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Brandtner EM, Muendlein A, Leiherer A, Armbruster FP, Dschietzig TB, Geiger K, Fraunberger P, Saely CH, Drexel H. Serum Parathyroid Hormone Predicts Mortality in Coronary Angiography Patients with Type 2 Diabetes. J Clin Endocrinol Metab 2020; 105:5891791. [PMID: 32785694 DOI: 10.1210/clinem/dgaa512] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Elevated serum levels of parathyroid hormone (PTH), one of the main regulators of calcium homeostasis and vitamin D metabolism, have been proposed as predictors of mortality. The impact of type 2 diabetes mellitus (T2DM) on the putative association between PTH and mortality has not been investigated thus far. AIM The aim of our study was to investigate the impact of T2DM on the power of PTH to predict mortality risk. METHODS Serum PTH levels were determined in 904 consecutive Caucasian patients referred to coronary angiography for the evaluation of established or suspected stable coronary artery disease (CAD), including 235 patients with T2DM. Prospectively, deaths were recorded over a mean follow-up period of 6.3 years. RESULTS PTH at baseline did not differ significantly between patients with and without T2DM (P = .307). Cox regression analysis revealed that the serum PTH level strongly predicted all-cause mortality in patients with T2DM (hazard ratio [HR] = 2.35 [1.37-4.03]; P = .002), whereas PTH did not predict all-cause mortality in patients without T2DM (HR = 1.04 [0.81-1.32]; P = .766). The interaction term PTH × T2DM was significant (P = .006), indicating a significantly stronger impact of PTH on mortality risk in patients with T2DM than in individuals without diabetes. The impact of PTH on mortality risk in patients with T2DM remained significant after adjustment for glycated hemoglobin A1c, diabetes duration, classical cardiovascular risk factors, serum levels of vitamin D, and kidney function (HR = 2.10 [1.10-4.10]; P = .030). CONCLUSION We conclude that PTH is a significantly stronger predictor of all-cause mortality in patients with T2DM than in those without T2DM.
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Affiliation(s)
- Eva Maria Brandtner
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria
| | - Axel Muendlein
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria
| | - Andreas Leiherer
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria
- Medical Central Laboratories, Feldkirch, Austria
- Private University of the Principality of Liechtenstein, Triesen, Liechtenstein
| | | | | | - Kathrin Geiger
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria
- Medical Central Laboratories, Feldkirch, Austria
| | | | - Christoph H Saely
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria
- Private University of the Principality of Liechtenstein, Triesen, Liechtenstein
- Department of Internal Medicine I, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria
- Private University of the Principality of Liechtenstein, Triesen, Liechtenstein
- Drexel University College of Medicine, Philadelphia, Pennsylvania
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Yu Y, Diao Z, Wang Y, Zhou P, Ding R, Liu W. Hemodialysis patients with low serum parathyroid hormone levels have a poorer prognosis than those with secondary hyperparathyroidism. Ther Adv Endocrinol Metab 2020; 11:2042018820958322. [PMID: 33014329 PMCID: PMC7513009 DOI: 10.1177/2042018820958322] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/20/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Low serum parathyroid hormone (PTH) level and secondary hyperparathyroidism (SHPT) are very common in hemodialysis patients. However, the outcomes of patients with low PTH level or SHPT have not been carefully compared. Therefore, in the present study, we compared the outcomes of hemodialysis patients with low PTH level or SHPT. METHODS This was a multi-center, prospective, cohort study of 647 patients. The patients were recruited between 1 September 2016 and 1 January 2017 and followed until 31 December 2018. The participants were allocated to a low PTH group [serum intact PTH (iPTH) concentration < 60 pg/ml] and an SHPT group (iPTH ⩾ 600 pg/ml) according to their mean iPTH concentration across the entire observation period, and the outcomes were compared between these groups. The primary outcome was a composite outcome, which comprised all-cause mortality, non-fatal acute myocardial infarction, non-fatal acute stroke, and acute heart failure. RESULTS A total of 197 hemodialysis patients were allocated to the two groups: 87 with low PTH level and 110 with SHPT; 450 patients with time-averaged iPTH concentrations of 60-600 pg/ml were excluded. Kaplan-Meier analysis of the composite endpoint revealed a significant difference between participants with low PTH level and those with SHPT (p = 0.002). Cox multiple regression showed that participants with low PTH level had a higher incidence of the composite endpoint than those with SHPT (relative risk: 1.337, 95% confidence interval: 1.059-1.688). CONCLUSION Hemodialysis patients with low PTH level had a higher incidence of mortality and non-fatal cardiovascular events than those with SHPT, irrespective of whether the participants were age-matched.
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Affiliation(s)
- Yue Yu
- Department of Nephrology, Beijing Friendship
Hospital, Capital Medical University, Beijing, China
- Department of Nephrology, Fu Xing Hospital,
Capital Medical University, Beijing, China
| | - Zongli Diao
- Department of Nephrology, Beijing Friendship
Hospital, Capital Medical University, 95 Yong’An Road, Beijing 100050,
China
| | - Ying Wang
- Department of Nephrology, Fu Xing Hospital,
Capital Medical University, Beijing, China
| | - Peiyi Zhou
- Department of Nephrology, People’s Hospital of
Beijing Daxing District, Beijing, China
| | - Rui Ding
- Department of Nephrology, The Hospital of Shunyi
District Beijing, Beijing, China
| | - Wenhu Liu
- Department of Nephrology, Beijing Friendship
Hospital, Capital Medical University, 95 Yong’An Road, Beijing 100050,
China
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Yamamoto S, Karaboyas A, Komaba H, Taniguchi M, Nomura T, Bieber BA, De Sequera P, Christensson A, Pisoni RL, Robinson BM, Fukagawa M. Mineral and bone disorder management in hemodialysis patients: comparing PTH control practices in Japan with Europe and North America: the Dialysis Outcomes and Practice Patterns Study (DOPPS). BMC Nephrol 2018; 19:253. [PMID: 30290781 PMCID: PMC6173912 DOI: 10.1186/s12882-018-1056-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/24/2018] [Indexed: 12/26/2022] Open
Abstract
Background High-circulating level of parathyroid hormone (PTH) is associated with elevated mortality in dialysis patients. The Japanese Society for Dialysis Therapy guideline suggests a lower PTH target than other international guidelines; thus, PTH control may differ in Japan compared with other regions, and be associated with mortality. Methods We analyzed data from hemodialysis patients with ≥3 measurements of PTH during the first 9 months after enrollment in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 4–5 (2009–2015). PTH control was assessed by the mean, slope, and mean squared error (MSE) of all PTH measurements over the 9-month run-in period. Distribution of each PTH control was assessed by regions (Europe/Australia/New Zealand [Eur/ANZ], Japan and North America) and dialysis vintage. Mortality rates were compared across PTH control categories using Cox regression models. Results Mean PTH was lower in Japan than in other regions across dialysis vintage categories. In patients with dialysis vintage < 90 days, PTH level was more likely to decline > 5% per month in Japan (48% of patients) versus Eur/ANZ (35%) and North America (35%). In patients with dialysis vintage > 1 year, Japanese patients maintained steady PTH, while patients in Eur/ANZ and North America were more likely to experience a PTH increase. Mean PTH was associated with mortality in the overall samples (highest mortality rate for PTH > 600 pg/mL, hazard ratio, 1.35; 95% confidence interval, 1.20 to 1.52 vs PTH 200–399 pg/mL), and the association was obvious in the prevalent patients (hazard ratio, 1.44; 95% confidence interval, 1.26 to 1.65). PTH slope and MSE did not show significant association with mortality in the overall sample as well as in subjects stratified both by region and dialysis vintage. Conclusion PTH control in hemodialysis patients, as measured by keeping a stable PTH level over 9 months, was observed in Japan contrasted with other regions. High PTH mean, but not increased PTH slope and MSE, was associated with mortality especially in prevalent patients.
