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Banerjee M, Kar A, Ahamed J, Bhattacharjee R, Maitra D, Maisnam I, Das TC, Sahana PK, Chowdhury S, Mukhopadhyay S. Renal Dysfunction in Primary Hyperparathyroidism is associated with nephrolithiasis, elevated serum calcium-phosphate product and parathormone levels. Endocrine 2024; 83:757-762. [PMID: 38091198 DOI: 10.1007/s12020-023-03631-0] [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: 09/27/2023] [Accepted: 11/25/2023] [Indexed: 03/01/2024]
Abstract
PURPOSE Baseline renal dysfunction predicts mortality in primary hyperparathyroidism (PHPT). However, it remains controversial whether renal insufficiency in PHPT is due to disease severity alone or other risk factors. This study aimed to explore the association of clinico-biochemical variables with renal dysfunction [estimated glomerular filtration rate (eGFR) < 60 ml/min/m2] in PHPT. METHODS A total of 112 patients of PHPT were selected and divided into following subgroups: renal dysfunction (n = 28) and normal renal function (n = 84). Demographic characteristics, traditional risk factors, phenotypes of PHPT based on target organ involvement, and biochemical parameters were compared between these subgroups. RESULTS Patient subgroups of PHPT with and without renal dysfunction had similar age, frequency of diabetes, and hypertension. Renal dysfunction was more prevalent in males (p < 0.05). Compared to normal renal function subgroup, individuals with renal dysfunction had higher serum levels of calcium, phosphate, alkaline phosphatase, intact parathormone (all p < 0.05), while having lower hemoglobin levels (p < 0.05) and higher nephrolithiasis rates (p < 0.05). Multiple regression analysis revealed that nephrolithiasis, serum calcium-phosphorous product (CaxP), parathormone levels were positively associated with baseline renal dysfunction (all p < 0.01). A baseline PTH > 456 pg/mL and CaxP > 30.0 mg2/dl2 could discriminate renal dysfunction from normal renal function with sensitivity and specificity of 75% and 74.5% and 92.6% and 74.4%, respectively. CONCLUSION Renal dysfunction was associated with presence of nephrolithiasis, elevated serum CaxP and PTH levels in our cohort with predominantly symptomatic PHPT, indicating an association with the underlying disease itself. Serum CaxP may additionally be appraised during risk assessment in PHPT.
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Affiliation(s)
- Mainak Banerjee
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research, Kolkata, 700020, India
| | - Anish Kar
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research, Kolkata, 700020, India
| | - Jan Ahamed
- Department of Endocrinology, Travancore Medical College and Hospital, Kollam, Kerala, India
| | - Rana Bhattacharjee
- Department of Endocrinology, Medical College and Hospital, Kolkata, 700007, India
| | - Dhritiman Maitra
- Department of Surgery, Medical College and Hospital, Kolkata, 700007, India
| | - Indira Maisnam
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research, Kolkata, 700020, India
| | - Tapas Chandra Das
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research, Kolkata, 700020, India
| | - Pranab Kumar Sahana
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research, Kolkata, 700020, India
| | - Subhankar Chowdhury
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research, Kolkata, 700020, India
| | - Satinath Mukhopadhyay
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research, Kolkata, 700020, India.
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Seib CD, Ganesan C, Furst A, Pao AC, Chertow GM, Leppert JT, Suh I, Montez-Rath ME, Harris AHS, Trickey AW, Kebebew E, Kurella Tamura M. Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism. Ann Intern Med 2023; 176:624-631. [PMID: 37037034 PMCID: PMC10866201 DOI: 10.7326/m22-2222] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Multidisciplinary guidelines recommend parathyroidectomy to slow the progression of chronic kidney disease in patients with primary hyperparathyroidism (PHPT) and an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2. Limited data address the effect of parathyroidectomy on long-term kidney function. OBJECTIVE To compare the incidence of a sustained decline in eGFR of at least 50% among patients with PHPT treated with parathyroidectomy versus nonoperative management. DESIGN Target trial emulation was done using observational data from adults with PHPT, using an extended Cox model with time-varying inverse probability weighting. SETTING Veterans Health Administration. PATIENTS Patients with a new biochemical diagnosis of PHPT in 2000 to 2019. MEASUREMENTS Sustained decline of at least 50% from pretreatment eGFR. RESULTS Among 43 697 patients with PHPT (mean age, 66.8 years), 2928 (6.7%) had a decline of at least 50% in eGFR over a median follow-up of 4.9 years. The weighted cumulative incidence of eGFR decline was 5.1% at 5 years and 10.8% at 10 years in patients managed with parathyroidectomy, compared with 5.1% and 12.0%, respectively, in those managed nonoperatively. The adjusted hazard of eGFR decline did not differ between parathyroidectomy and nonoperative management (hazard ratio [HR], 0.98 [95% CI, 0.82 to 1.16]). Subgroup analyses found no heterogeneity of treatment effect based on pretreatment kidney function. Parathyroidectomy was associated with a reduced hazard of the primary outcome among patients younger than 60 years (HR, 0.75 [CI, 0.59 to 0.93]) that was not evident among those aged 60 years or older (HR, 1.08 [CI, 0.87 to 1.34]). LIMITATION Analyses were done in a predominantly male cohort using observational data. CONCLUSION Parathyroidectomy had no effect on long-term kidney function in older adults with PHPT. Potential benefits related to kidney function should not be the primary consideration for PHPT treatment decisions. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine; Division of General Surgery, Palo Alto Veterans Affairs Health Care System; and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (C.D.S.)
| | - Calyani Ganesan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (C.G., M.E.M.)
| | - Adam Furst
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California (A.F., A.W.T.)
| | - Alan C Pao
- Division of Nephrology, Department of Medicine, and Department of Urology, Stanford University School of Medicine, Palo Alto, California (A.C.P., J.T.L.)
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, and Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, California (G.M.C.)
| | - John T Leppert
- Division of Nephrology, Department of Medicine, and Department of Urology, Stanford University School of Medicine, Palo Alto, California (A.C.P., J.T.L.)
| | - Insoo Suh
- Department of Surgery, New York University Grossman School of Medicine, New York, New York (I.S.)
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (C.G., M.E.M.)
| | - Alex H S Harris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, and Center for Innovation to Implementation, Veterans Affairs Palo Alto, Palo Alto, California (A.H.S.H.)
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California (A.F., A.W.T.)
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California (E.K.)
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (M.K.T.)
