicators P values are all greater than 0.05,showing that the direct and indirect comparison models have good consistency.The model is tested by trace plots,density plots and convergence diagnosis plots.The convergence of the model is slightly less than ideal,and the quality and quantity of the included studies need to be improved.Conclusions:Three types of parathyroidectomy can improve the symptoms of patients.Comparing with SPTX and TPTX+AT,TPTX has a lower recurrence rate and reoperation rate,and fewer surgical-related complications.There is a risk of hypocalcemia by TPTX,but no specific reports show that it is difficult to cure hypocalcemia with drugs.Considering the above aspects,TPTX is the best of the three surgical methods.However,there are no relevant indicators such as all-cause mortality,and there are certain differences in the details of the surgeon’s surgical procedures.The long-term prognosis of each surgical method cannot be clearly defined.Therefore,more prospective,large-sample,multi-center randomized controlled trials are urged to launch,and surgical skills and specifications for surgeons need to be improved.