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Karaca MO, Özyıldıran M, Savran MD, Başarır K, Yıldız HY. Brown tumors: Retrospective analysis of 26 cases. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05372-9. [PMID: 38795187 DOI: 10.1007/s00402-024-05372-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 05/07/2024] [Indexed: 05/27/2024]
Abstract
INTRODUCTION Brown tumors are reactive osteolytic lesions caused by hyperparathyroidism. These rare lesions are non-neoplastic processes that result from bone resorption. The purpose of this study was to retrospectively review a 34-year experience with brown tumors in our institution. MATERIALS AND METHODS We retrospectively analyzed the records of 26 consecutive patients with brown tumor who were treated in our institution between May 1988 and October 2020, with a mean follow-up of 36,1 months. RESULTS 17 male (65,4%) and 9 female (34,6%) patients with a mean age of 41,6 were included in the study. Localized bone pain was present in 13 cases (50,0%) as the first presenting symptom. 3 patients (11,5%) presented with diffuse bone pain. 7 patients (26,9%) were diagnosed with brown tumor while being investigated for pathological fractures. The other 3 patients (11,5%) were diagnosed while being evaluated for hypercalcemia symptoms. 7 patients (26,9%) had solitary lesions, while 19 patients (73,1%) had multiple lesions. Pelvis, femur, ribs, tibia, proximal humerus and mandible were the most common sites of localization. 23 patients (88,5%) were diagnosed with primary hyperparathyroidism, while the other 3 patients (11,5%) had secondary hyperparathyroidism. A total of the 65 lesions, 23 (35.4%) underwent orthopedic surgery, and 42 (64.6%) were followed up conservatively after parathyroidectomy. Orthopedic surgery was performed in 21 of 26 patients, the other 5 cases were followed up conservatively. Intralesional curettage was performed in 19 cases (82,6%). The resulting cavity was filled with bone cement in 11 cases (47,8%). Bone grafting was applied in 8 cases (34,8%). No recurrence was observed in any of the patients. CONCLUSION The diagnosis of brown tumor begins with clinical suspicion. Endocrinology and general surgery consultation is important before surgery. Treatment of brown tumors requires a multidisciplinary approach.
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Affiliation(s)
- Mustafa Onur Karaca
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
| | - Mustafa Özyıldıran
- Department of Orthopedics and Traumatology, Sandıklı State Hospital, Afyonkarahisar, Turkey.
| | - Merve Dursun Savran
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
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Şengül Ayçiçek G, Aydoğan Bİ, Şahin M, Emral R, Erdoğan MF, Güllü S, Başkal N, Çorapçıoğlu D. The impact of vitamin D deficiency on clinical, biochemical and metabolic parameters in primary hyperparathyroidism. ENDOCRINOLOGIA, DIABETES Y NUTRICION 2023; 70:56-62. [PMID: 36764749 DOI: 10.1016/j.endien.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/29/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND It has been suggested that vitamin D deficiency is associated with worse clinical outcomes in primary hyperparathyroidism (PHPT). We aimed to evaluate the relationship between vitamin D deficiency and clinical, biochemical and metabolic parameters in PHPT patients. METHODS A total of 128 patients with biochemically confirmed PHPT were included. Patients were categorized as vitamin D deficient if 25-OH vitamin D was <50nmol/L, or normal if vitamin D was ≥50nmol/L. Biochemical parameters, bone mineral densitometry (BMD), and urinary tract and neck ultrasonography were assessed. RESULTS In the study group, 66 (51.6%) patients had vitamin D deficiency and 60 (48.4%) had normal vitamin D levels. Nephrolithiasis and osteoporosis were found in 26.6% and 30.5% of subjects, respectively. The prevalence of metabolic syndrome (MetS), obesity (BMI≥30kg/m2) and hypertension (HTN) were higher in the vitamin D deficient group when compared to the normal group (p=0.04, p=0.01 and p=0.03, respectively). There was no difference regarding the presence of nephrolithiasis and osteoporosis between the groups. The mean adenoma size was similar in both groups. CONCLUSIONS Vitamin D deficiency was not associated with osteoporosis, nephrolithiasis, adenoma size or biochemical parameters in PHPT. However, vitamin D deficiency may be a risk factor for developing HTN and MetS in PHPT.
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Affiliation(s)
- Gözde Şengül Ayçiçek
- Ankara University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Berna İmge Aydoğan
- Ankara University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey.
| | - Mustafa Şahin
- Ankara University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Rıfat Emral
- Ankara University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Murat Faik Erdoğan
- Ankara University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Sevim Güllü
- Ankara University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Nilgün Başkal
- Ankara University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Demet Çorapçıoğlu
- Ankara University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
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TOPUZ E, TÜZÜN D, ÖZBAY ÜN, ŞAHİN M, KARA İ. A case of normocalcemic primary hyperparathyroidism presenting with a mass in the oral cavity and accompanying incidental papillary thyroid carcinoma. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1184876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Hyperparathyroidism (HPT) is an endocrine disorder characterized by high secretion of parathyroid hormone. Brown tumor is one of the skeletal manifestations of HPT. Its overall prevalence is low (about 0.1%). Involvement of facial bones is extremely rare. The mandible is involved in 4.5% of cases. Primary HPT (PHPT)with vitamin D deficiency worsens the clinical course. Parathyroid adenoma is detected in ectopic places with a rate of 8.5%. 0.2% is intrathyroidal, 2% is located in different neck regions, 4.1% is in the upper mediastinum, and 2.2% is in the lower mediastinum. The prevalence of papillary thyroid cancer (PTC) in PHPT patients has been reported to range from 2% to 15%. In the literature, incidentally detected papillary thyroid cancer in patients with hyperparathyroidism was detected in patients who underwent total thyroidectomy associated with intrathyroidal parathyroid adenoma.
In this article, we present a case of incidental papillary thyroid carcinoma with ectopic parathyroid adenoma accompanied by severe vitamin D, and diagnosed during accompanying surgery following a brown tumor was considered after primary hyperparathyroidism was detected. However, the patient was admitted with a mass in the oral cavity, diagnosed before as a pyogenic granuloma with a delayed diagnosis without considering brown tumor because it was normocalcemic. It is the first case in the literature of papillary thyroid carcinoma detected incidentally with ectopic parathyroid adenoma in the thyrothymic region.
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Affiliation(s)
- Emek TOPUZ
- Kahramanmaraş Sütçü İmam Tıp Fakültesi Endokrinoloji ve Metabolizma B.D
| | - Dilek TÜZÜN
- Kahramanmaraş Sütçü İmam Tıp Fakültesi Endokrinoloji ve Metabolizma B.D
| | - Ümit Nur ÖZBAY
- Kahramanmaraş Sütçü İmam Tıp Fakültesi Endokrinoloji ve Metabolizma B.D
| | - Murat ŞAHİN
- Kahramanmaraş Sütçü İmam Tıp Fakültesi Endokrinoloji ve Metabolizma B.D
| | - İrfan KARA
- Kahramanmaraş Sütçü İmam Tıp Fakültesi Kulak Burun Boğaz A.B.D
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4
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The impact of vitamin D deficiency on clinical, biochemical and metabolic parameters in primary hyperparathyroidism. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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5
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Castellano E, Attanasio R, Boriano A, Borretta V, Gennaro M, Latina A, Borretta G. Radiologic Manifestation of Bone Involvement in Primary Hyperparathyroidism: Prevalence and Clinical Significance in a Southern European Series. Endocr Pract 2020; 26:983-989. [PMID: 33471703 DOI: 10.4158/ep-2020-0095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/24/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Clinically overt symptomatic bone disease in primary hyperparathyroidism (PHPT) is rarely seen today, and osteoporosis is the dominant finding. Subperiosteal bone resorption in the fingers and skull mottling are typical bone PHPT findings, the contemporary prevalence of which is unknown. We evaluated these mild lesions and investigated the impact of their occurrence on PHPT clinical management. METHODS We evaluated retrospectively a monocentric series of 363 PHPT patients classified in Group 1 (n = 100) or Group 2 (n = 263) according to the presence or absence of bone involvement, respectively. Patients belonging to Group 1, in turn, were subdivided into Group 1A, with severe and symptomatic lesions (n = 48), and Group 1B, with milder signs of osteitis fibrosa cystica (OFC) without brown tumors or fractures (n = 52). RESULTS Serum total and ionized calcium, parathyroid hormone, osteocalcin, alkaline phosphatase, and its bone fraction levels were higher in Group 1 than in Group 2, while no gender or age differences were observed between the groups. Osteoporosis prevalence was similar in Group 1B and Group 2 patients but lower than in Group 1A. Mild OFC findings did not modify the surgical indication in any patient of Group 1B. CONCLUSION Minor radiologic signs of OFC are not uncommon in the modern PHPT phenotype and occur in patients with more active disease. These signs could identify PHPT patients in an earlier stage of typical bone involvement. However, these features do not seem to upgrade either the clinical classification of asymptomatic PHPT patients or the propensity toward surgical choice.
