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Brociek-Piłczyńska A, Brodowska-Kania D, Szczygielski K, Lorent M, Zieliński G, Kowalewski P, Jurkiewicz D. A rare combination of tumor-induced osteomalacia caused by sinonasal glomangiopericytoma and coexisting parathyroid adenoma: case report and literature review. BMC Endocr Disord 2022; 22:31. [PMID: 35090436 PMCID: PMC8796561 DOI: 10.1186/s12902-022-00934-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/05/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Tumor-induced osteomalacia (TIO) is a rare, acquired disease of renal phosphate wasting and disturbed vitamin D homeostasis as a result of the action of a phosphaturic protein - FGF-23, produced by a neoplasm. Although the clinical and biochemical profile of the syndrome is characteristic, it remains underreported and unrecognized by clinicians. Hyperparathyroidism is rarely associated with oncogenic osteomalacia, but it should be considered because of potentially life-threatening hypophosphatemia caused by both conditions. CASE PRESENTATION We report a case of a 42-year-old woman admitted to the Department of Otolaryngology of the Military Institute of Medicine in Warsaw for the endoscopic resection of hormonally active glomangiopericytoma extending into the anterior skull base. She presented with a 5-year history of musculoskeletal pain and progressive weakness of the extremities which finally led her to become bedridden. After the excision of the tumor her symptoms and laboratory results gradually improved except increasing PTH serum levels. Further examination revealed a parathyroid proliferative tumor, which was surgically removed. The patient walked without aids at follow-up 16 months after the surgery. CONCLUSIONS This case is unusual because of tumor-induced osteomalacia and parathyroid adenoma occurring concomitantly. Further investigations of FGF-23 and PTH interplay should be conducted to elucidate the pathogenesis of hyperparathyroidism and tumorigenesis in some cases of TIO. By presenting this case, we wanted to remind clinicians of a rare and misdiagnosed paraneoplastic syndrome and highlight the importance of monitoring PTH concentrations during the follow-up of patients with TIO.
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Affiliation(s)
- Agnieszka Brociek-Piłczyńska
- Department of Otolaryngology with Division of Cranio-Maxillo-Facial Surgery, Military Institute of Medicine, Szaserów 128, 04-141, Warsaw, Poland.
| | - Dorota Brodowska-Kania
- Department of Endocrinology and Isotope Therapy, Military Institute of Medicine, Warsaw, Poland
| | - Kornel Szczygielski
- Department of Otolaryngology with Division of Cranio-Maxillo-Facial Surgery, Military Institute of Medicine, Szaserów 128, 04-141, Warsaw, Poland
| | - Małgorzata Lorent
- Department of Pathology, Military Institute of Medicine, Warsaw, Poland
| | - Grzegorz Zieliński
- Department of Neurosurgery, Military Institute of Medicine, Warsaw, Poland
| | - Piotr Kowalewski
- Department of General Surgery, Military Institute of Aviation Medicine, Warsaw, Poland
| | - Dariusz Jurkiewicz
- Department of Otolaryngology with Division of Cranio-Maxillo-Facial Surgery, Military Institute of Medicine, Szaserów 128, 04-141, Warsaw, Poland
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Lecoq AL, Chaumet-Riffaud P, Blanchard A, Dupeux M, Rothenbuhler A, Lambert B, Durand E, Boros E, Briot K, Silve C, Francou B, Piketty M, Chanson P, Brailly-Tabard S, Linglart A, Kamenický P. Hyperparathyroidism in Patients With X-Linked Hypophosphatemia. J Bone Miner Res 2020; 35:1263-1273. [PMID: 32101626 DOI: 10.1002/jbmr.3992] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/17/2020] [Accepted: 02/22/2020] [Indexed: 12/22/2022]
Abstract
X-linked hypophosphatemia (XLH) is characterized by increased activity of circulating FGF23 resulting in renal phosphate wasting and abnormal bone mineralization. Hyperparathyroidism may develop in XLH patients; however, its prevalence, pathogenesis, and clinical presentation are not documented. This observational study (CNIL 171036 v 0) recruited XLH adult patients in a single tertiary referral center. Each patient was explored in standardized conditions and compared with two healthy volunteers, matched for sex, age, and 25-OH vitamin D concentrations. The primary endpoint was the proportion of patients with hyperparathyroidism. The secondary endpoints were the factors influencing serum parathyroid hormone (PTH) concentrations and the prevalence of hypercalcemic hyperparathyroidism. Sixty-eight patients (51 women, 17 men) were enrolled and matched with 136 healthy volunteers. Patients had higher PTH concentrations compared with healthy controls (53.5 ng/L, interquartile range [IQR] 36.7-72.7 versus 36.0 ng/L, IQR 27.7-44.0, p < .0001). Hyperparathyroidism was observed in 17 patients of 68 (25%). In patients, a positive relationship between PTH and calcium concentrations and a negative relationship between PTH and phosphate concentrations were observed. Seven (10%) patients (3 premenopausal women, 1 postmenopausal woman, and 3 men) were diagnosed with hypercalcemic hyperparathyroidism. All underwent parathyroid surgery, with consecutive normalization of calcium and PTH concentrations. Hyperparathyroidism is a frequent complication in XLH adult patients. Disruption of the physiological regulation of PTH secretion contributes to parathyroid disease. Early-onset hypercalcemic hyperparathyroidism can be effectively and safely cured by surgical resection. © 2020 American Society for Bone and Mineral Research.
