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Cao R, Jiang H, Liang G, Zhang W. Dynamic nomogram for predicting hungry bone syndrome before parathyroidectomy. Endocrine 2024; 83:196-204. [PMID: 37640988 DOI: 10.1007/s12020-023-03493-6] [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: 03/18/2023] [Accepted: 08/04/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE The objective of this study was to develop a dependable and uncomplicated prediction model utilizing clinical information readily accessible to patients before surgery. This model aimed to assess the likelihood of hungry bone syndrome occurrence in post-surgery patients with secondary hyperparathyroidism (SHPT), and to assist clinicians in adjusting treatment plans promptly. METHODS In this study, we constructed an online nomogram utilizing independent variables determined through multiple logistic regression to predict the probability of HBS occurrence after parathyroidectomy in patients with secondary hyperparathyroidism. To evaluate the precision and dependability of the nomogram, we used receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA). RESULTS Multivariate logistic regression analyses on 136 eligible patients identified age, parathyroid hormone (PTH), and blood calcium as independent HBS risk factors, which were then integrated into the nomogram. The area under ROC curve demonstrated the nomogram's strong predictive accuracy. The calibration curve demonstrates consistency between the model's prediction probability and observed probability, reflecting high prediction accuracy of the nomogram. Dynamic nomograms were found to hold significant practical clinical value as demonstrated by clinical decision analysis. It can be accessed on https://min115.shinyapps.io/dynnomapp/ . CONCLUSION In patients with secondary hyperparathyroidism, the dynamic nomogram based on age, parathyroid hormone, and blood calcium can more accurately predict the likelihood of HBS after parathyroidectomy, allowing doctors to make clinical decisions more quickly and adjust treatment plans in a timely manner to reduce the incidence of HBS.
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Affiliation(s)
- Runmin Cao
- Jinzhou Medical University Postgraduate Training Base (Jinzhou Central Hospital), Jinzhou City, Liaoning Province, China
| | - Honghe Jiang
- Anhui University of Science and Technology, Huainan City, Anhui Province, China
| | - Guangpeng Liang
- Jinzhou Medical University Postgraduate Training Base (Jinzhou Central Hospital), Jinzhou City, Liaoning Province, China
| | - Weibin Zhang
- Jinzhou Medical University Postgraduate Training Base (Jinzhou Central Hospital), Jinzhou City, Liaoning Province, China.
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Chang LC, Liu SI, Liang TJ. Neck Reoperation for Recurrent or Persistent Renal Hyperparathyroidism. World J Surg 2023; 47:2784-2791. [PMID: 37714965 DOI: 10.1007/s00268-023-07172-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Patients with renal hyperparathyroidism undergoing parathyroidectomy may experience relapse. Reoperation for persistent or recurrent disease, particularly in the neck region, is challenging and has a high complication rate because of difficult exploration. We aimed to evaluate the effectiveness of neck reoperation in renal hyperparathyroidism. METHODS Patients with recurrent or persistent renal hyperparathyroidism who underwent neck reoperation between January 2015 and August 2022 were investigated, focusing on operative findings, perioperative biochemical changes, and significance of intraoperative parathyroid hormone (PTH) measurements. RESULTS During reoperation, 35 parathyroid glands were identified and removed from the 26 enrolled patients, with one, two, and three glands retrieved from 19 (73.2%), five (19.2%), and two (7.6%) patients, respectively. Most removed glands (68.6%) were located in the lower neck, followed by the mediastinum, carotid sheath, and upper neck. Successful resection, defined as a postoperative PTH level of <300 pg/mL, was achieved in 21 patients (80.8%). The remaining four (15.4%) and one (3.9%) patients were classified as having persistent and recurrent disease, respectively. The extent of PTH reduction was correlated with specimen weight, specimen volume, and preoperative alkaline phosphatase (ALP) level. The mean intraoperative PTH ratio (10 min after excision/pre-excision) was 0.23, and all patients with persistent or recurrent disease had a PTH ratio >0.3. Severe hypocalcemia (<7.5 mg/dL) occurred in 19 (73.0%) patients after reoperation. CONCLUSIONS Neck reoperation is an effective therapeutic option in patients with recurrent or persistent renal hyperparathyroidism. A decrease in PTH level by >70% during reoperation (PTH ratio <0.3) predicts successful resection.
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Affiliation(s)
- Lu-Chia Chang
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Zuoying District, No. 386, Dazhong 1st Rd., Kaohsiung, Taiwan, 813414
| | - Shiuh-Inn Liu
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Zuoying District, No. 386, Dazhong 1st Rd., Kaohsiung, Taiwan, 813414
- School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec. 2, Linong Street, Taipei, Taiwan, 112304
| | - Tsung-Jung Liang
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Zuoying District, No. 386, Dazhong 1st Rd., Kaohsiung, Taiwan, 813414.
- School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec. 2, Linong Street, Taipei, Taiwan, 112304.
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Ramesh S, Vekaria S, Fisher JC, Wright K, Underwood H, Prescott J, Allendorf J, Patel KN, Suh I, Sum M. A Novel Risk Score to Predict Hungry Bone Syndrome After Parathyroidectomy for Renal Hyperparathyroidism. Endocr Pract 2023; 29:890-896. [PMID: 37678470 DOI: 10.1016/j.eprac.2023.08.007] [Citation(s) in RCA: 1] [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] [Received: 05/26/2023] [Revised: 08/13/2023] [Accepted: 08/16/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE Hungry bone syndrome (HBS) is a known complication of parathyroidectomy. Patients with renal hyperparathyroidism are particularly vulnerable to HBS because of their prolonged exposure to electrolyte abnormalities and elevated parathyroid hormone (PTH). However, in-depth characterization of predictive factors for HBS in these patients is lacking. METHODS A retrospective analysis was performed of patients with renal hyperparathyroidism who underwent parathyroidectomy at a single institution from 2011-2021. Patient demographics, clinical characteristics, and biochemical data were collected and analyzed. Boruta and binary logistic regression analyses were used to develop a scoring system. RESULTS Thirty-three patients were identified; 16 (48%) developed HBS. Patients with HBS had significantly higher preoperative levels of serum PTH (mean difference [MS] = 2167.2 pg/mL, P <.001), phosphorus (MD = 3.5 mg/dl, P <.001), and alkaline phosphatase (ALP) (MD = 344.2 U/L, P =.002) and significantly lower levels of preoperative serum calcium (MD = -0.96 mg/dL, P =.004). Stepwise regression analysis identified elevated ALP (>150 U/L) and markedly elevated PTH (>1000 pg/mL) as positive predictors of HBS. A two-point scoring system with these 2 variables had overall diagnostic accuracy of 96.8% (sensitivity 100% and specificity 94.1%) with 1 point conferring 93.8% positive predictive value and 2 points conferring 100% positive predictive value. CONCLUSION Preoperative serum PTH and ALP are significantly associated with HBS in patients with renal hyperparathyroidism undergoing parathyroidectomy for renal hyperparathyroidism. A scoring system with these 2 variables may be of clinical utility in predicting patients at high risk of HBS.
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Affiliation(s)
- Sruthi Ramesh
- NYU Grossman School of Medicine, NYU Langone Health, New York, New York
| | - Shivani Vekaria
- Division of Endocrinology, NYU Langone Health, New York, New York
| | - Jason C Fisher
- Department of Surgery, NYU Langone Health, New York, New York
| | - Kyla Wright
- NYU Grossman School of Medicine, NYU Langone Health, New York, New York
| | - Hunter Underwood
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jason Prescott
- Department of Surgery, NYU Langone Health, New York, New York
| | - John Allendorf
- Department of Surgery, NYU Langone Health, New York, New York
| | - Kepal N Patel
- Department of Surgery, NYU Langone Health, New York, New York
| | - Insoo Suh
- Department of Surgery, NYU Langone Health, New York, New York
| | - Melissa Sum
- Division of Endocrinology, NYU Langone Health, New York, New York.
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Carsote M, Nistor C. Forestalling Hungry Bone Syndrome after Parathyroidectomy in Patients with Primary and Renal Hyperparathyroidism. Diagnostics (Basel) 2023; 13:diagnostics13111953. [PMID: 37296804 DOI: 10.3390/diagnostics13111953] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
Hungry bone syndrome (HBS), severe hypocalcemia following parathyroidectomy (PTX) due to rapid drop of PTH (parathormone) after a previous long term elevated concentration in primary (PHPT) or renal hyperparathyroidism (RHPT), impairs the outcome of underlying parathyroid disease. OBJECTIVE overview HBS following PTx according to a dual perspective: pre- and post-operative outcome in PHPT and RHPT. This is a case- and study-based narrative review. INCLUSION CRITERIA key research words "hungry bone syndrome" and "parathyroidectomy"; PubMed access; in extenso articles; publication timeline from Inception to April 2023. EXCLUSION CRITERIA non-PTx-related HBS; hypoparathyroidism following PTx. We identified 120 original studies covering different levels of statistical evidence. We are not aware of a larger analysis on published cases concerning HBS (N = 14,349). PHPT: 14 studies (N = 1545 patients, maximum 425 participants per study), and 36 case reports (N = 37), a total of 1582 adults, aged between 20 and 72. Pediatric PHPT: 3 studies (N = 232, maximum of 182 participants per study), and 15 case reports (N = 19), a total of 251 patients, aged between 6 and 18. RHPT: 27 studies (N = 12,468 individuals, the largest cohort of 7171) and 25 case reports/series (N = 48), a total of 12,516 persons, aged between 23 and 74. HBS involves an early post-operatory (emergency) phase (EP) followed by a recovery phase (RP). EP is due to severe hypocalcemia with various clinical elements (<8.4 mg/dL) with non-low PTH (to be differentiated from hypoparathyroidism), starting with day 3 (1 to 7) with a 3-day duration (up to 30) requiring prompt intravenous calcium (Ca) intervention and vitamin D (VD) (mostly calcitriol) replacement. Hypophosphatemia and hypomagnesiemia may be found. RP: mildly/asymptomatic hypocalcemia controlled under oral Ca+VD for maximum 12 months (protracted HBS is up to 42 months). RHPT associates a higher risk of developing HBS as compared to PHPT. HBS prevalence varied from 15% to 25% up to 75-92% in RHPT, while in PHPT, mostly one out of five adults, respectively, one out of three children and teenagers might be affected (if any, depending on study). In PHPT, there were four clusters of HBS indicators. The first (mostly important) is represented by pre-operatory biochemistry and hormonal panel, especially, increased PTH and alkaline phosphatase (additional indicators were elevated blood urea nitrogen, and a high serum calcium). The second category is the clinical presentation: an older age for adults (yet, not all authors agree); particular skeleton involvement (level of case reports) such as brown tumors and osteitis fibrosa cystica; insufficient evidence for the patients with osteoporosis or those admitted for a parathyroid crisis. The third category involves parathyroid tumor features (increased weight and diameter; giant, atypical, carcinomas, some ectopic adenomas). The fourth category relates to the intra-operatory and early post-surgery management, meaning an associated thyroid surgery and, maybe, a prolonged PTx time (but this is still an open issue) increases the risk, as opposite to prompt recognition of HBS based on calcium (and PTH) assays and rapid intervention (specific interventional protocols are rather used in RHPT than in PHPT). Two important aspects are not clarified yet: the use of pre-operatory bisphosphonates and the role of 25-hydroxyitamin D assay as pointer of HBS. In RHPT, we mentioned three types of evidence. Firstly, risk factors for HBS with a solid level of statistical evidence: younger age at PTx, pre-operatory elevated bone alkaline phosphatase, and PTH, respectively, normal/low serum calcium. The second group includes active interventional (hospital-based) protocols that either reduce the rate or improve the severity of HBS, in addition to an adequate use of dialysis following PTx. The third category involves data with inconsistent evidence that might be the objective of future studies to a better understanding; for instance, longer pre-surgery dialysis duration, obesity, an elevated pre-operatory calcitonin, prior use of cinalcet, the co-presence of brown tumors, and osteitis fibrosa cystica as seen in PHPT. HBS remains a rare complication following PTx, yet extremely severe and with a certain level of predictability; thus, the importance of being adequately identified and managed. The pre-operatory spectrum of assessments is based on biochemistry and hormonal panel in addition to a specific (mostly severe) clinical presentation while the parathyroid tumor itself might provide useful insights as potential risk factors. Particularly in RHPT, prompt interventional protocols of electrolytes surveillance and replacement, despite not being yet a matter of a unified, HBS-specific guideline, prevent symptomatic hypocalcemia, reduce the hospitalization stay, and the re-admission rates.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy & C.I. Parhon National Institute of Endocrinology, Aviatorilor Ave. 34-38, Sector 1, 011863 Bucharest, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Carol Davila University of Medicine and Pharmacy & Thoracic Surgery Department, Dr. Carol Davila Central Emergency University Military Hospital, 050474 Bucharest, Romania
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Tai YL, Shen HY, Nai WH, Fu JF, Wang IK, Huang CC, Weng CH, Lee CC, Huang WH, Yang HY, Hsu CW, Yen TH. Hungry bone syndrome after parathyroid surgery. Hemodial Int 2023; 27:134-145. [PMID: 36719854 DOI: 10.1111/hdi.13067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/06/2022] [Accepted: 01/10/2023] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Data on the incidence rates of hungry bone syndrome after parathyroidectomy in patients on dialysis are inconsistent, as the published rates vary from 15.8% to 92.9%. METHODS Between 2009 and 2019, 120 hemodialysis patients underwent parathyroidectomy for secondary hyperparathyroidism at the Chang Gung Memorial Hospital. The patients were stratified into two groups based on the presence (n = 100) or absence (n = 20) of hungry bone syndrome after parathyroidectomy. FINDINGS Subtotal parathyroidectomy was the most common surgery performed (76.7%), followed by total parathyroidectomy with autoimplantation (23.3%). Pathological examination revealed parathyroid hyperplasia. Hungry bone syndrome developed within 0.3 ± 0.3 months and lasted for 11.1 ± 14.7 months. After surgery, compared with patients without hungry bone syndrome, patients with hungry bone syndrome had lower levels of nadir corrected calcium (P < 0.001), as well as lower nadir (P < 0.001) and peak (P < 0.001) intact parathyroid hormone levels. During 59.3 ± 44.0 months of follow-up, persistence and recurrence of hyperparathyroidism occurred in 25 (20.8%) and 30 (25.0%) patients, respectively. Furthermore, patients with hungry bone syndrome had a lower rate of persistent hyperparathyroidism than those without hungry bone syndrome (P < 0.001). Four patients (3.3%) underwent a second parathyroidectomy. Patients with hungry bone syndrome received fewer second parathyroidectomies than those without hungry bone syndrome (P < 0.001). Finally, a multivariate logistic regression model revealed that the preoperative blood ferritin level was a negative predictor of the development of hungry bone syndrome (P = 0.038). DISCUSSION Hungry bone syndrome is common (83.3%) after parathyroidectomy for secondary hyperparathyroidism in patients undergoing hemodialysis, and this complication should be monitored and managed appropriately.
