1
|
Petrović M, Brković V, Baralić M, Marić I, Petković N, Stanković S, Lalić N, Stanisavljević D, Đukanović L, Ležaić V. Comparative Analysis of Vascular Calcification Risk Factors in Pre-Hemodialysis and Prevalent Hemodialysis Adult Patients: Insights into Calcification Biomarker Associations and Implications for Intervention Strategies in Chronic Kidney Disease. Diagnostics (Basel) 2024; 14:824. [PMID: 38667470 PMCID: PMC11049133 DOI: 10.3390/diagnostics14080824] [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: 02/11/2024] [Revised: 04/06/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
This retrospective study aimed to compare risk factors for vascular calcification (VC) between pre-hemodialysis (HD) and prevalent HD adult patients while investigating associations with calcification biomarkers. Baseline data from 30 pre-HD and 85 HD patients were analyzed, including iPTH, vitamin D, FGF 23, fetuin-A, sclerostin, and VC scores (Adragao method). Prevalence of VC was similar in both groups, but HD patients had more frequent VC scores ≥ 6. Pre-HD patients were older, with higher prevalence of hypertension and less frequent use of calcium phosphate binders. Both groups showed similar patterns of hyperphosphatemia, low vitamin D, and iPTH. Fetuin-A and sclerostin levels were higher in pre-HD, while FGF 23 was elevated in HD patients. Higher VC risk in pre-HD patients was associated with male gender, older age, lower fetuin-A and higher sclerostin, lower ferritin, and no vitamin D treatment, while in HD patients with higher sclerostin, FGF 23 and urea, and lower iPTH. Conclusion: Biomarkers could be measurable indicators of biological processes underlying VC in CKD patients that may serve as a potential guide for considering personalized therapeutic approaches. Further studies are needed to elucidate the underlying pathways.
Collapse
Affiliation(s)
- Marko Petrović
- Department of Nephrology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.P.); (M.B.)
| | - Voin Brković
- Department of Nephrology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.P.); (M.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia (L.Đ.)
| | - Marko Baralić
- Department of Nephrology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.P.); (M.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia (L.Đ.)
| | - Ivko Marić
- Special Hospital for Internal Diseases, 11550 Lazarevac, Serbia
| | - Nenad Petković
- Fresenius Medical Care Dialysis Center, 76230 Šamac, Bosnia and Herzegovina
| | - Sanja Stanković
- Centre for Medical Biochemistry, University Clinical Centre of Serbia, 11000 Belgrade, Serbia;
- Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Nataša Lalić
- Uromedica Polyclinic Belgrade, 11000 Belgrade, Serbia
| | | | - Ljubica Đukanović
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia (L.Đ.)
| | - Višnja Ležaić
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia (L.Đ.)
| |
Collapse
|
2
|
Nitta K, Bieber B, Karaboyas A, Johnson DW, Kanjanabuch T, Kim YL, Lambie M, Hartman J, Shen JI, Naljayan M, Pecoits-Filho R, Robinson BM, Pisoni RL, Perl J, Kawanishi H. International variations in serum PTH and calcium levels and their mortality associations in peritoneal dialysis patients: Results from PDOPPS. Perit Dial Int 2024:8968608241235516. [PMID: 38501163 DOI: 10.1177/08968608241235516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Mineral bone disorder (MBD) in chronic kidney disease (CKD) is associated with high symptom burden, fractures, vascular calcification, cardiovascular disease and increased morbidity and mortality. CKD-MBD studies have been limited in peritoneal dialysis (PD) patients. Here, we describe calcium and parathyroid hormone (PTH) control, related treatments and mortality associations in PD patients. METHODS We used data from eight countries (Australia and New Zealand (A/NZ), Canada, Japan, Thailand, South Korea, United Kingdom, United States (US)) participating in the prospective cohort Peritoneal Dialysis Outcomes and Practice Patterns Study (2014-2022) among patients receiving PD for >3 months. We analysed the association of baseline PTH and albumin-adjusted calcium (calciumAlb) with all-cause mortality using Cox regression, adjusted for potential confounders, including serum phosphorus and alkaline phosphatase. RESULTS Mean age ranged from 54.6 years in South Korea to 63.5 years in Japan. PTH and serum calciumAlb were measured at baseline in 12,642 and 14,244 patients, respectively. Median PTH ranged from 161 (Japan) to 363 pg/mL (US); mean calciumAlb ranged from 9.1 (South Korea, US) to 9.8 mg/dL (A/NZ). The PTH/mortality relationship was U-shaped, with the lowest risk at PTH 300-599 pg/mL. Mortality was nearly 20% higher at serum calciumAlb 9.6+ mg/dL versus 8.4-<9.6 mg/dL. MBD therapy prescriptions varied substantially across countries. CONCLUSIONS A large proportion of PD patients in this multi-national study have calcium and/or PTH levels in ranges associated with substantially higher mortality. These observations point to the need to substantially improve MBD management in PD to optimise patient outcomes. LAY SUMMARY Chronic kidney disease-mineral bone disorder (MBD) is a systemic condition, common in dialysis patients, that results in abnormalities in parathyroid hormone (PTH), calcium, phosphorus and vitamin D metabolism. A large proportion of peritoneal dialysis (PD) patients in this current multi-national study had calcium and/or PTH levels in ranges associated with substantially higher risks of death. Our observational study design limits our ability to determine whether these abnormal calcium and PTH levels cause more death due to possible confounding that was not accounted for in our analysis. However, our findings, along with other recent work showing 48-75% higher risk of death for the one-third of PD patients having high phosphorus levels (>5.5 mg/dL), should raise strong concerns for a greater focus on improving MBD management in PD patients.
