1
|
Gronemeyer K, Fuss CT, Hermes F, Plass A, Koschker AC, Hannemann A, Völzke H, Hahner S. Renal complications in chronic hypoparathyroidism - a systematic cross-sectional assessment. Front Endocrinol (Lausanne) 2023; 14:1244647. [PMID: 38027217 PMCID: PMC10654620 DOI: 10.3389/fendo.2023.1244647] [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: 06/22/2023] [Accepted: 10/02/2023] [Indexed: 12/01/2023] Open
Abstract
Context Although renal long-term complications are acknowledged in chronic hypoparathyroidism (HPT), standardized investigations are scarce. Objective To systematically investigate renal complications and their predictors in hypoparathyroid patients compared to matched individuals. Design Prospective observational study in 161 patients with chronic HPT. Methods Patients received renal ultrasound, clinical and laboratory assessments. An individual 1:3 matching with participants from the German population-based Study of Health in Pomerania was performed. Results Of 161 patients (92% postoperative HPT), prevalence of eGFR <60ml/min/1.73m2 was 21%, hypercalciuria 41%. Compared to healthy individuals, HPT patients had a significantly lower eGFR (74.2 vs. 95.7 ml/min/1.73m², p<0.01). Renal ultrasound revealed calcifications in 10% (nephrocalcinosis in 7% and calculi in 3%). Patients with renal calcifications had higher levels of 24-hour urine calcium excretion (8.34 vs. 5.08 mmol/d, p=0.02), spot urine calcium excretion (4.57 vs. 2.01 mmol/L, p=0.01) and urine calcium-to-creatinine ratio (0.25 vs. 0.16, p<0.01) than patients without calcifications. Albumin-corrected calcium, phosphate, calcium-phosphate product, 25-hydroxyvitamin D in serum, eGFR, daily calcium intake or disease duration were not significantly different between these two groups. Including patients receiving rhPTH therapy, a lower serum phosphate concentration (odds ratio 1.364 [95% confidence interval (CI) 1.049-1.776], p<0.05) and a longer disease duration of HPT (odds ratio 1.063 [95% CI 1.021-1.106], p<0.01) were significant predictors for renal calcifications. Excluding patients receiving rhPTH therapy, a higher 24-hour urine calcium excretion (odds ratio 1.215 [95% CI 1.058-1.396], p<0.01) was a significant predictor for renal calcifications but not serum magnesium or disease duration. Conclusions Prevalence of impaired renal function among patients with chronic HPT is increased and independent from visible renal calcifications. Depending on exclusion of patients with rhPTH therapy, regression analysis revealed disease duration and serum phosphate or disease duration and 24-hour urinary calcium excretion as predictors for renal calcifications. Clin Trials Identifier NCT05585593.
Collapse
Affiliation(s)
- Karen Gronemeyer
- Department of Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Carmina Teresa Fuss
- Department of Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Franca Hermes
- Department of Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Armin Plass
- Department of Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Ann-Cathrin Koschker
- Department of Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Anke Hannemann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
- German Centre for Cardiovascular Research, Partner Site Greifswald, Greifswald, Germany
| | - Henry Völzke
- German Centre for Cardiovascular Research, Partner Site Greifswald, Greifswald, Germany
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Stefanie Hahner
- Department of Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| |
Collapse
|
2
|
Rejnmark L, Ayodele O, Lax A, Mu F, Swallow E, Gosmanova EO. The risk of chronic kidney disease development in adult patients with chronic hypoparathyroidism treated with rhPTH(1-84): A retrospective cohort study. Clin Endocrinol (Oxf) 2023; 98:496-504. [PMID: 35974422 DOI: 10.1111/cen.14813] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/16/2022] [Accepted: 06/26/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study assessed the risk of developing chronic kidney disease (CKD) and decline in estimated glomerular filtration rate (eGFR) over a period of up to 5 years in adult patients with chronic hypoparathyroidism treated with recombinant human parathyroid hormone (1-84) (rhPTH[1-84]) compared with a historical control cohort of patients not treated with rhPTH(1-84). DESIGN Retrospective cohort study of patients with chronic hypoparathyroidism treated with rhPTH(1-84) derived from the REPLACE (NCT00732615), RELAY (NCT01268098), RACE (NCT01297309) and HEXT (NCT01199614, and its continuation study NCT02910466) clinical trials and a historical control cohort who did not receive PTH selected from an electronic medical record database. PATIENTS One hundred and eighteen patients treated with rhPTH(1-84) and 497 patient controls. MEASUREMENTS Incident CKD was defined as ≥2 eGFR measurements <60 ml/min/1.73 m2 ≥3 months apart during the study and a sustained eGFR decline of ≥30% from baseline. RESULTS Over the 5-year period, Kaplan-Meier analyses showed that rhPTH(1-84)-treated patients had a significantly lower risk of developing CKD (log-rank p = .002) and a lower risk for a sustained eGFR decline ≥30% from baseline (log-rank p < .001) compared with patients in the control cohort. In adjusted analyses, patients in the rhPTH(1-84)-treated cohort had a 53% lower risk of developing CKD (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.25-0.87) and a 65% lower risk for sustained eGFR decline ≥30% from baseline (HR, 0.35; 95% CI, 0.13-0.89) compared with controls. CONCLUSIONS Patients with chronic hypoparathyroidism treated with rhPTH(1-84) in long-term clinical trials had a significantly lower risk of developing CKD compared with patients in a historical control cohort not treated with rhPTH(1-84).
Collapse
Affiliation(s)
- Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Olulade Ayodele
- Takeda Pharmaceuticals USA, Inc., Lexington, Massachusetts, USA
| | - Angela Lax
- Analysis Group, Inc., Boston, Massachusetts, USA
| | - Fan Mu
- Analysis Group, Inc., Boston, Massachusetts, USA
| | | | - Elvira O Gosmanova
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York, USA
| |
Collapse
|
3
|
Watts NB, Bilezikian JP, Bone HG, Clarke BL, Denham D, Levine MA, Mannstadt M, Peacock M, Rothman JG, Vokes TJ, Warren ML, Yin S, Sherry N, Shoback DM. Long-Term Safety and Efficacy of Recombinant Human Parathyroid Hormone (1-84) in Adults With Chronic Hypoparathyroidism. J Endocr Soc 2023; 7:bvad043. [PMID: 37091306 PMCID: PMC10119703 DOI: 10.1210/jendso/bvad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Indexed: 04/07/2023] Open
Abstract
Context Chronic hypoparathyroidism is conventionally treated with oral calcium and active vitamin D to reach and maintain targeted serum calcium and phosphorus levels, but some patients remain inadequately controlled. Objective To assess long-term safety and efficacy of recombinant human parathyroid hormone (1-84) (rhPTH(1-84)) treatment. Methods This was an open-label extension study at 12 US centers. Adults (n = 49) with chronic hypoparathyroidism were included. The intervention was rhPTH(1-84) for 6 years. The main outcome measures were safety, biochemical measures, oral supplement doses, bone indices. Results Thirty-eight patients (77.6%) completed the study. Throughout 72 months, mean albumin-adjusted serum calcium was within 2.00 to 2.25 mmol/L (8.0-9.0 mg/dL). At baseline, 65% of patients with measurements (n = 24/37) were hypercalciuric; of these, 54% (n = 13/24) were normocalciuric at month 72. Mean serum phosphorus declined from 1.6 ± 0.19 mmol/L at baseline (n = 49) to 1.3 ± 0.20 mmol/L at month 72 (n = 36). Mean estimated glomerular filtration rate was stable. rhPTH(1-84)-related adverse events were reported in 51.0% of patients (n = 25/49); all but 1 event were mild/moderate in severity. Mean oral calcium supplementation reduced by 45% ± 113.6% and calcitriol by 74% ± 39.3%. Bone turnover markers declined by month 32 to a plateau above pretreatment values; only aminoterminal propeptide of type 1 collagen remained outside the reference range. Mean bone mineral density z score fell at one-third radius and was stable at other sites. Conclusion 6 years of rhPTH(1-84) treatment was associated with sustained improvements in biochemical parameters, a reduction in the percentage of patients with hypercalciuria, stable renal function, and decreased supplement requirements. rhPTH(1-84) was well tolerated; no new safety signals were identified.
