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Benli S, Yesil E, Tazeoglu D, Ozcan C, Ozcan IT, Dag A. Changes in cardiac functions in patients treated with parathyroidectomy for secondary hyperparathyroidism. Updates Surg 2024:10.1007/s13304-024-01812-8. [PMID: 38530609 DOI: 10.1007/s13304-024-01812-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/04/2024] [Indexed: 03/28/2024]
Abstract
Our study aims to investigate the changes in cardiac functions, especially myocardial performance index (MPI), in patients who underwent parathyroidectomy for secondary hyperparathyroidism. Patients who underwent parathyroidectomy for secondary hyperparathyroidism between June 2010 and September 2021 were analyzed retrospectively. The patients were divided into two groups: those who underwent total parathyroidectomy (group 1) and those who underwent subtotal parathyroidectomy (group 2). The groups were compared according to the echocardiogram findings performed in the preoperative period and the postoperative sixth month. In addition, cardiac structure, and systolic and diastolic functions, especially myocardial performance index, were evaluated by echocardiography and Doppler imaging. Thirty-seven patients were examined; 16 (43.2%) underwent total parathyroidectomy, and 21 (56.8%) had subtotal parathyroidectomy performed. Group 1's mean left ventricular end-systolic diameter (LVES) decreased from 2.53 ± 0.57 to 2.35 ± 0.37 cm after parathyroidectomy. In Group 1, the postoperative value of LVES and end-systolic volume decreased significantly compared to the preoperative period (p = 0.042, p = 0.008, respectively). EF increased from 59.25 ± 0.05 to 67.81 ± 4.04. In Group 1, EF and EV postoperatively increased significantly compared to the preoperative period (p = 0.023, p = 0.021, respectively). The mean MPI decreased from 0.45 ± 0.07 to 0.39 ± 0.04 after parathyroidectomy in group 1. In group 2, it decreased from 0.46 ± 0.06 to 0.40 ± 0.04 (p < 0.001). The present study provides an improvement in myocardial functions after parathyroidectomy. While LVES, EF, ejection volume, end-systolic volume, and MPI improved in both groups, the MPI improvement was more evident in the total parathyroidectomy group.
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Affiliation(s)
- Sami Benli
- Department of General Surgery, Division of Surgical Oncology, Mersin University Medical Faculty, Mersin, Turkey.
| | - Emrah Yesil
- Department of Cardiology, Mersin University Medical Faculty, Mersin, Turkey
| | - Deniz Tazeoglu
- Department of General Surgery, Division of Surgical Oncology, Mersin University Medical Faculty, Mersin, Turkey
| | - Cumhur Ozcan
- Department of General Surgery, Division of Endocrine Surgery, Mersin University Medical Faculty, Mersin, Turkey
| | | | - Ahmet Dag
- Department of General Surgery, Division of Endocrine Surgery, Mersin University Medical Faculty, Mersin, Turkey
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Noguchi T, Sakamoto A, Kakehi K, Matsuda S. New method of local adjuvant therapy with bicarbonate Ringer's solution for tumoral calcinosis: A case report. World J Orthop 2024; 15:302-309. [PMID: 38596192 PMCID: PMC10999962 DOI: 10.5312/wjo.v15.i3.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/06/2024] [Accepted: 01/24/2024] [Indexed: 03/15/2024] Open
Abstract
BACKGROUND Tumoral calcinosis is a condition characterized by deposits of calcium phosphate crystals in extra-articular soft tissues, occurring in hemodialysis patients. Calcium phosphate crystals are mainly composed of hydroxyapatite, which is highly infiltrative to tissues, thus making complete resection difficult. An adjuvant method to remove or resolve the residual crystals during the operation is necessary. CASE SUMMARY A bicarbonate Ringer's solution with bicarbonate ions (28 mEq/L) was used as the adjuvant. After resecting calcium phosphate deposits of tumoral calcinosis as much as possible, while filling with the solution, residual calcium phosphate deposits at the pseudocyst wall can be gently scraped by fingers or gauze in the operative field. A 49-year-old female undergoing hemodialysis for 15 years had swelling with calcium deposition for 2 years in the shoulders, bilateral hip joints, and the right foot. A shoulder lesion was resected, but the calcification remained and early re-deposition was observed. Considering the difficulty of a complete rection, we devised a bicarbonate dissolution method and excised the foot lesion. After resection of the calcified material, the residual calcified material was washed away with bicarbonate Ringer's solution. CONCLUSION The bicarbonate dissolution method is a new, simple, and effective treatment for tumoral calcinosis in hemodialysis patients.