Collapse
Affiliation(s)
- Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Shinjuku, Japan
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - David W Johnson
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Department of Kidney and Transplant Services, Princess Alexandra, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine and Center of Excellence in Kidney Metabolic Disorders and Dialysis Policy & Practice Program (DiP3), School of Global Health, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yong-Lim Kim
- School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Mark Lambie
- Medicine and Health Sciences, Keele University, Keele, UK
| | | | - Jenny I Shen
- The Lundquist Institute at Harbor-University of California, Los Angeles Medical Center, Torrance, CA, USA
| | | | | | - Bruce M Robinson
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital and the Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Hideki Kawanishi
- Akane Foundation, Tsuchiya General Hospital, Nakaku, Hiroshima, Japan
| |
Collapse
|
3
|
Lalayiannis AD, Soeiro EMD, Moysés RMA, Shroff R. Chronic kidney disease mineral bone disorder in childhood and young adulthood: a 'growing' understanding. Pediatr Nephrol 2024; 39:723-739. [PMID: 37624528 PMCID: PMC10817832 DOI: 10.1007/s00467-023-06109-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/06/2023] [Accepted: 07/19/2023] [Indexed: 08/26/2023]
Abstract
Chronic kidney disease (CKD) mineral and bone disorder (MBD) comprises a triad of biochemical abnormalities (of calcium, phosphate, parathyroid hormone and vitamin D), bone abnormalities (turnover, mineralization and growth) and extra-skeletal calcification. Mineral dysregulation leads to bone demineralization causing bone pain and an increased fracture risk compared to healthy peers. Vascular calcification, with hydroxyapatite deposition in the vessel wall, is a part of the CKD-MBD spectrum and, in turn, leads to vascular stiffness, left ventricular hypertrophy and a very high cardiovascular mortality risk. While the growing bone requires calcium, excess calcium can deposit in the vessels, such that the intake of calcium, calcium- containing medications and high calcium dialysate need to be carefully regulated. Normal physiological bone mineralization continues into the third decade of life, many years beyond the rapid growth in childhood and adolescence, implying that skeletal calcium requirements are much higher in younger people compared to the elderly. Much of the research into the link between bone (de)mineralization and vascular calcification in CKD has been performed in older adults and these data must not be extrapolated to children or younger adults. In this article, we explore the physiological changes in bone turnover and mineralization in children and young adults, the pathophysiology of mineral bone disease in CKD and a potential link between bone demineralization and vascular calcification.
Collapse
Affiliation(s)
- Alexander D Lalayiannis
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK.
| | | | - Rosa M A Moysés
- Sao Paulo University Faculty of Medicine, Universidade de Sao Paulo Faculdade de Medicina, São Paulo, Brazil
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| |
Collapse
|
4
|
Gong L, Liu X, Yang Q, Jiang W, Liu X, Li X, Xu W. Full thermal ablation versus partial thermal ablation for secondary hyperparathyroidism: A meta-analysis. Medicine (Baltimore) 2023; 102:e36422. [PMID: 38050273 PMCID: PMC10695584 DOI: 10.1097/md.0000000000036422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/10/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Regarding the thermal ablation treatment of refractory secondary hyperparathyroidism (SHPT), there is no consensus on the ablation range of the hyperplastic parathyroid gland. Therefore, this meta-analysis was conducted to evaluate the efficacy and complications between full and partial thermal ablation in patients with refractory SHPT. METHODS Databases including PubMed, EMbase, the Cochrane Library, CNKI (China National Knowledge Infrastructure), and Wanfang databases were searched from inception to July 1, 2023. Eligible studies comparing full thermal ablation and partial thermal ablation for SHPT were included. Data were analyzed using Review Manager Version 5.3. RESULTS Four studies were included in the meta-analysis. Three cohort studies and one randomized controlled trial involving 62 patients in the full thermal ablation group and 63 patients in the partial thermal ablation group were included. The serum parathyroid hormone (PTH), calcium, and phosphorus levels after full ablation were all lower than those after partial ablation (P < .05). There was no significant difference between the partial and full ablation groups concerning the incidence rate of severe hypocalcemia (P = .09). There was no significant difference between the partial and full ablation groups concerning symptom improvement, including bone joint pain, itching, and myasthenia (P < .05). CONCLUSION Full ablation was superior to partial ablation in terms of reducing PTH, calcium and phosphorus levels. Full ablation might not significantly increase the incidence of severe hypocalcemia. Larger multicentre randomized controlled trials are necessary to confirm the conclusion.
Collapse
Affiliation(s)
- Lifeng Gong
- Department of Nephrology and Urology, Wujin Hospital Affiliated with Jiangsu University, Changzhou, China
- Department of Nephrology and Urology, The Wujin Clinical College of Xuzhou Medical University, Changzhou, China
| | - Xiaowu Liu
- Department of Nephrology and Urology, Wujin Hospital Affiliated with Jiangsu University, Changzhou, China
- Department of Nephrology and Urology, The Wujin Clinical College of Xuzhou Medical University, Changzhou, China
| | - Qichao Yang
- Department of Endocrinology, Wujin Hospital Affiliated with Jiangsu University, Changzhou, China
- Department of Endocrinology, The Wujin Clinical College of Xuzhou Medical University, Changzhou, China
| | - Wei Jiang
- Department of Nephrology and Urology, Wujin Hospital Affiliated with Jiangsu University, Changzhou, China
- Department of Nephrology and Urology, The Wujin Clinical College of Xuzhou Medical University, Changzhou, China
- Department of Nephrology, People’s Hospital of Hainan Tibetan Autonomous Prefecture, Hainan Tibetan Autonomous Prefecture, Qinghai, China
| | - Xiaoming Liu
- Department of Nephrology, People’s Hospital of Hainan Tibetan Autonomous Prefecture, Hainan Tibetan Autonomous Prefecture, Qinghai, China
| | - Xianping Li
- Department of Nephrology, People’s Hospital of Hainan Tibetan Autonomous Prefecture, Hainan Tibetan Autonomous Prefecture, Qinghai, China
| | - Wei Xu
- Department of Nephrology and Urology, Wujin Hospital Affiliated with Jiangsu University, Changzhou, China
- Department of Nephrology and Urology, The Wujin Clinical College of Xuzhou Medical University, Changzhou, China
