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Meriam H, Kaaroud H, Karray R, Ben Hamida F, Bouzid K, Abderrahim E. Recurrent Urolithiasis Revealing Primary Hyperparathyroidism in a Nephrology Department. Case Rep Nephrol 2024; 2024:1265364. [PMID: 38419822 PMCID: PMC10901575 DOI: 10.1155/2024/1265364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/12/2024] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Background Urinary lithiasis constitutes a recurrent pathology affecting a relatively young population. The risk of progression to chronic renal failure and the cost of treatment are the most important issues. Primary hyperparathyroidism (PHPT) is responsible for urolithiasis and nephrocalcinosis in 7% of patients, and it represents the 7th cause of urolithiasis in Tunisia. Unfortunately, it remains an underdiagnosed pathology although it is curable. We aim to determine the clinical, biological, therapeutic, and evolutionary particularities of urinary lithiasis associated with PHPT in a nephrology setting. Methods This is a monocentric, retrospective, descriptive study which took place in our nephrology department during the period from January 2010 to January 2023. Ten patients were included. All of them underwent blood and urine tests and a morphoconstitutional study of the urinary stones if possible. Results The median age at diagnosis of PHPT was 42 years (34-54). The median time from the onset of kidney stones to the diagnosis of PHPT was 6.2 years (1-17). The male/female gender ratio was 0.66. Five patients had hypertension, two patients had obesity, one patient had diabetes, and three patients had urinary tract infections. Kidney stones were bilateral in eight cases and unilateral in two cases. Nine patients underwent urological intervention: surgery in 5 cases associated with nephrectomy in one case, extracorporeal lithotripsy in 4 cases, and percutaneous nephrolithotomy in two cases. The diagnosis of PHPT was retained with high or uncontrolled PTH associated with hypercalcemia in 8 cases and normocalcemic PHPT was found in 2 patients. Two patients had parathyroid adenoma and one patient had mediastinal adenoma. Radiology exploration was normal for the others patients. Surgery was performed in 7 patients and histology revealed an adenoma in 5 cases and hyperplasia in one case. The predominant urinary risk factors in our study were hypercalciuria in 6 cases and insufficient diuresis in 4 cases. Conclusion This study underlines the role of the nephrologist in the exploration of urinary lithiasis and the prevention of recurrences, especially as PHPT is a curable aetiology of urolithiasis and affects a relatively young population. The determination of the epidemiological profile of patients with stones associated with primary PHPT and lithogenic risk factors allows the primary and secondary prevention of stone formation.
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Affiliation(s)
- Hajji Meriam
- Department of Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
- Kidney Pathology Laboratory LR00SP01, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
| | - Hayet Kaaroud
- Department of Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
- Kidney Pathology Laboratory LR00SP01, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
| | - Rahma Karray
- Department of Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
| | - Fethi Ben Hamida
- Department of Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
- Kidney Pathology Laboratory LR00SP01, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
| | - Kahena Bouzid
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
- Department of Biochemistry, Charles Nicolle Hospital, Tunis, Tunisia
| | - Ezzeddine Abderrahim
- Department of Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
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Yedla N, Kim H, Sharma A, Wang X. Vitamin D Deficiency and the Presentation of Primary Hyperparathyroidism: A Mini Review. Int J Endocrinol 2023; 2023:1169249. [PMID: 38115826 PMCID: PMC10728357 DOI: 10.1155/2023/1169249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 10/25/2023] [Accepted: 11/02/2023] [Indexed: 12/21/2023] Open
Abstract
The clinical presentation of primary hyperparathyroidism (PHPT) has evolved over the years from a symptomatic disorder to a predominantly asymptomatic condition. Altered vitamin D metabolism seems to play a role in the presentation of PHPT and may exacerbate the severity of disease. The epidemiology of PHPT differs in the developing versus the developed world, where more severe phenotypes occur in regions where vitamin D deficiency is common. Although it has been validated that patients with PHPT should be vitamin D sufficient, the threshold to supplement in relation to the severity of PHPT and the degree of vitamin D deficiency remains controversial. This review will highlight some of the controversy regarding vitamin D deficiency and the different phenotypes of PHPT.
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Affiliation(s)
- Niharika Yedla
- Department of Endocrinology, Quincy Medical Group, 1025 Maine Street, Quincy, IL 62301, USA
| | - Hyon Kim
- Division of Endocrinology, Metabolism and Nutrition, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, MEB 374, 1 RWJ Place, New Brunswick, NJ 08903-0019, USA
| | - Anupa Sharma
- Penn Medicine Princeton Medicine Physicians, 5 Plainsboro Road, Plainsboro, NJ 08536, USA
| | - Xiangbing Wang
- Division of Endocrinology, Metabolism and Nutrition, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, MEB 374, 1 RWJ Place, New Brunswick, NJ 08903-0019, USA
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Dos Santos LM, Ohe MN, Pallone SG, Nacaguma IO, Kunii IS, da Silva REC, Maeda SS, Vieira JGH, Lazaretti-Castro M. Levels of bioavailable, and free forms of 25(OH)D after supplementation with vitamin D 3 in primary hyperparathyroidism. Endocrine 2023; 80:183-190. [PMID: 36574149 DOI: 10.1007/s12020-022-03265-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 11/16/2022] [Indexed: 12/29/2022]
Abstract
The 25 hydroxyvitamin D [25(OH)D] is the major metabolite for ascertaining vitamin D status, which circulates bound to a specific carrier (vitamin D-binding protein - VDBP). A portion that circulates unbound vary according to the VDBP genotype. This study evaluates the behavior of different forms of 25(OH)D, before and after supplementation with 14,000 IU of vitamin D3, weekly for 12 weeks, in individuals with primary hyperparathyroidism and controls. Fifty-six patients with active primary hyperparathyroidism (PHPT) and 64 paired controls (CTRL), not taking vitamin D3 for the last three months, were enrolled. The genetic isotypes of VDBP were determined to calculate bioavailable and free 25(OH)D. A p < 0.05 was considered significant. There were no statistical differences in free, bioavailable, and total 25(OH)D levels between PHPT and CTRL groups at baseline. The distribution of VDBP haplotypes 1s/1s, 1f/1f, 1s/1f, 2/2, 1s/2, and 1f/2 was similar between groups. After supplementation, all three forms of 25(OH)D proportionally increased within each group, although the percentage increment was lower in the PHPT group (p < 0.05). Total 25(OH)D is better correlated with PTH in the PHPT group than bioavailable and free 25(OH)D (r = -0.41; p < 0.05). The concentrations of total, free, and bioavailable 25(OH)D were similar in both PHPT and CTRL groups, and all forms increased proportionally after supplementation, although this increment percentage was higher in the CTRL group, with a subsequent reduction of PTH and AP. Total 25(OH)D correlated better with PTH than other forms, suggesting no advantages in measuring free or bioavailable 25(OH)D in these situations.
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Affiliation(s)
- Lívia Marcela Dos Santos
- Department of Medicine, Endocrinology Unit, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil.
| | - Monique Nakayama Ohe
- Department of Medicine, Endocrinology Unit, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Sthefanie Giovanna Pallone
- Department of Medicine, Endocrinology Unit, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Isabela Ohki Nacaguma
- Department of Medicine, Endocrinology Unit, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Ilda Sizue Kunii
- Department of Medicine, Endocrinology Unit, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Renata Elen Costa da Silva
- Department of Medicine, Endocrinology Unit, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Sergio Setsuo Maeda
- Department of Medicine, Endocrinology Unit, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | - Marise Lazaretti-Castro
- Department of Medicine, Endocrinology Unit, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
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Santos LM, Ohe M, Pallone S, Nacaguma I, Kunii I, Silva R, Brandão CM, Vieira JG, Lazaretti-Castro M. Concentrations of total, bioavailable, and free 25OHD in individuals with and without primary hyperparathyroidism and their correlations to DXA and trabecular bone score. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2023; 67:242-250. [PMID: 36651703 PMCID: PMC10689035 DOI: 10.20945/2359-3997000000529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/08/2022] [Indexed: 01/19/2023]
Abstract
Objective This study aimed to investigate the association between 25OHD (total, bioavailable and free) with bone mass and microarchitecture among primary hyperparathyroidism (PHPT) patients and controls. Subjects and methods Sixty-four patients in the preoperative period of PHPT and 63 matched controls, who had not taken vitamin D in the last three months. To calculate the bioavailable and free 25OHD, the genetic variants of the vitamin D-binding protein (DBP) were determined. Bone mineral density (BMD) was determined by dual-energy X-ray absorptiometry (DXA). The distributions of total, bioavailable and free 25OHD and their correlation with TBS and DXA were evaluated. Results PHPT showed BMD and TBS values lower than CTRL in all locations (p < 0.05). There were no statistical differences in the levels of free, bioavailable and total 25OHD between the PHPT and CTRL groups [mean, min-max: 3.4 (1.4-8.6) vs. 3.1 (1.0- 9.8) pg/mL, 1.51 (0.43-3.58) vs. 1.41 (0.38-3.48) ng/mL, 22.6 (11.0-39.9) vs. 20.6 (8.9-35.3) ng/dL, respectively; (p > 0.05). The distribution of DBP haplotypes was similar between groups. DXA showed no correlation with any form of 25OHD in both groups. TBS presented a weak correlation with the total 25OHD in PHPT (r = 0.28; p = 0.02) and a moderate correlation with the total, free and bioavailable 25OHD in CTRL (r = 0.42; r = 0.42; r = 0.43; respectively, p < 0.01). Conclusion The concentrations of total, free and bioavailable 25OHD were similar in both the PHPT and control groups. 25OHD concentrations correlated positively with TBS and not with DXA, especially in controls, suggesting that this method may be more sensitive to assessing the consequences of vitamin D deficiency on bone quality in individuals without PHPT.
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Affiliation(s)
- Lívia Marcela Santos
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil,
| | - Monique Ohe
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
| | - Sthefanie Pallone
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
| | - Isabela Nacaguma
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
| | - Ilda Kunii
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
| | - Renata Silva
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
| | - Cynthia Maria Brandão
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
| | - José Gilberto Vieira
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brasil
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Tu CL, Chang W, Sosa JA, Koh J. Digital spatial profiling of human parathyroid tumors reveals cellular and molecular alterations linked to vitamin D deficiency. PNAS NEXUS 2023; 2:pgad073. [PMID: 36992820 PMCID: PMC10042281 DOI: 10.1093/pnasnexus/pgad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/22/2023] [Accepted: 03/02/2023] [Indexed: 03/12/2023]
Abstract
Primary hyperparathyroidism (PHPT) is a common endocrine neoplastic disorder characterized by disrupted calcium homeostasis secondary to inappropriately elevated parathyroid hormone (PTH) secretion. Low levels of serum 25-hydroxyvitamin D (25OHD) are significantly more prevalent in PHPT patients than in the general population (1-3), but the basis for this association remains unclear. We employed a spatially defined in situ whole-transcriptomics and selective proteomics profiling approach to compare gene expression patterns and cellular composition in parathyroid adenomas from vitamin D-deficient or vitamin D-replete PHPT patients. A cross-sectional panel of eucalcemic cadaveric donor parathyroid glands was examined in parallel as normal tissue controls. Here, we report that parathyroid tumors from vitamin D-deficient PHPT patients (Def-Ts) are intrinsically different from those of vitamin D-replete patients (Rep-Ts) of similar age and preoperative clinical presentation. The parathyroid oxyphil cell content is markedly higher in Def-Ts (47.8%) relative to Rep-Ts (17.8%) and normal donor glands (7.7%). Vitamin D deficiency is associated with increased expression of electron transport chain and oxidative phosphorylation pathway components. Parathyroid oxyphil cells, while morphologically distinct, are comparable to chief cells at the transcriptional level, and vitamin D deficiency affects the transcriptional profiles of both cell types in a similar manner. These data suggest that oxyphil cells are derived from chief cells and imply that their increased abundance may be induced by low vitamin D status. Gene set enrichment analysis reveals that pathways altered in Def-Ts are distinct from Rep-Ts, suggesting alternative tumor etiologies in these groups. Increased oxyphil content may thus be a morphological indicator of tumor-predisposing cellular stress.
