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Gao D, Liu Y, Cui W, Lu X, Lou Y. A nomogram prediction model for hungry bone syndrome in dialysis patients with secondary hyperparathyroidism after total parathyroidectomy. Eur J Med Res 2024; 29:208. [PMID: 38549160 PMCID: PMC10976803 DOI: 10.1186/s40001-024-01801-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/18/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVE Secondary hyperparathyroidism (SHPT) is a common complication of chronic kidney disease (CKD). Hungry bone syndrome (HBS) after parathyroidectomy (PTX) is a serious complication, which can lead to diarrhea, convulsion, arrhythmia and even death. This study was aimed to determine the risk factors for HBS after PTX in dialysis patients with SHPT and construct a nomogram prediction model to predict the incidence of postoperative complications. METHODS Clinical data were collected from 80 maintenance hemodialysis (MHD) patients with SHPT who received total PTX in the Second Hospital of Jilin University from January 2018 to September 2021. In line with the inclusion and exclusion criteria, totally 75 patients were finally enrolled for analysis. Patients were divided into two groups for retrospective analysis according to the severity of postoperative HBS, including HBS group and non-HBS (N-HBS) group. Univariate and multivariate logistic regression analyses were conducted to determine the risk factors for postoperative HBS. Afterwards, the receiver operating characteristic (ROC) curves were plotted based on the statistical analysis results, aiming to compare the prediction effects of different predicting factors. Finally, the nomogram was established to evaluate the occurrence probability of postoperative complications predicted by the risk factors. RESULTS Among the 75 patients, 32 had HBS (HBS group), while 43 did not have HBS (N-HBS group). Univariate analysis results indicated that, the preoperative intact parathyroid hormone (iPTH) and serum alkaline phosphatase (ALP) levels in HBS group were significantly higher than those in N-HBS group, while preoperative hemoglobin and preoperative albumin (Alb) levels were significantly lower than those in N-HBS group. As discovered by multivariate logistic regression analysis, preoperative iPTH (OR = 1.111, P = 0.029) and ALP (OR = 1.010, P < 0.001) were the independent risk factors for postoperative HBS. ROC curve analysis suggested that the area under the curve (AUC) values of these two indicators were 0.873 and 0.926, respectively (P < 0.0001). Subsequently, the nomogram model for predicting HBS was constructed. The model verification results indicated that the predicted values were basically consistent with the measured values, with the C-index of 0.943 (95% CI 0.892-0.994). Besides, the calibration curve was consistent with the ideal curve, demonstrating the favorable accuracy and discrimination of the model. CONCLUSIONS Preoperative iPTH and preoperative ALP are the risk factors for postoperative HBS, which can be used to guide the early clinical intervention.
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Affiliation(s)
- Dan Gao
- Department of Nephrology, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin, China
| | - Yali Liu
- Department of Nephrology, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin, China
| | - Wenpeng Cui
- Department of Nephrology, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin, China
| | - Xuehong Lu
- Department of Nephrology, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin, China
| | - Yan Lou
- Department of Nephrology, The Second Hospital of Jilin University, 218 Ziqiang Street, Changchun, 130041, Jilin, China.
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Yajima A, Tsuchiya K, Kuro-O M, Urena P, Tominaga Y, Okada M, Ichimori T, Tomosugi T, Hiramitsu T, Murata T, Nakamura M, Sasaki M, Ito A, Nitta K. Renal hyperparathyroidism. Vitam Horm 2022; 120:305-343. [PMID: 35953115 DOI: 10.1016/bs.vh.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The number of the patients with chronic kidney disease is now increasing in the world. The pathophysiology of renal hyperparathyroidism is closely associated with Klotho-FGF-endocrine axes, which must be solved definitively as early as possible. It was revealed that the expression of fgf23 is activated by calciprotein particles, which induces vascular ossification. And it is well known that phosphorus overload directly increases parathyroid hormone and hyperparathyroid bone disease develops in those subjects. On the other hand, low turnover bone disease is often recently. Both the patients with chronic kidney disease suffering from hyperparathyroid bone disease or low turnover bone disease are associated with increased fracture risk. Micropetrosis may be one of the causes of increased fracture risk in the subjects with low turnover bone disease. In this chapter, we now describe the diagnosis, pathophysiology and treatments of renal hyperparathyroidism.
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Affiliation(s)
- Aiji Yajima
- Department of Anatomy, Cell Biology and Physiology, Indiana University, School of Medicine, Indianapolis, IN, United States; Department of Urology, Tokyo, Teishin Hospital, Tokyo, Japan; Department Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan.
| | - Ken Tsuchiya
- Department Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Makoto Kuro-O
- Division of Anti-aging Medicine, Center for Molecular Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Pablo Urena
- Division of Nephrology, Clinique du Landy, Saint Ouen, France
| | - Yoshihiro Tominaga
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Manabu Okada
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Toshihiro Ichimori
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Toshihide Tomosugi
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Taro Murata
- Department of Urology, Tokyo, Teishin Hospital, Tokyo, Japan
| | - Masaki Nakamura
- Department of Nephrology and Urology, NTT East Kanto Hospital, Tokyo, Japan
| | - Masahiko Sasaki
- Department of Urology, Tokyo, Teishin Hospital, Tokyo, Japan
| | - Akemi Ito
- Ito Bone Histomorphometry Institute, Niigata, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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Komaba H, Hamano T, Fujii N, Moriwaki K, Wada A, Masakane I, Nitta K, Fukagawa M. Parathyroidectomy vs Cinacalcet Among Patients Undergoing Hemodialysis. J Clin Endocrinol Metab 2022; 107:2016-2025. [PMID: 35277957 DOI: 10.1210/clinem/dgac142] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Parathyroidectomy (PTx) and cinacalcet are both effective treatments for secondary hyperparathyroidism in hemodialysis patients, but limited data exist comparing the long-term outcomes of these interventions. OBJECTIVE We aimed to compare the risk of mortality among hemodialysis patients who underwent PTx and those who started treatment with cinacalcet. METHODS In this prospective cohort study, comprising patients from the Japanese Society for Dialysis Therapy Renal Data Registry, patients who had intact parathyroid hormone (PTH) levels ≥ 300 pg/mL in late 2007 and underwent PTx or started treatment with cinacalcet in 2008 to 2009 were matched by propensity score at 1:3. PTx and cinacalcet were compared for all-cause mortality within 6 years. RESULTS Among eligible patients, 894 patients who underwent PTx were matched with 2682 patients who started treatment with cinacalcet. The median baseline intact PTH levels were 588 pg/mL and 566 pg/mL in the PTx and cinacalcet groups, respectively. PTx resulted in greater reductions in intact PTH, calcium, and phosphorus levels compared with cinacalcet. During the 6-year follow-up period, 201 patients (22.5%) in the PTx group and 736 patients (27.4%) in the cinacalcet group died. PTx was associated with a lower risk of mortality compared with cinacalcet (hazard ratio, 0.78 [95% CI, 0.67-0.91]; P = 0.002). This association was more pronounced in patients with intact PTH levels ≥ 500 pg/mL and in patients with serum calcium levels ≥ 10.0 mg/dL (both P for interaction < 0.001). CONCLUSION PTx compared with cinacalcet is associated with a lower risk of mortality, particularly among patients with severe secondary hyperparathyroidism.
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Affiliation(s)
- Hirotaka Komaba
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
- The Institute of Medical Sciences, Tokai University, Isehara, Japan
| | - Takayuki Hamano
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
- Department of Nephrology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Naohiko Fujii
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
- Department of Nephrology, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Japan
| | - Kensuke Moriwaki
- Comprehensive Unit for Health Economic Evidence Review and Decision Support (CHEERS), Research Organization of Science and Technology, Ritsumeikan University, Kyoto, Japan
| | - Atsushi Wada
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
- Department of Nephrology, Kitasaito Hospital, Asahikawa, Japan
| | - Ikuto Masakane
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
- Department of Nephrology, Yabuki Hospital, Yamagata, Japan
| | - Kosaku Nitta
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
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Gao D, Lou Y, Cui Y, Liu S, Cui W, Sun G. Risk factors for hypocalcemia in dialysis patients with refractory secondary hyperparathyroidism after parathyroidectomy: a meta-analysis. Ren Fail 2022; 44:503-512. [PMID: 35285377 PMCID: PMC8928856 DOI: 10.1080/0886022x.2022.2048856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective Hypocalcemia after parathyroidectomy (PTX) results in tetany, diarrhea, cardiac arrhythmia, and even sudden death. However, a meta-analysis or systematic evaluation of risk factors with the occurrence and development of hypocalcemia in patients with secondary hyperparathyroidism (SHPT) after PTX has never been performed. Methods A thorough search of electronic databases, including PubMed, Web of Science, the Cochrane Library, and EMBASE, was performed to retrieve relevant studies from database inception to June 2021. Quality of the included studies was assessed by two independent reviewers using the Newcastle–Ottawa Scale. Review Manager 5.3 and Stata 16.0 were used for meta-analysis. The random-effects model was adopted to calculate the 95% CIs (I2> 50% or p < 0.05) of the combined effect size and the corresponding homogeneous data. Otherwise, a fixed-effects model was used. Results Thirteen studies including 2990 participants who met the inclusion criteria were enrolled in the present meta-analysis. The overall quality of the enrolled studies had a score of >7 points. Risk factors significantly related to hypocalcemia in patients with SHPT after PTX were preoperative serum calcium (OR 0.19, 95%CI 0.11–0.31), preoperative alkaline phosphatase (ALP) (OR 1.01, 95% CI 1.01–1.02), and preoperative intact parathyroid hormone (iPTH) (OR 1.38, 95%CI 1.20–1.58). Meanwhile, age (OR 0.97, 95%CI 0.87–1.10) was not significantly correlated with hypocalcemia after PTX. Conclusions Based on the current evidence, preoperative serum calcium, preoperative ALP, and preoperative iPTH were significant predictors of hypocalcemia in patients with SHPT after PTX. More attention should be given to patients with these risk factors for the prevention of postoperative hypocalcemia.