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Affiliation(s)
- Elena Castellano
- Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Cuneo, Italy.
| | - Roberto Attanasio
- Endocrinology Service, Galeazzi Orthopedic Institute IRCCS, Milan, Italy
| | - Alberto Boriano
- Medical Physics Department, Santa Croce and Carle Hospital, Cuneo, Italy
| | - Valentina Borretta
- Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Cuneo, Italy
| | - Marta Gennaro
- Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Cuneo, Italy
| | - Adele Latina
- Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Cuneo, Italy
| | - Giorgio Borretta
- Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Cuneo, Italy
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Minisola S, Colangelo L, Pepe J, Occhiuto M, Piazzolla V, Renella M, Biamonte F, Sonato C, Cilli M, Cipriani C. Vitamin D screening. J Endocrinol Invest 2020; 43:1047-1051. [PMID: 32189163 DOI: 10.1007/s40618-020-01220-w] [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: 02/15/2020] [Accepted: 03/09/2020] [Indexed: 02/07/2023]
Abstract
At present, there is no need and no sufficient evidence to support universal screening for vitamin D status. There are four categories of subjects in whom there is no requirement for screening, since a number of studies indicate beneficial effects of vitamin D supplementation; these are represented by children and adolescents, pregnant women, patients taking bone active drugs and subjects with documented hypovitaminosis D. In the remaining subjects, the utilization of adequate questionnaires will target with sufficient sensitivity and specificity those with hypovitaminosis D. These must be first supplemented and, at a later time, serum 25(OH)D assay should be requested to confirm attainment of sufficiency, independently of the threshold chosen. This strategy will cut costs deriving from both widespread use of vitamin D assays and vitamin D supplementation.
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Affiliation(s)
- S Minisola
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, "Sapienza", Rome University, Viale del Policlinico 155, 00161, Rome, Italy.
| | - L Colangelo
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, "Sapienza", Rome University, Viale del Policlinico 155, 00161, Rome, Italy
| | - J Pepe
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, "Sapienza", Rome University, Viale del Policlinico 155, 00161, Rome, Italy
| | - M Occhiuto
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, "Sapienza", Rome University, Viale del Policlinico 155, 00161, Rome, Italy
| | - V Piazzolla
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, "Sapienza", Rome University, Viale del Policlinico 155, 00161, Rome, Italy
| | - M Renella
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, "Sapienza", Rome University, Viale del Policlinico 155, 00161, Rome, Italy
| | - F Biamonte
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, "Sapienza", Rome University, Viale del Policlinico 155, 00161, Rome, Italy
| | - C Sonato
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, "Sapienza", Rome University, Viale del Policlinico 155, 00161, Rome, Italy
| | - M Cilli
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, "Sapienza", Rome University, Viale del Policlinico 155, 00161, Rome, Italy
| | - C Cipriani
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, "Sapienza", Rome University, Viale del Policlinico 155, 00161, Rome, Italy
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Physical Activity-Dependent Regulation of Parathyroid Hormone and Calcium-Phosphorous Metabolism. Int J Mol Sci 2020; 21:ijms21155388. [PMID: 32751307 PMCID: PMC7432834 DOI: 10.3390/ijms21155388] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/09/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022] Open
Abstract
Exercise perturbs homeostasis, alters the levels of circulating mediators and hormones, and increases the demand by skeletal muscles and other vital organs for energy substrates. Exercise also affects bone and mineral metabolism, particularly calcium and phosphate, both of which are essential for muscle contraction, neuromuscular signaling, biosynthesis of adenosine triphosphate (ATP), and other energy substrates. Parathyroid hormone (PTH) is involved in the regulation of calcium and phosphate homeostasis. Understanding the effects of exercise on PTH secretion is fundamental for appreciating how the body adapts to exercise. Altered PTH metabolism underlies hyperparathyroidism and hypoparathyroidism, the complications of which affect the organs involved in calcium and phosphorous metabolism (bone and kidney) and other body systems as well. Exercise affects PTH expression and secretion by altering the circulating levels of calcium and phosphate. In turn, PTH responds directly to exercise and exercise-induced myokines. Here, we review the main concepts of the regulation of PTH expression and secretion under physiological conditions, in acute and chronic exercise, and in relation to PTH-related disorders.
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Ferrone F, Pepe J, Danese VC, Fassino V, Cecchetti V, De Lucia F, Biamonte F, Colangelo L, Ferrazza G, Panzini E, Scillitani A, Nieddu L, Blocki F, Rao SD, Minisola S, Cipriani C. The relative influence of serum ionized calcium and 25-hydroxyvitamin D in regulating PTH secretion in healthy subjects. Bone 2019; 125:200-206. [PMID: 31129357 DOI: 10.1016/j.bone.2019.05.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND While the inverse relationship between serum ionized calcium (Ca2+) and PTH is well-established, the relationship between 25(OH)D and PTH showed conflicting results. The study aimed to evaluate the relative contributions of age, sex, serum Ca2+, ionized magnesium (Mg2+), 25(OH)D and 1,25(OH)2D in regulating PTH secretion in healthy subjects. METHODS This is a secondary analysis of an observational study performed from March 2014 to July 2015 carried out in 2259 blood donors (1652 men and 607 women, age range 18-68 years). Subjects with parathyroid disorders and taking drugs that affect mineral metabolism were excluded. RESULTS Significant correlations [between Ca2+ and PTH (r = -0.223, p < 0.001), 25(OH)D and PTH (r = -0.178, p < 0.001) and between PTH and age (r = 0.322, p < 0.001)] were found. As a preliminary step to multivariate analysis, a regression tree analysis was performed using PTH as response variable and age, Ca2+, Mg2+, 25(OH)D, 1,25(OH)2D and sex as explanatory variables to determine the effect of each covariate on the response variable. For subjects <38 years, 25(OH)D was the most important parameter in regulating PTH. For subjects ≥38 both 25(OH)D and Ca2+ levels regulated PTH secretion. Subjects with 25(OH)D < 13 ng/mL had average higher PTH; in this group only, subjects with Ca2+ ≥ 1.30 mmol/L had average lower PTH compared to subjects with Ca2+ < 1.30. The multivariate analysis showed that all variables had a significant effect (p < 0.001) on PTH. Anova Type III errors c indicated that 25(OH)D accounted for 32.1% of the total variance in PTH, Ca2+ accounted for 18% of the total variance, BMI for 14.3%, and 1,25(OH)2D for 11.1%. The remaining percentage was attributable to age and sex. This was confirmed by the regression tree approach, where 25(OH)D and Ca2+ accounted for the largest variation in the average levels of PTH. DISCUSSION Under stable conditions 25(OH)D plays a significant role in regulating PTH secretion. Under conditions of relative vitamin D sufficiency, Ca2+ also plays an important role.
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Affiliation(s)
- Federica Ferrone
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Vittoria Carmela Danese
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Valeria Fassino
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Veronica Cecchetti
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Federica De Lucia
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Federica Biamonte
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Luciano Colangelo
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
| | - Giancarlo Ferrazza
- Department of Immunohematology and Transfusion Medicine, "Sapienza" Rome University, Rome, Italy
| | - Enrico Panzini
- Department of Immunohematology and Transfusion Medicine, "Sapienza" Rome University, Rome, Italy
| | - Alfredo Scillitani
- Unit of Endocrinology "Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, Italy
| | | | - Frank Blocki
- DiaSorin Inc., 1951 Northwestern Avenue, Stillwater, MN, USA
| | - Sudhaker D Rao
- Bone and Mineral Research Laboratory, Division of Endocrinology, Diabetes, and Bone & Mineral Disorders, Henry Ford Hospital, Detroit, MI, USA
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy.
| | - Cristiana Cipriani
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy
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Minisola S, Gianotti L, Bhadada S, Silverberg SJ. Classical complications of primary hyperparathyroidism. Best Pract Res Clin Endocrinol Metab 2018; 32:791-803. [PMID: 30665547 DOI: 10.1016/j.beem.2018.09.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Traditionally, classical complications of primary hyperparathyroidism are mainly represented by skeletal, kidney and gastrointestinal involvement. The old picture of osteitis fibrosa cystica is no longer commonly seen, at least in the western world. However, new imagining techniques have highlighted deterioration of skeletal tissue in patients with primary hyperparathyroidism not captured by traditional DXA measurement. Concerning the kidney, the most common consequences of excessive parathyroid hormone secretion are hypercalciuria and kidney stones; however, the exact pathogenesis of urinary stone formation is still unknown. The 2013 International Congress on the management of Asymptomatic Primary Hyperparathyroidism, emphasized the role of imaging techniques for early discovery of both skeletal and renal complications in asymptomatic patients. Gastrointestinal manifestations include acid-peptic disease, constipation, pancreatitis and gall stone disease. More studies are needed in this area to find the exact pathophysiological mechanism underlying these manifestations and the effect of parathyroid surgery.