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3
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Frey S, Wargny M, Blanchard C, Caillard C, Hadjadj S, Cariou B, Figueres L, Mirallié E. Effects of parathyroidectomy on kidney function in patients with primary hyperparathyroidism: Results of a prospective study. Surgery 2023; 173:146-153. [PMID: 36167701 DOI: 10.1016/j.surg.2022.05.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Altered glomerular filtration rate is a controversial indication for parathyroidectomy in patients with primary hyperparathyroidism. The objective of this study was to evaluate the estimated glomerular filtration rate change 12 months after parathyroidectomy for primary hyperparathyroidism according to preoperative kidney function. METHOD Patients who underwent parathyroidectomy for primary hyperparathyroidism between 2016 and 2021 (n = 381) were enrolled in a monocentric prospective cohort. Patients without 1-year follow-up or with missing data were excluded (n = 135, 35%). Patients were dichotomized according to their baseline estimated glomerular filtration rate: <60 mL/min (group 1) and ≥60 mL/min (group 2). Parameters were measured before and then at 6 and 12 months after parathyroidectomy. RESULTS Out of 246 included patients, 27 (11%) were assigned to group 1 and 219 (89%) to group 2. The mean baseline estimated glomerular filtration rate was 46.8 ± 11.5 and 87.3 ± 14.7 mL/min in groups 1 and 2, respectively. Group 1 patients were older (P = .0006) and had a higher median serum parathyroid hormone level (P = .021). At 6 months postoperative, 224 patients (91%) were normocalcemic. The estimated glomerular filtration rate raw change after parathyroidectomy was significantly higher in group 1 than in group 2 (4.2 ± 7.8 vs -2.2 ± 9.1 mL/min, P = .0004). In group 1, 13/27 patients (48%) improved their chronic kidney disease stage after parathyroidectomy, including 6/13 (46%) with postoperative estimated glomerular filtration rate ≥60 mL/min, whereas 2/27 (7%) worsened. The baseline estimated glomerular filtration rate <60 mL/min and elevated serum calcium level were associated with postoperative estimated glomerular filtration rate improvement in multivariable analysis (P = .0023 and .039, respectively). CONCLUSION Parathyroidectomy for primary hyperparathyroidism is more likely to improve kidney function in patients with preoperative estimated glomerular filtration rate <60 mL/min. These results strengthen the current guidelines for surgery.
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Affiliation(s)
- Samuel Frey
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France; Université de Nantes, France; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France. https://twitter.com/samuelfrey13
| | - Matthieu Wargny
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France; CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11: Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des Données, France
| | - Claire Blanchard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France; Université de Nantes, France; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Cécile Caillard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France
| | - Samy Hadjadj
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Bertrand Cariou
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Lucile Figueres
- Université de Nantes, France; Service de Néphrologie-Immunologie Clinique, CHU de Nantes, France
| | - Eric Mirallié
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France; Université de Nantes, France.
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Bilezikian JP, Silverberg SJ, Bandeira F, Cetani F, Chandran M, Cusano NE, Ebeling PR, Formenti AM, Frost M, Gosnell J, Lewiecki EM, Singer FR, Gittoes N, Khan AA, Marcocci C, Rejnmark L, Ye Z, Guyatt G, Potts JT. Management of Primary Hyperparathyroidism. J Bone Miner Res 2022; 37:2391-2403. [PMID: 36054638 DOI: 10.1002/jbmr.4682] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 11/11/2022]
Abstract
Since the last international guidelines were published in 2014 on the evaluation and management of primary hyperparathyroidism (PHPT), new information has become available with regard to evaluation, diagnosis, epidemiology, genetics, classical and nonclassical manifestations, surgical and nonsurgical approaches, and natural history. To provide the most current summary of these developments, an international group, consisting of over 50 experts in these various aspects of PHPT, was convened. This paper provides the results of the task force that was assigned to review the information on the management of PHPT. For this task force on the management of PHPT, two questions were the subject of systematic reviews using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. The full report addressing surgical and nonsurgical management of PHPT, utilizing the GRADE methodology, is published separately in this series. In this report, we summarize the results of that methodological review and expand them to encompass a much larger body of new knowledge that did not specifically fit the criteria of the GRADE methodology. Together, both the systematic and narrative reviews of the literature, summarized in this paper, give the most complete information available to date. A panel of experts then considered the last set of international guidelines in light of the newer data and assessed the need for their revision. This report provides the evidentiary background to the guidelines report. In that report, evidence from all task forces is synthesized into a summary statement and revised guidelines for the evaluation and management of PHPT. © 2022 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)
- John P Bilezikian
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Francisco Bandeira
- Division of Endocrinology, University of Pernambuco Medical School Recife, Recife, Brazil
| | | | - Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Natalie E Cusano
- Division of Endocrinology, Department of Medicine, Lenox Hill Hospital, New York, NY, USA
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS Hospital, Milan, Italy
| | - Morten Frost
- Bone and Calcium Unit & Molecular Endocrinology Unit, Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Jessica Gosnell
- Department of Surgery, University of California, San Francisco, CA, USA
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - Frederick R Singer
- Endocrine/Bone Disease Program, Saint John's Cancer Institute, Santa Monica, CA, USA
| | - Neil Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Endocrine Unit 2, University Hospital of Pisa, Pisa, Italy
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Zhikang Ye
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - John T Potts
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Bilezikian JP, Khan AA, Silverberg SJ, Fuleihan GEH, Marcocci C, Minisola S, Perrier N, Sitges-Serra A, Thakker RV, Guyatt G, Mannstadt M, Potts JT, Clarke BL, Brandi ML, Balaya Z, Hofbauer L, Insogna K, Lacroix A, Liberman UA, Palermo A, Rizzoli R, Wermers R, Hannan FM, Pepe J, Cipriani C, Eastell R, Liu J, Mithal A, Moreira CA, Peacock M, Silva B, Walker M, Chakhtoura M, Schini M, Zein OE, Almquist M, Farias LCB, Duh Q, Lang BH, LiVolsi V, Swayk M, Vriens MR, Vu T, Yeh MW, Yeh R, Shariq O, Poch LL, Bandeira F, Cetani F, Chandran M, Cusano NE, Ebeling PR, Gosnell J, Lewiecki EM, Singer FR, Frost M, Formenti AM, Karonova T, Gittoes N, Rejnmark L. Evaluation and Management of Primary Hyperparathyroidism: Summary Statement and Guidelines from the Fifth International Workshop. J Bone Miner Res 2022; 37:2293-2314. [PMID: 36245251 DOI: 10.1002/jbmr.4677] [Citation(s) in RCA: 90] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 11/10/2022]
Abstract
The last international guidelines on the evaluation and management of primary hyperparathyroidism (PHPT) were published in 2014. Research since that time has led to new insights into epidemiology, pathophysiology, diagnosis, measurements, genetics, outcomes, presentations, new imaging modalities, target and other organ systems, pregnancy, evaluation, and management. Advances in all these areas are demonstrated by the reference list in which the majority of listings were published after the last set of guidelines. It was thus, timely to convene an international group of over 50 experts to review these advances in our knowledge. Four Task Forces considered: 1. Epidemiology, Pathophysiology, and Genetics; 2. Classical and Nonclassical Features; 3. Surgical Aspects; and 4. Management. For Task Force 4 on the Management of PHPT, Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology addressed surgical management of asymptomatic PHPT and non-surgical medical management of PHPT. The findings of this systematic review that applied GRADE methods to randomized trials are published as part of this series. Task Force 4 also reviewed a much larger body of new knowledge from observations studies that did not specifically fit the criteria of GRADE methodology. The full reports of these 4 Task Forces immediately follow this summary statement. Distilling the essence of all deliberations of all Task Force reports and Methodological reviews, we offer, in this summary statement, evidence-based recommendations and guidelines for the evaluation and management of PHPT. Different from the conclusions of the last workshop, these deliberations have led to revisions of renal guidelines and more evidence for the other recommendations. The accompanying papers present an in-depth discussion of topics summarized in this report. © 2022 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)
- John P Bilezikian
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, WHO CC for Metabolic Bone Disorders, Division of Endocrinology, American University of Beirut, Beirut, Lebanon
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Endocrine Unit 2, University Hospital of Pisa, Pisa, Italy
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | - Nancy Perrier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, Oxford, UK
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael Mannstadt
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - John T Potts
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Bart L Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Maria Luisa Brandi
- Fondazione Italiana sulla Ricerca sulle Malattie dell'Osso (F.I.R.M.O. Foundation), Florence, Italy
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg 2022; 276:e141-e176. [PMID: 35848728 DOI: 10.1097/sla.0000000000005522] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.