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Gobbi L, Innico G, Spagnolo P, Vertolli U, Calò LA. Massive lung calcifications in a four times renal transplanted patient: the fight against dialysis, hyper and hypoparathyroidism. Minerva Endocrinol (Torino) 2023; 48:122-124. [PMID: 34748295 DOI: 10.23736/s2724-6507.21.03612-5] [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: 11/08/2022]
Affiliation(s)
- Laura Gobbi
- Unit of Nephrology, Dialysis and Transplantation, Department of Medicine, University of Padua, Padua, Italy
| | - Georgie Innico
- Unit of Nephrology, Dialysis and Transplantation, Department of Medicine, University of Padua, Padua, Italy
| | - Paolo Spagnolo
- Unit of Respiratory Disease, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Ugo Vertolli
- Unit of Nephrology, Dialysis and Transplantation, Department of Medicine, University of Padua, Padua, Italy
| | - Lorenzo A Calò
- Unit of Nephrology, Dialysis and Transplantation, Department of Medicine, University of Padua, Padua, Italy -
| |
Collapse
|
7
|
Oruc M, Mercan S, Bakan S, Kose S, Ikitimur B, Trabulus S, Altiparmak MR. Do trace elements play a role in coronary artery calcification in hemodialysis patients? Int Urol Nephrol 2023; 55:173-182. [PMID: 35854190 DOI: 10.1007/s11255-022-03303-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 07/07/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Abnormalities of trace elements have previously been linked to inflammatory processes in hemodialysis (HD) patients. We aimed to establish the trace element status of maintenance HD patients, to investigate the relationship between coronary artery calcification scores (CACs) and whole blood levels of trace elements. METHODS Patients undergoing HD in three times a week for > 6 months and age-and sex-matched controls were included from October 2015 to June 2016. Data were collected from patient files. All subjects' whole blood levels of trace elements were measured by Inductively Coupled Plasma Mass Spectrometry (ICP-MS). CACs for patients were assessed by multi-detector computed tomography. RESULTS The 35 patients (male, 60%) with a mean age of 45.7 ± 10.4 years and 35 controls were included. HD patients showed significantly lower levels of selenium and uranium and higher cadmium (Cd), cobalt, lithium, manganese, nickel, lead, platinum, tin, strontium, and thallium levels compared to controls. Coronary artery calcification (CAC) was present in 21 patients (60%), and median CACs were 14.2 (IQR 0-149). Patients with CACs > median were significantly older, had a higher prevalence of hypertension and lower ALP levels than patients with CACs ≤ median. No significant differences in whole blood levels of trace elements were found between patients with CACs > median and patients with CACs ≤ median. A near significance was noted in median whole blood levels of Cd between these groups (P = 0.096). According to multivariate analysis, age was the only independent determinant for CAC development. CONCLUSION Age is independently associated with coronary vascular calcification. High Cd levels might play a role in CAC development in HD patients.
Collapse
Affiliation(s)
- Meric Oruc
- Department of Nephrology, Kartal Dr Lutfi Kirdar City Hospital, 34865, Istanbul, Turkey.
| | - Selda Mercan
- Department of Science, Institute of Forensic Sciences and Legal Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Selim Bakan
- Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sennur Kose
- Department of Nephrology, Istanbul Education and Research Hospital, Istanbul, Turkey
| | - Baris Ikitimur
- Department of Cardiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sinan Trabulus
- Department of Nephrology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mehmet Riza Altiparmak
- Department of Nephrology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| |
Collapse
|
8
|
Nagy E, Sobh MM, Abdalbary M, Elnagar S, Elrefaey R, Shabaka S, Elshabrawy N, Shemies R, Tawfik M, Santos CGS, Barreto FC, El-Husseini A. Is Adynamic Bone Always a Disease? Lessons from Patients with Chronic Kidney Disease. J Clin Med 2022; 11:jcm11237130. [PMID: 36498703 PMCID: PMC9736225 DOI: 10.3390/jcm11237130] [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: 11/10/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022] Open
Abstract
Renal osteodystrophy (ROD) is a common complication of end-stage kidney disease that often starts early with loss of kidney function, and it is considered an integral part in management of patients with chronic kidney disease (CKD). Adynamic bone (ADB) is characterized by suppressed bone formation, low cellularity, and thin osteoid seams. There is accumulating evidence supporting increasing prevalence of ADB, particularly in early CKD. Contemporarily, it is not very clear whether it represents a true disease, an adaptive mechanism to prevent bone resorption, or just a transitional stage. Several co-players are incriminated in its pathogenesis, such as age, diabetes mellitus, malnutrition, uremic milieu, and iatrogenic factors. In the present review, we will discuss the up-to-date knowledge of the ADB and focus on its impact on bone health, fracture risk, vascular calcification, and long-term survival. Moreover, we will emphasize the proper preventive and management strategies of ADB that are pivotal issues in managing patients with CKD. It is still unclear whether ADB is always a pathologic condition or whether it can represent an adaptive process to suppress bone resorption and further bone loss. In this article, we tried to discuss this hard topic based on the available limited information in patients with CKD. More studies are needed to be able to clearly address this frequent ROD finding.
Collapse
Affiliation(s)
- Eman Nagy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mahmoud M. Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Sherouk Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Rabab Elrefaey
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Shimaa Shabaka
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Nehal Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Rasha Shemies
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mona Tawfik
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Cássia Gomes S. Santos
- Department of Internal Medicine, Division of Nephrology, Federal University of Paraná, Curitiba 80060-00, PR, Brazil
| | - Fellype C. Barreto
- Department of Internal Medicine, Division of Nephrology, Federal University of Paraná, Curitiba 80060-00, PR, Brazil
| | - Amr El-Husseini
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40536-0298, USA
- Correspondence: ; Tel.: +1-859-218-0934; Fax: +1-859-323-0232
| |
Collapse
|
9
|
The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg 2022; 276:e141-e176. [PMID: 35848728 DOI: 10.1097/sla.0000000000005522] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.
