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Moinuddin Z, Wang K, Fullwood C, Wiredu E, Hutchison A, Vardhan A, Herrick SE, Summers A, Augustine T, van Dellen D. Renal hyperparathyroidism- a risk factor in the development of encapsulating peritoneal sclerosis. Front Endocrinol (Lausanne) 2024; 15:1282925. [PMID: 38567303 PMCID: PMC10985182 DOI: 10.3389/fendo.2024.1282925] [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: 08/25/2023] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
Background Encapsulating peritoneal sclerosis (EPS) is a rare complication of prolonged peritoneal dialysis (PD) exposure, characterised by peritoneal thickening, calcification, and fibrosis ultimately presenting with life-threatening bowel obstruction. The presence or role of peritoneal calcification in the pathogenesis of EPS is poorly characterised. We hypothesise that significantly aberrant bone mineral metabolism in patients on PD can cause peritoneal calcification which may trigger the development of EPS. We compared the temporal evolution of bone mineral markers during PD in EPS patients with non-EPS long-term PD controls. Methods Linear mixed model and logistic regression analysis were used to compare four-monthly serum levels of calcium, phosphate, parathyroid hormone, and alkaline phosphatase (ALP) over the duration of PD exposure in 46 EPS and 46 controls (PD, non-EPS) patients. Results EPS patients had higher mean calcium (2.51 vs. 2.41 mmol/L) and ALP (248.00 vs. 111.13 IU/L) levels compared with controls (p=0.01 and p<0.001 respectively, maximum likelihood estimation). Logistic regression analysis demonstrated that high serum calcium and phosphate levels during PD were associated with a 4.5 and 2.9 fold increase in the risk of developing EPS respectively. Conclusion High levels of calcium and phosphate in patients on PD were identified to be risk factors for EPS development. Possible reasons for this may be an imbalance of pro-calcifying factors and calcification inhibitors promoting peritoneal calcification which increases peritoneal stiffness. Mechanical alterations may trigger, unregulated fibrosis and subsequent development of EPS. Improved management of secondary hyperparathyroidism during PD may ultimately diminish the EPS risk.
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Affiliation(s)
- Zia Moinuddin
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary (National Commissioning Group (NCG) funded United Kingdom Referral Centre for EPS Surgery), Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Kelvin Wang
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary (National Commissioning Group (NCG) funded United Kingdom Referral Centre for EPS Surgery), Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Catherine Fullwood
- Department of Statistics, Research and Innovation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Centre for Biostatistics, University of Manchester, Manchester, United Kingdom
| | - Elizabeth Wiredu
- Medical Statistics, Data Solution Services, Liverpool, United Kingdom
| | - Alastair Hutchison
- Department of Nephrology, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Anand Vardhan
- Department of Nephrology, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Sarah E. Herrick
- School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Angela Summers
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary (National Commissioning Group (NCG) funded United Kingdom Referral Centre for EPS Surgery), Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Titus Augustine
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary (National Commissioning Group (NCG) funded United Kingdom Referral Centre for EPS Surgery), Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - David van Dellen
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary (National Commissioning Group (NCG) funded United Kingdom Referral Centre for EPS Surgery), Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
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Hiramitsu T, Hasegawa Y, Futamura K, Okada M, Goto N, Narumi S, Watarai Y, Tominaga Y, Ichimori T. Maximal parathyroid gland diameter as a predictive factor for autograft-dependent recurrent secondary hyperparathyroidism after total parathyroidectomy. Front Endocrinol (Lausanne) 2023; 14:1175237. [PMID: 37396185 PMCID: PMC10311438 DOI: 10.3389/fendo.2023.1175237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Following total parathyroidectomy (PTx), transcervical thymectomy, and forearm autograft for secondary hyperparathyroidism (SHPT), recurrent SHPT can occur in the autografted forearm. However, few studies have investigated the factors contributing to re-PTx due to autograft-dependent recurrent SHPT before the completion of the initial PTx. Methods A total of 770 patients who had autografted parathyroid fragments derived from only one of the resected parathyroid glands (PTGs) and who had undergone successful initial total PTx and transcervical thymectomy-defined by serum intact parathyroid hormone level < 60 pg/mL on postoperative day 1-between January 2001 and December 2022 were included in this retrospective cohort study. Factors contributing to re-PTx due to graft-dependent recurrent SHPT before the completion of the initial PTx were investigated using multivariate Cox regression analysis. Receiver operating characteristic (ROC) curve analysis was performed to obtain the optimal maximum diameter of PTG for autograft. Results Univariate analysis showed that dialysis vintage and maximum diameter and weight of the PTG for autograft were significant factors contributing to graft-dependent recurrent SHPT. However, multivariate analysis revealed that dialysis vintage (P=0.010; hazard ratio [HR], 0.995; 95% confidence interval [CI], 0.992-0.999) and the maximum diameter of the PTG for autograft (P=0.046; HR, 1.107; 95% CI, 1.002-1.224) significantly contributed to graft-dependent recurrent SHPT. ROC curve analysis showed that < 14 mm was the optimal maximum diameter of PTG for autograft (area under the curve, 0.628; 95% CI, 0.551-0.705). Conclusions The dialysis vintage and maximum diameter of PTG for autograft may contribute to re-PTx due to autograft-dependent recurrent SHPT, which can be prevented by using PTGs with a maximum diameter of < 14 mm for autograft.