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Matzen J, Bislev LS, Sikjær T, Rolighed L, Hitz MF, Eiken P, Hermann AP, Jensen JEB, Abrahamsen B, Rejnmark L. The effect of parathyroidectomy compared to non-surgical surveillance on kidney function in primary hyperparathyroidism: a nationwide historic cohort study. BMC Endocr Disord 2022; 22:14. [PMID: 34991581 PMCID: PMC8734053 DOI: 10.1186/s12902-021-00918-z] [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: 04/08/2021] [Accepted: 12/14/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Patients with primary hyperparathyroidism (pHPT) and impaired kidney function (estimated glomerular filtration rate (eGFR) < 60 mL/min) are offered parathyroidectomy (PTX) to protect them from further complications. Surprisingly, two recent uncontrolled cohort studies have suggested a further decrease in kidney function following PTX. We aimed to examine the effects of PTX compared to non-surgical surveillance on kidney function in pHPT patients. METHODS Historic cohort study. From the Danish National Patient Registry (NPR) and major medical biochemistry laboratories in Denmark, we identified 3585 patients with biochemically confirmed pHPT among whom n = 1977 (55%) were treated with PTX (PTX-group) whereas n = 1608 (45%) were followed without surgery (non-PTX group). Baseline was defined as time of diagnosis and kidney function was re-assessed 9-15 months after PTX (PTX group) or 9-15 months after diagnosis (non-PTX group). RESULTS At follow-up, eGFR had decreased significantly in the PTX- compared to the non-PTX-group (median - 4% vs. - 1%, p < 0.01). Stratification by baseline eGFR showed that the decrease was significant for those with a baseline eGFR value of 80-89 and > 90 mL/min, but not for those with lower eGFR values. Findings did not differ between patients with mild compared to moderate/severe hypercalcemia. However, after mutual adjustments, we identified baseline levels of calcium, PTH, and eGFR as well as age and treatment (PTX vs. no-PTX) as independent predictors for changes in kidney function. CONCLUSION Compared to non-surgical surveillance, PTX is associated with a small but significant decrease in kidney function in pHPT patients with an initial normal kidney function.
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Affiliation(s)
- Josephine Matzen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lise Sofie Bislev
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Tanja Sikjær
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Rolighed
- Department of Otorhinolaryngology, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Friberg Hitz
- Department of Medical Endocrinology, Zealand University Hospital Køge, Køge, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Pia Eiken
- Department of Endocrinology, Bispebjerg, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Jens-Erik Beck Jensen
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Bo Abrahamsen
- Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense C, Denmark
- Holbæk Hospital, Department of Medicine, Holbæk, Denmark
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Dandurand K, Ali DS, Khan AA. Primary Hyperparathyroidism: A Narrative Review of Diagnosis and Medical Management. J Clin Med 2021; 10:jcm10081604. [PMID: 33918966 PMCID: PMC8068862 DOI: 10.3390/jcm10081604] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/26/2021] [Accepted: 04/06/2021] [Indexed: 12/13/2022] Open
Abstract
Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia in the outpatient setting. Symptomatic presentation includes non-specific signs and symptoms of hypercalcemia, skeletal fragility, nephrolithiasis and nephrocalcinosis. The majority of individuals present at an asymptomatic stage following routine biochemical screening, without any signs or symptoms of calcium or parathyroid hormone (PTH) excess or target organ damage. Indications for surgery have recently been revised as published in recent guidelines and consensus statements. Parathyroidectomy is advised in patients younger than 50 years old and in the presence of either significant hypercalcemia, impaired renal function, renal stones or osteoporosis. Surgery is always appropriate in suitable surgical candidates, however, medical management may be considered in those with mild asymptomatic disease, contraindications to surgery or failed previous surgical intervention. We summarized the optimal medical interventions available in the care of PHPT patients not undergoing parathyroidectomy. Calcium and vitamin D intake should be optimized. Antiresorptive therapy may be used for skeletal protection in patients with an increased fracture risk. Cinacalcet, a calcimimetic agent, has been shown to effectively lower serum calcium and PTH levels. The effect of medical treatment on the reduction in fracture risk is unknown and should be the focus of future research.
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Agrawal K, Arya AK, Sood A, Kumari P, Singh P, Sapara M, Rastogi A, Behera A, Bhadada SK. A detailed appraisal of renal manifestations in primary hyperparathyroidism from Indian PHPT registry: Before and after curative parathyroidectomy. Clin Endocrinol (Oxf) 2021; 94:371-376. [PMID: 32789888 DOI: 10.1111/cen.14311] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) is a systemic disorder characterized by hypercalcaemia and inappropriately elevated parathyroid hormone (PTH). Renal manifestations are one of the main presenting features both in symptomatic and asymptomatic PHPT patients. OBJECTIVES We aimed to compare demographic, clinical and biochemical parameters of PHPT patients with and without renal manifestations and also analysed the influence of curative parathyroidectomy on renal functions. METHODS We retrospectively analysed the data of PHPT patients from the last 25 years (1995- March 2019) and compared the demographic and clinical presentation and biochemical measurements between patients with and without renal manifestations and evaluated the changes in renal functions after 1 year of curative parathyroidectomy. RESULTS Of the total 544 PHPT patients, 299 (55%) including 91 out of 141 (65%) males had renal manifestations. Among renal manifestations, nephrolithiasis and nephrocalcinosis were found in 41.7% and 27.6% PHPT patients, respectively. PHPT patients with renal manifestations had significantly higher creatinine (109.7 vs 79.6 µmol/L; P < .0001) and lower eGFR level (78.8 vs 93.9 mL/min/1.73 m2 ; P < .0001) compared to patients without renal manifestations. Parathyroidectomy resolved the clinical symptoms with biochemical cure in the patients from both the groups. Patients with renal manifestations showed improvement in creatinine and eGFR levels after 1 year of curative parathyroidectomy; however, patients without renal manifestations showed no change in creatinine and eGFR levels. CONCLUSION Young age and male gender are predictors of renal manifestations in PHPT. Curative parathyroidectomy improves renal functions in PHPT patients with renal manifestations compared to PHPT patients without renal manifestation.