Collapse
Affiliation(s)
- Nelson B Watts
- Osteoporosis and Bone Health Services, Mercy Health, Cincinnati, OH 45236, USA
| | - John P Bilezikian
- Division of Endocrinology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
| | - Henry G Bone
- Michigan Bone and Mineral Clinic, PC, Detroit, MI 48236, USA
| | - Bart L Clarke
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Douglas Denham
- Clinical Trials of Texas, Inc., San Antonio, TX 78229, USA
| | - Michael A Levine
- Division of Endocrinology and Diabetes and Center for Bone Health, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Munro Peacock
- Department of Medicine, Division of Endocrinology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | - Tamara J Vokes
- Section of Endocrinology, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Mark L Warren
- Endocrinology and Metabolism, Physicians East, PA, Greenville, NC 27834, USA
| | - Shaoming Yin
- Takeda Pharmaceuticals USA, Inc., Lexington, MA 02421, USA
| | - Nicole Sherry
- Takeda Pharmaceuticals USA, Inc., Lexington, MA 02421, USA
| | - Dolores M Shoback
- Endocrine Research Unit, San Francisco Veterans Affairs Medical Center, San Francisco, CA 94121, USA
- Department of Medicine, University of California, San Francisco, CA 94143, USA
| |
Collapse
|
4
|
Wang M, Zhang J, Kalantar-Zadeh K, Chen J. Focusing on Phosphorus Loads: From Healthy People to Chronic Kidney Disease. Nutrients 2023; 15:nu15051236. [PMID: 36904234 PMCID: PMC10004810 DOI: 10.3390/nu15051236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/05/2023] Open
Abstract
Phosphorus is an essential micromineral with a key role in cellular metabolism and tissue structure. Serum phosphorus is maintained in a homeostatic range by the intestines, bones, and kidneys. This process is coordinated by the endocrine system through the highly integrated actions of several hormones, including FGF23, PTH, Klotho, and 1,25D. The excretion kinetics of the kidney after diet phosphorus load or the serum phosphorus kinetics during hemodialysis support that there is a "pool" for temporary phosphorus storage, leading to the maintenance of stable serum phosphorus levels. Phosphorus overload refers to a state where the phosphorus load is higher than is physiologically necessary. It can be caused by a persistently high-phosphorus diet, renal function decline, bone disease, insufficient dialysis, and inappropriate medications, and includes but is not limited to hyperphosphatemia. Serum phosphorus is still the most commonly used indicator of phosphorus overload. Trending phosphorus levels to see if they are chronically elevated is recommended instead of a single test when judging phosphorus overload. Future studies are needed to validate the prognostic role of a new marker or markers of phosphorus overload.