Collapse
|
10
|
Rocha LAD, Neves MCD, Montenegro FLDM. Parathyroidectomy in chronic kidney disease. J Bras Nefrol 2021; 43:669-673. [PMID: 34910804 PMCID: PMC8823920 DOI: 10.1590/2175-8239-jbn-2021-s112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 06/04/2021] [Indexed: 12/03/2022] Open
Affiliation(s)
| | - Murilo Catafesta das Neves
- Universidade Federal de São Paulo, Head and Neck Surgery Discipline, Otorhinolaryngology and Head & Neck Surgery Department, São Paulo, SP, Brazil
| | - Fabio Luiz de Menezes Montenegro
- Universidade de São Paulo, Faculdade de Medicina, Central Institute of Hospital das Clínicas, Head and Neck Surgery Division, São Paulo, SP, Brazil
| |
Collapse
|
11
|
El-Husseini A, Sobh M, Elshabrawy N, Abdalbary M. Antiresorptives in patients with chronic kidney disease with adynamic bone: Is absence of evidence of harm equal to no harm? Kidney Int 2021; 100:1341-1342. [PMID: 34802559 DOI: 10.1016/j.kint.2021.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 01/15/2023]
Affiliation(s)
- Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA.
| | - Mahmoud Sobh
- Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - Nehal Elshabrawy
- Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - Mohamed Abdalbary
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA; Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| |
Collapse
|
12
|
Habas E, Eledrisi M, Khan F, Elzouki ANY. Secondary Hyperparathyroidism in Chronic Kidney Disease: Pathophysiology and Management. Cureus 2021; 13:e16388. [PMID: 34408941 PMCID: PMC8362860 DOI: 10.7759/cureus.16388] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 12/25/2022] Open
Abstract
Serum calcium concentration is the main determinant of parathyroid hormone (PTH) release. Defect in the activation of vitamin D in the kidneys due to chronic kidney disease (CKD) leads to hypocalcemia and hyperphosphatemia, resulting in a compensatory increase in parathyroid gland cellularity and parathyroid hormone production and causing secondary hyperparathyroidism (SHP). Correction and maintenance of normal serum calcium and phosphate are essential to preventing SHP, hungry bone disease, cardiovascular events, and anemia development. Understanding the pathophysiology of PTH and possible therapeutic agents can reduce the development and associated complications of SHP in patients with CKD. Medical interventions to control serum calcium, phosphate, and PTH such as vitamin D analogs, calcium receptor blockers, and parathyroidectomy are needed in some CKD patients. In this review, we discuss the pathophysiology, clinical presentation, and management of SHP in CKD patients.
Collapse
Affiliation(s)
| | | | - Fahmi Khan
- Internal Medicine, Hamad General Hospital, Doha, QAT
| | | |
Collapse
|
13
|
Lu XH, Li MS, Li YY, Zheng YD, Wu XY, Gao P. The Association between Changes in Low Parathyroid Hormone Levels and Cardiac Function Decline in Maintenance Hemodialysis Patients: A Prospective Observational Study. Med Princ Pract 2021; 30:550-556. [PMID: 34348325 PMCID: PMC8740217 DOI: 10.1159/000518791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 07/23/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The aim of this study was to investigate a possible association between changes in low parathyroid hormone (PTH) levels and cardiac function decline in maintenance hemodialysis (MHD) patients. METHODS A total of 150 MHD patients were included and followed for 24 months. The enrolled patients were divided into 3 groups based on their PTH status at baseline and 24 months. Factors potentially involved in changes in the PTH level and cardiac function were compared using multivariate logistic regression analysis. RESULTS At 24 months, the presence of low PTH levels increased by 26.7%. The main independent factors for low PTH levels were a low BMI, hemoglobin, and serum albumin and high serum calcium (p < 0.05). A persistently low PTH level at 24 months was associated with a decrease in the left ventricular ejection fraction (LVEF) and increase in valvular calcification (p < 0.05). Additionally, a decrease in PTH levels from normal or high to low values was associated with a decrease in LVEF and cardiac output (CO) and an increase in valvular calcification (p < 0.05). Furthermore, compared with those of the persistently low PTH level group, LVEF values were lower at 24 months in the group with a decrease from high/normal to low PTH level (p < 0.05). CONCLUSION Persistently low PTH levels and changes in the PTH level from high/normal to low were associated with cardiac function decline in MHD patients. Moreover, a PTH level change from high/normal to low showed a stronger correlation with cardiac function decline.
Collapse
Affiliation(s)
- Xiao-han Lu
- Department of Nephrology, Zhong Nan Hospital of Wuhan University, Wuhan, China
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Meng-si Li
- Department of Nephrology, Zhong Nan Hospital of Wuhan University, Wuhan, China
| | - Yao-yao Li
- Department of Nephrology, Zhong Nan Hospital of Wuhan University, Wuhan, China
| | - Yan-dan Zheng
- Department of Nephrology, Zhong Nan Hospital of Wuhan University, Wuhan, China
| | - Xiao-yan Wu
- Department of Nephrology, Zhong Nan Hospital of Wuhan University, Wuhan, China
| | - Ping Gao
- Department of Nephrology, Zhong Nan Hospital of Wuhan University, Wuhan, China
- *Ping Gao,
| |
Collapse
|
14
|
Gueiros APS, de Oliveira RA, Carvalho AB. Adynamic bone disease. J Bras Nefrol 2021; 43:650-653. [PMID: 34910800 PMCID: PMC8823915 DOI: 10.1590/2175-8239-jbn-2021-s108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/14/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
| | | | - Aluizio Barbosa Carvalho
- Universidade Federal de São Paulo, Department of Medicine, Nephrology Division, São Paulo, SP, Brazil
| |
Collapse
|
15
|
Kakani E, Elyamny M, Ayach T, El‐Husseini A. Pathogenesis and management of vascular calcification in CKD and dialysis patients. Semin Dial 2019; 32:553-561. [DOI: 10.1111/sdi.12840] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Elijah Kakani
- Division of Hospital Medicine University of Kentucky Lexington KY USA
| | - Mohamed Elyamny
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
| | - Taha Ayach
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
| | - Amr El‐Husseini
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
| |
Collapse
|
16
|
Kakani E, Sloan D, Sawaya BP, El-Husseini A, Malluche HH, Rao M. Long-term outcomes and management considerations after parathyroidectomy in the dialysis patient. Semin Dial 2019; 32:541-552. [PMID: 31313380 DOI: 10.1111/sdi.12833] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Parathyroidectomy (PTX) remains an important intervention for dialysis patients with poorly controlled secondary hyperparathyroidism (SHPT), though there are only retrospective and observational data that show a mortality benefit to this procedure. Potential consequences that we seek to avoid after PTX include persistent or recurrent hyperparathyroidism, and parathyroid insufficiency. There is considerable subjectivity in defining and diagnosing these conditions, given that we poorly understand the optimal PTH targets (particularly post PTX) needed to maintain bone and vascular health. While lowering PTH after PTX decreases bone turnover, long-term changes in bone activity have been poorly explored. High turnover bone disease, usually present at the time a PTX is considered, often swings to a state of low turnover in the setting of sufficiently low PTH levels. It remains unclear if all low bone turnover equate with disease. However, such changes in bone turnover appear to predispose to vascular calcification, with positive calcium balance after PTX being a potential contributor. We know little of how the post-PTX state resets calcium balance, how calcium and VDRA requirements change or what kind of adjustments are needed to avoid calcium loading. The current consensus cautions against excessive reduction of PTH although there is insufficient evidence-based guidance regarding the management of chronic kidney disease - mineral bone disease (CKD-MBD) parameters in the post-PTX state. This article aims to compile existing research, provide an overview of current practice with regard to PTX and post-PTX chronic management. It highlights gaps and controversies and aims to re-orient the focus to clinically relevant contemporary priorities in CKD-MBD management after PTX.