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Affiliation(s)
- Kanhaiya Agrawal
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Ashutosh Kumar Arya
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Ashwani Sood
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Poonam Kumari
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Priyanka Singh
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Mohin Sapara
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Ashu Rastogi
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Arunanshu Behera
- Department of General Surgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Sanjay Kumar Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
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Castellano E, Attanasio R, Boriano A, Borretta V, Gennaro M, Latina A, Borretta G. Radiologic Manifestation of Bone Involvement in Primary Hyperparathyroidism: Prevalence and Clinical Significance in a Southern European Series. Endocr Pract 2020; 26:983-989. [PMID: 33471703 DOI: 10.4158/ep-2020-0095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/24/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Clinically overt symptomatic bone disease in primary hyperparathyroidism (PHPT) is rarely seen today, and osteoporosis is the dominant finding. Subperiosteal bone resorption in the fingers and skull mottling are typical bone PHPT findings, the contemporary prevalence of which is unknown. We evaluated these mild lesions and investigated the impact of their occurrence on PHPT clinical management. METHODS We evaluated retrospectively a monocentric series of 363 PHPT patients classified in Group 1 (n = 100) or Group 2 (n = 263) according to the presence or absence of bone involvement, respectively. Patients belonging to Group 1, in turn, were subdivided into Group 1A, with severe and symptomatic lesions (n = 48), and Group 1B, with milder signs of osteitis fibrosa cystica (OFC) without brown tumors or fractures (n = 52). RESULTS Serum total and ionized calcium, parathyroid hormone, osteocalcin, alkaline phosphatase, and its bone fraction levels were higher in Group 1 than in Group 2, while no gender or age differences were observed between the groups. Osteoporosis prevalence was similar in Group 1B and Group 2 patients but lower than in Group 1A. Mild OFC findings did not modify the surgical indication in any patient of Group 1B. CONCLUSION Minor radiologic signs of OFC are not uncommon in the modern PHPT phenotype and occur in patients with more active disease. These signs could identify PHPT patients in an earlier stage of typical bone involvement. However, these features do not seem to upgrade either the clinical classification of asymptomatic PHPT patients or the propensity toward surgical choice.
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Affiliation(s)
- Elena Castellano
- Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Cuneo, Italy.
| | - Roberto Attanasio
- Endocrinology Service, Galeazzi Orthopedic Institute IRCCS, Milan, Italy
| | - Alberto Boriano
- Medical Physics Department, Santa Croce and Carle Hospital, Cuneo, Italy
| | - Valentina Borretta
- Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Cuneo, Italy
| | - Marta Gennaro
- Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Cuneo, Italy
| | - Adele Latina
- Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Cuneo, Italy
| | - Giorgio Borretta
- Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Cuneo, Italy
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11
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Miyaoka D, Imanishi Y, Kato E, Toi N, Nagata Y, Kurajoh M, Yamada S, Inaba M, Emoto M. Effects of denosumab as compared with parathyroidectomy regarding calcium, renal, and bone involvement in osteoporotic patients with primary hyperparathyroidism. Endocrine 2020; 69:642-649. [PMID: 32621048 DOI: 10.1007/s12020-020-02401-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/24/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE To evaluate the effects of denosumab (Dmb) on calcium, renal, and bone involvement in osteoporotic patients with primary hyperparathyroidism (PHPT) and compare with those who underwent a parathyroidectomy (PTX) procedure. METHODS This retrospective, longitudinal study included patients treated with Dmb (60 mg) once every 6 months (n = 19) and those who successfully underwent a PTX procedure (n = 19) corrected calcium (cCa), eGFR, bone mineral density (BMD) in the lumbar spine (LS), total hip (TH), and femoral neck (FN) and LS-trabecular bone score (TBS) changes at 1 year after beginning Dmb or undergoing PTX were measured. RESULTS Dmb group had older age, and showed milder disease activity and lower eGFR as compared with PTX group. In PTX group, cCa and eGFR were significantly decreased following surgery, while those were stable in Dmb group. There were significant increases in LS, TH, and FN-BMD in both Dmb (LS: 6.0 ± 0.8%, TH: 3.7 ± 1.0%, FN: 4.3 ± 1.5%) and PTX (LS: 11.2 ± 1.5%, TH: 7.5 ± 1.5%, FN: 7.9 ± 2.1%) groups. In Dmb group, LS-TBS was significantly improved by 3.0 ± 1.0%, while TBS change in PTX group approached significance (2.8 ± 1.5%). Percent change in TH-BMD was significantly correlated with baseline tartrate-resistant acid phosphatase-5b (TRACP-5b) in both groups. CONCLUSIONS Dmb treatment not only increased BMD, dependent on bone turnover status, the same as PTX, but also improved LS-TBS. In addition, it did not decrease the level of eGFR, whereas PTX did. These results suggest that Dmb treatment help in the clinical management of osteoporotic patients with PHPT who do not undergo surgery as alternative to PTX.
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Affiliation(s)
- Daichi Miyaoka
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Yasuo Imanishi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Eiko Kato
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Norikazu Toi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yuki Nagata
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masafumi Kurajoh
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinsuke Yamada
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masanori Emoto
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
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Kir S, Polat C. Effects of preoperative calcium levels and parathyroidectomy on renal function in primary hyperparathyroidism: a retrospective study. Croat Med J 2020; 61:33-39. [PMID: 32118376 PMCID: PMC7063550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 01/24/2020] [Indexed: 03/29/2024] Open
Abstract
AIM TTo assess the effects of preoperative calcium levels and parathyroidectomy on estimated glomerular filtration rate (eGFR) in patients of primary hyperparathyroidism (PHPT) with mild renal dysfunction or normal renal function. METHODS This retrospective study enrolled 71 patients who underwent parathyroidectomy for PHPT in the General Surgery Department at Ondokuz Mayis University Hospital from 2010 to 2018. All patients were histopathologically diagnosed with parathyroid adenoma. Total serum calcium, serum creatinine, serum intact parathyroid hormone (PTH), and serum 25-hydroxyvitamin D3 (25(OH)D3) were measured before and 3-6 months after surgery. Patients were assigned to the low eGFR group (60-90 mL/min/1.73 m2) or normal eGFR group (≥90 mL/min/1.73 m2) and to the low calcium group (≤11.2 mg/dL) or high calcium group (>11.2 mg/dL). RESULTS In the low eGFR and high calcium group, there were significantly more patients with hypertension and older age. In the normal eGFR and high calcium group, eGFR was significantly reduced after surgery. Independent predictors of eGFR change after surgery were age, pre- parathyroidectomy calcium, and pre-parathyroidectomy eGFR. CONCLUSIONS After surgery, patients with low eGFR had preserved renal function, whereas those with normal eGFR had decreased renal function. Mild renal dysfunction in PHPT was associated with older age, hypertension, and high calcium levels.