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Affiliation(s)
- Dan Gao
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Yan Lou
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Yingchun Cui
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Shengmao Liu
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Wenpeng Cui
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Guangdong Sun
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
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Jørgensen HS, Behets G, Bammens B, Claes K, Meijers B, Naesens M, Sprangers B, Kuypers DR, Cavalier E, D’Haese P, Evenepoel P. Natural History of Bone Disease following Kidney Transplantation. J Am Soc Nephrol 2022; 33:638-652. [PMID: 35046132 PMCID: PMC8975071 DOI: 10.1681/asn.2021081081] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/09/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Knowledge of the effect of kidney transplantation on bone is limited and fragmentary. The aim of this study was to characterize the evolution of bone disease in the first post-transplant year. METHODS We performed a prospective, observational cohort study in patients referred for kidney transplantation under a steroid-sparing immunosuppressive protocol. Bone phenotyping was done before, or at the time of, kidney transplantation, and repeated at 12 months post-transplant. The phenotyping included bone histomorphometry, bone densitometry by dual-energy x-ray absorptiometry, and biochemical parameters of bone and mineral metabolism. RESULTS Paired data were obtained for 97 patients (median age 55 years; 72% male; 21% of patients had diabetes). Bone turnover remained normal or improved in the majority of patients (65%). Bone histomorphometry revealed decreases in bone resorption (eroded perimeter, mean 4.6% pre- to 2.3% post-transplant; P<0.001) and disordered bone formation (fibrosis, 27% pre- versus 2% post-transplant; P<0.001). Whereas bone mineralization was normal in all but one patient pretransplant, delayed mineralization was seen in 15% of patients at 1 year post-transplant. Hypophosphatemia was associated with deterioration in histomorphometric parameters of bone mineralization. Changes in bone mineral density were highly variable, ranging from -18% to +17% per year. Cumulative steroid dose was related to bone loss at the hip, whereas resolution of hyperparathyroidism was related to bone gain at both spine and hip. CONCLUSIONS Changes in bone turnover, mineralization, and volume post-transplant are related both to steroid exposure and ongoing disturbances of mineral metabolism. Optimal control of mineral metabolism may be key to improving bone quality in kidney transplant recipients. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Evolution of Bone Histomorphometry and Vascular Calcification Before and After Renal Transplantation, NCT01886950.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Geert Behets
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Bert Bammens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Bjorn Meijers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Dirk R.J. Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, Liège, Belgium
| | - Patrick D’Haese
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium .,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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Abstract
Surgical intervention remains the mainstay of treatment of hyperparathyroidism and provides the highest chance at cure. After the disease is confirmed by biochemical testing, surgeons must use a combination of patient clinical history and radiographic imaging to determine the most appropriate surgical strategy. Through either minimally invasive parathyroidectomy or bilateral cervical exploration, surgeons provide high rates of cure for hyperparathyroidism with low rates of persistence or recurrence.
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Affiliation(s)
- Aditya S Shirali
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1484, PO Box 301402, Houston, TX 77030-4009, USA
| | - Uriel Clemente-Gutierrez
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1484, PO Box 301402, Houston, TX 77030-4009, USA
| | - Nancy D Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1484, PO Box 301402, Houston, TX 77030-4009, USA.
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Raj JJ, Kow RY, Ramalingam S, Low CL. Neck of Femur Fracture in Young Patients With End-Stage Renal Disease and Hyperparathyroidism: A Report of Three Cases and Proposed Treatment Algorithm. Cureus 2021; 13:e16155. [PMID: 34367767 PMCID: PMC8338123 DOI: 10.7759/cureus.16155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 11/05/2022] Open
Abstract
Secondary hyperparathyroidism is a complication arising from untreated end-stage renal disease (ESRD). It can invariably lead to osteoporosis and subsequently cause pathological neck of femur (NOF) fracture. Despite being young, osteosynthesis in neck of femur fractures of these patients often leads to nonunion and implant failure due to severely osteoporotic bone. We present our experience in managing three young patients with ESRD and secondary hyperthyroidism who sustained NOF fractures. All three patients were successfully treated and showed no complication at one year post-operation. Based on our experience and literature review, we propose a simple algorithm to guide the management of these patients.
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Affiliation(s)
- Jeffrey J Raj
- Department of Orthopaedics, Hospital Tengku Ampuan Afzan, Kuantan, MYS
| | - Ren Yi Kow
- Department of Orthopaedics, Traumatology & Rehabilitation, International Islamic University Malaysia, Kuantan, MYS.,Department of Orthopaedics, Hospital Tengku Ampuan Afzan, Kuantan, MYS
| | | | - Chooi Leng Low
- Department of Radiology, International Islamic University Malaysia, Kuantan, MYS
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8
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Abstract
Disturbances in mineral and bone metabolism are common in patients with chronic kidney disease (CKD), especially those undergoing dialysis. Renal osteodystrophy, which describes an alteration of bone morphology, is an important component of this systemic disorder and may explain the elevated risk of fracture which adversely affects morbidity and mortality. The most common form of renal osteodystrophy is high-turnover bone disease (osteitis fibrosa), which is induced by secondary hyperparathyroidism (SHPT). During the past decade, there has been considerable advances in the management of SHPT, with the introduction of the calcimimetic agents, the optimized use of nutritional and active vitamin D, and the accumulated experience with surgical parathyroidectomy. Studies supported that these advances could translate into improvement of renal bone disease and fracture prevention, as well as decreasing the risk of cardiovascular events and mortality. In this review, we summarize the available clinical evidence on the effect of old and new drugs on bone disorders in patients with CKD.
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Affiliation(s)
- Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
- The Institute of Medical Sciences, Tokai University, Isehara, Japan
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | | | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan.
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Stefanova D, Ullmann TM, Limberg J, Moore M, Beninato T, Zarnegar R, Fahey TJ, Finnerty BM. Risk Factors for Prolonged Length of Stay and Readmission After Parathyroidectomy for Renal Secondary Hyperparathyroidism. World J Surg 2020; 44:3751-3760. [PMID: 32737558 DOI: 10.1007/s00268-020-05711-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Population-based analyses of 30-day outcomes after parathyroidectomy for renal secondary hyperparathyroidism are limited. We sought to identify risk factors associated with prolonged length of stay (LOS) and readmission in this patient population. METHODS Patients with secondary hyperparathyroidism who underwent parathyroidectomy were reviewed in the ACS-NSQIP database (2011-2016). Patients were identified by ICD codes specific to secondary hyperparathyroidism of renal origin and the ACS-NSQIP variable for current preoperative dialysis. Multivariable logistic regression was used to identify independent factors associated with prolonged LOS and 30-day readmission after parathyroidectomy. RESULTS The cohort included 1846 patients with secondary hyperparathyroidism on dialysis who underwent parathyroidectomy. There were 416 (22.5%) patients classified under the prolonged LOS group. On multivariable analysis, factors associated with prolonged LOS included elevated preoperative alkaline phosphatase [OR 3.13 (95%-CI 2.09-4.70), p < 0.001], decreased preoperative hematocrit [OR 1.83 (95%-CI 1.25-2.68), p = 0.002], unplanned reoperation (OR 5.02 [95%-CI 2.22-11.3], p < 0.001) and any postoperative complication [OR 6.12 (95%-CI 3.31-11.3), p < 0.001]. The overall 30-day readmission rate was 15.0%. Hypocalcemia and hungry bone syndrome accounted for 47.0% (n = 93/198) of readmissions. On multivariable analysis, patients with a history of hypertension and those undergoing unplanned reoperation were at risk of readmission [2.16 (95%-CI 1.21-3.87), p = 0.009, and 2.40 (95%-CI 1.15-5.02), p = 0.020, respectively], whereas reoperative parathyroidectomy was inversely associated with readmission (OR 0.24, 95%-CI 0.07-0.80, p = 0.021). CONCLUSION In patients undergoing parathyroidectomy for renal secondary hyperparathyroidism, several readily available preoperative biochemical markers, including those of increased bone turnover and anemia, are associated with prolonged postoperative LOS. Unplanned reoperation was predictive of both increased LOS and readmission.
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Affiliation(s)
- Dessislava Stefanova
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Timothy M Ullmann
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Jessica Limberg
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Maureen Moore
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Toni Beninato
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA.
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Ishida H, Komaba H, Hamano N, Yamato H, Sawada K, Wada T, Nakamura M, Fukagawa M. Skeletal and mineral metabolic effects of risedronate in a rat model of high-turnover renal osteodystrophy. J Bone Miner Metab 2020; 38:501-510. [PMID: 32140785 DOI: 10.1007/s00774-020-01095-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/24/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION High-turnover bone disease is a major consequence of SHPT and may explain the high risk for fracture in patients with advanced chronic kidney disease (CKD). Bisphosphonates suppress bone turnover and improve bone strength, but their effects have not been fully characterized in advanced CKD with severe SHPT. Bisphosphonates also increase 1,25-dihydroxyvitamin D levels in normal and uremic rats, but the underlying mechanism remains to be determined. MATERIALS AND METHODS We investigated the skeletal and mineral metabolic effects of RIS, a pyridinyl bisphosphonate, in rats with severe SHPT induced by 5/6 nephrectomy plus a high phosphate diet. RESULTS Nephrectomized rats developed severe SHPT, along with hyperphosphatemia, low 1,25-dihydroxyvitamin D, and markedly increased FGF23. Moreover, these rats exhibited characteristic features of high-turnover renal osteodystrophy, including increased indices of trabecular bone turnover, decreased cortical bone thickness, inferior cortical biomechanical properties, and a prominent increase in peritrabecular fibrosis. RIS treatment increased bone volume and partially attenuated trabecular bone remodeling, cortical bone loss, and mechanical properties, whereas it produced a marked improvement in peritrabecular fibrosis along with a corresponding decrease in osteogenic gene markers. RIS treatment also suppressed the elevation of FGF23, which was associated with increased 1,25-dihydroxyvitamin D. CONCLUSIONS In a rat model of severe SHPT, treatment with RIS partially attenuated histological manifestations of high-turnover bone disease. RIS treatment also suppressed the elevation of FGF23, which may explain the increased 1,25-dihydroxyvitamin D production during the treatment.