Collapse
Affiliation(s)
- Mengjing Wang
- Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jiaying Zhang
- Nutritional Department, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA 92868, USA
- Fielding School of Public Health at UCLA, Los Angeles, CA 90095, USA
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA 90502, USA
| | - Jing Chen
- Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
- Correspondence: ; Tel.: +86-021-52889387
| |
Collapse
|
5
|
The Association between Admission Serum Phosphorus and Preoperative Deep Venous Thrombosis in Geriatric Hip Fracture: A Retrospective Study. Diagnostics (Basel) 2023; 13:diagnostics13030545. [PMID: 36766651 PMCID: PMC9914597 DOI: 10.3390/diagnostics13030545] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 12/30/2022] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE This study aimed to evaluate the association between serum phosphorus level and preoperative deep vein thrombosis (DVT) in geriatric hip fractures. METHODS Older adults with hip fractures were screened between January 2015 and September 2019. Demographic and clinical characteristics of the patients were collected. Multivariate binary logistic regression and generalized additive models were used to identify the linear and nonlinear associations between serum phosphorus levels and preoperative DVT. Analyses were performed using Empower Stats and R software. RESULTS In this study, 1818 patients were included, with an average age of 79.39 ± 6.87. Of these, 30.25% were males, and 580 patients had DVT. The study found that when serum phosphorus was used as a continuous variable, there was a statistically significant difference in the relationship between blood phosphorus and the occurrence of DVT (p < 0.05). Furthermore, we also found curvilinear relationships. Serum phosphorus = 0.71 mmol/L was the inflection point in the curve. When serum phosphorus was <0.71 mmol/L, the serum phosphorus was associated with DVT (OR = 1.64; 95% CI: 1.04-2.59; p = 0.0333). With a 0.1 mmol/L increase, the DVT increased 0.64 times. When phosphorus was >0.71 mmol/L, there was no significant difference in the correlation between serum phosphorus levels and DVT (OR = 1.03; 95% CI: 0.98-1.09; p = 0.186). CONCLUSION Serum phosphorus was nonlinearly associated with preoperative DVT in geriatric patients with hip fractures, and serum phosphorus level could be considered a predictor of DVT risk.
Collapse
|
6
|
Sakane EN, Vieira MCC, Vieira GMM, Maeda SS. Treatment options in hypoparathyroidism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:651-657. [PMID: 36382754 PMCID: PMC10118816 DOI: 10.20945/2359-3997000000554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hypoparathyroidism remains the single endocrine deficiency disease that is not habitually treated with the missing hormone. In this article, we aim to provide a review of the conventional approach and the novel therapies as well as an overview of the perspectives on the treatment of this rare condition. We conducted a literature review on the conventional therapy using vitamin D analogs and calcium salts, indications for thiazide diuretics and phosphorus binders, PTH analogs history and usage, and the drugs that are currently being tested in clinical trials. Conventional treatment involves calcium salts and vitamin D analogs. Thiazide diuretics can be used to reduce hypercalciuria in some cases. A low-phosphate diet is recommended, and phosphate binders are rarely needed. During pregnancy, a careful approach is necessary. The use of PTH analogs is a new approach despite the limitation of high cost. Studies have included modified PTH molecules, calcilytics, microencapsulation of human parathyroid cells, and allotransplantation.
Collapse
|
7
|
Puliani G, Hasenmajer V, Simonelli I, Sada V, Pofi R, Minnetti M, Cozzolino A, Napoli N, Pasqualetti P, Gianfrilli D, Isidori AM. Safety and Efficacy of PTH 1-34 and 1-84 Therapy in Chronic Hypoparathyroidism: A Meta-Analysis of Prospective Trials. J Bone Miner Res 2022; 37:1233-1250. [PMID: 35485213 PMCID: PMC9545848 DOI: 10.1002/jbmr.4566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 11/12/2022]
Abstract
Hypoparathyroidism is the only endocrine deficiency for which hormone replacement therapy is not the standard of care. Although conventional treatments may control hypocalcaemia, other complications such as hyperphosphatemia, kidney stones, peripheral calcifications, and bone disease remain unmet needs. This meta-analysis (PROSPERO registration number CRD42019126881) aims to evaluate and compare the efficacy and safety of PTH1-34 and PTH1-84 in restoring calcium metabolism in chronic hypoparathyroidism. EMBASE, PubMed, and CENTRAL databases were searched for randomized clinical trials or prospective studies published between January 1996 and March 2021. English-language trials reporting data on replacement with PTH1-34 or PTH1-84 in chronic hypoparathyroidism were selected. Three authors extracted outcomes, one author performed quality control, all assessed the risk of biases. Overall, data from 25 studies on 588 patients were analyzed. PTH therapy had a neutral effect on calcium levels, while lowering serum phosphate (-0.21 mmol/L; 95% confidence interval [CI], -0.31 to -0.11 mmol/L; p < 