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Affiliation(s)
- Chia-Ling Tu
- Endocrine Research Unit, Department of Medicine, San Francisco Department of Veterans Affairs Medical Center, University of California San Francisco, San Francisco, CA 94158
| | - Wenhan Chang
- Endocrine Research Unit, Department of Medicine, San Francisco Department of Veterans Affairs Medical Center, University of California San Francisco, San Francisco, CA 94158
| | - Julie A Sosa
- Endocrine Neoplasia Laboratory, Department of Surgery, University of California San Francisco, San Francisco, CA 94143
| | - James Koh
- Endocrine Neoplasia Laboratory, Department of Surgery, University of California San Francisco, San Francisco, CA 94143
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Minisola S, Arnold A, Belaya Z, Brandi ML, Clarke BL, Hannan FM, Hofbauer LC, Insogna KL, Lacroix A, Liberman U, Palermo A, Pepe J, Rizzoli R, Wermers R, Thakker RV. Epidemiology, Pathophysiology, and Genetics of Primary Hyperparathyroidism. J Bone Miner Res 2022; 37:2315-2329. [PMID: 36245271 PMCID: PMC10092691 DOI: 10.1002/jbmr.4665] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/18/2022] [Accepted: 07/29/2022] [Indexed: 11/11/2022]
Abstract
In this narrative review, we present data gathered over four decades (1980-2020) on the epidemiology, pathophysiology and genetics of primary hyperparathyroidism (PHPT). PHPT is typically a disease of postmenopausal women, but its prevalence and incidence vary globally and depend on a number of factors, the most important being the availability to measure serum calcium and parathyroid hormone levels for screening. In the Western world, the change in presentation to asymptomatic PHPT is likely to occur, over time also, in Eastern regions. The selection of the population to be screened will, of course, affect the epidemiological data (ie, general practice as opposed to tertiary center). Parathyroid hormone has a pivotal role in regulating calcium homeostasis; small changes in extracellular Ca++ concentrations are detected by parathyroid cells, which express calcium-sensing receptors (CaSRs). Clonally dysregulated overgrowth of one or more parathyroid glands together with reduced expression of CaSRs is the most important pathophysiologic basis of PHPT. The spectrum of skeletal disease reflects different degrees of dysregulated bone remodeling. Intestinal calcium hyperabsorption together with increased bone resorption lead to increased filtered load of calcium that, in addition to other metabolic factors, predispose to the appearance of calcium-containing kidney stones. A genetic basis of PHPT can be identified in about 10% of all cases. These may occur as a part of multiple endocrine neoplasia syndromes (MEN1-MEN4), or the hyperparathyroidism jaw-tumor syndrome, or it may be caused by nonsyndromic isolated endocrinopathy, such as familial isolated PHPT and neonatal severe hyperparathyroidism. DNA testing may have value in: confirming the clinical diagnosis in a proband; eg, by distinguishing PHPT from familial hypocalciuric hypercalcemia (FHH). Mutation-specific carrier testing can be performed on a proband's relatives and identify where the proband is a mutation carrier, ruling out phenocopies that may confound the diagnosis; and potentially prevention via prenatal/preimplantation diagnosis. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | - Andrew Arnold
- Center for Molecular Oncology and Division of Endocrinology & Metabolism, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Zhanna Belaya
- Department of Neuroendocrinology and Bone Disease, The National Medical Research Centre for Endocrinology, Moscow, Russia
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
| | - Bart L Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Fadil M Hannan
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, Oxford, UK.,Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Lorenz C Hofbauer
- Division of Endocrinology, Diabetes, and Bone Diseases & Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
| | - Karl L Insogna
- Yale Bone Center Yale School of Medicine, Yale University, New Haven, CT, USA
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
| | - Uri Liberman
- Department of Physiology and Pharmacology, Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Andrea Palermo
- Unit of Metabolic Bone and Thyroid Disorders, Fondazione Policlinico Universitario Campus Bio-Medico and Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Jessica Pepe
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | - René Rizzoli
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Robert Wermers
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition and Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, Oxford, UK.,Oxford National Institute for Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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Lee JE, Hong N, Kim JK, Lee CR, Kang SW, Jeong JJ, Nam KH, Chung WY, Rhee Y. Analysis of the cause and management of persistent laboratory abnormalities occurring after the surgical treatment of primary hyperparathyroidism. Ann Surg Treat Res 2022; 103:12-18. [PMID: 35919112 PMCID: PMC9300437 DOI: 10.4174/astr.2022.103.1.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/05/2022] [Accepted: 06/02/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose The surgical success rate for primary hyperparathyroidism (PHPT) is currently 95%–98%. However, 3%–24% of patients show persistently elevated (Pe) parathyroid hormone (PTH) levels after parathyroidectomy (PTX). This single-center retrospective study aimed to compare the outcomes of patients with normal PTH and PePTH levels after successful PTX and to identify the factors associated with PePTH. Methods The normal group, defined as patients with normal serum calcium and PTH levels immediately after PTX, was compared with the PePTH group (patients with normal or low serum calcium and increased serum PTH levels up to 6 months postoperatively) to determine the causes of disease in the PePTH group. Results There were no significant differences in age, sex, or preoperative estimated glomerular filtration rate between the normal PTH group (333 of 364, 91.5%) and the PePTH group (31 of 364, 8.5%). However, there were significant differences in preoperative 25-hydroxyvitamin D (17.9 and 11.8 ng/mL, respectively; P = 0.003) and PTH levels (125.5 and 212.4 pg/mL, respectively; P < 0.001) between the 2 groups. Among the 31 cases of the PePTH group, 18 were attributed to vitamin D deficiency. Conclusion Preoperative vitamin D deficiency is a predictive factor for PePTH. Therefore, preoperative administration of vitamin D supplements may reduce the probability of postoperative disease persistence. Patients with temporary laboratory abnormalities within 6 months after successful PTX should be monitored, and appropriate vitamin D and calcium supplementation may reduce the effort and cost of various examinations or reoperations.
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Affiliation(s)
- Ji-Eun Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Namki Hong
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyong Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Cho Rok Lee
- Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Sang-Wook Kang
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Ju Jeong
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kee-Hyun Nam
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Woong Youn Chung
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yumie Rhee
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Маганева ИС, Пигарова ЕА, Шульпекова НВ, Дзеранова ЛК, Еремкина АК, Милютина АП, Поваляева АА, Жуков АЮ, Богданов ВП, Рожинская ЛЯ, Мокрышева НГ. [Vitamin D metabolite and calcium phosphorus metabolism in in patients with primary hyperparathyroidism on the background of bolus therapy with colecalciferol]. PROBLEMY ENDOKRINOLOGII 2021; 67:68-79. [PMID: 35018763 PMCID: PMC9753807 DOI: 10.14341/probl12851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Vitamin D (25-hydroxyvitamin D [25(ОН)D]) deficiency (<20 ng/mL) and insufficiency (20-29 ng/mL) are common in primary hyperparathyroidism (PHPT), but data regarding the vitamin D metabolism in this population is limited. AIM The aim of this study is to estimate the vitamin D metabolites and their relationship with the main parameters of phosphorus-calcium metabolism in patients with PHPT at baseline and on the background of a single dose of cholecalciferol 150,000 IU. MATERIALS AND METHODS A single-center interventional, dynamic, prospective, comparative study has been carried out. The study included 54 participants, divided into two groups: the 1st group included 27 patients with confirmed PHPT, the 2nd control group (n = 27), matched on gender (p = 0.062). The study included 4 visits; the baseline laboratory examination and a bolus dose of cholecalciferol were performed at the visit 1, the subsequent visits included a dynamic laboratory examination. RESULTS Vitamin D deficiency (<20 ng/ml) was detected in 69% of patients with PHPT. In the PHPT group (before cholecalciferol therapy), there was a direct association of 1.25(OH)2 D3 with albumin-corrected and ionized calcium, as well as between the 25(OH)D3 /24.25(OH)2 D3 ratio with PTH and magnesium. After taking of cholecalciferol, the levels of 1.25(OH)2 D3 and 25(OH)D3 /24.25(OH)2 D3 were significantly increased, and the levels of 25(OH)D3 /1.25(OH)2 D3 were significantly declined at all visits among patients with PHPT. The common 25(OH)D level was comparable to the control group, however the levels of 1,25(OH)2 D3 in patients with PHPT were 55% higher at baseline, and after taking of cholecalciferol 150,000 IU. They remained increased by 3-7 days by an additional 23-36%, significantly higher than those in the control group: 44%, 74% and 65%, at visits 2, 3 and 4, respectively (p<0.05). The taking of 150,000 IU cholecalciferol in the PHPT group did not lead to a significant increase in hypercalcemia and hypercalciuria, which indicates the safety of this dose in patients with mild hypercalcemia (albumin corrected calcium <3 mmol/l). None of the study participants experienced any side effects. CONCLUSION The completely comprehensive assessment of vitamin D metabolites was carried out for the first time in patients with PHPT before and after using a bolus dose of cholecalciferol. The results confirmed the differences of vitamin D metabolism in chronic excessive secretion of PTH compared to control group, which is new data in the pathogenesis of the disease, and can be used to develop optimal regimens for cholecalciferol taking in this population.
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Affiliation(s)
- И. С. Маганева
- Национальный медицинский исследовательский центр эндокринологии
| | - Е. А. Пигарова
- Национальный медицинский исследовательский центр эндокринологии
| | | | - Л. К. Дзеранова
- Национальный медицинский исследовательский центр эндокринологии
| | - А. К. Еремкина
- Национальный медицинский исследовательский центр эндокринологии
| | - А. П. Милютина
- Национальный медицинский исследовательский центр эндокринологии
| | - А. А. Поваляева
- Национальный медицинский исследовательский центр эндокринологии
| | - А. Ю. Жуков
- Национальный медицинский исследовательский центр эндокринологии
| | - В. П. Богданов
- Национальный медицинский исследовательский центр эндокринологии
| | - Л. Я. Рожинская
- Национальный медицинский исследовательский центр эндокринологии
| | - Н. Г. Мокрышева
- Национальный медицинский исследовательский центр эндокринологии
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Bilezikian JP, Formenti AM, Adler RA, Binkley N, Bouillon R, Lazaretti-Castro M, Marcocci C, Napoli N, Rizzoli R, Giustina A. Vitamin D: Dosing, levels, form, and route of administration: Does one approach fit all? Rev Endocr Metab Disord 2021; 22:1201-1218. [PMID: 34940947 PMCID: PMC8696970 DOI: 10.1007/s11154-021-09693-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2021] [Indexed: 02/07/2023]
Abstract
The 4th International Conference on Controversies in Vitamin D was held as a virtual meeting in September, 2020, gathering together leading international scientific and medical experts in vitamin D. Since vitamin D has a crucial role in skeletal and extra-skeletal systems, the aim of the Conference was to discuss improved management of vitamin D dosing, therapeutic levels and form or route of administration in the general population and in different clinical conditions. A tailored approach, based on the specific mechanisms underlying vitamin D deficiency in different diseases that were discussed, was recommended. Specifically, in comparison to healthy populations, higher levels of vitamin D and greater amounts of vitamin D were deemed necessary in osteoporosis, diabetes mellitus, obesity (particularly after bariatric surgery), and in those treated with glucocorticoids. Emerging and still open issues were related to target vitamin D levels and the role of vitamin D supplementation in COVID-19 since low vitamin D may predispose to SARS-CoV-2 infection and to worse COVID-19 outcomes. Finally, whereas oral daily cholecalciferol appears to be the preferred choice for vitamin D supplementation in the general population, and in most clinical conditions, active vitamin D analogs may be indicated in patients with hypoparathyroidism and severe kidney and liver insufficiency. Parenteral vitamin D administration could be helpful in malabsorption syndromes or in states of vitamin D resistance.Specific guidelines for desired levels of vitamin D should be tailored to the different conditions affecting vitamin D metabolism with the goal to define disease-specific normative values.
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Affiliation(s)
- John P Bilezikian
- Department of Medicine, Endocrinology Division, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, San Raffaele, Vita-Salute University and IRCCS Hospital, Milano, Italy
| | - Robert A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | | | - Roger Bouillon
- Laboratory of Clinical and Experimental Endocrinology, Department of chronic diseases, metabolism and ageing, Leuven, KU, Belgium
| | - Marise Lazaretti-Castro
- Division of Endocrinology, Escola Paulista de Medicina - Universidade Federal de Sao Paulo (EPM-UNIFESP), Sao Paulo, Brazil
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
| | - Rene Rizzoli
- Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele, Vita-Salute University and IRCCS Hospital, Milano, Italy.
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Primary Hyperparathyroidism in Pregnancy: Literature Review of the Diagnosis and Management. J Clin Med 2021; 10:jcm10132956. [PMID: 34209340 PMCID: PMC8268799 DOI: 10.3390/jcm10132956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 12/28/2022] Open
Abstract
Background: Parathyroid disease is uncommon in pregnancy. During pregnancy, multiple changes occur in the calcium regulating hormones which may make the diagnosis of primary hyperparathyroidism more challenging. Close monitoring of serum calcium during pregnancy is necessary in order to optimize maternal and fetal outcomes. In this review, we will describe the diagnosis and management of primary hyperparathyroidism during pregnancy. Methods: We searched MEDLINE, CINAHL, EMBASE and Google scholar bases from 1 January 1990 to 31 December 2020. Case reports, case series, book chapters and clinical guidelines were included in this review. Conclusions: Medical management options for primary hyperparathyroidism during pregnancy are severely limited due to inadequate safety data with the various potential therapies available, and surgery is advised during the 2nd trimester of pregnancy in the presence of severe hypercalcemia (calcium adjusted for albumin greater than 3.0 mmol/L (12.0 mg/dL)). Hypercalcemia should be avoided during pregnancy in order to minimize maternal and fetal complications.
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11
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Dandurand K, Ali DS, Khan AA. Primary Hyperparathyroidism: A Narrative Review of Diagnosis and Medical Management. J Clin Med 2021; 10:jcm10081604. [PMID: 33918966 PMCID: PMC8068862 DOI: 10.3390/jcm10081604] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/26/2021] [Accepted: 04/06/2021] [Indexed: 12/13/2022] Open
Abstract
Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia in the outpatient setting. Symptomatic presentation includes non-specific signs and symptoms of hypercalcemia, skeletal fragility, nephrolithiasis and nephrocalcinosis. The majority of individuals present at an asymptomatic stage following routine biochemical screening, without any signs or symptoms of calcium or parathyroid hormone (PTH) excess or target organ damage. Indications for surgery have recently been revised as published in recent guidelines and consensus statements. Parathyroidectomy is advised in patients younger than 50 years old and in the presence of either significant hypercalcemia, impaired renal function, renal stones or osteoporosis. Surgery is always appropriate in suitable surgical candidates, however, medical management may be considered in those with mild asymptomatic disease, contraindications to surgery or failed previous surgical intervention. We summarized the optimal medical interventions available in the care of PHPT patients not undergoing parathyroidectomy. Calcium and vitamin D intake should be optimized. Antiresorptive therapy may be used for skeletal protection in patients with an increased fracture risk. Cinacalcet, a calcimimetic agent, has been shown to effectively lower serum calcium and PTH levels. The effect of medical treatment on the reduction in fracture risk is unknown and should be the focus of future research.
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12
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Lin X, Fan Y, Zhang Z, Yue H. Clinical Characteristics of Primary Hyperparathyroidism: 15-Year Experience of 457 Patients in a Single Center in China. Front Endocrinol (Lausanne) 2021; 12:602221. [PMID: 33716964 PMCID: PMC7947808 DOI: 10.3389/fendo.2021.602221] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/12/2021] [Indexed: 12/19/2022] Open
Abstract
Objective Primary hyperparathyroidism (PHPT) is a common endocrine disorder of calcium metabolism. However, data concerning a large cohort of PHPT patients in the Chinese population are scarce. Thus, the objective of this study was to determine the general clinical signatures of 457 Chinese PHPT patients and explore the clinical characteristic differences between benign and malignant PHPT. Methods A single-center retrospective study was designed. Medical records between preoperation and postoperative follow-up, were assessed and statistical analysis of the clinical data was performed. Results Patients with PHPT aged 12-87 years, with a mean onset age of 56.16 ± 14.60 years, were included. Most patients (68.7%) in our center had symptomatic patterns described as bone pain (74.8%), urolithiasis (25.5%), fatigue (17.5%), and pathological fracture (13.1%), but an increasing tendency has been established in the proportion of patients with asymptomatic forms. Correlation analysis revealed that patients with higher serum levels of parathyroid hormone (PTH) and calcium presented higher serum levels of bone turnover markers (BTMs) and lower 25-hydroxy-vitamin D (25OHD) values (P<0.001). Gains in bone mineral density (BMD) at L1-4, the femoral neck and the total hip were observed 1-2 years after parathyroidectomy (9.6, 5.9, and 6.8%). Parathyroid carcinoma patients presented prominently higher serum PTH and calcium levels and BTMs and lower BMD at femoral neck and total hip than benign PHPT patients (P<0.05), while no significant differences in age, sex, and serum 25OHD concentration were observed between benign and malignant PHPT patients. Conclusions PHPT should be paid attention to in the patients with bone pain. While, BMD and BTMs can differentiate parathyroid carcinoma from parathyroid adenoma and hyperplasia to some extent. In addition, anti-osteoporosis drugs could be used when necessary to avoid hip fractures in patients with parathyroid carcinoma.