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Affiliation(s)
- Hiroaki Ishida
- Department of Transplant Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan.
- Interactive Translational Research Center for Kidney Diseases, Tokai University School of Medicine, Isehara, Japan.
- The Institute of Medical Sciences, Tokai University, Isehara, Japan.
| | - Naoto Hamano
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
| | - Hideyuki Yamato
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
| | - Kaichiro Sawada
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
| | - Takehiko Wada
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
| | - Michio Nakamura
- Department of Transplant Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
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11
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Wang M, Chen B, Zou X, Wei T, Gong R, Zhu J, Li Z. A Nomogram to Predict Hungry Bone Syndrome After Parathyroidectomy in Patients With Secondary Hyperparathyroidism. J Surg Res 2020; 255:33-41. [PMID: 32540578 DOI: 10.1016/j.jss.2020.05.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/07/2020] [Accepted: 05/10/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Parathyroidectomy (PTX) has been demonstrated as an effective treatment for patients with secondary hyperparathyroidism (SHPT) of renal origin. However, severe hypocalcemia, called hungry bone syndrome (HBS), is a common complication following PTX in these patients and can lead to poor clinical outcomes, even death. Therefore, exploring risk factors for HBS and establishing a prediction nomogram allow intensive monitoring and prompt treating this postoperative complication, which is the main purpose of this study. METHODS From October 2016 to October 2018, PTX with autotransplantation (PTX + AT) procedures were performed in 131 patients with SHPT of renal origin by a surgeon and his team in the Thyroid and Parathyroid Surgery Center, West China Hospital, Sichuan University, China. After applying the inclusion and exclusion criteria, a total of 114 patients were enrolled for analyses in this study. Comprehensive data including preoperative, intraoperative, and postoperative variables were prospectively collected and retrospectively analyzed. The univariate and multivariate logistic regression analyses with internal validation by bootstrapping were used to confirm independent risk factors for postoperative HBS. The nomogram was developed based on the statistical analysis results. Receiver operator characteristic (ROC) curves were drawn to compare the prediction performance among different predictors. RESULTS The occurrence of postoperative HBS was 76.3% (87 out of 114 patients) in this study. Univariate analysis showed that preoperative intact parathyroid hormone (iPTH), serum alkaline phosphatase, bone-specific alkaline phosphatase (bone-ALP) were significantly higher in HBS group than those in non-HBS group, while preoperative corrected serum calcium and albumin were significantly lower in HBS group than those in non-HBS group. Total weight of resected parathyroid glands was significantly heavier in HBS group versus non-HBS group. Multivariate logistic regression analysis with internal validation by bootstrapping demonstrated preoperative iPTH, bone-ALP, preoperative corrected serum calcium, and total weight of resected parathyroid glands were independently associated with postoperative HBS. The nomogram including the abovementioned four independent predictors was constructed and showed better prediction performance than the other four predictors in terms of postoperative HBS. CONCLUSIONS On the basis of this study, we found higher preoperative iPTH level, higher bone-ALP level, heavier total weight of resected parathyroid glands, and lower preoperative corrected serum calcium level were independent predictors of postoperative HBS in patients with SHPT of renal origin. The nomogram can expediently, accurately, and objectively predict the risk of postoperative HBS in individual patient with SHPT of renal origin.
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12
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Huang Y, Wu H, Wu Y, Luo Z. Efficacy analysis of medical and surgical treatments in chronic kidney disease patients with secondary hyperparathyroidism. Am J Otolaryngol 2019; 40:102228. [PMID: 31375304 DOI: 10.1016/j.amjoto.2019.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 05/14/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To investigate the effects of surgical and medical treatments on chronic kidney disease (CKD) patients with secondary hyperparathyroidism (SHPT). MATERIALS AND METHODS A total of 198 CKD patients with SHPT were identified at Tongji Hospital from January 2013 to June 2017. RESULTS Surgical group (53 patients) received maintenance dialysis for 78.0 ± 4.9 months, while medical group (84 patients) for 62.0 ± 6.4 months. The serum intact parathyroid hormone (iPTH) in surgical group reduced apparently compared with medical group (P = 0.015) and maintained satisfied result during three years of follow-up (67.4 ± 7.4 pg/ml). The recurrence rate in surgical group was 7.5% and in medical group was 15.5% (P = 0.024). Beyond that, 5 (5.9%) patients suffered persistent hyperparathyroidism in medical group. CONCLUSION Although the progress of medical treatment is changing rapidly, surgical treatment is still an effective way to control serum iPTH and calcium chronically for SHPT patients. Complex SHPT patients can also receive satisfied effect by surgical treatment, without apparently increasing the risk of complications.
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13
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Yang G, Wang J, Sun J, Zha X, Wang N, Xing C. Perioperative hyperkalemia in hemodialysis patients undergoing parathyroidectomy for renal hyperparathyroidism. Intern Emerg Med 2019; 14:1065-1071. [PMID: 30648222 DOI: 10.1007/s11739-019-02031-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/08/2019] [Indexed: 02/06/2023]
Abstract
The present study investigates the incidence of perioperative hyperkalemia and the influence factors of serum potassium levels during and after parathyroidectomy (PTX) in hemodialysis patients with renal hyperparathyroidism (rHPT). A total of 204 hemodialysis patients with refractory rHPT undergoing successful total parathyroidectomy with autotransplantation (tPTX + AT) were analyzed retrospectively. Hyperkalemia was defined as serum potassium levels ≥ 5.5 mmol/L. The preoperative baseline level of serum potassium (K base+ ) was defined as a mean of the three preoperative prehemodialysis serum potassium levels. The higher levels of serum potassium during and immediately after surgery were recorded as K d0+ and the peak prehemodialysis serum potassium levels 3 days after surgery as K d3+ . 136/204 (66.7%) patients suffered from hyperkalemia during or immediately after surgery and 65/204 (31.9%) patients were affected with prehemodialysis hyperkalemia 3 days after surgery. K base+ was the only influencing factor for K d0+ . Serum K base+ , preoperative serum alkaline phosphatase, and total calcium supplement dosage during intravenous calcium supplement were the influencing factors for K d3+ . In the case of PTX, the serum potassium levels of patients with higher serum K base+ and severe postoperative hypocalcemia need to be monitored with extended attention perioperatively.
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Affiliation(s)
- Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Jing Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Jie Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Xiaoming Zha
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu, China.
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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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15
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Ge Y, Yang G, Wang N, Zha X, Yu X, Mao H, Sun B, Zeng M, Zhang B, Xing C. Bone metabolism markers and hungry bone syndrome after parathyroidectomy in dialysis patients with secondary hyperparathyroidism. Int Urol Nephrol 2019; 51:1443-1449. [PMID: 31264087 DOI: 10.1007/s11255-019-02217-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/18/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To explore the short-term variation in bone metabolic markers and the characteristics of hungry bone syndrome (HBS) after parathyroidectomy (PTX) with forearm autotransplantation in uremic patients with secondary hyperparathyroidism (SHPT) and to provide a basis for the pathogenesis, diagnosis and treatment of metabolic bone disease in SHPT. METHODS A total of 115 patients with SHPT receiving PTX from July 2015 to December 2017, hospitalized at the First Affiliated Hospital of Nanjing Medical University, were enrolled in our study. We retrospectively analyzed the baseline clinical data, the levels of bone metabolism markers before and on the third day after PTX, and the risk factors predicting HBS. RESULTS Preoperative baseline data showed that the levels of bone metabolic markers such as bone metabolism-regulating hormones: iPTH, calcitonin (CT); bone formation markers: phosphatase (ALP), osteocalcin (OC); bone resorption markers: type I collagen cross-linked N-telopeptides (NTX), type I collagen cross-linked C-telopeptides (CTX), tartrate-resistant acid phosphatase 5b (TRAP-5b) were all increased compared to normal levels. The levels of postoperative serum iPTH, CT, CTX and TRAP-5b decreased significantly compared to preoperative levels, while the levels of OC and ALP increased significantly. Of the 115 patients, 101 (87.8%) developed HBS after PTX. High preoperative serum ALP and low preoperative serum calcium level independently predicted the occurrence of HBS. Younger preoperative age, high preoperative serum ALP and iPTH level independently predicted the severity of HBS. CONCLUSIONS In severe SHPT, both bone formation and resorption were active, which suggested the presence of high-turnover bone diseases characterized by up-regulation of osteoclasts-osteoblasts functionally coupling activation in the patients. PTX could promote osteoblast activity and reduce osteoclast activity. HBS was common after PTX. Preoperative higher serum ALP and lower calcium were independent predictors of the occurrence of HBS. Younger patients with higher preoperative ALP and PTH may need to closely monitor serum calcium levels and intensive calcium supplementation after PTX.
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Affiliation(s)
- Yifei Ge
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Xiaoming Zha
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Xiangbao Yu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Bin Sun
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Bo Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China.
