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Rodrigues FG, Van Der Plas WY, Sotomayor CG, Van Der Vaart A, Kremer D, Pol RA, Kruijff S, Heilberg IP, Bakker SJL, De Borst MH. Pre-Transplant Hyperparathyroidism and Graft or Patient Outcomes After Kidney Transplantation. Transpl Int 2024; 37:11916. [PMID: 38384325 PMCID: PMC10880800 DOI: 10.3389/ti.2024.11916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 01/23/2024] [Indexed: 02/23/2024]
Abstract
The impact of pre-transplant parathyroid hormone (PTH) levels on early or long-term kidney function after kidney transplantation is subject of debate. We assessed whether severe hyperparathyroidism is associated with delayed graft function (DGF), death-censored graft failure (DCGF), or all-cause mortality. In this single-center cohort study, we studied the relationship between PTH and other parameters related to bone and mineral metabolism, including serum alkaline phosphatase (ALP) at time of transplantation with the subsequent risk of DGF, DCGF and all-cause mortality using multivariable logistic and Cox regression analyses. In 1,576 kidney transplant recipients (51.6 ± 14.0 years, 57.3% male), severe hyperparathyroidism characterized by pre-transplant PTH ≥771 pg/mL (>9 times the upper limit) was present in 121 patients. During 5.2 [0.2-30.0] years follow-up, 278 (15.7%) patients developed DGF, 150 (9.9%) DCGF and 432 (28.6%) died. A higher pre-transplant PTH was not associated with DGF (HR 1.06 [0.90-1.25]), DCGF (HR 0.98 [0.87-1.13]), or all-cause mortality (HR 1.02 [0.93-1.11]). Results were consistent in sensitivity analyses. The same applied to other parameters related to bone and mineral metabolism, including ALP. Severe pre-transplant hyperparathyroidism was not associated with an increased risk of DGF, DCGF or all-cause mortality, not supporting the need of correction before kidney transplantation to improve graft or patient survival.
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Affiliation(s)
- Fernanda Guedes Rodrigues
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Nutrition Post Graduation Program, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Willemijn Y. Van Der Plas
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Camilo German Sotomayor
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Amarens Van Der Vaart
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Daan Kremer
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Robert A. Pol
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Schelto Kruijff
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Surgery, Martini Hospital Groningen, Groningen, Netherlands
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ita Pfeferman Heilberg
- Nutrition Post Graduation Program, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Stephan J. L. Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | | | - Martin H. De Borst
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Ramirez-Sandoval JC, Marino L, Cojuc-Konigsberg G, Reul-Linares E, Pichardo-Cabrera ND, Cruz C, Hernández-Paredes EN, Berman-Parks N, Vidal-Ruíz V, Estrada-Linares JM, Reza-Albarrán AA, Correa-Rotter R, Morales-Buenrostro LE. Long-term effects of hypercalcemia in kidney transplant recipients with persistent hyperparathyroidism. J Nephrol 2023:10.1007/s40620-023-01815-5. [PMID: 38032457 DOI: 10.1007/s40620-023-01815-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Hypercalcemia is highly prevalent in kidney transplant recipients with hyperparathyroidism. However, its long-term impact on graft function is uncertain. METHODS We conducted a prospective cohort study investigating adverse graft outcomes associated with persistent hypercalcemia (free calcium > 5.2 mg/dL in ≥ 80% of measures) and inappropriately elevated intact parathyroid hormone (> 30 pg/mL) in kidney transplant recipients. Asymptomatic mild hypercalcemia was monitored unless complications developed. RESULTS We included 385 kidney transplant recipients. During a 4-year (range 1-9) median follow-up time, 62% of kidney transplant recipients presented persistent hypercalcemia. Compared to kidney transplant recipients without hypercalcemia, there were no significant differences in graft dysfunction (10% vs. 12%, p = 0.61), symptomatic urolithiasis (5% vs. 3%, p = 0.43), biopsy-proven calcium deposits (6% vs. 5%, p = 1.0), fractures (6% vs. 4%, p = 0.64), and a composite outcome of urolithiasis, calcium deposits, fractures, and parathyroidectomy indication (16% vs. 13%, p = 0.55). In a subset of 76 kidney transplant recipients, subjects with persistent hypercalcemia had higher urinary calcium (median 84 [43-170] vs. 38 [24-64] mg/day, p = 0.03) and intact fibroblast growth factor 23 (median 36 [24-54] vs. 27 [19-40] pg/mL, p = 0.04), and lower 25-hydroxyvitamin D levels (11.3 ± 1.2 vs. 16.3 ± 1.4 ng/mL, p < 0.001). In multivariate analysis, pretransplant intact parathyroid hormone < 300 pg/mL was associated with a reduced risk of post-transplant hypercalcemia (OR 0.51, 95% CI 0.32-0.80). CONCLUSIONS Long-term persistent mild hypercalcemia (tertiary hyperparathyroidism) was frequent in kidney transplant recipients in our series. This condition presented with lower phosphate and 25-hydroxyvitamin D, and higher urinary calcium and intact fibroblast growth factor 23 levels compared to kidney transplant recipients without hypercalcemia, resembling a mild form of primary hyperparathyroidism. Despite these metabolic derangements, the risk of adverse graft outcomes was low.