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Affiliation(s)
- Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, "Sapienza", Rome University, Italy.
| | - Laura Gianotti
- SC Endocrinologia Diabetologia e Metabolismo, Azienda Ospedaliera S. Croce e Carle, Cuneo, Italy.
| | - Sanjay Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India.
| | - Shonni J Silverberg
- Columbia University Medical College of Physicians & Surgeons, New York, USA.
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Tripto-Shkolnik L, Jaffe A, Liel Y. The impact of vitamin D status and parameters of calcium metabolism in patients with primary hyperparathyroidism. QJM 2018; 111:97-101. [PMID: 29462468 DOI: 10.1093/qjmed/hcx200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is ample evidence associating vitamin D deficiency in primary hyperparathyroidism (PHP) patients with more severe disease manifestations and increased risk of postoperative hypocalcemia. Yet, there is limited data regarding the safety of vitamin D repletion in these patients. AIM To assess the safety of vitamin D repletion in PHP patients in a real-world setting. DESIGN We included patients with asymptomatic PHP and few symptomatic patients who declined surgery, followed in our clinic, and treated on a routine basis with 2000 IU/day of vitamin D3. METHODS Serum calcium (sCa), PTH, 25-hydroxyvitamin D, and 24 h urinary calcium (uCa) and creatinine collections were compared between the lowest and the highest vitamin D time points. RESULTS There were 40 patients of a mean age was 63 ± 10 years. 25(OH)D at lowest and highest vitamin D time points was 15.5 ± 6.2 ng/ml and 33.2 ± 8, respectively (P < 0.001). Serum calcium was not affected by the changes in vitamin D levels. In none of the patients did sCa exceed 11.5 mg/dL. uCa was 220 ± 110 mg/24 h at the lowest vitamin D time point and 260 ± 140 at the highest vitamin D time point (P = 0.14). uCa exceeded 400 mg/24 h in two vs. five patients (P = 0.23) at the lowest and highest vitamin D time points, respectively. PTH was not significantly different between the different vitamin D time points. DISCUSSION/CONCLUSION Vitamin D repletion in PHP seems safe. Considering the documented adverse influence of vitamin D deficiency in PHP, particularly on skeletal manifestations and on the postoperative course, vitamin D repletion is warranted.
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Affiliation(s)
| | - A Jaffe
- Endocrine Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - Y Liel
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Viccica G, Cetani F, Vignali E, Miccoli M, Marcocci C. Impact of vitamin D deficiency on the clinical and biochemical phenotype in women with sporadic primary hyperparathyroidism. Endocrine 2017; 55:256-265. [PMID: 27033542 DOI: 10.1007/s12020-016-0931-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/17/2016] [Indexed: 10/22/2022]
Abstract
The purpose of the study was to evaluate the relationship between serum 25(OH)D and the clinical phenotype in 215 consecutive Italian Caucasian women with sporadic primary hyperparathyroidism (PHPT) not taking vitamin D supplements. The study was performed at a single Italian tertiary center. PHPT-related manifestations, serum 25(OH)D, and other parameters of calcium metabolism and bone mineral density (BMD) by DXA were recorded. Serum 25(OH)D was negatively correlated with age (r = -0.18; P = 0.006), BMI (r = -0.20; P = 0.002), PTH (r = -0.21; P = 0.001), bone-specific alkaline phosphatase (BSAP) (r = -0.27; P < 0.001), and eGFR (r = -0.22; P = 0.01), and positively with serum creatinine and 1/3 distal radius BMD (R-BMD; r = 0.17; P = 0.015). In a multivariate regression analysis, serum 25(OH)D remained significantly correlated with age (r = -0.18; P = 0.005), BMI (r = -0.23; P = 0.049), serum PTH (r = -0.01; P = 0.023), BSAP (r = -0.01; P = 0.023) and eGFR (r = -0.09; P = 0.001), but not with R-BMD. Serum 25(OHD) was higher in patients with nephrolithiasis than in those without nephrolithiasis (18.5 ± 8.8 vs. 15.6 ± 8.0 ng/ml; P = 0.029), whereas no difference was found between fractured and unfractured patients (16.8 ± 9.3 vs. 16.0 ± 7.7; P = 0.663). There was a statistically significant inverse correlation between vitamin D status [defined by quartiles of measured values as well as commonly accepted cutoffs of serum 25(OH)D] and severity of the disease, as reflected by higher PTH and BSAP, but not by meeting the latest guidelines for parathyroidectomy. In conclusion, a low vitamin D status is associated with some features reflecting a more severe biochemical and clinical phenotype of PHPT in Italian women not taking vitamin D supplements.
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Affiliation(s)
- Giuseppe Viccica
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | | | - Edda Vignali
- Endocrine Unit 2, University Hospital of Pisa, Pisa, Italy
| | - Mario Miccoli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
- Endocrine Unit 2, University Hospital of Pisa, Pisa, Italy.
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Battista C, Guarnieri V, Carnevale V, Baorda F, Pileri M, Garrubba M, Salcuni AS, Chiodini I, Minisola S, Romagnoli E, Eller-Vainicher C, Santini SA, Parisi S, Frusciante V, Fontana A, Copetti M, Hendy GN, Scillitani A, Cole DEC. Vitamin D status in primary hyperparathyroidism: effect of genetic background. Endocrine 2017; 55:266-272. [PMID: 27154872 DOI: 10.1007/s12020-016-0974-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 04/25/2016] [Indexed: 10/21/2022]
Abstract
Primary hyperparathyroidism (PHPT) is associated with hypovitaminosis D as assessed by serum total 25-hydroxyvitamin D (TotalD) levels. The aim of this study is to evaluate whether this is also the case for the calculated bioavailable 25-hydroxyvitamin D (BioD) or free 25-hydroxyvitamin D (FreeD), and whether the vitamin D status is influenced by genetic background. We compared vitamin D status of 88 PHPT patients each with a matched healthy family member sharing genetic background, i.e., first-degree relative (FDR), or not, namely an in-law relative (ILR). We compared TotalD and vitamin D-binding protein (DBP), using the latter to calculate BioD and FreeD. We also genotyped two common DBP polymorphisms (rs7041 and rs4588) likely to affect the affinity for and levels of vitamin D metabolites. TotalD was lower (p < 0.001) in PHPT (12.3 ± 6.6 ng/mL) than either family member group (FDR: 19.4 ± 12.1 and ILR: 23.2 ± 14.1), whether adjusted for DBP or not. DBP levels were also significantly lower (p < 0.001) in PHPT (323 ± 73 mg/L) versus FDR (377 ± 98) or ILR (382 ± 101). The differences between PHPT and control groups for TotalD, BioD, and FreeD were maintained after adjustment for season, gender, and serum creatinine. 25-hydroxyvitamin D, evaluated as total, free, or bioavailable fractions, is decreased in PHPT. No difference was seen between first-degree relative and in-law controls, suggesting that neither genetic nor non-genetic background greatly influences the genesis of the hypovitaminosis D seen in PHPT.
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Affiliation(s)
- Claudia Battista
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy
| | - Vito Guarnieri
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy
| | - Vincenzo Carnevale
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy
| | - Filomena Baorda
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy
| | - Mauro Pileri
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy
| | - Maria Garrubba
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy
| | - Antonio S Salcuni
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy
| | - Iacopo Chiodini
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Cà Granda, Department of Clinical Sciences and Community Health, University of Milan, 20122, Milan, Italy
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Discipline, "Sapienza" Rome University, 00185, Rome, Italy
| | - Elisabetta Romagnoli
- Department of Experimental Medicine, "Sapienza" Rome University, 00185, Rome, Italy
| | - Cristina Eller-Vainicher
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Cà Granda, Department of Clinical Sciences and Community Health, University of Milan, 20122, Milan, Italy
| | - Stefano A Santini
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy
| | - Salvatore Parisi
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy
| | - Vincenzo Frusciante
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy
| | - Andrea Fontana
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy
| | - Massimiliano Copetti
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy
| | - Geoffrey N Hendy
- Experimental Therapeutics and Metabolism, McGill University Health Centre-Research Institute, and Departments of Medicine, Physiology and Human Genetics, McGill University, Montreal, QC, H4A 3J1, Canada
| | - Alfredo Scillitani
- Unit of Endocrinology, Medical Genetics, Internal Medicine, Clinical Pathology, Radiotherapy, Nuclear Medicine, Biostatistics, IRCCS "Casa Sollievo della Sofferenza", 71013, San Giovanni Rotondo, Foggia, Italy.
