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Brad GF, Nicoară DM, Scutca AC, Bugi MA, Asproniu R, Olariu LG, Jugănaru I, Cristun LI, Mărginean O. Exploring Chronic Hypocalcemia: Insights into Autoimmune Polyglandular Syndrome Type 1-A Case Study and Literature Review. J Clin Med 2024; 13:2368. [PMID: 38673639 PMCID: PMC11051075 DOI: 10.3390/jcm13082368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/07/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Hypocalcemia is a common occurrence in pediatric patients, attributed to various causes and presenting with diverse clinical manifestations. A prompt evaluation is necessary to determine its underlying cause, whether it presents acutely or chronically, and to tailor treatment based on its severity. Among the potential causes of chronic hypocalcemia, primary hypoparathyroidism stands out. The case of a seven-year-old male patient with hypocalcemia reported in this article serves as an illustration, wherein targeted next-generation sequencing revealed a homozygous p.R257X mutation in the AIRE gene, indicative of autoimmune polyendocrine syndrome type 1 (APS-1). It poses challenges due to its multisystemic nature and involvement of specific autoantibodies, often leading to underdiagnosis, owing to its rarity, varied manifestations, and incomplete penetrance. A comprehensive review of the APS-1 literature was conducted to provide insights into the clinical manifestations, genetic spectrum, potential immunological mechanisms, and current medical strategies. Additionally, the recognition of AIRE gene mutations is crucial for facilitating genetic diagnosis, prognosis, and potential treatment strategies for APS-1. The management of such cases involves individualized approaches to treatment, regular monitoring, medication adjustments, and the early identification of associated conditions.
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Affiliation(s)
- Giorgiana-Flavia Brad
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
| | - Delia-Maria Nicoară
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
| | - Alexandra-Cristina Scutca
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
| | - Meda-Ada Bugi
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
- Research Center for Disturbances of Growth and Development in Children BELIVE, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Raluca Asproniu
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
| | - Laura-Gratiela Olariu
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
| | - Iulius Jugănaru
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
- Research Center for Disturbances of Growth and Development in Children BELIVE, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Lucian-Ioan Cristun
- Ph.D. School Department, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania;
| | - Otilia Mărginean
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
- Research Center for Disturbances of Growth and Development in Children BELIVE, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
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Charoenngam N, Bove-Fenderson E, Wong D, Cusano NE, Mannstadt M. Continuous Subcutaneous Delivery of rhPTH(1-84) and rhPTH(1-34) by Pump in Adults With Hypoparathyroidism. J Endocr Soc 2024; 8:bvae053. [PMID: 38562130 PMCID: PMC10983071 DOI: 10.1210/jendso/bvae053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Indexed: 04/04/2024] Open
Abstract
Context Continuous subcutaneous infusion of recombinant parathyroid hormone (rhPTH) through a pump has been proposed as a therapeutic alternative for patients with chronic hypoparathyroidism who remain symptomatic or hypercalciuric on conventional treatment (calcium and active vitamin D) or daily injections of rhPTH(1-84) or rhPTH(1-34). However, the real-world evidence of the outcome of this novel therapy is limited. Case Descriptions We report the clinical and biochemical outcomes of 12 adults with hypoparathyroidism (11 women, age 30-70 years, and 1 man, age 30 years) from 3 different clinical sites in the United States who were transitioned from conventional therapy to daily injections of rhPTH(1-84) or rhPTH(1-34) and then switched to continuous administration of rhPTH(1-84)/rhPTH(1-34) via pump therapy. In most patients, mean serum calcium concentrations increased while on PTH pump therapy compared with both conventional therapy (in 11 patients) and single/multiple daily rhPTH injections (in 8 patients). Despite this, 10 patients had lower median 24-hour urinary calcium levels while on PTH pump therapy compared with prior therapy (mean ± SD difference: -130 ± 222 mg/24 hours). All patients reported a qualitative decrease in hypocalcemic symptoms while receiving pump therapy. Three patients had pod failure at least once, and 1 patient developed an infusion site reaction. Conclusion In this case series of 12 patients with chronic hypoparathyroidism treated with rhPTH(1-84)/rhPTH(1-34) administered via a pump, improvement in clinical and biochemical parameters were observed in the majority of the patients. Our observations indicate benefits of pump administration of rhPTH that warrant further investigation.
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Affiliation(s)
- Nipith Charoenngam
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Erin Bove-Fenderson
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Daniel Wong
- Sutter Health, Sacramento, CA 95816, USA
- Baylor Scott & White Dallas Diagnostic Association, Garland, TX 75044, USA
| | - Natalie E Cusano
- Department of Medicine, Division of Endocrinology, Lenox Hill Hospital, New York, NY 10022, USA
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Ali DS, Marini F, Alsarraf F, Alalwani H, Alamri A, Khan AA, Brandi ML. Case Report: Calcium sensing receptor gene gain of function mutations: a case series and report of 2 novel mutations. Front Endocrinol (Lausanne) 2023; 14:1215036. [PMID: 37654565 PMCID: PMC10466028 DOI: 10.3389/fendo.2023.1215036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/20/2023] [Indexed: 09/02/2023] Open
Abstract
Autosomal dominant hypocalcemia (ADH1) is a genetic disorder characterized by low serum calcium and low or inappropriately normal levels of parathyroid hormone. The disease is caused by a heterozygous activating mutation of the calcium-sensing receptor (CaSR) gene, encoding a G-Protein-coupled cell membrane sensor of extracellular calcium concentration mainly expressed by parathyroid glands, renal tubules, and the brain. ADH1 has been linked to 113 unique germline mutations, of which nearly 96% are missense mutations. There is often a lack of a clear genotype/phenotype correlation in the reported literature. Here, we described a case series of 6 unrelated ADH1 probands, each one bearing a gain-of-function CaSR mutation, and two children of one of these cases, matching our identified mutations to the same ones previously reported in the literature, and comparing the clinical and biochemical characteristics, as well as the complication profile. As a result of these genetic and clinical comparisons, we propose that a genotype/phenotype correlation may exist because our cases showed similar presentation, characteristics, and severity, with respect to published cases with the same or similar mutations. We also contend that the severity of the presentation is highly influenced by the specific CaSR variant. These findings, however, require further evaluation and assessment with a systematic review.
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Affiliation(s)
- Dalal S. Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Francesca Marini
- Fondazione Italiana Ricerca sulle Malattie dell'Osso (FIRMO) Onlus, Italian Foundation for the Research on Bone Diseases, Florence, Italy
| | - Farah Alsarraf
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Hatim Alalwani
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Abdulrahman Alamri
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Aliya A. Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Maria Luisa Brandi
- Fondazione Italiana Ricerca sulle Malattie dell'Osso (FIRMO) Onlus, Italian Foundation for the Research on Bone Diseases, Florence, Italy
- Donatello Bone Clinic, Villa Donatello Hospital, Sesto Fiorentino, Italy
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Sait B, Chidambaram AC, Vidhyasagar K, Dinesh Babu RM, Sagayaraj B. Nephrocalcinosis in a 3-year-old child with hypocalcemia: Answers. Pediatr Nephrol 2023; 38:2565-2569. [PMID: 35925425 DOI: 10.1007/s00467-022-05695-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/02/2022] [Accepted: 07/04/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Benazer Sait
- Department of Pediatrics, Saveetha Institute of Medical and Technical Sciences, Chennai, 600056, India
| | | | | | - R M Dinesh Babu
- Department of Pediatrics, Saveetha Institute of Medical and Technical Sciences, Chennai, 600056, India
| | - Benjamin Sagayaraj
- Department of Pediatrics, Saveetha Institute of Medical and Technical Sciences, Chennai, 600056, India
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Tyagi R, Kalra N, Khatri A, Goyal T, Yangdol P, Sabherwal P. A Rare Case of Autoimmune Polyendocrinopathy-candidiasis-ectodermal Dystrophy Syndrome: Dental Perspective on Diagnosis and Management. Int J Clin Pediatr Dent 2023; 16:139-146. [PMID: 37020766 PMCID: PMC10067979 DOI: 10.5005/jp-journals-10005-2496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Aim To report a unique case of Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) in a young boy and discuss the oral health impact and management of the disease. Background Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autoimmune disorder with various clinical manifestations. Biallelic mutations in the autoimmune regulator (AIRE) gene lead to impairment of central immune tolerance and a targeted attack on various endocrine and non-endocrine organs. Patients classically suffer from a triad of disorders, including chronic mucocutaneous candidiasis (CMC), hypoparathyroidism, and adrenocortical failure (Addison's disease). Results In recent times, it has been observed that oral manifestations of the disorder, such as enamel hypoplasia, appear early and frequently. Affected individuals require a comprehensive preventive and minimally invasive approach for oral health along with follow-up throughout their lifespan to manage potentially life-threatening disease manifestations. Conclusion Prompt recognition by a pediatric dentist can facilitate an earlier diagnosis and allow for screening, preventive and therapeutic services. Clinical Significance To deliver oral health care in an effective and comprehensive manner, clinicians should be able to recognize, diagnose and manage the signs and symptoms of the disease. How to cite this article Tyagi R, Kalra N, Khatri A, et al. A Rare Case of Autoimmune Polyendocrinopathy-candidiasis-ectodermal Dystrophy Syndrome: Dental Perspective on Diagnosis and Management. Int J Clin Pediatr Dent 2023;16(1):139-146.