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Affiliation(s)
- Ya-Ling Tai
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Yi Shen
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Hsuan Nai
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fen Fu
- Department of Medical Research, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I-Kuan Wang
- Department of Nephrology, China Medical University Hospital, Taichung and College of Medicine, China Medical University, Taichung, Taiwan
| | - Chien-Chang Huang
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hao Weng
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Hung Huang
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Huang-Yu Yang
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Wei Hsu
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tzung-Hai Yen
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Cao L, Sun X, Zhang T, Niu Y, Suo H, Zhao Z, Wang C, Bai J. A reappraisal of risk factors for early hypocalcemia after parathyroidectomy in dialysis patients. Updates Surg 2022; 74:1961-1970. [PMID: 36194380 DOI: 10.1007/s13304-022-01395-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/29/2022] [Indexed: 11/30/2022]
Abstract
We aimed to identify risk factors for early hypocalcemia after parathyroidectomy in patients with secondary hyperparathyroidism. We retrospectively enrolled 106 of 120 consecutive patients with secondary hyperparathyroidism who underwent parathyroidectomy between January 2019 and July 2021. Perioperative laboratory parameters, preoperative computerized tomography (CT) images, and postoperative histology were evaluated. Parathyroid calcification was defined as hyperdense regions with a density of > 130 Hounsfield Units on CT images of the parathyroid. Subtotal parathyroidectomy, total parathyroidectomy without auto-transplantation, or total parathyroidectomy with auto-transplantation were performed in the present study. Postoperative hypocalcemia was defined as a serum calcium concentration < 2.1 mmol/L within 4 days of surgery. The participants were categorized according to the presence (n = 33) or absence (n = 73) of postoperative hypocalcemia. The demographics, comorbidities, and surgical details were similar in the two groups. Multivariate analysis showed that the preoperative alkaline phosphatase activity, serum intact parathyroid hormone and calcium concentrations, and parathyroid calcification were independent risk factors for postoperative hypocalcemia (all P < 0.05). Receiver operating characteristic analysis generated areas under the curves for preoperative alkaline phosphatase, intact parathyroid hormone, and parathyroid calcification of 0.82, 0.80, and 0.70, respectively (all P < 0.05). Cut-off values for preoperative alkaline phosphatase (> 242.9 IU/L) and intact parathyroid hormone (> 2,104 pg/mL) were found to be predictive of postoperative hypocalcemia. High preoperative alkaline phosphatase activity and serum intact parathyroid hormone concentration and low serum calcium are associated with higher risks of postoperative hypocalcemia. Calcification of the parathyroid may represent a novel radiologic means of predicting postoperative hypocalcemia.
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Affiliation(s)
- Long Cao
- Department of General Surgery, The 983th Hospital of Joint Logistic Support Force of PLA, 60 Huang Wei Road, Tianjin, 100042, People's Republic of China.,Center of Thyroid Treatment, The 983th Hospital of Joint Logistic Support Force of PLA, Tianjin, China
| | - Xinzeng Sun
- Department of General Surgery, The 983th Hospital of Joint Logistic Support Force of PLA, 60 Huang Wei Road, Tianjin, 100042, People's Republic of China.,Center of Thyroid Treatment, The 983th Hospital of Joint Logistic Support Force of PLA, Tianjin, China
| | - Ting Zhang
- Department of General Surgery, The 983th Hospital of Joint Logistic Support Force of PLA, 60 Huang Wei Road, Tianjin, 100042, People's Republic of China
| | - Yue Niu
- Department of General Surgery, The 983th Hospital of Joint Logistic Support Force of PLA, 60 Huang Wei Road, Tianjin, 100042, People's Republic of China
| | - Haijin Suo
- Department of General Surgery, The 983th Hospital of Joint Logistic Support Force of PLA, 60 Huang Wei Road, Tianjin, 100042, People's Republic of China
| | - Ziwen Zhao
- Department of General Surgery, The 983th Hospital of Joint Logistic Support Force of PLA, 60 Huang Wei Road, Tianjin, 100042, People's Republic of China
| | - Chen Wang
- Department of General Surgery, The 983th Hospital of Joint Logistic Support Force of PLA, 60 Huang Wei Road, Tianjin, 100042, People's Republic of China
| | - Jianping Bai
- Department of General Surgery, The 983th Hospital of Joint Logistic Support Force of PLA, 60 Huang Wei Road, Tianjin, 100042, People's Republic of China. .,Center of Thyroid Treatment, The 983th Hospital of Joint Logistic Support Force of PLA, Tianjin, China.
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Peng X, Xia X, Li Z, Cheng F, Zhu X. Factors influencing the development of bone starvation syndrome after total parathyroidectomy in patients with renal hyperparathyroidism. Front Surg 2022; 9:963231. [PMID: 36248359 PMCID: PMC9563016 DOI: 10.3389/fsurg.2022.963231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/09/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeTo investigate the factors affecting the development of bone starvation syndrome (HBS) after total parathyroidectomy in patients with renal hyperparathyroidism (SHPT).Patients and methodsThe clinical data and perioperative indices of 141 patients who underwent PTX for SHPT were retrospectively analyzed. The patients were divided into HBS and non-HBS groups based on postoperative minimum blood calcium <1.87 mmol/L. The differences in general clinical data and perioperative related indices between the two groups were compared; logistic regression analysis was performed to analyze the risk factors influencing HBS occurrence after surgery. Multiple linear regression method was used to analyze the factors influencing the maintenance time of intravenous calcium supplementation and total amount of calcium supplementation during intravenous calcium supplementation. The threshold value for the diagnosis of HBS was analyzed using the ROC subjects' working curve.ResultsHBS occurred in 46 (32.6%) patients. Univariate analysis showed statistically significant differences in dialysis age, preoperative calcitonin, preoperative parathyroid hormone, preoperative blood phosphorus, and preoperative alkaline phosphatase between both groups (P < 0.05). Logistic regression analysis using stepwise entry method concluded that preoperative alkaline phosphatase was an independent factor for the development of HBS after surgery. Preoperative parathyroid hormone was an independent factor for the duration of intravenous calcium supplementation and total calcium supplementation during intravenous calcium supplementation in the HBS group. Based on the ROC curve, for postoperative HBS, the cut-off ALP value was 199.5 U/L, with a sensitivity of 80.85% and specificity of 82.61%.ConclusionPreoperative serum ALP may be an independent factor for HBS occurrence after surgery. When preoperative ALP > 199.5 U/L, patients with SHPT are prone to HBS after surgery, and the higher the preoperative ALP, the higher the incidence of HBS, and vice versa. In addition, preoperative PTH may be the factor in the timing of postoperative intravenous calcium supplementation and the total amount of calcium supplementation during intravenous calcium supplementation in patients with HBS.
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Affiliation(s)
- Xuyang Peng
- Department of Cardiothoracic Surgery, Lishui People’s Hospital, Lishui, China
| | - Xiaofang Xia
- Department of Breast Surgery, Lishui Hospital of Zhejiang University, Lishui, China
| | - Zhouting Li
- Department of Thyroid Surgery, Lishui Hospital of Zhejiang University, Lishui, China
| | - Feng Cheng
- Department of Thyroid Surgery, Lishui Hospital of Zhejiang University, Lishui, China
| | - Xi Zhu
- Department of Thyroid Surgery, Lishui Hospital of Zhejiang University, Lishui, China
- Correspondence: Xi Zhu
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Chen CC, Chen HL, Chiang PL, Luo SD, Chang YH, Chen WC, Wang CK, Lin AN, Chen YS, Chi SY, Lin WC. Efficacy and safety of radiofrequency ablation for primary and secondary hyperparathyroidism with or without previous parathyroidectomy: a retrospective study. Int J Hyperthermia 2022; 39:907-917. [PMID: 35848429 DOI: 10.1080/02656736.2022.2097324] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
INTRODUCTION This study aimed to investigate and compare the therapeutic efficacy and safety of ultrasound-guided radiofrequency ablation (RFA), between primary hyperparathyroidism (PHPT) and secondary hyperparathyroidism (SHPT) patients, with or without previous parathyroidectomy (PTX). SUBJECTS AND METHODS A total of 21 patients (7 PHPT, 14 SHPT) underwent RFA for hyperparathyroidism (HPT) at Kaohsiung Chang Gung Memorial Hospital, Taiwan. Five of the 14 SHPT patients had previously received PTX. The laboratory data, volume change of each parathyroid nodule, symptomatic scores, and complications were analyzed and compared between all groups at 1 and 7 days, and at 1, 3, 6, and 12 months after RFA. RESULTS After RFA, the volume reduction ratio (VRR) for all patients at the last follow-up was 93.76%, and clinical symptoms significantly improved. At 12 months, all PHPT patients achieved successful treatment of intact PTH (iPTH). In SHPT patients, the mean iPTH value significantly decreased 1-day post-RFA, subsequently exhibiting a transient rebound which proceeded to decrease, with 57.1% reaching successful treatment standards. SHPT patients with PTX showed a lower complication score, shorter ablation time, higher iPTH baseline and outcomes, and lower VRR, compared to patients without PTX. The serum calcium level significantly decreased to normal range in 85.7% of all patients at 12 months. Severe hypocalcemia occurred in 23.8% at 1 week, and all were corrected with calcium supplements. CONCLUSIONS RFA demonstrates a therapeutic efficacy similar to PTX. It can thus be considered an effective alternative treatment for PHPT, SHPT, or post-PTX patients who are unsuitable for another PTX.
