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Amjad W, Ginzberg SP, Passman JE, Heintz J, Kelz RR, Wachtel H. Predictive Risk Score for Postparathyroidectomy Hungry Bone Syndrome in Patients With Secondary Hyperparathyroidism. J Clin Endocrinol Metab 2024; 109:603-610. [PMID: 37897423 DOI: 10.1210/clinem/dgad636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/03/2023] [Accepted: 10/25/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE Secondary hyperparathyroidism (SHPT) frequently affects patients with end-stage renal disease. Hungry bone syndrome (HBS) is a common complication among patients who undergo parathyroidectomy for SHPT and may cause prolonged hospitalization or require intensive care. The objective of this study is to develop a scoring system to stratify patients according to their risk of developing HBS. METHODS A retrospective cohort study was performed using the US Renal Data System (2010-2021). Univariable and multivariable logistic regression models were developed and weighted β-coefficients from the multivariable model were used to construct a risk score for the development of HBS. Positive and negative predictive values were assessed. RESULTS Of 17 074 patients who underwent parathyroidectomy for SHPT, 19.4% developed HBS. Intensive care unit admission was more common in patients who developed HBS (33.5% vs 24.6%, P < .001). On multivariable logistic regression analysis, younger age, renal osteodystrophy, longer duration of dialysis, longer duration of kidney transplant, and higher Elixhauser score were significantly associated with HBS. A risk score based on these clinical factors was developed, with a total of 6 possible points. Rates of HBS ranged from 8% in patients with 0 points to 44% in patients with 6 points. The risk score had a poor positive predictive value (20.3%) but excellent negative predictive value (89.3%) for HBS. CONCLUSION We developed a weighted risk score that effectively stratifies patients by risk for developing HBS after parathyroidectomy. This tool can be used to counsel patients and to identify patients who may not require postoperative hospitalization.
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Affiliation(s)
- Wajid Amjad
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Sara P Ginzberg
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Jesse E Passman
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Jonathan Heintz
- Biostatistics Analysis Center, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Rachel R Kelz
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Heather Wachtel
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Khairallah P, Nickolas TL. Managing Osteoporosis in Dialysis-A Medical Catch-22. JAMA 2024; 331:477-479. [PMID: 38241040 DOI: 10.1001/jama.2023.24072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Affiliation(s)
| | - Thomas L Nickolas
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
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Stewart F, Kistler K, Du Y, Singh RR, Dean BB, Kong SX. Exploring kidney dialysis costs in the United States: a scoping review. J Med Econ 2024; 27:618-625. [PMID: 38605648 DOI: 10.1080/13696998.2024.2342210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/09/2024] [Indexed: 04/13/2024]
Abstract
AIMS The increasing prevalence of end-stage renal disease (ESRD) in the United States (US) represents a considerable economic burden due to the high cost of dialysis treatment. This review examines data from real-world studies to identify cost drivers and explore areas where dialysis costs could be reduced. METHODS We identified and synthesized evidence published from 2016-2023 reporting direct dialysis costs in adult US patients from a comprehensive literature search of MEDLINE, Embase, and grey literature sources (e.g. US Renal Data System reports). RESULTS Most identified data related to Medicare expenditures. Overall Medicare spending in 2020 was $29B for hemodialysis and $2.8B for peritoneal dialysis (PD). Dialysis costs accounted for almost 80% of total Medicare expenditures on ESRD beneficiaries. Private insurance payers consistently pay more for dialysis; for example, per person per month spending by private insurers on outpatient dialysis was estimated at $10,149 compared with Medicare spending of $3,364. Dialysis costs were higher in specific high-risk patient groups (e.g. type 2 diabetes, hepatitis C). Spending on hemodialysis was higher than on PD, but the gap in spending between PD and hemodialysis is closing. Vascular access costs accounted for a substantial proportion of dialysis costs. LIMITATIONS Insufficient detail in the identified studies, especially related to outpatient costs, limits opportunities to identify key drivers. Differences between the studies in methods of measuring dialysis costs make generalization of these results difficult. CONCLUSIONS These findings indicate that prevention of or delay in progression to ESRD could have considerable cost savings for Medicare and private payers, particularly in patients with high-risk conditions such as type 2 diabetes. More efficient use of resources is needed, including low-cost medication, to improve clinical outcomes and lower overall costs, especially in high-risk groups. Widening access to PD where it is safe and appropriate may help to reduce dialysis costs.