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Affiliation(s)
- Rishi Tyagi
- Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi, India
| | - Namita Kalra
- Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi, India
| | - Amit Khatri
- Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi, India
| | - Tavisha Goyal
- Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi, India
| | - Padma Yangdol
- Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi, India
| | - Puja Sabherwal
- Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi, India
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Khan AA, Guyatt G, Ali DS, Bilezikian JP, Collins MT, Dandurand K, Mannstadt M, Murphy D, M'Hiri I, Rubin MR, Sanders R, Shrayyef M, Siggelkow H, Tabacco G, Tay YKD, Van Uum S, Vokes T, Winer KK, Yao L, Rejnmark L. Management of Hypoparathyroidism. J Bone Miner Res 2022; 37:2663-2677. [PMID: 36161671 DOI: 10.1002/jbmr.4716] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 12/24/2022]
Abstract
Hypoparathyroidism (HypoPT) is a rare disorder characterized by hypocalcemia in the presence of a low or inappropriately normal parathyroid hormone level. HypoPT is most commonly seen after neck surgery, which accounts for approximately 75% of cases, whereas approximately 25% have HypoPT due to nonsurgical causes. In both groups of patients, conventional therapy includes calcium and active vitamin D analogue therapy aiming to maintain serum calcium concentration in the low normal or just below the normal reference range and normalize serum phosphorus, magnesium concentrations, and urine calcium levels. The limitations of conventional therapy include wide fluctuations in serum calcium, high pill burden, poor quality of life, and renal complications. Parathyroid hormone (PTH) replacement therapy may improve the biochemical profile in those in whom conventional therapy proves unsatisfactory. Based on a systematic review and meta-analysis of the literature, the panel made a graded recommendation suggesting conventional therapy as first line therapy rather than administration of PTH (weak recommendation, low quality evidence). When conventional therapy is deemed unsatisfactory, the panel considers use of PTH. Because pregnancy and lactation are associated with changes in calcium homeostasis, close monitoring is required during these periods with appropriate adjustment of calcium and active vitamin D analogue therapy to ensure that serum calcium remains in the mid to low normal reference range in order to avoid maternal and fetal complications. Emerging therapies include molecules with prolonged PTH action as well as different mechanisms of action that may significantly enhance drug efficacy and safety. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - John P Bilezikian
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Michael T Collins
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Karel Dandurand
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Iman M'Hiri
- Bone Research and Education Centre, Oakville, Canada
| | - Mishaela R Rubin
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | | | | | - Heide Siggelkow
- Clinic of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Goettingen, Goettingen, Germany.,MVZ Endokrinologikum Goettingen, Goettingen, Germany
| | - Gaia Tabacco
- Unit of Metabolic Bone and Thyroid Diseases, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.,Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
| | - Yu-Kwang Donovan Tay
- Department of Medicine, Sengkang General Hospital, Singhealth and Duke-NUS Medical School, Singapore, Singapore
| | - Stan Van Uum
- Department of Medicine, Western University, London, Canada
| | - Tamara Vokes
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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7
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Yao L, Hui X, Li M, Li J, Ahmed MM, Lin C, Kandi M, Sreekanta A, Makhdami N, Tamilselvan D, Ali DS, Dandurand K, Yang K, Bilezikian JP, Brandi ML, Clarke BL, Mannstadt M, Rejnmark L, Khan AA, Guyatt G. Complications, Symptoms, Presurgical Predictors in Patients With Chronic Hypoparathyroidism: A Systematic Review. J Bone Miner Res 2022; 37:2642-2653. [PMID: 36375810 DOI: 10.1002/jbmr.4673] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 07/22/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022]
Abstract
The complications and symptoms of hypoparathyroidism remain incompletely defined. Measuring serum parathyroid hormone (PTH) and calcium levels early after total thyroidectomy may predict the development of chronic hypoparathyroidism. The study aimed (i) to identify symptoms and complications associated with chronic hypoparathyroidism and determine the prevalence of those symptoms and complications (Part I), and (ii) to examine the utility of early postoperative measurements of PTH and calcium in predicting chronic hypoparathyroidism (Part II). We searched Medline, Medline In-Process, EMBASE, and Cochrane CENTRAL to identify complications and symptoms associated with chronic hypoparathyroidism. We used two predefined criteria (at least three studies reported the complication and symptom and had statistically significantly greater pooled relative estimates). To estimate prevalence, we used the median and interquartile range (IQR) of the studies reporting complications and symptoms. For testing the predictive values of early postoperative measurements of PTH and calcium, we used a bivariate model to perform diagnostic test meta-analysis. In Part I, the 93 eligible studies enrolled a total of 18,973 patients and reported on 170 complications and symptoms. We identified nine most common complications or symptoms probably associated with chronic hypoparathyroidism. The complications or symptoms and the prevalence are as follows: nephrocalcinosis/nephrolithiasis (median prevalence among all studies 15%), renal insufficiency (12%), cataract (17%), seizures (11%), arrhythmia (7%), ischemic heart disease (7%), depression (9%), infection (11%), and all-cause mortality (6%). In Part II, 18 studies with 4325 patients proved eligible. For PTH measurement, regarding the posttest probability, PTH values above 10 pg/mL 12-24 hours postsurgery virtually exclude chronic hypoparathyroidism irrespective of pretest probability (100%). When PTH values are below 10 pg/mL, posttest probabilities range from 3% to 64%. Nine complications and symptoms are probably associated with chronic hypoparathyroidism. A PTH value above a threshold of 10 pg/mL 12-24 hours after total thyroidectomy is a strong predictor that the patients will not develop chronic hypoparathyroidism. Patients with PTH values below the threshold need careful monitoring as some will develop chronic hypoparathyroidism. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Xu Hui
- Evidence-Based Social Sciences Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Jing Li
- Evidence-Based Social Sciences Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Muhammad Muneeb Ahmed
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Clement Lin
- Faculty of Health Sciences, McMaster University, Canada
| | - Maryam Kandi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ashwini Sreekanta
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Nima Makhdami
- Internal Medicine Resident, Department of Internal Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Divya Tamilselvan
- Faculty of Health Sciences and Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Karel Dandurand
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Kehu Yang
- Evidence-Based Social Sciences Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - John P Bilezikian
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Maria Luisa Brandi
- Fondazione Italiana sulla Ricerca sulle Malattie dell'Osso (F.I.R.M.O. Foundation), Florence, Italy
| | - Bart L Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Rochester, MN, USA
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Lars Rejnmark
- Dept of Endocrinology and Internal Medicine, Aarhus University hospital, Aarhus, Denmark
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Khan AA, Bilezikian JP, Brandi ML, Clarke BL, Gittoes NJ, Pasieka JL, Rejnmark L, Shoback DM, Potts JT, Guyatt GH, Mannstadt M. Evaluation and Management of Hypoparathyroidism Summary Statement and Guidelines from the Second International Workshop. J Bone Miner Res 2022; 37:2568-2585. [PMID: 36054621 DOI: 10.1002/jbmr.4691] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 11/10/2022]
Abstract
This clinical practice guideline addresses the prevention, diagnosis, and management of hypoparathyroidism (HypoPT) and provides evidence-based recommendations. The HypoPT task forces included four teams with a total of 50 international experts including representatives from the sponsoring societies. A methodologist (GG) and his team supported the taskforces and conducted the systematic reviews. A formal process following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and the systematic reviews provided the structure for seven of the guideline recommendations. The task force used a less structured approach based on narrative reviews for 20 non-GRADEd recommendations. Clinicians may consider postsurgical HypoPT permanent if it persists for >12 months after surgery. To predict which patients will not develop permanent postsurgical HypoPT, we recommend evaluating serum PTH within 12 to 24 hours post total thyroidectomy (strong recommendation, moderate quality evidence). PTH > 10 pg/mL (1.05 pmol/L) virtually excludes long-term HypoPT. In individuals with nonsurgical HypoPT, genetic testing may be helpful in the presence of a positive family history of nonsurgical HypoPT, in the presence of syndromic features, or in individuals younger than 40 years. HypoPT can be associated with complications, including nephrocalcinosis, nephrolithiasis, renal insufficiency, cataracts, seizures, cardiac arrhythmias, ischemic heart disease, depression, and an increased risk of infection. Minimizing complications of HypoPT requires careful evaluation and close monitoring of laboratory indices. In patients with chronic HypoPT, the panel suggests conventional therapy with calcium and active vitamin D metabolites as first-line therapy (weak recommendation, low-quality evidence). When conventional therapy is deemed unsatisfactory, the panel considers the use of PTH. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Aliya A Khan
- Department of Medicine, Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - John P Bilezikian
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | | | - Bart L Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Rochester, MN, USA
| | - Neil J Gittoes
- Centre for Endocrinology Diabetes & Metabolism, Queen Elizabeth Hospital, Birmingham, UK