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Affiliation(s)
- Chi-Cheng Chen
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsiu-Ling Chen
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pi-Ling Chiang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Sheng-Dean Luo
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yen-Hsiang Chang
- Department of Nuclear Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Chih Chen
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-Kang Wang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - An-Ni Lin
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yueh-Sheng Chen
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shun-Yu Chi
- Departments of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Che Lin
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg 2022; 276:e141-e176. [PMID: 35848728 DOI: 10.1097/sla.0000000000005522] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.
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A predictive risk score to diagnose hypocalcemia after parathyroidectomy in patients with secondary hyperparathyroidism: a 22-year retrospective cohort study. Sci Rep 2022; 12:9548. [PMID: 35681076 PMCID: PMC9184730 DOI: 10.1038/s41598-022-13880-0] [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: 01/20/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022] Open
Abstract
Hypocalcemia is a common complication found in patients with secondary hyperparathyroidism (SHPT) who undergo parathyroidectomy. This study aimed to construct a predictive risk score for the occurrence of hypocalcemia after parathyroidectomy in patients with SHPT who underwent chronic renal replacement therapy (RRT). This 22-year retrospective cohort study enrolled 179 patients with SHPT who had their first parathyroidectomy. Eighty-two percent of patients developed hypocalcemia within 16.9 (95% CI 14.5–19.5) h after parathyroidectomy. This study demonstrated four factors as independent risk factors for post-parathyroidectomy hypocalcemia, including duration of RRT, preoperative serum phosphate, preoperative serum alkaline phosphatase (ALP) and mean difference of serum intact parathyroid hormone (iPTH). By using logistic regression analysis, this study demonstrated cut-off points for these four risk factors for the diagnosis of hypocalcemia after parathyroidectomy: 5 years for the duration of RRT, 5 mg/dL for serum phosphate, 387 U/L for serum ALP, and 97% for the mean difference of serum iPTH. Finally, the predictive risk score was constructed by assigning a score of one to each factor. With a total score of at least 2, the proposed predictive risk score has an AuROC of 0.755 with a sensitivity of 78.2%, a specificity of 71.4%, and an accuracy of 76.9%.
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Liu J, Fan XF, Yang M, Huang LP, Zhang L. Effect of calcium supplementation on severe hypocalcemia in patients with secondary hyperparathyroidism after total parathyroidectomy. World J Clin Cases 2022; 10:4033-4041. [PMID: 35665128 PMCID: PMC9131232 DOI: 10.12998/wjcc.v10.i13.4033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/28/2021] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe hypocalcemia (SH) is a dreaded complication of total parathyroidectomy (TPTX) without auto-transplantation.
AIM To compare conventional and preventive calcium supplementation (CS) regimens in terms of SH occurrence after TPTX.
METHODS This retrospective study included patients who underwent TPTX between January 2015 and May 2018 at the China-Japan Friendship Hospital. From January 2015 to May 2016, conventional CS was performed in patients who underwent TPTX, with calcium amounts adjusted according to postoperative serum calcium levels. From October 2016 to May 2018, preventive CS was performed according to preoperative alkaline phosphatase (ALP) levels. The patients were defined as low-risk (ALP < 500 U/L) and high-risk (ALP > 500 U/L) for SH. All preoperative blood samples were collected in the fasting state on the day before surgery. Postoperative blood samples were obtained at 6-7 AM from the first postoperative day.
RESULTS A total of 271 patients were included. These patients were 47.7 ± 11.1 years old, and 57.6% were male. Their mean body mass index (BMI) was 22.9 ± 3.8 kg/m2. There were no significant differences in sex, age, BMI, preoperative ALP, serum calcium, serum phosphorus, calcium-phosphorus ratio, and intact parathyroid hormone (iPTH) between the two CS groups. Compared with conventional CS, preventive CS led to lower occurrence rates of hypocalcemia within 48 h (46.0% vs 74.5%, P < 0.001) and SH (31.7% vs 64.1%, P < 0.001). Multivariable analysis showed that preoperative iPTH levels [odds ratio (OR) = 1.001, 95% confidence interval (CI): 1.000-1.001, P = 0.009), preoperative ALP amounts (OR = 1.002, 95%CI: 1.001-1.003, P = 0.002), preoperative serum phosphorus levels (OR = 8.729, 95%CI: 1.518-50.216, P = 0.015) and preventive CS (OR = 0.132, 95%CI: 0.067-0.261, P < 0.001) were independently associated with SH. In patients with preoperative ALP ≥ 500 U/L, only preventive CS (OR = 0.147, 95%CI: 0.038-0.562. P = 0.005) was independently associated with SH.
CONCLUSION This study suggests that preventive CS could reduce the occurrence of SH, indicating its critical value for hypocalcemia after TPTX.
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Affiliation(s)
- Jun Liu
- Department of General Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xue-Feng Fan
- Department of General Surgery, Shougang General Hospital, Shougang 553000, Guizhou Province, China
| | - Meng Yang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Lin-Ping Huang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Ling Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing 100029, China
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Gao D, Lou Y, Cui Y, Liu S, Cui W, Sun G. Risk factors for hypocalcemia in dialysis patients with refractory secondary hyperparathyroidism after parathyroidectomy: a meta-analysis. Ren Fail 2022; 44:503-512. [PMID: 35285377 PMCID: PMC8928856 DOI: 10.1080/0886022x.2022.2048856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective Hypocalcemia after parathyroidectomy (PTX) results in tetany, diarrhea, cardiac arrhythmia, and even sudden death. However, a meta-analysis or systematic evaluation of risk factors with the occurrence and development of hypocalcemia in patients with secondary hyperparathyroidism (SHPT) after PTX has never been performed. Methods A thorough search of electronic databases, including PubMed, Web of Science, the Cochrane Library, and EMBASE, was performed to retrieve relevant studies from database inception to June 2021. Quality of the included studies was assessed by two independent reviewers using the Newcastle–Ottawa Scale. Review Manager 5.3 and Stata 16.0 were used for meta-analysis. The random-effects model was adopted to calculate the 95% CIs (I2> 50% or p < 0.05) of the combined effect size and the corresponding homogeneous data. Otherwise, a fixed-effects model was used. Results Thirteen studies including 2990 participants who met the inclusion criteria were enrolled in the present meta-analysis. The overall quality of the enrolled studies had a score of >7 points. Risk factors significantly related to hypocalcemia in patients with SHPT after PTX were preoperative serum calcium (OR 0.19, 95%CI 0.11–0.31), preoperative alkaline phosphatase (ALP) (OR 1.01, 95% CI 1.01–1.02), and preoperative intact parathyroid hormone (iPTH) (OR 1.38, 95%CI 1.20–1.58). Meanwhile, age (OR 0.97, 95%CI 0.87–1.10) was not significantly correlated with hypocalcemia after PTX. Conclusions Based on the current evidence, preoperative serum calcium, preoperative ALP, and preoperative iPTH were significant predictors of hypocalcemia in patients with SHPT after PTX. More attention should be given to patients with these risk factors for the prevention of postoperative hypocalcemia.
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Affiliation(s)
- Dan Gao
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Yan Lou
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Yingchun Cui
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Shengmao Liu
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Wenpeng Cui
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Guangdong Sun
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
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Cheng J, Lv Y, Zhang L, Liu Y. Construction and validation of a predictive model for hypocalcemia after parathyroidectomy in patients with secondary hyperparathyroidism. Front Endocrinol (Lausanne) 2022; 13:1040264. [PMID: 36531501 PMCID: PMC9748676 DOI: 10.3389/fendo.2022.1040264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/31/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE We aimed to construct and validate a predictive model for the risk of hypocalcemia following parathyroidectomy (PTX) for the treatment of secondary(renal) hyperparathyroidism (SHPT). METHODS Information regarding patients with SHPT who underwent PTX between January 2019 and April 2022 was collected retrospectively. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for hypocalcemia following PTX and to construct predictive models. The areas under the receiver operating characteristic curve (AUC), the calibration curve, and the clinical decision curve (decision curve analysis, DCA) were used to assess the discrimination, calibration, and level of clinical benefit obtained using the predictive models. RESULTS We studied 238 patients who were randomly allocated in a 7:3 ratio to a training group (n=166) and a test group (n=72). Univariate and multivariate logistic regression analyses were performed, in which three variables (the circulating parathyroid hormone (PTH) and Ca concentrations, and alkaline phosphatase (ALP) activity) were interrogated for possible roles as independent risk factors for hypocalcemia in patients with SHPT who undergo PTX, and used to construct predictive models. The AUCs for the constructed models were high for both the training (0.903) and test (0.948) groups. The calibration curve showed good agreement between the incidence of postoperative hypocalcemia estimated using the predictive model and the actual incidence. The DCA curve indicated that the predictive model performed well. CONCLUSION A predictive model constructed using a combination of preoperative PTH, Ca, and ALP may represent a useful means of identifying patients with SHPT at high risk of developing hypocalcemia following PTX in clinical practice.
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Affiliation(s)
- Jingning Cheng
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yong Lv
- Department of Otolaryngology-Head and Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Ling Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Yafeng Liu
- School of Medicine, Anhui University of Science and Technology, Huainan, Anhui, China
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Wang L, Zhang X, Hu F, Yuan H, Gao Z, He L, Zou S. Impact of enhanced recovery after surgery program for hungry bone syndrome in patients on maintenance hemodialysis undergoing parathyroidectomy for secondary hyperparathyroidism. Ann Surg Treat Res 2022; 103:264-270. [DOI: 10.4174/astr.2022.103.5.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/14/2022] [Accepted: 08/30/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ling Wang
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Xiaohong Zhang
- Department of Nursing, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Fengqi Hu
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Hai Yuan
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Zhao Gao
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Li He
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Shuang Zou
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
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Williams-Karnesky RL, Krumeich L, Wachtel H, Fraker DL, Wirtalla C, Venuto FA, Sellers P, Kelz RR. Data to inform counseling on parathyroidectomy for secondary hyperparathyroidism of renal origin. Surgery 2022; 171:63-68. [PMID: 34497026 DOI: 10.1016/j.surg.2021.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The risk of postoperative hungry bone syndrome after parathyroidectomy for secondary hyperparathyroidism of renal origin may alter the course of treatment, including the hospital length of stay and readmission rates. We sought to identify additional patient or hospital factors that might contribute to hungry bone syndrome after parathyroidectomy in patients with secondary hyperparathyroidism of renal origin. METHODS Patients who underwent a parathyroidectomy for secondary hyperparathyroidism of renal origin were identified in a geographically diverse, 10-state, discharge data set. Covariates included demographic data, payer status, 31 comorbidities, and hospital characteristics. The primary outcome variable of interest was hospital length of stay. Secondary outcomes were complications and 30-day readmission. RESULTS Of 796 patients studied, 164 patients (20.6%) were diagnosed with hungry bone syndrome. There were no differences in the rates of hungry bone syndrome by race or number of comorbidities. The average age of hungry bone syndrome patients (45.7 years ± 13.9) was younger than that of non-hungry bone syndrome patients (50.7 ± 14.8; P < .001). Hungry bone syndrome was more common among obese patients than nonobese patients (25.0% vs 15.8%; P < .001). Parathyroid autotransplant was performed at similar rates in hungry bone syndrome and non-hungry bone syndrome patients (23.8% vs 23.1%; P = .821). Median length of stay was significantly longer for hungry bone syndrome patients (6 days, interquartile range: [4, 8] versus 3 days, interquartile range: [2-6]; P < .001). Similar 30-day readmission rates were observed (hungry bone syndrome: 41 (25%) versus non-hungry bone syndrome: 147 (23%); P = .640). CONCLUSION Hungry bone syndrome occurs in 1 of 5 patients after parathyroidectomy for secondary hyperparathyroidism of renal origin. Patients should be informed of the possibility of a relatively long (6 days) length of stay after surgery as well as the moderate possibility (>20%) of another hospitalization within the 30-day postdischarge period.
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Affiliation(s)
| | - Lauren Krumeich
- Department of Surgery, Division of Endocrine and Oncologic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Heather Wachtel
- Department of Surgery, Division of Endocrine and Oncologic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Douglas L Fraker
- Department of Surgery, Division of Endocrine and Oncologic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Chris Wirtalla
- Department of Surgery, Division of Endocrine and Oncologic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Frank Anthony Venuto
- Department of Surgery, Division of Endocrine and Oncologic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Pamela Sellers
- Department of Surgery, Division of Endocrine and Oncologic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Division of Endocrine and Oncologic Surgery, University of Pennsylvania, Philadelphia, PA.