| | - David E C Cole
- Departments of Laboratory Medicine and Pathobiology, Medicine and Genetics, University of Toronto, Toronto, ON, M4N 3M5, Canada
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Birla S, Malik E, Jyotsna VP, Sharma A. Novel multiple endocrine neoplasia type 1 variations in patients with sporadic primary hyperparathyroidism. Indian J Endocrinol Metab 2016; 20:432-436. [PMID: 27366707 PMCID: PMC4911830 DOI: 10.4103/2230-8210.183467] [Citation(s) in RCA: 2] [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] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Primary hyperparathyroidism (PHPT) can occur either as a sporadic case or in association with syndromes such as multiple endocrine neoplasia. Multiple endocrine neoplasia type 1 (MEN1) is a rare autosomal-dominant disease resulting from mutations in MEN1 gene encoding a 621 amino acid long tumor suppressor protein "menin." We report here the results of MEN1 screening in 31 patients diagnosed with sporadic PHPT. MATERIALS AND METHODS Diagnosis of sporadic PHPT was made when blood urea and serum creatinine were normal, serum parathyroid hormone was high, and parathyroid enlargement could be localized on ultrasound and/or parathyroid scan. A total of 31 patients and 50 healthy volunteers were recruited for molecular analysis after taking informed consent. RESULTS Major symptoms at presentation were bone pain, fatigue, muscle weakness, and renal stones. Molecular genetic analysis revealed the presence of two novel intronic variations, c. 913-79T>A and c. 784-129T>A which by human splicing finder are predicted to cause potential alteration of splicing by either activating an intronic cryptic acceptor site or converting a conserved exonic splicing silencer sequence to an exonic splicing enhancer site. Apart from these, two reported polymorphisms rs144677807 and rs669976 were seen only in patients and none of the controls. Other reported polymorphisms rs2071313 and rs654440 were identified both in controls and patients. CONCLUSIONS This is the first study of MEN1 gene screening in sporadic PHPT in India reporting on the clinical and genetic findings, wherein two novel intronic variations c. 913-79T>A and c. 784-129T>A were identified showing their possible role in disease causation.
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Affiliation(s)
- S Birla
- Laboratory of Cyto-Molecular Genetics, Department of Anatomy, AIIMS, New Delhi, India
| | - E Malik
- Laboratory of Cyto-Molecular Genetics, Department of Anatomy, AIIMS, New Delhi, India
| | - VP Jyotsna
- Department of Endocrinology and Metabolism, AIIMS, New Delhi, India
| | - A Sharma
- Laboratory of Cyto-Molecular Genetics, Department of Anatomy, AIIMS, New Delhi, India
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Pepe J, Piemonte S, Cipriani C, Cilli M, Minisola S. Emerging data on cardiovascular risk in primary hyperparathyroidism. Endocrine 2014; 47:345-7. [PMID: 25205449 DOI: 10.1007/s12020-014-0415-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 08/30/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, Sapienza University, Viale del Policlinico 155, 00161, Rome, Italy
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Minisola S, Pepe J, Cipriani C, Scillitani A, Piemonte S. Vitamin D: is evidence of absence, absence of evidence? Osteoporos Int 2014; 25:2499-500. [PMID: 25116385 DOI: 10.1007/s00198-014-2841-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 08/04/2014] [Indexed: 01/01/2023]
Affiliation(s)
- S Minisola
- Department of Internal Medicine and Medical Disciplines, "Sapienza" Rome University, Rome, Italy,
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Minisola S, Romagnoli E, Scillitani A, Rao SD. Hypovitaminosis D in primary hyperparathyroidism: to treat or not to treat? That is the question. J Endocrinol Invest 2014; 37:413-4. [PMID: 24647989 DOI: 10.1007/s40618-014-0060-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 02/03/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines "Sapienza", Rome University, Via del Policlinico155, 00161, Rome, Italy,
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Rathi MS, Gonzalez S, Wright D, Ellis NR, Peacey SR. Management of hypovitaminosis D in patients with primary hyperparathyroidism. J Endocrinol Invest 2014; 37:467-71. [PMID: 24515299 DOI: 10.1007/s40618-014-0056-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 01/21/2014] [Indexed: 10/25/2022]
Abstract
AIM Epidemiological studies suggest that vitamin D deficiency is common in patients with primary hyperparathyroidism (PHPT). They have higher levels of serum parathyroid hormone (PTH) and markers of bone turnover and fractures are more frequent than vitamin D-replete patients. However, there are concerns that Vitamin D repletion might exacerbate pre-existent hypercalcaemia. Therefore, we aimed to determine if vitamin D replacement improved biochemical indices of calcium metabolism without worsening underlying hypercalcaemia. SUBJECTS AND METHODS This is a prospective, observational study based on routine clinical practice, set up in a secondary care centre. 45 consecutive patients with mild biochemical hypercalcaemia due to PHPT and hypovitaminosis D were enrolled. The mean age of the cohort was 61 years (range 25-85 years), predominately Asian (32 patients) and female (41 patients). They received 20,000 IU of oral cholecalciferol, once a week, for 3 months. Calcium, phosphate, alkaline phosphatase and PTH were measured at baseline, 4, 8 and 12 weeks following treatment. Vitamin D levels were obtained at baseline and at 12 weeks, after they completed their treatment. RESULTS Vitamin D levels normalised at week 12 (mean ± SD, 18.8 ± 9.4 versus 76 ± 20 nmol/L, p = 0.0001) and PTH levels improved following treatment completion (21.2 ± 10 versus 16.2 ± 6 pmol/L, p = 0.026). There was no significant increase in serum calcium levels during vitamin D supplementation. CONCLUSIONS High doses of oral cholecalciferol normalised vitamin D levels without worsening underlying hypercalcaemia in individuals with PHPT.
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Affiliation(s)
- M S Rathi
- Department of Diabetes and Endocrinology, Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, BD9 6RJ, UK,
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18
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Tassone F, Gianotti L, Baffoni C, Visconti G, Pellegrino M, Cassibba S, Croce CG, Magro G, Cesario F, Attanasio R, Borretta G. Vitamin D status in primary hyperparathyroidism: a Southern European perspective. Clin Endocrinol (Oxf) 2013; 79:784-90. [PMID: 23521111 DOI: 10.1111/cen.12210] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 02/13/2013] [Accepted: 03/19/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Vitamin D deficiency (VDD) is common in patients with primary hyperparathyroidism (pHPT), and this could affect the clinical expression of the disease. However, few North American or North European studies have addressed this issue, showing vitamin D repletion in only about one-third of the patients. SUBJECTS AND METHODS Vitamin D status was evaluated both in an observational study in a series of 206 consecutive patients with pHPT at diagnosis and in a case-control analysis with 113 age- and sex-matched healthy blood donors. Vitamin D status was assessed by measuring plasma 25-hydroxy-vitamin D (25OHD) levels and was defined as VDD or severe VDD if 25OHD was <20 ng/ml (<50 nm) and <10 ng/ml (<25 nm), respectively. RESULTS No seasonal variability was observed in 25OHD levels. VDD was observed in 75 of 206 patients (36·4%). The VDD was severe in 24 of 75 patients (11·7%). There was no difference in prevalence of VDD between men and women nor between asymptomatic and 'bone and stone' symptomatic patients. 25OHD levels was negatively correlated with parathyroid hormone, ionized calcium, and bone turnover markers, and positively correlated with phosphate. 25OHD levels were also positively correlated with bone mineral density at all sites measured. In the case-control study, the overall prevalence of VDD and severe VDD was higher in patients with pHPT compared with controls (33·6% vs 10·6%, P < 0·0001, and 8·8% vs 1·8%, P = 0·0337, respectively). CONCLUSIONS Our study shows that VDD occurs in about one-third of patients with pHPT resident in a Southern European area, a lower figure than previously reported. Moreover, VDD is related to a more severe bone disease, and its prevalence is higher in patients with pHPT than in healthy matched subjects.
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Affiliation(s)
- Francesco Tassone
- Division of Endocrinology, Diabetology and Metabolism, Santa Croce e Carle Hospital, Cuneo, Italy
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Romagnoli E, Pepe J, Piemonte S, Cipriani C, Minisola S. Management of endocrine disease: value and limitations of assessing vitamin D nutritional status and advised levels of vitamin D supplementation. Eur J Endocrinol 2013; 169:R59-69. [PMID: 23847326 DOI: 10.1530/eje-13-0435] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The growing attention to the role of vitamin D in skeletal and extra-skeletal diseases over the last decade induced an increased demand for vitamin D determination as well as a dramatic rise of sales of vitamin D supplement. However, several critical points in this field remain to be clarified. We lack a clear consensus about the definition of vitamin D deficiency, insufficiency, and sufficiency. The identification of different thresholds defining vitamin D status has relevant implications in clinical practice. In fact, the worldwide prevalence of low vitamin D status is highly varying according to the level of 25(OH)D utilized to define sufficiency. Therefore, the assessment of 25-hydroxyvitamin D levels may have a critical role, but a number of different technical problems associated with its determination may interfere in interpreting the results. The hydrophobic nature of vitamin D and the tight binding to its carrier (vitamin D binding protein), the different forms circulating in blood, and the issue of standardization are among the most important factors influencing the measurement of this metabolite. Another controversial point relies on the conflicting guidance on prevention and treatment of vitamin D deficiency endorsed by different medical and scientific communities. In particular, uncertainty exists about how to replete vitamin D stores, how to maintain normal 25(OH)D levels after repletion, which form of vitamin D is preferable for supplementation, and which route of administration and dosing regimens are advisable. Finally, concerns have been raised regarding vitamin D toxicity and its adverse effects.
