Current opinions on nephrolithiasis associated with primary hyperparathyroidism

Role of Nutrition in the Management of Patients with Multiple Endocrine Neoplasia Type 1

Multiple endocrine neoplasia type 1 (MEN1) is a rare syndrome caused by inactivating mutations in the MEN1 tumor suppressor gene. The three main clinical manifestations of MEN1 are primary hyperparathyroidism (PHPT), duodenal-pancreatic neuroendocrine tumors (DP-NETs) and anterior pituitary tumors. Endocrine tumors in patients with MEN1 differ from sporadic tumors because of their younger age at onset, common multiple presentations and the different clinical course. MEN1 is characterized by a complex clinical phenotype; thus, patients should be followed by a multidisciplinary team of experts that includes an endocrinologist, a surgeon, a oncologist, a radiotherapist, and not least, a nutritionist. It is important to remember the fundamental role that diet plays as a primary prevention tool, together with a healthy and active lifestyle in preventing osteoporosis/osteopenia and reducing the risk of developing kidney stones due to hypercalciuria, two frequent clinical complications in MEN1 patients. Is very important for MEN1 patients to have an adequate intake of calcium, vitamin D, magnesium and phosphate to maintain good bone health. The intake of foods containing oxalates must also be kept under control because in combination with calcium they concur to form calcium oxalate crystals, increasing the risk of nephrolithiasis. Another aspect to consider is the management of patients with pancreatic neuroendocrine tumors undergoing major surgical resections of the pancreas that can lead to alterations in digestion and absorption mechanisms due to partial or total reduction in pancreatic enzymes such as amylase, lipase, and protease, resulting in malabsorption and malnutrition. Therefore, the nutritionist's aim should be to devise a dietary plan that takes into consideration each single patient, educating them about a healthy and active lifestyle, and accompanying them through various life stages by implementing strategies that can enhance their quality of life.

Delayed Diagnosis of Primary Hyperparathyroidism: A Case Report

Primary hyperparathyroidism (PHPT) is characterized by an elevation in serum calcium levels, sometimes leading to aggravated clinical conditions, namely nephrolithiasis, nephrocalcinosis, and/or fractures. A 55-year-old patient was admitted to the hospital with acute obstructive pyelonephritis in March 2021, having another episode one year later. Initial blood and urine analysis detected inflammatory markers, namely C-reactive protein, and the presence of leucocytes and blood in the urine. The renal computed tomography scan exhibited renal asymmetry, nephrocalcinosis, and multiple kidney stones. The patient was scheduled for a follow-up one year later to perform blood and urine analysis to uncover the cause of nephrocalcinosis, displaying high serum calcium and parathyroid hormone (PTH) levels. The thyroid ultrasound revealed a parathyroid adenoma, which was removed through a right lower parathyroidectomy, improving the symptoms. The clinical condition described here is an atypical manifestation of this disease because PHPT is normally asymptomatic. In the present case study, nephrocalcinosis and nephrolithiasis were strong indicators of the underlying disease. However, the delay in the follow-up consultation resulted in complications for the patient, such as microabscesses in the kidneys, which could lead to reduced renal function in the future. Early detection of key aspects of the disease could avoid further complications and suffering for the patient. For example, the family physician's follow-up of the patient's condition could surpass the waiting time between consultations with different specialties, and promote early treatment.

Neuroendocrine Parathyroid Tumors: Quality of Life in Patients with Primary Hyperparathyroidism