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Affiliation(s)
- Suguru Yamamoto
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan.
| | | | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | | | - Takanobu Nomura
- Medical Affairs Department, Kyowa Hakko Kirin Co. Ltd., Tokyo, Japan
| | - Brian A Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | | | | | | | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
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Sawalmeh O, Moala S, Hamdan Z, Masri H, Ayoub K, Khazneh E, Shraim M. Pulse versus daily oral Alfacalcidol treatment of secondary hyperparathyroidism in hemodialysis patients: a randomized controlled trial. Int J Nephrol Renovasc Dis 2018; 11:25-32. [PMID: 29391823 PMCID: PMC5774473 DOI: 10.2147/ijnrd.s149877] [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] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Secondary hyperparathyroidism is a common complication of chronic kidney disease and is managed using vitamin D replacement therapy. Very few studies have examined the effectiveness of pulse alfacalcidol therapy in comparison to daily oral alfacalcidol therapy in suppressing serum parathyroid hormone (PTH) levels in hemodialysis patients. The aim of this randomized controlled trial was to replicate the findings of prior studies comparing effectiveness of pulse oral alfacalcidol therapy versus daily oral alfacalcidol therapy in suppressing PTH after 13 weeks of therapy using a Palestinian sample of hemodialysis patients, and to identify demographic and biomedical characteristics of patients that are independently associated with PTH levels. METHODS One hundred and sixty-seven patients completed the study, 88 in the daily group and 79 in the pulse group. The pulse group had more clinically significant reduction in mean PTH level by 75 pg/dL at 13 weeks than the daily group, but this was not statistically significant. RESULTS The effect of alfacalcidol therapy on metabolism of phosphate and corrected calcium levels was comparable in both groups, and pulse therapy was not associated with increased risk of hypercalcemia and hyperphosphatemia. Serum PTH levels were independently and inversely associated with older age and diabetes. CONCLUSION Switching daily alfacalcidol therapy to thrice-weekly alfacalcidol pulse therapy seems safe and convenient, especially for hemodialysis patients with poor compliance with treatment. This study also highlights the importance of monitoring and preventing malnutrition in hemodialysis patients and maintaining optimal glycemic control in diabetic hemodialysis patients.
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Affiliation(s)
- Osama Sawalmeh
- Medicine Department, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Shaheed Moala
- Medicine Department, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | | | | | - Khubaib Ayoub
- Internal Medicine Department, An-Najah National University Hospital, Nablus, Palestine
| | | | - Mujahed Shraim
- Public Health Department, College of Health Sciences, Qatar University, Doha, Qatar
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Piccoli GB, Moio MR, Fois A, Sofronie A, Gendrot L, Cabiddu G, D'Alessandro C, Cupisti A. The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach. Nutrients 2017; 9:E372. [PMID: 28394304 PMCID: PMC5409711 DOI: 10.3390/nu9040372] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 03/17/2017] [Accepted: 03/31/2017] [Indexed: 12/25/2022] Open
Abstract
The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients' lives. In the early years of dialysis, potassium was identified as "the killer", and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the "third era" finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the "magic numbers" of nutritional requirements (calories: 30-35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on "conventional" thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of "vascular healthy" food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Maria Rita Moio
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Antioco Fois
- Nefrologia, Ospedale Brotzu, 09100 Cagliari, Italy.
| | - Andreea Sofronie
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Lurlinys Gendrot
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
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Villa-Bellosta R, Rodriguez-Osorio L, Mas S, Abadi Y, Rubert M, de la Piedra C, Gracia-Iguacel C, Mahillo I, Ortiz A, Egido J, González-Parra E. A decrease in intact parathyroid hormone (iPTH) levels is associated with higher mortality in prevalent hemodialysis patients. PLoS One 2017; 12:e0173831. [PMID: 28339474 PMCID: PMC5365126 DOI: 10.1371/journal.pone.0173831] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/27/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The mortality of dialysis patients is 10- to 100-fold higher than in the general population. Baseline serum PTH levels, and more recently, changes in serum PTH levels (ΔPTH) over time, have been associated to mortality in dialysis patients. METHODS We explored the relationship between ΔPTH over 1 year with mortality over the next year in a prospective cohort of 115 prevalent hemodialysis patients from a single center that had median baseline iPTH levels within guideline recommendations. RESULTS Median baseline iPTH levels were 205 (116.5, 400) pg/ml. ΔiPTH between baseline and 1 year was 85.2 ± 57.1 pg/ml. During the second year of follow-up, 27 patients died. ΔiPTH was significantly higher in patients who survived (+157.30 ± 25.82 pg/ml) than in those who died (+39.03 ± 60.95 pg/ml), while baseline iPTH values were not significantly different. The highest mortality (48%) was observed in patients with a decrease in ΔiPTH (ΔiPTH quartile 1, negative ΔiPTH) and the lowest (12%) mortality in quartile 3 ΔiPTH (ΔiPTH increase 101-300 pg/ml). In a logistic regression model, ΔiPTH was associated with mortality with an odds ratio (OR) of 0.998 (95% CI 0.996-0999, p = 0.038). In multivariable analysis, mortality risk was 73% and 88% lower for patients with ΔiPTH 0-100 pg/ml and 101-300 pg/ml, respectively, than for those with a decrease in ΔiPTH. In patients with a decrease in ΔiPTH, the OR for death was 4.131 (1.515-11.27)(p = 0.006). CONCLUSIONS In prevalent hemodialysis patients with median baseline iPTH values within the guideline recommended range, a decrease in ΔiPTH was associated with higher mortality. Further studies are required to understand the mechanisms and therapeutic implications of this observation that challenges current clinical practice.