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Grube M, Weber F, Kahl AL, Kribben A, Mülling N, Reinhardt W. Effect of High Dose Active Vitamin D Therapy on the Development of Hypocalcemia After Subtotal Parathyroidectomy in Patients on Chronic Dialysis. Int J Nephrol Renovasc Dis 2021; 14:399-410. [PMID: 34795499 PMCID: PMC8594789 DOI: 10.2147/ijnrd.s334227] [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] [Received: 08/14/2021] [Accepted: 10/09/2021] [Indexed: 11/23/2022] Open
Abstract
Background The period after parathyroidectomy (PTx) in dialysis patients is characterized by periods of severe hypocalcemia. This study aims to investigate the effect of high doses of active vitamin D immediately after PTx on the development of hypocalcemia. Materials and Methods We retrospectively reviewed 111 patients with secondary hyperparathyroidism receiving subtotal PTx between 2010 and 2019. A high dose group “HDG” (n = 67) receiving 12 µg alfacalcidol in combination with 8.550 mg calcium acetate per day, which was then adapted according to lab values, was compared with a low dose group “LDG” (n = 44) receiving up to 4 µg alfacalcidol per day. The laboratory values were recorded up to ten weeks postoperatively. Results The assumed drops in parathyroid hormone (PTH) and calcium were observed in both groups after PTx. We observed significantly lower calcium values in the LDG between days 4 and 18 postoperatively than in the HDG (p < 0.001). The proportion of severe hypocalcemia after PTx (total calcium <1.5 mmol/l) in the HDG was 8.5% on day 1 and 47% on day 4 in the LDG. Intravenous calcium requirements were significantly lower in the HDG (7.6%) than in the LDG (45.7%; p = 0.001). Conclusion The period after PTx in dialysis patients is characterized by an expected drop in PTH and calcium within the first days. Ongoing high turnover is observed in the 2nd and 3rd week after PTx. Administering high doses of alfacalcidol combined with calcium acetate diminishes the episodes of severe hypocalcemia and the need for intravenous calcium.
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Affiliation(s)
- Malina Grube
- Department of Nephrology, University Hospital Essen, Essen, Germany
| | - Frank Weber
- Department of General-, Visceral- and Transplantation Surgery, Section of Endocrine Surgery, University Hospital Essen, Essen, Germany
| | - Anna Lena Kahl
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, Essen, Germany
| | - Nils Mülling
- Department of Nephrology, University Hospital Essen, Essen, Germany
| | - Walter Reinhardt
- Department of Nephrology, University Hospital Essen, Essen, Germany
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Kritmetapak K, Kongpetch S, Chotmongkol W, Raruenrom Y, Sangkhamanon S, Pongchaiyakul C. Incidence of and risk factors for post-parathyroidectomy hungry bone syndrome in patients with secondary hyperparathyroidism. Ren Fail 2021; 42:1118-1126. [PMID: 33143476 PMCID: PMC7646547 DOI: 10.1080/0886022x.2020.1841655] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background Hungry bone syndrome (HBS) following parathyroidectomy is associated with severe hypocalcemia and increased morbidity. This study aims to determine the incidence and risk factors of post-parathyroidectomy HBS in dialysis patients with secondary hyperparathyroidism (SHPT). Methods A retrospective cohort study was conducted, and medical records of patients with SHPT requiring parathyroidectomy between January 2014 and January 2020 were reviewed. HBS was defined as the requirement of intravenous calcium administration due to hypocalcemia-related symptoms and/or reductions in serum calcium concentration (<8.4 mg/dL) within 72 h after parathyroidectomy. Results A total of 130 dialysis patients were enrolled. The majority of patients (85.4%) received hemodialysis and the remaining patients (14.6%) received peritoneal dialysis. Ectopic parathyroid glands were identified in 6.6% of patients by preoperative parathyroid scintigraphy. Diffuse parathyroid hyperplasia was the most common histopathological characteristic of SHPT (90.8%). HBS occurred in 82.3% of patients following parathyroidectomy. Preoperative serum intact parathyroid hormone (iPTH) concentration was significantly correlated with serum calcium (r = −0.48, p < 0.01) and alkaline phosphatase (ALP) concentration (r = 0.71, p < 0.01). Patients with HBS had significantly longer hospital stays than patients without (8 versus 3 days, p < 0.01). Based on multiple logistic regression analysis, young age (≤45 years), high preoperative serum ALP (>420 IU/L) and iPTH (>1,000 pg/mL), and absence of preoperative hypercalcemia (>10.2 mg/dL) were significantly associated with HBS. Conclusions Post-parathyroidectomy HBS is common in dialysis patients with SHPT. Young age, high preoperative serum ALP and iPTH, and low preoperative serum calcium concentrations were important risk factors for HBS.
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Affiliation(s)
- Kittrawee Kritmetapak
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sawinee Kongpetch
- Kidney Center of Excellence, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Wijittra Chotmongkol
- Kidney Center of Excellence, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Yutapong Raruenrom
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sakkarn Sangkhamanon
- Department of Pathology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chatlert Pongchaiyakul
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Gong W, Lin Y, Xie Y, Meng Z, Wang Y. Predictors of early postoperative hypocalcemia in patients with secondary hyperparathyroidism undergoing total parathyroidectomy. J Int Med Res 2021; 49:3000605211015018. [PMID: 34038214 PMCID: PMC8161902 DOI: 10.1177/03000605211015018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/12/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To summarize the clinical features of secondary hyperparathyroidism (SHPT) in patients with chronic renal failure and to explore the predictive factors of postoperative hypocalcemia after total parathyroidectomy in these patients. METHODS The clinical data of 87 patients admitted to Guangdong Electric Power Hospital from May 2013 to February 2020 were reviewed. All patients underwent total parathyroid resection and sternocleidomastoid microtransplantation. Age, sex, and the serum calcium, phosphorus, alkaline phosphatase (ALP), and intact parathyroid hormone (iPTH) concentrations were analyzed as predictive factors of postoperative hypocalcemia. RESULTS Bone pain was the most common clinical manifestation in this study population, and all 87 patients experienced relief from their clinical symptoms after the surgical procedure. Age and the preoperative serum calcium, ALP, and iPTH concentrations were determined to be early predictive factors of postoperative hypocalcemia. CONCLUSIONS Age and the preoperative calcium, ALP, and iPTH concentrations are independent risk factors for postoperative hypocalcemia in patients with SHPT and renal disease who undergo total parathyroidectomy with sternocleidomastoid microtransplantation. These factors can help identify high-risk patients who can be managed by a multidisciplinary team to improve graft survival and quality of life.
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Affiliation(s)
| | | | | | | | - Yudong Wang
- Yudong Wang, Department of Stomatology, The First Affiliated Hospital of Guangdong Pharmaceutical University, No. 19 Nonglinxia Road, Yuexiu District, Guangzhou 510062, China.
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Management of primary and renal hyperparathyroidism: guidelines from the German Association of Endocrine Surgeons (CAEK). Langenbecks Arch Surg 2021; 406:571-585. [PMID: 33880642 DOI: 10.1007/s00423-021-02173-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS The purpose of this review is to provide updated recommendations for the surgical management of primary (pHPT) and renal (rHPT) hyperparathyroidism, formulating a new guideline of the German Association of Endocrine Surgeons (CAEK). METHODS Evidence-based recommendations for the diagnosis and therapy of pHPT and rHPT were assessed by a multidisciplinary panel using PubMed for a comprehensive literature search together with a structured consensus dialogue (S2k guideline of the Association of the German Scientific Medical Societies, AWMF). RESULTS During the last 20 years, a variety of new preoperative localization procedures, such as sestamibi-SPECT, 4D-CT, and various PET/CT procedures, were established for pHPT. High-resolution imaging, together with intraoperative parathyroid hormone (IOPTH) measurement, enabled focused or minimally invasive surgery to become the most favored surgical technique. Patients with pHPT and nonlocalizing imaging have a higher risk of multiglandular disease. Surgical therapy provides very high cure rates, with a clear relation to the surgeon's experience in parathyroid procedures. Reoperative parathyroidectomy, children with pHPT or familial forms, and parathyroid carcinoma are addressed and require special surgical expertise. A multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons should assess the diagnosis and treatment of renal HPT. CONCLUSION Surgery is the only curative treatment for pHPT and should be considered for all patients with pHPT. For rHPT, a more selective approach is required, and parathyroidectomy is indicated only when conservative treatment options fail. In parathyroid carcinoma, the adequacy of local resection influences local disease control.
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Fonseca-Correa JI, Nava-Santana C, Tamez-Pedroza L, Paz-Cortes A, Santillan-Ceron A, Rojas-Concha LJ, Pantoja-Millán JP, Sierra-Salazar M, Velazquez-Fernández D, Herrera MF, Correa-Rotter R, Ramirez-Sandoval JC. Clinical factors associated with early and persistent hypocalcaemia after parathyroidectomy in patients on dialysis with severe hyperparathyroidism. Nephrology (Carlton) 2021; 26:408-419. [PMID: 33502071 DOI: 10.1111/nep.13854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/05/2021] [Accepted: 01/20/2021] [Indexed: 11/26/2022]
Abstract
AIM Severe hypocalcaemia following parathyroidectomy for secondary or tertiary hyperparathyroidism (SHPT/THPT) is scarcely studied. We aimed to describe and identify risk factors for early and persistent hypocalcaemia after parathyroidectomy. METHODS Retrospective pair-matched cohort study. We assessed 87 dialysis patients with SHPT (n = 73) or THPT (n = 14) paired with 146 subjects with primary hyperparathyroidism (PHPT) who underwent parathyroidectomy and were followed for 12 months. Early severe hypocalcaemia was defined as a free Ca ≤0.8 mmol/L [3.2 mg/dl] or corrected Ca ≤1.87 mmol/L [7.5 mg/dl] within 48 h. After parathyroidectomy and persistent hypocalcaemia, as an elemental Ca intake >3.0 g/day to achieve corrected Ca >2 mmol/L [8.0 mg/dl]. RESULTS Early severe hypocalcaemia occurred in 77% (67/87) versus 6.8% (10/146) of subjects with SHPT/THPT and PHPT, respectively (p < .001). In SHPT/THPT cases, persistent hypocalcaemia occurred in 77% (49/64) and 64% (35/54) after 6 and 12 months of parathyroidectomy, respectively. In PHPT cases, persistent hypocalcaemia occurred in 6.8% (10/146) after 4-12 months of parathyroidectomy. Preoperative serum alkaline phosphatase (ALP) was the only risk factor associated to early severe hypocalcaemia (OR 7.3, 95% C.I. 1.7-10.9, p = .006) and persistent hypocalcaemia (OR 7.1, 95% C.I: 2.1-14.2, p = .011). Subjects with persistently low intact parathormone (iPTH) (<5.3 pmol/L [50 ng/ml]), suggestive of adynamic bone disease) showed higher Ca increases and less oral calcium requirements compared to those who progressively increased iPTH after parathyroidectomy. CONCLUSION Early and persistent hypocalcaemia after parathyroidectomy in severe HPT were a common event associated directly to preoperative ALP levels. Subjects with persistently low postoperative iPTH normalized serum Ca more frequently after 1 year of follow up.
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Affiliation(s)
- Jorge I Fonseca-Correa
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos Nava-Santana
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Luis Tamez-Pedroza
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Armando Paz-Cortes
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Airy Santillan-Ceron
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Luis J Rojas-Concha
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan Pablo Pantoja-Millán
- Department of Endocrine Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Mauricio Sierra-Salazar
- Department of Endocrine Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - David Velazquez-Fernández
- Department of Endocrine Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Miguel F Herrera
- Department of Endocrine Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ricardo Correa-Rotter
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan C Ramirez-Sandoval
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Abstract
Objectives. Hungry bone syndrome (HBS) is a severe and underdiagnosed complication of parathyroidectomy in the treatment of primary hyperparathyroidism (PHP) and secondary hyper-parathyroidism to chronic kidney disease (SHP-CKD).Methods. A longitudinal study was conducted to compare the postoperative outcomes of patients who developed HBS in two different time frames: before and after implementing a protocol with an intensive electrolytic monitoring and an algorithm regarding electrolytic supplementation.Results. Overall, 77 parathyroidectomies were included. In PHP, a protocol implementation led to an increased admission of patients in the Intermediate Care Unit for intensive electrolytic monitoring (p<0.001) and an increased rate of oral calcium replacement during hospital stay (p=0.013) compared to pre-protocol era. In SHP-CKD, duration of intravenous calcium replacement was reduced (p=0.010). The prevalence of HBS (9.8% in PHP and 58.3% in SHP-CKD) was similar between the two periods, although its diagnosis had an increased trend in PHP since the protocol implementation. None of the diagnosis of HBS was established due to hypocalcemic symptoms in the post-protocol era (contrary to pre-protocol period, p=0.021). Both hypocalcemia length and duration of surgical ward hospitalization were reduced (p=0.047 and p=0.042, respectively).Conclusions. An improved assessment of hyperparathyroidism and a decrease in HBS severity were noted in the post-protocol era. We strongly recommend the implementation of a standardized protocol with an intensive phosphocalcium monitoring in the high-risk patients who undergo parathyroidectomy due to hyperparathyroidism as it improves the health care and management of HBS.
