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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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Meriam H, Kaaroud H, Karray R, Ben Hamida F, Bouzid K, Abderrahim E. Recurrent Urolithiasis Revealing Primary Hyperparathyroidism in a Nephrology Department. Case Rep Nephrol 2024; 2024:1265364. [PMID: 38419822 PMCID: PMC10901575 DOI: 10.1155/2024/1265364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/12/2024] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Background Urinary lithiasis constitutes a recurrent pathology affecting a relatively young population. The risk of progression to chronic renal failure and the cost of treatment are the most important issues. Primary hyperparathyroidism (PHPT) is responsible for urolithiasis and nephrocalcinosis in 7% of patients, and it represents the 7th cause of urolithiasis in Tunisia. Unfortunately, it remains an underdiagnosed pathology although it is curable. We aim to determine the clinical, biological, therapeutic, and evolutionary particularities of urinary lithiasis associated with PHPT in a nephrology setting. Methods This is a monocentric, retrospective, descriptive study which took place in our nephrology department during the period from January 2010 to January 2023. Ten patients were included. All of them underwent blood and urine tests and a morphoconstitutional study of the urinary stones if possible. Results The median age at diagnosis of PHPT was 42 years (34-54). The median time from the onset of kidney stones to the diagnosis of PHPT was 6.2 years (1-17). The male/female gender ratio was 0.66. Five patients had hypertension, two patients had obesity, one patient had diabetes, and three patients had urinary tract infections. Kidney stones were bilateral in eight cases and unilateral in two cases. Nine patients underwent urological intervention: surgery in 5 cases associated with nephrectomy in one case, extracorporeal lithotripsy in 4 cases, and percutaneous nephrolithotomy in two cases. The diagnosis of PHPT was retained with high or uncontrolled PTH associated with hypercalcemia in 8 cases and normocalcemic PHPT was found in 2 patients. Two patients had parathyroid adenoma and one patient had mediastinal adenoma. Radiology exploration was normal for the others patients. Surgery was performed in 7 patients and histology revealed an adenoma in 5 cases and hyperplasia in one case. The predominant urinary risk factors in our study were hypercalciuria in 6 cases and insufficient diuresis in 4 cases. Conclusion This study underlines the role of the nephrologist in the exploration of urinary lithiasis and the prevention of recurrences, especially as PHPT is a curable aetiology of urolithiasis and affects a relatively young population. The determination of the epidemiological profile of patients with stones associated with primary PHPT and lithogenic risk factors allows the primary and secondary prevention of stone formation.
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Affiliation(s)
- Hajji Meriam
- Department of Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
- Kidney Pathology Laboratory LR00SP01, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
| | - Hayet Kaaroud
- Department of Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
- Kidney Pathology Laboratory LR00SP01, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
| | - Rahma Karray
- Department of Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
| | - Fethi Ben Hamida
- Department of Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
- Kidney Pathology Laboratory LR00SP01, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
| | - Kahena Bouzid
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
- Department of Biochemistry, Charles Nicolle Hospital, Tunis, Tunisia
| | - Ezzeddine Abderrahim
- Department of Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, El Manar University, Tunis, Tunisia
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Anand N, Sachan R, Dhanda M, Husain N. Parathyroid carcinoma in a patient with primary hyperparathyroidism mimicking parathyroid adenoma. BMJ Case Rep 2023; 16:e255220. [PMID: 37730422 PMCID: PMC10514664 DOI: 10.1136/bcr-2023-255220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
Primary hyperparathyroidism caused by parathyroid carcinoma is extremely rare. Clinically, it is very challenging to differentiate between parathyroid carcinoma and adenoma. The correct diagnosis is made based on the histopathology of the resection specimen. This case report presents a woman in her 40s with body aches, knee joint pain, and fatigue, along with chronic kidney disease. Ultrasonography revealed a large hyperechoic lesion in the left parathyroid gland. Serum calcium, parathyroid hormone, urea, and creatinine levels were increased. The inferior parathyroid gland was surgically removed, and histopathological evaluation confirmed a diagnosis of parathyroid carcinoma. Unfortunately, many patients do not undergo complete resection due to a lack of a correct diagnosis during the initial surgery.