Tumors of the parathyroid glands, when associated with PTH (parathyroid hormone) excess, display a large area of complications; in addition to the classical clinical picture of primary hyperparathyroidism (PHP), a complex panel of other symptoms/signs can be identified, including memory and cognitive impairment, chronic asthenia/fatigue, reduced muscle functionality, depressive mood, non-specific bone pain, and loss of sleep quality. The perception of quality of life (QoL) can be supplementarily enhanced by their progressive onset, which makes many patients not be fully aware of them. Their improvement was reported very early after parathyroidectomy (PTx), yet the level of statistical evidence does not qualify these non-classical elements as standalone indications for PTx. Our objective is introducing an up-to-date on QoL scores with regards to the patients diagnosed with PHP, particularly taking into consideration PHP management from baseline to post-operatory outcome, including in cases with multiple endocrine neoplasia. This is a narrative review of literature. We revised full-length papers published in English through PubMed research conducted between January 2018 and May 2023 by using the key words "quality of life" and "primary hyperparathyroidism". We particularly looked at data on self-reported QoL (through questionnaires). We excluded from the search the studies focused on non-PTH related hypercalcemia, secondary, and/or renal/tertiary hyperparathyroidism, and vitamin D supplementation. Overall, we identified 76 papers and selected for the final analysis 16 original studies on QoL and PHP (a total of 1327 subjects diagnosed with syndromic and non-syndromic PHP). The studies with the largest number of individuals were of 92, 104, 110, 134, 159, as well as 191. A few cohorts (n = 5) were of small size (between 20 and 40 patients in each of them). Concerning the study design, except for 2 papers, all the mentioned studies provided longitudinal information, particularly the timeframe from baseline (before PTx) and after surgery. The post-operatory follow-up was of 3-6 months, but mostly between 1 and 3 years (maximum a decade of surveillance). The age of the patients varies between medians of 56, 62, 64, and 68 years. Most frequent questionnaires were SF-36, PHPQoL, and PAS. Despite not being unanimously similar, an overall reduced score of QoL in patients with PHP versus controls was registered, as well as general improvement following PTx. Variations of QoL results might have a multifactorial background from different comorbidities, studied populations, technical aspects of collecting the data, etc. QoL scores in PHP represents a complex heterogeneous picture, from their correlation with clinical features and lab assays (e.g., the level of serum calcium), the associated comorbidities (such as multiple endocrine neoplasia syndromes), up to the assessment of the QoL improvement after parathyroidectomy (PTx). While current studies do not unanimously agree on each QoL domain, the assessment of QoL might represent a supplementary argument to consider when deciding for PTx, especially in asymptomatic cases and in patients who do not fit into well-known categories of surgery candidates, according to current guidelines, thus assessing QoL in PHP is part of a current research gap. QoL evaluation in PHP remains an open issue, towards which awareness should be cultivated by both endocrinologists and surgeons. The introduction of a routine evaluation of the QoL scores in patients, as well as the selection of the most appropriate questionnaire(s), represents an open chapter thus awareness in mandatory.

Inhibitory role of microRNA-484 in kidney stone formation by repressing calcium oxalate crystallization via a VDR/FoxO1 regulator axis

Kidney stones are regarded as common malignant diseases in the developed world. As a result, significant research examining their formation is ongoing, with microRNAs (miRs) recently being linked with kidney stone formation. Here, we aim to define the potential role of miR-484 in regulating renal tubular epithelial cell (RTEC) viability and the attachment of calcium oxalate (CaOx) crystals to RTECs via vitamin D receptor (VDR)/forkhead box protein O1 (FoxO1) axis. The pathological condition of CaOx crystallization was induced and examined in Sprague-Dawley rats, while RTECs were isolated and cultured in vitro. Loss- and gain-function assays were performed to study the effects that miR-484, VDR, and FoxO1 on RTEC functions and CaOx crystallization in vitro and on kidney stone formation in vivo. The interaction between miR-484 and VDR was confirmed by dual-luciferase reporter gene assays. Downregulation of miR-484 and FoxO1 as well as overexpression of VDR were identified in kidney stone modelled rats. VDR was confirmed as a target gene of miR-484, while knockdown of VDR upregulated the FoxO1 expression. miR-484 overexpression or VDR suppression reduced RTEC cytotoxicity and crystal attachment to RTECs in vitro and reduced the CaOx crystallization in vivo. Taken together, these findings suggest that miR-484 overexpression may be a potential inhibitor of RTEC proliferation and CaOx crystallization through a VDR/FoxO1 regulatory axis, providing a novel therapeutic target for the treatment of kidney stone.