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Cunningham J, Block GA, Chertow GM, Cooper K, Evenepoel P, Iles J, Sun Y, Ureña-Torres P, Bushinsky DA. Etelcalcetide Is Effective at All Levels of Severity of Secondary Hyperparathyroidism in Hemodialysis Patients. Kidney Int Rep 2019; 4:987-994. [PMID: 31317120 PMCID: PMC6611952 DOI: 10.1016/j.ekir.2019.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/21/2019] [Accepted: 04/09/2019] [Indexed: 02/02/2023] Open
Abstract
Introduction Calcimimetics improve parameters of secondary hyperparathyroidism (sHPT) but are mostly initiated when patients have severe disease, potentially limiting effectiveness. We evaluated the effects of etelcalcetide on lowering intact parathyroid hormone, calcium, and phosphate at different disease severity levels. Methods This analysis examined data from 2 parallel, phase 3, randomized, placebo-controlled, 26-week trials conducted in 1023 adult (≥18 years old) patients with sHPT on maintenance hemodialysis. Etelcalcetide effects by baseline intact parathyroid hormone stratum (<600, 600-1000, and >1000 ng/l) on mean percentage change in intact parathyroid hormone; changes in calcium and phosphate; and achieving serum intact parathyroid hormone ≤300 ng/l, phosphate <1.78 mmol/l, and both combined, were assessed. Results Etelcalcetide reduced serum intact parathyroid hormone by a similar percentage across baseline strata. A similar proportion achieved >30% intact parathyroid hormone reduction across strata for the etelcalcetide arms. Parathyroid hormone increased modestly in each placebo-group stratum, most prominently in the lowest stratum. Serum calcium and phosphate concentrations decreased across strata in etelcalcetide-treated patients, with the most pronounced reductions in patients with highest baseline parathyroid hormone. However, the proportion of patients achieving parathyroid hormone, phosphate, and both targets was highest in the lowest baseline parathyroid hormone stratum, where etelcalcetide dose requirements were lowest. Etelcalcetide dose requirement was lowest among patients in the lowest intact parathyroid hormone stratum. Conclusion Etelcalcetide effectively lowered serum intact parathyroid hormone, calcium, and phosphate, irrespective of the severity of secondary hyperparathyroidism. The ability to achieve target goals was greatest, and dose requirement smallest, when etelcalcetide was initiated among patients with the lowest level of disease severity.
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Affiliation(s)
- John Cunningham
- The Royal Free Hospital and UCL Medical School, London, England
| | | | - Glenn M Chertow
- Stanford University School of Medicine, Stanford, California, USA
| | | | | | - Jan Iles
- Amgen Inc., Thousand Oaks, California, USA
| | - Yan Sun
- Amgen Inc., Thousand Oaks, California, USA
| | | | - David A Bushinsky
- University of Rochester School of Medicine, Nephrology Division, Rochester, New York, USA
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17
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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.
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18
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Abstract
Secondary hyperparathyroidism, characterized by increased PTH synthesis and secretion, is often seen in advanced stages of chronic kidney disease. Excessive proliferation of parathyroid cells leads to the development of diffuse hyperplasia that subsequently progresses to nodular histology. Refractory hyperparathyroidism occurs when parathyroid glands fail to respond to medical therapy. Parathyroidectomy (PTX), surgical resection of parathyroid glands, is usually performed in cases of persistent serum levels of PTH above 1000 pg/mL associated with hypercalcemia or when hyperparathyroidism is refractory to conservative therapy. Parathyroidectomy can be carried out using different procedures: subtotal PTX or total PTX with or without parathyroid autotransplantation. Parathyroid surgery may have undesirable consequences due to PTH oversuppression, such as the development of adynamic bone disease; hungry bone syndrome is quite common after this surgery. However, PTX improves survival and parameters of mineral metabolism. Parathyroidectomy needs to be considered in those patients with severe hyperparathyroidism with a poor response to pharmacological treatment and with distinct undesirable effects of PTH on bone and mineral metabolism parameters.
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Affiliation(s)
- María E Rodríguez-Ortiz
- Maimónides Institute for Biomedical Research (IMIBIC), Córdoba, Spain.,Reina Sofía University Hospital, Córdoba, Spain.,University of Córdoba, Córdoba, Spain.,Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
| | - María V Pendón-Ruiz de Mier
- Maimónides Institute for Biomedical Research (IMIBIC), Córdoba, Spain.,Reina Sofía University Hospital, Córdoba, Spain.,University of Córdoba, Córdoba, Spain.,Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
| | - Mariano Rodríguez
- Maimónides Institute for Biomedical Research (IMIBIC), Córdoba, Spain.,University of Córdoba, Córdoba, Spain.,Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain.,Nephrology Service, University Hospital Reina Sofía, Córdoba, Spain
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19
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Yajima A, Tsuchiya K, Burr DB, Minner DE, Condon KW, Miller CA, Satoh S, Inaba M, Nakayama T, Tanizawa T, Ito A, Nitta K. Osteocytic perilacunar/canalicular turnover in hemodialysis patients with high and low serum PTH levels. Bone 2018; 113:68-76. [PMID: 29738853 DOI: 10.1016/j.bone.2018.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 04/16/2018] [Accepted: 05/02/2018] [Indexed: 01/30/2023]
Abstract
Osteocytic perilacunar/canalicular turnover in hemodialysis patients has not yet been reported. Osteocyte lacunae in lamellar bone and woven bone were classified as eroded surface-, osteoid surface-, and quiescent surface-predominant osteocyte lacunae (ES-Lc, OS-Lc, QS-Lc, respectively) in 55 hemodialysis patients with either high- (n = 45) or low- (n = 10) parathyroid hormone levels, and 19 control subjects without chronic kidney disease. We calculated the area and number of ES-Lc, OS-Lc, and QS-Lc. The mineralized surface on the osteocyte lacunar walls was measured in each group, and compared among the three groups. The shapes of the osteocyte lacunar walls were validated by backscattered electron microscopy. While the number of ES-Lc per bone area (N.ES-Lc/B.Ar) was higher than the number of OS-Lc per bone area (N.OS-Lc/B.Ar) in all groups, N.ES-Lc/B.Ar and N.OS-Lc/B.Ar were greater in high-parathyroid hormone group than in low-parathyroid hormone and control groups. The total volume of ES-Lc per bone area (ES-Lc.Ar/B.Ar) was greater than the total volume of OS-Lc per bone area (OS-Lc.Ar/B.Ar) in both parathyroid hormone groups. However, both lacunar erosion and lacunar formation increased proportionally, suggesting that global coupling between them was maintained. N.ES-Lc/B.Ar was higher in woven bone than in lamellar bone. The rate of OS-Lc stained by tetracycline hydrochloride, the mineralized lacunar surface and the mean area of OS-Lc with Tc obtained from both parathyroid hormone groups were greater than those in the control group. We conclude that osteocytic perilacunar/canalicular turnover is increased in hemodialysis patients with high parathyroid hormone levels. Osteocytic perilacunar/canalicular turnover depends, at least in part, on serum parathyroid hormone level. However, the ideal PTH level for osteocytic perilacunar/canalicular turnover could not be determined but osteocytic osteolysis was predominant in both the high- and low-PTH groups in this study. Thus, attention should be paid to bone loss from the viewpoint of osteocytic perilacunar/canalicular turnover in hemodialysis patients.
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Affiliation(s)
- Aiji Yajima
- Department of Anatomy and Cell Biology, Indiana University, School of Medicine, Indianapolis, IN, USA; Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan.
| | - Ken Tsuchiya
- Department of Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - David B Burr
- Department of Anatomy and Cell Biology, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Daniel E Minner
- Department of Integrated Nanosystems Development Institute, Indiana University, Purdue University, Indianapolis, IN, USA
| | - Keith W Condon
- Department of Anatomy and Cell Biology, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Caroline A Miller
- Department of Anatomy and Cell Biology, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Shigeru Satoh
- Center for Kidney Disease and Transplantation, Akita University Hospital, Akita, Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | | | | | - Akemi Ito
- Ito Bone Histomorphometry Institute, Niigata, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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20
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Abstract
PURPOSE OF REVIEW Parathyroidectomy (PTx) is the definitive therapy for refractory secondary hyperparathyroidism (SHPT). The drastic effects of PTx on biochemical parameters of SHPT increases the possibility that this intervention will lead to a reduction in the adverse outcomes related to uncontrolled SHPT. RECENT FINDINGS The effect of PTx on mortality and cardiovascular outcomes among dialysis patients with severe SHPT have been evaluated in many observational studies from different regions of the world, including Asia, Europe, North America, and South America. In all but one small study, there was a significant association of PTx with lower all-cause mortality. In addition, in all studies, there was a trend in favor of PTx for cardiovascular morbidity and mortality. The effect of PTx on fractures has been evaluated in only one epidemiological study from the United States, which demonstrated a significant association of PTx and lower hip and combined fractures. SUMMARY Although randomized evidence is lacking, these highly consistent results may suggest a strong beneficial effect of PTx on long-term clinical outcomes and eliminate the potential concern of low parathyroid hormone after PTx.
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21
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Yang M, Zhang L, Huang L, Sun X, Ji H, Lu Y. Risk Factors for Elevated Preoperative Alkaline Phosphatase in Patients with Refractory Secondary Hyperparathyroidism. Am Surg 2017. [DOI: 10.1177/000313481708301220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Elevated preoperative levels of alkaline phosphatase (ALP) in patients with refractory secondary hyperparathyroidism are correlated with postoperative hypocalcemia and mortality. The aim of this study was to identify the predictors of preoperative ALP in patients with secondary hyperparathyroidism. From April 2012 to December 2015, 220 patients with refractory secondary hyperparathyroidism undergoing total parathyroidectomy without autotransplantation were reviewed. A total of 164 patients presented with elevated preoperative ALP. Univariate analysis showed that patients with elevated ALP were significantly younger. The elevated ALP group had significantly higher levels of preoperative parathyroid hormone (PTH), lower preoperative serum calcium, higher preoperative phosphorus, lower postoperative hypocalcemia, and a longer hospital stay. Logistic regression analysis showed that elevated preoperative PTH was a significant independent risk factor for elevated preoperative ALP (P = 0.000), and its value of 1624 pg/mL was the optimal cutoff point. Factors predictive of elevated preoperative ALP in patients with secondary hyperparathyroidism include preoperative PTH. Earlier surgery, aggressive calcium supplementation, and more careful or aggressive postoperative care for high-risk patients are needed.