Collapse
Affiliation(s)
- Elijah Kakani
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - David Sloan
- Division of Endocrine Surgery, University of Kentucky, Lexington, KY, USA
| | - B Peter Sawaya
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Hartmut H Malluche
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Madhumathi Rao
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| |
Collapse
|
17
|
Chandran M, Wong J. Secondary and Tertiary Hyperparathyroidism in Chronic Kidney Disease: An Endocrine and Renal Perspective. Indian J Endocrinol Metab 2019; 23:391-399. [PMID: 31741895 PMCID: PMC6844175 DOI: 10.4103/ijem.ijem_292_19] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Secondary Hyperparathyroidism (SHP) seen as a frequent complication in Chronic Kidney Disease (CKD) has many pathogenetic peculiarities that are still incompletely defined and understood. During the long course of chronic renal failure, SHP can also transform sometimes into the hypercalcemic state characterized by quasi-autonomous production of Parathyroid Hormone from the parathyroid glands: a disorder that is termed Tertiary Hyperparathyroidism. The clinical consequences of SHP in CKD are protean, encompassing bone and mineral abnormalities but as recently identified, also several metabolic and cardiovascular problems, the most important of which is vascular calcification. There have been several advances in the therapeutic armamentarium available for the treatment of SHP, though clear demonstration of a benefit regarding major clinical outcomes with any of the new agents is still lacking. This narrative review summarizes the current understanding about this disorder and highlights some of the recent research on the subject.
Collapse
Affiliation(s)
- Manju Chandran
- Department of Endocrinology, Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, Singapore
| | - Jiunn Wong
- Department of Renal Medicine, Singapore General Hospital, Singapore
| |
Collapse
|
18
|
Pires GO, Vieira IO, Hernandes FR, Teixeira AL, Oliveira IB, Dominguez WV, Dos Reis LM, Montenegro FM, Moysés RM, Carvalho AB, Jorgetti V. Effects of parathyroidectomy on the biology of bone tissue in patients with chronic kidney disease and secondary hyperparathyroidism. Bone 2019; 121:277-283. [PMID: 30738215 DOI: 10.1016/j.bone.2019.01.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 01/10/2019] [Accepted: 01/31/2019] [Indexed: 12/11/2022]
Abstract
Secondary hyperparathyroidism is a complication of chronic kidney disease that compromises skeletal integrity. In patients with secondary hyperparathyroidism undergoing parathyroidectomy, parathyroid hormone levels dramatically decrease. The effects of parathyroidectomy on bone tissue are poorly understood, especially regarding the proteins expressed by osteocytes, such as fibroblast growth factor 23, dentin matrix protein 1, matrix extracellular phosphoglycoprotein, sclerostin, receptor activator of nuclear factor kappa B ligand (RANKL) and osteoprotegerin, which regulate bone turnover. The objective of this study was to characterize the bone expression of these proteins by immunohistochemistry and correlate these results with those of bone histomorphometry before and after parathyroidectomy. We studied bone biopsies that were obtained from 23 patients before and 12 months after parathyroidectomy. We observed an improvement in bone microarchitecture, but impaired mineralization after parathyroidectomy. We found significant increases in sclerostin and osteoprotegerin expression and a decrease in the RANKL/osteoprotegerin ratio after parathyroidectomy, suggesting that their expression is regulated by parathormone. These proteins correlated with structural and bone formation parameters. We conclude that after parathyroidectomy, significant changes occur in the bone expression of osteocyte proteins and that these proteins potentially regulate bone remodeling.
Collapse
Affiliation(s)
- Geovanna O Pires
- LIM 16 - Laboratorio de Fisiopatologia Renal, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Itamar O Vieira
- LIM 16 - Laboratorio de Fisiopatologia Renal, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Fabiana R Hernandes
- Divisao de Nefrologia, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
| | - Andre L Teixeira
- LIM 16 - Laboratorio de Fisiopatologia Renal, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Ivone B Oliveira
- Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Wagner V Dominguez
- LIM 16 - Laboratorio de Fisiopatologia Renal, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Luciene M Dos Reis
- LIM 16 - Laboratorio de Fisiopatologia Renal, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Fábio M Montenegro
- Departamento de Cirurgia, Hospital das Clinicas, HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, Brazil
| | - Rosa M Moysés
- LIM 16 - Laboratorio de Fisiopatologia Renal, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil; Programa de Pos-Graduaçao em Medicina, Universidade Nove de Julho (UNINOVE), Sao Paulo, SP, Brazil
| | - Aluizio B Carvalho
- Divisao de Nefrologia, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
| | - Vanda Jorgetti
- LIM 16 - Laboratorio de Fisiopatologia Renal, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil; Hospital Samaritano Americas Serviços Medicos, Sao Paulo, SP, Brazil.