| | - Janice L Pasieka
- Department of Surgery and Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Dolores M Shoback
- Endocrine Research Unit, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, CA, USA
| | - John T Potts
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Koh AJ, Nam HK, Michalski MN, Do J, McCauley LK, Hatch NE. Anabolic actions of parathyroid hormone in a hypophosphatasia mouse model. Osteoporos Int 2022; 33:2423-2433. [PMID: 35871207 PMCID: PMC9568459 DOI: 10.1007/s00198-022-06496-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 07/07/2022] [Indexed: 11/17/2022]
Abstract
UNLABELLED Hypophosphatasia, the rare heritable disorder caused by TNAP enzyme mutations, presents wide-ranging severity of bone hypomineralization and skeletal abnormalities. Intermittent PTH (1-34) increased long bone volume in Alpl-/- mice but did not alter the skull phenotype. PTH may have therapeutic value for adults with TNAP deficiency-associated osteoporosis. INTRODUCTION Hypophosphatasia is the rare heritable disorder caused by mutations in the tissue non-specific alkaline phosphatase (TNAP) enzyme leading to TNAP deficiency. Individuals with hypophosphatasia commonly present with bone hypomineralization and skeletal abnormalities. The purpose of this study was to determine the impact of intermittent PTH on the skeletal phenotype of TNAP-deficient Alpl-/- mice. METHODS Alpl-/- and Alpl+/+ (wild-type; WT) littermate mice were administered PTH (1-34) (50 µg/kg) or vehicle control from days 4 to 12 and skeletal analyses were performed including gross measurements, micro-CT, histomorphometry, and serum biochemistry. RESULTS Alpl-/- mice were smaller with shorter tibial length and skull length compared to WT mice. Tibial BV/TV was reduced in Alpl-/- mice and daily PTH (1-34) injections significantly increased BV/TV and BMD but not TMD in both WT and Alpl-/- tibiae. Trabecular spacing was not different between genotypes and was decreased by PTH in both genotypes. Serum P1NP was unchanged while TRAcP5b was significantly lower in Alpl-/- vs. WT mice, with no PTH effect, and no differences in osteoclast numbers. Skull height and width were increased in Alpl-/- vs. WT mice, and PTH increased skull width in WT but not Alpl-/- mice. Frontal skull bones in Alpl-/- mice had decreased BV/TV, BMD, and calvarial thickness vs. WT with no significant PTH effects. Lengths of cranial base bones (basioccipital, basisphenoid, presphenoid) and lengths of synchondroses (growth plates) between the cranial base bones, plus bone of the basioccipitus, were assessed. All parameters were reduced (except lengths of synchondroses, which were increased) in Alpl-/- vs. WT mice with no PTH effect. CONCLUSION PTH increased long bone volume in the Alpl-/- mice but did not alter the skull phenotype. These data suggest that PTH can have long bone anabolic activity in the absence of TNAP, and that PTH may have therapeutic value for individuals with hypophosphatasia-associated osteoporosis.
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Affiliation(s)
- Amy J Koh
- Department of Periodontology and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Hwa Kyung Nam
- Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Megan N Michalski
- Department of Cell Biology, Van Andel Institute, Grand Rapids, MI, USA
| | - Justin Do
- Department of Periodontology and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Laurie K McCauley
- Department of Periodontology and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI, USA.
- Department of Pathology, School of Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Nan E Hatch
- Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI, USA.
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10
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Wu Y, Zhang C, Huang X, Cao L, Liu S, Zhong P. Autosomal dominant hypocalcemia with a novel CASR mutation: a case study and literature review. J Int Med Res 2022; 50:3000605221110489. [PMID: 35818129 PMCID: PMC9280832 DOI: 10.1177/03000605221110489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Autosomal dominant hypocalcemia type 1 (ADH1) is a rare inherited disorder characterized by hypocalcemia with low parathyroid hormone (PTH) levels and high urinary calcium. Its clinical presentation varies from mild asymptomatic to severe hypocalcemia. It is caused by gain-of-function mutations in the calcium-sensing receptor gene (CASR) which affect PTH secretion from the parathyroid gland and calcium resorption in the kidney. Here, we describe a case who presented with symptoms of recurrent seizure caused by hypocalcemia with a novel CASR variant. We comprehensively analyzed the phenotypic features of this presentation and reviewed the current literature to better understand clinical manifestations and the genetic spectrum.
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Affiliation(s)
- Yingying Wu
- Department of Neurology, Suzhou Hospital of Anhui Medical University, Suzhou, China.,Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Chao Zhang
- Department of Neurology, Suzhou Hospital of Anhui Medical University, Suzhou, China
| | - Xiaojun Huang
- Department of Neurology and Instituted of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Cao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Shihua Liu
- Department of Neurology, Suzhou Hospital of Anhui Medical University, Suzhou, China
| | - Ping Zhong
- Department of Neurology, Suzhou Hospital of Anhui Medical University, Suzhou, China
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11
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Puliani G, Hasenmajer V, Simonelli I, Sada V, Pofi R, Minnetti M, Cozzolino A, Napoli N, Pasqualetti P, Gianfrilli D, Isidori AM. Safety and Efficacy of PTH 1-34 and 1-84 Therapy in Chronic Hypoparathyroidism: A Meta-Analysis of Prospective Trials. J Bone Miner Res 2022; 37:1233-1250. [PMID: 35485213 PMCID: PMC9545848 DOI: 10.1002/jbmr.4566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 11/12/2022]
Abstract
Hypoparathyroidism is the only endocrine deficiency for which hormone replacement therapy is not the standard of care. Although conventional treatments may control hypocalcaemia, other complications such as hyperphosphatemia, kidney stones, peripheral calcifications, and bone disease remain unmet needs. This meta-analysis (PROSPERO registration number CRD42019126881) aims to evaluate and compare the efficacy and safety of PTH1-34 and PTH1-84 in restoring calcium metabolism in chronic hypoparathyroidism. EMBASE, PubMed, and CENTRAL databases were searched for randomized clinical trials or prospective studies published between January 1996 and March 2021. English-language trials reporting data on replacement with PTH1-34 or PTH1-84 in chronic hypoparathyroidism were selected. Three authors extracted outcomes, one author performed quality control, all assessed the risk of biases. Overall, data from 25 studies on 588 patients were analyzed. PTH therapy had a neutral effect on calcium levels, while lowering serum phosphate (-0.21 mmol/L; 95% confidence interval [CI], -0.31 to -0.11 mmol/L; p < 0.001) and urinary calcium excretion (-1.21 mmol/24 h; 95% CI, -2.03 to -0.41 mmol/24 h; p = 0.003). Calcium phosphate product decreased under PTH1-84 therapy only. Both treatments enabled a significant reduction in calcium and calcitriol supplementation. PTH therapy increased bone turnover markers and lumbar spine mineral density. Quality of life improved and there was no difference in the safety profile between PTH and conventionally treated patients. Results for most outcomes were similar for the two treatments. Limitations of the study included considerable population overlap between the reports, incomplete data, and heterogeneity in the protocol design. In conclusion, the meta-analysis of data from the largest collection to date of hypoparathyroid patients shows that PTH therapy is safe, well-tolerated, and effective in normalizing serum phosphate and urinary calcium excretion, as well as enabling a reduction in calcium and vitamin D use and improving quality of life. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Giulia Puliani
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.,Oncological Endocrinology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Ilaria Simonelli
- Service of Medical Statistics and Information Technology, Fatebenefratelli Foundation of Health Research and Education, Rome, Italy.,Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Sada
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessia Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Nicola Napoli
- Operative Research Unit of Osteo-metabolic and thyroid diseases, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.,Division of Bone and Mineral Diseases, Washington University in St. Louis, St. Louis, MO, USA
| | - Patrizio Pasqualetti
- Department of Public Health and Infectious Diseases, Section of Medical Statistics, Sapienza University of Rome, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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12
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Graham A, Javidi H, Stern M, Rogers HJ. The Impacts of Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dysplasia (APECED) on the Oral Health of Children and Young People: A Review and Case Report. JOURNAL OF ADVANCED ORAL RESEARCH 2022. [DOI: 10.1177/23202068221075961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim: Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare, highly variable disease with significant oral health impacts. The aim of the study is to examine the existing evidence base surrounding the oral health impacts of APECED and consider the wider clinical significance of the condition relevant to the provision of pediatric dental care. Materials and Methods: The evidence surrounding APECED and the oral health impacts obtained from a review of multiple databases was qualitatively summarized in the form of a literature review. A case study was used to illustrate the relevance of literature in caring patients with APECED. Results: The literature describes a broad range of impacts from APECED, although it is characterized by chronic candidal infection, autoimmune hypoparathyroidism, and Addison’s disease. Oral manifestations of APECED appear frequently and can present early. Developmental defects of the teeth affect a large proportion of patients with APECED and together with candidiasis, characterize the key oral manifestations of the disease. An enhanced preventive and minimally invasive approach to oral health care is recommended for these patients in light of the complexities of their medical condition. Conclusion: Patients with APECED require careful multidisciplinary care to ensure that the optimal oral health outcomes are achieved.