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Affiliation(s)
- Elisabetta Romagnoli
- Department of Internal Medicine and Medical Disciplines, University of Rome 'Sapienza', Viale del Policlinico 155, 00161 Rome, Italy
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Romagnoli E, Cipriani C, Nofroni I, Castro C, Angelozzi M, Scarpiello A, Pepe J, Diacinti D, Piemonte S, Carnevale V, Minisola S. "Trabecular Bone Score" (TBS): an indirect measure of bone micro-architecture in postmenopausal patients with primary hyperparathyroidism. Bone 2013; 53:154-9. [PMID: 23228370 DOI: 10.1016/j.bone.2012.11.041] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 11/28/2012] [Accepted: 11/29/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with primary hyperparathyroidism (PHPT) generally show reduced bone mineral density (BMD) at cortical sites with relatively preserved trabecular bone. However, the increased fracture risk at all skeletal sites suggests that areal BMD probably is not effective in capturing all the determinants of bone strength. "Trabecular Bone Score" (TBS) has been recently proposed as an indirect measure of bone micro-architecture. Our study was aimed to investigate TBS in patients with PHPT. METHODS Seventy-three Caucasian postmenopausal women with PHPT and 74 age-matched healthy women (C) were studied. In all participants BMD at lumbar spine (LS) and at femoral sites (Neck-FN and total hip-TH) was measured by DXA and, in 67 patients and 34 C, also at the distal 1/3 of the radius (R). TBS was measured in the region of LS-BMD. Spine X ray was assessed in all patients. RESULTS Mean TBS values were significantly reduced in PHPT (1.19 ± 0.10) compared to C (1.24 ± 0.09, p<0.01). Patients and controls did not differ for age, years since menopause (YSM), BMI, 25(OH)D serum levels, creatinine clearance, LS-BMD and FN-BMD. On the contrary, mean BMD values at both TH and R were significantly lower in PHPT patients compared to controls (p<0.01 and p<0.0001, respectively). In PHPT with vertebral fractures (VF+, n=29) TBS was significantly lower than in those without fracture (VF-, n=44)(1.14 ± 0.10 vs. 1.22 ± 0.10, respectively; p<0.01), whose TBS values did not differ from C. Mean TBS values in patients with (n=18) and without (n=55) non-vertebral fractures did not significantly differ (1.16 ± 0.09 vs. 1.20 ± 0.11). The presence of vertebral fractures was independently associated with the reduction of TBS (OR=0.003, 95% CI=0-0.534, p=0.028) and with YSM (OR=1.076, 95% CI=1.017-1.139, p=0.011), but not with age, the reduction of LS-BMD and the increase of BMI. The combination of YSM > 10 years plus TBS < 1.2 was associated with a significant risk of VF (OR=11.73, 95% CI 2.43-66.55, p<0.001). A TBS value <1.2 showed a better performance in individuating VF (sensibility 79.3%, specificity 61.4%, positive predictive value 57.5%, and negative predictive value 81.8%) in respect to YSM > 10 years. CONCLUSIONS TBS seems to indirectly reflect an alteration of bone micro-architecture in postmenopausal women with PHPT.
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Affiliation(s)
- Elisabetta Romagnoli
- Department of Internal Medicine and Medical Disciplines, University of Rome Sapienza, Rome, Italy.
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De Lucia F, Minisola S, Romagnoli E, Pepe J, Cipriani C, Scillitani A, Parikh N, Rao DS. Effect of gender and geographic location on the expression of primary hyperparathyroidism. J Endocrinol Invest 2013; 36:123-6. [PMID: 22718266 DOI: 10.3275/8455] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The effect of gender on the expression of primary hyperparathyroidism (PHPT) is not well characterized. AIM We therefore evaluated two Caucasian populations (US and Italian) of men and women with PHPT, matched for age and body mass index (BMI), in a cross-sectional retrospective observational study. METHODS We studied 74 US (23 men) and 126 Italian (42 men) patients evaluating main biochemical indices of the disease and bone mineral density (BMD) at the spine and proximal femur. RESULTS Mean serum calcium levels were higher both in Italian men compared to women (11.7 ± 1.22 mg/dl and 11.1 ± 0.83, p<0.01) and in Italian compared to US patients (11.3 ± 1.01 and 10.8 ± 0.58, p<0.001), with similar results for the serum ionized calcium. Mean serum PTH levels were not different either between the genders or between the countries. After controlling for BMI, the mean BMD at both the femoral neck and total hip in females US patients was significantly higher compared with Italian female patients. CONCLUSION Despite similar levels of circulating PTH, Italian patients have more pronounced effects of the disease as assessed by serum calcium and a more significant cortical involvement in women as assessed by BMD.
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Affiliation(s)
- F De Lucia
- Department of Internal Medicine and Medical Disciplines, University of Rome "Sapienza", Viale del Policlinico 155, 00161 Rome, Italy
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Mshelia DS, Hatutale AN, Mokgoro NP, Nchabaleng ME, Buscombe JR, Sathekge MM. Correlation between serum calcium levels and dual-phase 99mTc-sestamibi parathyroid scintigraphy in primary hyperparathyroidism. Clin Physiol Funct Imaging 2011; 32:19-24. [DOI: 10.1111/j.1475-097x.2011.01048.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Clinical significance of vitamin D deficiency in primary hyperparathyroidism, and safety of vitamin D therapy. South Med J 2011; 104:29-33. [PMID: 21079532 DOI: 10.1097/smj.0b013e3181fcd772] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Vitamin D deficiency occurs more frequently in patients with primary hyperparathyroidism (PHPT) compared with the general population, and is usually associated with an aggravated form of the disease. Current guidelines recommend measurement of serum levels of 25-hydroxy vitamin D (25-OHD) in all patients with PHPT, and their repletion if the levels are less than 50 mmol/L (20 ng/mL). Limited data suggest that vitamin D treatment is generally safe in subjects with mild PHPT and coexisting vitamin D deficiency. Adverse effects include hypercalcuria and, less commonly, exacerbation of hypercalcemia. Well-designed trials are needed to evaluate the safety of vitamin D replacement therapy in a wide spectrum of patients with concomitant PHPT and vitamin D deficiency. These trials should address the impact of such therapy on the complications and course of PHPT.
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La moitié des patients atteints d’hyperparathyroïdies primaires ont un déficit en vitamine D aggravant l’atteinte osseuse. Presse Med 2011; 40:e120-7. [DOI: 10.1016/j.lpm.2010.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Revised: 07/29/2010] [Accepted: 08/26/2010] [Indexed: 11/18/2022] Open
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Souberbielle JC, Maury E, Friedlander G, Cormier C. Vitamin D and primary hyperparathyroidism (PHPT). J Steroid Biochem Mol Biol 2010; 121:199-203. [PMID: 20398761 DOI: 10.1016/j.jsbmb.2010.03.077] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Revised: 03/22/2010] [Accepted: 03/26/2010] [Indexed: 11/16/2022]
Abstract
Vitamin D deficiency and PHPT are two common conditions, especially in postmenopausal women. Vitamin D deficiency is said to be even more frequent in PHPT patients than in the general population due to an accelerated conversion of 25OHD into calcitriol or 24-hydroxylated compounds. Although several studies have reported worsening of PHPT phenotype (larger tumours, higher PTH levels, more severe bone disease) when vitamin D deficiency coexists whereas vitamin D supplementation in PHPT patients with a serum calcium level<3 mmol/L has been shown to be safe (no increase in serum or urinary calcium) and to decrease serum PTH concentration, that many physicians are afraid to give vitamin D to already hypercalcemic PHPT patients. On the other hand, it is possible that, in some patients, a persistent vitamin D deficiency induces, in the long-term, an autonomous secretion of PTH (i.e. tertiary hyperparathyroidism). The mechanism by which this could occur is unclear however. Finally, as many, otherwise normal, subjects with vitamin D insufficiency may have an increased serum PTH level we believe that those with vitamin D insufficiency should be excluded from a reference population for serum PTH levels. By doing that, we found that the upper normal limit for serum PTH was 25-30% lower than in the whole population.
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Affiliation(s)
- Jean-Claude Souberbielle
- Service d'Explorations Fonctionnelles, Hôpital Necker-Enfants Malades, and Faculté de Médecine, Centre de Recherche Croissance et Signalisation (INSERM U845), Université Paris Descartes, France.