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Affiliation(s)
- Ricardo Villa-Bellosta
- Servicio de Nefrología, Fundación Jiménez Díaz, Madrid, España
- Fundación Instituto de Investigación Sanitaria, Fundación Jiménez Díaz (IIS-FJD), Madrid, España
- Spanish Biomedical Research Network in Diabetes and Associated Metabolic Disorders (CIBERDEM), Madrid, Spain
| | - Laura Rodriguez-Osorio
- Servicio de Nefrología, Fundación Jiménez Díaz, Madrid, España
- Fundación Instituto de Investigación Sanitaria, Fundación Jiménez Díaz (IIS-FJD), Madrid, España
- Spanish Kidney Research Network (REDINREN), Madrid, Spain
| | - Sebastian Mas
- Servicio de Nefrología, Fundación Jiménez Díaz, Madrid, España
- Fundación Instituto de Investigación Sanitaria, Fundación Jiménez Díaz (IIS-FJD), Madrid, España
- Spanish Biomedical Research Network in Diabetes and Associated Metabolic Disorders (CIBERDEM), Madrid, Spain
| | - Younes Abadi
- Servicio de Nefrología, Fundación Jiménez Díaz, Madrid, España
| | - Mercedes Rubert
- Servicio de Laboratorio de Bioquímica, Fundación Jiménez Díaz, Madrid, España
| | | | - Carolina Gracia-Iguacel
- Servicio de Nefrología, Fundación Jiménez Díaz, Madrid, España
- Fundación Instituto de Investigación Sanitaria, Fundación Jiménez Díaz (IIS-FJD), Madrid, España
| | - Ignacio Mahillo
- Fundación Instituto de Investigación Sanitaria, Fundación Jiménez Díaz (IIS-FJD), Madrid, España
| | - Alberto Ortiz
- Servicio de Nefrología, Fundación Jiménez Díaz, Madrid, España
- Fundación Instituto de Investigación Sanitaria, Fundación Jiménez Díaz (IIS-FJD), Madrid, España
- Spanish Kidney Research Network (REDINREN), Madrid, Spain
- Universidad Autónoma de Madrid, Madrid, España
| | - Jesús Egido
- Servicio de Nefrología, Fundación Jiménez Díaz, Madrid, España
- Fundación Instituto de Investigación Sanitaria, Fundación Jiménez Díaz (IIS-FJD), Madrid, España
- Spanish Biomedical Research Network in Diabetes and Associated Metabolic Disorders (CIBERDEM), Madrid, Spain
- Universidad Autónoma de Madrid, Madrid, España
| | - Emilio González-Parra
- Servicio de Nefrología, Fundación Jiménez Díaz, Madrid, España
- Fundación Instituto de Investigación Sanitaria, Fundación Jiménez Díaz (IIS-FJD), Madrid, España
- Spanish Kidney Research Network (REDINREN), Madrid, Spain
- Universidad Autónoma de Madrid, Madrid, España
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7
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Merle E, Roth H, London GM, Jean G, Hannedouche T, Bouchet JL, Drüeke T, Fouque D, Daugas E. Low parathyroid hormone status induced by high dialysate calcium is an independent risk factor for cardiovascular death in hemodialysis patients. Kidney Int 2016; 89:666-74. [PMID: 26880460 DOI: 10.1016/j.kint.2015.12.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 09/28/2015] [Accepted: 10/08/2015] [Indexed: 10/22/2022]
Abstract
Here we studied a possible association between low parathyroid hormone (PTH) status and mortality in incident patients undergoing hemodialysis . A total of 1983 patients were included at baseline and prospectively followed for 24 months. Patients were classified according to their Kidney Disease: Improving Global Outcomes PTH status at baseline and at 12 months, and mortality evaluated at 12 to 24 months using adjusted Cox analysis. Factors potentially involved in PTH status variability between baseline and 12 months were analyzed. A decrease in serum PTH from normal or high to low values between baseline and 12 months was associated with significantly increased cardiovascular mortality at 12 to 24 months (hazard ratio, 2.03; 95% confidence interval, 1.22-3.36). For patients with high or normal baseline PTH levels, the main independent factor at 6 months for a decrease to low PTH levels at 12 months was high dialysate calcium (1.75 mmol/L), whereas prescription of non-calcium-based phosphate binders was associated with a lower risk of PTH decrease. In the high cardiovascular (CV) mortality risk subgroup of patients who acquired a low PTH status at 12 months, the main independent factor at 12 months associated with significant 12- to 24-month CV mortality was high dialysate calcium (odds ratio, 5.44; 95% CI, 2.52-11.75). Thus, patients with a serum PTH decrease to low values after 1 year of hemodialysis treatment are at high risk of short-term CV death. High dialysate calcium was an important contributor to PTH oversuppression, and continued use was associated with increased CV mortality.
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Affiliation(s)
- Emilie Merle
- Nephrology, Bichat Hospital, DHU FIRE, APHP, Paris Diderot University, INSERM U1149, Paris, France
| | - Hubert Roth
- Centre de Recherche en Nutrition Humaine Rhône-Alpes, CHU-Grenoble, France and Inserm U1055-Bioénergétique, Université Grenoble Alpes, Grenoble, France
| | | | | | - Thierry Hannedouche
- Service de Néphrologie, Hôpitaux Universitaires de Strasbourg, and Faculté de Médecine, Strasbourg, France
| | - Jean-Louis Bouchet
- Centre de Traitement des Maladies Rénales Saint-Augustin, Bordeaux, France
| | - Tilman Drüeke
- Inserm Unit 1088, UFR de Médecine et Pharmacie, Université de Picardie Jules Verne, Amiens, France
| | - Denis Fouque
- Department of Nephrology, Hôpital Lyon Sud, Université de Lyon, CENS, Lyon, France
| | - Eric Daugas
- Nephrology, Bichat Hospital, DHU FIRE, APHP, Paris Diderot University, INSERM U1149, Paris, France.