0.001) and urinary calcium excretion (-1.21 mmol/24 h; 95% CI, -2.03 to -0.41 mmol/24 h; p = 0.003). Calcium phosphate product decreased under PTH1-84 therapy only. Both treatments enabled a significant reduction in calcium and calcitriol supplementation. PTH therapy increased bone turnover markers and lumbar spine mineral density. Quality of life improved and there was no difference in the safety profile between PTH and conventionally treated patients. Results for most outcomes were similar for the two treatments. Limitations of the study included considerable population overlap between the reports, incomplete data, and heterogeneity in the protocol design. In conclusion, the meta-analysis of data from the largest collection to date of hypoparathyroid patients shows that PTH therapy is safe, well-tolerated, and effective in normalizing serum phosphate and urinary calcium excretion, as well as enabling a reduction in calcium and vitamin D use and improving quality of life. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
Collapse
Affiliation(s)
- Giulia Puliani
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.,Oncological Endocrinology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Ilaria Simonelli
- Service of Medical Statistics and Information Technology, Fatebenefratelli Foundation of Health Research and Education, Rome, Italy.,Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Sada
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessia Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Nicola Napoli
- Operative Research Unit of Osteo-metabolic and thyroid diseases, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.,Division of Bone and Mineral Diseases, Washington University in St. Louis, St. Louis, MO, USA
| | - Patrizio Pasqualetti
- Department of Public Health and Infectious Diseases, Section of Medical Statistics, Sapienza University of Rome, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
8
|
Grigoravičius D, Šiaulienė L, Visockienė Ž. Unrecognized Primary Hypoparathyroidism with Severe Hypocalcemia in the Presence of COVID-19 Infection. Acta Med Litu 2022; 29:136-143. [PMID: 36061936 PMCID: PMC9428647 DOI: 10.15388/amed.2021.29.1.9] [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: 04/26/2021] [Revised: 07/29/2021] [Accepted: 08/11/2021] [Indexed: 11/22/2022] Open
Abstract
Primary hypoparathyroidism (PHPT) is a rare disease most commonly caused by surgical parathyroid glands destruction or genetic disorders. PHPT manifestation varies from subclinical to acute or even lethal symptoms. In atypical presentation the signs of hypocalcemia could be missed, and asymptotic chronic hypocalcemia could manifest only in the presence of exacerbated comorbidities, infections, hypomagnesemia or certain medications. We present a case of PHPT with severe hypocalcemia manifesting as seizures and delirium in a presence of COVID-19 infection.
Collapse
|
9
|
Gosmanova EO, Ayodele O, Chen K, Cook EE, Mu F, Young JA, Rejnmark L. Association of Calcium and Phosphate Levels with Incident Chronic Kidney Disease in Patients with Hypoparathyroidism: A Retrospective Case-Control Study. Int J Endocrinol 2022; 2022:6078881. [PMID: 36389126 PMCID: PMC9646300 DOI: 10.1155/2022/6078881] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 07/14/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Reasons for the increased incidence of chronic kidney disease (CKD) in patients with chronic hypoparathyroidism are poorly understood. This study evaluated associations between levels of albumin-corrected serum calcium, serum phosphate, and calcium-phosphate product and the odds of CKD development in patients with chronic hypoparathyroidism. DESIGN A retrospective nested case-control study of adult patients with chronic hypoparathyroidism who had ≥1 prescription for calcitriol who developed CKD and matched controls who did not develop CKD were selected from the IBM® Explorys electronic medical record database. Patients. The study included a cohort of 300 patients for the albumin-corrected serum calcium analysis and 80 patients for the serum phosphate and calcium-phosphate product analyses. Measurements. We examined associations between albumin-corrected serum calcium, serum phosphate and calcium-phosphate product levels, and the risk of devloping CKD (defined as ≥2 outpatient estimated glomerular filtration values <60 mL/min/1.73 m2 occuring ≥3 months apart or ≥1 diagnostic code for CKD stages 3-5). RESULTS Individuals who had ≥67% of albumin-corrected serum calcium measurements outside, above, or below the study-defined range (2.00-2.25 mmol/L [8.0-9.0 mg/dL]) had 3.5-, 2.9-, and 2.7-fold higher odds of developing CKD (adjusted odds ratios [95% CI]: 3.46 [1.82-6.56], 2.85 [1.30-6.28], and 2.68 [1.16-6.15]), respectively, compared with patients who had <33% of albumin-corrected calcium measurements in those ranges. There was no association between developing CKD and having any serum phosphate measurements or any calcium-phosphate product measurements above normal population ranges. CONCLUSION In adult patients with chronic hypoparathyroidism, a higher proportion of albumin-corrected calcium measurements outside of the 2.00-2.25 mmol/L (8.0-9.0 mg/dL) range was associated with higher odds of developing CKD.