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Affiliation(s)
- Anne-Lise Lecoq
- Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Filière OSCAR, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Philippe Chaumet-Riffaud
- Hôpital de Bicêtre, Service de Biophysique et Médecine Nucléaire, AP-HP, Le Kremlin-Bicêtre, France
| | - Anne Blanchard
- Hôpital Européen Georges Pompidou, Centre d'Investigations Cliniques 1418, AP-HP, Le Kremlin-Bicêtre, France
| | - Margot Dupeux
- Hôpital de Bicêtre, Service d'Anatomie et Cytologie Pathologiques, AP-HP, Le Kremlin-Bicêtre, France
| | - Anya Rothenbuhler
- Hôpital de Bicêtre, Endocrinologie et Diabétologie de l'Enfant, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Filière OSCAR, AP-HP, Le Kremlin-Bicêtre, France
| | - Benoit Lambert
- Hôpital de Bicêtre, Service de Chirurgie Viscérale et Digestive, AP-HP, Le Kremlin-Bicêtre, France
| | - Emmanuel Durand
- Hôpital de Bicêtre, Service de Biophysique et Médecine Nucléaire, AP-HP, Le Kremlin-Bicêtre, France
| | - Erika Boros
- Hôpital de Bicêtre, Endocrinologie et Diabétologie de l'Enfant, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Filière OSCAR, AP-HP, Le Kremlin-Bicêtre, France
| | - Karine Briot
- Hôpital Cochin, Service de Rhumatologie, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate Filière OSCAR, AP-HP, Paris, France
| | - Caroline Silve
- Hôpital Cochin, Service de Génétique et Biologie Moléculaires, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Filière OSCAR, AP-HP, Paris, France
| | - Bruno Francou
- Hôpital de Bicêtre, Laboratoire de Génétique Moléculaire, Pharmacogénétique et Hormonologie, AP-HP, Le Kremlin-Bicêtre, France
| | - Marie Piketty
- Hôpital Necker, Service d'Explorations fonctionnelles Physiologie et Neurophysiologie, AP-HP, Paris, France
| | - Philippe Chanson
- Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Filière OSCAR, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France.,Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Sylvie Brailly-Tabard
- Hôpital de Bicêtre, Laboratoire de Génétique Moléculaire, Pharmacogénétique et Hormonologie, AP-HP, Le Kremlin-Bicêtre, France
| | - Agnès Linglart
- Hôpital de Bicêtre, Endocrinologie et Diabétologie de l'Enfant, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Filière OSCAR, AP-HP, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Peter Kamenický
- Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Filière OSCAR, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France.,Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
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Lecoq AL, Brandi ML, Linglart A, Kamenický P. Management of X-linked hypophosphatemia in adults. Metabolism 2020; 103S:154049. [PMID: 31863781 DOI: 10.1016/j.metabol.2019.154049] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/23/2019] [Accepted: 11/25/2019] [Indexed: 11/27/2022]
Abstract
X-linked hypophosphatemia (XLH) is caused by mutations in the PHEX gene which result in Fibroblast Growth Factor-23 (FG-F23) excess and phosphate wasting. Clinically, XLH children present with rickets, bone deformities and short stature. In adulthood, patients may still be symptomatic with bone and joint pain, osteomalacia-related fractures or pseudofractures, precocious osteoarthrosis, enthesopathy, muscle weakness and severe dental anomalies. Besides these musculoskeletal and dental manifestations, adult XLH patients are also prone to secondary and tertiary hyperparathyroidism, cardiovascular and metabolic disorders. Pathophysiology of hyperparathyroidism is only partially understood but FGF23 excess and deficient production of calcitriol likely contributes to its development. Similarly, the pathophysiological mechanisms of potential cardiovascular and metabolic involvements are not clear, but FGF-23 excess may play an essential role. Treatment should be considered in symptomatic patients, patients undergoing orthopedic or dental surgery and women during pregnancy and lactation. Treatment with oral phosphate salts and active vitamin D analogs has incomplete efficacy and potential risks. Burosumab, a recombinant human monoclonal antibody against FGF-23, has proven its efficacy in phase 2 and phase 3 clinical trials in adult patients with XLH, but currently its position as first line or second line treatment differ among the countries.
