Association between Parathyroid Hormone, 25 (OH) Vitamin D, and Chronic Kidney Disease: A Population-Based Study

Combined associations of 25-hydroxivitamin D and parathyroid hormone with diabetes risk and associated comorbidities among U.S. white and black women

Background/objectives

There is evidence of black–white differences in vitamin D status and cardiometabolic health. This study aimed to further evaluate the joint associations of 25-hydroxyvitamin D [25(OH)D] and parathyroid hormone (PTH) with risks of diabetes and related cardiometabolic comorbidities among white and black women.

Subjects/methods

We cross-sectionally and prospectively analyzed data from 1850 black and 3000 white postmenopausal women without cardiovascular disease or dialysis at baseline from the Women’s Health Initiative—Observational Study. Weighted Cox proportional hazards analyses and weighted logistic regression models were used to examine the joint associations of 25(OH)D and PTH with incident diabetes and prevalence of other diabetes-related cardiometabolic comorbidities (including CKD, hypertension, or obesity).

Results

We identified 3322 cases of obesity (n = 1629), hypertension (n = 2759), or CKD (n = 318) at baseline and 453 incident cases of diabetes during 11 years of follow-up. Cross-sectionally, lower 25(OH)D and higher PTH were independently associated with higher prevalence of hypertension [odds ratio (OR) = 0.79; 95% confidence interval (CI): 0.72–0.87 and OR = 1.55; 95% CI: 1.39–1.73] among white women only. When stratified by diabetes status, compared to women with 25(OH)D ≥50 nmol/L and PTH ≤6.89 pmol/L (65 pg/mL), women who did not have diabetes with vitamin D deficiency (<50 nmol/L) and PTH excess (>6.89 pmol/L) had higher prevalence of CKD, hypertension, or obesity (OR = 4.23; 95% CI: 2.90–6.18) than women who had diabetes (OR = 1.89; 95% CI: 0.96–3.71). Prospectively, lower 25(OH)D was associated with lower diabetes incidence [hazard ratio (HR) = 0.73; 95% CI: 0.62–0.86] in white women. Jointly, compared to the group with 25(OH)D ≥50 nmol/L and PTH ≤6.89 pmol/L, white women with 25(OH)D deficiency (<50 nmol/L) had elevated risk for diabetes, regardless of PTH levels.

Conclusions

Low 25(OH)D and high PTH were jointly associated with increased risk of diabetes among white women only. Their joint associations with high prevalence of CKD, hypertension, and obesity were more pronounced among women without diabetes.

[The clinical practice guidelines for primary hyperparathyroidism, short version]

Primary hyperparathyroidism (PHPT) is an endocrine disorder of parathyroid glands characterized by excessive secretion of parathyroid hormone (PTH) with an upper normal or elevated blood calcium level. Classical PHPT refers to a symptomatic, multi-system disorder, wich can lead to a significant decrease in the quality of life, disability of patients, and even an increased risk of premature death. Hypercalcemia and the catabolic effect of PTH on various cells are considered as the main pathogenetic mechanisms of the PHPT associated complications. In the last two decades, there has been an increase in the incidence of PHPT, mainly due to the mild forms of the disease, primarily due to the routine calcium screening in North America, Western Europe and, Asia. High prevalence of the disease, as well as the variety of clinical manifestations, cause the attention of different specialists - physicians, rheumatologists, urologists, nephrologists, cardiologists and other doctors. This review cover the main issues of Russian guidelines for the management of PHPT, approved in 2020, including laboratory and instrumental methods, differential diagnosis, surgical and conservative approach, short-term and long-term follow-up. This guidelines also include the recommendations for special groups of patients with hereditary forms of PHPT, parathyroid carcinoma, PHPT during pregnancy.