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Affiliation(s)
- Fiona Stewart
- Cencora, Biopharma Services, Conshohocken, Pennsylvania, USA
| | - Kristin Kistler
- Cencora, Biopharma Services, Conshohocken, Pennsylvania, USA
| | - Yuxian Du
- Bayer HealthCare Pharmaceuticals, Whippany, New Jersey, USA
| | - Rakesh R Singh
- Bayer HealthCare Pharmaceuticals, Whippany, New Jersey, USA
| | - Bonnie B Dean
- Cencora, Biopharma Services, Conshohocken, Pennsylvania, USA
| | - Sheldon X Kong
- Cencora, Biopharma Services, Conshohocken, Pennsylvania, USA
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Tartaglione L, Rotondi S, Aucella F, Bonomini M, Caruso MR, Casino F, Cuzziol C, Farcomeni A, Filippini A, Lomonte C, Marinelli R, Rolla D, Rubino F, Seminara G, Pasquali M, Mazzaferro S. Parathyroidectomy and survival in a cohort of Italian dialysis patients: results of a multicenter, observational, prospective study. J Nephrol 2023; 36:1947-1955. [PMID: 37351832 PMCID: PMC10543527 DOI: 10.1007/s40620-023-01658-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 04/28/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Severe secondary hyperparathyroidism (SHPT) is associated with mortality in end stage kidney disease (ESKD). Parathyroidectomy (PTX) becomes necessary when medical therapy fails, thus highlighting the interest to compare biochemical and clinical outcomes of patients receiving either medical treatment or surgery. METHODS We aimed to compare overall survival and biochemical control of hemodialysis patients with severe hyperparathyroidism, treated by surgery or medical therapy followed-up for 36 months. Inclusion criteria were age older than 18 years, renal failure requiring dialysis treatment (hemodialysis or peritoneal dialysis) and ability to sign the consent form. A control group of 418 patients treated in the same centers, who did not undergo parathyroidectomy was selected after matching for age, sex, and dialysis vintage. RESULTS From 82 Dialysis units in Italy, we prospectively collected data of 257 prevalent patients who underwent parathyroidectomy (age 58.2 ± 12.8 years; M/F: 44%/56%, dialysis vintage: 15.5 ± 8.4 years) and of 418 control patients who did not undergo parathyroidectomy (age 60.3 ± 14.4 years; M/F 44%/56%; dialysis vintage 11.2 ± 7.6 y). The survival rate was higher in the group that underwent parathyroidectomy (Kaplan-Meier log rank test = 0.002). Univariable analysis (HR 0.556, CI: 0.387-0.800, p = 0.002) and multivariable analysis (HR 0.671, CI:0.465-0.970, p = 0.034), identified parathyroidectomy as a protective factor of overall survival. The prevalence of patients at KDOQI targets for PTH was lower in patients who underwent parathyroidectomy compared to controls (PTX vs non-PTX: PTH < 150 pg/ml: 59% vs 21%, p = 0.001; PTH at target: 18% vs 37% p = 0.001; PTH > 300 pg/ml 23% vs 42% p = 0.001). The control group received more intensive medical treatment with higher prevalence of vitamin D (65% vs 41%, p = 0.0001), calcimimetics (34% vs 14%, p = 0.0001) and phosphate binders (77% vs 66%, p = 0.002). CONCLUSIONS Our data suggest that parathyroidectomy is associated with survival rate at 36 months, independently of biochemical control. Lower exposure to high PTH levels could represent an advantage in the long term.
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Affiliation(s)
| | - Silverio Rotondi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Filippo Aucella
- Nephrology Unit, Casa Sollievo della Sofferenza, Monte Rotondo, Italy
| | - Mario Bonomini
- Department of Medicine and Aging Sciences, G. D'annunzio University, Chieti, Italy
| | | | | | | | - Alessio Farcomeni
- Department of Economics and Finance, Tor Vergata University Rome, Rome, Italy
| | | | - Carlo Lomonte
- Nephrology Department, Ospedale Generale Regionale "F. Miulli", Acquaviva delle Fonti, Italy
| | | | - Davide Rolla
- Sant'Andrea Hospital La Spezia, La Spezia, Italy
| | | | | | | | - Sandro Mazzaferro
- Nephrology Unit, Azienda Policlinico Umberto I, Rome, Italy.