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Affiliation(s)
- Juan Carlos Ramirez-Sandoval
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico.
| | - Lluvia Marino
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Gabriel Cojuc-Konigsberg
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Estefania Reul-Linares
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Nathalie Desire Pichardo-Cabrera
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Cristino Cruz
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Elisa Naomi Hernández-Paredes
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Nathan Berman-Parks
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Vanessa Vidal-Ruíz
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Jonathan Mauricio Estrada-Linares
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Alfredo Adolfo Reza-Albarrán
- Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ricardo Correa-Rotter
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Luis Eduardo Morales-Buenrostro
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
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Adams A, Cendales LC, Cooper DKC, Cozzi E, Gill J, Judd E, Katz E, Kirk AD, Fishman JA, Reese PP, Wall A, Markmann JF. American Society of Transplant Surgeons-American Society of Transplantation report of FDA meeting on regulatory expectations for xenotransplantation products. Am J Transplant 2023; 23:1290-1299. [PMID: 37217005 DOI: 10.1016/j.ajt.2023.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/02/2023] [Accepted: 05/17/2023] [Indexed: 05/24/2023]
Abstract
In June 2022, the US Food and Drug Administration Center for Biologics Evaluation and Research held the 73rd meeting of the Cellular, Tissue, and Gene Therapies Advisory Committee for public discussion of regulatory expectations for xenotransplantation products. The members of a joint American Society of Transplant Surgeons/American Society of Transplantation committee on xenotransplantation compiled a meeting summary focusing on 7 topics believed to be key by the committee: (1) preclinical evidence supporting progression to a clinical trial, (2) porcine kidney function, (3) ethical aspects, (4) design of initial clinical trials, (5) infectious disease issues, (6) industry perspectives, and (7) regulatory oversight.
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Affiliation(s)
- Andrew Adams
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Linda C Cendales
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emanuele Cozzi
- Department of Cardiothoracic and Vascular Surgery, University of Padua, Padua, Italy
| | - John Gill
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Judd
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Allan D Kirk
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Jay A Fishman
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts, USA; Transplant Infectious Disease and Compromised Host Program and MGH Transplant Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter P Reese
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Anji Wall
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
| | - James F Markmann
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts, USA.
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Persistent hyperparathyroidism in long-term kidney transplantation: time to consider a less aggressive approach. Curr Opin Nephrol Hypertens 2023; 32:20-26. [PMID: 36250468 DOI: 10.1097/mnh.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Persistent hyperparathyroidism affects 50% of long-term kidney transplants with preserved allograft function. Timing, options and the optimal target for treatment remain unclear. Clinical practice guidelines recommend the same therapeutic approach as patients with chronic kidney disease. RECENT FINDINGS Mild to moderate elevation of parathyroid hormone (PTH) levels in long-term kidney transplants may not be associated with bone loss and fracture. Recent findings on bone biopsy revealed the lack of association between hypercalcaemic hyperparathyroidism with pathology of high bone turnover. Elevated PTH levels may be required to maintain normal bone volume. Nevertheless, several large observational studies have revealed the association between hypercalcemia and the elevation of PTH levels with unfavourable allograft and patient outcomes. Both calcimimetics and parathyroidectomy are effective in lowering serum calcium and PTH. A recent meta-analysis suggested parathyroidectomy may be performed safely after kidney transplantation without deterioration of allograft function. SUMMARY Treatment of persistent hyperparathyroidism is warranted in kidney transplants with hypercalcemia and markedly elevated PTH levels. A less aggressive approach should be applied to those with mild to moderate elevation. Whether treatments improve outcomes remain to be elucidated.
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Lucander ACK, Judd E, Cooper DKC. What is the clinical relevance of deviant serum calcium and phosphate levels after pig-to-primate kidney xenotransplantation? Xenotransplantation 2022; 29:e12785. [PMID: 36300760 PMCID: PMC10154070 DOI: 10.1111/xen.12785] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/06/2022] [Indexed: 01/15/2023]
Abstract
Experience from human renal allotransplantation informs us that disturbances in serum calcium and phosphate levels are relatively common. Post-transplant hypercalcemia is associated with an increased risk of recipient mortality, but not of graft loss or nephropathy, and post-transplant hyperphosphatemia with an increased risk of both recipient mortality and death-censored graft failure, but neither post-transplant hypocalcemia nor hypophosphatemia is associated with adverse outcome. Studies after pig-to-nonhuman primate kidney xenotransplantation have demonstrated consistent supranormal serum calcium and subnormal serum phosphate levels. If these trends in serum electrolyte levels were to occur following pig-to-human kidney xenotransplantation, the data from allotransplant studies would indicate an increased risk of recipient mortality (associated with hypercalcemia) but not of graft loss or nephropathy, and no adverse outcome from hypophosphatemia. Furthermore, some nonhuman primates are now surviving in a healthy state for longer than a year after life-supporting pig kidney transplantation, suggesting that chronic hypercalcemia and/or hypophosphatemia are not detrimental to long-term survival, and should not prevent clinical trials of pig kidney transplantation from being undertaken.