The Correlation between Estimated Glomerular Filtration Rate and Parathyroid Hormone Levels in Predialysis-chronic Kidney Disease Adult Patients at Sanglah General Hospital, Bali, Indonesia

BACKGROUND: Chronic kidney disease (CKD) is a structural or functional kidney disease for more than 3 months. In predialysis CKD patients, the serum parathyroid hormone levels increase progressively since the early stages of the disease to maintain phosphate homeostasis. Glomerular filtration rate (GFR) has been widely accepted to assess renal function. The GFR assessment is used to determine the CKD stadium. AIM: This study aims to analyze the correlation between GFR and parathyroid hormone levels in predialysis CKD patients undergoing treatment at Sanglah General Hospital Denpasar. METHODS: A cross-sectional observational study was conducted among predialysis CKD patients undergoing treatment at Sanglah General Hospital Denpasar who met the inclusion and exclusion criteria. The inclusion criteria were adult patients (≥18 years) who were accepting to participate in the study. Exclusion criteria were patients with predialysis CKD after thyroidectomy and/or parathyroidectomy and liver disease. The parathyroid hormone levels, blood urea nitrogen, creatinine, and GFR were examined and analyzed by SPSS version 17 for Windows. RESULTS: A total of 77 patients with predialysis CKD in this study obtained a median of e-GFR of 21.09 (4.72–75.80) mL/min/1.73 m2. The median level of parathyroid hormone was 82.07 pg/mL (15.83–716.60 pg/mL). Spearman’s correlation analysis results obtained a strong and significant negative correlation between the e-GFR value and parathyroid hormone levels (r = −0.540; p = 0.000). CONCLUSION: The parathyroid hormone levels assessment could be used as a recommendation in evaluating the CKD progressivity among predialysis adult patients at Sanglah General Hospital, Bali, Indonesia, due to the strong significant correlation.

The association of secondary hyperparathyroidism and myocardial damages in hemodialysis end-stage renal disease patients: assessed by cardiovascular magnetic resonance native T1 mapping

BACKGROUND

Secondary hyperparathyroidism is a common complication of end-stage renal disease (ESRD), which may be associated with cardiovascular diseases. Thus, this study aimed to explore myocardial damage using non-contrast cardiovascular magnetic resonance (CMR) in ESRD patients undergoing hemodialysis and further investigate its relationship with parathyroid hormone (PTH) toxicity.

METHODS

Seventy-two adult ESRD patients receiving regular hemodialysis and 30 healthy subjects underwent CMR examination. Continuous CMR cine sections from the mitral valve level to the left ventricular (LV) apex in the short-axis plane, cine series of vertical two-chamber long-axis plane, and horizontal four-chamber plane were acquired. Native T1 mapping was obtained using modified Look-Locker inversion recovery (MOLLI) sequences. Native T1 values and myocardial strain were analyzed.  Immunoreactive parathyroid hormone (iPTH) was obtained from all enrolled patients.

RESULTS

Forty (55.6%) hemodialysis ESRD patients were found to have increased iPTH levels. LV ejection fraction (LVEF) of both ESRD patients with targeted and increased iPTH levels was decreased compared with healthy subjects (55.9 ± 12.0% vs. 65.0 ± 4.5%; 51.7 ± 12.8 vs. 65.0 ± 4.5%, both P < 0.05). The mean peak radial strain (PRS), peak circumferential strain (PCS), and peak longitudinal strain (PLS) were lowest in ESRD patients with increased iPTH; however, no significant difference was observed among these three groups. Segmentally, from base to apex, the native T1 of ESRD patients with increased iPTH levels tended to be higher than those with targeted iPTH and healthy subjects (all P < 0.05). In ESRD patients with targeted iPTH, both native T1 of basal and middle segments were significantly higher than normal subjects (basal, 1304 ± 41 ms vs. 1238 ± 36 ms, P = 0.001; middle, 1300 ± 43 ms vs. 1242 ± 50 ms, P < 0.001). Comparing global native T1 values in the three groups, ESRD patients with targeted and increased iPTH level showed increased native T1 (1305 ± 41 ms vs. 1251 ± 49 ms, P = 0.001; 1334 ± 40 ms vs. 1251 ± 49 ms, P < 0.001, respectively). Native T1 values of the basal segment and global native T1 were moderately associated with iPTH (r = 0.4, P < 0.001; r = 0.5, P < 0.001). Multiple linear regression analysis showed that global native T1 values (beta = 1.0, P = 0.01) were independently associated with iPTH.