Discovery of primary hyperparathyroidism following an endoscopic resection of the prostate: case report

Urological complaints related to primary hyperparathyroidism are frequently caused by the formation of urolithiasis. We report another rare clinical manifestation of primary hyperparathyroidism associated with urological symptoms. A 68-year-old man presented with dysuria related to benign prostatic hyperplasia. After undergoing endoscopic resection of the prostate, the patient's urinary complaints persisted for several months thereafter. Urinary ultrasound revealed numerous calcifications on the prostatic resection area, requiring a cystoscopy for excision and analysis of the calcifications. This was followed by an endocrine evaluation that revealed a primary hyperparathyroidism due to a single parathyroid adenoma, which was responsible for the prostatic calcifications and the patient's atypical symptomatology. The clinical evolution was favorable after parathyroidectomy. Symptomatic prostatic calcifications, due to primary hyperparathyroidism, on an area of the endoscopic prostate resection are uncommon. The only treatment is endocrine surgery.

Treatment options for hypercalcemia after cosmetic oil injections: Lessons from human tissue cultures and a pilot intervention study

OBJECTIVE

Granuloma formation following self-administered cosmetic oil injections can lead to severe hypercalcemia and renal calcifications due to extra-renal vitamin D activation. This translational study aims to identify Prednisolone sparing therapeutics for hypercalcemia after development of granulomatous disease secondary to paraffin oil injections.

MATERIALS AND METHODS

Granuloma tissue isolated from five men were cultured ex vivo and treated with selected drugs to block generation of activated vitamin D (1,25(OH)₂D₃). In a retrospective study, we included data before and during different treatments of 21 men with paraffin oil induced granulomatous hypercalcemia (46 treatment courses) where serum calcium, parathyroid hormone, vitamin D metabolites, creatinine and inflammatory markers were measured.

RESULTS

Addition of Ketoconazole or Ciclosporin to granuloma tissue ex vivo culture, significantly suppressed production of 1,25(OH)₂D₃ after 48 h (both p < 0.05). Prednisolone was the first treatment option in most men and lowered serum levels of ionized calcium after 1, 2, 3 and 6 months compared with baseline (p < 0.05). Ketoconazole or Hydroxychloroquine had no significant effect on serum calcium levels and were unable to reduce the concomitant daily Prednisolone doses (p > 0.05). Azathioprine did not reduce calcium levels. However, addition of Tacrolimus to Prednisolone treatment enabled a reduction in Prednisolone dose after 3 months (p = 0.014), but with no additional effect on calcium homeostasis.

CONCLUSION

This study verifies that Prednisolone is an effective treatment and suggests that calcineurin inhibitors may be used as Prednisolone sparing treatment for paraffin oil-induced granulomatous hypercalcemia. Randomized clinical trials are needed to determine clinical efficacy.

Primary Hyperparathyroidism in the Common Orthopaedic Practice

An extensive review of the publications on primary hyperparathyroidism (pHPT) is presented in this report. It has strongly been emphasized in the literature that patients with pHPT may present either with the classical symptomatology or with asymptomatic disease, emerged due to biochemical screening. The clinical and epidemiological presentation of pHPT in western countries has changed profoundly during the past few decades, and bone disease is nowadays a distinct rarity. The introduction of serum calcium screening for osteoporosis and the technological advances in the laboratory assessment of parathyroid hormone have played important roles in early diagnosis. Subsequently, the disease is increasingly being detected as asymptomatic hypercalcaemia without guiding signs or symptoms. A third type of disease, the normocalcaemic variant, has been recently described in the literature. However, the potential diagnosis of pHPT should always be on the orthopaedics’ list of differential diagnoses in female or elderly patients with vertebral fractures and nephrolithiasis, either symptomatic or asymptomatic, as well as when solitary or multiple osteolytic lesions are encountered on the radiographs.