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8
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Affiliation(s)
| | - Christoph Wanner
- Renal Division, University of Würzburg, University Hospital, Wurzburg, Germany
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9
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Lamb EJ, Delaney MP. Does PTH offer additive value to ALP measurement in assessing CKD-MBD? Perit Dial Int 2015; 34:687-91. [PMID: 25520480 DOI: 10.3747/pdi.2014.00246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Edmund J Lamb
- Clinical Biochemistry, Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, CT1 3NG, UK
| | - Michael P Delaney
- Clinical Biochemistry, Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, CT1 3NG, UK
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Effect of High-Flux Dialysis on Circulating FGF-23 Levels in End-Stage Renal Disease Patients: Results from a Randomized Trial. PLoS One 2015; 10:e0128079. [PMID: 26024521 PMCID: PMC4449206 DOI: 10.1371/journal.pone.0128079] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 04/21/2015] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND In patients undergoing maintenance hemodialysis (HD), increased levels of circulating fibroblast growth factor-23 (FGF-23) are independently associated with cardiovascular events and mortality. Interventional strategies aiming to reduce levels of FGF-23 in HD patients are of particular interest. The purpose of the current study was to compare the impact of high-flux versus low-flux HD on circulating FGF-23 levels. METHODS We conducted a post-hoc analysis of the MINOXIS study, including 127 dialysis patients randomized to low-flux (n = 62) and high-flux (n = 65) HD for 52 weeks. Patients with valid measures for FGF-23 investigated baseline and after 52 weeks were included. RESULTS Compared to baseline, a significant increase in FGF-23 levels after one year of low-flux HD was observed (Delta plasma FGF-23: +4026 RU/ml; p < 0.001). In contrast, FGF-23 levels remained stable in the high flux group (Delta plasma FGF-23: +373 RU/ml, p = 0.70). The adjusted difference of the absolute change in FGF-23 levels between the two treatment groups was statistically significant (p < 0.01). CONCLUSIONS Over a period of 12 months, high-flux HD was associated with stable FGF-23 levels, whereas the low-flux HD group showed an increase of FGF-23. However, the implications of the different FGF 23 time-trends in patients on high flux dialysis, as compared to the control group, remain to be explored in specifically designed clinical trials. TRIAL REGISTRATION German Clinical Trials Register (DRKS) DRKS00007612.
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Tentori F, Wang M, Bieber BA, Karaboyas A, Li Y, Jacobson SH, Andreucci VE, Fukagawa M, Frimat L, Mendelssohn DC, Port FK, Pisoni RL, Robinson BM. Recent changes in therapeutic approaches and association with outcomes among patients with secondary hyperparathyroidism on chronic hemodialysis: the DOPPS study. Clin J Am Soc Nephrol 2014; 10:98-109. [PMID: 25516917 DOI: 10.2215/cjn.12941213] [Citation(s) in RCA: 197] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Elevated parathyroid hormone levels may be associated with adverse clinical outcomes in patients on dialysis. After the introduction of practice guidelines suggesting higher parathyroid hormone targets than those previously recommended, changes in parathyroid hormone levels and treatment regimens over time have not been well documented. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using data from the international Dialysis Outcomes and Practice Patterns Study, trends in parathyroid hormone levels and secondary hyperparathyroidism therapies over the past 15 years and the associations between parathyroid hormone and clinical outcomes are reported; 35,655 participants from the Dialysis Outcomes and Practice Patterns Study phases 1-4 (1996-2011) were included. RESULTS Median parathyroid hormone increased from phase 1 to phase 4 in all regions except for Japan, where it remained stable. Prescriptions of intravenous vitamin D analogs and cinacalcet increased and parathyroidectomy rates decreased in all regions over time. Compared with 150-300 pg/ml, in adjusted models, all-cause mortality risk was higher for parathyroid hormone=301-450 (hazard ratio, 1.09; 95% confidence interval, 1.01 to 1.18) and >600 pg/ml (hazard ratio, 1.23; 95% confidence interval, 1.12 to 1.34). Parathyroid hormone >600 pg/ml was also associated with higher risk of cardiovascular mortality as well as all-cause and cardiovascular hospitalizations. In a subgroup analysis of 5387 patients not receiving vitamin D analogs or cinacalcet and with no prior parathyroidectomy, very low parathyroid hormone (<50 pg/ml) was associated with mortality (hazard ratio, 1.25; 95% confidence interval, 1.04 to 1.51). CONCLUSIONS In a large international sample of patients on hemodialysis, parathyroid hormone levels increased in most countries, and secondary hyperparathyroidism treatments changed over time. Very low and very high parathyroid hormone levels were associated with adverse outcomes. In the absence of definitive evidence in support of a specific parathyroid hormone target, there is an urgent need for additional research to inform clinical practice.
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Affiliation(s)
- Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mia Wang
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Brian A Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Yun Li
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Stefan H Jacobson
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | | | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Luc Frimat
- Clinical Epidemiology, Inserm CIC-EC and Nephrology Department, Centre Hospitalier Universitaire de Nancy, Vandoeuvre-lès-Nancy, France
| | - David C Mendelssohn
- Department of Nephrology, Humber River Regional Hospital and University of Toronto, Weston, Ontario, Canada; and
| | | | - Ronald L Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Streja E, Wang HY, Lau WL, Molnar MZ, Kovesdy CP, Kalantar-Zadeh K, Park J. Mortality of combined serum phosphorus and parathyroid hormone concentrations and their changes over time in hemodialysis patients. Bone 2014; 61:201-7. [PMID: 24486956 PMCID: PMC4024455 DOI: 10.1016/j.bone.2014.01.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 01/08/2014] [Accepted: 01/21/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Mineral and bone disorder (MBD) is common and associated with mortality in patients with chronic kidney disease (CKD) Given that disarrays in serum phosphorus (P) and parathyroid hormone (PTH) levels and their changes over time are closely interrelated, modeling mortality-predictability of their combinations may help improve CKD patient management. METHODS A historical cohort study was undertaken to evaluate the joint effect of serum P and PTH levels on mortality in 107,299 chronic hemodialysis (HD) patients. Changes in serum P and PTH levels over 6months, in particular discordant changes, were also modeled with mortality. RESULTS HD patients were 64±15 (mean±SD)years old and included 45% women, 33% African-American, and 59% diabetic. Compared with serum P level ≥7.0mg/dL and PTH level ≥600pg/mL, adjusted hazard ratio (HR) tended to be lowest in patients with serum P level of 3.5-<5.5mg/dL combined with PTH level of 150-<300pg/mL (HR 0.64, 95% confidence interval 0.61-0.67). A change over time in serum P level towards the 3.5-<5.5mg/dL range from higher or lower ranges was associated with a decreased mortality, whereas only change in PTH level from <150pg/mL to 150-<300pg/mL range was associated with a lower risk of mortality. Upon discordant changes of PTH and P, i.e., decrease in one of the two measures while the other increased, no change in mortality risk was observed. CONCLUSION In CKD-MBD management, patent survival is the greatest with controlling both serum P and PTH levels in balance. Tailoring an individualized treatment strategy in CKD-MBD may benefit patients. Further studies are needed.