CONCLUSIONS

Elevated iPTH level was associated with and was an independent risk factor for myocardial damage in ESRD patients undergoing maintenance hemodialysis.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( http://www.chictr.org.cn/index.aspx ) ChiCTR-DND-17012976, 13/12/2017, retrospectively registered.

Vitamin D and Kidney Diseases: A Narrative Review

Vitamin D (Vit. D) is among the most important elements of the human body that play pivotal roles in health and disease. It belongs to the fat-soluble secosteroid family, which is provided by either foods or direct exposure to sunlight that converts 7-hydroxycholesterol to the Vit. D precursor. An alternative step is bio-activation, which delivers an active form of Vit. D (Vit. D3), which participates in various noticeable functions including calcium regulation, bone remodeling, fertility, glucose control, and detoxification. The most recent literature is carefully reviewed (2049 articles) and the relative information was collected and discussed meticulously. Inclusion criteria were the articles that mentioned the relationship between Vit. D, adipokine, and kidney disease and exclusion criteria were nonrelevant articles. Vit. D plays several roles in the normal function of the kidney and metabolism. It has been revealed that Vit. D has a crucial impact on kidney disease and that its deficiency leads to kidney dysfunction and further renal disorder. Apart from the direct relationship of Vit. D with kidney disease, the association of adipocytes and adipokines with Vit. D and kidney function has also been studied. The noticeable role of Vit. D in kidney disease is investigated in various studies. It has been found that Vit. D has a pivotal role in kidney function and metabolism. Further study can reveal the better-detailed information about the exact relation of Vit. D and kidney disorders. The aim of the review was to provide a better insight into the exact role of Vit. D and adipokine in the kidney disease.

Race-specific associations of 25-hydroxyvitamin D and parathyroid hormone with cardiometabolic biomarkers among US white and black postmenopausal women

BACKGROUND

Concentrations of 25-hydroxyvitamin D [25(OH)D] tend to be lower in African Americans than in non-Hispanic whites, but whether adding information on parathyroid hormone (PTH) can help explain the higher cardiometabolic risk among African Americans is unknown.

OBJECTIVES

This study examined race (black/white)-specific independent and joint associations of 25(OH)D and PTH with cardiometabolic biomarkers including high-sensitivity C-reactive protein (hs-CRP), estimated glomerular filtration rate (eGFR), and homeostasis model assessment of insulin resistance (HOMA-IR) and β-cell function (HOMA-B).

METHODS

Among 1500 white and 1300 black postmenopausal women without cardiovascular disease from the Women's Health Initiative Observational Study, a weighted linear regression analysis and a novel penalized spline-based semiparametric model with contour plots, accounting for possible nonlinear relations and interactions simultaneously, were used to investigate the race-specific independent and joint associations of 25(OH)D and PTH with each biomarker.

RESULTS

Black women had lower concentrations of 25(OH)D and higher PTH, HOMA-IR, HOMA-B, hs-CRP, and eGFR than white women (all P values < 0.0001). Lower 25(OH)D and higher PTH were each independently and jointly associated with higher HOMA-IR in both white and black women, whereas a similar joint relation with HOMA-B was observed in white women only. In contrast, PTH was nonlinearly associated with HOMA-B in black women and positively associated with hs-CRP in white women, independently of 25(OH)D. Whereas there was an inverse linear relation between PTH and eGFR in white women after accounting for 25(OH)D, PTH and 25(OH)D were jointly and nonlinearly associated with eGFR in black women.

CONCLUSIONS

We found that the joint association of 25(OH)D and PTH with β-cell function, systemic inflammation, and kidney function apparently differed between white and black women. Further studies are needed to determine whether differences in the vitamin D-PTH endocrine system contribute to racial disparities in cardiovascular health.