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Cianciolo G, Tondolo F, Barbuto S, Angelini A, Ferrara F, Iacovella F, Raimondi C, La Manna G, Serra C, De Molo C, Cavicchi O, Piccin O, D'Alessio P, De Pasquale L, Felisati G, Ciceri P, Galassi A, Cozzolino M. OUP accepted manuscript. Clin Kidney J 2022; 15:1459-1474. [PMID: 35892022 PMCID: PMC9308095 DOI: 10.1093/ckj/sfac050] [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: 12/09/2021] [Indexed: 11/25/2022] Open
Abstract
Chronic kidney disease mineral and bone disorder may persist after successful kidney transplantation. Persistent hyperparathyroidism has been identified in up to 80% of patients throughout the first year after kidney transplantation. International guidelines lack strict recommendations about the management of persistent hyperparathyroidism. However, it is associated with adverse graft and patient outcomes, including higher fracture risk and an increased risk of all-cause mortality and allograft loss. Secondary hyperparathyroidism may be treated medically (vitamin D, phosphate binders and calcimimetics) or surgically (parathyroidectomy). Guideline recommendations suggest medical therapy first but do not clarify optimal parathyroid hormone targets or indications and timing of parathyroidectomy. There are no clear guidelines or long-term studies about the impact of hyperparathyroidism therapy. Parathyroidectomy is more effective than medical treatment, although it is associated with increased short-term risks. Ideally parathyroidectomy should be performed before kidney transplantation to prevent persistent hyperparathyroidism and improve graft outcomes. We now propose a roadmap for the management of secondary hyperparathyroidism in patients eligible for kidney transplantation that includes the indications and timing (pre- or post-kidney transplantation) of parathyroidectomy, the evaluation of parathyroid gland size and the integration of parathyroid gland size in the decision-making process by a multidisciplinary team of nephrologists, radiologists and surgeons.
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Affiliation(s)
- Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Francesco Tondolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Simona Barbuto
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Andrea Angelini
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Francesca Ferrara
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Francesca Iacovella
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Concettina Raimondi
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Carla Serra
- Interventional, Diagnostic and Therapeutic Ultrasound Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria Sant’Orsola Malpighi Hospital, Bologna, Italy
| | - Chiara De Molo
- Interventional, Diagnostic and Therapeutic Ultrasound Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria Sant’Orsola Malpighi Hospital, Bologna, Italy
| | - Ottavio Cavicchi
- Department of Otolaryngology Head and Neck Surgery, IRCSS Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Ottavio Piccin
- Department of Otolaryngology Head and Neck Surgery, IRCSS Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Pasquale D'Alessio
- Department of Otolaryngology Head and Neck Surgery, IRCSS Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Loredana De Pasquale
- Department of Otolaryngology, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Giovanni Felisati
- Department of Otolaryngology, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Paola Ciceri
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
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Stricter ioPTH criterion for successful parathyroidectomy in stage III CKD patients with primary hyperparathyroidism. Surgery 2018; 164:1306-1310. [DOI: 10.1016/j.surg.2018.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/17/2018] [Accepted: 05/01/2018] [Indexed: 11/21/2022]
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Lau WL, Obi Y, Kalantar-Zadeh K. Parathyroidectomy in the Management of Secondary Hyperparathyroidism. Clin J Am Soc Nephrol 2018; 13:952-961. [PMID: 29523679 PMCID: PMC5989682 DOI: 10.2215/cjn.10390917] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Secondary hyperparathyroidism develops in CKD due to a combination of vitamin D deficiency, hypocalcemia, and hyperphosphatemia, and it exists in nearly all patients at the time of dialysis initiation. There is insufficient data on whether to prefer vitamin D analogs compared with calcimimetics, but the available evidence suggests advantages with combination therapy. Calcium derangements, patient adherence, side effects, and cost limit the use of these agents. When parathyroid hormone level persists >800 pg/ml for >6 months, despite exhaustive medical interventions, monoclonal proliferation with nodular hyperplasia is likely present along with decreased expression of vitamin D and calcium-sensing receptors. Hence, surgical parathyroidectomy should be considered, especially if concomitant disorders exist, such as persistent hypercalcemia or hyperphosphatemia, tissue or vascular calcification including calciphylaxis, and/or worsening osteodystrophy. Parathyroidectomy is associated with 15%-57% greater survival in patients on dialysis, and it also improves hypercalcemia, hyperphosphatemia, tissue calcification, bone mineral density, and health-related quality of life. The parathyroidectomy rate in the United States declined to approximately seven per 1000 dialysis patient-years between 2002 and 2011 despite an increase in average parathyroid hormone levels, reflecting calcimimetics introduction and uncertainty regarding optimal parathyroid hormone targets. Hospitalization rates are 39% higher in the first postoperative year. Hungry bone syndrome occurs in approximately 25% of patients on dialysis, and profound hypocalcemia requires high doses of oral and intravenous calcium along with calcitriol supplementation. Total parathyroidectomy with autotransplantation carries a higher risk of permanent hypocalcemia, whereas risk of hyperparathyroidism recurrence is higher with subtotal parathyroidectomy. Given favorable long-term outcomes from observational parathyroidectomy cohorts, despite surgical risk and postoperative challenges, it is reasonable to consider parathyroidectomy in more patients with medically refractory secondary hyperparathyroidism.