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Affiliation(s)
- Meng Yang
- Department of Breast and Thyroid Surgery, China-Japan Friendship Hospital, Beijing, China and
| | - Ling Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Linping Huang
- Department of Breast and Thyroid Surgery, China-Japan Friendship Hospital, Beijing, China and
| | - Xiaoliang Sun
- Department of Breast and Thyroid Surgery, China-Japan Friendship Hospital, Beijing, China and
| | - Haoyang Ji
- Department of Breast and Thyroid Surgery, China-Japan Friendship Hospital, Beijing, China and
| | - Yao Lu
- Department of Breast and Thyroid Surgery, China-Japan Friendship Hospital, Beijing, China and
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Ma L, Zhao S, Li Z. Effects of parathyroidectomy on bone metabolism in haemodialysis patients with secondary hyperparathyroidism. Scand J Clin Lab Invest 2017; 77:527-534. [PMID: 28741963 DOI: 10.1080/00365513.2017.1354256] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the outcome of bone metabolism and bone mineral density (BMD) in haemodialysis patients after parathyroidectomy (PTX). METHODS A total of 31 haemodialysis patients with secondary hyperparathyroidism (SHPT) were treated with PTX. BMD of lumbar spine (LS) and femoral neck (FN) was determined by dual energy X-ray absorptiometry. RESULTS Parathyroidectomy ledds to significant decrease of serum β-crosslaps (β-CTX), osteocalcin (OC) and procollagen type I amino-terminal propeptide (PINP) while serum sclerostin (SOST) increased after surgery. BMD was markedly improved in both LS and FN after PTX. Z-scores analysis further confirmed that PTX significantly benefited bone metabolism in haemodialysis patients, which well correlated with the improvement of serum iPTH and OC. CONCLUSIONS Parathyroidectomy leads to significant improvement of serum OC, PINP, β-CTX and SOST, which may beneficially modify calcium-phosphorus metabolism and BMD in haemodialysis patients with SHPT.
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Affiliation(s)
- Lijie Ma
- a Department of Nephrology , Beijing Chaoyang Hospital, Capital Medical University , Beijing , China
| | - Sumei Zhao
- a Department of Nephrology , Beijing Chaoyang Hospital, Capital Medical University , Beijing , China
| | - Zhongxin Li
- b Department of Nephrology , Beijing Lu He Hospital, Capital Medical University , Beijing , China
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Polistena A, Sanguinetti A, Lucchini R, Galasse S, Avenia S, Monacelli M, Johnson LB, Jeppsson B, Avenia N. Surgical treatment of secondary hyperparathyroidism in elderly patients: an institutional experience. Aging Clin Exp Res 2017; 29:23-28. [PMID: 27830521 DOI: 10.1007/s40520-016-0669-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/01/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Secondary hyperparathyroidism in elderly fragile patients presents clinical difficulties due to severity of symptoms and related comorbidity. The optimal surgical approach for this group of patients is still debated. AIM The aim of the study was to define the optimal technique of parathyroidectomy in elderly patients with secondary hyperparathyroidism. METHODS Retrospective analysis in a series of 253 patients including 35 elderly individuals at a single institution was carried out. Postoperative parathyroid hormone decrease, surgical complications and symptoms control were analyzed for all patients in relation to the types of parathyroidectomy performed. RESULTS In elderly patients, total parathyroidectomy was the most used approach. Subtotal parathyroidectomy was mostly reserved for younger patients suitable for kidney transplantation. No elderly patients treated with total parathyroidectomy were autotransplanted. No significant difference in surgical complications was observed between younger and elderly patients and considering the different procedures. Adequate symptom control after surgery was achieved in almost 90% of patients. A limited rate of recurrence requiring repeat surgery was observed only after subtotal parathyroidectomy. DISCUSSION Considering the features of all types of parathyroidectomy, very low recurrence rate, contained postoperative hypocalcemia and limited complications following total parathyroidectomy, might represent specific advantages for elderly patients. CONCLUSIONS Total parathyroidectomy without parathyroid transplantation is safe for elderly patients with secondary hyperparathyroidism and a good alternative to the well-established total parathyroidectomy with autografting.
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Affiliation(s)
- Andrea Polistena
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy.
| | - Alessandro Sanguinetti
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Roberta Lucchini
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Segio Galasse
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Stefano Avenia
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Massimo Monacelli
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Louis Banka Johnson
- Surgical Department, Skåne University Hospital, University of Lund, Malmö, Sweden
| | - Bengt Jeppsson
- Surgical Department, Skåne University Hospital, University of Lund, Malmö, Sweden
| | - Nicola Avenia
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
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Abstract
Renal hyperparathyroidism (rHPT) is a common complication of chronic kidney disease characterized by elevated parathyroid hormone levels secondary to derangements in the homeostasis of calcium, phosphate, and vitamin D. Patients with rHPT experience increased rates of cardiovascular problems and bone disease. The Kidney Disease: Improving Global Outcomes guidelines recommend that screening and management of rHPT be initiated for all patients with chronic kidney disease stage 3 (estimated glomerular filtration rate, < 60 mL/min/1.73 m(2)). Since the 1990s, improving medical management with vitamin D analogs, phosphate binders, and calcimimetic drugs has expanded the treatment options for patients with rHPT, but some patients still require a parathyroidectomy to mitigate the sequelae of this challenging disease.
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Affiliation(s)
- Noah K Yuen
- Surgical Resident at the University of California, Davis in Sacramento.
| | - Shubha Ananthakrishnan
- Assistant Professor of Internal Medicine at the University of California, Davis in Sacramento.
| | - Michael J Campbell
- Assistant Professor in the Department of Surgery at the University of California, Davis in Sacramento.
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Yang M, Zhang L, Huang L, Sun X, Ji H, Lu Y. Factors predictive of critical value of hypocalcemia after total parathyroidectomy without autotransplantation in patients with secondary hyperparathyroidism. Ren Fail 2016; 38:1224-7. [DOI: 10.1080/0886022x.2016.1202731] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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26
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Moe SM, Abdalla S, Chertow GM, Parfrey PS, Block GA, Correa-Rotter R, Floege J, Herzog CA, London GM, Mahaffey KW, Wheeler DC, Dehmel B, Goodman WG, Drüeke TB. Effects of Cinacalcet on Fracture Events in Patients Receiving Hemodialysis: The EVOLVE Trial. J Am Soc Nephrol 2015; 26:1466-75. [PMID: 25505257 PMCID: PMC4446874 DOI: 10.1681/asn.2014040414] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 09/07/2014] [Indexed: 11/03/2022] Open
Abstract
Fractures are frequent in patients receiving hemodialysis. We tested the hypothesis that cinacalcet would reduce the rate of clinical fractures in patients receiving hemodialysis using data from the Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events trial, a placebo-controlled trial that randomized 3883 hemodialysis patients with secondary hyperparathyroidism to receive cinacalcet or placebo for ≤64 months. This study was a prespecified secondary analysis of the trial whose primary end point was all-cause mortality and non-fatal cardiovascular events, and one of the secondary end points was first clinical fracture event. Clinical fractures were observed in 255 of 1935 (13.2%) patients randomized to placebo and 238 of 1948 (12.2%) patients randomized to cinacalcet. In an unadjusted intention-to-treat analysis, the relative hazard for fracture (cinacalcet versus placebo) was 0.89 (95% confidence interval [95% CI], 0.75 to 1.07). After adjustment for baseline characteristics and multiple fractures, the relative hazard was 0.83 (95% CI, 0.72 to 0.98). Using a prespecified lag-censoring analysis (a measure of actual drug exposure), the relative hazard for fracture was 0.72 (95% CI, 0.58 to 0.90). When participants were censored at the time of cointerventions (parathyroidectomy, transplant, or provision of commercial cinacalcet), the relative hazard was 0.71 (95% CI, 0.58 to 0.87). Fracture rates were higher in older compared with younger patients and the effect of cinacalcet appeared more pronounced in older patients. In conclusion, using an unadjusted intention-to-treat analysis, cinacalcet did not reduce the rate of clinical fracture. However, when accounting for differences in baseline characteristics, multiple fractures, and/or events prompting discontinuation of study drug, cinacalcet reduced the rate of clinical fracture by 16%-29%.
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Affiliation(s)
- Sharon M Moe
- Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis, Indiana;
| | - Safa Abdalla
- Stanford University School of Medicine, Palo Alto, California
| | - Glenn M Chertow
- Stanford University School of Medicine, Palo Alto, California
| | | | | | - Ricardo Correa-Rotter
- Salvador Zubirán National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
| | | | | | | | | | | | | | | | - Tilman B Drüeke
- French Institute of Health and Medical Research (INSERM) Unit 1088, Faculty of Medicine/Pharmacy, University of Picardie, Amiens, France
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Affiliation(s)
- Yoshihiro Tominaga
- Department of Transplant and Endocrine Surgery , Nagoya Second Red Cross Hospital , Nagoya , Japan
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28
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Liu S, Zhu W, Li S, Cui T, Li Z, Zhang B, Li Z, Wu J, Liang X, Lin Z, Shi W. The effect of bovine parathyroid hormone withdrawal on MC3T3-E1 cell proliferation and phosphorus metabolism. PLoS One 2015; 10:e0120402. [PMID: 25775025 PMCID: PMC4361577 DOI: 10.1371/journal.pone.0120402] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 01/25/2015] [Indexed: 11/18/2022] Open
Abstract
Hypocalcemia and hypophosphatemia are common complications after parathyroidectomy (PTX). Sudden removal of high circulating levels of parathyroid hormone (PTH) causes decreased osteoclastic resorption resulting in a decreased bone remodeling space. These phenomena are likely due to an increased influx of calcium and phosphorus into bone. However, there are currently no data to support this hypothesis. In this study, we found that PTX significantly reduced levels of PTH, calcium and phosphate. Compared with preoperative levels, after 1 year, postoperative PTH, calcium and phosphate levels were 295.6 ± 173.7 pg/mL (P < 0.05), 86.62 ± 15.98 mg/dL (P < 0.05) and 5.56 ± 2.03 mg/dL (P < 0.05), respectively. We investigated continuous bovine PTH administration as well as withdrawal of bovine PTH stimulation in the mouse osteoblast precursor cell line MC3T3-E1. MC3T3-E1 cells were cultured with continuous bovine PTH treatment for 20 days or with transient bovine PTH treatment for 10 days. High doses of continuous bovine PTH exposure strongly reduced cell proliferation, alkaline phosphatase activity and the number of mineralized calcium nodules. However, withdrawal of bovine PTH (100 ng/mL) significantly increased the number of mineralized calcium nodules and caused a rapid decline in calcium and phosphorus content of culture medium. In conclusion, continuous exposure to bovine PTH inhibited osteoblast differentiation and reduced the formation of mineralized nodules. However, this inhibition was removed and mineralized nodule formation resumed with withdrawal of bovine PTH. According to the results of our clinical examinations and in vitro experiments, we hypothesize that the sudden removal of high levels of PTH may cause an increased influx of calcium and phosphorus into bone after PTX.