Additionally, a middle aged woman with parathyroid adenoma and subsequent brown tumors detected on the pelvic radiographs is reported. Her initial laboratory findings indicated a minimal increase of the serum calcium, a mild increase of the erythrocyte sedimentation rate, and a significant increase in total serum alkaline phosphatase. Finally, the detection of elevated parathyroid hormone levels indicated the diagnosis of pHPT and necessitated imaging studies of the parathyroid glands, which indicated a parathyroid adenoma. Following successful excision of the parathyroid adenoma, the patient suffered from the hungry bone syndrome. After a follow-up of 20 years, the patient had normal calcium, vitamin D, and parathyroid hormone serum levels, while a pelvic radiograph indicated no significant changes in the appearance of the brown tumors.

Primary Hyperparathyroidism in the Common Orthopaedic Practice

An extensive review of the publications on primary hyperparathyroidism (pHPT) is presented in this report. It has strongly been emphasized in the literature that patients with pHPT may present either with the classical symptomatology or with asymptomatic disease, emerged due to biochemical screening. The clinical and epidemiological presentation of pHPT in western countries has changed profoundly during the past few decades, and bone disease is nowadays a distinct rarity. The introduction of serum calcium screening for osteoporosis and the technological advances in the laboratory assessment of parathyroid hormone have played important roles in early diagnosis. Subsequently, the disease is increasingly being detected as asymptomatic hypercalcaemia without guiding signs or symptoms. A third type of disease, the normocalcaemic variant, has been recently described in the literature. However, the potential diagnosis of pHPT should always be on the orthopaedics’ list of differential diagnoses in female or elderly patients with vertebral fractures and nephrolithiasis, either symptomatic or asymptomatic, as well as when solitary or multiple osteolytic lesions are encountered on the radiographs.

Additionally, a middle aged woman with parathyroid adenoma and subsequent brown tumors detected on the pelvic radiographs is reported. Her initial laboratory findings indicated a minimal increase of the serum calcium, a mild increase of the erythrocyte sedimentation rate, and a significant increase in total serum alkaline phosphatase. Finally, the detection of elevated parathyroid hormone levels indicated the diagnosis of pHPT and necessitated imaging studies of the parathyroid glands, which indicated a parathyroid adenoma. Following successful excision of the parathyroid adenoma, the patient suffered from the hungry bone syndrome. After a follow-up of 20 years, the patient had normal calcium, vitamin D, and parathyroid hormone serum levels, while a pelvic radiograph indicated no significant changes in the appearance of the brown tumors.

Occurrence of Klinefelter Syndrome Mosaic 45,X/46,XY/47,XXY/48,XXYY/48,XXXY and Primary Hyperparathyroidism

Objective

The presence of primary hyperparathyroidism (PHPT) and Klinefelter syndrome (KS) is rare, and its association with KS mosaicism is even rarer. We report an unusual combination of these entities with a mild phenotype of KS.

Methods

The patient was a 44-year-old male with a history of PHPT who had recurrent urolithiasis despite being treated with a successful parathyroidectomy. On examination, he had axillary hair growth, bilateral gynecomastia, a large port-wine stain at the right hemithorax and upper right limb, and genitalia and pubic hair corresponding to Tanner IV classification with small, normal consistency testicles.

Results

Laboratory findings were unremarkable except for a slightly elevated luteinizing hormone, which was normal on repeat testing. Because of the picture of unexplained gynecomastia, laboratory findings, and low-volume testis, a diagnosis of KS was considered. Chromosomal analysis revealed a rare 45,X/46,XY/47,XXY/48,XXYY/48,XXXY KS mosaic.

Conclusions

KS phenotypes are largely variable, and their association with PHPT remains to be elucidated.