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Affiliation(s)
- Xiaoyun Lin
- Shanghai Clinical Research Center of Bone Diseases, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Youben Fan
- Department of General Surgery, Thyroid and Parathyroid Center, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Zhenlin Zhang
- Shanghai Clinical Research Center of Bone Diseases, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Hua Yue
- Shanghai Clinical Research Center of Bone Diseases, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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13
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Salman MA, Rabiee A, Salman A, Youssef A, E-D Shaaban H, Ftohy TE, Maurice KK, Balamoun H. Role of Vitamin D Supplements in Prevention of Hungry Bone Syndrome after Successful Parathyroidectomy for Primary Hyperparathyroidism: A Prospective Study. Scand J Surg 2020; 110:329-334. [PMID: 33019891 DOI: 10.1177/1457496920962601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND We postulated that the preoperative correction of vitamin D levels can significantly reduce the incidence of hunger bone syndrome among patients undergoing parathyroidectomy for primary hyperparathyroidism. METHODS We performed a prospective, randomized, open-label study on 102 patients with primary hyperparathyroidism and coexisting vitamin D deficiency who were scheduled to undergo parathyroidectomy. Patients were divided into the following two groups: group I which included 52 patients who did not receive preoperative vitamin D supplementation; and group II which included 50 patients who received cholecalciferol 1000-2000 IU daily or 50000 IU weekly until they achieve vitamin D levels >20 ng/mL (group IIa = 25 patients) or vitamin D levels >30 ng/mL (group IIb = 25 patients). RESULTS The incidence of hunger bone syndrome in group IIb was lower than group I and group IIa (8% versus 16% versus 23%, respectively); however, this difference did not reach the level of statistical significance (p = 0.22). Patients with hunger bone syndrome were significantly younger and had higher serum phosphorus, alkaline phosphatase, magnesium, and bone mineral density at baseline than patients without hunger bone syndrome. On the other hand, patients with hunger bone syndrome had significantly lower 25-hydroxyvitamin D at baseline than patients without hunger bone syndrome (p = 0.001). The ROC curve showed that the baseline level of serum 25-hydroxyvitamin D was not an independent discriminator of hunger bone syndrome (area under curve = 0.21 (95% CI: 0.06-0.34); p = 0.011). CONCLUSION Preoperative course of vitamin D supplements has no preventive role on the postoperative incidence of hunger bone syndrome among patients with primary hyperparathyroidism and coexisting vitamin D deficiency undergoing parathyroidectomy.
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Affiliation(s)
- M A Salman
- General Surgery Department, Kasralainy School of Medicine, Cairo University, Cairo, Egypt
| | - A Rabiee
- Internal Medicine Department, Kasralainy School of Medicine, Cairo University, Cairo, Egypt
| | - A Salman
- Internal Medicine Department, Kasralainy School of Medicine, Cairo University, Cairo, Egypt
| | - A Youssef
- Internal Medicine Department, Kasralainy School of Medicine, Cairo University, Cairo, Egypt
| | - H E-D Shaaban
- National Hepatology and Tropical Medicine Research Institute, Gastroenterology and Hepatology, Cairo, Egypt
| | - T E Ftohy
- Head and Neck Surgery, Sohag University, Sohag, Egypt
| | - K K Maurice
- General Surgery Department, Kasralainy School of Medicine, Cairo University, Cairo, Egypt
| | - H Balamoun
- General Surgery Department, Kasralainy School of Medicine, Cairo University, Cairo, Egypt
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14
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Strother RK, Meunier M. Hypercalcemia in the Presence of an Ectopic Mediastinal Mass. J Prim Care Community Health 2020; 11:2150132720932411. [PMID: 32552312 PMCID: PMC7307481 DOI: 10.1177/2150132720932411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 72-year-old gentleman who presented to the outpatient clinic for a preventive health appointment with symptoms of depression and fatigue was found to have persistent hypercalcemia on routine laboratory monitoring. Initial laboratory testing was consistent with primary hyperparathyroidism with elevation in parathyroid hormone and low vitamin D levels. Further imaging demonstrated an ectopic mediastinal parathyroid adenoma. The ectopic lesion was treated surgically and lead to normalization of calcium levels and objective improvement in depressive symptoms. Primary hyperparathyroidism, which can be secondary to an adenoma, multigland hyperplasia, or neoplasm, can lead to the development of bone pain, fractures, and nephrolithiasis among other symptoms. The evaluation of hypercalcemia and the identification of primary hyperparathyroidism are important for the primary care physician to recognize so as to reduce disease morbidity as well as identify patients in need of further specialty care.
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15
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Manaka K, Sato J, Kinoshita Y, Ito N, Fujita M, Iiri T, Nangaku M, Makita N. Effectiveness and safety of cinacalcet for primary hyperparathyroidism: a single center experience. Endocr J 2019; 66:683-689. [PMID: 31092749 DOI: 10.1507/endocrj.ej19-0034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Primary hyperparathyroidism (PHPT) is a common endocrine disease. Although surgical treatment is curative in most cases, there are few alternative therapies for the hypercalcemia caused by PHPT. Cinacalcet is a positive allosteric modulator of the calcium sensing receptor and was conditionally approved in Japan in 2014 to treat PHPT cases. However, there have been few reports on the outcomes. In our present study, we investigated the efficacy and safety of cinacalcet in 61 PHPT patients who were treated with this agent at our hospital between January 2014 and March 2017. The corrected serum Ca and intact PTH levels were significantly reduced by this treatment, whereas the serum phosphorus levels significantly increased. There were no significant differences in the eGFR or urinary Ca to urinary creatinine ratio between baseline and the maintenance phase. In terms of bone mineral density, there were significant increases observed in the 16 cases for whom a baseline value was available, 11 of whom had been treated for osteoporosis. The most common adverse events from cinacalcet treatment were gastrointestinal symptom, such as nausea and appetite loss. Other adverse events included severe dehydration due to hypercalcemia, myalgia, hypocalcemia, and increased urinary calcium excretion. Seven patients were switched to surgical treatment, and the drug was discontinued in 9 other patients, due to adverse effects. Our present study findings demonstrate that cinacalcet is an effective therapeutic option for PHPT from the perspective of hypercalcemia improvement but that adverse gastrointestinal effects of this drug occur at a frequency of about 10%.
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Affiliation(s)
- Katsunori Manaka
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Junichiro Sato
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Yuka Kinoshita
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Ito
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Megumi Fujita
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Taroh Iiri
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
- Department of Pharmacology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masaomi Nangaku
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Noriko Makita
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
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16
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Sencar ME, Sakiz D, Unsal IO, Hepsen S, Calapkulu M, Gumus P, Ucan B, Ozbek M, Cakal E. Serum Vitamin D Level Does not Affect The Sensitivity of Parathyroid Adenoma Localization Tests. Sci Rep 2019; 9:12035. [PMID: 31427650 PMCID: PMC6700071 DOI: 10.1038/s41598-019-48536-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/07/2019] [Indexed: 11/09/2022] Open
Abstract
The aim of the present study was to evaluate the predictive value of 25-hydroxyvitamin D, calcium and parathormone level, co-existence of thyroid nodule, thyroidectomy history and adenoma volume on the success of neck ultrasound (US) and technetium-99m sestamibi (MIBI) scan in primary hyperparathyroidism (PHP) patients. This study included 256 patients with PHP who underwent parathyroidectomy. 169 (%66) patients had vitamin D deficiency and 56 (%22) of patients had insufficiency. The sensitivity of US and MIBI studies showed no difference between vitamin D deficiency, insufficiency and replete groups (%80.5, %82 and %71 (p > 0.05) and %81, %84 and %71 respectively (p > 0.05)). Vitamin D level was not found to be an independent predictor of localization on either US or MIBI scan after adjusting for different variables (p > 0.05). Calcium level was found to be an independent predictor for US sensitivity (r2:0,033, p:0,032) and parathormone level for MIBI sensitivity (r2:0,05, p:0,025). The co-existence of nodular thyroid disease and history of thyroidectomy significantly decreased the sensitivity of US (%76 and %43). MIBI sensitivity was not impaired by nodular disease but the history of thyroidectomy also impaired the sensitivity of MIBI (%43). As a result vitamin D level does not affect the sensitivity of preoperative localization tests.
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Affiliation(s)
- Muhammed Erkam Sencar
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey.
| | - Davut Sakiz
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ilknur Ozturk Unsal
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Sema Hepsen
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Murat Calapkulu
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Pelin Gumus
- Department of Internal Medicine, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Bekir Ucan
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Mustafa Ozbek
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Erman Cakal
- Department of Endocrinology and Metabolism, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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17
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Yao XA, Wei BJ, Jiang T, Chang H. The characteristics of clinical changes in primary hyperparathyroidism in Chinese patients. J Bone Miner Metab 2019; 37:336-341. [PMID: 29721808 DOI: 10.1007/s00774-018-0922-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
Abstract
In Western countries, the presentation of primary hyperparathyroidism (PHPT) changed from a symptomatic to an asymptomatic disease after the 1970s, whereas in China, only one study has evaluated the changing clinical characteristics and biochemical profiles of PHPT patients. The aim of this study was to explore changes in the clinical characteristics of PHPT in Chinese patients. Overall, 140 consecutive patients with PHPT were studied between January 1, 2010 and June 30, 2016. The patients were divided into two groups: 32 consecutive patients from January 1, 2010 to March 31, 2013 were included in group 1, and 108 consecutive patients from April 1, 2013 to June 30, 2016 were included in group 2. The most frequent complaints were ostealgia (46.02%), urolithiasis (41.59%), constipation (25.66%), fatigue (18.58%), polydipsia and polyuria (15.93%) and fracture history (15.04%). The number of cases in group 2 was 3.38-fold greater than that of group 1. The parathyroid hormone (PTH) and fasting blood glucose (FPG) levels were higher in group 1 than those in group 2 (p = 0.039, p < 0.001). In 62.14% of patients with PHPT, the proportion of the first diagnosis due to hypercalcemia found using a multichannel autoanalyzer in group 1 was lower than that found in group 2 (p = 0.039), and the proportion of the first diagnosis due to parathyroid lesions captured using routine neck ultrasonography in group 1 was higher than in group 2 (p = 0.003). The proportion of parathyroid carcinoma cases was higher in group 1 than group 2 (p = 0.036). Cases of PHPT increased with time, but the proportion of parathyroid carcinoma cases was lower in group 1 than that in group 2. Over time, the first diagnosis switched from parathyroid lesions captured by routine neck ultrasound to hypercalcemia found by a multichannel autoanalyser. At our centre, PHPT in Chinese patients still demonstrates classic characteristics.
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Affiliation(s)
- Xiao-Ai Yao
- Department of Endocrinology, Beijing Shijitan Hospital, Capital Medical University, No. 10, Tieyi Road, Haidian District, Beijing, 100038, China
| | - Bo-Jun Wei
- Department of Otolaryngology Head and Neck Surgery, Beijing Shijitan Hospital, Capital Medical University, No. 10, Tieyi Road, Haidian District, Beijing, 100038, China.
- Department of Thyroid and Neck Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, China.
| | - Tao Jiang
- Department of Endocrinology, Beijing Shijitan Hospital, Capital Medical University, No. 10, Tieyi Road, Haidian District, Beijing, 100038, China.
| | - Hong Chang
- Department of Pathology, Beijing Shijitan Hospital, Capital Medical University, No. 10, Tieyi Road, Haidian District, Beijing, 100038, China
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18
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Chun RF, Shieh A, Gottlieb C, Yacoubian V, Wang J, Hewison M, Adams JS. Vitamin D Binding Protein and the Biological Activity of Vitamin D. Front Endocrinol (Lausanne) 2019; 10:718. [PMID: 31708871 PMCID: PMC6821678 DOI: 10.3389/fendo.2019.00718] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 10/04/2019] [Indexed: 12/15/2022] Open
Abstract
Vitamin D has a long-established role in bone health. In the last two decades, there has been a dramatic resurgence in research interest in vitamin D due to studies that have shown its possible benefits for non-skeletal health. Underpinning the renewed interest in vitamin D was the identification of the vital role of intracrine or localized, tissue-specific, conversion of inactive pro-hormone 25-hydroxyvitamin D [25(OH)D] to active 1,25-dihydroxyvitamin D [1,25(OH)2D]. This intracrine mechanism is the likely driving force behind vitamin D action resulting in positive effects on human health. To fully capture the effect of this localized, tissue-specific conversion to 1,25(OH)2D, adequate 25(OH)D would be required. As such, low serum concentrations of 25(OH)D would compromise intracrine generation of 1,25(OH)2D within target tissues. Consistent with this is the observation that all adverse human health consequences of vitamin D deficiency are associated with a low serum 25(OH)D level and not with low 1,25(OH)2D concentrations. Thus, clinical investigators have sought to define what concentration of serum 25(OH)D constitutes adequate vitamin D status. However, since 25(OH)D is transported in serum bound primarily to vitamin D binding protein (DBP) and secondarily to albumin, is the total 25(OH)D (bound plus free) or the unbound free 25(OH)D the crucial determinant of the non-classical actions of vitamin D? While DBP-bound-25(OH)D is important for renal handling of 25(OH)D and endocrine synthesis of 1,25(OH)2D, how does DBP impact extra-renal synthesis of 1,25(OH)2D and subsequent 1,25(OH)2D actions? Are their pathophysiological contexts where total 25(OH)D and free 25(OH)D would diverge in value as a marker of vitamin D status? This review aims to introduce and discuss the concept of free 25(OH)D, the molecular biology and biochemistry of vitamin D and DBP that provides the context for free 25(OH)D, and surveys in vitro, animal, and human studies taking free 25(OH)D into consideration.