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Affiliation(s)
- Shuangxin Liu
- Department of Nephrology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan No. 2 Road, Guangzhou, China
| | - Weiping Zhu
- Department of Nephrology, the Fifth Affiliated Hospital of Sun Yat-sen University, No.52 Meihua Road, Zhuhai, China
| | - Sijia Li
- Department of Nephrology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan No. 2 Road, Guangzhou, China
| | - Tongxia Cui
- Department of Nephrology, the Fifth Affiliated Hospital of Sun Yat-sen University, No.52 Meihua Road, Zhuhai, China
| | - Zhonghe Li
- Department of Nephrology, the Fifth Affiliated Hospital of Sun Yat-sen University, No.52 Meihua Road, Zhuhai, China
| | - Bin Zhang
- Department of Nephrology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan No. 2 Road, Guangzhou, China
| | - Zhuo Li
- Department of Nephrology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan No. 2 Road, Guangzhou, China
| | - Jianxiong Wu
- Department of Nephrology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan No. 2 Road, Guangzhou, China
| | - Xinling Liang
- Department of Nephrology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan No. 2 Road, Guangzhou, China
| | - Zheng Lin
- Department of Nephrology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan No. 2 Road, Guangzhou, China
| | - Wei Shi
- Department of Nephrology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan No. 2 Road, Guangzhou, China
- * E-mail:
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29
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Fukagawa M, Yokoyama K, Koiwa F, Taniguchi M, Shoji T, Kazama JJ, Komaba H, Ando R, Kakuta T, Fujii H, Nakayama M, Shibagaki Y, Fukumoto S, Fujii N, Hattori M, Ashida A, Iseki K, Shigematsu T, Tsukamoto Y, Tsubakihara Y, Tomo T, Hirakata H, Akizawa T. Clinical Practice Guideline for the Management of Chronic Kidney Disease-Mineral and Bone Disorder. Ther Apher Dial 2013; 17:247-88. [DOI: 10.1111/1744-9987.12058] [Citation(s) in RCA: 251] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Christov M, Waikar SS, Pereira RC, Havasi A, Leaf DE, Goltzman D, Pajevic PD, Wolf M, Jüppner H. Plasma FGF23 levels increase rapidly after acute kidney injury. Kidney Int 2013; 84:776-85. [PMID: 23657144 DOI: 10.1038/ki.2013.150] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 01/22/2013] [Accepted: 02/22/2013] [Indexed: 12/19/2022]
Abstract
Emerging evidence suggests that fibroblast growth factor 23 (FGF23) levels are elevated in patients with acute kidney injury (AKI). In order to determine how early this increase occurs we used a murine folic acid nephropathy model and found that plasma FGF23 levels increased significantly from baseline already after 1 hour of AKI, with an 18-fold increase at 24 hours. Similar elevations of FGF23 levels were found when AKI was induced in mice with osteocyte-specific parathyroid hormone receptor ablation or the global deletion of parathyroid hormone or vitamin D receptor, indicating that the increase in FGF23 was independent of parathyroid hormone and vitamin D signaling. Furthermore, FGF23 levels increased to a similar extent in wild-type mice maintained on normal or phosphate-depleted diets prior to induction of AKI, indicating that the marked FGF23 elevation is at least partially independent of dietary phosphate. Bone production of FGF23 was significantly increased in AKI. The half-life of intravenously administered recombinant FGF23 was only modestly increased. Consistent with the mouse data, plasma FGF23 levels rose 15.9-fold by 24 hours following cardiac surgery in patients who developed AKI. The levels were significantly higher than in those without postoperative AKI. Thus, circulating FGF23 levels rise rapidly during AKI in rodents and humans. In mice this increase is independent of established modulators of FGF23 secretion.
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Abstract
Parathyroid hormone (PTH) is a uremic toxin with multiple systemic effects including bone disorders (renal osteodystrophy), myopathy, neurologic abnormalities, anemia, pruritus, and cardiomyopathy. Hyperparathyroidism is common in CKD and results in significant morbidity and mortality if left untreated. Clinical practice guidelines from the Kidney Disease Improving Global Outcomes initiative broadened the optimal PTH range to >2 and <9 times the upper limit of normal for the assay measured. Furthermore, the guidelines recommend following trends in PTH to determine the appropriate therapy. These guidelines overcome issues with the assay variability and help clinicians make judgments when treating individual patients. They also require frequent measurement in order to determine trends and implement appropriate treatments.
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Affiliation(s)
- Stuart M Sprague
- Division of Nephrology and Hypertension, NorthShore University HealthSystem, Evanston, IL 60201, USA.
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32
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Christen P, Ito K, Müller R, Rubin MR, Dempster DW, Bilezikian JP, van Rietbergen B. Patient-specific bone modelling and remodelling simulation of hypoparathyroidism based on human iliac crest biopsies. J Biomech 2012; 45:2411-6. [PMID: 22883080 DOI: 10.1016/j.jbiomech.2012.06.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 05/28/2012] [Accepted: 06/28/2012] [Indexed: 01/18/2023]
Abstract
We previously developed a load-adaptive bone modelling and remodelling simulation model that can predict changes in the bone micro-architecture as a result of changes in mechanical loading or cell activity. In combination with a novel algorithm to estimate loading conditions, this offers the possibility for patient-specific predictions of bone modelling and remodelling. Based on such models, the underlying mechanisms of bone diseases and/or the effects of certain drugs and their influence on the bone micro-architecture can be investigated. In the present study we test the ability of this approach to predict changes in bone micro-architecture during hypoparathyroidism (HypoPT), as an illustrative example. We hypothesize that, apart from reducing bone turnover, HypoPT must also lead to increased osteocyte mechanosensitivity in order to explain the changes in bone mass seen in patients. Healthy human iliac crest biopsies were used as the starting point for the simulations that mimic HypoPT conditions and the resultant micro-architectures were compared to age-matched clinical HypoPT biopsies. Simulation results were in good agreement with the clinical data when osteocyte mechanosensitivity was increased by 40%. In conclusion, the results confirm our hypothesis, and also demonstrate that patient-specific bone modelling and remodelling simulations are feasible.
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Affiliation(s)
- Patrik Christen
- Eindhoven University of Technology, Department of Biomedical Engineering, Orthopaedic Biomechanics, PO Box 513, 5600 MB Eindhoven, The Netherlands.
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Hung KC, Huang CY, Liu CC, Wu CJ, Chen SY, Chu P, Wu CC, Lo L, Diang LK, Lu KC. Serum bone resorption markers after parathyroidectomy for renal hyperparathyroidism: correlation analyses for the cross-linked N-telopeptide of collagen I and tartrate-resistant acid phosphatase. ScientificWorldJournal 2012; 2012:503945. [PMID: 22919331 PMCID: PMC3417170 DOI: 10.1100/2012/503945] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 06/05/2012] [Indexed: 12/03/2022] Open
Abstract
Patients on long-term dialysis may develop secondary hyperparathyroidism (SHPT) with increased serum concentrations of bone resorption markers such as the cross-linked N-telopeptide of type I collagen (NTX) and type-5b tartrate-resistant acid phosphatase (TRAP). When SHPT proves refractory to treatment, parathyroidectomy (PTX) may be needed. Renal patients on maintenance HD who received PTX for refractory SHPT (n = 23) or who did not develop refractory SHPT (control subjects; n = 25) were followed prospectively for 4 weeks. Serum intact parathyroid hormone (iPTH), NTX, TRAP, and bone alkaline phosphatase (BAP) concentrations were measured serially and correlation analyses were performed. iPTH values decreased rapidly and dramatically. BAP values increased progressively with peak increases observed at 2 weeks after surgery. NTX and TRAP values decreased concurrently and progressively through 4 weeks following PTX. A significant correlation between TRAP and NTX values was observed before PTX but not at 4 weeks after PTX. Additionally, the fractional changes in serum TRAP were larger than those in serum NTX at all times examined after PTX. Serum iPTH, TRAP, and NTX values declined rapidly following PTX for SHPT. Serum TRAP values declined to greater degrees than serum NTX values throughout the 4-week period following PTX.