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Affiliation(s)
- Seher Kir
- Seher Kir, Ondokuz Mayıs University, Faculty of Medicine, 55139 Samsun, Turkey,
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Sato T, Kikkawa Y, Yamamoto S, Tanaka Y, Kazama JJ, Tominaga Y, Ichimori T, Okada M, Hiramitsu T, Fukagawa M. Disrupted tubular parathyroid hormone/parathyroid hormone receptor signaling and damaged tubular cell viability possibly trigger postsurgical kidney injury in patients with advanced hyperparathyroidism. Clin Kidney J 2019; 12:686-692. [PMID: 31583093 PMCID: PMC6768296 DOI: 10.1093/ckj/sfy136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Parathyroidectomy (PTX) that alleviates clinical manifestations of advanced hyperparathyroidism, including hypercalcemia and hypophosphatemia, is considered the best protection from calcium overload in the kidney. However, little is known about the relationship between postsurgical robust parathyroid hormone (PTH) reduction and perisurgical renal tubular cell viability. Post-PTX kidney function is still a crucial issue for primary hyperparathyroidism (PHPT) and tertiary hyperparathyroidism after kidney transplantation (THPT). METHODS As a clinical study, we examined data from 52 consecutive patients (45 with PHPT, 7 with THPT) who underwent PTX in our center between 2015 and 2017 to identify post-PTX kidney injury. Their clinical data, including urinary liver-type fatty acid-binding protein (L-FABP), a tubular biomarker for acute kidney injury (AKI), were obtained from patient charts. An absolute change in serum creatinine level of 0.3 mg/dL (26.5 µmol/L) on Day 2 after PTX defines AKI. Post-PTX calcium supplement dose adjustment was performed to strictly maintain serum calcium at the lower half of the normal range. To mimic post-PTX-related kidney status, a unique parathyroidectomized rat model was produced as follows: 13-week-old rats underwent thyroparathyroidectomy (TPTX) and/or 5/6 subtotal nephrectomy (NX). Indicated TPTX rats were given continuous infusion of a physiological level of 1-34 PTH using a subcutaneously implanted osmotic minipump. Immunofluorescence analyses were performed by polyclonal antibodies against PTH receptor (PTHR) and a possible key modulator of kidney injury, Klotho. RESULTS Patients' estimated glomerular filtration rate (eGFR) did not have any clinically relevant change (62.5 ± 22.0 versus 59.4 ± 21.9 mL/min/1.73 m2, NS), whereas serum calcium (2.7 ± 0.18 versus 2.2 ± 0.16 mmol/L, P < 0.0001) and phosphorus levels (0.87 ± 0.19 versus 1.1 ± 0.23 mmol/L, P < 0.0001) were normalized and PTH decreased robustly (181 ± 99.1 versus 23.7 ± 16.8 pg/mL, P < 0.0001) after successful PTX. However, six patients who met postsurgical AKI criteria had lower eGFR and greater L-FABP than those without AKI. Receiver operating characteristics (ROC) analysis revealed eGFR <35 mL/min/1.73 m2 had 83% accuracy. Strikingly, L-FABP >9.8 µg/g creatinine had 100% accuracy in predicting post-PTX-related AKI. Rat kidney PTHR expression was lower in TPTX. PTH infusion (+PTH) restored tubular PTHR expression in rats that underwent TPTX. Rats with TPTX, +PTH and 5/6 NX had decreased PTHR expression compared with those without 5/6 NX. 5/6 NX partially cancelled tubular PTHR upregulation driven by +PTH. Tubular Klotho was modestly expressed in normal rat kidneys, whereas enhanced patchy tubular expression was identified in 5/6 NX rat kidneys. This Klotho and expression and localization pattern was absolutely canceled in TPTX, suggesting that PTH indirectly modulated the Klotho expression pattern. TPTX +PTH recovered tubular Klotho expression and even triggered diffusely abundant Klotho expression. 5/6 NX decreased viable tubular cells and eventually downregulated tubular Klotho expression and localization. CONCLUSIONS Preexisting tubular damage is a potential risk factor for AKI after PTX although, overall patients with hyperparathyroidism are expected to keep favorable kidney function after PTX. Patients with elevated tubular cell biomarker levels may suffer post-PTX kidney impairment even though calcium supplement is meticulously adjusted after PTX. Our unique experimental rat model suggests that blunted tubular PTH/PTHR signaling may damage tubular cell viability and deteriorate kidney function through a Klotho-linked pathway.
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Affiliation(s)
- Tetsuhiko Sato
- Division of Diabetes and Endocrinology, Masuko Memorial Hospital/Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yamato Kikkawa
- Laboratory of Clinical Biochemistry, Tokyo University of Pharmacy and Life Sciences, Hachioji, Japan
| | - Suguru Yamamoto
- Division of Clinical Nephrology and Rheumatology, Graduate School of Medical and Dental Science, Niigata University, Niigata, Japan
| | - Yusuke Tanaka
- Laboratory of Clinical Biochemistry, Tokyo University of Pharmacy and Life Sciences, Hachioji, Japan
| | - Junichiro J Kazama
- Division of Nephrology and Hypertension, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yoshihiro Tominaga
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Toshihiro Ichimori
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Manabu Okada
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
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¿Mejora la función renal tras la paratiroidectomía en el hiperparatirodismo primario? Nefrologia 2019; 39:160-167. [DOI: 10.1016/j.nefro.2018.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/29/2018] [Accepted: 08/09/2018] [Indexed: 11/21/2022] Open
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Minisola S, Gianotti L, Bhadada S, Silverberg SJ. Classical complications of primary hyperparathyroidism. Best Pract Res Clin Endocrinol Metab 2018; 32:791-803. [PMID: 30665547 DOI: 10.1016/j.beem.2018.09.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Traditionally, classical complications of primary hyperparathyroidism are mainly represented by skeletal, kidney and gastrointestinal involvement. The old picture of osteitis fibrosa cystica is no longer commonly seen, at least in the western world. However, new imagining techniques have highlighted deterioration of skeletal tissue in patients with primary hyperparathyroidism not captured by traditional DXA measurement. Concerning the kidney, the most common consequences of excessive parathyroid hormone secretion are hypercalciuria and kidney stones; however, the exact pathogenesis of urinary stone formation is still unknown. The 2013 International Congress on the management of Asymptomatic Primary Hyperparathyroidism, emphasized the role of imaging techniques for early discovery of both skeletal and renal complications in asymptomatic patients. Gastrointestinal manifestations include acid-peptic disease, constipation, pancreatitis and gall stone disease. More studies are needed in this area to find the exact pathophysiological mechanism underlying these manifestations and the effect of parathyroid surgery.
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Affiliation(s)
- Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, "Sapienza", Rome University, Italy.
| | - Laura Gianotti
- SC Endocrinologia Diabetologia e Metabolismo, Azienda Ospedaliera S. Croce e Carle, Cuneo, Italy.
| | - Sanjay Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India.
| | - Shonni J Silverberg
- Columbia University Medical College of Physicians & Surgeons, New York, USA.