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Affiliation(s)
- Elani Streja
- Harold Simmons Center for Kidney Disease Research & Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Hsin-Yi Wang
- Harold Simmons Center for Kidney Disease Research & Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Wei Ling Lau
- Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Miklos Z Molnar
- Harold Simmons Center for Kidney Disease Research & Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA; Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Csaba P Kovesdy
- Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN, USA; University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research & Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA; Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA; Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
| | - Jongha Park
- Harold Simmons Center for Kidney Disease Research & Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA; Division of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea.
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Inaba M, Okuno S, Imanishi Y, Ishimura E, Yamakawa T, Shoji S. Increased active PTH(1-84) fraction as a predictor of poor mortality in male hemodialysis patients. Osteoporos Int 2013; 24:2863-70. [PMID: 24030285 DOI: 10.1007/s00198-012-2245-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Accepted: 11/29/2012] [Indexed: 10/26/2022]
Abstract
UNLABELLED We reported previously that serum parathyroid hormone [PTH(1-84)]/intact PTH[PTH(1-84) + PTH(7-84)] ratio provides the better marker for parathyroid function and bone turnover state than serum PTH level itself. The present study demonstrated that higher PTH(1-84)/intact PTH ratio, but not serum PTH(1-84) and intact PTH, predicted higher all-cause mortality in 177 male hemodialysis patients. INTRODUCTION We reported that PTH(1-84)/intact PTH ratio provides a clinically relevant marker for parathyroid function and the resultant bone turnover state. The purpose of our study was to investigate the association of PTH(1-84)/intact PTH ratio with all-cause mortality (ACM) in male hemodialysis patients. METHODS The study was performed for 70 months. Serum PTH in 177 male hemodialysis patients was measured with PTH(1-84)-specific whole PTH assay and intact PTH assay which cross-reacts with N-truncated PTH including PTH(7-84). RESULTS The patients (n = 177) were divided into higher and lower halves based on serum levels of PTH(1-84)/intact PTH ratio (cutoff value, 0.484), intact PTH (143.8 pg/mL), and PTH(1-84) (64.1 pg/mL). In Kaplan-Meier analysis, the higher group in whole PTH/intact PTH ratio had significantly higher ACM than the lower group (P = 0.020 by log-rank test), in contrast with the insignificant difference between the higher and lower groups in intact PTH and PTH(1-84). Multivariate Cox regression hazard analysis identified higher log [PTH(1-84)/intact PTH ratio], but not log intact PTH or log PTH(1-84) as a significant independent predictor [hazard ratio 14.428 (95% CI 2.486-83.728)] for ACM after adjustment for various factors including age, hemodialysis duration, presence/absence of diabetes mellitus, BMI, log C-reactive protein, serum albumin, calcium, and phosphate. The association existed between log [PTH(1-84)/intact PTH ratio] and ACM in those without vitamin D administration (n = 95). CONCLUSION Higher PTH(1-84)/intact PTH ratio, which provides a relevant marker for parathyroid function, may be a significant predictor of ACM in male hemodialysis patients.
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Affiliation(s)
- M Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Internal Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan,
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14
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Palmer SC, Navaneethan SD, Craig JC, Johnson DW, Perkovic V, Nigwekar SU, Hegbrant J, Strippoli GFM. HMG CoA reductase inhibitors (statins) for dialysis patients. Cochrane Database Syst Rev 2013; 2013:CD004289. [PMID: 24022428 PMCID: PMC10754478 DOI: 10.1002/14651858.cd004289.pub5] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND People with advanced kidney disease treated with dialysis experience mortality rates from cardiovascular disease that are substantially higher than for the general population. Studies that have assessed the benefits of statins (HMG CoA reductase inhibitors) report conflicting conclusions for people on dialysis and existing meta-analyses have not had sufficient power to determine whether the effects of statins vary with severity of kidney disease. Recently, additional data for the effects of statins in dialysis patients have become available. This is an update of a review first published in 2004 and last updated in 2009. OBJECTIVES To assess the benefits and harms of statin use in adults who require dialysis (haemodialysis or peritoneal dialysis). SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 29 February 2012 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care or other statins on mortality, cardiovascular events and treatment-related toxicity in adults treated with dialysis were sought for inclusion. DATA COLLECTION AND ANALYSIS Two or more authors independently extracted data and assessed study risk of bias. Treatment effects were summarised using a random-effects model and subgroup analyses were conducted to explore sources of heterogeneity. Treatment effects were expressed as mean difference (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI). MAIN RESULTS The risk of bias was high in many of the included studies. Random sequence generation and allocation concealment was reported in three (12%) and four studies (16%), respectively. Participants and personnel were blinded in 13 studies (52%), and outcome assessors were blinded in five studies (20%). Complete outcome reporting occurred in nine studies (36%). Adverse events were only reported in nine studies (36%); 11 studies (44%) reported industry funding.We included 25 studies (8289 participants) in this latest update; 23 studies (24 comparisons, 8166 participants) compared statins with placebo or no treatment, and two studies (123 participants) compared statins directly with one or more other statins. Statins had little or no effect on major cardiovascular events (4 studies, 7084 participants: RR 0.95, 95% CI 0.88 to 1.03), all-cause mortality (13 studies, 4705 participants: RR 0.96, 95% CI 0.90 to 1.02), cardiovascular mortality (13 studies, 4627 participants: RR 0.94, 95% CI 0.84 to 1.06) and myocardial infarction (3 studies, 4047 participants: RR 0.87, 95% CI 0.71 to 1.07); and uncertain effects on stroke (2 studies, 4018 participants: RR 1.29, 95% CI 0.96 to 1.72).Risks of adverse events from statin therapy were uncertain; these included effects on elevated creatine kinase (5 studies, 3067 participants: RR 1.25, 95% CI 0.55 to 2.83) or liver function enzymes (4 studies, 3044 participants; RR 1.09, 95% CI 0.41 to 1.25), withdrawal due to adverse events (9 studies, 1832 participants: RR 1.04, 95% CI 0.87 to 1.25) or cancer (2 studies, 4012 participants: RR 0.90, 95% CI 0.72 to 1.11). Statins reduced total serum cholesterol (14 studies, 1803 participants; MD -44.86 mg/dL, 95% CI -55.19 to -34.53) and low-density lipoprotein cholesterol (12 studies, 1747 participants: MD -39.99 mg/dL, 95% CI -52.46 to -27.52) levels. Data comparing statin therapy directly with another statin were sparse. AUTHORS' CONCLUSIONS Statins have little or no beneficial effects on mortality or cardiovascular events and uncertain adverse effects in adults treated with dialysis despite clinically relevant reductions in serum cholesterol levels.