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Ying LMM, Yang ZMD, Hong ZBS, Yuanyuan CMM, Jian WMD, Juan WBS, Bin WMM, Changyu CMM, Ming YMM. Utilization of Ultrasound for Management of Surgical Intervention of Secondary Hyperparathyroidism and Prolonged Hypocalcemia Post-Parathyroidectomy. ADVANCED ULTRASOUND IN DIAGNOSIS AND THERAPY 2021. [DOI: 10.37015/audt.2021.200060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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23
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Wen P, Xu L, Zhao S, Gan W, Hou D, Zhang L, Cao J, Xiong M, Jiang L, Yang J. Risk Factors for Severe Hypocalcemia in Patients with Secondary Hyperparathyroidism after Total Parathyroidectomy. Int J Endocrinol 2021; 2021:6613659. [PMID: 33868402 PMCID: PMC8035008 DOI: 10.1155/2021/6613659] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/08/2021] [Accepted: 03/23/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hypocalcemia is the most common complication of total parathyroidectomy in secondary hyperparathyroidism (SHPT) and is associated with adverse consequences such as spasms, epilepsy, and arrhythmia and even death if the serum calcium level decreases rapidly. Previous studies have identified several risk factors for postoperative severe hypocalcemia (SH) in patients with SHPT, but the sample sizes were small and thus the results may not be reliable. OBJECTIVES This study was performed to investigate the risk factors for SH after total parathyroidectomy without autotransplantation (tPTX) in a large sample of patients with uremic hyperparathyroidism. METHODS We retrospectively investigated the records of 1,095 patients with SHPT treated with tPTX between January 2008 and December 2018. Based on the postoperative serum calcium concentration, the patients were grouped into SH and non-SH groups. The clinical characteristics and biochemical results were analyzed, and binary logistic regression analysis was used to identify the risk factors for SH. RESULTS After surgery, 25.9% of the patients developed SH. Age, diastolic blood pressure (DBP), heart rate, frequency of bone pain, weight of resected glands, preoperative serum calcium, intact parathyroid hormone (iPTH), alkaline phosphatase (ALP), and hemoglobin levels differed between the two groups. Binary logistic regression analyses identified preoperative serum calcium, iPTH, and ALP levels as independent predictors of SH after surgery. CONCLUSIONS The preoperative serum calcium, iPTH, and ALP levels can be used to assess the risk of postoperative SH in patients with SHPT. Such patients should thus be monitored closely in order to initiate prompt interventions to avoid SH.
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Affiliation(s)
- Ping Wen
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lingling Xu
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shasha Zhao
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Gan
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Dawei Hou
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Liang Zhang
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinlong Cao
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mingxia Xiong
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Jiang
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Junwei Yang
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Liu J, Huang Q, Yang M, Huang L, Zhang L. Risk factors predicting severe hypocalcemia after total parathyroidectomy without autotransplantation in patients with secondary hyperparathyroidism. J Int Med Res 2020; 48:300060519897505. [PMID: 31948313 PMCID: PMC7113811 DOI: 10.1177/0300060519897505] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Objective This study was performed to investigate the risk factors for severe hypocalcemia (SH) after total parathyroidectomy without autotransplantation (TPTX) in patients with secondary hyperparathyroidism. Methods We retrospectively analyzed the records of 136 patients with secondary hyperparathyroidism treated by TPTX. The patients were categorized as having SH or non-SH based on their postoperative blood calcium concentration. The risk factors for SH were identified by comparing the clinical characteristics between the two groups and by performing multiple logistic regression analyses. Results After surgery, 46.0% of the patients had hypocalcemia and 31.7% had SH. Evidence of renal osteodystrophy on lumbar radiographs and the serum concentrations of intact parathyroid hormone (iPTH), calcium, and alkaline phosphatase (ALP) were different between the two groups. The SH group had higher preoperative iPTH and ALP concentrations than the non-SH group. In addition, more patients with SH showed renal osteodystrophy. Logistic regression analyses indicated that preoperative hypocalcemia and a high ALP concentration were independent predictors of SH. Conclusion Preoperative hypocalcemia and a high ALP concentration were identified as risk factors for SH following TPTX.
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Affiliation(s)
- Jun Liu
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Qinghua Huang
- Digital Plastic Center of Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Meng Yang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Linping Huang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Ling Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
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Ahmed C, Kendi F, Gebran N, Barcebal C, Dahmani K, El Houni A, Budruddin M. Use of Recombinant Human Parathyroid Hormone to Treat Hungry Bone Syndrome in Hemodialysis Patient. Oman Med J 2020; 35:e164. [PMID: 32904907 PMCID: PMC7459415 DOI: 10.5001/omj.2020.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/04/2019] [Indexed: 11/23/2022] Open
Abstract
We report the case of a 35-year-old female with end-stage renal disease on hemodialysis for nine years. She was diagnosed with secondary hyperparathyroidism complicated with a brown tumor in the mandible. After medical therapy failed, she underwent total parathyroidectomy (PTX), which was complicated by severe and prolonged hypocalcemia (hungry bone syndrome). Post-surgery, she required prolonged and frequent intravenous calcium and a high dose of vitamin D resulting in frequent admission with symptomatic hypocalcemia. Her serum magnesium was noted to be in the normal range. She continued to be hypocalcemic for nearly eight months post-surgery despite the intensive treatment. Recombinant human parathyroid hormone (teriparatide) 20 mg daily resulted in normalization of calcium within two weeks. The use of parathyroid hormone proved to be an effective treatment approach in this case. Proper pre-operative preparation and subtotal PTX with an adequate dose of vitamin D and calcium supplement may have been a rational option for this case.
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Affiliation(s)
- Chaaban Ahmed
- Department of Nephrology, Tawam Hospital in affiliation with John Hopkins, Al Ain, UAE
| | - Fatima Kendi
- Department of Nephrology, Tawam Hospital in affiliation with John Hopkins, Al Ain, UAE
| | - Nicole Gebran
- Department of Nephrology, Tawam Hospital in affiliation with John Hopkins, Al Ain, UAE
| | | | - Khalid Dahmani
- Department of Nephrology, Tawam Hospital in affiliation with John Hopkins, Al Ain, UAE
| | - Ali El Houni
- Department of Nephrology, Tawam Hospital in affiliation with John Hopkins, Al Ain, UAE
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A Nomogram to Predict Hungry Bone Syndrome After Parathyroidectomy in Patients With Secondary Hyperparathyroidism. J Surg Res 2020; 255:33-41. [PMID: 32540578 DOI: 10.1016/j.jss.2020.05.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/07/2020] [Accepted: 05/10/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Parathyroidectomy (PTX) has been demonstrated as an effective treatment for patients with secondary hyperparathyroidism (SHPT) of renal origin. However, severe hypocalcemia, called hungry bone syndrome (HBS), is a common complication following PTX in these patients and can lead to poor clinical outcomes, even death. Therefore, exploring risk factors for HBS and establishing a prediction nomogram allow intensive monitoring and prompt treating this postoperative complication, which is the main purpose of this study. METHODS From October 2016 to October 2018, PTX with autotransplantation (PTX + AT) procedures were performed in 131 patients with SHPT of renal origin by a surgeon and his team in the Thyroid and Parathyroid Surgery Center, West China Hospital, Sichuan University, China. After applying the inclusion and exclusion criteria, a total of 114 patients were enrolled for analyses in this study. Comprehensive data including preoperative, intraoperative, and postoperative variables were prospectively collected and retrospectively analyzed. The univariate and multivariate logistic regression analyses with internal validation by bootstrapping were used to confirm independent risk factors for postoperative HBS. The nomogram was developed based on the statistical analysis results. Receiver operator characteristic (ROC) curves were drawn to compare the prediction performance among different predictors. RESULTS The occurrence of postoperative HBS was 76.3% (87 out of 114 patients) in this study. Univariate analysis showed that preoperative intact parathyroid hormone (iPTH), serum alkaline phosphatase, bone-specific alkaline phosphatase (bone-ALP) were significantly higher in HBS group than those in non-HBS group, while preoperative corrected serum calcium and albumin were significantly lower in HBS group than those in non-HBS group. Total weight of resected parathyroid glands was significantly heavier in HBS group versus non-HBS group. Multivariate logistic regression analysis with internal validation by bootstrapping demonstrated preoperative iPTH, bone-ALP, preoperative corrected serum calcium, and total weight of resected parathyroid glands were independently associated with postoperative HBS. The nomogram including the abovementioned four independent predictors was constructed and showed better prediction performance than the other four predictors in terms of postoperative HBS. CONCLUSIONS On the basis of this study, we found higher preoperative iPTH level, higher bone-ALP level, heavier total weight of resected parathyroid glands, and lower preoperative corrected serum calcium level were independent predictors of postoperative HBS in patients with SHPT of renal origin. The nomogram can expediently, accurately, and objectively predict the risk of postoperative HBS in individual patient with SHPT of renal origin.
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Ko WC, Liu CL, Lee JJ, Liu TP, Wu CJ, Cheng SP. Osteocalcin is an Independent Predictor for Hungry Bone Syndrome After Parathyroidectomy. World J Surg 2019; 44:795-802. [DOI: 10.1007/s00268-019-05251-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Ge Y, Yang G, Wang N, Zha X, Yu X, Mao H, Sun B, Zeng M, Zhang B, Xing C. Bone metabolism markers and hungry bone syndrome after parathyroidectomy in dialysis patients with secondary hyperparathyroidism. Int Urol Nephrol 2019; 51:1443-1449. [PMID: 31264087 DOI: 10.1007/s11255-019-02217-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/18/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To explore the short-term variation in bone metabolic markers and the characteristics of hungry bone syndrome (HBS) after parathyroidectomy (PTX) with forearm autotransplantation in uremic patients with secondary hyperparathyroidism (SHPT) and to provide a basis for the pathogenesis, diagnosis and treatment of metabolic bone disease in SHPT. METHODS A total of 115 patients with SHPT receiving PTX from July 2015 to December 2017, hospitalized at the First Affiliated Hospital of Nanjing Medical University, were enrolled in our study. We retrospectively analyzed the baseline clinical data, the levels of bone metabolism markers before and on the third day after PTX, and the risk factors predicting HBS. RESULTS Preoperative baseline data showed that the levels of bone metabolic markers such as bone metabolism-regulating hormones: iPTH, calcitonin (CT); bone formation markers: phosphatase (ALP), osteocalcin (OC); bone resorption markers: type I collagen cross-linked N-telopeptides (NTX), type I collagen cross-linked C-telopeptides (CTX), tartrate-resistant acid phosphatase 5b (TRAP-5b) were all increased compared to normal levels. The levels of postoperative serum iPTH, CT, CTX and TRAP-5b decreased significantly compared to preoperative levels, while the levels of OC and ALP increased significantly. Of the 115 patients, 101 (87.8%) developed HBS after PTX. High preoperative serum ALP and low preoperative serum calcium level independently predicted the occurrence of HBS. Younger preoperative age, high preoperative serum ALP and iPTH level independently predicted the severity of HBS. CONCLUSIONS In severe SHPT, both bone formation and resorption were active, which suggested the presence of high-turnover bone diseases characterized by up-regulation of osteoclasts-osteoblasts functionally coupling activation in the patients. PTX could promote osteoblast activity and reduce osteoclast activity. HBS was common after PTX. Preoperative higher serum ALP and lower calcium were independent predictors of the occurrence of HBS. Younger patients with higher preoperative ALP and PTH may need to closely monitor serum calcium levels and intensive calcium supplementation after PTX.