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Affiliation(s)
- Rene F. Chun
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- *Correspondence: Rene F. Chun
| | - Albert Shieh
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Carter Gottlieb
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Vahe Yacoubian
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jeffrey Wang
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Martin Hewison
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - John S. Adams
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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19
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Tay YKD, Yeh R, Kuo JH, McManus C, Lee JA, Bilezikian JP. Pre-operative localization of abnormal parathyroid tissue by 99mTc-sestamibi in primary hyperparathyroidism using four-quadrant site analysis: an evaluation of the predictive value of vitamin D deficiency. Endocrine 2018; 60:36-45. [PMID: 29404903 DOI: 10.1007/s12020-018-1528-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 01/09/2018] [Indexed: 10/18/2022]
Abstract
CONTEXT Accurate preoperative localization of abnormal parathyroid tissue aids importantly in minimally invasive parathyroidectomy in patients with primary hyperparathyroidism. Vitamin D deficiency may possibly influence the success and characteristics of pre-operative localization because it is associated with more active disease and possibly larger adenomas. This could increase the sensitivity of the sestamibi to identify abnormal parathyroid tissue, but earlier reports are conflicting. Vitamin D deficiency could also influence the nature of preoperative localization because it could lead to multi-gland stimulation of parathyroid tissue giving an appearance of multi-gland disease, which may lower accuracy of preoperative localization with sestamibi. OBJECTIVE To examine the relationship between vitamin D deficiency and correct parathyroid tissue localization by four-pole thyroid quadrant analysis. DESIGN Retrospective study. SETTING Referral center. PARTICIPANTS A total of 138 patients were divided into three groups according to the level of 25OHD; <20 ng/mL (vitamin D deficient), ≥20 to <30 ng/mL (vitamin D insufficient) and ≥30 ng/mL (vitamin D replete). MAIN OUTCOMES Quadrant localization using 99mTc-sestamibi/SPECT. RESULTS Among those with single-gland disease, the proportion of patients with correct quadrant localization were 60.0, 68.3 and 63.5% (p = 0.778), and the accuracy of sestamibi was 89.3, 90.6 and 89.9% for the deficient, insufficiency and replete groups, respectively. Among those with multi-gland disease, the proportion of patients with correct quadrant localization were 50.0, 25.0 and 18.2% (p = 0.619) while the accuracy was 50.0, 50.0 and 45.5%, respectively. Multi-gland disease did not occur more frequently in any of the three groups (p = 0.296). CONCLUSIONS Vitamin D levels do not affect the accuracy of preoperative localization with sestamibi.
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Affiliation(s)
- Yu-Kwang Donovan Tay
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA.
- Department of Medicine, Sengkang Health, Singapore, Singapore.
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore.
| | - Randy Yeh
- Department of Radiology, Columbia University Medical Center, New York, NY, USA
| | - Jennifer H Kuo
- Department of GI/Endocrine Surgery, Columbia University, New York, NY, USA
| | - Catherine McManus
- Department of GI/Endocrine Surgery, Columbia University, New York, NY, USA
| | - James A Lee
- Department of GI/Endocrine Surgery, Columbia University, New York, NY, USA
| | - John P Bilezikian
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA.
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Abstract
In this Review, we describe the pathogenesis, diagnosis and management of primary hyperparathyroidism (PHPT), with a focus on recent advances in the field. PHPT is a common endocrine disorder that is characterized by hypercalcaemia and elevated or inappropriately normal serum levels of parathyroid hormone. Most often, the presentation of PHPT is asymptomatic in regions of the world where serum levels of calcium are routinely measured. In addition to mild hypercalcaemia, PHPT can manifest with osteoporosis and hypercalciuria as well as with vertebral fractures and nephrolithiasis, both of which can be asymptomatic. Other clinical forms of PHPT, such as classical disease and normocalcaemic PHPT, are less common. Parathyroidectomy, the only curative treatment for PHPT, is recommended in patients with symptoms and those with asymptomatic disease who are at risk of progression or have subclinical evidence of end-organ sequelae. Parathyroidectomy results in an increase in BMD and a reduction in nephrolithiasis. Various medical therapies can increase BMD or reduce serum levels of calcium, but no single drug can do both. More data are needed regarding the neuropsychological manifestations of PHPT and the pathogenetic mechanisms leading to sporadic PHPT, as well as on risk factors for complications of the disorder. Future work that advances our knowledge in these areas will improve the management of the disorder.
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Affiliation(s)
- Marcella D Walker
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA
| | - Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA
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Tripto-Shkolnik L, Jaffe A, Liel Y. The impact of vitamin D status and parameters of calcium metabolism in patients with primary hyperparathyroidism. QJM 2018; 111:97-101. [PMID: 29462468 DOI: 10.1093/qjmed/hcx200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is ample evidence associating vitamin D deficiency in primary hyperparathyroidism (PHP) patients with more severe disease manifestations and increased risk of postoperative hypocalcemia. Yet, there is limited data regarding the safety of vitamin D repletion in these patients. AIM To assess the safety of vitamin D repletion in PHP patients in a real-world setting. DESIGN We included patients with asymptomatic PHP and few symptomatic patients who declined surgery, followed in our clinic, and treated on a routine basis with 2000 IU/day of vitamin D3. METHODS Serum calcium (sCa), PTH, 25-hydroxyvitamin D, and 24 h urinary calcium (uCa) and creatinine collections were compared between the lowest and the highest vitamin D time points. RESULTS There were 40 patients of a mean age was 63 ± 10 years. 25(OH)D at lowest and highest vitamin D time points was 15.5 ± 6.2 ng/ml and 33.2 ± 8, respectively (P < 0.001). Serum calcium was not affected by the changes in vitamin D levels. In none of the patients did sCa exceed 11.5 mg/dL. uCa was 220 ± 110 mg/24 h at the lowest vitamin D time point and 260 ± 140 at the highest vitamin D time point (P = 0.14). uCa exceeded 400 mg/24 h in two vs. five patients (P = 0.23) at the lowest and highest vitamin D time points, respectively. PTH was not significantly different between the different vitamin D time points. DISCUSSION/CONCLUSION Vitamin D repletion in PHP seems safe. Considering the documented adverse influence of vitamin D deficiency in PHP, particularly on skeletal manifestations and on the postoperative course, vitamin D repletion is warranted.
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Affiliation(s)
| | - A Jaffe
- Endocrine Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - Y Liel
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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22
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Piedra M, Berja A, Ramos L, García-Unzueta MT, Morán JM, Ruiz D, Amado JA. Analysis of the influence of the T393C polymorphism of the GNAS gene on the clinical expression of primary hyperparathyroidism. ACTA ACUST UNITED AC 2017; 64:524-530. [PMID: 29179855 DOI: 10.1016/j.endinu.2017.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 08/06/2017] [Accepted: 08/10/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The receptor of parathyroid hormone and parathyroid hormone-related-protein (PTH/PTHrp) is located in the cell membrane of target tissues - kidney and osteoblasts. It is a G protein-coupled-receptor whose Gsα subunit is encoded by the GNAS gene. Our aim was to study whether the single nucleotide polymorphism (SNP) T393C of the GNAS gene is associated with renal stones, bone mineral density (BMD), or bone remodelling markers in primary hyperparathyroidism (PHPT). METHODS An analysis was made of clinical and biochemical parameters and densitometric values in three areas and their relationship with the T393C SNP of the GNAS gene in 261 patients with primary hyperparathyroidism and in 328 healthy controls. Genotyping was performed using the Custom Taqman® SNP Genotyping assay. RESULTS The genotype frequencies of GNAS T/C 393 were similar in the control and PHPT groups. No association was found between genotypes and clinical expression of PHPT (renal stones and bone fractures). A nonstatistically significant trend was seen to lower BMD in the lumbar spine, femoral neck, and total hip in both PHPT and control C homozygote subjects. CONCLUSION Genetic susceptibility to PHPT related to the GNAS T393C polymorphism or a major influence in its development and clinical expression were found. A C allele-related susceptibility to lower BMD in trabecular bone in both PHPT and control subjects is not sufficient to suggest a more severe clinical expression of PHPT. This trend may be considered as a basis for further studies with larger sample sizes and complementary functional evaluation.
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Affiliation(s)
- María Piedra
- Servicio de Endocrinología, Hospital Universitario "Marqués de Valdecilla", Instituto de Investigación "Marqués de Valdecilla" (IDIVAL), Universidad de Cantabria, Avda. de Valdecilla s/n, Santander 39008, Cantabria, Spain.
| | - Ana Berja
- Servicio de Endocrinología, Hospital Universitario "Marqués de Valdecilla", Instituto de Investigación "Marqués de Valdecilla" (IDIVAL), Universidad de Cantabria, Avda. de Valdecilla s/n, Santander 39008, Cantabria, Spain
| | - Laura Ramos
- Servicio de Endocrinología, Hospital Universitario "Marqués de Valdecilla", Instituto de Investigación "Marqués de Valdecilla" (IDIVAL), Universidad de Cantabria, Avda. de Valdecilla s/n, Santander 39008, Cantabria, Spain
| | - María Teresa García-Unzueta
- Servicio de Bioquímica, Hospital Universitario "Marqués de Valdecilla", Instituto de Investigación "Marqués de Valdecilla" (IDIVAL), Universidad de Cantabria, Avda. de Valdecilla s/n, Santander 39008, Cantabria, Spain
| | - Jesús Manuel Morán
- Servicio de Endocrinología, Hospital Universitario "Marqués de Valdecilla", Instituto de Investigación "Marqués de Valdecilla" (IDIVAL), Universidad de Cantabria, Avda. de Valdecilla s/n, Santander 39008, Cantabria, Spain
| | - David Ruiz
- Servicio de Endocrinología, Hospital Universitario "Marqués de Valdecilla", Instituto de Investigación "Marqués de Valdecilla" (IDIVAL), Universidad de Cantabria, Avda. de Valdecilla s/n, Santander 39008, Cantabria, Spain
| | - José Antonio Amado
- Servicio de Endocrinología, Hospital Universitario "Marqués de Valdecilla", Instituto de Investigación "Marqués de Valdecilla" (IDIVAL), Universidad de Cantabria, Avda. de Valdecilla s/n, Santander 39008, Cantabria, Spain
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23
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Rajeev P, Movseysan A, Baharani A. Changes in bone turnover markers in primary hyperparathyroidism and response to surgery. Ann R Coll Surg Engl 2017; 99:559-562. [PMID: 28853593 DOI: 10.1308/rcsann.2017.0092] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Involvement of the bone is common in primary hyperparathyroidism. The aim of the study was to assess bone turnover markers in response to surgery for primary hyperparathyroidism. Methods This was a retrospective study of patients diagnosed and treated for parathyroid disease between 2005 and 2012. Interventions studied were surgery and medical treatment. The main outcome measures studied were serum levels of calcium, intact parathyroid hormone (iPTH), bone-specific alkaline phosphatase, N-terminal cross-linking propeptide of type 1 procollagen (P1NP) and C-terminal cross-linking telopeptides of type I collagen (CTX), both pre- and postoperatively at 6 months and 1 year; bone mineral density (at the spine and hip assessed by dual-energy x-ray absorptiometry after 1 year of treatment. Results A total of 122 (110 female, 12 male) patients (age range 25-91 years) underwent treatment for parathyroid disease during the study period; 30 patients were treated conservatively and 92 proceeded to surgery following localisation studies. Following surgical intervention, P1NP dropped significantly from a mean of 64.68 ng/ml (standard deviation, SD ± 68.07 ng/ml) preoperatively to 26.37 ng/ml (SD ± 20.94 ng/ml) and CTX from 0.69 pg/ml (SD ± 0.44 pg/ml) to 0.15 pg/ml (SD ± 0.16 pg/ml) at 6-12 months (P < 0.0001). This change was reflected in improvement in bone mineral density (T scores) of the hip and spine by 43% (P < 0.03) and 38% (P < 0.01), respectively, following surgery. In patients treated conservatively (n = 30), there was no improvement either in the bone turnover markers or bone densitometry scans. Conclusions Surgery improves bone density in patients with parathyroid disease. Improvement in serum bone turnover markers is seen following parathyroidectomy. The association with bone density needs further evaluation in larger studies.
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Affiliation(s)
- P Rajeev
- Department of Endocrine Surgery, National University Hospital , Singapore
| | - A Movseysan
- Department of Endocrine and General Surgery, St Mary's Hospital, Newport , Isle of Wight , UK
| | - A Baharani
- Department of Endocrine and General Surgery, St Mary's Hospital, Newport , Isle of Wight , UK
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24
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Makay Ö, Özçınar B, Şimşek T, Arıcı C, Güngör B, Özbaş S, Akça T, Emre AU, Karadeniz Çakmak G, Akçay M, Ünal B, Girgin M, Girgin S, Görgülü S, Sezer A, Karataş A, Özemir İA, Aksakal N, Erel S, Uğurlu MÜ, Filiz Aİ, Atalay C, Uzunköy A, Deveci U, Kotan Ç, İçöz G, Kurt Y, Kebudi A, Cantürk NZ, Erbil Y, Pandev R, Güllüoğlu BM. Regional Clinical and Biochemical Differences among Patients with Primary Hyperparathyroidism. Balkan Med J 2017; 34:28-34. [PMID: 28251020 PMCID: PMC5322512 DOI: 10.4274/balkanmedj.2015.0865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 01/27/2016] [Indexed: 01/03/2023] Open
Abstract
Background: Environmental habitat may play a role in clinical disparities of primary hyperparathyroidism (pHPT) patients. Aims: To compare preoperative clinical symptoms and associated conditions and surgical findings in patients with pHPT, living in different geographical regions from the Black Sea, Mediterranean and Anatolia regions. Study Design: Retrospective, clinical-based multi-centric study of 694 patients with pHPT. Methods: Patients from 23 centers and 8 different geographical regions were included. Data related to baseline demographics, clinical, pathologic and treatment characteristics of 8 regions were collected and included age, gender, residential data, symptoms, history of fracture, existence of brown tumor, serum total Ca and p levels, serum parathormone (PTH) levels, serum 25-OH vitamin D levels, bone mineral density, size of the resected abnormal parathyroid gland(s), histology, as well as the presence of ectopia, presence of dual adenoma, and multiple endocrine neoplasia (MEN)- or familial-related disease. Results: The median age was 54. Asymptomatic patient rate was 25%. The median PTH level was 232 pg/mL and serum total Ca was 11.4 mg/dL. Eighty-seven percent of patients had an adenoma and 90% of these had a single adenoma. Hyperplasia was detected in 79 patients and cancer in 9 patients. The median adenoma size was 16 mm. Significant parameters differing between regions were preoperative symptoms, serum Ca and p levels, and adenoma size. All patients from South-East Anatolia were symptomatic, while the lowest p values were reported from East Anatolia and the largest adenoma size, as well as highest Ca levels, were from Bulgaria. Conclusion: Habitat conditions vary between geographical regions. This affects the clinicopathological features of patients with pHPT.