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Affiliation(s)
- Takashi Noguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Akio Sakamoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Kensaku Kakehi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
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Carsote M, Nistor C. Forestalling Hungry Bone Syndrome after Parathyroidectomy in Patients with Primary and Renal Hyperparathyroidism. Diagnostics (Basel) 2023; 13:diagnostics13111953. [PMID: 37296804 DOI: 10.3390/diagnostics13111953] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
Hungry bone syndrome (HBS), severe hypocalcemia following parathyroidectomy (PTX) due to rapid drop of PTH (parathormone) after a previous long term elevated concentration in primary (PHPT) or renal hyperparathyroidism (RHPT), impairs the outcome of underlying parathyroid disease. OBJECTIVE overview HBS following PTx according to a dual perspective: pre- and post-operative outcome in PHPT and RHPT. This is a case- and study-based narrative review. INCLUSION CRITERIA key research words "hungry bone syndrome" and "parathyroidectomy"; PubMed access; in extenso articles; publication timeline from Inception to April 2023. EXCLUSION CRITERIA non-PTx-related HBS; hypoparathyroidism following PTx. We identified 120 original studies covering different levels of statistical evidence. We are not aware of a larger analysis on published cases concerning HBS (N = 14,349). PHPT: 14 studies (N = 1545 patients, maximum 425 participants per study), and 36 case reports (N = 37), a total of 1582 adults, aged between 20 and 72. Pediatric PHPT: 3 studies (N = 232, maximum of 182 participants per study), and 15 case reports (N = 19), a total of 251 patients, aged between 6 and 18. RHPT: 27 studies (N = 12,468 individuals, the largest cohort of 7171) and 25 case reports/series (N = 48), a total of 12,516 persons, aged between 23 and 74. HBS involves an early post-operatory (emergency) phase (EP) followed by a recovery phase (RP). EP is due to severe hypocalcemia with various clinical elements (<8.4 mg/dL) with non-low PTH (to be differentiated from hypoparathyroidism), starting with day 3 (1 to 7) with a 3-day duration (up to 30) requiring prompt intravenous calcium (Ca) intervention and vitamin D (VD) (mostly calcitriol) replacement. Hypophosphatemia and hypomagnesiemia may be found. RP: mildly/asymptomatic hypocalcemia controlled under oral Ca+VD for maximum 12 months (protracted HBS is up to 42 months). RHPT associates a higher risk of developing HBS as compared to PHPT. HBS prevalence varied from 15% to 25% up to 75-92% in RHPT, while in PHPT, mostly one out of five adults, respectively, one out of three children and teenagers might be affected (if any, depending on study). In PHPT, there were four clusters of HBS indicators. The first (mostly important) is represented by pre-operatory biochemistry and hormonal panel, especially, increased PTH and alkaline phosphatase (additional indicators were elevated blood urea nitrogen, and a high serum calcium). The second category is the clinical presentation: an older age for adults (yet, not all authors agree); particular skeleton involvement (level of case reports) such as brown tumors and osteitis fibrosa cystica; insufficient evidence for the patients with osteoporosis or those admitted for a parathyroid crisis. The third category involves parathyroid tumor features (increased weight and diameter; giant, atypical, carcinomas, some ectopic adenomas). The fourth category relates to the intra-operatory and early post-surgery management, meaning an associated thyroid surgery and, maybe, a prolonged PTx time (but this is still an open issue) increases the risk, as opposite to prompt recognition of HBS based on calcium (and PTH) assays and rapid intervention (specific interventional protocols are rather used in RHPT than in PHPT). Two important aspects are not clarified yet: the use of pre-operatory bisphosphonates and the role of 25-hydroxyitamin D assay as pointer of HBS. In RHPT, we mentioned three types of evidence. Firstly, risk factors for HBS with a solid level of statistical evidence: younger age at PTx, pre-operatory elevated bone alkaline phosphatase, and PTH, respectively, normal/low serum calcium. The second group includes active interventional (hospital-based) protocols that either reduce the rate or improve the severity of HBS, in addition to an adequate use of dialysis following PTx. The third category involves data with inconsistent evidence that might be the objective of future studies to a better understanding; for instance, longer pre-surgery dialysis duration, obesity, an elevated pre-operatory calcitonin, prior use of cinalcet, the co-presence of brown tumors, and osteitis fibrosa cystica as seen in PHPT. HBS remains a rare complication following PTx, yet extremely severe and with a certain level of predictability; thus, the importance of being adequately identified and managed. The pre-operatory spectrum of assessments is based on biochemistry and hormonal panel in addition to a specific (mostly severe) clinical presentation while the parathyroid tumor itself might provide useful insights as potential risk factors. Particularly in RHPT, prompt interventional protocols of electrolytes surveillance and replacement, despite not being yet a matter of a unified, HBS-specific guideline, prevent symptomatic hypocalcemia, reduce the hospitalization stay, and the re-admission rates.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy & C.I. Parhon National Institute of Endocrinology, Aviatorilor Ave. 34-38, Sector 1, 011863 Bucharest, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Carol Davila University of Medicine and Pharmacy & Thoracic Surgery Department, Dr. Carol Davila Central Emergency University Military Hospital, 050474 Bucharest, Romania