| |
Collapse
|
19
|
Dual Roles of the Mineral Metabolism Disorders Biomarkers in Prevalent Hemodilysis Patients: In Renal Bone Disease and in Vascular Calcification. J Med Biochem 2019; 38:134-144. [PMID: 30867641 PMCID: PMC6411002 DOI: 10.2478/jomb-2018-0026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 06/16/2018] [Indexed: 12/21/2022] Open
Abstract
Background Vascular calcification (VC) is highly prevalent in dialysis (HD) patients, and its mechanism is multifactorial. Most likely that systemic or local inhibitory factor is overwhelmed by promoters of VC in these patients. VC increased arterial stiffness, and left ventricular hypertrophy. Thus, the present study aimed to investigate the association of VC and myocardial remodeling and to analyze their relationship with VC promoters (fibroblast growth factor 23-FGF23, Klotho, intact parathormon-iPTH, vitamin D) in 56 prevalent HD patients (median values: age 54 yrs, HD vintage 82 months). Methods Besides routine laboratory analyzes, serum levels of FGF 23, soluble Klotho, iPTH, 1,25-dihydroxyvitamin D3; pulse wave velocity (PWV); left ventricular (LV) mass by ultrasound; and VCs score by Adragao method were measured. Results VC was found in 60% and LV concentric or eccentric hypertrophy in 50% patients. Dialysis vintage (OR 1.025, 95%CI 1.007–1.044, p=0.006) FGF23 (OR 1.006, 95% CI 0.992–1.012, p=0.029) and serum magnesium (OR 0.000, 95%CI 0.000–0.214, p=0.04) were associated with VC. Changes in myocardial geometry was associated with male sex (beta=-0.273, 95% CI -23.967 1.513, p=0.027), iPTH (beta 0.029, 95%CI -0.059–0.001, p=0.027) and vitamin D treatment (beta 25.49, 95%CI 11.325–39.667, p=0.001). Also, patients with the more widespread VC had the highest LV remodeling categories. PWV was associated patient’s age, cholesterol, diastolic blood pressure, LV mass (positively) and serum calcium (negatively), indicating potential link with atherosclerotic risk. Conclusions Despite to different risk factors for VC and myocardial remodeling, obtained results could indicate that risk factors intertwine in long-term treatment of HD patients and therefore careful and continuous correction of mineral metabolism disorders is undoubtedly of the utmost importance.
Collapse
|
20
|
Hou YC, Lu CL, Lu KC. Mineral bone disorders in chronic kidney disease. Nephrology (Carlton) 2019; 23 Suppl 4:88-94. [PMID: 30298663 DOI: 10.1111/nep.13457] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2018] [Indexed: 12/11/2022]
Abstract
As the GFR loss aggravates, the disturbed mineral metabolism worsens the bone microstructure and remodelling - scenario, which is known as CKD-mineral bone disease (MBD). CKD-MBD is characterized by : (i) abnormal metabolism of calcium, phosphorus, parathyroid hormone (PTH), or vitamin D; (ii) abnormalities in bone turnover, mineralization, volume linear growth or strength; (iii) soft-tissue calcifications, either vascular or extra-osseous. Uremic vascular calcification and osteoporosis are the most common complications related to CKD-MBD. Disregulated bone turnover by uremic toxin or secondary hyperparathyroidism disturbed bone mineralization and makes it difficult for calcium and inorganic phosphate to enter into bone, resulting in increased serum calcium and inorganic phosphate. Vascular calcification worsens by hyperphosphatemia and systemic inflammation. Since vitamin D deficiency plays an important role in renal osteodystrophy, supplement of nutritional vitamin D is important in treating uremic osteoporosis and vascular calcification at the same time. Its pleotropic effect improves the bone remodeling initiated by osteoblast and alleviates the risk factors for vascular calcification with less hypercalcemia than vitamin D receptor analogs. Therefore, nutritional vitamin D should be considered in managing CKDMBD.
Collapse
Affiliation(s)
- Yi-Chou Hou
- Department of Internal Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Chien-Lin Lu
- Department of Medicine, Fu-Jen Catholic University Hospital, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Kuo-Cheng Lu
- Department of Medicine, Fu-Jen Catholic University Hospital, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| |
Collapse
|
21
|
Isaksson E, Ivarsson K, Akaberi S, Muth A, Prütz KG, Clyne N, Sterner G, Almquist M. Total versus subtotal parathyroidectomy for secondary hyperparathyroidism. Surgery 2018; 165:142-150. [PMID: 30413319 DOI: 10.1016/j.surg.2018.04.076] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/06/2018] [Accepted: 04/15/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND It remains unclear whether total or subtotal parathyroidectomy for secondary hyperparathyroidism yields the best outcomes. We investigated mortality, cardiovascular events, hip fracture, and recurrent parathyroidectomy after total versus subtotal parathyroidectomy in patients on renal replacement therapy. METHODS Using the Swedish Renal Registry, the surgical registry for thyroid and parathyroid surgery, and the National Inpatient Registry, we identified patients who underwent parathyroidectomy between 1991 and 2013. We calculated the risk of outcome after total versus subtotal parathyroidectomy using COX's regression, adjusting for age, sex, cause of renal disease, time with a functioning graft before and after parathyroidectomy, Charlson comorbidity index, year of surgery, prevalent cardiovascular disease, time on dialysis, renal transplantation at parathyroidectomy, and treatment with calcimimetics before parathyroidectomy. RESULTS There were 824 patients who underwent parathyroidectomy, 388 total and 436 subtotal. There was no difference in mortality or risk of incident hip fracture between groups. Comparing the subtotal with the total parathyroidectomy, the adjusted hazard ratio (95% confidence interval) for cardiovascular events was 0.43 (0.25-0.72) and for recurrent parathyroidectomy 3.33 (1.33-8.32). CONCLUSION There was a higher risk of cardiovascular events in patients after total parathyroidectomy compared with subtotal parathyroidectomy, but a lower risk of recurrent parathyroidectomy.
Collapse
Affiliation(s)
- Elin Isaksson
- Lund University, Faculty of Medicine, Department of Clinical Sciences, Nephrology, Malmö, Sweden
| | - Kerstin Ivarsson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
| | - Shahriar Akaberi
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
| | - Andreas Muth
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Karl-Göran Prütz
- Director, Swedish Renal Registry, Helsingborg Hospital, Department of Internal Medicine, Helsingborg, Sweden
| | - Naomi Clyne
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
| | - Gunnar Sterner
- Lund University, Faculty of Medicine, Department of Clinical Sciences, Nephrology, Malmö, Sweden
| | - Martin Almquist
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden.