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Affiliation(s)
- Özer Makay
- Department of General Surgery, Division of Endocrine Surgery, Ege University School of Medicine, İzmir, Turkey
| | - Beyza Özçınar
- Department of General Surgery, Division of Endocrine Surgery, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Turgay Şimşek
- Department of General Surgery, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Cumhur Arıcı
- Department of General Surgery, Division of Endocrine Surgery, Akdeniz University School of Medicine, Antalya, Turkey
| | - Bülent Güngör
- Department of General Surgery, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Serdar Özbaş
- Department of General Surgery, Güven Hospital, Ankara, Turkey
| | - Tamer Akça
- Department of General Surgery, Division of Endocrine Surgery, Mersin University School of Medicine, Mersin, Turkey
| | - Ali Uğur Emre
- Department of General Surgery, Bülent Ecevit University School of Medicine, Zonguldak, Turkey
| | | | - Müfide Akçay
- Department of General Surgery, Atatürk University School of Medicine, Erzurum, Turkey
| | - Bülent Ünal
- Department of General Surgery, İnönü University School of Medicine, Malatya, Turkey
| | - Mustafa Girgin
- Department of General Surgery, Fırat University School of Medicine, Elazığ, Turkey
| | - Sadullah Girgin
- Department of General Surgery, Dicle University School of Medicine, Diyarbakır, Turkey
| | - Semih Görgülü
- Department of General Surgery, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Atakan Sezer
- Department of General Surgery, Trakya University School of Medicine, Edirne, Turkey
| | - Adem Karataş
- Department of General Surgery, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - İbrahim Ali Özemir
- Department of General Surgery, İstanbul Medeniyet University School of Medicine, İstanbul, Turkey
| | - Nihat Aksakal
- Department of General Surgery, Division of Endocrine Surgery, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Serap Erel
- Department of General Surgery, Ankara Training and Research Hospital, Ankara, Turkey
| | - M Ümit Uğurlu
- Department of General Surgery, Marmara University School of Medicine, İstanbul, Turkey
| | - Ali İlker Filiz
- Department of General Surgery, Okan University School of Medicine, Istanbul, Turkey
| | - Can Atalay
- Department of General Surgery, Ankara Oncology Training Hospital, Ankara, Turkey
| | - Ali Uzunköy
- Department of General Surgery, Harran University School of Medicine, Şanlıurfa, Turkey
| | - Uğur Deveci
- Department of Gernral Surgery, Sultan Abdülhamid Training and Research Hospital, İstanbul, Turkey
| | - Çetin Kotan
- Department of General Surgery, Yüzüncü Yıl University School of Medicine, Van, Turkey
| | - Gökhan İçöz
- Department of General Surgery, Division of Endocrine Surgery, Ege University School of Medicine, İzmir, Turkey
| | - Yavuz Kurt
- Department of Gernral Surgery, Sultan Abdülhamid Training and Research Hospital, İstanbul, Turkey
| | - Abut Kebudi
- Department of General Surgery, Okan University School of Medicine, Istanbul, Turkey
| | - N Zafer Cantürk
- Department of General Surgery, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Yeşim Erbil
- Department of General Surgery, Division of Endocrine Surgery, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Rumen Pandev
- Department of General Surgery, Division of Endocrine Surgery, Tsaritsa Yoanna University School of Medicine, Sofia, Bulgaria
| | - Bahadır M Güllüoğlu
- Department of General Surgery, Marmara University School of Medicine, İstanbul, Turkey
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25
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Walker MD, Bilezikian JP. Vitamin D and primary hyperparathyroidism: more insights into a complex relationship. Endocrine 2017; 55:3-5. [PMID: 27858283 PMCID: PMC5226876 DOI: 10.1007/s12020-016-1169-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 11/01/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Marcella D Walker
- Department of Medicine, Metabolic Bone Diseases Unit, College of Physicians and Surgeons, Columbia University, New York, NY, 10032, USA.
| | - John P Bilezikian
- Department of Medicine, Metabolic Bone Diseases Unit, College of Physicians and Surgeons, Columbia University, New York, NY, 10032, USA
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26
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Viccica G, Cetani F, Vignali E, Miccoli M, Marcocci C. Impact of vitamin D deficiency on the clinical and biochemical phenotype in women with sporadic primary hyperparathyroidism. Endocrine 2017; 55:256-265. [PMID: 27033542 DOI: 10.1007/s12020-016-0931-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/17/2016] [Indexed: 10/22/2022]
Abstract
The purpose of the study was to evaluate the relationship between serum 25(OH)D and the clinical phenotype in 215 consecutive Italian Caucasian women with sporadic primary hyperparathyroidism (PHPT) not taking vitamin D supplements. The study was performed at a single Italian tertiary center. PHPT-related manifestations, serum 25(OH)D, and other parameters of calcium metabolism and bone mineral density (BMD) by DXA were recorded. Serum 25(OH)D was negatively correlated with age (r = -0.18; P = 0.006), BMI (r = -0.20; P = 0.002), PTH (r = -0.21; P = 0.001), bone-specific alkaline phosphatase (BSAP) (r = -0.27; P < 0.001), and eGFR (r = -0.22; P = 0.01), and positively with serum creatinine and 1/3 distal radius BMD (R-BMD; r = 0.17; P = 0.015). In a multivariate regression analysis, serum 25(OH)D remained significantly correlated with age (r = -0.18; P = 0.005), BMI (r = -0.23; P = 0.049), serum PTH (r = -0.01; P = 0.023), BSAP (r = -0.01; P = 0.023) and eGFR (r = -0.09; P = 0.001), but not with R-BMD. Serum 25(OHD) was higher in patients with nephrolithiasis than in those without nephrolithiasis (18.5 ± 8.8 vs. 15.6 ± 8.0 ng/ml; P = 0.029), whereas no difference was found between fractured and unfractured patients (16.8 ± 9.3 vs. 16.0 ± 7.7; P = 0.663). There was a statistically significant inverse correlation between vitamin D status [defined by quartiles of measured values as well as commonly accepted cutoffs of serum 25(OH)D] and severity of the disease, as reflected by higher PTH and BSAP, but not by meeting the latest guidelines for parathyroidectomy. In conclusion, a low vitamin D status is associated with some features reflecting a more severe biochemical and clinical phenotype of PHPT in Italian women not taking vitamin D supplements.
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Affiliation(s)
- Giuseppe Viccica
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | | | - Edda Vignali
- Endocrine Unit 2, University Hospital of Pisa, Pisa, Italy
| | - Mario Miccoli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
- Endocrine Unit 2, University Hospital of Pisa, Pisa, Italy.
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Gatu A, Velicescu C, Grigorovici A, Danila R, Muntean V, Mogoş SJ, Mogoş V, Vulpoi C, Preda C, Branisteanu D. THE VOLUME OF SOLITARY PARATHYROID ADENOMA IS RELATED TO PREOPERATIVE PTH AND 25OH-D3, BUT NOT TO CALCIUM LEVELS. ACTA ENDOCRINOLOGICA-BUCHAREST 2017; 13:441-446. [PMID: 31149214 DOI: 10.4183/aeb.2017.441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Purpose To correlate the volume of parathyroid adenomas with the hormonal and metabolic profile at patients diagnosed with primary hyperparathyroidism (pHPTH). Patients and Methods Cross-sectional multicentric study, enrolling 52 patients with pHPTH from two medical institutions. Serum calcium and PTH were evaluated in all patients before surgery, whereas 25OHD3 was measured only in the 33 patients recruited form one medical unit. The volume of parathyroid adenoma was measured by using the formula of a rotating ellipsoid. Results We observed a significant correlation of the volume of parathyroid adenomas with PTH at patients from the two units and in the whole group (p < 0.0001), but not with serum calcium (p = 0.494). Twenty-five out of the 33 patients at whom 25OHD3 was measured had levels in the range of deficiency. 25OHD3 was not correlated with PTH or calcium levels, but was negatively correlated to the adenoma volume and positively to the PTH/volume ratio (p = 0.041 and p = 0.048, respectively). Conclusions The volume of parathyroid adenoma seems to be related to preoperative PTH and 25OHD3, but not to calcium level. Vitamin D deficiency is frequently found at patients with pHPTH and may contribute to particular disease profiles, including larger parathyroid adenomas.
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Affiliation(s)
- A Gatu
- "Gr.T.Popa" University of Medicine and Pharmacy, Dept. of Endocrinology, Romania
| | - C Velicescu
- "Gr.T.Popa" University of Medicine and Pharmacy, Dept. of General Surgery, "St. Spiridon" Hospital, Romania.,"Gr.T.Popa" University of Medicine and Pharmacy, 4th unit of surgery, Romania
| | - A Grigorovici
- "Gr.T.Popa" University of Medicine and Pharmacy, Dept. of General Surgery, "St. Spiridon" Hospital, Romania
| | - R Danila
- "Gr.T.Popa" University of Medicine and Pharmacy, Dept. of General Surgery, "St. Spiridon" Hospital, Romania
| | - V Muntean
- "Iuliu Hatieganu" University of Medicine and Pharmacy Cluj-Napoca, Dept. of Surgery, Romania
| | - S J Mogoş
- "Gr.T.Popa" University of Medicine and Pharmacy, Dept. of Endocrinology, Romania
| | - V Mogoş
- "Gr.T.Popa" University of Medicine and Pharmacy, Dept. of Endocrinology, Romania.,"Gr.T.Popa" University of Medicine and Pharmacy, Dept. of Endocrinology, Iasi, Romania
| | - C Vulpoi
- "Gr.T.Popa" University of Medicine and Pharmacy, Dept. of Endocrinology, Romania
| | - C Preda
- "Gr.T.Popa" University of Medicine and Pharmacy, Dept. of Endocrinology, Romania
| | - D Branisteanu
- "Gr.T.Popa" University of Medicine and Pharmacy, Dept. of Endocrinology, Romania
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Randle RW, Balentine CJ, Wendt E, Schneider DF, Chen H, Sippel RS. Should vitamin D deficiency be corrected before parathyroidectomy? J Surg Res 2016; 204:94-100. [PMID: 27451873 DOI: 10.1016/j.jss.2016.04.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/21/2016] [Accepted: 04/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Vitamin D deficiency is common in patients with hyperparathyroidism, but the importance of replacement before surgery is controversial. We aimed to evaluate the impact of vitamin D deficiency on the extent of resection and risk of postoperative hypocalcemia for patients undergoing parathyroidectomy for primary hyperparathyroidism. METHODS We identified patients with primary hyperparathyroidism undergoing parathyroid surgery between 2000 and 2015 using a prospectively maintained database. Patients with normal (≥30 ng/mL) vitamin D were compared to those with levels less than 30 ng/mL. RESULTS There were 1015 (54%) patients with normal vitamin D and 872 (46%) patients with vitamin D deficiency undergoing parathyroidectomy for primary hyperparathyroidism. Vitamin D deficiency was associated with higher preoperative parathyroid hormone (median 90 versus 77 pg/mL, P < 0.001) and calcium (median 10.5 versus 10.4 mg/dL, P < 0.001) compared with normal vitamin D. To achieve similar cure rates, patients with vitamin D deficiency were less likely to require removal of more than one gland (20% versus 30%, P < 0.001) than patients with normal vitamin D. Patients with vitamin D deficiency had similar rates of persistent (1.5% versus 2.0%, P = 0.43) and recurrent (1.7% versus 2.6%, P = 0.21) hyperparathyroidism. Postoperatively, both groups had equivalent rates of transient (2.3% versus 2.3%, P = 0.97) and permanent (0.2% versus 0.4%, P = 0.52) hypocalcemia. CONCLUSIONS Restoring vitamin D in deficient patients should not delay the appropriate surgical treatment of primary hyperparathyroidism. Deficient patients are more likely to be cured with the excision of a single adenoma and no more likely to suffer persistence, recurrence, or hypocalcemia than patients with normal vitamin D.
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Affiliation(s)
- Reese W Randle
- Department of Surgery, University of Wisconsin, Madison, Wisconsin.
| | | | - Elizabeth Wendt
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | | | - Herbert Chen
- Department of Surgery, University of Alabama, Birmingham, Alabama
| | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
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29
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Kirdak T, Canturk NZ, Korun N, Ocakoglu G. Characteristics of patients operated for primary hyperparathyroidism at university hospitals in Türkiye: differences among Türkiye's geographical regions. Ann Surg Treat Res 2016; 91:8-16. [PMID: 27433459 PMCID: PMC4942541 DOI: 10.4174/astr.2016.91.1.8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/25/2016] [Accepted: 05/16/2016] [Indexed: 11/30/2022] Open
Abstract
Purpose The aim of this study was to define the clinical and laboratory characteristics of patients operated on for primary hyperpatathyroidism (PHPT) at university hospitals in Türkiye, and to investigate the differences in the clinical presentations of the disease between different geographical regions. Methods Patients operated on for PHPT in the university hospitals of Türkiye were included in the study. The demographic, clinical, and laboratory findings and the operational data of the patients were investigated according to the whole country and to different geographical regions. Comparisons were performed according to whole country and regions. Results A total of 1,162 cases were included in the study from different regions and 20 university hospitals. The mean age of patients was 52.4 ± 0.38 (mean ± standard error) in the general population of Türkiye. The rates of hypertension, urolithiasis, bone disease and 25-hydroxyvitamin D insufficiency were 35%, 18.6%, 67.6%, and 63%, respectively. The median parathormone (PTH), serum total calcium (Ca+2) and phosphorus value were 220 pg/mL (range, 70–2,500 pg/mL), 11.2 mg/dL (range, 9.5–11.2 mg/dL), and 2.4 mg/dL (range, 1–4.7 mg/dL), respectively. The median size of the adenomas resected was 16 mm (range, 4–70 mm). Significant differences were observed in the clinical and laboratory findings of the patients operated on due to PHPT between different geographical regions of Türkiye (P < 0.05). Conclusion The clinical and laboratory characteristics of the patients with PHPT in different geographical regions of Türkiye differ. Furthermore, the general findings of the cases in Türkiye give us a hint that the severity of the disease here is somewhere between Eastern and Western countries.