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Nasiri S, Meshkati Yazd SM, Heshmati A, Mokhtari Ardekani A, Najafi M, Shahriarirad R. Investigating the effectiveness of intraoperative rapid parathyroid hormone assay in parathyroidectomy surgery in patients with secondary hyperparathyroidism. BMC Endocr Disord 2023; 23:120. [PMID: 37231458 DOI: 10.1186/s12902-023-01378-3] [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: 03/01/2023] [Accepted: 05/21/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION The use of Rapid Intraoperative parathyroid hormone (Io-PTH) assay during surgery in the management of parathyroid tissue in cases of primary hyperparathyroidism has been proven to be effective, while its utilization in secondary hyperparathyroidism (SHPT) has been rarely reported. In the present study, we aim to demonstrate the application of rapid Io-PTH assay in patients with SHPT following chronic kidney disease undergoing parathyroidectomy surgery. METHOD In this prospective study, five blood samples were taken from patients undergoing parathyroidectomy and upper thymectomy. Among the samples, two were pre-excision, including prior to the first incision, after exploration, and before parathyroids resection. Two additional samples were taken 10 and 20 min after the excision of the parathyroid glands. Another sample was collected twenty-four hours after the operation. Serum Calcium levels and PTH levels were evaluated and analyzed. RESULTS We successfully managed SHPT in all 36 patients in our study. The patients included 24 males (66.7%) with a mean age of 49.97 ± 14.92. The mean PTH decreased significantly at 10 min, 20 min, one day, and six months after surgery (P < 0.001). The highest reduction occurred 10 min after removal of the parathyroid glands so the mean PTH compared to time zero was reduced from 1737 to 439, and in 100% of cases, more than 50% reduction was seen in PTH. CONCLUSION A 60% or more reduction in PTH Rapid at 10 min after parathyroidectomy has an accuracy of 94.4% and a positive predictive value of 100%. Thus, if the PTH level does not decrease by more than 60% at 10 min or more than 80% at 20 min, tissue exploration is continued with the aim of finding the ectopic parathyroid gland.
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Affiliation(s)
- Shirzad Nasiri
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Alireza Heshmati
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Abnoos Mokhtari Ardekani
- Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Science, & Physiology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Masoud Najafi
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Shahriarirad
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran.
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Huang Y, Wang J, Zeng M, Wan H, Wang N, Yang G. Predictive value of characteristics of resected parathyroid glands for persistent secondary hyperparathyroidism during parathyroidectomy. BMC Surg 2023; 23:36. [PMID: 36788539 PMCID: PMC9926574 DOI: 10.1186/s12893-023-01936-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Parathyroidectomy (PTX), an effective treatment for refractory secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD) patients, still has a high persistent rate. This study aimed to analyze the predictive value of characteristics of resected parathyroid glands for postoperative persistent SHPT. METHODS The clinical data of patients with persistent SHPT and successful PTX controls who had or underwent total parathyroidectomy with forearm autotransplantation (TPTX + AT) was retrospectively collected. The characteristics including the number, minimum weight, maximum weight and total weight of resected parathyroid glands from each patient were recorded. Characteristics and cutoff value of resected parathyroid glands for the prediction of persistent SHPT were analyzed. RESULTS A total of 227 patients (62 persistent SHPT patients and 165 successful PTX controls) were enrolled in the study. Forty-one (66%) persistent SHPT cases related to supernumerary parathyroid and the remaining 21 (34%) cases related to residual undetected parathyroid. In addition, ectopic parathyroid was found in 8 patients (13%) before PTX. The average number of resected glands in the persistent SHPT group and successful PTX group was 3.53 ± 0.72 and 3.93 ± 0.25 respectively (p < 0.001). There was significance in the number of patients with different resected parathyroid glands between two groups (p < 0.001). When the resected gland number was 4, minimum weight of the parathyroid was noted to be heavier in the persistent SHPT group than that in the successful PTX group (0.52 ± 0.31 g vs. 0.38 ± 0.19 g, p < 0.001). For persistent SHPT prediction, cutoff value of minimum weight was 0.535 g, with sensitivity of 46% and specificity of 82% (AUC = 0.611; p = 0.029). CONCLUSIONS Major reason for the persistent SHPT is the existence of supernumerary parathyroid glands or resection of less than 4 glands. When 4 glands were resected, a minimum total parathyroid gland weight heavier than 0.535 g implied the potential presence of a missed supernumerary parathyroid gland, which also contributed to the persistent SHPT.
