Meta Analysis Of Total Parathyroidectomy Versus Parathyroidectomy Plus Autograft In The Treatment Of Hyperparathyroidism Secondary To Chronic Kidney Failure

Objective: Patients with chronic kidney disease(CKD)have varying degrees of secondary hyperparathyroidism(SHPT)with increasing dialysis years and progressive renal failure.Parathyroidectomy is required for refractory to medical treatments or patients with poor medical results that are in compliance with surgical indications,aiming to improve the clinical symptoms.The clinical symptoms of SHPT patients involve multiple systems such as heart,bone,hematopoietic system and lipid metabolism.The incidence of cardiovascular events and mortality is high,so it is important to select safe and effective surgical methods for the recovery of patients during perioperative period and prognosis after surgery.There is no consensus on the surgical methods of SHPT patients at home and abroad.There is no strong evidence to support which surgical methods are better for the treatment of SHPT.This meta analysis is to compare the long term outcome of TPTX and TPTX + AT,and determine which treatment is better for SHPT,so that provide evidence-based guidence for clinical treatment of SHPT.Methods: Foreign language database including PubMed,EMBASE,Cochrane Library,MEDLINE,Scopus,and Chinese database including China Biomedical Literature Database(CBM),Wanfang database,Weipu,CNKI were searched and collected by keyword and free word without language limited.The search time is range from the construction of the library to december 31,2018.The two researchers searched literature independent following the inclusion and exclusion criteria,and extracted data which is designed in advance.During the collection process,the two people disagreed and decided through consultation with the third researcher.The quality of the literature included in the study was evaluated,and the data was analyzed using RevMan 5.3.0.The analysis of the binary categorical variables used odds ratios(OR)and 95% confidence interval(CI);the continuous variables used mean difference(MD)or standardized mean difference(SMD).At the same time,the heterogeneity and publication bias analysis of the included studies were carried out,and the results were showed on funnel chart which is obtained by using STATA12.0.Results: Finally,16 articles were included in the literature.A total of 2002 samples were included in the study,including 754 in the TPTX group,844 in the TPTX+AT group,and 404 in the other.Compared with the TPTX+AT group,the postoperative recurrence rate was lower in the TPTX group(P<0.00001),reoperation rate due to recurrence or persistent HPT was also lower(P=0.002),operation time was shorter(P=0.01),and the monthly Hb level was higher(P=0.008)and the Hct level was also higher at 6 months after surgery(P=0.0003)in the TPTX group.The incidence of persistent HPT in the two groups(P=0.84)and the incidence of hypoparathyroidism(P=0.29)was no significant difference.Other outcomes including the incidence of hypocalcemia(P=0.85),the postoperative symptom relief rate(P=0.83),postoperative calcium or vitamin D supplement(P=0.66),all-cause mortality(P=0.31)and hospital stay(P=0.98).Morever,There was no significant difference in postoperative complications,including recurrent laryngeal nerve injury(P=0.41),postoperative bleeding(P=0.19).Hb level(P=0.29),and Hct level(P=0.56)which was following up one year were no significant difference between the two group,including the serum phosphorus level(P=0.76)6 months after the surgery.As far as the surgical recurrence rates,there was no heterogeneity between the studies and there was no literature bias.CONCLUSIONS: This meta-analysis showed that comparing with the TPTX+AT group,the postoperative recurrence rate was lower in the TPTX group,the reoperation rate due to recurrence or persistent HPT was lower,the operation time was shorter,and the improvement of renal anemia was better at 6 months after surgery.There was no significant difference in the incidence of persistent HPT,the incidence of hypoparathyroidism,the incidence of hypocalcemia,and the postoperative symptom relief rate between the two groups.There were no significant differences in postoperative complications,postoperative medication(calcium or vitamin D supplyment),all-cause mortality,and length of hospital stay.From the above perspectives,TPTX is a better choice for patients with SHPT.However,there is no statistical analysis of the specific causes of postoperative persistent HPT,such as ectopic parathyroid glands and transplant-related hyperparathyroidism.In addition,the effects of different autograft locations on graft-related HPT recurrence were not systematically analyzed.As for the incidence of hypocalcemia,postoperative calciumor vitamin D supplementation after surgery,this meta-analysis included fewer studies which were not provide strong evidence.Large-sample multi-center RCT studies are still needed to provide a higher level of evidence to support and correctly guide clinical practice.