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Affiliation(s)
- Wei Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California, Irvine, California
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Risk-factors for nodular hyperplasia of parathyroid glands in sHPT patients. PLoS One 2017; 12:e0186093. [PMID: 29040300 PMCID: PMC5645091 DOI: 10.1371/journal.pone.0186093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/25/2017] [Indexed: 12/27/2022] Open
Abstract
Introduction Nodular hyperplasia of parathyroid glands (PG) is the most probable cause of medical treatment failure in secondary hyperparathyroidism (sHPT). This prospective cohort study is located at the interface of medical and surgical consideration of sHPT treatment options and identifies risk-factors for nodular hyperplasia of PG. Material and methods One-hundred-eight resected PG of 27 patients with a broad spectrum of sHPT severity were classified according to the degree of hyperplasia by histopathology. Twenty routinely gathered parameters from medical history, ultrasound findings of PG and laboratory results were analyzed for their influence on nodular hyperplasia of PG by risk-adjusted multivariable binary regression. A prognostic model for non-invasive assessment of PG was developed and used to weight the individual impact of identified risk-factors on the probability of nodular hyperplasia of single PG. Results Independent risk-factors for nodular hyperplasia of single PG were duration of dialysis in years, PG volume in mm3 determined by ultrasound and serum level of parathyroid hormone in pg/mL. Multivariable analyses computed a model with an Area Under the Receiver Operative Curve of 0.857 (95%-CI:0.773–0.941) when predicting nodular hyperplasia of PG. Theoretical assessment of risk-factor interaction revealed that the duration of dialysis had the strongest influence on the probability of nodular hyperplasia of single PG. Conclusions The three identified risk-factors (duration of dialysis, PG volume determined by ultrasound and serum level of parathyroid hormone) can be easily gathered in daily routine and could be used to non-invasively assess the probability of nodular hyperplasia of PG. This assessment would benefit from periodically collected data sets of PG changes during the course of sHPT, so that the choice of medical or surgical sHPT treatment could be adjusted more to the naturally changing type of histological PG lesion on an individually adopted basis in the future.
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Subtotal parathyroidectomy for secondary renal hyperparathyroidism: a 20-year surgical outcome study. Langenbecks Arch Surg 2016; 401:965-974. [PMID: 27233241 PMCID: PMC5086343 DOI: 10.1007/s00423-016-1447-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 05/10/2016] [Indexed: 11/04/2022]
Abstract
Aim The aim of this study was to evaluate the outcomes of surgery for patients with secondary renal hyperparathyroidism (rHPT). Methods This is a retrospective cohort study. Our institutional database was searched for eligible patients treated in 1995–2014. The inclusion criterion was initial parathyroidectomy for rHPT. Clinical and follow-up data were analyzed to estimate the cure rate (primary outcome), and morbidity (secondary outcome). Results The study group comprised 297 patients (154 females, age 44.5 ± 13.7 years, follow-up 24.6 ± 10.5 months), including 268 (90.2 %) patients who had underwent subtotal parathyroidectomy, and 29 (9.8 %) who had had incomplete parathyroidectomy. Intraoperative iPTH assay was utilized in 207 (69.7 %) explorations. Persistent rHPT occurred in 12/268 (4.5 %) patients after subtotal parathyroidectomy and 5/29 (17.2 %) subjects after incomplete parathyroidectomy (p = 0.005). The patients operated on with intraoperative iPTH assay had a higher cure rate than non-monitored individuals, 201/207 (97.1 %) vs. 79/90 (87.8 %), respectively (p = 0.001). In-hospital mortality occurred in 1/297 (0.3 %) patient. The hungry bone syndrome occurred in 84/268 (31.3 %) patients after subtotal parathyroidectomy and 2/29 (6.9 %) subjects after incomplete parathyroidectomy (p = 0.006). Transient recurrent laryngeal nerve paresis occurred in 14/594 (2.4 %) and permanent in 5/594 (0.8 %) nerves at risk. Conclusions Subtotal parathyroidectomy is a safe and efficacious treatment for patients with rHPT. Utilization of intraoperative iPTH assay can guide surgical exploration and improve the cure rate.