Collapse
Affiliation(s)
| | | | - Kristina Chen
- Takeda Pharmaceuticals USA, Inc., Lexington, MA, USA
| | | | - Fan Mu
- Analysis Group, Inc., Boston, MA, USA
| | | | - Lars Rejnmark
- Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Phosphate, Calcium, and Vitamin D: Key Regulators of Fetal and Placental Development in Mammals. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1354:77-107. [PMID: 34807438 DOI: 10.1007/978-3-030-85686-1_5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Normal calcium and bone homeostasis in the adult is virtually fully explained by the interactions of several key regulatory hormones, including parathyroid hormone, 1,25 dihydroxy vitamin D3, fibroblast growth factor-23, calcitonin, and sex steroids (estradiol and testosterone). In utero, bone and mineral metabolism is regulated differently from the adult. During development, it is the placenta and not the fetal kidneys, intestines, or skeleton that is the primary source of minerals for the fetus. The placenta is able to meet the almost inexhaustible needs of the fetus for minerals by actively driving the transport of calcium and phosphorus from the maternal circulation to the growing fetus. These fundamentally important minerals are maintained in the fetal circulation at higher concentrations than those in maternal blood. Maintenance of these inordinately higher fetal levels is necessary for the developing skeleton to accrue sufficient minerals by term. Importantly, in livestock species, prenatal mineralization of the skeleton is crucial for the high levels of offspring activity soon after birth. Calcium is required for mineralization, as well as a plethora of other physiological functions. Placental calcium and phosphate transport are regulated by several mechanisms that are discussed in this review. It is clear that phosphate and calcium metabolism is intimately interrelated and, therefore, placental transport of these minerals cannot be considered in isolation.