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Affiliation(s)
- Anne-Lise Lecoq
- AP-HP, Department of Endocrinology and Reproductive Diseases, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, filière OSCAR, and Platform of Expertise for Rare Disorders, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, University Hospital of Florence, Florence, Italy
| | - Agnès Linglart
- AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, filière OSCAR, and Platform of Expertise for Rare Disorders, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France; Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Peter Kamenický
- AP-HP, Department of Endocrinology and Reproductive Diseases, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, filière OSCAR, and Platform of Expertise for Rare Disorders, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France; Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France.
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DeLacey S, Liu Z, Broyles A, El-Azab SA, Guandique CF, James BC, Imel EA. Hyperparathyroidism and parathyroidectomy in X-linked hypophosphatemia patients. Bone 2019; 127:386-392. [PMID: 31276850 PMCID: PMC6836672 DOI: 10.1016/j.bone.2019.06.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/18/2019] [Accepted: 06/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND X-linked hypophosphatemia (XLH) causes rickets, osteomalacia, skeletal deformities and growth impairment, due to elevated fibroblast growth factor 23 and hypophosphatemia. Conventional therapy requires high doses of phosphate salts combined with active vitamin D analogues. Risks of this regimen include nephrocalcinosis and secondary hyperparathyroidism or progression to tertiary (hypercalcemic) hyperparathyroidism. METHODS The primary goals were to estimate the prevalence of hyperparathyroidism and to characterize parathyroidectomy outcomes regarding hypercalcemia among XLH patients. XLH patients attending our center from 1/2000 to 12/2017 were included in a retrospective chart review. Prevalence of nephrocalcinosis and eGFR < 60 ml/min/1.73m2 was also assessed. RESULTS Of 104 patients with XLH, 84 had concurrent measurements of calcium and PTH (40 adults and 44 children). Of these, 70/84 (83.3%), had secondary or tertiary hyperparathyroidism at any time point. Secondary hyperparathyroidism was persistent in 62.2% of those with data at multiple timepoints. Tertiary hyperparathyroidism had an overall prevalence of 14/84 (16.7%) patients. Parathyroidectomy was performed in 8/84 (9.5%) of the total population. After parathyroidectomy, persistent or recurrent tertiary hyperparathyroidism was detected in 6/8 (75%) patients at a median of 6 years (from 0 to 29 years). One patient had chronic post-surgical hypoparathyroidism and one patient remained normocalcemic 4 years after surgery. Nephrocalcinosis was more prevalent in patients with tertiary hyperparathyroidism than those without (60.0% vs 18.6%). Chronic kidney disease (eGFR < 60 ml/min/1.73m2) was also more prevalent in patients with tertiary hyperparathyroidism than those without (35.7% vs 1.5%). CONCLUSION The majority of patients with XLH develop secondary hyperparathyroidism during treatment with phosphate and active vitamin D. A significant proportion develops tertiary hyperparathyroidism and most have recurrence or persistence of hypercalcemia after surgery.
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Affiliation(s)
- Sean DeLacey
- Indiana University School of Medicine, Department of Medicine, United States of America; Indiana University School of Medicine, Department of Pediatrics, United States of America
| | - Ziyue Liu
- Indiana University School of Public Health, Department of Biostatistics, United States of America
| | - Andrea Broyles
- Regenstrief Institute, Data Core Services, United States of America
| | - Sarah A El-Azab
- Regenstrief Institute, Data Core Services, United States of America
| | | | - Benjamin C James
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Surgery, United States of America
| | - Erik A Imel
- Indiana University School of Medicine, Department of Medicine, United States of America; Indiana University School of Medicine, Department of Pediatrics, United States of America.