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Khan AA, Hanley DA, Rizzoli R, Bollerslev J, Young JEM, Rejnmark L, Thakker R, D'Amour P, Paul T, Van Uum S, Shrayyef MZ, Goltzman D, Kaiser S, Cusano NE, Bouillon R, Mosekilde L, Kung AW, Rao SD, Bhadada SK, Clarke BL, Liu J, Duh Q, Lewiecki EM, Bandeira F, Eastell R, Marcocci C, Silverberg SJ, Udelsman R, Davison KS, Potts JT, Brandi ML, Bilezikian JP. Primary hyperparathyroidism: review and recommendations on evaluation, diagnosis, and management. A Canadian and international consensus. Osteoporos Int 2017; 28:1-19. [PMID: 27613721 PMCID: PMC5206263 DOI: 10.1007/s00198-016-3716-2] [Citation(s) in RCA: 265] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 07/20/2016] [Indexed: 01/02/2023]
Abstract
The purpose of this review is to assess the most recent evidence in the management of primary hyperparathyroidism (PHPT) and provide updated recommendations for its evaluation, diagnosis and treatment. A Medline search of "Hyperparathyroidism. Primary" was conducted and the literature with the highest levels of evidence were reviewed and used to formulate recommendations. PHPT is a common endocrine disorder usually discovered by routine biochemical screening. PHPT is defined as hypercalcemia with increased or inappropriately normal plasma parathyroid hormone (PTH). It is most commonly seen after the age of 50 years, with women predominating by three to fourfold. In countries with routine multichannel screening, PHPT is identified earlier and may be asymptomatic. Where biochemical testing is not routine, PHPT is more likely to present with skeletal complications, or nephrolithiasis. Parathyroidectomy (PTx) is indicated for those with symptomatic disease. For asymptomatic patients, recent guidelines have recommended criteria for surgery, however PTx can also be considered in those who do not meet criteria, and prefer surgery. Non-surgical therapies are available when surgery is not appropriate. This review presents the current state of the art in the diagnosis and management of PHPT and updates the Canadian Position paper on PHPT. An overview of the impact of PHPT on the skeleton and other target organs is presented with international consensus. Differences in the international presentation of this condition are also summarized.
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Affiliation(s)
- A A Khan
- McMaster University, Hamilton, Canada.
- Bone Research and Education Center, 223-3075 Hospital Gate, Oakville, ON, Canada.
| | | | - R Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | | | - L Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - T Paul
- Western University, London, ON, Canada
| | - S Van Uum
- Western University, London, ON, Canada
| | - M Zakaria Shrayyef
- Division of Endocrinology, University of Toronto, Mississauga, ON, Canada
| | | | - S Kaiser
- Dalhousie University, Halifax, Canada
| | - N E Cusano
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | | | | | - A W Kung
- University of Hong Kong, Hong Kong, China
| | - S D Rao
- Henry Ford Hospital, Detroit, MI, USA
| | - S K Bhadada
- Postgraduate Institute of Medical Education and Research, Chandigarth, India
| | | | - J Liu
- Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Q Duh
- University of California, San Francisco, CA, USA
| | - E Michael Lewiecki
- New Mexico Clinical Research and Osteoporosis Center, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - F Bandeira
- Division of Endocrinology, Diabetes and Metabolic Bone Diseases, Agamenon Magalhaes Hospital, Brazilian Ministry of Health, University of Pernambuco Medical School, Recife, Brazil
| | - R Eastell
- Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | - C Marcocci
- Department for Clinical and Experimental Medicine, University of Pisa, Endocrine Unit 2, University Hospital of Pisa, Pisa, Italy
| | - S J Silverberg
- Division of Endocrinology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - R Udelsman
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | | | - J T Potts
- Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | | | - J P Bilezikian
- Division of Endocrinology, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Tay YKD, Khoo J, Chandran M. Surgery or no surgery: What works best for the kidneys in primary hyperparathyroidism? A study in a multi-ethnic Asian population. Indian J Endocrinol Metab 2016; 20:55-61. [PMID: 26904469 PMCID: PMC4743385 DOI: 10.4103/2230-8210.172285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Whether parathyroidectomy is more beneficial to renal function when compared to medical therapy or observation in primary hyperparathyroidism (PHPT) is unclear. Neither has this premise been explored in non-Caucasian populations. The estimated glomerular filtration rate (eGFR) threshold below which parathyroid hormone (PTH) levels rise if at all in PHPT has also not been established. We determined if surgery was superior to medical therapy and observation in a multi-ethnic Asian patient population with PHPT and whether there was an eGFR threshold below which PTH levels further increased in them. METHODS Retrospective evaluation of patients with PHPT. RESULTS There were 68.6% Chinese, 17.4% Malays, 10.7% Indians, and 3.3% Eurasians. The median (interquartile range) follow-up was 18.0 months (4.5-46.8). At last follow-up, eGFR in the surgical (80 ± 30 ml/min) was higher than the medical (52 ± 32 ml/min) or observation groups (48 ± 33 ml/min); P < 0.01. This difference persisted after adjusting for age, gender, ethnicity, pre-intervention eGFR levels, nephrolithiasis, serum calcium, phosphate, urinary calcium, and duration of follow-up; P = 0.035. There was no definite eGFR level below which PTH values rose. CONCLUSION Our study provides compelling evidence that in PHPT, surgery may be associated with a better renal outcome compared to medical management or observation. This has to be confirmed through prospective randomized controlled trials and the reasons for this finding have to be elucidated through functional and histological measures. The finding in our study of a lack of a specific eGFR threshold below which PTH levels further rose challenges the concept of a fixed renal threshold for secondary elevations of PTH in PHPT.
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Affiliation(s)
- Yu Kwang Donovan Tay
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore
| | - Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore
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Marcocci C, Brandi ML, Scillitani A, Corbetta S, Faggiano A, Gianotti L, Migliaccio S, Minisola S. Italian Society of Endocrinology Consensus Statement: definition, evaluation and management of patients with mild primary hyperparathyroidism. J Endocrinol Invest 2015; 38:577-93. [PMID: 25820553 DOI: 10.1007/s40618-015-0261-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/16/2015] [Indexed: 12/21/2022]
Affiliation(s)
- C Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 27, 56127, Pisa, Italy.