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Isidro ML, Ruano B. Biochemical effects of calcifediol supplementation in mild, asymptomatic, hyperparathyroidism with concomitant vitamin D deficiency. Endocrine 2009; 36:305-10. [PMID: 19598008 DOI: 10.1007/s12020-009-9211-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 06/18/2009] [Accepted: 06/29/2009] [Indexed: 10/20/2022]
Abstract
It has been proposed to cautiously supplement with vitamin D to any patient with asymptomatic primary hyperparathyroidism (PHTP) and a plasma 25-hydroxyvitamin D [25(OH)D] concentration <50 nmol/l. Evidence about the safeness of this intervention is limited to two studies. Our aim was to prospectively assess the biochemical effects of one-year 25(OH)D supplementation in this context. Twenty-seven patients were included in this study. Calcifediol was started at a dose of 480-960 IU/24 h (8-16 microg/24 h) and adjusted up to a maximum of 960 IU/24 h (16 microg/24 h). Basal calcium, phosphate, albumin, total alkaline phosphatase (ALP), creatinine, 24 h calcium urinary excretion, intact PTH (iPTH) and 25(OH)D were measured before and during vitamin D supplementation. The mean basal 25(OH)D was 28.7 +/- 8.0 nmol/l, and at 12 months was 71.5 +/- 32.5 nmol/l (P = 0.00 vs. baseline). After 3, 6 and 12 months iPTH levels were 141.7 +/- 108.4 ng/l (P = 0.00 vs. baseline), 131.1 +/- 95.7 ng/l (P = 0.03 vs. baseline) and 162.2 +/- 139.3 ng/l (P = ns vs. baseline). Mean calcium did not change. Mean urinary calcium excretion increased significantly (basal: 5.7 +/- 2.9 mmol/24 h, 12 months: 7.9 +/- 4.9 mmol/24 h, P = 0.02). Cautious calcifediol supplementation significantly increased mean 25(OH)D and temporarily reduced mean iPTH. It did not change mean serum calcium, but urinary calcium excretion increased significantly. We suggest that serum calcium and 24 h calciuria be measured at regular intervals in patients with PHTP, while on calcifediol supplementation.
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Affiliation(s)
- M Luisa Isidro
- Endocrine Department, Complejo Hospitalario Universitario, As Xubias 84, A Coruña, 15006, Spain.
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Martínez Díaz-Guerra G, Hawkins Carranza F. [Concept, etiology and epidemiology of primary hyperparathyroidism]. ACTA ACUST UNITED AC 2009; 56 Suppl 1:2-7. [PMID: 19627754 DOI: 10.1016/s1575-0922(09)70849-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Primary hyperparathyroidism (PHPT) is one of the most frequent endocrinological disorders. In PHPT, there is abnormal regulation of parathyroid hormone (PTH) by calcium, which translates into inappropriately high PTH secretion for the level of calcemia. Most patients with PHPT have increased serum PTH levels, with increases in serum calcium, especially ionic calcium. The incidence of PHPT rises with age, the mean age at diagnosis being 55 years. This disorder affects mainly women with a female-to-male ratio of approximately 3:1. Most (80-85%) of cases are produced by chief cell parathyroid adenomas. The factors involved in the genesis of PHPT are largely unknown. Gene mutations affecting oncogenes (cyclin D1, RET) or tumor suppressor genes (MEN1, HRPT2) are found in a minority of cases. These mutations are especially important in familial forms of PHPT, such as multiple endocrine neoplasia syndrome (MEN1, MEN2A). No mutations affecting the calcium-sensing receptor (CaSR) or vitamin D receptor (VDR) gene have been found. In parathyroid adenomas and hyperplasias, there may be abnormal Wnt signalling, with mutations of the coreceptor LRP5 gene and beta-catenin accumulation. Expression of the Klotho protein, which intervenes in serum calcium regulation, is reduced. Low levels of 25(OH) vitamin D frequently coexist, although whether vitamin D deficiency plays a pathogenic role in PHPT is unknown.
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Rey-Sánchez P, Lavado-García JM, Canal-Macías ML, Gómez-Zubeldia MA, Roncero-Martín R, Pedrera-Zamorano JD. Ultrasound bone mass in schizophrenic patients on antipsychotic therapy. Hum Psychopharmacol 2009; 24:49-54. [PMID: 19016257 DOI: 10.1002/hup.984] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine bone mass using quantitative phalangeal bone ultrasound in institutionalized schizophrenic patients under chronic treatment with antipsychotic drugs. METHODS A total of 73 patients with schizophrenia (25 women, mean age 59.84 +/- 17.01 years; 48 men, mean age 61.89 +/- 12.95 years) and 73 healthy subjects (25 women, mean age 60.37 +/- 17.16 years; 48 men, mean age 61.24 +/- 13.09 years) participated in the study. Bone status was assessed using an ultrasound device that measures the amplitude-dependent speed of sound (Ad-SoS) in metres per second. Measurements were made on the phalanges (II-V) of the non-dominant hand, and the mean value was computed. RESULTS The schizophrenic women had higher levels of prolactin (PRL), parathyroid hormone (PTH), alkaline phosphatase (AlPh), and tartrate-resistant acid phosphatase (TRAP) (all p < 0.0001), and lower 25-hydroxyvitamin D(25(OH)D3) levels (p < 0.0001) and Ad-SoS values (p < 0.05) than controls. Ad-SoS was higher in schizophrenic men (p < 0.05). CONCLUSIONS Schizophrenic women in treatment with antipsychotic drugs had a loss of phalangeal bone mass that was associated with the levels of vitamin D or PTH, and increased bone turnover.
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Moosgaard B, Christensen SE, Vestergaard P, Heickendorff L, Christiansen P, Mosekilde L. Vitamin D metabolites and skeletal consequences in primary hyperparathyroidism. Clin Endocrinol (Oxf) 2008; 68:707-15. [PMID: 17980013 DOI: 10.1111/j.1365-2265.2007.03109.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) is associated with reduced bone mineral density (BMD) mainly at sites rich in cortical bone. However, successful parathyroidectomy causes an increase in BMD especially at sites rich in trabecular bone. Plasma 25-hydroxyvitamin D (25OHD) levels are typically reduced and plasma 1,25-dihydroxyvitamin D [1,25(OH)(2)D] slightly increased in PHPT. These variations in vitamin D metabolites may influence variations in BMD and fracture risk. AIM To investigate relations between preoperative vitamin D metabolites and skeletal consequences in patients with untreated PHPT and to appraise the influence of preoperative vitamin D metabolites on postoperative changes in BMD. Design Cross-sectional and cohort study. MATERIALS Two hundred and forty-six consecutive Caucasian PHPT patients aged 19-91 years. (median 63, 87% females). RESULTS BMD was reduced at the femoral neck (P < 0.001) and forearm (P < 0.001), but normal at the lumbar spine (P = 0.11). Levels of biochemical bone markers were associated with high plasma PTH, high plasma 1,25(OH)(2)D and low plasma levels of 25OHD. Moreover, low plasma 25OHD was associated with low levels of BMD at the femoral neck (r(p) = 0.23), the forearm (r(p) = 0.19) and the whole body (r(p) = 0.30), whereas plasma 1,25(OH)(2)D was inversely associated with BMD at all regional sites and the whole body. Plasma PTH only showed an inverse association with BMD at the forearm (r(p) = -0.21). No association was observed between biochemical variables and prevalent spinal fractures, all peripheral fractures or osteoporotic peripheral fractures. The annual increase in spinal BMD after surgery was positively associated with preoperative plasma PTH (r(p) = 0.40), whereas the annual increase in whole body BMD was inversely associated with plasma 25OHD (r(p) = -0.32). No change in BMD at the femoral neck and forearm was observed 1 year after surgery. CONCLUSION Low vitamin D status and high plasma 1,25(OH)(2)D are associated with increased bone turnover and decreased BMD in patients with PHPT.
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Affiliation(s)
- B Moosgaard
- Aarhus Bone and Mineral Research Group: Department of Endocrinology and Metabolism C, Aarhus University Hospital, DK 8000 Aarhus C, Denmark.