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Affiliation(s)
- Turkay Kirdak
- Department of Surgery, Uludag University Faculty of Medicine, Bursa, Türkiye
| | - Nuh Zafer Canturk
- Department of Surgery, Kocaeli University Faculty of Medicine, Kocaeli, Türkiye
| | - Nusret Korun
- Department of Surgery, Uludag University Faculty of Medicine, Bursa, Türkiye
| | - Gokhan Ocakoglu
- Department of Biostatistics, Uludag University Faculty of Medicine, Bursa, Türkiye
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Walker MD, Nishiyama KK, Zhou B, Cong E, Wang J, Lee JA, Kepley A, Zhang C, Guo XE, Silverberg SJ. Effect of Low Vitamin D on Volumetric Bone Mineral Density, Bone Microarchitecture, and Stiffness in Primary Hyperparathyroidism. J Clin Endocrinol Metab 2016; 101:905-13. [PMID: 26745256 PMCID: PMC4803169 DOI: 10.1210/jc.2015-4218] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with 25-hydroxyvitamin D deficiency (25OHD <20 ng/ml) and primary hyperparathyroidism (PHPT) have more severe disease reflected by higher serum PTH levels compared to those with vitamin D levels in the insufficient (20-29 ng/ml) or replete range (≥ 30 ng/ml). OBJECTIVE To study the effect of low vitamin D in PHPT on volumetric bone mineral density (vBMD), bone microarchitecture, and bone strength. DESIGN, SETTING, AND PARTICIPANTS This is a cross-sectional analysis of 99 PHPT patients with and without 25OHD insufficiency and deficiency from a university hospital. OUTCOME MEASURES Bone microarchitecture and strength were assessed with high-resolution peripheral quantitative computed tomography (HRpQCT), microfinite element analysis, and individual trabecula segmentation. RESULTS In this cohort, 25OHD levels were deficient in 18.1%, insufficient in 35.4% and replete in 46.5%. Those with lower 25OHD levels had higher PTH (P < .0001), were younger (P = .001) and tended to weigh more (P = .053). There were no age-, weight- and sex-adjusted between-group differences (<20 vs 20-29 vs ≥ 30 ng/ml) in any HRpQCT, microfinite element analysis, or individual trabecula segmentation indices. Because few participants had 25OHD below 20 ng/ml, we also compared those with 25OHD below 30 vs at least 30 ng/ml and found only a trend toward lower adjusted cortical vBMD (3.1%, P = .08) and higher cortical porosity (least squares mean ± SEM 7.5 ± 0.3 vs 6.6 ± 0.3%, P = .07) at the tibia but not the radius. Stiffness did not differ at either site. In multiple regression analysis, 25OHD accounted for only three of the 49.2% known variance in cortical vBMD; 25OHD was not significant in the model for cortical porosity at the tibia. CONCLUSION Low 25OHD levels are associated with higher PTH levels in PHPT, but contrary to our hypothesis, these differences did not significantly affect vBMD or microarchitecture, nor did they result in lower stiffness. Low vitamin D in PHPT using current 25OHD thresholds for insufficiency and deficiency did not significantly affect skeletal integrity as assessed by HRpQCT.
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Affiliation(s)
- Marcella D Walker
- Department of Medicine (M.D.W., K.K.N., E.C., A.K., C.Z., S.J.S.), Columbia University, College of Physicians and Surgeons, New York, New York 10032; Bone Bioengineering Laboratory (B.Z., J.W., X.E.G.), Columbia University, New York, New York 10027; Department of Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - Kyle K Nishiyama
- Department of Medicine (M.D.W., K.K.N., E.C., A.K., C.Z., S.J.S.), Columbia University, College of Physicians and Surgeons, New York, New York 10032; Bone Bioengineering Laboratory (B.Z., J.W., X.E.G.), Columbia University, New York, New York 10027; Department of Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - Bin Zhou
- Department of Medicine (M.D.W., K.K.N., E.C., A.K., C.Z., S.J.S.), Columbia University, College of Physicians and Surgeons, New York, New York 10032; Bone Bioengineering Laboratory (B.Z., J.W., X.E.G.), Columbia University, New York, New York 10027; Department of Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - Elaine Cong
- Department of Medicine (M.D.W., K.K.N., E.C., A.K., C.Z., S.J.S.), Columbia University, College of Physicians and Surgeons, New York, New York 10032; Bone Bioengineering Laboratory (B.Z., J.W., X.E.G.), Columbia University, New York, New York 10027; Department of Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - Ji Wang
- Department of Medicine (M.D.W., K.K.N., E.C., A.K., C.Z., S.J.S.), Columbia University, College of Physicians and Surgeons, New York, New York 10032; Bone Bioengineering Laboratory (B.Z., J.W., X.E.G.), Columbia University, New York, New York 10027; Department of Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - James A Lee
- Department of Medicine (M.D.W., K.K.N., E.C., A.K., C.Z., S.J.S.), Columbia University, College of Physicians and Surgeons, New York, New York 10032; Bone Bioengineering Laboratory (B.Z., J.W., X.E.G.), Columbia University, New York, New York 10027; Department of Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - Anna Kepley
- Department of Medicine (M.D.W., K.K.N., E.C., A.K., C.Z., S.J.S.), Columbia University, College of Physicians and Surgeons, New York, New York 10032; Bone Bioengineering Laboratory (B.Z., J.W., X.E.G.), Columbia University, New York, New York 10027; Department of Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - Chengchen Zhang
- Department of Medicine (M.D.W., K.K.N., E.C., A.K., C.Z., S.J.S.), Columbia University, College of Physicians and Surgeons, New York, New York 10032; Bone Bioengineering Laboratory (B.Z., J.W., X.E.G.), Columbia University, New York, New York 10027; Department of Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - X Edward Guo
- Department of Medicine (M.D.W., K.K.N., E.C., A.K., C.Z., S.J.S.), Columbia University, College of Physicians and Surgeons, New York, New York 10032; Bone Bioengineering Laboratory (B.Z., J.W., X.E.G.), Columbia University, New York, New York 10027; Department of Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - Shonni J Silverberg
- Department of Medicine (M.D.W., K.K.N., E.C., A.K., C.Z., S.J.S.), Columbia University, College of Physicians and Surgeons, New York, New York 10032; Bone Bioengineering Laboratory (B.Z., J.W., X.E.G.), Columbia University, New York, New York 10027; Department of Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
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Walker MD, Cong E, Lee JA, Kepley A, Zhang C, McMahon DJ, Bilezikian JP, Silverberg SJ. Low vitamin D levels have become less common in primary hyperparathyroidism. Osteoporos Int 2015; 26:2837-43. [PMID: 26084258 PMCID: PMC4793903 DOI: 10.1007/s00198-015-3199-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/03/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED We compared temporal trends in serum 25-hydroxyvitamin D and parathyroid hormone (PTH) in two primary hyperparathyroidism (PHPT) cohorts recruited 20 years apart. The prevalence of 25-hydroxyvitamin D levels <20 and <30 ng/mL declined by 30-50 %, respectively, and was accompanied by lower PTH. In the older cohort, higher PTH may be due to lower 25-hydroxyvitamin D. INTRODUCTION Vitamin D deficiency may exacerbate PHPT. Whether there have been temporal trends in 25-hydroxyvitamin D (25OHD) levels in PHPT is unclear. The prevalence of low vitamin D levels (25OHD <20 and <30 ng/mL) and associated biochemical and bone mineral density (BMD) profiles were assessed in two PHPT cohorts recruited over 20 years apart. METHODS This is a cross-sectional comparison of serum 25OHD levels, calciotropic hormones, and BMD between two PHPT cohorts recruited at the same hospital: the "old" (N = 103) and "new" (N = 100) cohorts were enrolled between 1984 and 1991 and between 2010 and 2014, respectively. RESULTS Mean 25OHD levels were 26 % higher in the new cohort (23 ± 10 vs. 29 ± 10 ng/mL, p < 0.0001). Levels of 25OHD <20 and <30 ng/mL declined from 46 and 82 %, respectively, to 19 and 54 % (both p < 0.0001). Supplemental vitamin D use was common in the new (64 %) but not the old cohort (0 %). The new cohort demonstrated 33 % lower serum PTH levels (p < 0.0001). Neither serum nor urine calcium differed. BMD was higher in the new cohort at all skeletal sites (all p < 0.001). CONCLUSION With the rise in vitamin D supplementation over the last two decades, low 25OHD levels are no longer common in PHPT patients in the New York area. Those with 25OHD <20 and <30 ng/mL have declined by over 50 and 30 %, respectively. The lower mean PTH levels in the new cohort are most likely accounted for by higher vitamin D intake. Whether improved vitamin D status also underlies the relatively higher BMD in the more vitamin D replete cohort of PHPT patients is unknown.
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Affiliation(s)
- M D Walker
- Department of Medicine, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, PH 8 West - 864, New York, NY, 10032, USA.
| | - E Cong
- Department of Medicine, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, PH 8 West - 864, New York, NY, 10032, USA
| | - J A Lee
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, 10032, USA
| | - A Kepley
- Department of Medicine, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, PH 8 West - 864, New York, NY, 10032, USA
| | - C Zhang
- Department of Medicine, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, PH 8 West - 864, New York, NY, 10032, USA
| | - D J McMahon
- Department of Medicine, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, PH 8 West - 864, New York, NY, 10032, USA
| | - J P Bilezikian
- Department of Medicine, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, PH 8 West - 864, New York, NY, 10032, USA
| | - S J Silverberg
- Department of Medicine, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, PH 8 West - 864, New York, NY, 10032, USA
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Walker MD, Cong E, Lee JA, Kepley A, Zhang C, McMahon DJ, Silverberg SJ. Vitamin D in Primary Hyperparathyroidism: Effects on Clinical, Biochemical, and Densitometric Presentation. J Clin Endocrinol Metab 2015; 100:3443-51. [PMID: 26079779 PMCID: PMC4570160 DOI: 10.1210/jc.2015-2022] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Vitamin D (25-hydroxyvitamin D [25OHD]) deficiency (<20 ng/mL) and insufficiency (20-29 ng/mL) are common in primary hyperparathyroidism (PHPT), but data regarding their skeletal effects in PHPT are limited. OBJECTIVE The objective was to evaluate the association between 25OHD levels and PHPT severity. DESIGN, SETTINGS, AND PARTICIPANTS This is a cross-sectional analysis of 100 PHPT patients with and without 25OHD insufficiency and deficiency from a university hospital setting. OUTCOME MEASURES We measured calciotropic hormones, bone turnover markers, and bone mineral density (BMD) by dual x-ray absorptiometry. RESULTS Lower 25OHD was associated with some (PTH: r = -0.42; P < .0001; 1,25-dihydroxyvitamin D: r = -0.27; P = .008; serum PO4: r = 0.31; P = .002) but not all (serum/urine calcium) indicators of PHPT severity. Lower 25OHD was also associated with younger age, higher body mass index, male gender, better renal function, and lower vitamin D intake. Comparison of those with deficient (<20 ng/mL; 19%) vs insufficient (20-29 ng/mL; 35%) vs replete (≥30 ng/mL; 46%) 25OHD demonstrated more severe PHPT as reflected by higher PTH (mean ± SEM, 126 ± 10 vs 81 ± 7 vs 72 ± 7 pg/mL; P < .0001) but no difference in nephrolithiasis, osteoporosis, fractures, serum or urinary calcium, bone turnover markers, or BMD after adjustment for age and weight. In women, T-scores at the 1/3 radius were lower in those with 25OHD of 20-29 ng/mL, compared to those who were vitamin D replete (P = .048). In multiple regression modeling, 25OHD (but not PTH) was an independent predictor of 1/3 radius BMD. CONCLUSION Vitamin D deficiency is associated with more severe PHPT as reflected by PTH levels, but effects on BMD are limited to the cortical 1/3 radius and are quite modest. These data support international guidelines that consider PHPT patients with 25OHD <20 ng/mL to be deficient. However, in this cohort with few profoundly vitamin D-deficient patients, vitamin D status did not appear to significantly impact clinical presentation or bone density.
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Affiliation(s)
- Marcella D Walker
- Departments of Medicine (M.D.W., E.C., A.K., C.Z., D.J.M., S.J.S.) and Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - Elaine Cong
- Departments of Medicine (M.D.W., E.C., A.K., C.Z., D.J.M., S.J.S.) and Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - James A Lee
- Departments of Medicine (M.D.W., E.C., A.K., C.Z., D.J.M., S.J.S.) and Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - Anna Kepley
- Departments of Medicine (M.D.W., E.C., A.K., C.Z., D.J.M., S.J.S.) and Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - Chiyuan Zhang
- Departments of Medicine (M.D.W., E.C., A.K., C.Z., D.J.M., S.J.S.) and Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - Donald J McMahon
- Departments of Medicine (M.D.W., E.C., A.K., C.Z., D.J.M., S.J.S.) and Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
| | - Shonni J Silverberg
- Departments of Medicine (M.D.W., E.C., A.K., C.Z., D.J.M., S.J.S.) and Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
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Christensen MHE, Fenne IS, Nordbø Y, Varhaug JE, Nygård KO, Lien EA, Mellgren G. Novel inflammatory biomarkers in primary hyperparathyroidism. Eur J Endocrinol 2015; 173:9-17. [PMID: 25850829 DOI: 10.1530/eje-14-1038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 04/07/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Primary hyperparathyroidism (PHPT) has been associated with low-grade inflammation and increased risk of cardiovascular disease (CVD). The aim of the study was to investigate systemic levels of pro-inflammatory proteins that previously have not been examined in patients with PHPT. The selection of the pro-inflammatory biomarkers included in this study, MMP9, S100A4, S100A8/A9 and the receptors sCD14 and RAGE, was based on a previous microarray screen of mRNAs in adipose tissue from PHPT patients. DESIGN A prospective study was conducted on a total of 57 patients with PHPT and a control group of 20 healthy blood donors. METHODS PHPT patients with normalisation of serum calcium levels after parathyroidectomy were followed for 6 months. Forty-two patients participated in the longitudinal study, in which blood samples were taken at inclusion, and 1, 3 and 6 months after surgery. RESULTS We observed increased serum levels of MMP9 (P=0.029), S100A4 (P<0.001) and sCD14 (P=0.002) in the 57 patients with PHPT compared to the control-group. During 6 months of follow up, S100A4 (P=0.022) and sCD14 (0.002) decreased significantly, while serum levels of MMP9 increased (P=0.025). CONCLUSIONS The results demonstrate an increased inflammatory response in PHPT patients shown by elevated MMP9, S100A4 and sCD14 at inclusion. During the 6 months of follow-up, MMP9 increased further, possibly due to the tissue repair process after parathyroidectomy. S100A4 and sCD14 decreased after surgery demonstrating a partial reversal of the systemic inflammation.