Collapse
|
12
|
Gosmanova EO, Chen K, Rejnmark L, Mu F, Swallow E, Briggs A, Ayodele O, Sherry N, Ketteler M. Risk of Chronic Kidney Disease and Estimated Glomerular Filtration Rate Decline in Patients with Chronic Hypoparathyroidism: A Retrospective Cohort Study. Adv Ther 2021; 38:1876-1888. [PMID: 33687651 PMCID: PMC8004481 DOI: 10.1007/s12325-021-01658-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/08/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Chronic hypoparathyroidism, treated with conventional therapy of oral calcium supplements and active vitamin D, may increase the risk of kidney complications. This study examined risks of development and progression of chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) decline in patients with chronic hypoparathyroidism. METHODS A retrospective cohort study using a managed care claims database in the United States from January 2007 to June 2017 included patients with chronic hypoparathyroidism (excluding those receiving parathyroid hormone) and randomly selected patients without hypoparathyroidism followed for up to 5 years. Main outcome measures were (1) development of CKD, defined as new diagnosis of CKD stage 3 and higher or ≥ 2 eGFR measurements < 60 ml/min/1.73 m2 ≥ 3 months apart, (2) progression of CKD, defined as increase in baseline CKD stage, (3) progression to end-stage kidney disease (ESKD), and (4) eGFR decline ≥ 30% from baseline. Time-to-event analyses included Kaplan-Meier analyses with log-rank tests, and both unadjusted and adjusted Cox proportional hazards models were used to compare outcomes between cohorts. RESULTS The study included 8097 adults with and 40,485 without chronic hypoparathyroidism. In Kaplan-Meier analyses, patients with chronic hypoparathyroidism had higher risk of developing CKD and CKD progression and higher rates of eGFR decline (all P < 0.001). In multivariable Cox models adjusted for baseline characteristics, hazard ratios (95% confidence intervals [CIs]) were 2.91 (2.61-3.25) for developing CKD, 1.58 (1.23-2.01) for CKD stage progression, 2.14 (1.51-3.04) for progression to ESKD, and 2.56 (1.62-4.03) for eGFR decline (all P < 0.001) among patients with chronic hypoparathyroidism compared with those without hypoparathyroidism. CONCLUSION Patients with chronic hypoparathyroidism have increased risk of development and progression of CKD and eGFR decline compared with those without hypoparathyroidism. Further studies are warranted to understand underlying mechanisms for the associations between chronic hypoparathyroidism and kidney disease.
Collapse
Affiliation(s)
- Elvira O Gosmanova
- Division of Nephrology and Hypertension, Albany Medical College, Albany, NY, USA.
| | - Kristina Chen
- Shire Human Genetic Therapies, Inc., a Takeda Company, Lexington, MA, USA
| | - Lars Rejnmark
- Aarhus University and Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Fan Mu
- Analysis Group, Inc., Boston, MA, USA
| | | | | | - Olulade Ayodele
- Shire Human Genetic Therapies, Inc., a Takeda Company, Lexington, MA, USA
| | - Nicole Sherry
- Shire Human Genetic Therapies, Inc., a Takeda Company, Lexington, MA, USA
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
- University of Split School of Medicine (USSM), Split, Croatia
| |
Collapse
|
13
|
Abstract
Phosphorus, a 5A element with atomic weight of 31, comprises just over 0.6% of the composition by weight of plants and animals. Three isotopes are available for studying phosphorus metabolism and kinetics. 31P is stable, whereas the radioactive isotope 33P has a half-life of 25 days and 32P has a half-life of 14 days. Phosphate ester and phosphoanhydride are common chemical linkages and phosphorus is a key element in organic molecules involved in a wide variety of essential cellular functions. These include biochemical energy transfer via adenosine triphosphate (ATP), maintenance of genetic information with nucleotides DNA and RNA, intracellular signaling via cyclic adenosine monophosphate (cAMP), and membrane structural integrity via glycerophospholipids. However, this review focuses on the metabolism of inorganic phosphorus (Pi) acting as a weak acid. Phosphoric acid has all three hydrogens attached to oxygen and is a weak diprotic acid. It has 3 pKa values: pH 2.2, pH 7.2, and pH 12.7. At physiological pH of 7.4, Pi exists as both H2PO4(-) and HPO4(2-) and acts as an extracellular fluid (ECF) buffer. Pi is the form transported across tissue compartments and cells. Measurement of Pi in biological fluids is based on its reaction with ammonium molybdate which does not measure organic phosphorus. In humans, 80% of the body