Structural prerequisites for the hypotensive action of parathyroid hormone

Long-term renal graft outcome after parathyroidectomy - a retrospective single centre study

BACKGROUND

Surgical correction of hyperparathyroidism after kidney transplantation has been associated with significant graft function decline. We examined the effects of parathyroidectomy on short- and long-term graft function and its potential predictors.

METHODS

For this retrospective, monocentric study we identified 48 (5.5%) out of 892 patients from our protocol biopsy program who received renal transplantation between 2000 and 2007, with parathyroidectomy after transplantation. Data from up to three years after parathyroidectomy was collected and analyzed with multivariable linear regression analyses.

RESULTS

Main indications for parathyroidectomy were hypercalcemia and graft calcifications. Parathyroidectomy was successful in 47 patients, with a median drop in serum intact parathormone (iPTH) from 394 to 21 pg/ml. Mean estimated glomerular fitration rate (eGFR) before parathyroidectomy was 60 ± 26 ml/min. At three months after parathyroidectomy, the eGFR was 46 ± 18 ml/min (p < 0.001) but remained stable at one and three years (50 ± 20; 49 ± 20 ml/min). The median annual eGFR change was - 0.5 ml/min before and + 1.0 ml/min after parathyroidectomy. Multivariable modeling identified high iPTH levels and higher eGFR before parathyroidectomy as predictors of the eGFR drop after parathyroidectomy. Lower graft function twelve months after parathyroidectomy was predicted by the eGFR before and the iPTH drop after surgery.

CONCLUSIONS

These results indicate that the extent of parathyroidectomy is critical and too much lowering of iPTH should be avoided by timely parathyroidectomy, before reaching extreme high iPTH values. In view of the observed loss of eGFR, parathyroidectomy can be considered safe in patients with an eGFR above 30 ml/min.

Full normalization of severe hypertension after parathryoidectomy - a case report and systematic review

Background

Although the relationship between hyperparathyroidism and hypertension has been described for decades, the role of hyperparathyroidism in hypertension in dialysis is still unclear. Following the case of a severely hypertensive dialysis patient, in which parathyroidectomy (PTX) corrected the metabolic imbalance and normalized blood pressure (BP), we tried to contextualize our observation with a systematic review of the recent literature on the effect of PTX on BP.

Case presentation

A dialysis patient, aged 19 years at the time of this report, with chronic kidney disease (CKD) from childhood; he was an early-preterm baby with very low birth weight (910 g), and is affected by a so-far unidentified familial nephropathy. He started dialysis in emergency at the age of 17. Except for low-dose Bisoprolol, he refused all chronic medication; hypertension (165–200/90–130 mmHg) did not respond to attainment of dry weight (Kt/V > 1.7; BNP 70–200 pg/ml pre-dialysis). He underwent subtotal PTX 1 year after dialysis start; after PTX, his blood pressure stabilized in the 100–140/50–80 range, and is normal without treatment 5 months later.

Conclusion

Our patient has some peculiar features: he is young, has a non-immunologic disease, poor compliance to drug therapy, excellent dialysis efficiency. His lack of compliance allows observing the effect of PTX on BP without pharmacologic interference.

The prompt, complete and long-lasting BP normalization led us to systematic review the current literature (Pubmed, Embase, Cochrane Collaboration 2000–2016) retrieving 8 case series (194 cases), and one case report (3 patients).

The meta-analysis showed a significant, albeit moderate, improvement in BP after PTX (difference: systolic BP -8.49 (CI 2.21–14.58) mmHg; diastolic BP -4.14 (CI 1.45–6.84) mmHg); analysis is not fully conclusive due to lack of information on anti-hypertensive agents. The 3 cases reported displayed a sharp reduction in BP after PTX.

In summary, PTX may have a positive influence on BP control, and may result in complete correction or even hypotension in some patients. The potential clinical relevance of this relationship warrants prospective large-scale studies.

Structural requirements for parathyroid hormone action in mature bone. Effects on release of cyclic adenosine monophosphate and bone gamma-carboxyglutamic acid-containing protein from perfused rat hindquarters

To determine the structural requirements for parathyroid hormone (PTH) activity in mature bone, we perfused the surgically isolated hindquarters of adult male rats with either native bovine PTH-(1-84) [bPTH-(1-84)] or the synthetic amino-terminal fragment, bovine PTH-(1-34) [bPTH-(1-34)]. Changes in the release of cyclic AMP (cAMP) and bone Gla protein (BGP) were monitored as evidence of bone-specific response to PTH; tissue specificity of the cAMP response was confirmed through in vitro examination on nonskeletal tissue response to PTH. Biologically active, monoiodinated 125I-bPTH-(1-84) was administered to determine if mature murine bone cleaves native hormone. We found that perfused rat bone continuously releases BGP, and that both bPTH-(1-84) and bPTH-(1-34) acutely suppress this release. In addition, both hormones stimulate cAMP release from perfused rat hindquarters. When examined on a molar basis, the magnitude of the cAMP response was dose-dependent and similar for both hormones, with doses yielding half-maximal cAMP responses. The response for bPTH-(1-34) was 0.5 nmol and for bPTH-(1-84) was 0.7 nmol. Moreover, biologically active 125I-bPTH-(1-84) was not metabolized in our hindquarter perfusion system. These findings indicate that PTH-(1-84) does not require extraskeletal or skeletal cleavage to an amino-terminal fragment in order to stimulate cAMP generation in, or suppress BGP release from, mature rat bone.