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Affiliation(s)
- Yaoyu Huang
- grid.89957.3a0000 0000 9255 8984Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029 Jiangsu China
| | - Jing Wang
- grid.89957.3a0000 0000 9255 8984Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029 Jiangsu China
| | - Ming Zeng
- grid.89957.3a0000 0000 9255 8984Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029 Jiangsu China
| | - Huiting Wan
- grid.89957.3a0000 0000 9255 8984Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029 Jiangsu China
| | - Ningning Wang
- grid.89957.3a0000 0000 9255 8984Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029 Jiangsu China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China.
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[Evolution of the incidence and results at 12 months of parathyroidectomy: 40 years of experience in a dialysis center with two successive surgical departments]. Nephrol Ther 2022; 18:616-626. [PMID: 36328900 DOI: 10.1016/j.nephro.2022.07.400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 05/18/2022] [Accepted: 07/19/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Secondary hyperparathyroidism remains the main complication of mineral and bone metabolism in patients with chronic kidney disease. In case of resistance to medical treatment (native and active vitamin D, calcium and calcimimetics), surgical parathyroidectomy is indicated. The aim of this retrospective study is to show the evolution of the incidence and results of surgical parathyroidectomy in our center between 1980 and 2020 as patient characteristics, diagnostic and therapeutic strategies have changed. PATIENTS AND METHODS We collected data from dialysis patients who had a first surgical parathyroidectomy between 2000 and 2020 (period 2) in the same surgical department and compared them with historical data between 1980 and 1999 (period 1) operated in one other center. RESULTS In period 1, 53 surgical parathyroidectomy were performed (2.78/year, 0 to 5, 8.5/1000 patients-year) vs.56 surgical parathyroidectomy in period 2 (2.8/year, 0 to 9, 8/1000 patients-year). The patients of the 2 periods were comparable except for the higher dialysis vintage in period 1 (149±170 vs.89±94 months; P=0.02). In comparison with dialysis patients not requiring surgical parathyroidectomy during the same period, patients who had surgical parathyroidectomy were younger, had higher dialysis vintage and lower diabetes prevalence, but more frequently carriers of glomerulopathy or polycystosis. Systematically performed in period 2, cervical ultrasound identified at least one visible gland in 78.6% of cases while the scintigraphy, performed only in 66% of cases, found at least one gland in 81% of cases. Twelve months after surgery, PTH > 300 pg/mL (marker of secondary hyperparathyroidism recurrence or surgery failure) was present in 30% of patients in period 1 vs. 5.3% in period 2. Hypoparathyroidism was also more frequently observed in period 2 (35.7 vs. 18.8%). Surgical complications were also higher in period 1. CONCLUSION Despite therapeutic and strategic advances, severe secondary hyperparathyroidism is still as common as ever. It is favored by excessively high PTH targets, by suboptimal prevention before dialysis and poor tolerance of calcimimetics. The surgical parathyroidectomy is effective and safe in the hands of a specialized team with an ultrasound and scintigraphic preoperative assessment.