The relationship between estimated glomerular filtration rate and urine m/creatinine ratio and parathyroid hormone in elderly Koreans

This study aimed to assess the relationship between estimated glomerular filtration rate (eGFR), urine microalbumin/creatinine ratio (uACR), and parathyroid hormone (PTH) levels in elderly Korean men and women. Data were analyzed from 2880 adults (1262 men and 1618 women) aged ≥ 50 years from the Fifth Korean National Health and Nutrition Examination Survey V-2 (KNHANES V-2). In men, after adjusting for related variables, the odds ratios (ORs) of the high PTH levels (PTH > 78.0 ng/L) were significantly higher in the decreased eGFR group [eGFR < 60 ml/min/1.73 m²; 1.353 (95% confidence interval [CI], 0.989-1.851)], elevated uACR group [uACR ≥ 30 mg/g; 1.804 (95% CI, 1.004-3.239)], and decreased eGFR plus elevated uACR group [eGFR < 60 ml/min/1.73 m² and uACR ≥ 30 mg/g; 2.158 (95% CI, 1.208-3.858)] relative to the normal group (eGFR ≥ 60 ml/min/1.73 m² and uACR < 30 mg/g). In women, after adjusting for related variables, the ORs of the high PTH levels were significantly higher in the decreased eGFR group [1.585 (95% CI, 0.911-2.760)], elevated uACR group [1.645 (95% CI, 1.127-2.400)], and decreased eGFR plus elevated uACR group [2.934 (95% CI, 1.267-6.795)] relative to the normal group. In conclusion, PTH was positively associated with an increase in uACR in elderly Korean men and women but was not associated with a decrease in eGFR. In addition, PTH increased greatly when both a decrease in eGFR and increase in uACR appeared simultaneously.

Severe, Symptomatic Hypocalcemia due to Denosumab Administration: Treatment and Clinical Course

Denosumab is a receptor activator of nuclear factor kappa-B (RANK) ligand inhibitor used in the treatment of osteoporosis. Blockade of RANK ligand prevents osteoclastic resorption of bone, but in doing so impairs the parathyroid hormone (PTH)-driven maintenance of serum calcium. A subsequent elevation of PTH remains active at sites other than bone, potentially lowering serum phosphate by inhibiting proximal tubular reabsorption. We present 2 patients who developed severe, symptomatic hypocalcemia after administration of denosumab. These patients provide an opportunity to describe the clinical course and treatment, including the need to consider a continuous calcium infusion, of severe, symptomatic hypocalcemia caused by denosumab.

25-Hydroxyvitamin D Is Associated with Kidney Function: The Dong-gu Study

Although the kidneys play a leading part in the biosynthesis of vitamin D, there is no consensus regarding the relationship of the vitamin D concentration with kidney function. Thus, we aimed to estimate the correlation among 25-hydroxyvitamin D (25(OH)D), estimated glomerular filtration rate (eGFR), and albumin/creatinine ratio (ACR) in participants aged ≥50 y in Korea. This study consisted of 9,166 people who participated in a basic survey of the Dong-gu Study. Following an overnight fast, the blood and urine sample were assessed. The serum 25(OH)D, eGFR, ACR of each subject were measured. When adjusting for covariates and log-transformed ACR (Model III), the lower eGFR value was significantly associated with increasing 25(OH)D levels (<10.0: 71.5[70.5-72.4]; 10.0-14.9: 70.0 [69.5-70.4]; 15.0-19.9: 68.7 [68.3-69.2]; ≥20.0: 67.4 [66.8-67.9] mL/min/1.73 m², p<0.001). When adjusted for the same covariates and log-transformed eGFR (Model III), the lower ACR value was significantly associated with increasing 25(OH)D levels (<10.0: 57.4 [48.0-66.9]; 10.0-14.9: 40.8 [36.5-45.2]; 15.0-19.9: 34.0 [29.5-38.5]; ≥20.0: 34.3 [28.8-39.8] μg/mg creatinine, p<0.001). In conclusion, the mean values of eGFR were significantly decreased with increasing 25(OH)D levels independent of ACR. In additon, the mean values of ACR were significantly decreased with increasing 25(OH)D levels independent of eGFR in participants aged ≥50 y in Korea.