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Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Sankar D Navaneethan
- Glickman Urological and Kidney Institute, Cleveland ClinicDepartment of Nephrology and HypertensionClevelandOHUSA44195
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - David W Johnson
- Princess Alexandra HospitalDepartment of NephrologyIpswich RdWoolloongabbaQueenslandAustralia4102
| | - Vlado Perkovic
- The George Institute for Global HealthRenal and Metabolic DivisionCamperdownNSWAustralia
| | - Sagar U Nigwekar
- Harvard Medical SchoolBrigham and Women's Hospital, Massachusetts General Hospital, Scholars in Clinical Sciences ProgramBostonMAUSA
| | - Jorgen Hegbrant
- Diaverum Renal Services GroupMedical OfficePO Box 4167LundSwedenSE‐227 22
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly70100
- Mario Negri Sud ConsortiumDepartment of Clinical Pharmacology and EpidemiologySanta Maria ImbaroItaly
- DiaverumMedical‐Scientific OfficeLundSweden
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Chertow GM, Block GA, Correa-Rotter R, Drüeke TB, Floege J, Goodman WG, Herzog CA, Kubo Y, London GM, Mahaffey KW, Mix TCH, Moe SM, Trotman ML, Wheeler DC, Parfrey PS. Effect of cinacalcet on cardiovascular disease in patients undergoing dialysis. N Engl J Med 2012; 367:2482-94. [PMID: 23121374 DOI: 10.1056/nejmoa1205624] [Citation(s) in RCA: 593] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Disorders of mineral metabolism, including secondary hyperparathyroidism, are thought to contribute to extraskeletal (including vascular) calcification among patients with chronic kidney disease. It has been hypothesized that treatment with the calcimimetic agent cinacalcet might reduce the risk of death or nonfatal cardiovascular events in such patients. METHODS In this clinical trial, we randomly assigned 3883 patients with moderate-to-severe secondary hyperparathyroidism (median level of intact parathyroid hormone, 693 pg per milliliter [10th to 90th percentile, 363 to 1694]) who were undergoing hemodialysis to receive either cinacalcet or placebo. All patients were eligible to receive conventional therapy, including phosphate binders, vitamin D sterols, or both. The patients were followed for up to 64 months. The primary composite end point was the time until death, myocardial infarction, hospitalization for unstable angina, heart failure, or a peripheral vascular event. The primary analysis was performed on the basis of the intention-to-treat principle. RESULTS The median duration of study-drug exposure was 21.2 months in the cinacalcet group, versus 17.5 months in the placebo group. The primary composite end point was reached in 938 of 1948 patients (48.2%) in the cinacalcet group and 952 of 1935 patients (49.2%) in the placebo group (relative hazard in the cinacalcet group vs. the placebo group, 0.93; 95% confidence interval, 0.85 to 1.02; P=0.11). Hypocalcemia and gastrointestinal adverse events were significantly more frequent in patients receiving cinacalcet. CONCLUSIONS In an unadjusted intention-to-treat analysis, cinacalcet did not significantly reduce the risk of death or major cardiovascular events in patients with moderate-to-severe secondary hyperparathyroidism who were undergoing dialysis. (Funded by Amgen; EVOLVE ClinicalTrials.gov number, NCT00345839.).
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16
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Bone-specific alkaline phosphatase concentrations are less variable than those of parathyroid hormone in stable hemodialysis patients. Kidney Int 2012; 82:100-5. [PMID: 22456600 PMCID: PMC3376309 DOI: 10.1038/ki.2012.77] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Abnormalities of bone mineral metabolism and vascular calcification are prevalent in patients with kidney failure. Clinical management is based on biochemical targets, in particular parathyroid hormone (PTH) concentrations, but this has many limitations including high biological variation. A possible alternative is bone-specific alkaline phosphatase (ALP); therefore, we evaluated the biological variation of this marker in patients undergoing hemodialysis. Bone ALP was measured in non-fasting serum samples taken twice a week over a 6-week period in 22 stable hemodialysis patients and 12 healthy volunteers. The within-individual coefficients of variance were calculated and used to derive the critical difference required to be certain that an observed change was significant. The coefficient of variance for bone ALP was significantly higher in hemodialysis patients compared to healthy individuals. Seven samples were required to estimate the homeostatic set point of bone ALP, within 10%, in a hemodialysis patient. The concentration of serial bone ALP measurements would need to change by 36% between any two measurements before it can be considered a significant change. Since the biological variation of bone ALP is less than half that reported for PTH, our study provides further support for the use of bone ALP as an alternative marker of bone mineral metabolism in the setting of chronic kidney disease–mineral and bone disorder.
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Garrett G, Sardiwal S, Lamb EJ, Goldsmith DJA. PTH--a particularly tricky hormone: why measure it at all in kidney patients? Clin J Am Soc Nephrol 2012; 8:299-312. [PMID: 22403273 DOI: 10.2215/cjn.09580911] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Plasma parathyroid hormone (PTH) concentrations are commonly measured in the context of CKD, as PTH concentration elevation is typical in this clinical context. Much has been inferred from this raised PTH concentration tendency, both about the state of skeletal integrity and health and also about the potential clinical outcomes for patients. However, we feel that reliance on PTH concentrations alone is a dangerous substitute for the search for, and use of, more precise and reliable biomarkers. In this article, we rehearse these arguments, bringing together patient-level and analytical considerations for the first time.