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Zhang X, Xu W, Huang T, Huang J, Zhang C, Zhang Y, Xie X, Xu M. The value of clinical-ultrasonographic feature model to predict the severity of secondary hyperparathyroidism. Ren Fail 2022; 44:146-154. [PMID: 35164637 PMCID: PMC8856024 DOI: 10.1080/0886022x.2022.2027784] [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
Objectives To analyze conventional ultrasound (CUS) and contrast-enhanced ultrasound (CEUS) features in patients with secondary hyperparathyroidism (SHPT) and to evaluate the clinical-ultrasonographic feature based model for predicting the severity of SHPT. Methods From February 2016 to March 2021, a total of 59 patients (age 51.3 ± 11.7 years, seCr 797.8 ± 431.7 μmol/L, iPTH 1535.1 ± 1063.9 ng/L) with SHPT (including 181 parathyroid glands (PTGs)) without the history of intact parathyroid hormone (iPTH)-reducing drugs using were enrolled. The patients were divided into the mild SHPT group (mSHPT, iPTH <800 ng/L) and the severe SHPT group (sSHPT, iPTH ≥ 800 ng/L) according to the serum iPTH level. The clinical test data of patients were collected and CUS and CEUS examinations were performed for every patient. Multivariable logistic regression model according to clinical-ultrasonographic features was adopted to establish a nomogram. We performed K-fold cross-validation on this nomogram model and nomogram performance was determined by its discrimination, calibration, and clinical usefulness. Results There were 19 patients in the mSHPT group and 40 patients in the sSHPT group. Multivariable logistic regression indicated serum calcium, serum phosphorus and total volume of PTGs were independent predictors related with serum iPTH level. Even though CEUS score of wash-in and wash-out were showed related to severity of SHPT in univariate logistic regression analysis, they were not predictors of SHPT severity (p = 0.539, 0.474 respectively). The nomogram developed by clinical and ultrasonographic features showed good calibration and discrimination. The accuracy and the area under the curve (AUC), positive predictive value (PPV), negative predictive value (NPV) and accuracy of this model were 0.888, 92.5%, 63.2% and 83.1%, respectively. When applied to internal validation, the score revealed good discrimination with stratified fivefold cross-validation in the cohort (mean AUC = 0.833). Conclusions The clinical-ultrasonographic features model has good performance for predicting the severity of SHPT.
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Affiliation(s)
- Xiaoer Zhang
- Department of Medical Ultrasonics, The First Affiliated Hospital, Institute of Diagnostic and Interventional Ultrasound, Sun Yat-Sen University, Guangzhou, China
| | - Wenxin Xu
- Department of Medical Ultrasonics, The First Affiliated Hospital, Institute of Diagnostic and Interventional Ultrasound, Sun Yat-Sen University, Guangzhou, China
| | - Tongyi Huang
- Department of Medical Ultrasonics, The First Affiliated Hospital, Institute of Diagnostic and Interventional Ultrasound, Sun Yat-Sen University, Guangzhou, China
| | - Jingzhi Huang
- Department of Medical Ultrasonics, The First Affiliated Hospital, Institute of Diagnostic and Interventional Ultrasound, Sun Yat-Sen University, Guangzhou, China
| | - Chunyang Zhang
- Department of Medical Ultrasonics, The First Affiliated Hospital, Institute of Diagnostic and Interventional Ultrasound, Sun Yat-Sen University, Guangzhou, China
| | - Yutong Zhang
- Department of Medical Ultrasonics, The First Affiliated Hospital, Institute of Diagnostic and Interventional Ultrasound, Sun Yat-Sen University, Guangzhou, China
| | - Xiaoyan Xie
- Department of Medical Ultrasonics, The First Affiliated Hospital, Institute of Diagnostic and Interventional Ultrasound, Sun Yat-Sen University, Guangzhou, China
| | - Ming Xu
- Department of Medical Ultrasonics, The First Affiliated Hospital, Institute of Diagnostic and Interventional Ultrasound, Sun Yat-Sen University, Guangzhou, China
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Ralston MR, Stevenson KS, Mark PB, Geddes CC. Clinical factors associated with severe hypophosphataemia after kidney transplant. BMC Nephrol 2021; 22:407. [PMID: 34886802 PMCID: PMC8656060 DOI: 10.1186/s12882-021-02624-3] [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] [Received: 05/08/2021] [Accepted: 11/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The mechanism by which hypophosphataemia develops following kidney transplantation remains debated, and limited research is available regarding risk factors. This study aimed to assess the association between recipient and donor variables, and the severity of post-transplantation hypophosphataemia. METHODS We performed a single-centre retrospective observational study. We assessed the association between demographic, clinical and biochemical variables and the development of hypophosphataemia. We used linear regression analysis to assess association between these variables and phosphate nadir. RESULTS 87.6% of patients developed hypophosphataemia. Patients developing hypophosphataemia were younger, had a shorter time on renal replacement therapy, were less likely to have had a parathyroidectomy or to experience delayed graft function, were more likely to have received a living donor transplant, from a younger donor. They had higher pre-transplantation calcium levels, and lower alkaline phosphatase levels. Receipt of a living donor transplant, lower donor age, not having had a parathyroidectomy, receiving a transplant during the era of tacrolimus-based immunosuppression, not having delayed graft function, higher pre-transplantation calcium, and higher pre-transplantation phosphate were associated with lower phosphate nadir by multiple linear regression. CONCLUSIONS This analysis demonstrates an association between variables relating to better graft function and hypophosphataemia. The links with biochemical measures of mineral-bone disease remain less clear.