| |
Collapse
|
22
|
Ureña-Torres PA, Vervloet M, Mazzaferro S, Oury F, Brandenburg V, Bover J, Cavalier E, Cohen-Solal M, Covic A, Drüeke TB, Hindié E, Evenepoel P, Frazão J, Goldsmith D, Kazama JJ, Cozzolino M, Massy ZA. Novel insights into parathyroid hormone: report of The Parathyroid Day in Chronic Kidney Disease. Clin Kidney J 2018; 12:269-280. [PMID: 30976408 PMCID: PMC6452197 DOI: 10.1093/ckj/sfy061] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease (CKD) is often associated with a mineral and bone disorder globally described as CKD-Mineral and Bone Disease (MBD), including renal osteodystrophy, the latter ranging from high bone turnover, as in case of secondary hyperparathyroidism (SHPT), to low bone turnover. The present article summarizes the important subjects that were covered during ‘The Parathyroid Day in Chronic Kidney Disease’ CME course organized in Paris in September 2017. It includes the latest insights on parathyroid gland growth, parathyroid hormone (PTH) synthesis, secretion and regulation by the calcium-sensing receptor, vitamin D receptor and fibroblast growth factor 23 (FGF23)–Klotho axis, as well as on parathyroid glands imaging. The skeletal action of PTH in early CKD stages to the steadily increasing activation of the often downregulated PTH receptor type 1 has been critically reviewed, emphasizing that therapeutic strategies to decrease PTH levels at these stages might not be recommended. The effects of PTH on the central nervous system, in particular cognitive functions, and on the cardiovascular system are revised, and the reliability and exchangeability of second- and third-generation PTH immunoassays discussed. The article also reviews the different circulating biomarkers used for the diagnosis and monitoring of CKD-MBD, including PTH and alkaline phosphatases isoforms. Moreover, it presents an update on the control of SHPT by vitamin D compounds, old and new calcimimetics, and parathyroidectomy. Finally, it covers the latest insights on the persistence and de novo occurrence of SHPT in renal transplant recipients.
Collapse
Affiliation(s)
- Pablo A Ureña-Torres
- Ramsay-Générale de Santé, Clinique du Landy, Department of Nephrology and Dialysis and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Marc Vervloet
- Department of Nephrology and Amsterdam Cardiovascular Sciences (ACS), VU University Medical Center, Amsterdam, The Netherlands
| | - Sandro Mazzaferro
- Department of Cardiovascular Respiratory Nephrologic Anaesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Franck Oury
- INEM, Centre de Mdecine Moléculaire Faculté de Médecine Paris Descartes, Sorbonne, Paris Cité Bâtiment Leriche, France
| | - Vincent Brandenburg
- Department of Cardiology, University Hospital RWTH Aachen, Pauwelsstraße, Aachen, Germany
| | - Jordi Bover
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350 Barcelona, Spain
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU Sart-Tilman, Liège, Belgium
| | - Martine Cohen-Solal
- INSERM U1132 & USPC Paris-Diderot, Department of Rheumatology, Hôpital Lariboisière, Paris, France
| | - Adrian Covic
- Department of Nephrology, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Romania
| | - Tilman B Drüeke
- Inserm Unit 1018, CESP, Team 5, Paul Brousse Hospital, Villejuif/Paris, France
| | - Elif Hindié
- Nuclear Medicine, University of Bordeaux, Haut-Lévêque Hospital, Pessac, France
| | - Pieter Evenepoel
- Department of Medicine, Division of Nephrology, University Hospital Leuven, Leuven, Belgium.,Dienst nefrologie, Universitair Ziekenhuis Gasthuisberg, Herestraat, Leuven, Belgium
| | - João Frazão
- Institute of Investigation and Innovation in Health, University of Porto, Porto, Portugal.,INEB-National Institute of Biomedical Engineer, University of Porto, Porto, Portugal.,Department of Nephrology, São João Hospital Center, Porto, Portugal.,School of Medicine of University of Porto, Porto, Portugal
| | | | - Junichiro James Kazama
- Department of Nephrology and Hypertension, Fukushima Medical University, 1 Hikarigaoka, Fukushima 960-1247, Japan
| | - Mario Cozzolino
- Renal Division, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré University Medical Center, APHP, University of Paris Ouest (UVSQ), Boulogne Billancourt/Paris, France
| | | |
Collapse
|
23
|
Ruderman I, Holt SG, Hewitson TD, Smith ER, Toussaint ND. Current and potential therapeutic strategies for the management of vascular calcification in patients with chronic kidney disease including those on dialysis. Semin Dial 2018; 31:487-499. [PMID: 29733462 DOI: 10.1111/sdi.12710] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with CKD have accelerated vascular stiffening contributing significantly to excess cardiovascular morbidity and mortality. Much of the arterial stiffening is thought to involve vascular calcification (VC), but the pathogenesis of this phenomenon is complex, resulting from a disruption of the balance between promoters and inhibitors of calcification in a uremic milieu, along with derangements in calcium and phosphate metabolic pathways. Management of traditional cardiovascular risk factors to reduce VC may be influential but has not been shown to significantly improve mortality. Control of mineral metabolism may potentially reduce the burden of VC, although using conventional approaches of restricting dietary phosphate, administering phosphate binders, and use of active vitamin D and calcimimetics, remains controversial because recommended biochemical targets are hard to achieve and clinical relevance hard to define. Increasing time on dialysis is perhaps another therapy with potential effectiveness in this area. Despite current treatments, cardiovascular morbidity and mortality remain high in this group. Novel therapies for addressing VC include magnesium and vitamin K supplementation, which are currently being investigated in large randomized control trials. Other therapeutic targets include crystallization inhibitors, ligand trap for activin receptors and BMP-7. This review summarizes current treatment strategies and therapeutic targets for the future management of VC in patients with CKD.