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Affiliation(s)
- Yifei Ge
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Xiaoming Zha
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Xiangbao Yu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Bin Sun
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Bo Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China.
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Abstract
Significant advances in immunosuppressive therapies have been made in renal transplantation, leading to increased allograft and patient survival. Despite improvement in overall patient survival, patients continue to require management of persistent post-transplant hyperparathyroidism. Medications that treat persistent hyperparathyroidism include vitamin D, vitamin D analogues, and calcimimetics. Medication side effects such as hypocalcemia or hypercalcemia, and adynamic bone disease, may lead to a decrease in the drugs. When medical management fails to control persistent post-transplant hyperparathyroidism, treatment is a parathyroidectomy. Surgical techniques are not uniform between centers and surgeons. Undergoing the surgery may include a subtotal technique or a technique including total parathyroid gland resection with partial heterotopic gland reimplantation. In addition, there are possible post-surgical complications. The ideal treatment for persistent post-transplant hyperparathyroidism is the treatment and prevention of the condition while patients are being managed for their late-stage chronic kidney disease and end-stage renal disease.
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Affiliation(s)
- Rowena Delos Santos
- Division of Nephrology, Washington University in St. Louis, 660 S. Euclid Ave, Campus Box 8126, St. Louis, MO, 63110, USA.
| | - Ana Rossi
- Division of Nephrology and Transplantation, Maine Medical Center, Maine Transplant Program, 19 West St., Portland, ME, 04102, USA
| | - Daniel Coyne
- Division of Nephrology, Washington University in St. Louis, 660 S. Euclid Ave, Campus Box 8126, St. Louis, MO, 63110, USA
| | - Thin Thin Maw
- Division of Nephrology and Hypertension, Keck School of Medicine of USC, 2020 Zonal Ave, IRD 806, Los Angeles, CA, 90033, USA
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Yang G, Ge Y, Zha X, Mao H, Wang N, Xing C. Peritoneal dialysis can alleviate the clinical course of hungry bone syndrome after parathyroidectomy in dialysis patients with secondary hyperparathyroidism. Int Urol Nephrol 2019; 51:535-542. [PMID: 30689179 DOI: 10.1007/s11255-019-02076-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/03/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE It is unclear whether clinical courses of hungry bone syndrome (HBS) after parathyroidectomy (PTX) in peritoneal dialysis (PD) and hemodialysis (HD) patients are different. The present study aimed to investigate the possible differences of postoperative hypocalcemia and hyperkalemia between PD and HD patients. METHODS We performed retrospectively 29 PD patients as the PD group and 169 HD patients as the HD group undergoing successful total PTX with autotransplantation. Calcium supplement after surgery was recorded. Higher levels of serum potassium during and immediately after surgery were recorded as K+d0. K+d3 was recorded as peak pre-dialysis serum potassium level 3 days post-surgery. RESULTS There were 157 (92.90%) patients in HD group and 22 (75.86%) patients in PD group suffered from HBS after surgery, with significant difference between the groups (P = 0.004). Patients in PD group had significantly shorter intravenous calcium supplement duration (P = 0.037) and significantly smaller intravenous calcium supplement dosage (P = 0.042) and total calcium supplement dosage during hospitalization (P = 0.012) than patients in HD group. The levels of serum K+d0 (P < 0.001) and K+d3 (P < 0.001) were both significantly lower in PD group than those in HD group. Peritoneal dialysis was one of the independent influencing factors with negative correlation for calcium supplement, serum K+d0 and serum K+d3. CONCLUSIONS Compared with HD patients, the clinical course of HBS after PTX in PD patients was alleviated. Efforts should be devoted to individual perioperative management for PD patients undergoing PTX.
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Affiliation(s)
- Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Yifei Ge
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Xiaoming Zha
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China.
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Walsh NJ, Caten AJ, White JJ, Terris DJ. Protocol driven outcomes in renal parathyroid surgery. Head Neck 2019; 41:880-884. [DOI: 10.1002/hed.25413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 06/27/2018] [Accepted: 07/12/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
| | | | - John J. White
- Department of NephrologyAugusta University Augusta Georgia
| | - David J. Terris
- Department of OtolaryngologyAugusta University Augusta Georgia
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Rodríguez-Ortiz ME, Pendón-Ruiz de Mier MV, Rodríguez M. Parathyroidectomy in dialysis patients: Indications, methods, and consequences. Semin Dial 2019; 32:444-451. [PMID: 30656752 DOI: 10.1111/sdi.12772] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Secondary hyperparathyroidism, characterized by increased PTH synthesis and secretion, is often seen in advanced stages of chronic kidney disease. Excessive proliferation of parathyroid cells leads to the development of diffuse hyperplasia that subsequently progresses to nodular histology. Refractory hyperparathyroidism occurs when parathyroid glands fail to respond to medical therapy. Parathyroidectomy (PTX), surgical resection of parathyroid glands, is usually performed in cases of persistent serum levels of PTH above 1000 pg/mL associated with hypercalcemia or when hyperparathyroidism is refractory to conservative therapy. Parathyroidectomy can be carried out using different procedures: subtotal PTX or total PTX with or without parathyroid autotransplantation. Parathyroid surgery may have undesirable consequences due to PTH oversuppression, such as the development of adynamic bone disease; hungry bone syndrome is quite common after this surgery. However, PTX improves survival and parameters of mineral metabolism. Parathyroidectomy needs to be considered in those patients with severe hyperparathyroidism with a poor response to pharmacological treatment and with distinct undesirable effects of PTH on bone and mineral metabolism parameters.
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Affiliation(s)
- María E Rodríguez-Ortiz
- Maimónides Institute for Biomedical Research (IMIBIC), Córdoba, Spain.,Reina Sofía University Hospital, Córdoba, Spain.,University of Córdoba, Córdoba, Spain.,Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
| | - María V Pendón-Ruiz de Mier
- Maimónides Institute for Biomedical Research (IMIBIC), Córdoba, Spain.,Reina Sofía University Hospital, Córdoba, Spain.,University of Córdoba, Córdoba, Spain.,Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
| | - Mariano Rodríguez
- Maimónides Institute for Biomedical Research (IMIBIC), Córdoba, Spain.,University of Córdoba, Córdoba, Spain.,Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain.,Nephrology Service, University Hospital Reina Sofía, Córdoba, Spain
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Ferreira D, Vilayur E, Gao M, Sankoorikal C, Bendinelli C. Calcitriol loading before total parathyroidectomy with autotransplant in patients with end-stage kidney disease: does it prevent postoperative hypocalcaemia? Intern Med J 2018; 49:886-893. [PMID: 30552793 DOI: 10.1111/imj.14209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 11/16/2018] [Accepted: 12/12/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hungry bone syndrome (HBS) is one of the most serious complications following parathyroidectomy for severe hyperparathyroidism. There is a lack of literature informing the treatment and risk factors for this condition and the ideal pre-operative strategy for prevention. AIMS The primary aims were to examine the incidence of HBS with pre-operative calcitriol loading for 10 days and to determine the risk factors for HBS. The secondary aims were to determine the rate of intravenous calcium replacement in those with HBS and to assess whether cinacalcet removal has increased rates of parathyroidectomy in the end-stage kidney disease population. METHODS We performed a retrospective study from 2011 to 2018 on 45 patients with end-stage kidney disease undergoing total parathyroidectomy with autotransplantation for severe hyperparathyroidism. This was based at the John Hunter and Newcastle Private Hospitals in New South Wales. RESULTS 28.3% of patients with calcitriol loading undergoing parathyroidectomy fulfilled criteria for HBS. Pre-operative variables that were associated with HBS were elevated parathyroid hormone (P = 0.028) and longer duration of renal replacement therapy (P = 0.033). Rates of total parathyroidectomy were higher after the removal of calcimimetics from the Pharmaceutical Benefits Scheme (P = 0.0024). CONCLUSIONS HBS remains a common complication of parathyroidectomy, even with prolonged high-dose calcitriol loading. This emphasises the need for further trials investigating other targeted therapies, such as bisphosphonates, to prevent HBS. Those most at risk of HBS are patients with high bone turnover and prolonged renal replacement therapy.
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Affiliation(s)
- David Ferreira
- Department of Nephrology, Medical and Interventional Services, John Hunter Hospital, School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Eswari Vilayur
- School of Epidemiology and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Michael Gao
- Department of Nephrology, Medical and Interventional Services, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Christy Sankoorikal
- Endocrinology Department, Medical and Interventional Services, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Cino Bendinelli
- Endocrine and General Surgery, Department of Surgery, John Hunter Hospital and Newcastle Private Hospital, Newcastle, New South Wales, Australia
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Shigematsu T, Fukagawa M, Yokoyama K, Akiba T, Fujii A, Odani M, Akizawa T. Effects of the Intravenous Calcimimetic Etelcalcetide on Bone Turnover and Serum Fibroblast Growth Factor 23: Post Hoc Analysis of an Open-label Study. Clin Ther 2018; 40:2099-2111. [PMID: 30473399 DOI: 10.1016/j.clinthera.2018.10.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/18/2018] [Accepted: 10/16/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Secondary hyperparathyroidism (SHPT) is a serious complication that increases the risk of bone disorders in patients with chronic kidney disease (CKD) undergoing hemodialysis. Etelcalcetide is the first injectable calcimimetic approved for treatment of SHPT, which reduces bone turnover markers and suppresses intact fibroblast growth factor 23 (iFGF-23). This study aimed to explore the associations between etelcalcetide-induced changes in circulating factors and serum iFGF-23 levels. METHODS This study was a post hoc analysis of data from a previous multicenter, open-label study of etelcalcetide administered to 191 Japanese patients with SHPT undergoing hemodialysis for 52 weeks. Correlations were analyzed between changes from baseline in serum iFGF-23 and serum intact parathyroid hormone (iPTH), corrected calcium, phosphate, bone alkaline phosphatase (BAP), tartrate-resistant acid phosphatase-5b (TRACP-5b), and 1α,25-dihydroxyvitamin D (1,25[OH]2D) levels at 1, 2, 3, 6, and 12 months. Akaike's Information Criterion (AIC) was calculated using serum iPTH, corrected calcium, phosphate, BAP, TRACP-5b, and 1,25(OH)2D levels as potential predictor variables at each time point. Four models with the smallest AIC at the 3-month time point were chosen as the fitted models to predict changes in iFGF-23 levels, and stepwise multivariate analysis was performed to determine the predictor variables with the greatest contribution to the change in iFGF-23 levels by calculating the partial coefficients of determination. FINDINGS The etelcalcetide-induced reduction in iFGF-23 was positively correlated with serum levels of corrected calcium and phosphate and negatively with BAP. By calculating the AIC, corrected calcium, phosphate, iPTH, BAP, and TRACP-5b were suggested to be predictors of iFGF-23 levels. Stepwise multivariate analysis found that phosphate, corrected calcium, BAP, and TRACP-5b correlated with iFGF-23, in order from strongest to weakest. IMPLICATIONS These results suggest that etelcalcetide effectively lowered iFGF-23 and that this reduction may occur via improvements in phosphate, corrected calcium, BAP, and TRACP-5b. Etelcalcetide is thus a promising calcimimetic for decreasing iFGF-23 and improving bone turnover in patients with CKD undergoing hemodialysis with severe SHPT, in addition to decreasing PTH itself. JapicCTI identifier: 142,665.