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Affiliation(s)
- Giorgia Garrett
- East Kent Hospitals University, NHS Foundation Trust, Canterbury, Kent, United Kingdom
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18
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Secondary hyperparathyroidism: benign bystander or culpable contributor to adverse health outcomes? South Med J 2012; 105:36-42. [PMID: 22189665 DOI: 10.1097/smj.0b013e31823c4155] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Elevation in serum parathyroid hormone (PTH) often accompanies vitamin D deficiency and renal impairment. PTH elevation in renal failure is viewed as an unfavorable development. Evidence is increasing that PTH elevation may be associated with increased morbidity and mortality. In many instances these PTH effects appear to be independent of vitamin D status. PTH mediates its effects through the ubiquitous type 1 PTH/PTH-related peptide receptor, which is notably present in the cardiovascular system. Increased PTH may promote cardiovascular disease through diminished cardiac contractility, enhanced coronary risk, and cardiac valvular and vascular calcification. High PTH levels appear to be linked to the metabolic syndrome and are aligned with hyperlipidemia, decreased insulin sensitivity, and, perhaps, decreased insulin secretion. Increased PTH also is associated with neuroendocrine activation, increased sympathetic activity, and endothelial stress. The relation between PTH and vitamin D is complex and may show significant threshold variations, especially when calcium intake, age, and race are considered. Moreover, evidence is increasing that fragments of PTH may not only be hormonally active but also may have opposing effects to PTH. Despite these caveats, PTH values provide useful clinical diagnostic and prognostic information in monitoring many chronic ailments such as heart and renal failure and multiple sclerosis.
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Abstract
Vitamin D receptor agonists (VDRA) are currently recommended for the treatment of secondary hyperparathyroidism in stage 5 CKD. They are considered to be contraindicated in the presence of low or normal (for a dialysis patient) levels of PTH due to the risk of developing adynamic bone disease, with consequent vascular calcification. However, these recommendations are increasingly at odds with the epidemiological evidence, which consistently shows a large survival advantage for patients treated with low-dose VDRAs, regardless of plasma calcium, phosphate, or PTH. A large number of pleiotropic effects of vitamin D have been described, including inhibition of renin activity, anti-inflammation, and suppression of vascular calcification stimulators and stimulation of vascular calcification inhibitors present in the uremic milieu. Laboratory studies suggest that a normal cellular vitamin D level is necessary for normal cardiomyocyte and vascular smooth muscle function. While pharmacological doses of VDRA can be harmful, the present evidence suggests that the level of 1,25-dihydroxycholecalciferol should also be more physiological in stage 5 CKD, and that widespread use of low-dose VDRA would be beneficial. A randomized controlled trial to test this hypothesis is warranted.
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Affiliation(s)
- James Goya Heaf
- Department of Nephrology, University of Copenhagen Herlev Hospital, Herlev, Denmark.
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20
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Ritz D, Nourrit-Poirette F. Les effets délétères de la parathormone sur le coeur. Nephrol Ther 2011; 7:H13-6. [DOI: 10.1016/s1769-7255(11)70006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Feroze U, Molnar MZ, Dukkipati R, Kovesdy CP, Kalantar-Zadeh K. Insights into nutritional and inflammatory aspects of low parathyroid hormone in dialysis patients. J Ren Nutr 2011; 21:100-4. [PMID: 21195929 PMCID: PMC3032422 DOI: 10.1053/j.jrn.2010.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In individuals with advanced chronic kidney disease, secondary hyperparathyroidism is known to be associated with high turnover bone disease. Low serum parathyroid hormone (PTH) levels may not necessarily be because of hypodynamic bone, but could be another facet of the malnutrition-inflammation-cachexia syndrome (MICS). A recent 5-year cohort study in 748 stable hemodialysis outpatients showed that after the confounding effect by the MICS was removed, the moderately low levels of PTH in the 100 to 150 pg/mL range was associated with the greatest survival rate. Data from Japanese dialysis patients show similar survival advantages of having a lower PTH range. Low levels of serum PTH seem to be associated with markers of protein-energy wasting and inflammation, and this association may confound the relationship between serum PTH and alkaline phosphatase. PTH stimulates lipogenesis through influx of calcium into the adipocytes. PTH secretion is suppressed by interleukin-1 beta and interleukin-6, which are proinflammatory cytokines that are associated with poor outcome in dialysis patients. These cytokines inhibits PTH secretion in cultured parathyroid tissue slices. In this article, we review the association of a low serum PTH level with the MICS in patients with chronic kidney disease and suggest avoiding over-interpretation of low serum PTH level as an indicator of low turnover bone disease.
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Affiliation(s)
- Usama Feroze
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502
| | - Miklos Z Molnar
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502
| | - Ramanath Dukkipati
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502
- Division of Nephrology & Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502
| | | | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502
- Division of Nephrology & Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502
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Drechsler C, Grootendorst DC, Boeschoten EW, Krediet RT, Wanner C, Dekker FW. Changes in parathyroid hormone, body mass index and the association with mortality in dialysis patients. Nephrol Dial Transplant 2010; 26:1340-6. [DOI: 10.1093/ndt/gfq541] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Drechsler C, Pilz S, Obermayer-Pietsch B, Verduijn M, Tomaschitz A, Krane V, Espe K, Dekker F, Brandenburg V, März W, Ritz E, Wanner C. Vitamin D deficiency is associated with sudden cardiac death, combined cardiovascular events, and mortality in haemodialysis patients. Eur Heart J 2010; 31:2253-61. [PMID: 20688781 PMCID: PMC2938469 DOI: 10.1093/eurheartj/ehq246] [Citation(s) in RCA: 177] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Aims Dialysis patients experience an excess mortality, predominantly of sudden cardiac death (SCD). Accumulating evidence suggests a role of vitamin D for myocardial and overall health. This study investigated the impact of vitamin D status on cardiovascular outcomes and fatal infections in haemodialysis patients. Methods and results 25-hydroxyvitamin D [25(OH)D] was measured in 1108 diabetic haemodialysis patients who participated in the German Diabetes and Dialysis Study and were followed up for a median of 4 years. By Cox regression analyses, we determined hazard ratios (HR) for pre-specified, adjudicated endpoints according to baseline 25(OH)D levels: SCD (n = 146), myocardial infarction (MI, n = 174), stroke (n = 89), cardiovascular events (CVE, n = 414), death due to heart failure (n = 37), fatal infection (n = 111), and all-cause mortality (n = 545). Patients had a mean age of 66 ± 8 years (54% male) and median 25(OH)D of 39 nmol/L (interquartile range: 28–55). Patients with severe vitamin D deficiency [25(OH)D of≤ 25 nmol/L] had a 3-fold higher risk of SCD compared with those with sufficient 25(OH)D levels >75 nmol/L [HR: 2.99, 95% confidence interval (CI): 1.39–6.40]. Furthermore, CVE and all-cause mortality were strongly increased (HR: 1.78, 95% CI: 1.18–2.69, and HR: 1.74, 95% CI: 1.22–2.47, respectively), all persisting in multivariate models. There were borderline non-significant associations with stroke and fatal infection while MI and deaths due to heart failure were not meaningfully affected. Conclusion Severe vitamin D deficiency was strongly associated with SCD, CVE, and mortality, and there were borderline associations with stroke and fatal infection. Whether vitamin D supplementation decreases adverse outcomes requires further evaluation.