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
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Cowan A, Jeyakumar N, McArthur E, Fleet JL, Kanagalingam T, Karp I, Khan T, Muanda FT, Nash DM, Silver SA, Thain J, Weir MA, Garg AX, Clemens KK. Hypocalcemia Risk of Denosumab Across the Spectrum of Kidney Disease: A Population-Based Cohort Study. J Bone Miner Res 2023; 38:650-658. [PMID: 36970786 DOI: 10.1002/jbmr.4804] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/28/2023] [Accepted: 03/21/2023] [Indexed: 04/11/2023]
Abstract
Denosumab can be used in patients with chronic kidney disease (CKD) but has been linked with cases of severe hypocalcemia. The incidence of and risk factors for hypocalcemia after denosumab use are not well established. Using linked health care databases at ICES, we conducted a population-based cohort study of adults >65 years old with a new prescription for denosumab or a bisphosphonate between 2012 and 2020. We assessed incidence of hypocalcemia within 180 days of drug dispensing and stratified results by estimated glomerular filtration rate (eGFR in mL/min/1.73 m2 ). We used Cox proportional hazards to assess risk factors for hypocalcemia. There were 59,151 and 56,847 new denosumab and oral bisphosphonate users, respectively. Of the denosumab users, 29% had serum calcium measured in the year before their prescription, and one-third had their serum calcium checked within 180 days after their prescription. Mild hypocalcemia (albumin corrected calcium <2.00 mmol/L) occurred in 0.6% (95% confidence interval [CI] 0.6, 0.7) of new denosumab users and severe hypocalcemia (<1.8 mmol/L) in 0.2% (95% CI 0.2, 0.3). In those with an eGFR <15 or receiving maintenance dialysis, the incidence of mild and severe hypocalcemia was 24.1% (95% CI 18.1, 30.7) and 14.9% (95% CI 10.1, 20.7), respectively. In this group, kidney function and baseline serum calcium were strong predictors of hypocalcemia. We did not have information on over-the-counter vitamin D or calcium supplementation. In new bisphosphonate users, the incidence of mild hypocalcemia was 0.3% (95% CI 0.3, 0.3) with an incidence of 4.7% (95% CI 1.5, 10.8) in those with an eGFR <15 or receiving maintenance dialysis. In this large population-based cohort, we found that the overall risk of hypocalcemia with new denosumab use was low but increased substantially in those with eGFR <15 mL/min/1.73 m2 . Future studies should investigate strategies to mitigate hypocalcemia. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Andrea Cowan
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
| | - Nivethika Jeyakumar
- ICES, Toronto, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Eric McArthur
- ICES, Toronto, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Jamie L Fleet
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Department of Physical Medicine and Rehabilitation, Western University, London, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
| | | | - Igor Karp
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | - Tayyab Khan
- Department of Medicine, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
| | | | - Danielle M Nash
- ICES, Toronto, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | | | - Jenny Thain
- Department of Medicine, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
| | - Matthew A Weir
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Amit X Garg
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | - Kristin K Clemens
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Canada
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Tai YL, Shen HY, Nai WH, Fu JF, Wang IK, Huang CC, Weng CH, Lee CC, Huang WH, Yang HY, Hsu CW, Yen TH. Hungry bone syndrome after parathyroid surgery. Hemodial Int 2023; 27:134-145. [PMID: 36719854 DOI: 10.1111/hdi.13067] [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: 05/25/2022] [Revised: 11/06/2022] [Accepted: 01/10/2023] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Data on the incidence rates of hungry bone syndrome after parathyroidectomy in patients on dialysis are inconsistent, as the published rates vary from 15.8% to 92.9%. METHODS Between 2009 and 2019, 120 hemodialysis patients underwent parathyroidectomy for secondary hyperparathyroidism at the Chang Gung Memorial Hospital. The patients were stratified into two groups based on the presence (n = 100) or absence (n = 20) of hungry bone syndrome after parathyroidectomy. FINDINGS Subtotal parathyroidectomy was the most common surgery performed (76.7%), followed by total parathyroidectomy with autoimplantation (23.3%). Pathological examination revealed parathyroid hyperplasia. Hungry bone syndrome developed within 0.3 ± 0.3 months and lasted for 11.1 ± 14.7 months. After surgery, compared with patients without hungry bone syndrome, patients with hungry bone syndrome had lower levels of nadir corrected calcium (P < 0.001), as well as lower nadir (P < 0.001) and peak (P < 0.001) intact parathyroid hormone levels. During 59.3 ± 44.0 months of follow-up, persistence and recurrence of hyperparathyroidism occurred in 25 (20.8%) and 30 (25.0%) patients, respectively. Furthermore, patients with hungry bone syndrome had a lower rate of persistent hyperparathyroidism than those without hungry bone syndrome (P < 0.001). Four patients (3.3%) underwent a second parathyroidectomy. Patients with hungry bone syndrome received fewer second parathyroidectomies than those without hungry bone syndrome (P < 0.001). Finally, a multivariate logistic regression model revealed that the preoperative blood ferritin level was a negative predictor of the development of hungry bone syndrome (P = 0.038). DISCUSSION Hungry bone syndrome is common (83.3%) after parathyroidectomy for secondary hyperparathyroidism in patients undergoing hemodialysis, and this complication should be monitored and managed appropriately.
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Affiliation(s)
- Ya-Ling Tai
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Yi Shen
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Hsuan Nai
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fen Fu
- Department of Medical Research, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I-Kuan Wang
- Department of Nephrology, China Medical University Hospital, Taichung and College of Medicine, China Medical University, Taichung, Taiwan
| | - Chien-Chang Huang
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hao Weng
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Hung Huang
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Huang-Yu Yang
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Wei Hsu
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tzung-Hai Yen
- Department of Nephrology, Clinical Poison Center, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
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