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Rafaelsen S, Johansson S, Ræder H, Bjerknes R. Hereditary hypophosphatemia in Norway: a retrospective population-based study of genotypes, phenotypes, and treatment complications. Eur J Endocrinol 2016; 174:125-36. [PMID: 26543054 PMCID: PMC4674593 DOI: 10.1530/eje-15-0515] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 11/04/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Hereditary hypophosphatemias (HH) are rare monogenic conditions characterized by decreased renal tubular phosphate reabsorption. The aim of this study was to explore the prevalence, genotypes, phenotypic spectrum, treatment response, and complications of treatment in the Norwegian population of children with HH. DESIGN Retrospective national cohort study. METHODS Sanger sequencing and multiplex ligand-dependent probe amplification analysis of PHEX and Sanger sequencing of FGF23, DMP1, ENPP1KL, and FAM20C were performed to assess genotype in patients with HH with or without rickets in all pediatric hospital departments across Norway. Patients with hypercalcuria were screened for SLC34A3 mutations. In one family, exome sequencing was performed. Information from the patients' medical records was collected for the evaluation of phenotype. RESULTS Twety-eight patients with HH (18 females and ten males) from 19 different families were identified. X-linked dominant hypophosphatemic rickets (XLHR) was confirmed in 21 children from 13 families. The total number of inhabitants in Norway aged 18 or below by 1st January 2010 was 1,109,156, giving an XLHR prevalence of ∼1 in 60,000 Norwegian children. FAM20C mutations were found in two brothers and SLC34A3 mutations in one patient. In XLHR, growth was compromised in spite of treatment with oral phosphate and active vitamin D compounds, with males tending to be more affected than females. Nephrocalcinosis tended to be slightly more common in patients starting treatment before 1 year of age, and was associated with higher average treatment doses of phosphate. However, none of these differences reached statistical significance. CONCLUSIONS We present the first national cohort of HH in children. The prevalence of XLHR seems to be lower in Norwegian children than reported earlier.
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Affiliation(s)
- Silje Rafaelsen
- Section for PediatricsDepartment of Clinical Science, Haukeland University Hospital, University of Bergen, N-5021 Bergen, NorwayCenter for Medical Genetics and Molecular MedicineDepartment of PediatricsHaukeland University Hospital, Bergen, Norway
| | - Stefan Johansson
- Section for PediatricsDepartment of Clinical Science, Haukeland University Hospital, University of Bergen, N-5021 Bergen, NorwayCenter for Medical Genetics and Molecular MedicineDepartment of PediatricsHaukeland University Hospital, Bergen, Norway Section for PediatricsDepartment of Clinical Science, Haukeland University Hospital, University of Bergen, N-5021 Bergen, NorwayCenter for Medical Genetics and Molecular MedicineDepartment of PediatricsHaukeland University Hospital, Bergen, Norway
| | - Helge Ræder
- Section for PediatricsDepartment of Clinical Science, Haukeland University Hospital, University of Bergen, N-5021 Bergen, NorwayCenter for Medical Genetics and Molecular MedicineDepartment of PediatricsHaukeland University Hospital, Bergen, Norway Section for PediatricsDepartment of Clinical Science, Haukeland University Hospital, University of Bergen, N-5021 Bergen, NorwayCenter for Medical Genetics and Molecular MedicineDepartment of PediatricsHaukeland University Hospital, Bergen, Norway
| | - Robert Bjerknes
- Section for PediatricsDepartment of Clinical Science, Haukeland University Hospital, University of Bergen, N-5021 Bergen, NorwayCenter for Medical Genetics and Molecular MedicineDepartment of PediatricsHaukeland University Hospital, Bergen, Norway Section for PediatricsDepartment of Clinical Science, Haukeland University Hospital, University of Bergen, N-5021 Bergen, NorwayCenter for Medical Genetics and Molecular MedicineDepartment of PediatricsHaukeland University Hospital, Bergen, Norway
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Carpenter TO, Olear EA, Zhang JH, Ellis BK, Simpson CA, Cheng D, Gundberg CM, Insogna KL. Effect of paricalcitol on circulating parathyroid hormone in X-linked hypophosphatemia: a randomized, double-blind, placebo-controlled study. J Clin Endocrinol Metab 2014; 99:3103-11. [PMID: 25029424 PMCID: PMC4154090 DOI: 10.1210/jc.2014-2017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
CONTEXT Hyperparathyroidism occurs frequently in X-linked hypophosphatemia (XLH) and may exacerbate phosphaturia, potentially affecting skeletal abnormalities. OBJECTIVE The objective of the study was to suppress elevated PTH levels in XLH patients. DESIGN This was a prospective, randomized, placebo-controlled, double-blind, 1-year trial of paricalcitol, with outcomes measured at entry and 1 year later. SETTING PATIENTS were recruited from the investigators' clinics or referred from throughout the United States. Data were collected in an in-patient hospital research unit. PATIENTS Subjects with a clinical diagnosis of XLH and hyperparathyroidism were offered participation and were eligible if they were 9 years old or older and not pregnant, and their serum calcium level was less than 10.7 mg/dL, their 25-hydroxyvitamin D level was 20 ng/mL or greater, and their creatinine level was 1.5 mg/dL or less. INTERVENTION The intervention for this study was the use of paricalcitol or placebo for 1 year. MAIN OUTCOME MEASURES Determined prior to trial onset was the change in PTH area under the curve. Secondary outcomes included renal phosphate threshold per glomerular filtration rate, serum phosphorus, serum alkaline phosphatase activity, and (99m)Tc-methylenediphosphonate bone scans. RESULTS PTH area under the curve decreased 17% with paricalcitol, differing (P = .007) from the 20% increase with placebo. The renal phosphate threshold per glomerular filtration rate increased 17% with paricalcitol and decreased 21% with placebo (P = .05). Serum phosphorus increased 12% with paricalcitol but did not differ from placebo. Paricalcitol decreased alkaline phosphatase activity in adults by 21% (no change with placebo, P = .04). Bone scans improved in 6 of 17 paricalcitol subjects, whereas no placebo-treated subject improved. Hypercalciuria developed in six paricalcitol subjects and persisted from baseline in one placebo subject. CONCLUSIONS Suppression of PTH may be a useful strategy for skeletal improvement in XLH patients with hyperparathyroidism, and paricalcitol appears to be an effective adjunct to standard therapy in this setting. Although paricalcitol was well tolerated, urinary calcium and serum calcium and creatinine should be monitored closely with its use.