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Affiliation(s)
- Maximilian R Ralston
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF, UK.
| | - Karen S Stevenson
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - Patrick B Mark
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Colin C Geddes
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF, UK
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Hatano M, Kitajima I, Yamamoto S, Nakamura M, Isawa K, Hirota Y, Hoshino J, Sawa N, Ubara Y. Case report: Osteomalacia due to bisphosphonate treatment in a patient on hemodialysis. BMC Nephrol 2021; 22:298. [PMID: 34479496 PMCID: PMC8414854 DOI: 10.1186/s12882-021-02509-5] [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] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 08/20/2021] [Indexed: 01/23/2023] Open
Abstract
Background No publications have reported on osteomalacia in patients receiving intermittent cyclical therapy with etidronate (a bisphosphonate) and undergoing long-term hemodialysis (HD). Case presentation We report on a 46-year-old Japanese man admitted to our hospital for further examination of left forearm pain. Maintenance HD was started at age 24 years, and the man had been on HD since then. At age 38 years, surgical parathyroidectomy was performed for secondary hyperparathyroidism; iliac crest bone biopsy performed at the same time showed osteitis fibrosa. The active vitamin D3 preparation calcitriol was started, and intermittent cyclical etidronate therapy was introduced 2 years later for osteoporosis. At age 45 years, the patient stopped taking calcitriol because of hypercalcemia but continued with etidronate. At age 46 years, a pseudofracture with a Looser zone occurred in the left ulna, and left femur bone biopsy revealed osteomalacia. Etidronate was discontinued, and calcitriol was restarted; open reduction and internal fixation with an angular stability plate were performed. Union of the bone was achieved 10 months after the operation. At age 49 years, a lumber bone biopsy confirmed improved bone morphometry. Conclusions We believe that intermittent cyclical etidronate therapy without administration of active vitamin D3 during long-term HD might have induced osteomalacia, resulting in the ulna insufficiency fracture. Therefore, we propose that administration of active vitamin D3 is essential to prevent osteomalacia in patients on long-term HD who are receiving bisphosphonates and have potential vitamin D3 deficiency.
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Affiliation(s)
- Masaki Hatano
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan.
| | - Izuru Kitajima
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Seizo Yamamoto
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Masaki Nakamura
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Kazuya Isawa
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Yutaka Hirota
- Department of Orthopaedic Surgery, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan
| | - Junichi Hoshino
- Department of Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan.,Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Naoki Sawa
- Department of Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan.,Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Yoshifumi Ubara
- Department of Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Tokyo, Kanagawa, 212-0015, Japan. .,Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan.