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Affiliation(s)
- Kuo-Chin Hung
- Department of Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, No. 510, Zhongzheng Road, Xinzhuang District, New Taipei City 24205, Taiwan
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Chu P, Wu CC, Chen CC, Lu KC. Parathyroidectomy leads to decreased blood lead levels in patients with refractory secondary hyperparathyroidism. Bone 2012; 50:1032-8. [PMID: 22373954 DOI: 10.1016/j.bone.2012.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 02/07/2012] [Accepted: 02/12/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Secondary hyperparathyroidism (SHPT) is characterized by high bone turnover and may result in increased release of lead (Pb) from bone stores. Parathyroidectomy (PTX) drastically changes bone remodeling. This study investigated the effects of PTX on the levels of blood lead (blood Pb) in patients with refractory SHPT. METHODS The study included 30 patients on long-term hemodialysis (HD) who underwent PTX in the nephrology units of two Taiwanese hospitals. Changes in serum levels of intact parathyroid hormone (iPTH), bone-specific alkaline phosphatase (BAP), type 5b tartrate-resistant acid phosphatase (TRAP), total calcium (tCa), and blood Pb were analyzed. RESULTS After PTX, serum iPTH was markedly decreased while serum BAP was progressively increased and peaked 2weeks after PTX. Serum TRAP levels were progressively decreased during the 4week follow-up period. Serum tCa and blood Pb levels decreased sharply immediately after PTX. There was a positive correlation between the percentage of decrease in tCa and blood Pb at one day after PTX. Further analysis indicated a significant positive correlation between levels of blood Pb and serum iPTH (r=0.378, p<0.001), blood Pb and serum TRAP (r=0.180, p<0.05), and a negative correlation between blood Pb and serum BAP (r=-0.205, p<0.05). CONCLUSION PTX effectively suppressed the elevated levels of blood Pb and serum bone remodeling markers, which are common features of SHPT. In addition to decreased Pb release from bone, an increased store of Pb in bone may play a role in decreasing serum blood Pb levels. These findings suggest that patients undergoing PTX for refractory SHPT should strictly avoid environmental exposure to Pb.
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Affiliation(s)
- Pauling Chu
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Lu KC, Ma WY, Yu JC, Wu CC, Chu P. Bone turnover markers predict changes in bone mineral density after parathyroidectomy in patients with renal hyperparathyroidism. Clin Endocrinol (Oxf) 2012; 76:634-42. [PMID: 22007930 DOI: 10.1111/j.1365-2265.2011.04265.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Patients on long-term dialysis may develop secondary hyperparathyroidism (SHPT), which causes varying degrees of bone mass loss. This condition is treated with parathyroidectomy (PTX). We investigated whether serial serum bone turnover markers could predict changes in bone mineral density (BMD) after PTX. DESIGN AND PATIENTS Renal patients on maintenance haemodialysis who received PTX for refractory SHPT (n = 26, male/female: 13/13; mean age: 48·6 ± 10·7 year) and control subjects without SHPT (n = 25) were prospectively followed for 1 year at two tertiary hospitals in Taiwan. MEASUREMENTS Serum intact parathyroid hormone (iPTH), bone-specific alkaline phosphatase (BAP) and type 5b tartrate-resistant acid phosphatase (TRAP) were measured serially. Additionally, femoral neck (FN) and lumbar spine (LS) BMD were measured before and 1 year after PTX. RESULTS After PTX, iPTH levels decreased markedly and persistently. BMDs increased in both the FN and LS, but particularly in the LS. Serum BAP progressively increased to a peak at 2 weeks after PTX. Serum TRAP levels progressively decreased over 6 months after PTX. In univariate correlation analyses, baseline iPTH correlated positively with T-score changes in FN (r = 0·45, P = 0·021) and LS (r = 0·48, P = 0·013). In multivariate regression models, changes in FN T-scores were negatively predicted by baseline BAP levels (r = -0·615, P = 0·005) and baseline FN T-scores (r = -0·563, P = 0·012), and they were positively predicted by baseline TRAP(r = 0·6, P = 0·007). Changes in LS T-scores were positively predicted by baseline TRAP values (r = 0·528, P = 0·01) and negatively predicted by the percentage change in BAP after 2 weeks (r = -0·501, P = 0·015). CONCLUSIONS Parathyroidectomy provided marked, sustained improvements in BMD for up to 1 year. Furthermore, markers of bone turnover predicted 1-year changes in FN and LS BMDs after PTX.
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Affiliation(s)
- Kuo-Cheng Lu
- Division of Nephrology, Department of Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
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Zheng CM, Chu P, Wu CC, Ma WY, Hung KC, Hsu YH, Lin YF, Diang LK, Lu KC. Association between increased serum osteoprotegerin levels and improvement in bone mineral density after parathyroidectomy in hemodialysis patients. TOHOKU J EXP MED 2012; 226:19-27. [PMID: 22156488 DOI: 10.1620/tjem.226.19] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Secondary hyperparathyroidism (SHPT) is a common complication in chronic renal disease. Osteoprotegerin (OPG), an extracellular cytokine receptor secreted by osteoblasts, can promote bone formation by inhibiting the function of osteoclasts. Hemodialysis (HD) patients have elevated serum OPG levels. OPG secretion can be suppressed with high parathyroid hormone (PTH) levels. HD patients with refractory SHPT can benefit from parathyroidectomy (PTX) treatment, but the changes of serum OPG, bone turnover markers and bone mineral density (BMD) following PTX in HD patients remain unclear. In this study, patients on maintenance HD who received PTX for refractory SHPT (n = 28) were prospectively followed for 1 year. Serum intact PTH (iPTH), alkaline phosphatase (Alk-P), and OPG were measured serially; BMD was measured pre-PTX and at 1 year after PTX. After PTX, serum iPTH levels reduced profoundly. Serum Alk-P levels increased rapidly, peaking at 2 weeks post-PTX, while serum OPG levels gradually increased at 2 weeks after PTX and peaked at 2 months. BMD improved in both femoral neck (FN; cancellous and cortical bone) and lumbar spine (LS; cancellous bone). Higher baseline iPTH levels were associated with greater FN and LS BMD improvements at one year after PTX. The increment of serum OPG was correlated with the increase in LS BMD, implying that inhibition of osteoclastic bone resorption may improve BMD within the first year after PTX. These findings suggest that PTX removes the suppressive effects of high PTH on OPG secretion, resulting in the increased serum OPG levels that may contribute to BMD improvement.
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Affiliation(s)
- Cai-Mei Zheng
- Division of Nephrology, Department of Medicine, Taipei Medical University-Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
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Lu KC, Wu CC, Ma WY, Chen CC, Wu HC, Chu P. Decreased blood lead levels after calcitriol treatment in hemodialysis patients with secondary hyperparathyroidism. Bone 2011; 49:1306-10. [PMID: 21985997 DOI: 10.1016/j.bone.2011.09.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 09/16/2011] [Accepted: 09/22/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Secondary hyperparathyroidism (SHP) is characterized by high bone turnover, which may, in turn, result in increased release of lead from bone stores. This study investigated the effects of intravenous calcitriol on blood lead (BL) levels in patients with SHP. METHODS Intravenous calcitriol therapy was administered for 16 wk to 28 patients who were on maintenance hemodialysis (HD) and had intact parathyroid hormone (iPTH) plasma levels of >300 pg/mL. Blood was drawn at baseline and every 4 wk for 16 wk to determine the levels of iPTH; bone remodeling markers, including bone-specific alkaline phosphatase (bAP) and type 5b tartrate-resistant acid phosphatase (TRAP); and BL. RESULTS Of the 28 patients, 25 responded to calcitriol therapy; they exhibited significant decrements in serum iPTH levels by the end of 4 wk of therapy and thereafter. After 16 wk of therapy, these patients had significant reductions in serum iPTH levels (p<0.01) and significant and parallel decreases in the levels of bAP (p<0.01), TRAP (p<0.01), and BL (p<0.01). Further analysis showed a significant positive correlation between the levels of BL and serum iPTH (r=0.34, p<0.01) and BL and serum TRAP (r=0.22, p<0.05). However, there was no significant correlation between the levels of BL and serum bAP. CONCLUSION Elevated levels of BL and serum bone remodeling markers, which are common features of SHP, can be effectively suppressed by calcitriol therapy. This indicates that hyperparathyroidism not only accelerates bone remodeling but may also enhance bone lead mobilization in patients on maintenance HD.
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Affiliation(s)
- Kuo-Cheng Lu
- Division of Nepheology, Department of Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan.
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Yajima A, Inaba M, Tominaga Y, Nishizawa Y, Ikeda K, Ito A. Increased osteocyte death and mineralization inside bone after parathyroidectomy in patients with secondary hyperparathyroidism. J Bone Miner Res 2010; 25:2374-81. [PMID: 20499355 DOI: 10.1002/jbmr.126] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In order to gain insight into the mechanisms underlying the dynamic changes in bone metabolism and bone quality after parathyroidectomy (PTX) in secondary hyperparathyroid patients with high levels of parathyroid hormone (PTH), we performed bone histomorphometric analysis with tetracycline labeling in iliac bone biopsy specimens taken before and after PTX, with special attention paid to osteocytes. At 2 to 4 weeks after PTX, PTH concentrations decreased markedly with evident reductions in bone turnover markers. Histomorphometry revealed that at 2 to 4 weeks following PTX, the osteoclast surface decreased to nearly 0%, with a substantial increase in osteoid volume and a reduction in fibrosis volume. Labeling with tetracycline was observed not only at the mineralization front on the bone surface but also around the osteocyte lacunar walls and canaliculi within both the basic multicellular units (BMUs) and bone structural units (BSUs), suggesting that mineralization was taking place along the lacunocanalicular system after PTX. The tetracycline-labeled area was much greater in the BSUs than in the BMUs and at the mineralization front, and the tetracycline labeling in the BSUs was markedly increased after PTX compared with that in the low- and high-PTH control groups without PTX. The osteocyte number was decreased significantly after PTX, concomitant with an increase in the number of empty lacunae and a reduction of lacunar volume. Thus the increased osteocyte death and mineralization around the lacunocanalicular system in association with a rapid decline in PTH may underlie the changes in bone metabolism and quality that occur following PTX.
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Affiliation(s)
- Aiji Yajima
- Department of Nephrology, Towa Hospital, Adachi-ku, Tokyo, Japan.