| | - M L Brandi
- Department of Surgery and Translational Medicine, University of Florence, Largo Brambilla 3, 50134, Firenze, Italy
| | - A Scillitani
- Unit of Endocrinology, Ospedale "Casa Sollievo della Sofferenza", IRCCS, 71013, San Giovanni Rotondo, FG, Italy
| | - S Corbetta
- Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, MI, Italy
| | - A Faggiano
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Via Pansini 5, 80131, Napoli, Italy
| | - L Gianotti
- Section of Endocrinology, Diabetology and Metabolism, Azienda Ospedaliera S.Croce e Carle, Via M Coppino 26, 12100, Cuneo, Italy
| | - S Migliaccio
- Department of Motor Sciences and Health, "Foro Italico" Rome University, Piazza L. de Bosis 6, 00135, Roma, Italy
| | - S Minisola
- Department of Internal Medicine and Medical DIsciplines, "Sapienza" Rome University, Viale del Policlinico 155, 00161, Roma, Italy
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Hendrickson CD, Castro Pereira DJ, Comi RJ. Renal impairment as a surgical indication in primary hyperparathyroidism: do the data support this recommendation? J Clin Endocrinol Metab 2014; 99:2646-50. [PMID: 24758187 DOI: 10.1210/jc.2014-1379] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTENT Management of primary hyperparathyroidism has evolved over the past two decades, yet impaired renal function has consistently been a surgical indication. This recommendation has been based upon the historical association between primary hyperparathyroidism and renal impairment, and a review of the literature is needed to determine whether such a recommendation is warranted. EVIDENCE ACQUISITION AND SYNTHESIS PubMed was utilized to identify English-language articles published between January 1990 and February 2014 using keywords related to hyperparathyroidism and renal function. The keywords were "primary hyperparathyroidism," "surgery," "parathyroidectomy," "kidney," "renal," "glomerular filtration rate," and "creatinine." Of the 1926 articles obtained with this search, all articles germane to the topic that quantified the relationship between primary hyperparathyroidism and renal function were included. All references within these articles were investigated for inclusion. When helpful, data tables were constructed to summarize the results succinctly. CONCLUSIONS A secondary elevation of PTH levels has not been consistently shown to occur at the threshold currently indicated for surgical intervention. While renal impairment is seen with more significant disease, mild asymptomatic primary hyperparathyroidism has not been conclusively associated with renal impairment. Furthermore, there is no evidence to suggest that surgically curing primary hyperparathyroidism via a parathyroidectomy has any impact upon renal function.
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Affiliation(s)
- Chase D Hendrickson
- Sections of Endocrinology, Diabetes, and Metabolism (C.D.H., R.J.C.) and Nephrology and Hypertension (D.J.C.P.), Dartmouth-Hitchcock Medical Center, Department of Medicine, Lebanon, New Hampshire 03756
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Walker MD, Nickolas T, Kepley A, Lee JA, Zhang C, McMahon DJ, Silverberg SJ. Predictors of renal function in primary hyperparathyroidism. J Clin Endocrinol Metab 2014; 99:1885-92. [PMID: 24527717 PMCID: PMC4010697 DOI: 10.1210/jc.2013-4192] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 02/06/2014] [Indexed: 12/23/2022]
Abstract
CONTEXT Current guidelines for parathyroidectomy in primary hyperparathyroidism (PHPT) include an estimated glomerular filtration rate (eGFR) less than 60 mL/min per 1.73 m(2). Although the biochemical abnormalities associated with PHPT could impair renal function, there are currently no data examining whether more severe hypercalcemia, hypercalciuria, or nephrolithiasis are associated with chronic kidney disease (CKD) in mild PHPT. OBJECTIVE This cross-sectional study evaluated predictors of renal function in PHPT. DESIGN This is a case series of PHPT patients with (eGFR < 60 mL/min per 1.73 m(2)) and without (eGFR ≥ 60 mL/min per 1.73 m(2)) CKD. SETTINGS AND PARTICIPANTS We studied 114 PHPT patients in a university hospital setting. OUTCOME MEASURES We identified predictors of renal function using multiple linear regression. RESULTS eGFR was associated with age, hypertension, antihypertensive medication use, fasting glucose, and 25-hydroxyvitamin D. eGFR was positively rather than negatively associated with several PHPT disease severity indices including history of nephrolithiasis, 24-hour urinary calcium excretion, and 1,25-dihydroxyvitamin D but not serum calcium or PTH levels. An eGFR less than 60 mL/min per 1.73 m(2) was observed in 15% (n = 17), all of whom had stage 3 CKD (eGFR 30-59 mL/min per 1.73 m(2)). Those with CKD were older, had higher 25-hydroxyvitamin D levels and lower 1,25-dihydroxyvitamin D levels, and were more likely to be hypertensive than those without CKD. There were no between-group (<60 vs ≥60 mL/min per 1.73 m(2)) differences in serum calcium, PTH, nephrolithiasis, or meeting surgical criteria other than eGFR. Multiple linear regression indicated that age and diastolic blood pressure were negatively associated with eGFR, whereas serum calcium, kidney stones, and alcohol use were positive predictors. Calculation of eGFR using either the Modification of Diet in Renal Disease or Chronic Kidney Disease Epidemiology Collaboration equation yielded similar results. CONCLUSIONS PHPT patients with stage 3 CKD do not have biochemical or clinical evidence of more severe hyperparathyroidism compared with those without CKD. Traditional risk factors, rather than clinical or biochemical indices of PHPT, are associated with lower eGFR in mild PHPT.
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Affiliation(s)
- Marcella D Walker
- Departments of Medicine (M.D.W., T.N., A.K., C.Z., D.J.M., S.J.S.) and Surgery (J.A.L.), Columbia University, College of Physicians and Surgeons, New York, New York 10032
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Walker MD, Dempster DW, McMahon DJ, Udesky J, Shane E, Bilezikian JP, Silverberg SJ. Effect of renal function on skeletal health in primary hyperparathyroidism. J Clin Endocrinol Metab 2012; 97:1501-7. [PMID: 22399521 PMCID: PMC3339888 DOI: 10.1210/jc.2011-3072] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Current guidelines recommend parathyroidectomy in patients with primary hyperparathyroidism (PHPT) who have an estimated glomerular filtration rate (eGFR) less than 60 ml/min per 1.73 m(2). It is unclear, however, whether values below this threshold of renal impairment affect bone and mineral metabolism in PHPT. OBJECTIVE The purpose of this study was to assess the effect of renal function on skeletal health in PHPT. DESIGN This is a retrospective analysis of PHPT patients with (eGFR < 60 ml/min per 1.73 m(2)) and without chronic kidney disease (CKD) from our previously described PHPT cohort recruited from 1984 to 1991. SETTING The study was conducted in a university hospital metabolic bone unit. PARTICIPANTS One hundred thirty-eight women and men with PHPT were studied. OUTCOME MEASURES We assessed bone mineral density (BMD) by dual-energy x-ray absorptiometry; quantitative histomorphometric indices from transiliac bone biopsies; and biochemical markers of mineral metabolism. RESULTS Although there was no difference in serum or urinary calcium or PTH level, calcitriol levels were lower and phosphate levels higher in patients with CKD. BMD adjusted for weight did not differ at any site between groups. Histomorphometric analysis (n = 30 of 138) revealed a 45% greater eroded surface in those with CKD (P = 0.02). Eroded surface negatively correlated with eGFR (r = -0.46, P = 0.02) and phosphate (r = -0.48, P = 0.02) and positively correlated with serum calcium level (r = 0.51, P = 0.009) but not with PTH, alkaline phosphatase, vitamin D metabolites, or urinary calcium excretion. CONCLUSION Although cardinal biochemical indices (such as calcium and PTH) and BMD do not differ in PHPT patients with an eGFR below 60 ml/min per 1.73 m(2), these patients have higher phosphate and histomorphometric evidence of altered bone remodeling compared with those without CKD.