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Affiliation(s)
- Christiane Drechsler
- Department of Internal Medicine 1, Division of Nephrology, University of Würzburg, Oberdürrbacher Str. 6, D-97080 Würzburg, Germany.
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24
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Dukkipati R, Kovesdy CP, Kim Y, Colman S, Budoff MJ, Nissenson AR, Sprague SM, Kopple JD, Kalantar-Zadeh K. Association of relatively low serum parathyroid hormone with malnutrition-inflammation complex and survival in maintenance hemodialysis patients. J Ren Nutr 2010; 20:243-54. [PMID: 20199875 PMCID: PMC3175364 DOI: 10.1053/j.jrn.2009.10.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Low serum parathyroid hormone (PTH) has been implicated as a primary biochemical marker of adynamic bone disease in individuals with chronic kidney disease (CKD) who undergo maintenance hemodialysis (MHD) treatment. We hypothesized that the malnutrition-inflammation complex is associated with low PTH levels in these patients and confounds the PTH-survival association. METHODS We examined 748 stable MHD outpatients in southern California and followed them for up to 5 years (October 2001-December 2006). RESULTS In 748 MHD patients, serum PTH <150pg/mL was more prevalent among non-blacks and diabetics. There was no association between serum PTH and coronary artery calcification score, bone mineral density, or dietary protein or calorie intake. Low serum PTH was associated with markers of protein-energy wasting and inflammation, and this association confounded the relationship between serum PTH and alkaline phosphatase. Although 5-year crude mortality rates were similar across PTH increments, after adjustment for the case-mix and surrogates of malnutrition and inflammation, a moderately low serum PTH in 100-150pg/mL range was associated with the greatest survival compared to other serum PTH levels, i.e., a death hazard ratio of 0.52 (95% confidence interval: 0.29-0.92, p<0.001) compared to PTH of 300-600pg/mL (reference). CONCLUSIONS Low serum PTH may be another facet of the malnutrition-inflammation complex in CKD, and after controlling for this confounder, a moderately low PTH in 100-150pg/mL range appears associated with the greatest survival. Limitations of observational studies should be considered.
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Affiliation(s)
- Ramanath Dukkipati
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Torrance, CA 90502
| | | | - Youngmee Kim
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Torrance, CA 90502
| | | | - Matthew J Budoff
- Division of Cardiology; Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502
- David Geffen UCLA School of medicine, Los Angeles, CA
| | - Allen R. Nissenson
- David Geffen UCLA School of medicine, Los Angeles, CA
- DaVita, El Segundo, CA
| | - Stuart M. Sprague
- Northwestern University Feinberg School of Medicine, Evanston Northwestern Healthcare, Evanston, IL
| | - Joel D Kopple
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Torrance, CA 90502
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Torrance, CA 90502
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Recent advances in the rapidly evolving field of fibroblast growth factor 23 in chronic kidney disease. Curr Opin Nephrol Hypertens 2010; 19:335-42. [DOI: 10.1097/mnh.0b013e328338f536] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Pilz S, Tomaschitz A, Drechsler C, Ritz E, Boehm BO, Grammer TB, März W. Parathyroid hormone level is associated with mortality and cardiovascular events in patients undergoing coronary angiography. Eur Heart J 2010; 31:1591-8. [PMID: 20439261 DOI: 10.1093/eurheartj/ehq109] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Elevated parathyroid hormone (PTH) levels have been associated with increased cardiovascular risk in the general population. We aimed to elucidate whether PTH levels are associated with mortality and fatal cardiovascular events in patients referred for coronary angiography. METHODS AND RESULTS Intact PTH was measured in 3232 Caucasian patients from the LUdwigshafen RIsk and Cardiovascular Health (LURIC) study, who underwent coronary angiography at baseline (1997-2000). During a median follow-up time of 7.7 years, 742 patients died including 467 deaths due to cardiovascular causes. Unadjusted Cox proportional hazard ratios (HRs) (with 95% confidence intervals) in the fourth when compared to the first PTH quartile were 2.13 (1.75-2.60) for all-cause and 2.47 (1.92-3.17) for cardiovascular mortality. After adjustments for common cardiovascular risk factors, these HRs remained significant with 1.71 (1.39-2.10) for all-cause and 2.02 (1.55-2.63) for cardiovascular mortality. Among specific cardiovascular events we observed a particularly strong association of PTH with sudden cardiac death (SCD). The adjusted HR for SCD in the first vs. the fourth PTH quartile was 2.68 (1.71-4.22). CONCLUSION Our results among patients undergoing coronary angiography show that PTH levels are an independent risk factor for mortality and cardiovascular events warranting further studies to evaluate whether PTH modifying treatments reduce cardiovascular risk.
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Affiliation(s)
- Stefan Pilz
- Division of Endocrinology and Nuclear Medicine, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria.
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Sherman RA. Briefly Noted. Semin Dial 2010. [DOI: 10.1111/j.1525-139x.2009.00687.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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28
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Wasting modifies the association between PTH and mortality in dialysis patients. Nat Rev Nephrol 2009. [DOI: 10.1038/nrneph.2009.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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