Collapse
Affiliation(s)
- Irene Ruderman
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Tim D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| |
Collapse
|
24
|
Fülöp T, Koch CA, Farah Musa AR, Clark CM, Gharaibeh KA, Lengvársky Z, Hamrahian M, Pitman KT, Dixit MP. Targeted surgical parathyroidectomy in end-stage renal disease patients and long-term metabolic control: A single-center experience in the current era. Hemodial Int 2018; 22:394-404. [PMID: 29446565 DOI: 10.1111/hdi.12639] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The long-term results of surgical parathyroidectomy (PTX) in end-stage renal disease (ESRD) patients are less well known in the modern era of newer activated vitamin-D analogs, calcimimetics and intraoperative monitoring of parathyroid hormone (PTH). METHODS We performed a retrospective chart review of all ESRD patients undergoing PTX at the University of Mississippi Medical Center between January 2005 and August 2011, with follow-up data as available up to 4 years. All PTXs were performed with intraoperative second-generation PTH monitoring and targeted gland size reduction. RESULTS The cohort (N = 37) was relatively young with a mean (±SD) age of 48.4 ± 13.9. 94.6% of the subjects were African American and 59.5% female. Preoperatively, 45.9% received cinacalcet (CNC) at a mean dose of 63.5 ± 20.9 mg. The size of the largest removed glands measured 1.7 ± 0.8 cm and almost all (94.6%) glands had hyperplasia on histology. The mean length of inpatient stay was 5.5 ± 2.4 days. Preoperative calcium/phosphorus measured 9.6 ± 1.2/6.6 ± 1.7 mg/dL with PTH concentrations of 1589 ± 827 pg/mL. Postoperative PTH values measured 145.4 ± 119.2 pg/mL. Preoperative PTH strongly correlated (P < 0.0001) with both alkaline phosphatase (ALP) levels (r: 0.596) and the number of inpatient days (r: 0.545), but not with CNC administration. Independent predictors for the duration of hospitalization were preoperative ALP (beta 0.469; P = 0.001) and age (beta -0.401; P = 0.005) (R2 0.45); for postoperative hypocalcemia, age (beta: -0.321; P = 0.006) and preoperative PTH (beta: 0.431; P = 0.036) were significant in linear regression models with stepwise selection. CONCLUSION Gland-sparing PTX achieved acceptable control of ESRD-associated hyperparathyroidism in most patients from a socioeconomically challenged, underserved population of the United States.
Collapse
Affiliation(s)
- Tibor Fülöp
- Division of Nephrology, Diabetes and Metabolism, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Christian A Koch
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA.,G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi, USA.,Cancer Institute, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Abdeen R Farah Musa
- Division of Nephrology, Diabetes and Metabolism, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Christopher M Clark
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Kamel A Gharaibeh
- Division of Nephrology, Diabetes and Metabolism, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Zsolt Lengvársky
- Department of Mathematics, Louisiana State University Shreveport, Shreveport, Louisiana, USA
| | | | - Karen T Pitman
- Johns Hopkins Department of Otolaryngology, Milton J. Dance Jr. Head and Neck Center, Baltimore, Maryland, USA
| | - Mehul P Dixit
- Division of Pediatric Nephrology, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| |
Collapse
|
25
|
El-Husseini A, Wang K, Edon A, Saxon D, Lima F, Sloan D, Sawaya BP. Value of Intraoperative Parathyroid Hormone Assay during Parathyroidectomy in Dialysis and Renal Transplant Patients with Secondary and Tertiary Hyperparathyroidism. Nephron Clin Pract 2017; 138:119-128. [PMID: 29131092 DOI: 10.1159/000482016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/05/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In dialysis and renal transplant patients with secondary and tertiary hyperparathyroidism (HPT), the value of intraoperative parathyroid hormone (ioPTH) during parathyroidectomy (PTX) and its association with long-term PTH levels are unknown. The present study aims at evaluating the relationship of ioPTH with long-term PTH levels post-PTX in dialysis and renal transplant patients in a single-center study. METHODS The ioPTH was measured in 57 dialysis patients (33 females and 24 males) and 18 renal transplant recipients (12 males and 6 females) who underwent PTX from 2005 to 2015 for refractory HPT. Near-total PTX was performed in 56 patients and total PTX with autotransplantation in 20 patients. The PTH monitoring included 3 samples: pre-intubation, 10- and 20-min (pre-ioPTH, 10-ioPTH, and 20-ioPTH) post parathyroid gland excision. Patients were followed up for up to 5 years. RESULTS In the dialysis group, the median (25th-75th percentile) pre-, 10-, and 20-ioPTH levels were 1,447 pg/mL (938-2,176), 143 pg/mL (78-244) and 112 pg/mL (59-153) respectively. In the renal transplant group, pre-, 10-, and 20-ioPTH levels were 273 pg/mL (180-403), 42 pg/mL (25-72), and 34 pg/mL (23-45) respectively. All patients in the transplant group had a functional kidney transplant at the time of PTX with a median serum creatinine of 1.3 mg/dL (1.2-1.7) and estimated glomerular filtration rate of 55 mL/min (40-60). The median time between renal transplant and PTX surgeries was 22 months (7-81). The last median follow-up PTH level was 66 pg/mL (15-201) in the dialysis group and 54 pg/mL (17-72) in the transplant group (p = 0.438). The mean time for last PTH post-PTX was 2.3 ± 2.0 years. In both groups, there was no significant difference between 20-ioPTH and any-time post-PTX PTH levels (p = 0.6 and p = 0.9). Nineteen patients (25%) were readmitted within 90 days because of hypocalcemia. One patient in the dialysis group was readmitted for post-PTX hematoma evacuation. No patient required repeat PTX because of recurrent HPT that was refractory to medical therapy. Only one dialysis patient required repeat PTX because the first procedure failed. CONCLUSIONS The 20-ioPTH is a good indicator of long-term PTH levels in dialysis and renal transplant patients. Hypocalcemia is a common complication, particularly in dialysis patients, and it is the main reason for readmission after PTX. Hypoparathyroidism is a potential concern after PTX in dialysis patients.
Collapse
Affiliation(s)
- Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA.,Division of Nephrology, Mansoura University, Mansoura, Egypt
| | - Kevin Wang
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Annick Edon
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - David Saxon
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Florence Lima
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - David Sloan
- Section of Endocrine Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - B Peter Sawaya
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| |
Collapse
|
26
|
El-Husseini A, Wang K, Edon AA, Sawaya BP. Parathyroidectomy-A last resort for hyperparathyroidism in dialysis patients. Semin Dial 2017; 30:385-389. [DOI: 10.1111/sdi.12632] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism; University of Kentucky; Lexington KY USA
- Division of Nephrology; Mansoura University; Mansoura Egypt
| | - Kevin Wang
- Division of Nephrology, Bone and Mineral Metabolism; University of Kentucky; Lexington KY USA
| | - Adeleye Annick Edon
- Division of Nephrology, Bone and Mineral Metabolism; University of Kentucky; Lexington KY USA
| | - B. Peter Sawaya
- Division of Nephrology, Bone and Mineral Metabolism; University of Kentucky; Lexington KY USA
| |
Collapse
|