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Affiliation(s)
- Anna Graham
- Paediatric Dental Department, Guys and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, England, United Kingdom
| | - Hanieh Javidi
- Orthodontic Department, School of Medical Sciences, Manchester University, Oxford Road, Manchester, England, United Kingdom
| | - Melanie Stern
- Orthodontic Department, Charles Clifford Dental Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, United Kingdom
| | - Helen J. Rogers
- School of Dental Sciences, Faculty of Medical Sciences, Newcastle University, Tyne, England, United Kingdom
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13
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Shulman D. Subcutaneous infusion of rhPTH 1-34 during pregnancy and nursing in a woman with autosomal dominant hypoparathyroidism 1. J Endocr Soc 2022; 6:bvac031. [PMID: 35350394 PMCID: PMC8944315 DOI: 10.1210/jendso/bvac031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Indexed: 11/19/2022] Open
Abstract
We report a successful pregnancy in a young woman with autosomal dominant hypoparathyroidism type 1 (ADH1) due to an activating mutation of the calcium sensing receptor (CASR) (c.2519C>T; p.Ala840Val) who was treated with recombinant human parathyroid hormone (rhPTH)1-34 delivered via continuous subcutaneous infusion using an OmniPod pump. She experienced no tetany or hospitalizations during the pregnancy. Serum calcium levels ranged from 7.2 to 9.8 mg/dL. Due to mild preeclampsia, her infant was delivered at 37 weeks. There were no physical anomalies. The patient continued pump therapy while nursing her daughter, who was ultimately confirmed to have the same CASR mutation. Breastfeeding appeared to protect the infant from significant hypocalcemia without the need for calcium or calcitriol supplementation until weaning at a year of age. A role for parathyroid hormone-related protein (PTHrP) is suggested.
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14
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Bhatt ND, Heh JL, Hudspeth MP, Williams KW, Twombley KE. Teriparatide Therapy in a 4-Month-Old With Severe Hypoparathyroidism. J Pediatr Pharmacol Ther 2022; 27:80-84. [PMID: 35002563 DOI: 10.5863/1551-6776-27.1.80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/24/2021] [Indexed: 11/11/2022]
Abstract
Teriparatide is a human parathyroid hormone analog approved for the treatment of osteoporosis in adult patients. Its use for hypocalcemia and hypoparathyroidism in the pediatric population is described through case reports and small case series; however, larger studies that demonstrate long-term efficacy and safety are limited. At our institution, a 4-month-old premature (gestational age: 32 weeks) infant with multiple congenital anomalies, functional athymia, and severe hypoparathyroidism and receiving calcitriol, vitamin D, and calcium carbonate supplementation was initiated on subcutaneous injection of teriparatide. During the course of treatment, her calcium carbonate, vitamin D, and calcitriol supplementation requirements substantially decreased. Teriparatide effectively increased serum ionized calcium concentrations and decreased serum phosphorus concentrations in the present case-study over a 6-month period. Teriparatide was well tolerated, and no evidence of hypercalcemia was observed throughout treatment.
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Affiliation(s)
- Neelam D Bhatt
- Department of Pharmacy Services (NDB, JLH), Shawn Jenkins Children's Hospital, Charleston, SC
| | - Julie L Heh
- Department of Pharmacy Services (NDB, JLH), Shawn Jenkins Children's Hospital, Charleston, SC
| | - Michelle P Hudspeth
- Division of Pediatric Hematology/Oncology (MPH), Shawn Jenkins Children's Hospital, Charleston, SC
| | - Kelli W Williams
- Division of Pediatric Pulmonology, Allergy & Immunology (KWW), Shawn Jenkins Children's Hospital, Charleston, SC
| | - Katherine E Twombley
- Division of Pediatric Nephrology (KET), Shawn Jenkins Children's Hospital, Charleston, SC
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15
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Kovaleva EV, Eremkina AK, Elfimova AR, Krupinova JA, Bibik EE, Maganeva IS, Gorbacheva AM, Dobreva EA, Melnichenko GA, Mokrysheva NG. The Russian Registry of Chronic Hypoparathyroidism. Front Endocrinol (Lausanne) 2022; 13:800119. [PMID: 35250859 PMCID: PMC8889095 DOI: 10.3389/fendo.2022.800119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/13/2022] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Chronic hypoparathyroidism is a relatively rare disease associated with multicomponent medical therapy and various complications. The analysis of large databases of patients with chronic hypoparathyroidism is a necessary tool to enhance quality of medical care, as well as to determine the optimal clinical and therapeutic approaches, and prognostic markers of the disease. THE AIM of this study is to estimate the clinical and biochemical profile, long-term complications, medical therapy and disease control of the patients with chronic postsurgical and non-surgical hypoparathyroidism. MATERIALS AND METHODS the cross-sectional, observational, continuous study was based on the Russian Registry of patients with hypoparathyroidism. 544 patients from 63 regions of the Russian Federation were included in this study. RESULTS The majority of cases had postsurgical etiology (88.4%). Postsurgical hypoparathyroidism prevailed in females (р<0.001). About a half of patients had blood calcium and phosphorus targets, 56 and 52% respectively. Nephrolithiasis was confirmed in 32.5%, nephrocalcinosis - in 12.3% of cases. The risk of nephrocalcinosis/nephrolithiasis increased by 1.85 times with disease duration more than 4.5 years. The cataract was found in 9.4%. The cut-off point for the development of cataracts was 9.5 years, with a 6.96-fold increased risk. The longer duration of hypoparathyroidism of any etiology was associated with more frequent cataract (p=0.0018).We found brain calcification in 4%, arrhythmias in 7.2% and neuropsychiatric symptoms in 5.15% of cases. Generally, the BMD in the studied group corresponded to age values, and there was no evidence for the phenomenon of high bone density. TBS was consistent with normal bone microarchitectonics. In our study, the majority of patients (83.5%) was treated with standard therapy of calcium and vitamin D supplements. 5 patients with severe disease course were treated with rhPTH (1-34). CONCLUSIONS Analysis of the presented database indicates insufficient diagnosis of the complications associated with chronic hypoparathyroidism. Overall, hypoparathyroidism is associated with higher risks of renal stone formation, decreased GFR, cataract especially in patients with longer duration of disease.