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Affiliation(s)
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Keitaro Yokoyama
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | | | - Akifumi Fujii
- Clinical Development Planning, Ono Pharmaceutical Co, Ltd, Osaka, Japan
| | - Motoi Odani
- Data Science, Ono Pharmaceutical Co Ltd, Osaka, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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van der Plas WY, Engelsman AF, Umakanthan M, Mather A, Sidhu SB, Delbridge LW, Pollock C, Waugh D, Sywak MS, Kruijff S. Treatment strategy of end stage renal disease-related hyperparathyroidism before, during, and after the era of calcimimetics. Surgery 2018; 165:135-141. [PMID: 30413324 DOI: 10.1016/j.surg.2018.04.092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/03/2018] [Accepted: 04/07/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Since 2004, end-stage renal disease related hyperparathyroidism patients are treated mainly with cinacalcet, which ceased to be subsidized through the Australian Pharmaceutical Benefits Scheme in 2015. We aimed to investigate the impact of these changes on the treatment strategy in the Australian end-stage renal disease population. METHODS The following groups were formed according to the date of parathyroidectomy: A, before calcimimetics; B, during the era of calcimimetics; and C, after cinacalcet removal by the Australian Pharmaceutical Benefits Scheme. The primary outcome was time from start of dialysis to parathyroidectomy. Regression analysis was used to examine trends in parathyroidectomy rates. RESULTS Between 1998 and 2016, 195 parathyroidectomies were performed. Median time to referral was 69 (33-123), 67 (31-110) and 44 (23-102) months for groups A, B, and C, respectively (P = .55). Parathyroidectomy rates increased throughout the years (CI 0.09-1.13, R2=0.27, P = .02). A trend toward a dip in parathyroidectomy rates was seen during the era of cinacalcet (P = .08). Median preoperative parathyroid hormone levels increased significantly (842 [418-1,553] versus 1,040 [564-1,810] versus 1,350 [1,037-1,923] pg/mL, for groups A, B, and C, respectively [P < .01]). CONCLUSION Parathyroidectomy rates seem to vary according to the availability of cinacalcet. This change in treatment strategy is accompanied with increased preoperative parathyroid hormone levels, reflecting delayed surgery and increased disease severity.
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Affiliation(s)
- Willemijn Y van der Plas
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Anton F Engelsman
- Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia; Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marille Umakanthan
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - Amanda Mather
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - Stan B Sidhu
- Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Leigh W Delbridge
- Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Carol Pollock
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - David Waugh
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - Mark S Sywak
- Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Schelto Kruijff
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
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Challenges and controversies in the surgical management of uremic hyperparathyroidism: A systematic review. Am J Surg 2018; 216:713-722. [DOI: 10.1016/j.amjsurg.2018.07.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 05/19/2018] [Accepted: 07/17/2018] [Indexed: 01/08/2023]
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Yang G, Zha X, Mao H, Yu X, Wang N, Xing C. Hypocalcemia-based prediction of hungry bone syndrome after parathyroidectomy in hemodialysis patients with refractory secondary hyperparathyroidism. J Int Med Res 2018; 46:4985-4994. [PMID: 30064280 PMCID: PMC6300944 DOI: 10.1177/0300060518788744] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective This study was performed to explore the risk factors for hungry bone syndrome (HBS) and establish prediction equations for calcium supplementation after parathyroidectomy in hemodialysis patients with secondary hyperparathyroidism. Methods We retrospectively analyzed data from 252 hemodialysis patients undergoing successful total parathyroidectomy with autotransplantation. HBS was defined according to a minimum postoperative serum corrected calcium (PcCa) concentration of <2.0 mmol/L. Independent predictors of HBS were analyzed, and prediction equations for HBS were derived accordingly. Results The incidence of HBS was 71.4%. The serum corrected calcium and preoperative serum alkaline phosphatase (ALP) concentrations were independent predictors of HBS. The preoperative serum ALP, intact parathyroid hormone (iPTH), and hemoglobin concentrations were independent factors influencing the average descending velocity of the PcCa concentration before calcium supplementation (PcCa-V), intravenous calcium supplement holding time (IVCa-T), and intravenous calcium supplement dosage (IVCa), while the serum ALP and iPTH concentrations were independent predictors of the oral calcium supplement dosage (OCa). Four prediction equations for PcCa-V, IVCa-T, IVCa, and OCa were established. Conclusions Establishment of prediction equations for HBS may contribute to a new individualized therapy for patients with HBS.
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Affiliation(s)
- Guang Yang
- 1 Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaoming Zha
- 2 Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Huijuan Mao
- 1 Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiangbao Yu
- 1 Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ningning Wang
- 1 Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Changying Xing
- 1 Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Lau WL, Obi Y, Kalantar-Zadeh K. Parathyroidectomy in the Management of Secondary Hyperparathyroidism. Clin J Am Soc Nephrol 2018; 13:952-961. [PMID: 29523679 PMCID: PMC5989682 DOI: 10.2215/cjn.10390917] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Secondary hyperparathyroidism develops in CKD due to a combination of vitamin D deficiency, hypocalcemia, and hyperphosphatemia, and it exists in nearly all patients at the time of dialysis initiation. There is insufficient data on whether to prefer vitamin D analogs compared with calcimimetics, but the available evidence suggests advantages with combination therapy. Calcium derangements, patient adherence, side effects, and cost limit the use of these agents. When parathyroid hormone level persists >800 pg/ml for >6 months, despite exhaustive medical interventions, monoclonal proliferation with nodular hyperplasia is likely present along with decreased expression of vitamin D and calcium-sensing receptors. Hence, surgical parathyroidectomy should be considered, especially if concomitant disorders exist, such as persistent hypercalcemia or hyperphosphatemia, tissue or vascular calcification including calciphylaxis, and/or worsening osteodystrophy. Parathyroidectomy is associated with 15%-57% greater survival in patients on dialysis, and it also improves hypercalcemia, hyperphosphatemia, tissue calcification, bone mineral density, and health-related quality of life. The parathyroidectomy rate in the United States declined to approximately seven per 1000 dialysis patient-years between 2002 and 2011 despite an increase in average parathyroid hormone levels, reflecting calcimimetics introduction and uncertainty regarding optimal parathyroid hormone targets. Hospitalization rates are 39% higher in the first postoperative year. Hungry bone syndrome occurs in approximately 25% of patients on dialysis, and profound hypocalcemia requires high doses of oral and intravenous calcium along with calcitriol supplementation. Total parathyroidectomy with autotransplantation carries a higher risk of permanent hypocalcemia, whereas risk of hyperparathyroidism recurrence is higher with subtotal parathyroidectomy. Given favorable long-term outcomes from observational parathyroidectomy cohorts, despite surgical risk and postoperative challenges, it is reasonable to consider parathyroidectomy in more patients with medically refractory secondary hyperparathyroidism.
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Affiliation(s)
- Wei Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California, Irvine, California
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Abstract
PURPOSE OF REVIEW In the United States, the number of parathyroidectomies among patients with chronic dialysis has remained stable in the last decade. A fall in serum calcium concentration is common postparathyroidectomy in patients with hyperparathyroidism, which usually resolves in 2-4 days. A severe drop in serum total calcium concentration less than 2.1 mmol/L and/or prolonged hypocalcemia for more than 4 days postparathyroidectomy is called hungry bone syndrome (HBS). Concomitant hypophosphatemia, hypomagnesemia, and hyperkalemia can be seen. Hypocalcemia and hypophosphatemia can persist for months to years. In contemporary clinical practice, HBS may be more commonly seen in patients with secondary compared to primary hyperparathyroidism. Preoperative radiological changes in bone, elevated serum alkaline phosphatase and parathyroid hormone (PTH) levels, and high numbers of osteoclasts on bone biopsy may identify patients at risk. Treatment consists of high-dose oral calcium and calcitriol supplementation. A low-dose pamidronate infusion 1-2 days prior to surgery may prevent HBS. RECENT FINDINGS Recent in-vitro studies reported net calcium movement into bone because of a sudden fall in serum PTH level after a prolonged period of elevation. This supports a previous hypothesis that a sudden drop in serum PTH level after surgery results in the unopposed action of osteoblasts and influx of calcium into bone. SUMMARY Incidence of HBS and its association with morbidity and mortality remains unclear in contemporary clinical practice. It is more common to encounter HBS in chronic dialysis patients with secondary hyperparathyroidism than those with primary hyperparathyroidism that undergo parathyroidectomies. Use of bisphosphonates to prevent HBS should be explored in future studies.
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Tayyebi-Khosroshahi H, Farnood F, Ghorbanian M, Karkon-Shayan F, Naghavi-Behzad M. Persistent hypocalcemia and hungry bone syndrome after parathyroidectomy and renal transplantation in a patient with end-stage renal disease. Niger Med J 2017; 58:50-52. [PMID: 29238129 PMCID: PMC5715567 DOI: 10.4103/0300-1652.218416] [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] [Indexed: 12/28/2022] Open
Abstract
Hungry bone syndrome (HBS) defines as persistent and severe hypocalcemia after parathyroidectomy surgery. It is treated by oral or venous discrimination of calcium carbonate. The present treatment is mostly effective. Hereby, we describe a 60-year-old man who had developed hyperparathyroidism secondary to end-stage renal disease and then parathyroidectomy was performed for him twice before renal transplantation. Up to 500 vials of calcium gluconate (100 mg/ml calcium gluconate 10%) were administered for him to control serum calcium level after parathyroidectomy and renal transplantation. Furthermore, high-dose calcium carbonate was administered for his outpatient care. Therefore, HBS, which was resistant to standard treatment, was detected for him.
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Affiliation(s)
| | - Farahnoush Farnood
- Chronic Renal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maryam Ghorbanian
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farid Karkon-Shayan
- Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Naghavi-Behzad
- Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.,Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Low THH, Yoo J. Subtotal Parathyroidectomy and Relocation of the Parathyroid Remnant for Renal Hyperparathyroidism: modification of a traditional operation. J Otolaryngol Head Neck Surg 2017; 46:60. [PMID: 29061193 PMCID: PMC5654001 DOI: 10.1186/s40463-017-0238-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/09/2017] [Indexed: 11/22/2022] Open
Abstract
Background We describe a modification of the conventional subtotal parathyroidectomy operation where the parathyroid gland(s) remnant is repositioned with intact vascular supply to a plane superficial to the infrahyoid strap muscles and immediately under the skin incision. This technique called Subtotal Parathyroidectomy and Remnant Relocation (SPARE) retains all the metabolic advantages of the conventional operation with the added advantage of easier identification of a recurrent hyperplastic remnant if re-exploration becomes necessary. Methods In the SPARE technique, four parathyroid glands were identified and the quality of each gland and the length of each vascular pedicle to the parathyroid glands were assessed. The optimal parathyroid gland was relocated to a plane superficial to the strap muscles. The remainder of the glands were removed. Results In total, 30 patients with hyperparathyroidism secondary to renal failure (HSRF) underwent parathyroidectomy with the SPARE technique. The mean age was 53.1±12.5 years and median follow-up was 17.1 months (range 1-78.9 months). There were no recurrent laryngeal nerve (RLN) injuries or hematomas. The pre- and post-operative value for corrected calcium and PTH were 158.4±109.4 pmol/L and 11.4±12.1 pmol/L, respectively (p < 0.05). Three recurrences were noted (10.0%), with a mean time to recurrence of 15.3±6.6 months. One patient had excision of the remnant parathyroid glands performed under local anaesthetic (29 min); one had re-exploration performed under general anaesthetic (81 min), and one was managed medically. Conclusion We described a novel parathyroidectomy technique for patients with HSRF, which provides the advantages of conventional subtotal parathyroidectomy while mitigating the challenges of thyroid bed re-exploration when recurrences arise.
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Affiliation(s)
- Tsu-Hui Hubert Low
- Head and Neck Department, Chris O'Brien Lifehouse, Missenden Road, Camperdown, NSW, Australia
| | - John Yoo
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine& Dentistry, Western University, 800 Commissioners Road East, Suite B3-433A, London, ON, N6A 5W9, Canada.
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Ge P, Liu S, Sheng X, Li S, Xu M, Jiang J, Chen S. Serum parathyroid hormone and alkaline phosphatase as predictors of calcium requirements after total parathyroidectomy for hypocalcemia in secondary hyperparathyroidism. Head Neck 2017; 40:324-329. [PMID: 28963816 DOI: 10.1002/hed.24965] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 07/27/2017] [Accepted: 08/16/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND To prevent hypocalcemia, this study examined the efficiency of a calcium supplement formula guided by predicted calcium requirement in patients with renal failure after parathyroidectomy with autotransplantation. METHODS In the first phase, a protocol was followed whereby intravenous calcium gluconate was repeatedly titrated based on serum calcium levels in 22 patients with parathyroidectomy with autotransplantation. In the second phase, the first equation protocol was applied in 74 patients with parathyroidectomy with autotransplantation and revised. RESULTS There is a significant correlation between the postoperative amount of calcium requirement and preoperative serum alkaline phosphatase level (r = 0.442; P < .001) and parathyroid hormone level (PTH; r = 0.889; P < .001). For prediction of insufficient calcium supplement, the cutoff point of PTH and alkaline phosphatase level values were calculated by receiver operating characteristic (ROC) curve analysis and modified equations were developed by regression analysis. CONCLUSION The preoperative PTH and alkaline phosphatase levels can predict postoperative calcium requirements, such that equations of calcium supplement allow the management of hypocalcemia efficiently in patients on dialysis after parathyroidectomy with autotransplantation.