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10
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Chen H, Ren W, Gao Z, Zeng M, Tang S, Xu F, Huang Y, Zhang L, Cui Y, Yang G, Qian H, Zhou W, Ouyang C, Gao X, Zhang J, Xiao Y, Zhao B, Wang J, Bian A, Li F, Wan H, Gao W, Wang X, Xing C, Zha X, Wang N. Effects of parathyroidectomy on plasma PTH fragments and heart rate variability in stage 5 chronic kidney disease patients. Ren Fail 2021; 43:890-899. [PMID: 34044733 PMCID: PMC8168729 DOI: 10.1080/0886022x.2021.1931318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Circulating intact parathyroid hormone (iPTH) levels include full-length (1-84) PTH and long C-PTH fragments, but primarily (7-84) PTH, which have been reported to have antagonistic effects on the bones and kidneys. However, their effects on the cardiovascular system remain unclear. In this study, the relationships between the plasma PTH fragments levels and heart rate variability (HRV) in stage 5 chronic kidney disease (CKD5) patients are explored. Furthermore, the effects of parathyroidectomy (PTX) on the above indices are investigated. METHODS In this cross-sectional study, 164 healthy controls and 354 CKD5 patients, including 208 secondary hyperparathyroidism (SHPT) subgroup with PTX, were enrolled. Circulating (7-84) PTH levels were calculated by subtracting plasma (1-84) PTH levels from iPTH levels. The HRV parameters were measured using a 24-hour Holter. RESULTS The baseline levels of plasma iPTH, (1-84) PTH, and (7-84) PTH in the CKD5 patients were 930.40 (160.65, 1792.50) pg/mL, 448.60 (99.62, 850.45) pg/mL, and 468.20 (54.22, 922.55) pg/mL, respectively. In the CKD5 patients, plasma (1-84) PTH levels were independently correlated with the standard deviation of the normal-to-normal R-R intervals (SDNN) and the standard deviation of the five-minute average of the normal R-R intervals (SDANN). With a median follow up time of 6.50 months after PTX in the SHPT patients (n = 30), improved SDNN and SDANN markers were related with decreased (1-84) PTH levels. Furthermore, an improved SDNN was related with decreased (7-84) PTH levels. CONCLUSIONS The CKD5 patients' baseline (1-84) PTH levels were correlated with the SDNN and SDANN. After PTX, an improved SDNN was related with decreased (1-84) PTH and (7-84) PTH levels, while improved SDANN was related with decreased (1-84) PTH levels. No antagonistic effects of (1-84) PTH and (7-84) PTH on HRV were found in the CKD5 patients.
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Affiliation(s)
- Huimin Chen
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Department of Nephrology, Taizhou People's Hospital, Taizhou, China
| | - Wenkai Ren
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Zhanhui Gao
- Department of Nephrology, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Shaowen Tang
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Fangyan Xu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yaoyu Huang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Lina Zhang
- Department of Nephrology, Henan Provincial Key Laboratory of Kidney Disease and Immunology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Cui
- Department of Nephrology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Hanyang Qian
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Wenbin Zhou
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Chun Ouyang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Department of Nephrology, Liyang Branch, Jiangsu Province Hospital, Liyang People's Hospital, Liyang, China
| | - Xueyan Gao
- Department of General Medicine, Geriatric Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yujie Xiao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Baiqiao Zhao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Jing Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Anning Bian
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Fan Li
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Huiting Wan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Wei Gao
- National Health Commission Key Laboratory of Antibody Techniques, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, China
| | - Xiaoyun Wang
- Department of Nephrology, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Xiaoming Zha
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
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Rodríguez-Ortiz ME, Rodríguez M. Recent advances in understanding and managing secondary hyperparathyroidism in chronic kidney disease. F1000Res 2020; 9:F1000 Faculty Rev-1077. [PMID: 32913635 PMCID: PMC7463297 DOI: 10.12688/f1000research.22636.1] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2020] [Indexed: 12/31/2022] Open
Abstract
Secondary hyperparathyroidism is a complex pathology that develops as chronic kidney disease progresses. The retention of phosphorus and the reductions in calcium and vitamin D levels stimulate the synthesis and secretion of parathyroid hormone as well as the proliferation rate of parathyroid cells. Parathyroid growth is initially diffuse but it becomes nodular as the disease progresses, making the gland less susceptible to be inhibited. Although the mechanisms underlying the pathophysiology of secondary hyperparathyroidism are well known, new evidence has shed light on unknown aspects of the deregulation of parathyroid function. Secondary hyperparathyroidism is an important feature of chronic kidney disease-mineral and bone disorder and plays an important role in the development of bone disease and vascular calcification. Thus, part of the management of chronic kidney disease relies on maintaining acceptable levels of mineral metabolism parameters in an attempt to slow down or prevent the development of secondary hyperparathyroidism. Here, we will also review the latest evidence regarding several aspects of the clinical and surgical management of secondary hyperparathyroidism.