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Inoue Y, Kaji H, Hisa I, Tobimatsu T, Naito J, Iu MF, Sugimoto T, Chihara K. Vitamin D status affects osteopenia in postmenopausal patients with primary hyperparathyroidism. Endocr J 2008; 55:57-65. [PMID: 18187872 DOI: 10.1507/endocrj.k07-102] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Controversy still exists about whether vitamin D status is related to the severity of primary hyperparathyroidism (pHPT), although vitamin D insufficiency is frequent in pHPT. The present study was therefore performed to examine the relationships between vitamin D status and various parameters in 30 postmenopausal pHPT patients. BMD values were measured by dual-energy x-ray absorptiometry at the lumbar spine (L(2-4)), femoral neck (FN) and distal one third of the radius (Rad 1/3). Serum levels of 25 hydroxy-vitamin D(3) [25(OH)D] and 1,25-dihydroxy vitamin D(3) [1,25(OH) (2)D(3)] were 15.8 +/- 3.5 microg/l and 69.3 +/- 33.3 ng/l in pHPT patients, respectively. Serum levels of calcium and PTH seemed to be negatively correlated to serum 25(OH)D levels, although the differences were not significant. However, when subjects with the highest serum PTH levels (PTH>1000 pg/ml) were excluded from the analysis, the correlation was significant between serum 25(OH)D levels and PTH, indicating that vitamin D status affects the severity of pHPT when severe cases were excluded. In addition, serum levels of 1,25(OH)(2)D(3) were significantly and negatively correlated to serum 25(OH)D levels. On the other hand, serum levels of 25(OH)D were significantly and positively correlated to BMD (Z-score) at the lumbar spine, but not at the radius and femoral neck; however, serum 25(OH)D levels were not correlated to the levels of any bone metabolic indices measured. Moreover, serum levels of 25(OH)D were not related to urinary calcium and the tubular reabsorption rate of phosphorus, and they were similar in groups with and without renal stones. In conclusion, vitamin D status seemed to be related to the severity of disease in postmenopausal patients with pHPT. In particular, the relationship between serum 25(OH)D level and BMD at the lumbar spine was predominant.
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Affiliation(s)
- Yoshifumi Inoue
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
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Abstract
Temporally associated with the improvement in vitamin D nutrition in many Western countries in the mid-20th century, there was a change in many characteristics of primary hyperparathyroidism. Osteitis fibrosa cystica became a rare manifestation of what is now frequently an asymptomatic disease. At the same time, in patients with the disease, levels of PTH and parathyroid adenoma weights have fallen dramatically. In view of these observations and others, an association between vitamin D deficiency and severity of primary hyperparathyroidism has been proposed. Data support an association on two distinct levels. First, regardless of the clinical severity of primary hyperparathyroidism, the disease seems to be more severe in those with concomitant vitamin D deficiency. Second, vitamin D deficiency and insufficiency seem to be more prevalent in patients with primary hyperparathyroidism than in geographically matched populations. The association between vitamin D deficiency and primary hyperparathyroidism has clear implications. Co-existing vitamin D deficiency may cause the serum calcium level to fall into the normal range, which can lead to diagnostic uncertainty. With regard to management, preliminary data on vitamin D repletion in patients with mild primary hyperparathyroidism suggest that, in some cases, correction of vitamin D deficiency may be accomplished without worsening the underlying hypercalcemia. Vitamin D-deficient patients undergoing parathyroidectomy are also at increased risk of postoperative hypocalcemia and "hungry bone syndrome," which underscores the importance of preoperative assessment of vitamin D status in all patients with primary hyperparathyroidism.
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Beyer TD, Chen EL, Nilubol N, Prinz RA, Solorzano CC. Short-Term Outcomes of Parathyroidectomy in Patients With or Without 25-Hydroxy Vitamin D Insufficiency. J Surg Res 2007; 143:145-50. [DOI: 10.1016/j.jss.2007.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Revised: 06/01/2007] [Accepted: 06/21/2007] [Indexed: 02/07/2023]
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De Geronimo S, Romagnoli E, Diacinti D, D'Erasmo E, Minisola S. The risk of fractures in postmenopausal women with primary hyperparathyroidism. Eur J Endocrinol 2006; 155:415-20. [PMID: 16914595 DOI: 10.1530/eje.1.02225] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the prevalence of vertebral (vFr) and non-vertebral (nvFr) fractures in postmenopausal women with primary hyperparathyroidism (PHPT). MATERIALS AND METHODS We studied 98 patients with PHPT, divided into 'mild' (M, n = 25) and 'non-mild' (NM, n = 73) sub-groups, according to recently published guidelines (2002), and 89 healthy women (C) matched for age, years since menopause and body mass index. vFr was evaluated according to a visual semiquantitative method; bone mineral density (BMD) at the lumbar spine (LS), and femoral sites (femoral neck, FN and total femur, FT) was measured by dual energy X-ray absorptiometry. Volumetric BMD of the third lumbar vertebra (vBMDL3) was also calculated. RESULTS The prevalence of vFr was significantly higher (P < 0.001) in both M and NM PHPT patients compared with C; this prevalence did not differ between M and NM patients. BMD was significantly lower (P < 0.05) in NM patients compared with both C and M patients. BMD at LS in M patients was also significantly higher with respect to C. Similar results were also obtained for vBMDL3; in M patients, vBMDL3 was also significantly higher compared to C. When M and NM patients were subdivided according to the presence or lack of vFr, no difference was found between fractured and unfractured patients for either BMD or vBMDL3 values. CONCLUSIONS The risk of vFr is higher in postmenopausal patients with mild PHPT even if BMD appears well preserved. This finding suggests that other factors, such as bone quality, seem to be relevant in determining fracture risk, especially when gonadal function is lacking.
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Affiliation(s)
- Simona De Geronimo
- Department of Clinical Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
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Abstract
During the past decade, major advances have been made in vitamin D research that transcend the simple concept that vitamin D is Important for the prevention of rickets in children and has little physiologic relevance for adults. Inadequate vitamin D, in addition to causing rickets, prevents children from attaining their genetically programmed peak bone mass, contributes to and exacerbates osteoporosis in adults, and causes the often painful bone disease osteomalacia. Adequate vitamin D is also important for proper muscle functioning, and controversial evidence suggests it may help prevent type 1 diabetes mellitus, hypertension, and many common cancers. Vitamin D inadequacy has been reported in approximately 36% of otherwise healthy young adults and up to 57% of general medicine inpatients in the United States and in even higher percentages in Europe. Recent epidemiological data document the high prevalence of vitamin D inadequacy among elderly patients and especially among patients with osteoporosis. Factors such as low sunlight exposure, age-related decreases in cutaneous synthesis, and diets low in vitamin D contribute to the high prevalence of vitamin D inadequacy. Vitamin D production from cutaneous synthesis or intake from the few vitamin D-rich or enriched foods typically occurs only intermittently. Supplemental doses of vitamin D and sensible sun exposure could prevent deficiency in most of the general population. The purposes of this article are to examine the prevalence of vitamin D inadequacy and to review the potential implications for skeletal and extraskeletal health.
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Affiliation(s)
- Michael F Holick
- Vitamin D, Skin and Bone Research Laboratory, Section of Endocrinology, Diabetes, and Nutrition, Department of Medicine, Boston University School of Medicine, Boston, Mass 02118, USA.
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Stewart ZA, Blackford A, Somervell H, Friedman K, Garrett-Mayer E, Dackiw APB, Zeiger MA. 25-hydroxyvitamin D deficiency is a risk factor for symptoms of postoperative hypocalcemia and secondary hyperparathyroidism after minimally invasive parathyroidectomy. Surgery 2005; 138:1018-25; discussion 1025-6. [PMID: 16360386 DOI: 10.1016/j.surg.2005.09.018] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Revised: 09/15/2005] [Accepted: 09/22/2005] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients with primary hyperparathyroidism who undergo minimally invasive parathyroidectomy (MIP) may have postoperative symptoms of hypocalcemia or secondary hyperparathyroidism. This study sought to identify factors predictive of these events. METHODS Between 1998 and 2004, 190 patients with primary hyperparathyroidism underwent MIP with excision of a single adenoma. Age, gender, race, prior head and neck surgery, use of preoperative thyroid hormone or calcium-channel blockers, preoperative levels of calcium, 25-hydroxyvitamin D (25[OH]D) and intact parathyroid hormone (iPTH), the presence of osteopenia or osteoporosis, intraoperative iPTH levels, and adenoma weight were evaluated by univariate analysis as predictors of postoperative symptoms of hypocalcemia and secondary hyperparathyroidism. RESULTS None of the following were predictors of postoperative symptoms of hypocalcemia: age, gender, race, prior head and neck surgery, preoperative medications, preoperative calcium and iPTH levels, osteopenia or osteoporosis, intraoperative iPTH levels, or adenoma weight. However, patients with postoperative symptoms of hypocalcemia had significantly lower preoperative 25[OH]D levels (P = .01). Further, higher preoperative iPTH levels (P < .01) and lower preoperative 25[OH]D levels (P = .05) were associated with secondary hyperparathyroidism postoperatively. CONCLUSIONS A low preoperative 25[OH]D level is associated with postoperative symptoms of hypocalcemia and secondary hyperparathyroidism in patients undergoing MIP. One might consider instituting empiric calcium supplementation postoperatively in patients with low 25[OH]D levels.