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Affiliation(s)
- Aaron C K Lucander
- Medical Scientist Training Program, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Eric Judd
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Charlestown, Massachusetts, USA
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Surgical Treatment for Empyema Thoracis: Prognostic Role of Preoperative Transthoracic Echocardiography and Serum Calcium. J Pers Med 2022; 12:jpm12061014. [PMID: 35743797 PMCID: PMC9225271 DOI: 10.3390/jpm12061014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/16/2022] [Accepted: 06/19/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Empyema is a major cause of mortality and hospitalization. Symptoms include difficulty breathing and chest pain. Calcium plays an essential role in the physiology of the cardiovascular system. However, there is little evidence on the role of echocardiography and the serum calcium levels of patients undergoing video-assisted thoracoscopic surgery (VATS) for empyema. This study aimed to investigate the risk factors for postoperative mortality in patients with empyema who required surgery. Methods: This single-institution retrospective study compared the outcomes of VATS for thoracic empyema (in terms of survival and mortality) in 122 patients enrolled between July 2015 and June 2019. Results: This study examined patients with thoracic empyema. The majority of the patients were males (100/122, 81.9%). The in-hospital/30-day mortality rate was 10.6% (13 patients). The calcium levels were 7.82 ± 1.17 mg/dL in the survival group and 6.88 ± 1.88 mg/dL in the mortality group (p = 0.032). In the mortality group, the utilization of echocardiography and serum calcium levels independently contributed to the risk prediction more than clinical variables. Patients in our cohort exhibited elevated pulmonary artery systolic pressure (PASP) and hypocalcemia, which were associated with increased postoperative mortality. Conclusion: Elevated PASP and calcium levels at the low end of the normal range demonstrated significant prognostic value in predicting mortality in patients with thoracic empyema who required surgical intervention. Recognizing this potential is critical in order to obtain better outcomes.
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Torregrosa JV, Ferreira AC, Cucchiari D, Ferreira A. Bone Mineral Disease After Kidney Transplantation. Calcif Tissue Int 2021; 108:551-560. [PMID: 33765230 DOI: 10.1007/s00223-021-00837-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/09/2021] [Indexed: 12/18/2022]
Abstract
Chronic kidney disease-mineral bone disorder (CKD-MBD) after kidney transplantation is a mix of pre-existing disorders and new alterations. The final consequences are reflected fundamentally as abnormal mineral metabolism (hypercalcemia, hypophosphatemia) and bone alterations [high or low bone turnover disease (as fibrous osteitis or adynamic bone disease), an eventual compromise of bone mineralization, decrease bone mineral density and bone fractures]. The major cause of post-transplantation hypercalcemia is the persistence of severe secondary hyperparathyroidism, and treatment options include calcimimetics or parathyroidectomy. On turn, hypophosphatemia is caused by both the persistence of high blood levels of PTH and/or high blood levels of FGF23, with its correction being very difficult to achieve. The most frequent bone morphology alteration is low bone turnover disease, while high-turnover osteopathy decreases in frequency after transplantation. Although the pathogenic mechanisms of these abnormalities have not been fully clarified, the available evidence suggests that there are a number of factors that play a very important role, such as immunosuppressive treatment, persistently high levels of PTH, vitamin D deficiency and hypophosphatemia. Fracture risk is four-fold higher in transplanted patients compared to general population. The most relevant risk factors for fracture in the kidney transplant population are diabetes mellitus, female sex, advanced age (especially > 65 years), dialysis vintage, high PTH levels and low phosphate levels, osteoporosis, pre-transplant stress fracture and high doses or prolonged steroids therapy. Treatment alternatives for CKD-MBD after transplantation include minimization of corticosteroids, use of calcium and vitamin D supplements, antiresorptives (bisphosphonates or Denosumab) and osteoformers (synthetic parathyroid hormone). As both mineral metabolism and bone disorders lead to increased morbidity and mortality, the presence of these changes after transplantation has to be prevented (if possible), minimized, diagnosed, and treated as soon as possible.
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Affiliation(s)
- Josep-Vicent Torregrosa
- Nephrology & Renal Transplant Department - Hospital Clínic, Barcelona, Spain.
- Universidad de Barcelona, Barcelona, Spain.
| | - Ana Carina Ferreira
- Nephrology Department, Centro Hospitalare, Universitário de Lisboa Central, Lisbon, Portugal
- Nova Medical School, Nova University, Lisbon, Portugal
| | - David Cucchiari
- Nephrology & Renal Transplant Department - Hospital Clínic, Barcelona, Spain
| | - Aníbal Ferreira
- Nephrology Department, Centro Hospitalare, Universitário de Lisboa Central, Lisbon, Portugal
- Nova Medical School, Nova University, Lisbon, Portugal
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