甲状旁腺激素水平在原发性醛固酮增多症及肾上腺无功能瘤患者鉴别诊断中的应用价值

李亚楠; 张赛春; 臧丽; 谷伟军; 李冰; 陈康; 裴育; 杜锦; 郭清华; 巴建明; 吕朝晖; 窦京涛; 母义明

doi:10.3969/j.issn.2095-5227.2021.09.004

甲状旁腺激素水平在原发性醛固酮增多症及肾上腺无功能瘤患者鉴别诊断中的应用价值

Value of parathyroid hormone level in differential diagnosis of patients with primary aldosteronism and nonfunctional adrenal tumors

摘要

摘要:
背景原发性醛固酮增多症(primary aldosteronism，PA)是继发性高血压的常见病因，PA的分型中以醛固酮瘤(aldosterone-producing adenoma，APA)和特发性醛固酮增多症(idiopathic aldosteronism，IHA)最为常见。PA患者与肾上腺无功能瘤(nonfunctional adrenal tumors，NFAT)患者血清甲状旁腺激素(parathyroid hormone，PTH)水平存在差异，不同亚型PA患者血清PTH水平也存在差异。
目的比较PA与NFAT患者以及APA与IHA患者血清PTH水平的差异，并分析影响PTH的因素，探讨PTH在PA及NFAT患者鉴别诊断中的应用价值。
方法收集解放军总医院第一医学中心2016 - 2020年收治的PA患者414例女176例，男238例；平均年龄(50.90 ± 10.40)岁；APA患者263例，IHA患者151例和NFAT患者275例女112例，男163例；平均年龄(52.74 ± 11.20)岁的临床资料。比较PA与NFAT患者以及APA与IHA患者血清PTH、血电解质、尿电解质、血浆肾素、血浆醛固酮、尿醛固酮水平的差异。采用Pearson相关性分析探讨影响PTH的因素。分析PTH鉴别PA与NFAT以及APA与IHA的最佳切点。
结果 PA患者中位PTH水平明显高于NFAT患者64.82(62.36，67.28) pg/mL vs 45.23(35.02，54.74) pg/mL，P ＜ 0.001，APA患者中位PTH水平明显高于IHA患者65(51.28，76.60) pg/mL vs 55.81(43.46，68.15) pg/mL，P ＜ 0.001。PTH水平与血钾呈负相关(r=-0.460，P ＜ 0.001)，与(血、尿)醛固酮呈正相关(血醛固酮r=0.293，P ＜ 0.001；尿醛固酮r=0.173，P=0.000)。ROC分析结果：PTH鉴别PA与NFAT的ROC-AUC(95% CI)为0.742(0.526 ～ 0.948)，理论阈值为52 pg/mL；鉴别PA患者中APA与IHA两分型的ROC-AUC(95% CI)为0.674(0.375 ～ 0.967)，理论阈值为60 pg/mL。
结论 PA与NFAT患者以及APA与IHA患者血清PTH水平均存在差异，PTH水平受血钾及醛固酮水平的影响，在PA的诊断及分型中有一定的参考价值。

Abstract:
Background Primary aldosteronism (PA) is one of the most common causes of secondary hypertension. Aldosterone-producing adenoma (APA) and idiopathic aldosteronism (IHA) are the most common types of PA. Studies have demonstrated that the parathyroid hormone (PTH) levels in PA and nonfunctional adrenal tumors (NFAT) are different.
Objective To investigate the differences of PTH level in PA and NFAT patients, as well as in APA and IHA patients, and discuss the value of parathyroid hormone level in the differential diagnosis of patients with primary aldosteronism and nonfunctional adrenal tumors.
Methods Clinical data about 414 PA patients (176 females, 238 males, average age of 50.90 ± 10.40 years, 263 cases of APA and 151 cases of IHA) and 275 NFAT patients (112 females, 163 males, average age of 52.74 ± 11.20 years) in the First Medical Center of Chinese PLA General Hospital from 2016 to 2020 were analyzed. The changes of biochemical indicators such as PTH, blood electrolytes, urine electrolytes, supine renin, supine aldosterone, ortho renin, ortho aldosterone and urine aldosterone were compared between PA, NFAT patients and APA, IHA patients. Then Pearson correlation analysis was adopted to investigate the factors affecting the PTH level.
Results Compared with the NFAT patients, PTH level in the PA patients elevated 64.82(62.36, 67.28) pg/mL vs 45.23(35.02, 54.74) pg/mL, P＜ 0.001. Compared with the IHA patients, PTH level in the APA patients elevated 65(51.28, 76.60) pg/mL vs 55.81(43.46, 68.15) pg/mL, P＜0.001. The PTH level was negatively correlated with blood potassium (r =-0.460, P＜0.001) and positively correlated with aldosterone (blood aldosterone r=0.293, P＜0.001; urinary aldosterone r=0.173, P＜0.001). ROC analysis results showed that the ROC-AUC (95% CI) of PTH to distinguish PA from NFAT was 0.742 (0.526 - 0.948), and the theoretical threshold was 52 pg/mL. The ROC-AUC (95% CI) for distinguishing the classification of APA from IHA in PA patients was 0.674 (0.375 - 0.967), and the theoretical threshold was 60 pg/mL.
Conclusion PTH level is different in PA and NFAT patients, as well as in APA and IHA patients. PTH levels are affected by serum potassium and aldosterone levels, and have certain reference value in the diagnosis and classification of PA.

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