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Affiliation(s)
- Thomas O Carpenter
- Departments of Pediatrics (Endocrinology) (T.O.C., E.A.O., B.K.E.), Internal Medicine (Endocrinology) (C.A.S., K.L.I.), Orthopaedics and Rehabilitation (T.O.C., C.M.G.), and Diagnostic Radiology (Nuclear Medicine) (D.C.), Yale University School of Medicine, New Haven, Connecticut 06520; and the Veterans Administration Cooperative Studies Program Coordinating Center (JHZ), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut 06516
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Abstract
We reviewed the etiology and management of secondary and tertiary hyperparathyroidism. Secondary hyperparathyroidism is characterized by an increase in parathyroid hormone (PTH) that is appropriate and in response to a stimulus, most commonly low serum calcium. In secondary hyperparathyroidism, the serum calcium is normal and the PTH level is elevated. Tertiary hyperparathyroidism is characterized by excessive secretion of PTH after longstanding secondary hyperparathyroidism, in which hypercalcemia has ensued. Tertiary hyperparathyroidism typically occurs in men and women with chronic kidney disease usually after kidney transplant. The etiology and treatment of secondary hyperparathyroidism is relatively straightforward whereas data on the management of tertiary hyperparathyroidism is limited to a few small trials with short follow-up.
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Affiliation(s)
- Sophie A Jamal
- University of Toronto, Women's College Research Institute, Toronto, Ontario, Canada.
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Nephrolithiasis and Its Interrelationship with Vitamin D, Parathyroid Hormone, and Calcium. Urolithiasis 2012. [DOI: 10.1007/978-1-4471-4387-1_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
The recent recognition that hyperphosphatemia is a strong predictor of survival on dialysis has rekindled interest in the regulation and control of serum phosphate. In incipient renal failure hyperphosphatemia is prevented by increased fractional renal phosphate excretion mediated via an increase in parathyroid hormone and the novel phosphaturic hormone FGF-23 (and possibly others). At a glomerular filtration rate of approximately 30 ml/min this compensatory mechanism fails and hyperphosphatemia ensues. Pre-dialytic serum phosphate concentrations of >6 mg/dl increase cardiac mortality presumably to a large extent, but not exclusively, via promoting vascular calcification. It has recently been recognized that vascular calcification is not only a passive precipitation process following transgression of the critical Ca-x-P product, but is an active process accompanied by expression of osteoblastic bone markers in the vessel wall. Because of the recent recognition of the relation between vascular calcification and serum phosphate as well as serum calcium, there is a need for novel calcium-free phosphate binders. Currently sevelamer and lanthanum carbonate have been introduced and trivalent iron preparations are under development.
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Affiliation(s)
- Eberhard Ritz
- Department Internal Medicine and Pathology, Ruperto Carola University, Heidelberg, Germany.
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Hernández García B, Morey Villar M, Escorihuela Esteban R, Soriano Guillén L. Aparición de hiperparatiroidismo en el raquitismo hipofosfatémico familiar dominante ligado al cromosoma X: ¿causa iatrogénica o genética? Med Clin (Barc) 2010; 134:136-8. [DOI: 10.1016/j.medcli.2009.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Accepted: 02/05/2009] [Indexed: 11/30/2022]
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Abstract
Hyperparathyroidism is due to increased activity of the parathyroid glands, either from an intrinsic abnormal change altering excretion of parathyroid hormone (primary or tertiary hyperparathyroidism) or from an extrinsic abnormal change affecting calcium homoeostasis stimulating production of parathyroid hormone (secondary hyperparathyroidism). Primary hyperparathyroidism is the third most common endocrine disorder, with the highest incidence in postmenopausal women. Asymptomatic disease is common, and severe disease with renal stones and metabolic bone disease arises less frequently now than it did 20-30 years ago. Primary hyperparathyroidism can be cured by surgical removal of an adenoma, increasingly by minimally invasive parathyroidectomy. Medical management of mild disease is possible with bisphosphonates, hormone replacement therapy, and calcimimetics. Vitamin D deficiency is a common cause of secondary hyperparathyroidism, particularly in elderly people. However, the biochemical definition of vitamin D deficiency and its treatment are subject to much debate. Secondary hyperparathyroidism as the result of chronic kidney disease is important in the genesis of renal bone disease, and several new treatments could help achieve the guidelines set out by the kidney disease outcomes quality initiative.