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Affiliation(s)
- M H E Christensen
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - I S Fenne
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - Y Nordbø
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - J E Varhaug
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - K O Nygård
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - E A Lien
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - G Mellgren
- Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway Department of Clinical ScienceUniversity of Bergen, Bergen, NorwayHormone LaboratoryDepartment of SurgeryHaukeland University Hospital, 5021 Bergen, NorwayDepartment of Surgical ScienceUniversity of Bergen, Bergen, NorwayKG Jebsen Center for Diabetes ResearchBergen, NorwayDepartment of Heart DiseaseHaukeland University Hospital, Bergen, Norway
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Vélayoudom-Céphise FL, Wémeau JL. Primary hyperparathyroidism and vitamin D deficiency. ANNALES D'ENDOCRINOLOGIE 2015; 76:153-62. [PMID: 25916759 DOI: 10.1016/j.ando.2015.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 03/11/2015] [Indexed: 12/01/2022]
Abstract
Primary hyperparathyroidism (PHPT) and vitamin D (VD) deficiency are frequent conditions due to the widespread application of assays for calcium and VD. PHPT presentation is dominated by diversity in its expression and the current predominance of asymptomatic forms. VD, which plays a major role in calcium and phosphate homeostasis, is also involved in many physiological processes in this disease, such as lipid and glucose metabolism, and in the signalling pathways and functioning of many cell types. The bone and cardiometabolic complications described in PHPT are exacerbated by vitamin D deficiency, the prevalence of which varies according to many parameters (environment, skin pigmentation, associated chronic diseases, liver and kidney function, assay kit used, etc.). In response to this observation, experts in field from medical societies validated the indication for systematic assay of VD occurring with PHPT and the need for replacement in case of deficiency. Several epidemiological studies have confirmed that replacement with natural vitamin D is well tolerated and safe in subjects with PHPT and VD deficiency. This supplementation reduces hyperparathormonemia, does not have symptomatic effects on calciuria, and especially improves the bone and functional condition of patients.
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Affiliation(s)
- Fritz-Line Vélayoudom-Céphise
- Service d'endocrinologie-diabétologie, CHU de Pointe-à-Pitre, Pointe-à-Pitre, Guadeloupe; Équipe de recherche ECM-LAMIA EA4540, université des Antilles, Antilles, Guadeloupe.
| | - Jean-Louis Wémeau
- Clinique endocrinologique Marc-Linquette, CHRU de Lille, 59037 Lille, France
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Duquenne M, Duquenne C, Souberbielle JC, Hamy A, Rohmer V. [Severe hypercalcemia after substitution of prolonged deficiency of vitamin D in a patient with primary hyperparathyroidism]. Presse Med 2014; 43:1391-4. [PMID: 25443637 DOI: 10.1016/j.lpm.2014.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 04/07/2014] [Accepted: 04/23/2014] [Indexed: 11/27/2022] Open
Affiliation(s)
- Marc Duquenne
- Centre hospitalier du Mans, service de diabétologie, endocrinologie, 72037 Le Mans cedex 9, France.
| | - Carole Duquenne
- Centre hospitalier universitaire de Brest, service de rhumatologie, 29609 Brest cedex, France
| | | | - Antoine Hamy
- Centre hospitalier universitaire d'Angers, service de chirurgie viscérale, 49033 Angers cedex, France
| | - Vincent Rohmer
- Centre hospitalier universitaire d'Angers, service endocrinologie, diabétologie, nutrition, 49033 Angers cedex, France
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Aliabadi-Wahle S, Kelly TL, Rozenfeld Y, Carlisle JR, Naeole LK, Negreanu FA, Schuman E, Hammill CW. Treatment Strategies for Primary Hyperparathyroidism: What is the Cost? Am Surg 2014. [DOI: 10.1177/000313481408001132] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Primary hyperparathyroidism (HPT) contributes to the onset of many chronic conditions. Although parathyroidectomy is the only definitive treatment, observation remains a valid option. Over a 3-year span, a major health plan was queried for HPT and benign parathyroid neoplasm. Patients with secondary and tertiary HPT, Stage III to V kidney disease, and prior renal transplant were excluded. Patients were divided into: observation (Group 1), parathyroidectomy during the study period (Group 2), and parathyroidectomy before the study group (Group 3), and were compared with a control group of 27,092 adult members without HPT using analysis of variance. The 3-year mean total allowed expenditure for Group One (n = 559), Group Two (n = 93), and Group Three (n = 48) were $21,267, $37,043, and $14,702, respectively. Groups One and Two had significantly higher use than the nonparathyroid group ( P < 0.0001), whereas that of Group Three was comparable. Group Two had the highest cost, whereas Group Three had a significantly lower cost than Group One ( P 0.0001). Primary hyperparathyroidism is associated with a higher use of healthcare resources. Patients observed incurred a higher allowed expenditure than those with prior parathyroidectomy. Surgical treatment may represent a cost-effective strategy for treatment of hyperparathyroidism, although more comprehensive studies are needed to confirm these findings.
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Affiliation(s)
- Shaghayegh Aliabadi-Wahle
- The Oregon Clinic, Portland, Oregon
- Providence Cancer Center, Portland, Oregon; and
- Legacy Health System, Portland, Oregon
| | | | | | | | | | | | | | - Chet W. Hammill
- The Oregon Clinic, Portland, Oregon
- Providence Cancer Center, Portland, Oregon; and
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Shah VN, Shah CS, Bhadada SK, Rao DS. Effect of 25 (OH) D replacements in patients with primary hyperparathyroidism (PHPT) and coexistent vitamin D deficiency on serum 25(OH) D, calcium and PTH levels: a meta-analysis and review of literature. Clin Endocrinol (Oxf) 2014; 80:797-803. [PMID: 24382124 DOI: 10.1111/cen.12398] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 08/18/2013] [Accepted: 12/23/2013] [Indexed: 11/28/2022]
Abstract
CONTEXT The safety of vitamin D replacement in subjects with primary hyperparathyroidism (PHPT) and coexistent vitamin D deficiency is not well established. OBJECTIVE To evaluate the safety of vitamin D replacement in PHPT. DATA SOURCE Data were searched from Medline, EMBASE, Cochrane CENTRAL and abstracts form annual scientific meetings of various international bone and mineral societies. STUDY SELECTION Studies examining the effect of preoperative vitamin D replacement in patients with PHPT and coexisting vitamin D deficiency, irrespective of year and language of the publication were included in the present meta-analysis. DATA EXTRACTION Data were extracted from text of the included publications or abstract of conferences. DATA SYNTHESIS Ten studies enrolling 340 subjects with PHPT were analysed in this meta-analysis. After vitamin D replacement, there was significant increase in 25(OH) D levels by 55·3 nmol/l (95% CI 33·3-77·3), reduction in serum parathyroid hormone levels by 3·5 pmol/l (5·8 to -1·2) without change in serum calcium (-0·08 mmol/l, -0·2 to +0·03) and urinary calcium levels (0·72 mmol/24 h, P = 0·2) compared to baseline. CONCLUSION Vitamin D replacement in subjects with PHPT and coexistent vitamin D deficiency increase 25 (OH) D and reduce serum PTH significantly without causing hypercalcaemia and hypercalciuria. The finding of the study needs to be confirmed by a large randomized trial in patient with PHPT and coexistent vitamin D deficiency.
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Affiliation(s)
- Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado, Denver, CO, USA
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Lindeman BM, Pesce CE, Tsai HL, Somervell H, Umbricht CB, Kowalski J, Zeiger MA. Lower Vitamin D Levels in Surgical Hyperparathyroidism versus Thyroid Patients. Am Surg 2014. [DOI: 10.1177/000313481408000524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Low vitamin D levels have been shown to be associated with primary hyperparathyroidism, but it is unclear whether vitamin D deficiency may be an etiologic factor in the development of primary hyperparathyroidism. To investigate this, we compared preoperative vitamin D levels of patients undergoing surgery for primary hyperparathyroidism with those of patients undergoing surgery for benign thyroid disease. With Institutional Review Board approval, data were collected prospectively on patients undergoing parathyroidectomy or thyroidectomy by one surgeon between March 2006 and July 2011. Patients were excluded if they underwent simultaneous thyroid and parathyroid surgery, had secondary or tertiary hyperparathyroidism, if no preoperative vitamin D level was measured, or if they took vitamin D supplements. Inclusion criteria were met by 219 patients who underwent parathyroidectomy and 186 patients who underwent thyroid surgery. Patient age, sex, race, and preoperative vitamin D levels (vitamin D 25-OH; normal, 32 to 100 pg/mL) were collected. Statistical analysis was performed using linear regression. Vitamin D levels were significantly lower in the parathyroid group compared with the thyroid group (23.8 vs 28.5 pg/mL; P < 0.001). This difference was also observed after adjustment for age, sex, and race with a mean difference of 4.87 pg/mL ( P < 0.001). Statistically significant associations between lower vitamin D levels and patients younger than 50 years ( P = 0.048), male sex ( P = 0.03), and nonwhite race were identified ( P < 0.001). Patients with primary hyperparathyroidism are more likely to have lower vitamin D levels than a control surgical population. Further study is needed to determine whether low vitamin D levels may be an etiologic factor associated with the development of hyperparathyroidism.
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Affiliation(s)
- Brenessa M. Lindeman
- Departments of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Catherine E. Pesce
- Departments of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hua-Ling Tsai
- Departments of Biostatistics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Helina Somervell
- Departments of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher B. Umbricht
- Departments of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeanne Kowalski
- Departments of Biostatistics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martha A. Zeiger
- Departments of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Norenstedt S, Pernow Y, Zedenius J, Nordenström J, Sääf M, Granath F, Nilsson IL. Vitamin D supplementation after parathyroidectomy: effect on bone mineral density-a randomized double-blind study. J Bone Miner Res 2014; 29:960-7. [PMID: 24115138 DOI: 10.1002/jbmr.2102] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 08/06/2013] [Accepted: 09/12/2013] [Indexed: 02/01/2023]
Abstract
Patients with primary hyperparathyroidism (PHPT) have higher bone turnover, lower bone mineral density (BMD), and an increased risk of fractures. They also have a high incidence of low vitamin D levels (25-OH-vitamin D <50 nmol/L) that could worsen the negative effect on the bone. In this double-blinded clinical trial, 150 patients with PHPT were randomized, after successful parathyroidectomy (PTX), to 1-year daily treatment with either cholecalciferol 1600 IU and calcium carbonate 1000 mg (D+) or calcium carbonate alone (D-). BMD was measured in the lumbar spine, femoral neck, total hip, distal and 33% radius using dual-energy X-ray absorptiometry (DXA) before surgery and after 1 year of study medication. Median age was 60 (range 30-80) years and there were 119 (79%) women and 31 (21%) men; 76% had 25-OH-D <50 nmol/L before PTX and 50% had persistent elevated parathyroid hormone (PTH) 6 weeks after PTX. A similar increase in BMD in the lumbar spine, femoral neck, and total hip was observed in both groups (D+ : 3.6%, 3.2%, and 2.7%, p<0.001, respectively; and D-: 3.0%, 2.3%, and 2.1%, respectively, p<0.001). Patients with vitamin D supplementation also increased their BMD in distal radius (median 2.0%; interquartile range, -1.7% to 5.4%; p=0.013). The changes in BMD, especially in the hips, were correlated to the baseline concentrations of PTH, ionized calcium, and bone markers (p<0.001). A benefit from vitamin D substitution was observed among patients with a persistent postoperative PTH elevation, who also improved their BMD at 33% radius and radius ultradistal (p<0.05). In conclusion, except for a minor improvement of radius BMD, our data show no beneficial effect on BMD or bone turnover markers of vitamin D supplementation after PTX. Preoperative PTH seems to have the strongest association with improvement in BMD.
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Affiliation(s)
- Sophie Norenstedt
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
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Wang X, Shapses SA, Wei S, Sukumar D, Ghosh J. Vitamin D-binding protein levels in female patients with primary hyperparathyroidism. Endocr Pract 2014; 19:609-13. [PMID: 23425651 DOI: 10.4158/ep12371.or] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether low levels of vitamin D-binding protein (DBP) are related to 25-hydroxyvitamin D (25[OH]D) deficiency in female patients with primary hyperparathyroidism (PHPT). METHODS Twenty-five female patients with PHPT (serum calcium level >10.2 mg/dL and intact parathyroid hormone (iPTH) level >66 pg/mL) and 25 healthy age- and body mass index-matched female control subjects were xaminod. Serum calcium and iPTH levels were determined by commercial laboratories. Levels of 25(OH)D and 1,25-dihydroxyvitamin D (1,25[OH]₂D) were determined by radioimmunoassay, and DBP level was determined by enzyme-linked immunosorbent assay. RESULTS Serum iPTH and calcium levels were higher in PHPT patients than control subjects (P<.001). Levels of 25(OH)D, albumin, and DBP were lower in the serum of PHPT patients than control subjects (P<.01). There were no significant differences in 1,25(OH)₂D and free 25(OH)D levels between PHPT patients and control subjects. DBP level was inversely correlated with calcium (r = -0.47; P<.01) and iPTH (r = -0.31; P<.05) levels. The 25(OH)D level correlated positively with both DBP (r = 0.28; P<.05) and albumin (r = 0.44; P<.05) levels. CONCLUSION Both serum 25(OH)D and DBP levels were lower in female patients with PHPT compared with control subjects. We suggest that a low DBP level contributes to the low 25(OH)D level observed in female PHPT patients. The etiology of the decrease in DBP and its relationship to calcium, 25(OH)D, and PTH levels require further investigation.
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Affiliation(s)
- Xiangbing Wang
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Robert Wood Johnson Medical School-RWJMS, New Brunswick, NJ 08903-0019, USA.