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16
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Karunakar P, Krishnamurthy S, Rajavelu TN, Deepthi B, Thangaraj A, Chidambaram AC. A child with tetany, convulsions, and nephrocalcinosis: Answers. Pediatr Nephrol 2021; 36:4119-4122. [PMID: 34491438 DOI: 10.1007/s00467-021-05238-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Pediredla Karunakar
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Sriram Krishnamurthy
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India.
| | | | - Bobbity Deepthi
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Abarna Thangaraj
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Aakash Chandran Chidambaram
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
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17
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Winer KK, Ye S, Ferré EMN, Schmitt MM, Zhang B, Cutler GB, Lionakis MS. Therapy with PTH 1-34 or calcitriol and calcium in diverse etiologies of hypoparathyroidism over 27 years at a single tertiary care center. Bone 2021; 149:115977. [PMID: 33932619 DOI: 10.1016/j.bone.2021.115977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/14/2021] [Accepted: 04/22/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Hypoparathyroidism has heterogeneous genetic and acquired etiologies with a broad spectrum of severity. Herein we describe the clinical outcomes of the largest cohort of hypoparathyroid patients reported to date, who were followed over 27-years. DESIGN Pooled analysis of current and past studies describing the differential responses to PTH 1-34 injections vs conventional therapy among the varied hypoPT etiologies. METHODS 192 participants (ages 2-74 years) with hypoparathyroidism who received either calcitriol and calcium or PTH 1-34 by subcutaneous injection. RESULTS Among the 4 main etiologic categories of hypoparathyroidism (autoimmune polyglandular failure type 1, activating mutation of the calcium receptor, surgical, and idiopathic hypoparathyroidism), we reveal significant differences in PTH 1-34 dose requirements, prevalence of nephrocalcinosis, biomarkers of mineral homeostasis, and pharmacodynamic profiles. Serum 1,25-dihydroxyvitamin D3 increased significantly (P < 0.001) and 25-hydroxyvitamin D levels decreased during PTH 1-34 injections compared to calcitriol therapy (P < 0.01). Post-surgical patients achieved consistently lower urine calcium excretion over long-term PTH 1-34 therapy compared to conventional therapy (p < 0.001), but this was not achieved in the other etiologies. At study entry, patients had a high prevalence of renal insufficiency and nephrocalcinosis which were directly related to the duration of hypoparathyroidism (P < 0.03). Renal function remained stable during participation in our studies for both PTH 1-34 and conventional therapies. CONCLUSIONS We conclude that the effects and dose-response of PTH 1-34 treatment differ according to the etiology of hypoparathyroidism. Postsurgical hypoPT maintained mean serum calcium levels in the mid- to low-normal range while concurrently maintaining normal mean urine calcium during long-term twice-daily PTH 1-34 therapy.
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Affiliation(s)
- Karen K Winer
- Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD), NIH, Bethesda, MD, USA.
| | - Shangyuan Ye
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Elise M N Ferré
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Monica M Schmitt
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Bo Zhang
- Department of Neurology and ICCTR Biostatistics and Research Design Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gordon B Cutler
- Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD), NIH, Bethesda, MD, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
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18
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Laurer E, Grünberger J, Naidoo U, Lanzersdorfer R, Wimleitner M, Tischlinger K, Högler W. Recombinant human parathyroid hormone (1-84) replacement therapy in a child with hypoparathyroidism. Bone 2021; 144:115834. [PMID: 33359892 DOI: 10.1016/j.bone.2020.115834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 12/17/2020] [Accepted: 12/19/2020] [Indexed: 10/22/2022]
Abstract
First line conventional therapy of hypoparathyroidism comprises oral calcium and active vitamin D analogues. This approach may fail to correct hypocalcemia and hyperphosphatemia caused by the absence of parathyroid hormone and carries the risk of long-term complications including ectopic calcifications and renal damage. Full-length recombinant human parathyroid hormone (rhPTH[1-84]) is approved for the treatment of hypoparathyroidism in adults refractory to conventional therapy. To date, there is no data in children. Here, we report the successful use of rhPTH(1-84) in a 5-year old girl with hypoparathyroidism and concomitant chronic diarrhea manifesting as part of the autoimmune polyglandular syndrome type 1. Prior to starting rhPTH(1-84), the patient had been on conventional and later on rhPTH(1-34) continuous pump therapy. Conventional therapy failed to meet serum and urinary calcium target levels, whilst the pump therapy wasn't well tolerated and posed handling difficulties. Dose optimization for rhPTH(1-84) was informed by serum ionized calcium, spot urinary calcium-to-creatinine ratio and 24-hour urinary calcium excretion. Twice-daily subcutaneous injections of rhPTH(1-84) with a total dose of 3.35 μg/kg/d was well-tolerated, raised serum ionized calcium to target range (1.05-1.15 mmol/L) and normalized serum phosphate levels. Urinary calcium excretion was slightly above the recommended limit of 4 mg/kg/24 h, but improved compared to conventional therapy, with no evidence of nephrocalcinosis. Twice-daily administration stabilized serum calcium and phosphate levels compared to once-daily injections. rhPTH(1-84) treatment was well tolerated and the girl did not manifest any acute clinical complications of hypoparathyroidism throughout the entire observation period. Our experience with this case indicates that rhPTH(1-84) may be a physiological hormone replacement for managing hypoparathyroidism in children.
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Affiliation(s)
- Elisabeth Laurer
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Austria.
| | - Johanna Grünberger
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Austria
| | - Uvistra Naidoo
- South African Tuberculosis Vaccine Institute, University of Cape Town, South Africa
| | - Roland Lanzersdorfer
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Austria
| | - Marlene Wimleitner
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Austria
| | - Katharina Tischlinger
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Austria
| | - Wolfgang Högler
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Austria
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Winer KK, Schmitt MM, Ferre EMN, Fennelly KP, Olivier KN, Heller T, Lionakis MS. Impact of periprocedural subcutaneous parathyroid hormone on control of hypocalcaemia in APS-1/APECED patients undergoing invasive procedures. Clin Endocrinol (Oxf) 2021; 94:377-383. [PMID: 32955743 DOI: 10.1111/cen.14335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/09/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022]
Abstract
CONTEXT The monogenic disorder autoimmune polyendocrine syndrome type 1 (APS-1) or autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) manifests frequently with hypoparathyroidism, which requires treatment with oral supplementation with calcium and active vitamin D analogs. The majority of APS-1/APECED patients also suffer from intestinal malabsorption, which complicates the management of hypoparathyroidism and may lead to refractory severe hypocalcaemia. In such situations, reliance on intravenous calcium carries a high risk of nephrocalcinosis and renal damage. METHODS Here, we report our experience of periprocedural subcutaneous administration of recombinant human parathyroid hormone (rhPTH 1-34) in APS-1/APECED patients. Serum calcium was measured up to five times within the 36-hour period starting the evening before the scheduled procedure and ending the morning following the procedure. RESULTS Twenty-seven APS-1/APECED patients with hypoparathyroidism (aged 4-67 years) underwent 31 invasive gastrointestinal and/or pulmonary procedures. The patients received an average rhPTH1-34 dose of 9.6 ± 1.4 µg by subcutaneous injection. 92% of the adults and 54% of children in our cohort had evidence of nephrocalcinosis. Mean calcium levels remained stable and ranged from 2.06 to 2.17 mmol/L with minimal fluctuation. None of our patients experienced periprocedural adverse events connected with hypocalcaemia. CONCLUSION rhPTH 1-34 is an alternative to conventional therapy in patients with APS-1/APECED and hypoparathyroidism undergoing invasive procedures. Subcutaneous PTH1-34 given directly before and after procedures resulted in well-controlled serum calcium levels maintained in the low-normal range and avoided the need for intravenous calcium which may contribute to renal calcifications and tubular damage.