Hypercalcemia After Cosmetic Oil Injections: Unraveling Etiology, Pathogenesis, and Severity

Intramuscular injections of paraffin oil can cause foreign body granuloma formation and hypercalcemia. Macrophages with the ability to produce high levels of 1,25(OH)₂ D₃ may induce the mineral disturbance, but no major series of patients have been published to date. Here, medical history, physical evaluation, biochemical, and urinary analysis for calcium homeostasis were obtained from 88 males, who 6 years previously had injected paraffin or synthol oil into skeletal muscle. Moreover, granuloma tissue from three men was cultured for 48 hours ex vivo to determine 1,25(OH)₂ D₃ production supported by qPCR and immunohistochemistry of vitamin D metabolism and immune cell populations after treatment with 14 different drugs. The 88 men were stratified into men with hypercalcemia (34%), whereas normocalcemic men were separated into men with either normal (42%) or suppressed parathyroid hormone (PTH) (24%). All men had high calcium excretion, and nephrolithiasis was found in 48% of hypercalcemic men, 22% of normocalcemic men with normal PTH, and 47% of normocalcemic men with suppressed PTH. Risk factors for developing hypercalcemia were oil volume injected, injection of heated oil, high serum interleukin-2 receptor levels, and high urine calcium. High 1,25(OH)₂ D₃ /25OHD ratio, calcium excretion, and low PTH was associated with nephrolithiasis. The vitamin D activating enzyme CYP27B1 was markedly expressed in granuloma tissue, and 1,25(OH)₂ D₃ was released in concentrations corresponding to 40% to 50% of the production by human kidney specimens. Dexamethasone, ketoconazole, and ciclosporin significantly suppressed granulomatous production of 1,25(OH)₂ D₃ . In conclusion, this study shows that injection of large oil volumes alters calcium homeostasis and increases the risk of nephrolithiasis. Hypercalciuria is an early sign of disease, and high granulomatous 1,25(OH)₂ D₃ production is part of the cause. Prospective clinical trials are needed to determine if ciclosporin, ketoconazole, or other drugs can be used as prednisolone-sparing treatment. © 2020 American Society for Bone and Mineral Research (ASBMR).

Normocalcaemic primary hyperparathyroidism: An update on diagnostic and management challenges

Normocalcaemic primary hyperparathyroidism is a condition that can present with intermittent hypercalcemia or may evolve into hypercalcemic primary hyperparathyroidism. This milder biochemical entity remains incompletely understood because of a lack of long-term health outcomes regarding both medical and surgical approaches to its management. Medical therapies have shown some efficacy. A limited number of studies have found that bisphosphonates increase bone mineral density, and calcimimetics may decrease the risk of nephrolithiasis in patients with normocalcaemic primary hyperparathyroidism. Studies have also described patient outcomes after applying the same surgical criteria used for patients with hypercalcaemic primary hyperparathyroidism to those with the normocalcaemic form of the disease. These studies suggest that parathyroid surgery appears to be effective in normalizing elevated serum parathyroid hormone concentrations and decreasing adverse renal and skeletal outcomes in patients with normocalcaemic hyperparathyroidism. Given the available data and overall lack of consensus regarding the optimal management of these patients, a reasonable approach is to tailor treatment to the individual patient by considering their risk factors for new or accelerated bone loss, kidney stones, diminished quality of life, and cardiovascular disease.

Physical Activity-Dependent Regulation of Parathyroid Hormone and Calcium-Phosphorous Metabolism

Exercise perturbs homeostasis, alters the levels of circulating mediators and hormones, and increases the demand by skeletal muscles and other vital organs for energy substrates. Exercise also affects bone and mineral metabolism, particularly calcium and phosphate, both of which are essential for muscle contraction, neuromuscular signaling, biosynthesis of adenosine triphosphate (ATP), and other energy substrates. Parathyroid hormone (PTH) is involved in the regulation of calcium and phosphate homeostasis. Understanding the effects of exercise on PTH secretion is fundamental for appreciating how the body adapts to exercise. Altered PTH metabolism underlies hyperparathyroidism and hypoparathyroidism, the complications of which affect the organs involved in calcium and phosphorous metabolism (bone and kidney) and other body systems as well. Exercise affects PTH expression and secretion by altering the circulating levels of calcium and phosphate. In turn, PTH responds directly to exercise and exercise-induced myokines. Here, we review the main concepts of the regulation of PTH expression and secretion under physiological conditions, in acute and chronic exercise, and in relation to PTH-related disorders.