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Walker MD, Cong E, Kepley A, Di Tullio MR, Rundek T, Homma S, Lee JA, Liu R, Young P, Zhang C, McMahon DJ, Silverberg SJ. Association between serum 25-hydroxyvitamin D level and subclinical cardiovascular disease in primary hyperparathyroidism. J Clin Endocrinol Metab 2014; 99:671-80. [PMID: 24285686 PMCID: PMC3913802 DOI: 10.1210/jc.2013-3523] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
CONTEXT Vitamin D (25OHD) deficiency may be a modifiable cardiovascular (CV) risk factor. 25OHD insufficiency (20-29 ng/mL) and deficiency (<20 ng/mL) are common in primary hyperparathyroidism (PHPT), but their association with CV disease in PHPT has not been systematically investigated. OBJECTIVE This study evaluated whether low 25OHD is associated with subclinical CV disease in PHPT. DESIGN This is a cross-sectional analysis of PHPT patients with and without low 25OHD. SETTINGS AND PARTICIPANTS We studied 110 PHPT patients in a university hospital setting. OUTCOME MEASURES We measured carotid intima-media thickness; carotid plaque presence/thickness; carotid strain and stiffness; left ventricular mass index; cardiac systolic and diastolic function; and mitral annular calcification. RESULTS Low 25OHD levels (<30 ng/mL) were observed in 28%, but only 9% had 25OHD deficiency (<20 ng/mL). In the whole group, 25OHD levels negatively correlated with body mass index (r = -0.33, P = .0005), PTH (r = -0.30, P = .001), calcium (r = -0.29, P = .002), renal function, and PHPT duration. CV indices were normal except for carotid intima-media thickness, stiffness, and plaque thickness, which were increased, regardless of 25OHD status. Isovolumic relaxation time was the only CV measure associated with 25OHD (r = -0.26, P = .01). Those with 25OHD less than 20 ng/mL had more severe PHPT and a higher rate of nephrolithiasis. Those with 25OHD less than 30 ng/mL were younger, had higher body mass index, had lower serum phosphate, and were more likely to be male, nonwhite, and Hispanic. Other than lower tissue Doppler e' and higher isovolumic relaxation time within normal range in those with 25OHD less than 30 vs greater than 30 ng/mL, there were no differences in CV indices using either 25OHD threshold. CONCLUSIONS Patients with mild PHPT have subclinical carotid abnormalities, but low 25OHD is not associated with abnormal carotid or cardiac measures. To the extent that PTH levels differentiated those with 25OHD less than 20 but not 30 ng/mL, these data support a 25OHD threshold of 20 ng/mL as clinically relevant in PHPT.
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Affiliation(s)
- Marcella D Walker
- Departments of Medicine (M.D.W., E.C., A.K., M.R.D.T., S.H., R.L., P.Y., C.Z., D.J.M., S.J.S.) and Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032; and Department of Neurology (T.R.), Miller School of Medicine, University of Miami, Miami, Florida 33136
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Norenstedt S, Pernow Y, Brismar K, Sääf M, Ekip A, Granath F, Zedenius J, Nilsson IL. Primary hyperparathyroidism and metabolic risk factors, impact of parathyroidectomy and vitamin D supplementation, and results of a randomized double-blind study. Eur J Endocrinol 2013; 169:795-804. [PMID: 24026893 PMCID: PMC3805017 DOI: 10.1530/eje-13-0547] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Vitamin D insufficiency may increase the risk for cardio metabolic disturbances in patients with primary hyperparathyroidism (PHPT). OBJECTIVE To analyze the vitamin D status and indices of the metabolic syndrome in PHPT patients and the effect of vitamin D supplementation after parathyroid adenomectomy (PTX). DESIGN AND METHODS Double-blinded, randomized clinical trial (ClinicalTrials.gov identifier: NCT00982722) performed at Karolinska University Hospital, Sweden, April 2008 to November 2011. One hundred and fifty consecutive patients with PHPT (119 women) were randomized after PTX, 75 to oral treatment with calcium carbonate 1000 mg daily and 75 to calcium carbonate 1000 mg and cholecalciferol 1600 IU daily over 12 months. Changes in metabolic profile and ambulatory blood pressure (BP) were analyzed. Main outcome measures were changes in metabolic factors, BP, and body composition. RESULTS The 25-hydroxyvitamin D (25-OH-D)-level was <50 nmol/l in 76% of the patients before PTX. After PTX, glucose, insulin, and IGF1 decreased, while the 25-OH-D and the IGF-binding protein 1 increased and remained unchanged at follow-up after study medication. One year of vitamin D supplementation resulted in lower parathyroid hormone (PTH) (40 (34-52) vs 49 (38-66) ng/l) and higher 25-OH-D (76 (65-93) vs 49 (40-62) nmol/l; P<0.05). Other laboratory parameters were stable compared with after PTX. Systolic BP decreased and total bone mineral content increased in both groups. CONCLUSION Except for the lowering of the PTH level, no additive effect of vitamin D supplementation was seen. However, PTX proved effective in reducing insulin resistance.
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Affiliation(s)
- Sophie Norenstedt
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
- Department of Endocrine SurgeryKarolinska University HospitalStockholmSweden
- (Correspondence should be addressed to S Norenstedt who is now at Department of Breast and Endocrine Surgery, Karolinska University Hospital, P9:03, SE-171 76 Stockholm, Sweden; )
| | - Ylva Pernow
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
- Department of Endocrinology, Metabolism and DiabetesKarolinska University HospitalStockholmSweden
| | - Kerstin Brismar
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
- Department of Endocrinology, Metabolism and DiabetesKarolinska University HospitalStockholmSweden
| | - Maria Sääf
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
- Department of Endocrinology, Metabolism and DiabetesKarolinska University HospitalStockholmSweden
| | - Ayla Ekip
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | | | - Jan Zedenius
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
- Department of Endocrine SurgeryKarolinska University HospitalStockholmSweden
| | - Inga-Lena Nilsson
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
- Department of Endocrine SurgeryKarolinska University HospitalStockholmSweden
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Tassone F, Gianotti L, Baffoni C, Visconti G, Pellegrino M, Cassibba S, Croce CG, Magro G, Cesario F, Attanasio R, Borretta G. Vitamin D status in primary hyperparathyroidism: a Southern European perspective. Clin Endocrinol (Oxf) 2013; 79:784-90. [PMID: 23521111 DOI: 10.1111/cen.12210] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 02/13/2013] [Accepted: 03/19/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Vitamin D deficiency (VDD) is common in patients with primary hyperparathyroidism (pHPT), and this could affect the clinical expression of the disease. However, few North American or North European studies have addressed this issue, showing vitamin D repletion in only about one-third of the patients. SUBJECTS AND METHODS Vitamin D status was evaluated both in an observational study in a series of 206 consecutive patients with pHPT at diagnosis and in a case-control analysis with 113 age- and sex-matched healthy blood donors. Vitamin D status was assessed by measuring plasma 25-hydroxy-vitamin D (25OHD) levels and was defined as VDD or severe VDD if 25OHD was <20 ng/ml (<50 nm) and <10 ng/ml (<25 nm), respectively. RESULTS No seasonal variability was observed in 25OHD levels. VDD was observed in 75 of 206 patients (36·4%). The VDD was severe in 24 of 75 patients (11·7%). There was no difference in prevalence of VDD between men and women nor between asymptomatic and 'bone and stone' symptomatic patients. 25OHD levels was negatively correlated with parathyroid hormone, ionized calcium, and bone turnover markers, and positively correlated with phosphate. 25OHD levels were also positively correlated with bone mineral density at all sites measured. In the case-control study, the overall prevalence of VDD and severe VDD was higher in patients with pHPT compared with controls (33·6% vs 10·6%, P < 0·0001, and 8·8% vs 1·8%, P = 0·0337, respectively). CONCLUSIONS Our study shows that VDD occurs in about one-third of patients with pHPT resident in a Southern European area, a lower figure than previously reported. Moreover, VDD is related to a more severe bone disease, and its prevalence is higher in patients with pHPT than in healthy matched subjects.
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Affiliation(s)
- Francesco Tassone
- Division of Endocrinology, Diabetology and Metabolism, Santa Croce e Carle Hospital, Cuneo, Italy
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Christensen MHE, Apalset EM, Nordbø Y, Varhaug JE, Mellgren G, Lien EA. 1,25-dihydroxyvitamin D and the vitamin D receptor gene polymorphism Apa1 influence bone mineral density in primary hyperparathyroidism. PLoS One 2013; 8:e56019. [PMID: 23418495 PMCID: PMC3572149 DOI: 10.1371/journal.pone.0056019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 01/09/2013] [Indexed: 01/08/2023] Open
Abstract
Objective Parathyroid hormone (PTH) and vitamin D are the most important hormones regulating calcium metabolism. In primary hyperparathyroidism (PHPT) excessive amounts of PTH are produced. Bone turnover is enhanced, leading to reduced bone mineral density and elevated levels of serum calcium. The aim of this study was to investigate relations between serum levels of 25-hydroxyvitamin D (25(OH)D), 1,25-dihydroxyvitamin D (1,25(OH)2D) and bone mineral density, as well as known genetic polymorphisms in the vitamin D receptor and enzymes metabolising vitamin D in patients with PHPT. Design/Subjects We conducted a cross-sectional study of 52 patients with PHPT. Results Mean level of 25(OH)D was 58.2 nmol/L and median 1,25(OH)2D level was 157 pmol/L. Among our patients with PHPT 36.5% had 25(OH)D levels below 50 nmol/L. Serum 1,25(OH)2D was inversely correlated to bone mineral density in distal radius (p = 0.002), but not to bone mineral density at lumbar spine or femoral neck. The vitamin D receptor polymorphism Apa1 (rs7975232) was associated with bone mineral density in the lumbar spine. Conclusions The results suggest that PHPT patients with high blood concentrations of 1,25(OH)2D may have the most deleterious skeletal effects. Randomized, prospective studies are necessary to elucidate whether vitamin D supplementation additionally increases serum 1,25(OH)2D and possibly enhances the adverse effects on the skeleton in patients with PHPT.
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Silverberg SJ, Walker MD, Bilezikian JP. Asymptomatic primary hyperparathyroidism. J Clin Densitom 2013; 16:14-21. [PMID: 23374736 PMCID: PMC3987990 DOI: 10.1016/j.jocd.2012.11.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 11/18/2012] [Indexed: 02/07/2023]
Abstract
The clinical profile of primary hyperparathyroidism (PHPT) as it is seen in the United States and most Western countries has evolved significantly over the past half century. The introduction of the multichannel serum autoanalyzer in the 1970s led to the recognition of a cohort of individuals with asymptomatic hypercalcemia, in whom evaluation led to the diagnosis of PHPT. The term "asymptomatic primary hyperparathyroidism" was introduced to describe patients who lack obvious signs and symptoms referable to either excess calcium or parathyroid hormone. Although it was expected that asymptomatic patients would eventually develop classical symptoms of PHPT, observational data suggest that most patients do not evolve over time to become overtly symptomatic. In most parts of the world, the asymptomatic phenotype of PHPT has replaced classical PHPT. This report is a selective review of data on asymptomatic PHPT: its demographic features, presentation and natural history, as well as biochemical, skeletal, neuromuscular, psychological, and cardiovascular manifestations. In addition, we will summarize available information on treatment indications and options for those with asymptomatic disease.
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Affiliation(s)
- Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
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Rolighed L, Vestergaard P, Heickendorff L, Sikjaer T, Rejnmark L, Mosekilde L, Christiansen P. BMD improvements after operation for primary hyperparathyroidism. Langenbecks Arch Surg 2012; 398:113-20. [DOI: 10.1007/s00423-012-1026-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 10/23/2012] [Indexed: 11/30/2022]
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Souberbielle JC, Bienaimé F, Cavalier E, Cormier C. Vitamin D and primary hyperparathyroidism (PHPT). ANNALES D'ENDOCRINOLOGIE 2012; 73:165-9. [DOI: 10.1016/j.ando.2012.04.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 04/25/2012] [Indexed: 11/25/2022]
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Pyram R, Mahajan G, Gliwa A. Primary hyperparathyroidism: Skeletal and non-skeletal effects, diagnosis and management. Maturitas 2011; 70:246-55. [PMID: 21943558 DOI: 10.1016/j.maturitas.2011.07.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 07/22/2011] [Indexed: 12/23/2022]
Abstract
Primary hyperparathyroidism (PHPT) is the third most common endocrinopathy seen today, and is most frequently found in the 6th to 7th decade of life. PHPT can present with various degrees of symptoms, and can affect many organ systems, including the skeletal, renal, central nervous system and cardiovascular system. Despite this, the most common presentation of hyperparathyroidism is "asymptomatic" with the diagnosis being made incidentally with the initial finding of hypercalcemia on routine laboratory studies, leading to further investigation. Surgical versus medical management is usually based on factors such as age and complications related to hyperparathyroidism (i.e. the presence of renal stones, renal insufficiency and bone loss and significant increases in serum calcium). Treatment options include parathyroidectomy, bisphosphonates, calcitonin and calcimimetics. In this review, we discuss primary hyperparathyroidism in detail with a focus on clinical manifestations particularly in the elderly population. We highlight the indications for surgical versus medical management and compare some of the uses of newer therapeutic agents relative to traditional ones.
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Affiliation(s)
- Ronald Pyram
- Division of Endocrinology SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203, USA
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Clinical significance of vitamin D deficiency in primary hyperparathyroidism, and safety of vitamin D therapy. South Med J 2011; 104:29-33. [PMID: 21079532 DOI: 10.1097/smj.0b013e3181fcd772] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Vitamin D deficiency occurs more frequently in patients with primary hyperparathyroidism (PHPT) compared with the general population, and is usually associated with an aggravated form of the disease. Current guidelines recommend measurement of serum levels of 25-hydroxy vitamin D (25-OHD) in all patients with PHPT, and their repletion if the levels are less than 50 mmol/L (20 ng/mL). Limited data suggest that vitamin D treatment is generally safe in subjects with mild PHPT and coexisting vitamin D deficiency. Adverse effects include hypercalcuria and, less commonly, exacerbation of hypercalcemia. Well-designed trials are needed to evaluate the safety of vitamin D replacement therapy in a wide spectrum of patients with concomitant PHPT and vitamin D deficiency. These trials should address the impact of such therapy on the complications and course of PHPT.
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