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Affiliation(s)
- Karen K Winer
- Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD), NIH, Bethesda, MD, USA
| | - Monica M Schmitt
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Elise M N Ferre
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Kevin P Fennelly
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD, USA
| | - Kenneth N Olivier
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
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Dayal D, Panigrahi I, Varma TH, Gupta S, Gupta A, Kumar R, Sachdeva N. Ten-year use of recombinant parathyroid hormone for the treatment of hypoparathyroidism in a boy with partial Jacobsen syndrome. Pediatr Endocrinol Diabetes Metab 2021; 27:57-61. [PMID: 33191722 PMCID: PMC10227483 DOI: 10.5114/pedm.2020.100402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/08/2020] [Indexed: 06/07/2023]
Abstract
Pediatric hypoparathyroidism (HPT) is caused by inherited or acquired defects involving the synthesis or secretion of PTH, resistance to PTH action, or inappropriate regulation of PTH. Several syndromes such as DiGeorge syndrome, HDR (hypoparathyroidism, sensorineural deafness and renal dysplasia) syndrome, HRD (hypoparathyroidism, retardation, and dysmorphism) syndrome, Kenny-Caffey syndrome etc. may have associated HPT. In the present communication, we describe, the hitherto unreported, occurrence of HPT in a child with partial Jacobsen syndrome. Chromosomal Microarray analysis showed a heterozygous deletion of 4.7 Mb at cytoband 11q24.3q25 encompassing approximately 20 genes including JAM3 and NTM genes. The child was treated with recombinant human parathyroid hormone (rhPTH1-34) for 10 years. Throughout follow up, he required several adjustments in dosages of rhPTH1-34 and oral calcium to maintain serum calcium concentrations in low normal ranges. The bone turnover markers remained normal and oral calcium supplements were completely taken off after 8 years. In conclusion, our single-case experience indicates that long-term therapy of chronic HPT with rhPTH1-34 is safe and reduces the need for additional therapies.
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Affiliation(s)
- Devi Dayal
- Endocrinology and Diabetes Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, India
| | - Inusha Panigrahi
- Genetic-Metabolic Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Tandra Harish Varma
- Endocrinology and Diabetes Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, India
| | - Saniya Gupta
- Endocrinology and Diabetes Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, India
| | - Atul Gupta
- Endocrinology and Diabetes Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, India
| | - Rakesh Kumar
- Endocrinology and Diabetes Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, India
| | - Naresh Sachdeva
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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21
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Bernardor J, Flammier S, Cabet S, Lemoine S, Chapurlat R, Molin A, Bertholet-Thomas A, Bacchetta J. Intermittent Bi-Daily Sub-cutaneous Teriparatide Administration in Children With Hypoparathyroidism: A Single-Center Experience. Front Pediatr 2021; 9:764040. [PMID: 34820344 PMCID: PMC8606674 DOI: 10.3389/fped.2021.764040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The use of teriparatide has been reported in children with hypoparathyroidism as an investigational physiologic replacement therapy. Methods: We aimed to retrospectively report our pediatric experience of bi-daily sub-cutaneous teriparatide. Results are presented as median (25th-75th quartile). As part of the routine follow-up of these patients with hypoparathyroidism, total calcium at H0 (i.e., just before injection) and H4 (i.e., 4 h after teriparatide injection) and other biomarker parameters were regularly assessed. Results: At a median age of 10.7 (8.1-12.6) years, an estimated glomerular filtration rate (eGFR) of 110 (95-118) mL/min/1.73 m2, calcium levels of 1.87 (1.81-1.96) mmol/L and an age-standardized phosphate of 3.8 (2.5-4.9) SDS, teriparatide therapy was introduced in 10 patients at the dose of 1.1 (0.7-1.5) μg/kg/day (20 μg twice daily), with further adjustment depending on calcium levels. Six patients already displayed nephrocalcinosis. Severe side effects were reported in one child: two episodes of symptomatic hypocalcemia and one of iatrogenic hypercalcemia; one teenager displayed dysgueusia. Calcium levels at H0 did not significantly increase whilst calcium at H4 and phosphate levels significantly increased and decreased, respectively. After 12 months, eGFR, calcium and age-standardized phosphate levels were 108 (90-122) mL/min/1.73 m2, 2.36 (2.23-2.48) mmol/L, 0.5 (-0.1 to 1.5), and 68 (63-74) nmol/L, respectively, with a significant decrease in phosphate levels (p = 0.01). Urinary calcium and calcium/creatinine ratio remained stable; no nephrolithiasis was observed but two moderate nephrocalcinosis appeared. Conclusion: Intermittent teriparatide therapy significantly improves calcium and phosphate control, without increasing calciuria. It appears to be safe and well-tolerated in children.
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Affiliation(s)
- Julie Bernardor
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR, ORKID et ERKNet, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron, France.,INSERM UMR S1033 Research Unit, Lyon, France.,Service de Néphrologie Pédiatrique, CHU de Nice, Hôpital Archet, Nice, France.,Faculté de Médecine, Université Côte d'Azur, Nice, France
| | - Sacha Flammier
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR, ORKID et ERKNet, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron, France
| | - Sara Cabet
- Département de Radiologie Pédiatrique et Fœtale, Hôpital Femme Mère Enfant, Lyon, France
| | - Sandrine Lemoine
- Service d'Exploration Fonctionnelle Rénale, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR et ORKID, Département de Néphrologie, Hôpital Edouard Herriot, Lyon, France.,Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France
| | - Roland Chapurlat
- INSERM UMR S1033 Research Unit, Lyon, France.,Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France.,Service de Rhumatologie, Hôpital Edouard Herriot, Lyon, France
| | - Arnaud Molin
- Université de Normandie, UNICAEN, Unité de génétique, EA7450 BioTARGen, CHU de Caen Normandie, Caen, France
| | - Aurélia Bertholet-Thomas
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR, ORKID et ERKNet, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron, France
| | - Justine Bacchetta
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR, ORKID et ERKNet, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron, France.,INSERM UMR S1033 Research Unit, Lyon, France.,Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France
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22
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Mosca M, Bernardor J, Lemoine S, Bertholet-Thomas A, Bacchetta J. Rare diseases of phosphate and calcium metabolism: Crossing glances between nephrology and endocrinology. ANNALES D'ENDOCRINOLOGIE 2020; 82:30-35. [PMID: 33316222 DOI: 10.1016/j.ando.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Rare diseases of phosphate/calcium metabolism correspond to a wide and heterogeneous spectrum of diseases. Recent knowledge in physiology and genetics has made it possible to better characterize them and to propose attractive therapeutic approaches based on the underlying pathophysiology. These diseases are often at the interface between nephrology and endocrinology. In this spirit of a multidisciplinary care, each specialty can bring its own critical point of view and its own specificities to improve patient care. The objective of this manuscript is to "read" with a nephrologist's point of view the main frameworks of diseases of phosphate/calcium metabolism, to illustrate the three crucial messages of nephro-protection sent to endocrinologists. First, calciuria must be interpreted both in absolute value (concentration hypercalciuria) and in ratio (flow hypercalciuria). Second, renal monitoring of therapies inducing hypercalciuria on kidneys with normal renal function (e.g. active vitamin D analogs or teriparatide) should be systematic. Last, hyperphosphatemia, often latent in hypoparathyroidism and pseudo-hypoparathyroidism, should be detected and at least benefit from dietary measures, in the context of Western diets rich in phosphate hidden in food additives.
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Affiliation(s)
- Mélodie Mosca
- Centre de référence des maladies rares du calcium et du phosphore, centre de référence des maladies rénales rares, filières de santé maladies rares OSCAR, ORKID et ERKNet, service de néphrologie rhumatologie et dermatologie pédiatriques, hôpital femme mère enfant, Bron, France
| | - Julie Bernardor
- INSERM 1033, prévention des maladies osseuses, Lyon, France; Service de néphrologie pédiatrique, CHU de Nice, hôpital Archet, Nice, France
| | - Sandrine Lemoine
- Service d'exploration fonctionnelle rénale, centre de référence des maladies rares du calcium et du phosphore, centre de référence des maladies rénales rares, filières de santé maladies rares OSCAR et ORKID, département de néphrologie, hôpital Edouard-Herriot, Lyon, France; Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France
| | - Aurélia Bertholet-Thomas
- Centre de référence des maladies rares du calcium et du phosphore, centre de référence des maladies rénales rares, filières de santé maladies rares OSCAR, ORKID et ERKNet, service de néphrologie rhumatologie et dermatologie pédiatriques, hôpital femme mère enfant, Bron, France; INSERM 1033, prévention des maladies osseuses, Lyon, France
| | - Justine Bacchetta
- Centre de référence des maladies rares du calcium et du phosphore, centre de référence des maladies rénales rares, filières de santé maladies rares OSCAR, ORKID et ERKNet, service de néphrologie rhumatologie et dermatologie pédiatriques, hôpital femme mère enfant, Bron, France; INSERM 1033, prévention des maladies osseuses, Lyon, France; Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France.