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Nambunmee K, Honda R, Nishijo M, Swaddiwudhipong W, Nakagawa H, Ruangyuttikarn W. Bone resorption acceleration and calcium reabsorption impairment in a Thai population with high cadmium exposure. Toxicol Mech Methods 2009; 20:7-13. [DOI: 10.3109/15376510903452941] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Goto S, Fujii H, Matsui Y, Fukagawa M. Marked increase in bone formation markers after cinacalcet treatment by mechanisms distinct from hungry bone syndrome in a haemodialysis patient. NDT Plus 2009; 3:71-3. [PMID: 25949410 PMCID: PMC4421542 DOI: 10.1093/ndtplus/sfp138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 08/28/2009] [Indexed: 01/24/2023] Open
Abstract
A 59-year-old female who was on dialysis due to diabetic nephropathy was referred to our hospital for severe hyperparathyroidism refractory to intravenous vitamin D receptor activator treatment. With subsequent cinacalcet hydrochloride treatment, parathyroid hormone (PTH) levels were only slightly suppressed. However, progressive increases were observed in serum alkaline phosphatase (ALP) and bone-specific alkaline phosphatase (BAP) levels with mild hypocalcaemia. A bone biopsy, obtained immediately before surgical parathyroidectomy after 3 months of cinacalcet treatment, revealed no disappearance of osteoclasts. These data suggest that cinacalcet hydrochloride treatment may induce a marked promotion of bone formation by mechanisms distinct from hungry bone syndrome that usually develops after parathyroidectomy.
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Affiliation(s)
- Shunsuke Goto
- Division of Nephrology and Kidney Center , Kobe University School of Medicine , Kobe
| | - Hideki Fujii
- Division of Nephrology and Kidney Center , Kobe University School of Medicine , Kobe
| | | | - Masafumi Fukagawa
- Division of Nephrology and Kidney Center , Kobe University School of Medicine , Kobe
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Tominaga Y, Matsuoka S, Uno N. Surgical and Medical Treatment of Secondary Hyperparathyroidism in Patients on Continuous Dialysis. World J Surg 2009; 33:2335-42. [DOI: 10.1007/s00268-009-9943-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Yajima A, Akizawa T, Tsukamoto Y, Kurihara S, Ito A. Impact of cinacalcet hydrochloride on bone histology in patients with secondary hyperparathyroidism. Ther Apher Dial 2009; 12 Suppl 1:S38-43. [PMID: 19032526 DOI: 10.1111/j.1744-9987.2008.00630.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Serum parathyroid hormone (PTH) levels are effectively decreased by cinacalcet hydrochloride (HCl) in patients with secondary hyperparathyroidism. We assessed the impact of cinacalcet HCl on bone histology in these patients. Four hemodialysis patients with secondary hyperparathyroidism (intact PTH > or = 300 pg/mL) were treated with cinacalcet HCl with low-doses of vitamin D sterols as well as calcium-based phosphate binders for 52 weeks. Patients 1, 2, 3 and 4 were aged 55, 65, 61 and 70 years old, and the duration of hemodialysis in the patients was 84, 176, 125 and 216 months, respectively. Serum intact PTH, serum bone metabolism markers and bone histomorphometric parameters were determined before and after 52 weeks of the treatment. Serum intact PTH decreased from 1110, 880, 330 and 980 pg/mL to 233, 80, 88 and 116 pg/mL, respectively, in the four patients after 52 weeks of treatment with cinacalcet HCl. Serum levels of bone metabolism markers and all of the histomorphometric resorption parameters decreased in these patients. In particular, fibrosis volume decreased to 0% in all of the patients. Static formation parameters, including osteoblast surface and osteoid-related parameters, all decreased after the treatment, indicating an increase of mineralized bone volume during the treatment. Dynamic parameters except for activation frequency decreased after the treatment, indicating significant suppression of bone turnover. Cinacalcet HCl with low-doses of vitamin D sterols suppressed serum PTH with no significant changes of serum calcium levels. In addition, long-term administration of cinacalcet HCl improved hyperparathyroid bone diseases in patients with secondary hyperparathyroidism.
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Affiliation(s)
- Aiji Yajima
- Department of Nephrology, Towa Hospital, Tokyo, Japan.
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Cheng S, Liu C, Chen H, Lee J, Liu T, Yang T. Prolonged Hospital Stay After Parathyroidectomy for Secondary Hyperparathyroidism. World J Surg 2009; 33:72-9. [DOI: 10.1007/s00268-008-9787-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Yajima A, Inaba M, Tominaga Y, Ito A. Bone formation by minimodeling is more active than remodeling after parathyroidectomy. Kidney Int 2008; 74:775-81. [PMID: 18528319 DOI: 10.1038/ki.2008.242] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bone formation using the process known as minimodeling forms only lamellar bone in the absence of prior bone resorption even in uremic patients. In patients undergoing parathyroidectomy for secondary hyperparathyroidism, we compared the contribution of minimodeling to remodeling during the change in bone volume. Iliac bone biopsies were used to measure parameters related to minimodeling and remodeling before, at 3 to 4 weeks and 10 to 12 weeks after parathyroidectomy. Osteoblast surface due to minimodeling was greater than the entire bone osteoblast surface before and at 10 to 12 weeks after parathyroidectomy, but not 3 to 4 weeks after surgery. Minimodeling significantly increased osteoid volume 3 to 4 weeks after parathyroidectomy. The rate of change of osteoid volume by minimodeling was greater than that of osteoid volume during the first 3 to 4 weeks after surgery, indicating osteoid formation was more active at the minimodeling surface than at the entire bone surface. Furthermore, higher mineral apposition rates at the minimodeling sites than at remodeling sites yielded increased minimodeling bone volume at 10 to 12 weeks after surgery. Our results show that bone formation by minimodeling is more active than by remodeling and accounts, in part, for the increase of bone volume following parathyroidectomy.
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Yajima A, Inaba M, Tominaga Y, Ito A. Minimodeling Reduces the Rate of Cortical Bone Loss in Patients With Secondary Hyperparathyroidism. Am J Kidney Dis 2007; 49:440-51. [PMID: 17336706 DOI: 10.1053/j.ajkd.2006.11.045] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Accepted: 11/28/2006] [Indexed: 11/11/2022]
Abstract
BACKGROUND Secondary hyperparathyroidism often causes progressive cortical thinning because of increased bone resorption at the endocortical surface and increases cortical porosity because of increased resorption at the intracortical surface. Because bone formation by minimodeling has not yet been reported in cortical bone, we investigated the effects of cortical minimodeling on the decrease in rate of bone loss. METHODS Thirty-five patients with secondary hyperparathyroidism were enrolled. Remodeling and minimodeling parameters at the endocortical and periosteal surfaces, as well as at the intracortical surface, were measured. Relationships between remodeling parameters and minimodeling parameters at each surface were investigated by using linear regression analysis. Cortical bone specimens were classified into 3 groups according to cortical width and cortical porosity values. Relationships of minimodeling parameters at the endocortical surface with cortical width and at the intracortical surface with cortical porosity were investigated. RESULTS Some minimodeling parameters showed positive correlations with serum parathyroid hormone levels and remodeling parameters. Minimodeling bone volume at the endocortical surface was greater in the narrow-cortical-width group than wide-cortical-width group, possibly slowing the progression of cortical thinning. Minimodeling volume at the intracortical surface was greater in the high-porosity than low-porosity group, possibly slowing the progression of intracortical resorption space enlargement. Minimodeling of the periosteal surface was found in 1 specimen. CONCLUSION Results show enhanced cortical minimodeling in patients with secondary hyperparathyroidism, possibly representing the decrease in rate of cortical bone loss.
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Affiliation(s)
- Aiji Yajima
- Department of Nephrology, Towa Hospital, Tokyo, Japan.
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Hata T, Irei I, Tanaka K, Nagatsuka H, Hosoda M. Macrognathia secondary to dialysis-related renal osteodystrophy treated successfully by parathyroidectomy. Int J Oral Maxillofac Surg 2006; 35:378-82. [PMID: 16360304 DOI: 10.1016/j.ijom.2005.08.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2005] [Revised: 07/29/2005] [Accepted: 08/19/2005] [Indexed: 11/28/2022]
Abstract
Renal osteodystrophy (ROD) is one of the most common complications affecting patients with chronic renal failure both before and after the initiation of maintenance dialysis, but macrognathia secondary to ROD is rare. Usually, enlarged jaws due to ROD do not return to their normal contours after the treatment of hyperparathyroidism. To the authors' knowledge, this article describes the second case of macrognathia secondary to dialysis-related ROD treated successfully by parathyroidectomy. Immunohistochemical study of the maxilla confirmed that parathyroidectomy could stop maladaptive parathyroid hormone stimulation, which leads not only to the formation of osteoblastic progenitors that become fibroblast-like cells but also to osteoclast formation.
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Affiliation(s)
- T Hata
- Department of Oral Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki-shi, Okayama 701-0192, Japan.
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Abstract
Parathyroid hyperplasia, oversecretion of parathyroid hormone (PTH), and hyperparathyroid bone disease are characteristic features of chronic uremia; they develop early in the course of uremia and often in a progressive way. This review focuses on the potential for arrest or regression of hyperparathyroid-induced bone disease. For this purpose, the review addresses investigations that have used bone histology and not investigations that indirectly attempted to demonstrate changes in the skeleton by measurements of bone mineral density or laboratory indices of bone turnover, other than PTH. A prerequisite for inducing regression of the hyperparathyroid bone disease is a significant suppression of PTH secretion or reversal of hyperparathyroidism and uremia. It is concluded, on the basis of paired bone biopsy studies in patients with established hyperparathyroid bone disease, that bone histology can be improved or normalized after treatment that diminishes PTH levels. Oversuppression of PTH levels, however, might lead to adynamic bone disease.
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Affiliation(s)
- Klaus Olgaard
- University of Copenhagen, Department of Nephrology, P2132, Rigshospitalet, 9 Blegdamsvej, DK-2100 Copenhagen, Denmark.
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