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Affiliation(s)
- Pingjiang Ge
- Department of Otolaryngology Head and Neck, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou City, People's Republic of China.,South China University of Technology, Tianhe District, Guangzhou, Guangdong Province
| | - Shuangxin Liu
- Department of Nephrology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou City, People's Republic of China
| | - Xiaoli Sheng
- Department of Otolaryngology Head and Neck, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou City, People's Republic of China
| | - Sijia Li
- Department of Nephrology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou City, People's Republic of China
| | - Mimi Xu
- Department of Otolaryngology Head and Neck, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou City, People's Republic of China
| | - Jie Jiang
- Department of Otolaryngology Head and Neck, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou City, People's Republic of China
| | - Shaohua Chen
- Department of Otolaryngology Head and Neck, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou City, People's Republic of China
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Peculiarity of Postoperative Period in Hemodialysis Patients after Parathyroidectomy. BIONANOSCIENCE 2017. [DOI: 10.1007/s12668-016-0373-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Qi HJ, Yang WW, Zhang LD, Shi XJ, Li QY, Ye T. Peripherally inserted central catheters for calcium requirements after successful parathyroidectomy: a comparison with centrally inserted catheters. Ann R Coll Surg Engl 2017; 99:358-362. [PMID: 28462656 PMCID: PMC5449693 DOI: 10.1308/rcsann.2017.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Intravenous calcium supplements are often required following parathyroidectomy to avoid postoperative hypocalcaemia. The aim of this study was to compare application effect of a femoral central venous catheter (CVC) and peripherally inserted central catheter (PICC) on intravenous calcium supplements after parathyroidectomy. METHODS We retrospectively reviewed the hospital records of 73 patients with secondary hyperparathyroidism who underwent a successful parathyroidectomy at the Huashan Hospital attached to Fudan University between 1 April 2011 and 1 February 2016. RESULTS Of the 73 study participants, 39 (53.4%) had a PICC and 34 (46.6%) had a CVC, respectively. Patients in the CVC group needed 6-7 days of intravenous calcium supplements, while patients in PICC group needed only 2-3 days to achieve normal serum calcium concentration (2.2-2.6 mmol/L). Furthermore, the duration of calcium supplementation was 71.62 ± 4.48 hours in PICC group and 100.4 ± 5.43 hours in CVC group (P < 0.05). Of the patients in PICC group, the incidence of catheter occlusion, operation failure and hypocalcaemia was 0%, which was significantly lower than those in CVC group (2.56%, 7.69% and 7.69%, respectively). CONCLUSIONS PICC is a safe and efficient alternative in contrast to CVC for providing venous access for calcium supplementation in surgical patients after parathyroidectomy.
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Affiliation(s)
- H J Qi
- Clinical Pharmacy Laboratory, Huashan Hospital North, Fudan University , Shanghai , China
| | - W W Yang
- General Surgery Unit, Huashan Hospital, Fudan University , Shanghai , China
| | - L D Zhang
- Clinical Pharmacy Laboratory, Huashan Hospital North, Fudan University , Shanghai , China
| | - X J Shi
- Clinical Pharmacy Laboratory, Huashan Hospital North, Fudan University , Shanghai , China
| | - Q Y Li
- Clinical Pharmacy Laboratory, Huashan Hospital North, Fudan University , Shanghai , China
| | - T Ye
- Clinical Pharmacy Laboratory, Huashan Hospital North, Fudan University , Shanghai , China
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Polistena A, Sanguinetti A, Lucchini R, Galasse S, Avenia S, Monacelli M, Johnson LB, Jeppsson B, Avenia N. Surgical treatment of secondary hyperparathyroidism in elderly patients: an institutional experience. Aging Clin Exp Res 2017; 29:23-28. [PMID: 27830521 DOI: 10.1007/s40520-016-0669-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/01/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Secondary hyperparathyroidism in elderly fragile patients presents clinical difficulties due to severity of symptoms and related comorbidity. The optimal surgical approach for this group of patients is still debated. AIM The aim of the study was to define the optimal technique of parathyroidectomy in elderly patients with secondary hyperparathyroidism. METHODS Retrospective analysis in a series of 253 patients including 35 elderly individuals at a single institution was carried out. Postoperative parathyroid hormone decrease, surgical complications and symptoms control were analyzed for all patients in relation to the types of parathyroidectomy performed. RESULTS In elderly patients, total parathyroidectomy was the most used approach. Subtotal parathyroidectomy was mostly reserved for younger patients suitable for kidney transplantation. No elderly patients treated with total parathyroidectomy were autotransplanted. No significant difference in surgical complications was observed between younger and elderly patients and considering the different procedures. Adequate symptom control after surgery was achieved in almost 90% of patients. A limited rate of recurrence requiring repeat surgery was observed only after subtotal parathyroidectomy. DISCUSSION Considering the features of all types of parathyroidectomy, very low recurrence rate, contained postoperative hypocalcemia and limited complications following total parathyroidectomy, might represent specific advantages for elderly patients. CONCLUSIONS Total parathyroidectomy without parathyroid transplantation is safe for elderly patients with secondary hyperparathyroidism and a good alternative to the well-established total parathyroidectomy with autografting.
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Affiliation(s)
- Andrea Polistena
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy.
| | - Alessandro Sanguinetti
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Roberta Lucchini
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Segio Galasse
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Stefano Avenia
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Massimo Monacelli
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Louis Banka Johnson
- Surgical Department, Skåne University Hospital, University of Lund, Malmö, Sweden
| | - Bengt Jeppsson
- Surgical Department, Skåne University Hospital, University of Lund, Malmö, Sweden
| | - Nicola Avenia
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
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Ho LY, Wong PN, Sin HK, Wong YY, Lo KC, Chan SF, Lo MW, Lo KY, Mak SK, Wong AKM. Risk factors and clinical course of hungry bone syndrome after total parathyroidectomy in dialysis patients with secondary hyperparathyroidism. BMC Nephrol 2017; 18:12. [PMID: 28073343 PMCID: PMC5223390 DOI: 10.1186/s12882-016-0421-5] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 12/20/2016] [Indexed: 12/18/2022] Open
Abstract
Background Hungry bone syndrome (HBS) is an important postoperative complication after parathyroidectomy for severe secondary hyperparathyroidism (SHPT). There is, however, little data in the literature on its detailed clinical course, and the associated risk factors remain controversial. Methods We did a single-center retrospective study on 62 consecutive dialysis patients who underwent total parathyroidectomy for SHPT to examine the risk factors, clinical course and outcome. Data on demographic characteristics, perioperative laboratory parameters including serum calcium, phosphate, alkaline phosphatase (ALP) and parathyroid hormone (PTH), drug treatment for SHPT and operative details of parathyroidectomy were collected. Results Seventeen (27.4%) patients developed severe postoperative hypocalcemia with HBS. The serum calcium dropped progressively while serum ALP rose after operation until 2 weeks later when serum calcium reached the trough and serum ALP peaked. Serum phosphate also fell but stabilized between 4 and 14 days. The total postoperative calcium and vitamin D supplementation was significantly larger, and hospital stay was significantly longer in the group with HBS as compared with those without HBS. Young age, high body weight, high preoperative ALP level, and low preoperative calcium level independently predicted the development of HBS while preoperative PTH and use of cinacalcet or paricalcitol did not. Conclusion HBS was common after total parathyroidectomy in patients with SHPT, and it is important to closely monitor the postoperative serum calcium, phosphate and ALP levels in the following 2 weeks, especially for those at risk. The implications of our findings on perioperative management are discussed.
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Affiliation(s)
- Lo-Yi Ho
- Department of Medicine & Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China
| | - Ping-Nam Wong
- Department of Medicine & Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China.
| | - Ho-Kwan Sin
- Department of Medicine & Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China
| | - Yuk-Yi Wong
- Department of Medicine & Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China
| | - Kwok-Chi Lo
- Department of Medicine & Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China
| | - Shuk-Fan Chan
- Department of Medicine & Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China
| | - Man-Wai Lo
- Department of Medicine & Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China
| | - Kin-Yee Lo
- Department of Medicine & Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China
| | - Siu-Ka Mak
- Department of Medicine & Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China
| | - Andrew Kui-Man Wong
- Department of Medicine & Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China
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Afshan S, Farah Musa AR, Echols V, Lerant AA, Fülöp T. Persisting Hypocalcemia After Surgical Parathyroidectomy: The Differential Effectiveness of Calcium Citrate Versus Calcium Carbonate With Acid Suppression. Am J Med Sci 2017; 353:82-86. [DOI: 10.1016/j.amjms.2016.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/14/2016] [Accepted: 04/19/2016] [Indexed: 12/30/2022]
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Festuccia F, Jafari MT, Moioli A, Fofi C, Barberi S, Amendola S, Sciacchitano S, Punzo G, Menè P. Safety and efficacy of denosumab in osteoporotic hemodialysed patients. J Nephrol 2016; 30:271-279. [PMID: 27394428 DOI: 10.1007/s40620-016-0334-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 06/28/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS In elderly subjects, renal insufficiency and osteoporosis often coexist with high risk of fracture and elevated socio-economic burden. Today a large number of effective anti-osteoporotic drugs are available but generally they are contraindicated in patients with chronic kidney disease (CKD) because of their progressive accumulation. Denosumab, instead, does not require dose adjustments for different degrees of renal impairment so it can be a valid treatment in osteoporotic patients with CKD. Limited data are available in the literature concerning the use of denosumab in hemodialysis (HD). The aim of our study was, therefore, to study the efficacy and tolerability of this drug in this particular subset of patients. METHODS We retrospectively reviewed the charts of 12 osteoporotic HD patients who received a single 60-mg subcutaneous dose of denosumab every 6 months for an observation period of 24 months. Serum electrolyte, markers of bone turnover and quantitative ultrasound (QUS) were evaluated. RESULTS Over 24 months, we observed a gradual improvement of bone metabolism: β-CrossLaps from 2567.08 ± 1264 to 1492.5 ± 1182.5 pg/ml; bone alkaline phosphatase (BALP) from 33.5 ± 28.8 to 11.8 ± 3.7 mcg/l, and of QUS index (T-score from -5.33 ± 1.58 to -4.84 ± 1.2; risk of fracture from 13.9 ± 4.7 to 11.07 ± 5.3 %). Few cases of hypocalcemia were detected, more significant after the first and second injection, but with careful monitoring of serum calcium and rapid therapy adjustment we could easily manage serum Ca levels. CONCLUSIONS Our pilot experience highlights the safety and efficacy of denosumab in the treatment of osteoporosis in HD patients, potentially supporting its use to reduce the burden of fractures in this patient population.
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Affiliation(s)
- Francescaromana Festuccia
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy. .,Division of Nephrology, Sant'Andrea University Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
| | - Maryam Tayefeh Jafari
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Alessandra Moioli
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy. .,Division of Nephrology, Sant'Andrea University Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
| | - Claudia Fofi
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy.,Division of Nephrology, Sant'Andrea University Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Simona Barberi
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy.,Division of Nephrology, Sant'Andrea University Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Stefano Amendola
- Section of Endocrinology and Diabetology, Ospedale Israelitico, Rome, Italy
| | - Salvatore Sciacchitano
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy.,Laboratory of Biomedical Research, Niccolò Cusano University Foundation, Rome, Italy
| | - Giorgio Punzo
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy.,Division of Nephrology, Sant'Andrea University Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Paolo Menè
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy.,Division of Nephrology, Sant'Andrea University Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
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Yang M, Zhang L, Huang L, Sun X, Ji H, Lu Y. Factors predictive of critical value of hypocalcemia after total parathyroidectomy without autotransplantation in patients with secondary hyperparathyroidism. Ren Fail 2016; 38:1224-7. [DOI: 10.1080/0886022x.2016.1202731] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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50
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The Changing Landscape of Primary, Secondary, and Tertiary Hyperparathyroidism: Highlights from the American College of Surgeons Panel, “What's New for the Surgeon Caring for Patients with Hyperparathyroidism”. J Am Coll Surg 2016; 222:1240-50. [DOI: 10.1016/j.jamcollsurg.2016.02.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 02/11/2016] [Accepted: 02/12/2016] [Indexed: 12/27/2022]
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