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Florescu MC, Islam KM, Plumb TJ, Smith-Shull S, Nieman J, Mandalapu P. Calcium supplementation after parathyroidectomy in dialysis and renal transplant patients. Int J Nephrol Renovasc Dis 2014; 7:183-90. [PMID: 24868170 PMCID: PMC4027938 DOI: 10.2147/ijnrd.s56995] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Data on the risk factors and clinical course of hungry bone syndrome are lacking in dialysis and renal transplant patients who undergo parathyroidectomy. In this study, we aimed to assess the risks and clinical course of hungry bone syndrome and calcium repletion after parathyroidectomy in dialysis and renal transplant patients. Methods We performed a retrospective review of parathyroidectomies performed at The Nebraska Medical Center. Results We identified 41 patients, ie, 30 (73%) dialysis and eleven (27%) renal transplant patients. Dialysis patients had a significantly higher pre-surgery intact parathyroid hormone (iPTH, P<0.001) and a larger iPTH drop after surgery (P<0.001) than transplant recipients. Post-surgery hypocalcemia in dialysis patients was severe and required aggressive and prolonged calcium replacement (11 g) versus a very mild hypocalcemia requiring only brief and minimal replacement (0.5 g) in transplant recipients (P<0.001). Hypophosphatemia was not detected in the dialysis group. Phosphorus did not increase immediately after surgery in transplant recipients. The hospital stay was significantly longer in dialysis patients (8.2 days) compared with transplant recipients (3.2 days, P<0.001). Conclusion The clinical course of hungry bone syndrome is more severe in dialysis patients than in renal transplant recipients. Young age, elevated alkaline phosphatase, elevated pre-surgery iPTH, and a large decrease in post-surgical iPTH are risk factors for severe hungry bone syndrome in dialysis patients.
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Affiliation(s)
| | | | | | - Sara Smith-Shull
- Department of Pharmacy, The Nebraska Medical Center, Omaha, NE, USA
| | - Jennifer Nieman
- Department of Pharmacy, The Nebraska Medical Center, Omaha, NE, USA
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Kampschreur LM, Hoogeveen EK, op den Akker JW, Beutler JJ, Beems T, Dorresteijn LDA, de Sévaux RGL. A haemodialysis patient with back pain: brown tumour as a cause of spinal cord compression under cinacalcet therapy. NDT Plus 2010; 3:291-295. [PMID: 28657067 PMCID: PMC5477967 DOI: 10.1093/ndtplus/sfq052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Revised: 03/21/2010] [Accepted: 03/22/2010] [Indexed: 11/16/2022] Open
Abstract
A 43-year-old haemodialysis patient was admitted to hospital because of paroxysmal pain in the upper abdominal region radiating to the back. Laboratory tests showed severe hyperparathyroidism [intact parathyroid hormone (iPTH) 69 pmol/L; reference range: 1.3-6.8 pmol/L], hypercalcaemia (2.79 mmol/L), hyperphosphataemia (1.6 mmol/L) and elevated serum total alkaline phosphatase (200 U/L). After developing a disturbed sensation and paraesthesia in both feet, epidural compression of the spinal cord was suspected. Magnetic resonance imaging showed a tumour that severely compressed the myelum of the thoracic spine. Histological investigation revealed a brown tumour or osteoclastoma, an erosive bony lesion caused by increased osteoclastic activity and peritrabecular fibrosis. A brown tumour is a benign tumour that is a rare complication of severe renal hyperparathyroidism. The brown tumour developed despite a 1-year treatment of the patient with cinacalcet, which, however, did not result in a major decrease in serum iPTH concentration (from 110 to 69 pmol/L: 37% reduction). Urgent decompressive neurosurgery and subtotal parathyroidectomy resulted in a complete recovery.
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Affiliation(s)
| | - Ellen K. Hoogeveen
- Department of Nephrology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Jeroen W. op den Akker
- Department of Radiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jaap J. Beutler
- Department of Nephrology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Tjemme Beems
- Department of Neurosurgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Ruud G. L. de Sévaux
- Department of Nephrology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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