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MESH Headings
- Acute Disease
- Algorithms
- Calcium/physiology
- Causality
- Decision Trees
- Diagnosis, Differential
- Homeostasis/physiology
- Humans
- Hyperparathyroidism, Primary/diagnosis
- Hyperparathyroidism, Primary/epidemiology
- Hyperparathyroidism, Primary/etiology
- Hyperparathyroidism, Primary/therapy
- Hyperparathyroidism, Secondary/diagnosis
- Hyperparathyroidism, Secondary/epidemiology
- Hyperparathyroidism, Secondary/etiology
- Hyperparathyroidism, Secondary/therapy
- Incidence
- Kidney Failure, Chronic/complications
- Mass Screening
- Parathyroid Hormone/physiology
- Parathyroidectomy
- Patient Selection
- Practice Guidelines as Topic
- Prevalence
- Vitamin D Deficiency/complications
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Affiliation(s)
- William D Fraser
- Unit of Clinical Chemistry, School of Clinical Sciences, University of Liverpool, Liverpool, UK.
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An Unusual Case of Autonomous Hyperparathyroidism in a Patient With X-Linked Hypophosphatemic Rickets and Kallmann Syndrome. Am J Med Sci 2009; 337:134-7. [DOI: 10.1097/maj.0b013e31816ecb00] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Autonomous Hyperparathyroidism Following Long-term Phosphate Treatment for Tumor-Induced Osteomalacia. ACTA ACUST UNITED AC 2007. [DOI: 10.1097/ten.0b013e3181514e2b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Su DH, Liao KM, Chang YC, Tsai KS. Secondary hyperparathyroidism as a palpable intrathyroid parathyroid gland in a patient with hypophosphatemic osteomalacia. J Bone Miner Metab 2006; 24:114-7. [PMID: 16502117 DOI: 10.1007/s00774-005-0656-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2005] [Accepted: 10/03/2005] [Indexed: 10/25/2022]
Abstract
Secondary hyperparathyroidism is sometimes seen in patients with hypophosphatemic osteomalacia after long-term oral phosphate therapy. Parathyroidectomy is sometimes needed for the correction of hypercalcemia in these patients, and is rarely performed in patients without hypercalcemia. A 46-year-old female patient had hypophosphatemic osteomalacia with unknown cause and secondary hyperparathyroidism. A palpable neck mass developed after long-term oral phosphate therapy. An intrathyroid parathyroid gland was confirmed through partial thyroidectomy and parathyroidectomy. Renal phosphate wasting decreased strongly, and serum parathyroid hormone was in the normal range after the operation. A correction of secondary hyperparathyroidism may partially overcome hyperphosphaturia in some patients with hypophosphatemic rickets.
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Affiliation(s)
- Deng-Huang Su
- Department of Internal Medicine, Far Eastern Polyclinic, Taipei, Taiwan
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MacIsaac R, Tsalamandris C, Panagiotopoulos S, Smith T, McNeill K, Jerums G. Type 2 Diabetes: Absence of Proteinuria Does Not Preclude Loss of Renal Function. J Am Soc Nephrol 2005. [DOI: 10.1681/asn.2004110976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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16
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Bai X, Miao D, Li J, Goltzman D, Karaplis AC. Transgenic mice overexpressing human fibroblast growth factor 23 (R176Q) delineate a putative role for parathyroid hormone in renal phosphate wasting disorders. Endocrinology 2004; 145:5269-79. [PMID: 15284207 DOI: 10.1210/en.2004-0233] [Citation(s) in RCA: 271] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Fibroblast growth factor 23 (FGF23) is a recently characterized protein likely involved in the regulation of serum phosphate homeostasis. Increased circulating levels of FGF23 have been reported in patients with renal phosphate-wasting disorders, but it is unclear whether FGF23 is the direct mediator responsible for the decreased phosphate transport at the proximal renal tubules and the altered vitamin D metabolism associated with these states. To examine this question, we generated transgenic mice expressing and secreting from the liver human FGF23 (R176Q), a mutant form that fails to be degraded by furin proteases. At 1 and 2 months of age, mice carrying the transgene recapitulated the biochemical (decreased urinary phosphate reabsorption, hypophosphatemia, low serum 1,25-dihydroxyvitamin D(3)) and skeletal (rickets and osteomalacia) alterations associated with these disorders. Unexpectantly, marked changes in parameters of calcium homeostasis were also observed, consistent with secondary hyperparathyroidism. Moreover, in the kidney the anticipated alterations in the expression of hydroxylases associated with vitamin D metabolism were not observed despite the profound hypophosphatemia and increased circulating levels of PTH, both major physiological stimuli for 1,25-dihydroxyvitamin D(3) production. Our findings strongly support the novel concept that high circulating levels of FGF23 are associated with profound disturbances in the regulation of phosphate and vitamin D metabolism as well as calcium homeostasis and that elevated PTH levels likely also contribute to the renal phosphate wasting associated with these disorders.