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23
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Nasomyont N, Keefe C, Tian C, Hornung L, Khoury J, Tilden JC, Hochwalt P, Jackson E, Rybalsky I, Wong BL, Rutter MM. Safety and efficacy of teriparatide treatment for severe osteoporosis in patients with Duchenne muscular dystrophy. Osteoporos Int 2020; 31:2449-2459. [PMID: 32676823 DOI: 10.1007/s00198-020-05549-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/08/2020] [Indexed: 01/07/2023]
Abstract
UNLABELLED Osteoporosis is a major concern in patients with Duchenne muscular dystrophy. In this novel study of teriparatide treatment in 6 patients with severe osteoporosis, bone health (fractures, vertebral morphometry, and DXA) remained stable, with no adverse events. These findings will help inform future osteoporosis research in this challenging population. INTRODUCTION Despite standard therapy with vitamin D and bisphosphonates (BP), many patients with Duchenne muscular dystrophy (DMD) continue to sustain fragility fractures due to long-term glucocorticoid treatment and limited mobility. We aimed to evaluate the safety and efficacy of teriparatide for the treatment of severe osteoporosis in adolescent and young adult patients with DMD. METHODS We prospectively treated 6 patients with DMD who had severe osteoporosis with teriparatide 20 mcg subcutaneously daily for 1-2 years. Inclusion criteria were long-term glucocorticoid therapy, and severe osteoporosis despite treatment with BP, or intolerance to BP. We examined long bone and vertebral fracture outcomes, including vertebral morphometry measures, bone mineral density and content, bone formation markers, safety indices, and adverse events. RESULTS The mean age at teriparatide start was 17.9 years (range 13.9-22.1 years). All 6 patients were on daily glucocorticoids (mean ± SD; duration 10.9 ± 2.5 years) and 5 were non-ambulatory. Five patients had been treated with BP for 7.9 ± 4.2 years. All had vertebral and a history of long bone fragility fractures at baseline. Vertebral heights and Genant fracture grading remained stable. Long bone fracture rate appeared to decrease (from 0.84/year to 0.09/year); one patient sustained a long bone fracture at 6 months of treatment. Trajectories for change in bone mineral density and content were not different post- vs. pre-teriparatide. Procollagen type 1 amino-terminal propeptide (P1NP) increased, while laboratory safety indices remained stable and non-concerning. No adverse events were observed. CONCLUSION In six patients with DMD treated with teriparatide for severe osteoporosis, we observed stable bone health and modest increases in P1NP, without safety concerns. Further studies are needed to better understand teriparatide efficacy for treatment of osteoporosis in patients with DMD.
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Affiliation(s)
- N Nasomyont
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7012, Cincinnati, OH, 45229-3026, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - C Keefe
- Diabetes and Endocrinology, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - C Tian
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - L Hornung
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Khoury
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7012, Cincinnati, OH, 45229-3026, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - P Hochwalt
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - E Jackson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - I Rybalsky
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - B L Wong
- Department of Pediatrics, University of Massachusetts Memorial Children's Medical Center, University of Massachusetts Medical School, Worcester, MA, USA
| | - M M Rutter
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7012, Cincinnati, OH, 45229-3026, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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24
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Hawkes CP, Shulman DI, Levine MA. Recombinant human parathyroid hormone (1-84) is effective in CASR-associated hypoparathyroidism. Eur J Endocrinol 2020; 183:K13-K21. [PMID: 33112267 PMCID: PMC7853300 DOI: 10.1530/eje-20-0710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/29/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Gain-of-function mutations in the CASR gene cause Autosomal Dominant Hypocalcemia Type 1 (ADH1), the most common genetic cause of isolated hypoparathyroidism. Subjects have increased calcium sensitivity in the renal tubule, leading to increased urinary calcium excretion, nephrocalcinosis and nephrolithiasis when compared with other causes of hypoparathyroidism. The traditional approach to treatment includes activated vitamin D but this further increases urinary calcium excretion. METHODS In this case series, we describe the use of recombinant human parathyroid hormone (rhPTH)1-84 to treat subjects with ADH1, with improved control of serum and urinary calcium levels. RESULTS We describe two children and one adult with ADH1 due to heterozygous CASR mutations who were treated with rhPTH(1-84). Case 1 was a 9.4-year-old female whose 24-h urinary calcium decreased from 7.5 to 3.9 mg/kg at 1 year. Calcitriol and calcium supplementation were discontinued after titration of rhPTH(1-84). Case 2 was a 9.5-year-old male whose 24-h urinary calcium decreased from 11.7 to 1.7 mg/kg at 1 year, and calcitriol was also discontinued. Case 3 was a 24-year-old female whose treatment was switched from multi-dose teriparatide to daily rhPTH(1-84). All three subjects achieved or maintained target serum levels of calcium and normal or improved urinary calcium levels with daily rhPTH(1-84) monotherapy. CONCLUSIONS We have described three subjects with ADH1 who were treated effectively with rhPTH(1-84). In all cases, hypercalciuria improved by comparison to treatment with conventional therapy consisting of calcium supplementation and calcitriol.
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Affiliation(s)
- Colin Patrick Hawkes
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Dorothy I Shulman
- University of South Florida Diabetes Center, USF Morsani College of Medicine, Tampa, FL, USA
| | - Michael A Levine
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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25
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Kovaleva EV, Ajnetdinova AR, Eremkina AK, Mokrysheva NG. [Evaluation of chronic hypoparathyroidism course according to the Database of Endocrinology Research Centre]. ACTA ACUST UNITED AC 2020; 66:7-14. [PMID: 33369368 DOI: 10.14341/probl12675] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 09/25/2020] [Accepted: 09/25/2020] [Indexed: 12/26/2022]
Abstract
BACKGRAUND Currently high frequency of thyroid or parathyroid surgery is associated with significant increased incidence of hypoparathyroidism. Evaluation of the epidemiological and clinical features of chronic hypoparathyroidism is necessary to predict social-significant complications and to improve the quality of medical care. AIMS To estimate clinical and demographic features, different regimens and efficacy of conventional therapy in patients with chronic postsurgical and nonsurgical hypoparathyroidism. MATERIALS AND METHODS The cross-sectional, observational, continuous study was carried out based on Database of patients with chronic postsurgical and nonsurgical hypoparathyroidism of Endocrinology Research Centre, Moscow. 293 patients from 61 regions of the Russian Federation were included in this study. Statistical analysis was done on June 2020. The descriptive statistics are presented by medians (Ме) and the first and third quartiles (Q1; Q3) and by absolute and relative frequencies. RESULTS Hypoparathyroidism was most often recorded in women (85%) at the age of 43 [32; 52] years, after thyroid surgery. Less than a half of the study group had target indicators of serum calcium and phosphate levels (31% and 47%, respectively) despite ongoing treatment. A complex instrumental examination for the disease complications was performed in 58% of cases (n = 169). Among them, kidney disorders were detected in 38%, visual disturbance in 14%, brain calcification in 10%, arrhythmias in 4% and neuropsychiatric symptoms in 6%. Conventional therapy with calcium supplements and activated vitamin D analogues was noted in 75% of patients. CONCLUSIONS The analysis of large databases of patients with chronic hypoparathyroidism is a necessary tool for determining of optimal clinical and therapeutic approaches, as well as prognostic markers of disease complications.