phosphorus is present in the form of calcium phosphate crystals (apatite) that confer hardness to bone and teeth, and function as the major phosphorus reservoir (Fig. 1). The remainder is present in soft tissues and ECF. Dietary phosphorus, comprising both inorganic and organic forms, is digested in the upper gastrointestinal tract. Absorbed Pi is transported to and from bone, skeletal muscle and soft tissues, and kidney at rates determined by ECF Pi concentration, rate of blood flow, and activity of cell Pi transporters (Fig. 2). During growth, there is net accretion of phosphorus, and with aging, net loss of phosphorus occurs. The bone phosphorus reservoir is depleted and repleted by overall phosphorus requirement. Skeletal muscle is rich in phosphorus used in essential biochemical energy transfer. Kidney is the main regulator of ECF Pi concentration by virtue of having a tubular maximum reabsorptive capacity for Pi (TmPi) that is under close endocrine control. It is also the main excretory pathway for Pi surplus which is passed in urine. Transcellular and paracellular Pi transports are performed by a number of transport mechanisms widely distributed in tissues, and particularly important in gut, bone, and kidney. Pi transporters are regulated by a hormonal axis comprising fibroblast growth factor 23 (FGF23), parathyroid hormone (PTH), and 1,25 dihydroxy vitamin D (1,25D). Pi and calcium (Ca) metabolism are intimately interrelated, and clinically neither can be considered in isolation. Diseases of Pi metabolism affect bone as osteomalacia/rickets, soft tissues as ectopic mineralization, skeletal muscle as myopathy, and kidney as nephrocalcinosis and urinary stone formation. Fig. 1 Content of phosphorus in human adult: skeleton, soft tissue, and extracellular fluid (grams, log scale). Corresponding data for calcium are shown for comparison Fig. 2 Phosphate (Pi) transport to and from tissue compartments in mg/24 h. At a dietary phosphorus of 1400 mg, 1120 mg is absorbed in upper intestine to the ECF, 210 mg returned to intestine by endogenous secretion, resulting in 910 mg net Pi absorption and 490 mg fecal excretion. At bone, 180 mg is deposited by bone formation and 180 mg return to the ECF by bone resorption. At kidney, 5040 mg is filtered at the glomerulus and 4130 mg return to the ECF by tubular reabsorption with 910 mg excreted in the urine. In soft tissue, Pi is exchanged between ECF and cells.
Collapse
Affiliation(s)
- Munro Peacock
- Division of Endocrinology, Department of Medicine, Indiana University School of Medicine, 1120 W Michigan Street, CL365, Indianapolis, IN, 46202, USA.
| |
Collapse
|
14
|
Abstract
BACKGROUND Hypoparathyroidism is a rare endocrine disorder characterized by hypocalcemia and low or undetectable levels of parathyroid hormone. METHODS This review is an evidence-based summary of hypoparathyroidism in terms of relevant pathophysiological, clinical, and therapeutic concepts. RESULTS Many clinical manifestations of hypoparathyroidism are due to the lack of the physiological actions of parathyroid hormone on its 2 major target organs: the skeleton and the kidney. The skeleton is inactive, accruing bone without remodeling it. The kidneys lose the calcium-conserving actions of parathyroid hormone and, thus, excrete a greater fraction of calcium. Biochemical manifestations, besides hypocalcemia and low or undetectable levels of parathyroid hormone, include hyperphosphatemia and low levels of 1,25-dihydroxyvitamin D. Calcifications in the kidney, brain, and other soft tissues are common. Removal of, or damage to, the parathyroid glands at the time of anterior neck surgery is, by far, the most likely etiology. Autoimmune destruction of the parathyroid glands and other genetic causes represent most of the other etiologies. Conventional treatment with calcium and active vitamin D can maintain the serum calcium level but high doses may be required, adding to the risk of long-term soft tissue calcifications. The advent of replacement therapy with recombinant human PTH(1-84) represents a major step in the therapeutics of this disease. CONCLUSIONS Advances in our knowledge of hypoparathyroidism have led to greater understanding of the disease itself and our approach to it.
Collapse
Affiliation(s)
- John P Bilezikian
- Department of Medicine, Division of Endocrinology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Correspondence and Reprint Requests: John P. Bilezikian, Vice-Chair, International Research and Education, Department of Medicine, Vagelos College of Physicians and Surgeons, 630 W. 168th Street, New York, NY 10032. E-mail:
| |
Collapse
|