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Affiliation(s)
- Xiuying Bai
- Division of Endocrinology, Department of Medicine, Sir Mortimer B. Davis-Jewish General Hospital, 3755 Cote Ste. Catherine Road, Montréal, Québec, Canada
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17
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Moltz KC, Friedman AH, Nehgme RA, Kleinman CS, Carpenter TO. Ectopic cardiac calcification associated with hyperparathyroidism in a boy with hypophosphatemic rickets. Curr Opin Pediatr 2001; 13:373-5. [PMID: 11717565 DOI: 10.1097/00008480-200108000-00015] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
An adolescent with hypophosphatemic rickets developed cardiac calcifications in the absence of hypercalcemia or elevation of the phosphocalcic product (the product of the total serum calcium and phosphorus concentrations). Cardiac calcifications led to aortic and mitral valve dysfunction, myocardial calcification, and arrhythmia. Hyperparathyroidism probably played a significant role in the development of this complication, which emphasizes the necessity for intermittent assessment of parathyroid status in individuals receiving medical therapy for hypophosphatemic rickets.
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Affiliation(s)
- K C Moltz
- Department of Pediatrics, Pediatric Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
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18
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Kozlowski K, Posen S. Malignant hypophosphathaemic bone disease. Eur J Radiol 2001; 37:134-8. [PMID: 11223481 DOI: 10.1016/s0720-048x(00)00247-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A case of crippling osteoporosis with muscular weakness, hypophosphatemia, hyperparathyroidism, defective skeletal calcification and cartilage destruction is reported. The patient, a male was observed from the age of 2 1/2 until his death at the age of 33 years. This bone/cartilage disease failed to respond to phosphate supplementation, parathyroidectomy and calcitriol. We believe this may represent a hitherto undescribed entity.
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Affiliation(s)
- K Kozlowski
- Department of Radiology, Royal Alexandra Hospital for Children, Sydney, Australia
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Affiliation(s)
- N Thomas
- Department of Endocrinology, Royal Adelaide Hospital, Adelaide, Australia.
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Silva IV, Blaisdell CJ, Guggino SE, Guggino WB. PTH regulates expression of ClC-5 chloride channel in the kidney. Am J Physiol Renal Physiol 2000; 278:F238-45. [PMID: 10662728 DOI: 10.1152/ajprenal.2000.278.2.f238] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Mutations in the chloride channel, ClC-5, have been described in several inherited diseases that result in the formation of kidney stones. To determine whether ClC-5 is also involved in calcium homeostasis, we investigated whether ClC-5 mRNA and protein expression are modulated in rats deficient in 1alpha,25(OH)(2) vitamin D(3) with and without thyroparathyroidectomy. Parathyroid hormone (PTH) was replaced in some animals. Vitamin D-deficient, thyroparathyrodectomized rats had lower serum and higher urinary calcium concentrations compared with control animals as well as lower serum PTH and calcitonin concentrations. ClC-5 mRNA and protein levels in the cortex decrease in vitamin D-deficient, thyroparathyroidectomized rats compared with both control and vitamin D-deficient animals. ClC-5 mRNA and protein expression increase near to control levels in vitamin D-deficient, thyroparathyroidectomized rats injected with PTH. No significant changes in ClC-5 mRNA and protein expression in the medulla were detected in any experimental group. Our results suggest that PTH modulates the expression of ClC-5 in the kidney cortex and that neither 1alpha,25(OH)(2) vitamin D(3) nor PTH regulates ClC-5 expression in the medulla. The pattern of expression of ClC-5 varies with urinary calcium. Animals with higher urinary calcium concentrations have lower levels of ClC-5 mRNA and protein expression, suggesting that the ClC-5 chloride channel plays a role in calcium reabsorption.