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Zavatta G, Clarke BL. Challenges in the management of chronic hypoparathyroidism. Endocr Connect 2020; 9:EC-20-0366.R2. [PMID: 33486471 PMCID: PMC7707836 DOI: 10.1530/ec-20-0366] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/24/2020] [Indexed: 01/12/2023]
Abstract
The first adjunctive hormone therapy for chronic hypoparathyroidism, recombinant human parathyroid hormone (1-84) [rhPTH(1-84)] was approved by the FDA in January 2015. Since the approval of rhPTH(1-84), growing interest has developed in other agents to treat this disorder in both the scientific community and among pharmaceutical companies. For several reasons, conventional therapy with calcium and activated vitamin D supplementation, magnesium supplementation as needed, and occasionally thiazide-type diuretic therapy remains the mainstay of treatment, while endocrinologists and patients are constantly challenged by limitations of conventional treatment. Serum calcium fluctuations, increased urinary calcium, hyperphosphatemia, and a constellation of symptoms that limit mental and physical functioning are frequently associated with conventional therapy. Understanding how conventional treatment and hormone therapy work in terms of pharmacokinetics and pharmacodynamics is key to effectively managing chronic hypoparathyroidism. Multiple questions remain regarding the effectiveness of PTH adjunctive therapy in preventing or slowing the onset and progression of the classical complications of hypoparathyroidism, such as chronic kidney disease, calcium-containing kidney stones, cataracts, or basal ganglia calcification. Several studies point toward an improvement in quality of life during replacement therapy. This review will discuss current clinical and research challenges posed by treatment of chronic hypoparathyroidism.
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Affiliation(s)
- Guido Zavatta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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27
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Abstract
PURPOSE OF REVIEW Hypoparathyroidism is a rare endocrine disorder characterized by low or insufficient parathyroid hormone (PTH) concentrations leading to hypocalcemia, hyperphosphatemia, and markedly reduced bone turnover. Despite being a rare disease, hypoparathyroidism has a profound impact on affected patients. RECENT FINDINGS Recent epidemiologic surveys demonstrate a prevalence of between 5.3 and 40/100 000, confirming the orphan status of this disease. There is a female predominance, and anterior neck surgery is the most common etiology. Recent studies have better elucidated the chronic manifestations of the disease, impacting quality of life and multiple organ systems including the renal, cardiovascular, and skeletal systems. There are now data on longer term use of parathyroid hormone (PTH) and PTH analogs. SUMMARY This review focuses on recent contributions to the literature on the prevalence and epidemiology of the disease, risk of chronic manifestations, and treatment with PTH(1-34) and rhPTH(1-84). Further research is needed to determine the pathophysiology of complications in hypoparathyroidism and whether interventions can decrease future risk of these complications. In addition, further data are needed with regards to more physiologic dosing regimens and long-term treatment with PTH and PTH analogs.
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28
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Nadar R, Shaw N. Investigation and management of hypocalcaemia. Arch Dis Child 2020; 105:399-405. [PMID: 31900251 DOI: 10.1136/archdischild-2019-317482] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/04/2019] [Accepted: 12/05/2019] [Indexed: 12/19/2022]
Abstract
Hypocalcaemia is a common clinical scenario in children with a range of aetiological causes. It will often present with common symptoms but may occasionally be identified in an asymptomatic child. An understanding of the physiological regulation of plasma calcium is important in understanding the potential cause of hypocalcaemia and its appropriate management. The age of presentation will influence the likely differential diagnosis. We have presented a stepwise approach to the investigation of hypocalcaemia dependent on the circulating serum parathyroid hormone level at the time of presentation. The acute and long-term management of the underlying condition is also reviewed.
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Affiliation(s)
- Ruchi Nadar
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Nick Shaw
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK .,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, West Midlands, UK
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29
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Tuli G, Buganza R, Tessaris D, Einaudi S, Matarazzo P, de Sanctis L. Teriparatide (rhPTH 1-34) treatment in the pediatric age: long-term efficacy and safety data in a cohort with genetic hypoparathyroidism. Endocrine 2020; 67:457-465. [PMID: 31705387 DOI: 10.1007/s12020-019-02128-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/30/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hypoparathyroidism is characterized by the absence or inadequately low circulating concentrations of the parathyroid hormone, resulting in hypocalcemia, hyperphosphatemia, and elevated fractional excretion of calcium in the urine. The use of activated vitamin D analogs and calcium supplements represent conventional therapy. Subcutaneous recombinant human parathormone [rhPTH(1-34)] has been proposed as a substitutive treatment, even to avoid side effects of vitamin D and calcium. OBJECTIVE To assess the long-term safety and efficacy of rhPTH(1-34) in a pediatric cohort of patients with genetic hypoparathyroidism. METHODS The study is a 9.2-year self-controlled study of six pediatric patients (four males and two females, aged 9.4 ± 5.2) with DiGeorge, hypoparathyroidism-deafness-renal dysplasia (HDR) or autoimmune-candidiasis-polyendocrinopathy-ectodermal-dysplasia (APECED) syndrome, associated with autoimmune intestinal malabsorption in a patient. The presence of clinical signs of hypocalcemia and biochemical parameters, such as calcium, phosphate, alkaline phosphatase in the blood and calcium-creatinine ratio in urine, were compared during conventional treatment and rhPTH(1-34) (teriparatide, 12.5 μg twice daily). RESULTS The rhPTH(1-34) treatment allowed a reduction, although not always a complete suspension, of calcium supplementation and a slight reduction of calcitriol therapy. The number of tetanic episodes was reduced in four patients during the rhPTH(1-34) treatment. Mean blood calcium, alkaline phosphatase, and phosphate did not significantly change, while a significant reduction of the urinary calcium-to-creatinine ratio (0.55 ± 0.32 vs 0.16 ± 0.09, p = 0.03) was obtained. Renal ultrasound examination showed a worsening in three patients, while it did not change in the remaining three subjects during the follow-up. CONCLUSIONS In children with syndromic hypoparathyroidism presented here, replacement therapy with rhPTH(1-34) allowed to maintain adequate levels of the calcium and phosphate in the blood, normalize urinary calcium excretion, and reduce tetanic episodes. In patients with low compliance to conventional therapy or intestinal malabsorption, the use of rhPTH(1-34) could be considered, also to reduce the side effects of treatment with vitamin D and calcium.
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Affiliation(s)
- Gerdi Tuli
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, City of Health and Science University Hospital of Turin, Turin, Italy.
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy.
| | - Raffaele Buganza
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, City of Health and Science University Hospital of Turin, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Daniele Tessaris
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, City of Health and Science University Hospital of Turin, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Silvia Einaudi
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, City of Health and Science University Hospital of Turin, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Patrizia Matarazzo
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, City of Health and Science University Hospital of Turin, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Luisa de Sanctis
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, City of Health and Science University Hospital of Turin, Turin, Italy
- Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
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Winer KK. Advances in the treatment of hypoparathyroidism with PTH 1-34. Bone 2019; 120:535-541. [PMID: 30243992 DOI: 10.1016/j.bone.2018.09.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 09/20/2018] [Accepted: 09/20/2018] [Indexed: 11/18/2022]
Abstract
Hypoparathyroidism is a rare disorder of calcium metabolism which is treated with calcium and vitamin D analogs. Although conventional therapy effectively raises serum calcium, it bypasses the potent calcium reabsorption effects of PTH on the kidney which leads to hypercalciuria and an increased risk of nephrocalcinosis and renal insufficiency. Twenty-five years ago, we launched the first systematic investigation into synthetic human PTH 1-34 replacement therapy in both adults and children. These studies led to our current understanding of the complex nature of PTH 1-34 therapy and to the challenges we still face in our pursuit of a safe and effective physiologic replacement therapy for hypoparathyroidism. The normalization and minimal fluctuation of serum and urine calcium levels were the primary management goals. As the frequency of PTH 1-34 injections increased, the total daily dose required to normalize calcium homeostasis decreased and episodes of hypercalcemia and hypercalciuria diminished, producing a more physiologic biochemical profile. Twice-daily injections achieved simultaneous normalization of serum and urine calcium levels in many patients but the persistent elevation of bone markers and the difficulty in reducing urine calcium to normal levels in the more severe cases, suggested an alternative to PTH 1-34 injections was needed. The studies with PTH 1-34 delivered by insulin pump represent an important advance in the management of hypoparathyroidism. PTH 1-34 delivered by insulin pump normalized serum and urine calcium and markers of bone turnover. Additionally, pump delivery of PTH 1-34 produced stable magnesium values within the normal range and reduced magnesium excretion. Currently, PTH 1-34 delivery by pump is the only alternative to PTH injections that has been tested in both adults and children and proven to achieve a physiologic biochemical profile.
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Affiliation(s)
- Karen K Winer
- Eunice Kennedy Shriver National Institutes of Child health and Human Development, NIH, Bethesda, MD, United States.
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