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Affiliation(s)
- Zoe A Stewart
- Division of Endocrine and Oncologic Surgery, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
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Moosgaard B, Vestergaard P, Heickendorff L, Melsen F, Christiansen P, Mosekilde L. Vitamin D status, seasonal variations, parathyroid adenoma weight and bone mineral density in primary hyperparathyroidism. Clin Endocrinol (Oxf) 2005; 63:506-13. [PMID: 16268801 DOI: 10.1111/j.1365-2265.2005.02371.x] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) and vitamin D insufficiency are common conditions that can occur in combination. However, low plasma 25-hydroxyvitamin D (25OHD) may also enhance the risk of PHPT or modify disease severity. AIM To compare the risk of vitamin D insufficiency and deficiency stratified by age, sex and season between PHPT patients and controls and to assess associations between plasma 25OHD and adenoma weight, biochemical variables, bone mineral density (BMD) and clinical complications. DESIGN Cross-sectional study. MATERIAL A total of 289 consecutive Caucasian patients with PHPT aged 65.9 (24-92) years, 289 sex-, age- and season-matched normocalcaemic controls and 187 healthy adult blood donors. PHPT diagnosis was confirmed in 214 by neck exploration. RESULTS Vitamin D insufficiency (plasma 25OHD < 50 nmol/l) was observed in 81% of PHPT patients compared with 60% of sex- and age-matched controls (P < 0.001) and 35% of blood donors (P < 0.001). During summer, 77%vs. 53% (P < 0.001) and 4% (P < 0.001), respectively, had vitamin D insufficiency. Average plasma 25OHD was 41 (range 9-87) nmol/l among 27 PHPT patients compared with 87 (21-173) nmol/l (P < 0.001) among aged-matched blood donors. During winter, 86%vs. 66% (P < 0.001) and 71% (P < 0.05), respectively, had vitamin D insufficiency. Vitamin D deficiency (plasma 25OHD < 25 nmol/l) was observed in 33% of PHPT patients compared with 20% of age- and sex-matched controls (P < 0.001) and 13% of blood donors (P < 0.001). Both PHPT patients and controls showed seasonal variations in 25OHD related to the average number of sun hours, but values were lower in PHPT patients at all calendar months. In PHPT patients low plasma 25OHD was associated with higher plasma levels of calcium, PTH and alkaline phosphatase and with lower renal calcium excretion, femoral neck and forearm BMD. No association was found between plasma 25OHD and adenoma weight (total or divided into tertiles). There was a trend towards increased risk of osteoporotic fractures (P < 0.08) with low plasma 25OHD. CONCLUSION Vitamin D insufficiency and deficiency are common findings in PHPT and occur more often than in a sex- and age-matched control group referred from general practice and in normal blood donors irrespective of season. Low plasma 25OHD levels are associated with an aggravated clinical presentation of PHPT but do not affect adenoma size.
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Affiliation(s)
- B Moosgaard
- Aarhus Bone and Mineral Research Group: Department of Endocrinology and Metabolism C, Aarhus University Hospital, Denmark.
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Gaugris S, Heaney RP, Boonen S, Kurth H, Bentkover JD, Sen SS. Vitamin D inadequacy among post-menopausal women: a systematic review. QJM 2005; 98:667-76. [PMID: 16006498 DOI: 10.1093/qjmed/hci096] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Vitamin D inadequacy has been studied extensively, due to concerns about ageing populations, associations with osteoporosis and other disorders (including non-musculoskeletal), and high prevalence. AIM To review recent reports on the prevalence of vitamin D inadequacy among post-menopausal women with and without osteoporosis and/or other musculoskeletal diseases. DESIGN Systematic review. METHODS We reviewed publications in the past 10 years reporting prevalence estimates for vitamin D inadequacy, reported as serum 25(OH)D values below various levels. Thirty published studies in the English language were identified, from January 1994 through April 2004. RESULTS In osteoporotic populations, the prevalence of 25(OH) vitamin D concentration <12 ng/ml ranged from 12.5% to 76%, while prevalence rates reached 50% to 70% of patients with a history of fracture(s) using a cut-off of 15 ng/ml. In post-menopausal women, the prevalence of 25(OH) vitamin D concentrations <or=20 ng/ml ranged from 1.6% to 86% for community-living and institutionalized women, respectively. The most common factors associated with inadequate vitamin D levels included limited sun exposure, lack of dietary vitamin D intake, nursing home environment, wintertime, and increasing age (over 70 years). DISCUSSION The prevalence of inadequate vitamin D levels appears to be high in post-menopausal women, especially in those with osteoporosis and history of fracture. Vitamin D supplementation in this group might offer scope for prevention of falls and fracture, especially in elderly and osteoporotic populations.
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Affiliation(s)
- S Gaugris
- Rutgers University, Piscataway, NJ, USA
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Laflamme N, Giroux S, Loredo-Osti JC, Elfassihi L, Dodin S, Blanchet C, Morgan K, Giguère V, Rousseau F. A frequent regulatory variant of the estrogen-related receptor alpha gene associated with BMD in French-Canadian premenopausal women. J Bone Miner Res 2005; 20:938-44. [PMID: 15883633 DOI: 10.1359/jbmr.050203] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2004] [Revised: 01/19/2005] [Accepted: 02/02/2005] [Indexed: 11/18/2022]
Abstract
UNLABELLED Genes are important BMD determinants. We studied the association of an ESRRA gene functional variant with BMD in 1335 premenopausal women. The ESRRA genotype was an independent predictor of L2-L4 BMD, with an effect similar to smoking and equivalent to a 10-kg difference in weight. INTRODUCTION Several genetic polymorphisms have been associated with osteoporosis or osteoporosis fractures, but no functional effect has been shown for most of these gene variants. Because functional studies have implicated estrogen-related receptor alpha (ESRRA) in bone metabolism, we evaluated whether a recently described regulatory variant of the ESRRA gene is associated with lumbar and hip BMD as measured by DXA and with heel bone parameters as measured by quantitative ultrasound (QUS). MATERIALS AND METHODS Heel bone parameters were measured by right calcaneal QUS in 1335 healthy French-Canadian premenopausal women, and one-half of these women also had their BMD evaluated at two sites: femoral neck and lumbar spine (L2-L4) by DXA. All bone measures were tested separately for association with the ESRRA genotype by analysis of covariance. The significance of the ESRRA contribution to the model was also assessed by two different permutation tests. RESULTS A statistically significant association between ESRRA genotype and lumbar spine BMD was observed: women carrying the long ESRRA genotype had a 3.9% (0.045 g/cm2) higher lumbar spine BMD than those carrying the short ESRRA genotype (p = 0.004), independently of other risk factors measured. This effect of ESRRA genotype is similar to the effect of smoking and equivalent to a 10-kg difference in weight. This association was confirmed by permutation tests (p = 0.004). The same trend was observed for femoral neck BMD (2.6%, p = 0.07). However, no association was observed between ESRRA and QUS heel bone measures. CONCLUSION These results support the genetic influence of this ESRRA regulatory variant on BMD.
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Affiliation(s)
- Nathalie Laflamme
- Institut National de Santé Publique du Quebec, Ste-Foy, Quebec, Canada.
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Grey A, Lucas J, Horne A, Gamble G, Davidson JS, Reid IR. Vitamin D repletion in patients with primary hyperparathyroidism and coexistent vitamin D insufficiency. J Clin Endocrinol Metab 2005; 90:2122-6. [PMID: 15644400 DOI: 10.1210/jc.2004-1772] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Vitamin D insufficiency is common in patients with primary hyperparathyroidism (PHPT) and may be associated with more severe and progressive disease. Uncertainty exists, however, as to whether repletion of vitamin D should be undertaken in patients with PHPT. Here we report the effects of vitamin D repletion on biochemical outcomes over 1 yr in a group of 21 patients with mild PHPT [serum calcium <12 mg/dl (3 mmol/liter)] and coexistent vitamin D insufficiency [serum 25 hydroxyvitamin D [25(OH)D] <20 microg/liter (50 nmol/liter)]. In response to vitamin D repletion to a serum 25(OH)D level greater than 20 microg/liter (50 nmol/liter), mean levels of serum calcium and phosphate did not change, and serum calcium did not exceed 12 mg/dl (3 mmol/liter) in any patient. Levels of intact PTH fell by 24% at 6 months (P < 0.01) and 26% at 12 months (P < 0.01). There was an inverse relationship between the change in serum 25(OH)D and that in intact PTH (r = -0.43, P = 0.056). At 12 months, total serum alkaline phosphatase was significantly lower, and urine N-telopeptides tended to be lower than baseline values (P = 0.02 and 0.13, respectively). In two patients, 24-h urinary calcium excretion rose to exceed 400 mg/d, but the group mean 24-h urinary calcium excretion did not change. These preliminary data suggest that vitamin D repletion in patients with PHPT does not exacerbate hypercalcemia and may decrease levels of PTH and bone turnover. Some patients with PHPT may experience an increase in urinary calcium excretion after vitamin D repletion.
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Affiliation(s)
- Andrew Grey
- Department of Medicine, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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