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Affiliation(s)
- I V Silva
- Eudowood Division of Respiratory Sciences, The Johns Hopkins School of Medicine, The Johns Hopkins University, Baltimore, Maryland 21205, USA
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Estepa JC, Aguilera-Tejero E, Lopez I, Almaden Y, Rodriguez M, Felsenfeld AJ. Effect of phosphate on parathyroid hormone secretion in vivo. J Bone Miner Res 1999; 14:1848-54. [PMID: 10571684 DOI: 10.1359/jbmr.1999.14.11.1848] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Alterations in phosphate homeostasis play an important role in the development of secondary hyperparathyroidism in renal failure. Until recently, it was accepted that phosphate retention only increased parathyroid hormone (PTH) secretion through indirect mechanisms affecting calcium regulation and calcitriol synthesis. However, recent in vitro studies have suggested that phosphate may directly affect PTH secretion. Our goal was to determine whether in vivo an intravenous phosphate infusion stimulated PTH secretion in the absence of changes in serum calcium. Three different doses of phosphate were infused intravenously during 120 minutes to increase the serum phosphate concentration in dogs. Sulfate was also infused intravenously as a separate experimental control. A simultaneous calcium clamp was performed to maintain a normal ionized calcium concentration throughout all studies. At the lowest dose of infused phosphate (1.2 mmol/kg), serum phosphate values increased to approximately 3 mM, but PTH values did not increase. At higher doses of infused phosphate (1.6 mmol/kg and 2.4 mmol/kg), the increase in serum phosphate to values of approximately 4 mM and 5 mM, respectively, was associated with increases in PTH, even though the ionized calcium concentration did not change. Increases in PTH were not observed until 30-60 minutes into the study. These increases were not sustained, since by 120 minutes PTH values were not different from baseline or controls despite the maintenance of marked hyperphosphatemia. During the sulfate infusion, serum sulfate values increased by approximately 3-fold, but no change in PTH values were observed. In conclusion, an acute elevation in serum phosphate stimulated PTH secretion in the intact animal, but the magnitude of hyperphosphatemia exceeded the physiologic range. Future studies are needed to determine whether PTH stimulation is more sensitive to phosphate loading in states of chronic phosphate retention. Moreover, the mechanisms responsible for the delay in PTH stimulation and the failure to sustain the increased PTH secretion need further evaluation.
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Affiliation(s)
- J C Estepa
- Departamento de Medicina y Cirugía Animal Facultad de Veterinaria, Universidad de Cordoba, Cordoba, Spain
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Eddy MC, McAlister WH, Whyte MP. X-linked hypophosphatemia: normal renal function despite medullary nephrocalcinosis 25 years after transient vitamin D2-induced renal azotemia. Bone 1997; 21:515-20. [PMID: 9430241 DOI: 10.1016/s8756-3282(97)00199-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Nephrocalcinosis (NC) detected by ultrasound is a recognized abnormality for some patients with X-linked hypophosphatemia (XLH) who received vitamin D2 and inorganic phosphate therapy, but is commonly observed in XLH patients treated with 1,25-dihydroxyvitamin D3 and inorganic phosphate supplementation. Nevertheless, long-term follow-up of kidney function in XLH patients with NC detected ultrasonographically has not been reported. We investigated two women with XLH, ages 31 (patient 1) and 39 (patient 2) years, each of whom had suffered at least one documented episode of vitamin D2-induced hypercalcemia and renal azotemia during childhood. Patient 2 had also been treated with inorganic phosphate. No medications for XLH had been taken during adulthood. Renal ultrasonography at our institution demonstrated marked bilateral medullary NC in both women. No other explanation was found for their NC that apparently occurred several decades earlier from medical therapy for XLH. Detailed studies (including creatinine clearance, beta2-microglobulin excretion, and fasting urinary osmolality and acidification) revealed no impairment of kidney function in either patient. Our findings indicate that subradiographic medullary NC acquired during medical therapy for XLH may persist for decades, but with no adverse renal sequelae. Definitive (long-term) assessment of kidney function in the XLH population with NC, however, will be necessary to fully understand the risk of current medical treatment for this most common heritable form of rickets.
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Affiliation(s)
- M C Eddy
- Metabolic Research Unit, Shriners Hospital for Children, St. Louis, MO 63131-3597, USA
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Abstract
This article updates the practicing pediatrician's knowledge of the hypophophatemic disorders that may occur in children. The classic X-linked disorder is emphasized. Details of clinical manifestations, the wide spectrum of disease severity, and complications of the disorder in adults are reviewed. Recent research, new genetic findings, and speculations regarding pathophysiology are discussed. A strategy for approaching medical treatment of X-linked hypophosphatemic rickets is provided, together with complications of treatment and treatment after cessation of growth.
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Affiliation(s)
- T O Carpenter
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
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