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Affiliation(s)
- María E. Rodríguez-Ortiz
- Maimónides Institute for Biomedical Research (IMIBIC), Avda. Menéndez Pidal, S/N. 14004 Córdoba, Spain
- University of Córdoba, Avda. Medina Azahara, 5. 14071 Córdoba, Spain
- University Hospital Reina Sofía, Avda. Menéndez Pidal, S/N. 14004 Córdoba, Spain
- Spanish Renal Research Network (REDinREN), Carlos III Health Institute, Madrid, Spain
| | - Mariano Rodríguez
- Maimónides Institute for Biomedical Research (IMIBIC), Avda. Menéndez Pidal, S/N. 14004 Córdoba, Spain
- University of Córdoba, Avda. Medina Azahara, 5. 14071 Córdoba, Spain
- Spanish Renal Research Network (REDinREN), Carlos III Health Institute, Madrid, Spain
- Nephrology Clinical Management Unit, University Hospital Reina Sofía, Avda. Menéndez Pidal, S/N. 14004 Córdoba, Spain
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12
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Naveh-Many T, Volovelsky O. Parathyroid Cell Proliferation in Secondary Hyperparathyroidism of Chronic Kidney Disease. Int J Mol Sci 2020; 21:ijms21124332. [PMID: 32570711 PMCID: PMC7352987 DOI: 10.3390/ijms21124332] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/14/2020] [Accepted: 06/15/2020] [Indexed: 12/12/2022] Open
Abstract
Secondary hyperparathyroidism (SHP) is a common complication of chronic kidney disease (CKD) that correlates with morbidity and mortality in uremic patients. It is characterized by high serum parathyroid hormone (PTH) levels and impaired bone and mineral metabolism. The main mechanisms underlying SHP are increased PTH biosynthesis and secretion as well as increased glandular mass. The mechanisms leading to parathyroid cell proliferation in SHP are not fully understood. Reduced expressions of the receptors for calcium and vitamin D contribute to the disinhibition of parathyroid cell proliferation. Activation of transforming growth factor-α-epidermal growth factor receptor (TGF-α-EGFR), nuclear factor kappa B (NF-kB), and cyclooxygenase 2- prostaglandin E2 (Cox2-PGE2) signaling all correlate with parathyroid cell proliferation, underlining their roles in the development of SHP. In addition, the mammalian target of rapamycin (mTOR) pathway is activated in parathyroid glands of experimental SHP rats. Inhibition of mTOR by rapamycin prevents and corrects the increased parathyroid cell proliferation of SHP. Mice with parathyroid-specific deletion of all miRNAs have a muted increase in serum PTH and fail to increase parathyroid cell proliferation when challenged by CKD, suggesting that miRNA is also necessary for the development of SHP. This review summarizes the current knowledge on the mechanisms of parathyroid cell proliferation in SHP.
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Affiliation(s)
- Tally Naveh-Many
- Minerva Center for Calcium and Bone Metabolism, Nephrology Services, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel;
- The Wohl Institute for Translational Medicine, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel
| | - Oded Volovelsky
- The Wohl Institute for Translational Medicine, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel
- Pediatric Nephrology Unit and Research Lab, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel
- Correspondence: ; Tel.: +972-26777213
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13
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Fatal Hypocalcaemia Due to Hungry Bone Syndrome with Secondary Refractory HyperParathyroidism after Parathyroidectomy: A Case Report. J Crit Care Med (Targu Mures) 2019; 5:140-144. [PMID: 31915720 PMCID: PMC6942454 DOI: 10.2478/jccm-2019-0021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 09/09/2019] [Indexed: 11/21/2022] Open
Abstract
Abstract
Introduction
Hungry bone syndrome (HBS) refers to the rapid, profound, and prolonged hypocalcaemia associated with hypophosphatemia and hypomagnesaemia, and is exacerbated by suppressed parathyroid hormone (PTH) levels, which follows parathyroidectomy in patients with severe primary hyperparathyroidism (PHPT) and preoperative high bone turnover. [1]
Case report
This report concerns a dialysed patient who underwent surgical treatment for secondary refractory hyperparathyroidism. Haemodialysis was carried out pre-operatively, and subsequently, a total parathyroidectomy with auto-transplantation of parathyroid tissue in the sternocleidomastoid muscle (SCM) was performed. Rapid and progressive hypocalcaemia symptoms developed during the second day postoperatively. Acute cardiac symptoms with tachyarrhythmia, haemodynamic instability and finally asystole occurred, which required cardiopulmonary resuscitation (CPR). The ionic calcium level was 2.2 mg/dL being consistent with a diagnosis of HBS. A second cardiac arrest unresponsive to CPR followed an initial period of normal sinus rhythm. Death ensued shortly after. Before death, the ionic calcium was 3.1 mg/dL.
Conclusion
HBS, after parathyroidectomy in patients with secondary hyperparathyroidism (SHPT), may be severe, prolonged and sometimes fatal. Generally, HBS symptomatology is that of a mild hypocalcaemia. It can, however, include heart rhythm disturbances with haemodynamic alterations requiring intensive care measurements and even cardiopulmonary resuscitation. A close clinical and laboratory post-parathyroidectomy monitoring of dialysed patients is of the utmost importance.
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