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Affiliation(s)
- Marcella D Walker
- Columbia University College of Physicians and Surgeons, Department of Medicine, New York, New York 10032, USA.
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Siilin H, Lundgren E, Mallmin H, Mellström D, Ohlsson C, Karlsson M, Orwoll E, Ljunggren Ö. Prevalence of Primary Hyperparathyroidism and Impact on Bone Mineral Density in Elderly Men: MrOs Sweden. World J Surg 2011; 35:1266-72. [DOI: 10.1007/s00268-011-1062-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Tassone F, Gianotti L, Emmolo I, Ghio M, Borretta G. Glomerular filtration rate and parathyroid hormone secretion in primary hyperparathyroidism. J Clin Endocrinol Metab 2009; 94:4458-61. [PMID: 19808852 DOI: 10.1210/jc.2009-0587] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT The recent Third International Workshop on the Management of Asymptomatic Primary Hyperparathyroidism (PHPT) set 60 ml/min as the precise level of glomerular filtration rate (GFR) below which surgery is recommended because it is considered a threshold of concern in patients with PHPT. OBJECTIVE The aim of the study was to investigate the relationship between different stages of renal insufficiency and PTH levels in PHPT patients. DESIGN We conducted a cross-sectional study. PATIENTS AND METHODS We studied 294 consecutive PHPT patients. Biochemical evaluation included total and ionized serum calcium, phosphate, creatinine, immunoreactive intact PTH, and 25-hydroxyvitamin D3 levels in the fasting state. GFR was assessed with the Modification of Diet in Renal Disease Study formula. RESULTS The mean GFR of the whole group of PHPT patients was 92.3 +/- 31.6 ml/min x 1.73 m(2). The patients were divided into four groups according to National Kidney Foundation Disease Outcomes Quality Initiative (K/DOQI) guidelines: group 1 with normal or increased GRF (>90 ml/min x 1.73 m(2); n = 153); group 2 with mild decreased GFR (60-89 ml/min x 1.73 m(2); n = 90); group 3 with moderately decreased GFR (30-59 ml/min x 1.73 m(2); n = 45); and group 4 with severely decreased GFR (<30 ml/min x 1.73 m(2); n = 6). PTH levels were comparable across groups 1-3, whereas group 4 showed significantly higher PTH levels (P < 0.0001). CONCLUSION In our series of PHPT patients, only a severe impairment of GFR was characterized by a further PTH increase. These findings challenge the concept of a PTH elevation below the threshold of 60 ml/min of GFR.
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Affiliation(s)
- F Tassone
- Division of Endocrinology and Metabolism, Santa Croce and Carle Hospital, 12100 Cuneo, Italy.
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Gianotti L, Tassone F, Pia A, Bovio S, Reimondo G, Visconti G, Terzolo M, Borretta G. May an altered hypothalamo-pituitary-adrenal axis contribute to cortical bone damage in primary hyperparathyroidism? Calcif Tissue Int 2009; 84:425-9. [PMID: 19381429 DOI: 10.1007/s00223-009-9245-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 03/22/2009] [Indexed: 11/27/2022]
Abstract
Cortisol secretion has been reported to be increased in primary hyperparathyroidism (PHPT). Our aim was to evaluate circulating and urinary cortisol levels and the relationships with biochemical and bone parameters in patients with PHPT at the time of diagnosis. We studied 180 consecutive patients with PHPT (mean age +/- SD 60.0 +/- 13.2 years; F/M 140/40, BMI 25.8 +/- 4.8 kg/m(2)) and 56 subjects with incidentally discovered adrenal adenoma who served as controls (age 56.2 +/- 12.8 years, F/M 40/16, BMI 25.7 +/- 3.9 kg/m(2)). Serum morning and midnight cortisol and urinary free cortisol were measured in both groups. In PHPT patients bone mineral density was measured at the lumbar spine, femur, and forearm. Serum morning cortisol and urinary cortisol were similar in PHPT patients and controls, whereas midnight cortisol was higher in PHPT patients (5.3 +/- 4.7 vs. 2.9 +/- 0.9 microg/dL, P = 0.001). In this group, midnight cortisol correlated positively with age (r = 0.27, P = 0.008) and negatively with forearm (r = -0.36, P = 0.003) and total-femur T score (r = -0.30, P = 0.02). Multivariate regression analysis, including age, calcium, parathyroid hormone (PTH), and midnight cortisol as independent variables and forearm T score as dependent variable, indicated that age (beta = -0.29, P < 0.0001), PTH (beta = -0.33, P < 0.0001), and midnight cortisol (beta = -0.14, P < 0.04) were independently associated with forearm T score. Our findings show increased midnight cortisol levels in patients with PHPT, indicating a subtle alteration of the hypothalamo-pituitary-adrenal axis dynamics that is unrelated to the degree of disease activity; further data are needed to demonstrate the supplementary effect of this subtle alteration to bone damage in this condition.
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Affiliation(s)
- Laura Gianotti
- Division of Endocrinology and Metabolism, Department of Medicine, A.S.O.S. Croce & Carle Hospital, Via M. Coppino 26, Cuneo, Italy.
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Gómez Sáez JM. [Clinical manifestations and asymptomatic forms of primary hyperparathyroidism]. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2009; 56 Suppl 1:8-13. [PMID: 19627755 DOI: 10.1016/s1575-0922(09)70850-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The clinical profile of primary hyperparathyroidism (PHPT) has changed considerably, especially since the introduction of autoanalyzers in the laboratory, allowing calcium to be determined more frequently and a large number of cases of hypercalcemia to be detected. The most frequent causes are PHPT and cancer-related hypercalcemia. All of these factors have modified the prevalence of the clinical manifestations and currently the presence of recurrent kidney stones is observed in 20% of patients, while bone lesions, even the most subtle, are infrequent. Differentiating and establishing the limits between symptomatic and asymptomatic PHPT is difficult and many asymptomatic cases will never show disease progression, such as severe hypercalcemia, bone disease, hypercalciuria and/or kidney stones. An important question is whether patients not showing the classical manifestations of PHPT will benefit from surgery. This question is all the more important since, among patients not surgically treated, many are lost to follow-up after 5 to 10 years and the cost of follow-up exceeds that of surgery. Those against intervention base their arguments on the lack of progression in many patients and the possibility of alternative treatments.
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Affiliation(s)
- José Manuel Gómez Sáez
- Servicio de Endocrinología y Nutrición, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España.
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Bibliography. Current world literature. Parathyroids, bone and mineral metabolism. Curr Opin Endocrinol Diabetes Obes 2007; 14:494-501. [PMID: 17982358 DOI: 10.1097/med.0b013e3282f315ef] [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: 11/26/2022]
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