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Affiliation(s)
- Nidhi Anand
- Pathology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Ruchita Sachan
- Pathology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Mallika Dhanda
- Endocrine Surgery, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Nuzhat Husain
- Pathology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
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Zhu CY, Zhou HX, Tseng CH, Fackelmayer OJ, Haigh PI, Adams AL, Yeh MW. Long-term effects of primary hyperparathyroidism and parathyroidectomy on kidney function. Eur J Endocrinol 2023; 189:115-122. [PMID: 37449311 DOI: 10.1093/ejendo/lvad081] [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: 01/30/2023] [Revised: 04/10/2023] [Accepted: 06/23/2023] [Indexed: 07/18/2023]
Abstract
IMPORTANCE Limited evidence supports kidney dysfunction as an indication for parathyroidectomy in asymptomatic primary hyperparathyroidism (PHPT). OBJECTIVE To investigate the natural history of kidney function in PHPT and whether parathyroidectomy alters renal outcomes. DESIGN Matched control study. SETTING A vertically integrated health care system serving 4.6 million patients in Southern California. PARTICIPANTS 6058 subjects with PHPT and 16 388 matched controls, studied from 2000 to 2016. EXPOSURES Biochemically confirmed PHPT with varying serum calcium levels. MAIN OUTCOMES Estimated glomerular filtration rate (eGFR) trajectories were compared over 10 years, with cases subdivided by severity of hypercalcemia: serum calcium 2.62-2.74 mmol/L (10.5-11 mg/dL), 2.75-2.87 (11.1-11.5), 2.88-2.99 (11.6-12), and >2.99 (>12). Interrupted time series analysis was conducted among propensity-score-matched PHPT patients with and without parathyroidectomy to compare eGFR trajectories postoperatively. RESULTS Modest rates of eGFR decline were observed in PHPT patients with serum calcium 2.62-2.74 mmol/L (−1.0 mL/min/1.73 m2/year) and 2.75-2.87 mmol/L (−1.1 mL/min/1.73 m2/year), comprising 56% and 28% of cases, respectively. Compared with the control rate of −1.0 mL/min/1.73 m2/year, accelerated rates of eGFR decline were observed in patients with serum calcium 2.88-2.99 mmol/L (−1.5 mL/min/1.73 m2/year, P < .001) and >2.99 mmol/L (−2.1 mL/min/1.73 m2/year, P < .001), comprising 9% and 7% of cases, respectively. In the propensity score–matched population, patients with serum calcium >2.87 mmol/L exhibited mitigation of eGFR decline after parathyroidectomy (−2.0 [95% CI: −2.6 to −1.5] to −0.9 [95% CI: −1.5 to 0.4] mL/min/1.73 m2/year). CONCLUSIONS AND RELEVANCE Compared with matched controls, accelerated eGFR decline was observed in the minority of PHPT patients with serum calcium >2.87 mmol/L (11.5 mg/dL). Parathyroidectomy was associated with mitigation of eGFR decline in patients with serum calcium >2.87 mmol/L.
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Affiliation(s)
- Catherine Y Zhu
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, United States
| | - Hui X Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
| | - Chi-Hong Tseng
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Oliver J Fackelmayer
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, United States
| | - Philip I Haigh
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, United States
| | - Annette L Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Michael W Yeh
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, United States
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El-Hajj Fuleihan G, Chakhtoura M, Cipriani C, Eastell R, Karonova T, Liu JM, Minisola S, Mithal A, Moreira CA, Peacock M, Schini M, Silva B, Walker M, El Zein O, Marcocci C. Classical and Nonclassical Manifestations of Primary Hyperparathyroidism. J Bone Miner Res 2022; 37:2330-2350. [PMID: 36245249 DOI: 10.1002/jbmr.4679] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 11/09/2022]
Abstract
This narrative review summarizes data on classical and nonclassical manifestations of primary hyperparathyroidism (PHPT). It is based on a rigorous literature search, inclusive of a Medline search for systematic reviews from 1940 to December 2020, coupled with a targeted search for original publications, covering four databases, from January 2013-December 2020, and relevant articles from authors' libraries. We present the most recent information, identify knowledge gaps, and suggest a research agenda. The shift in the presentation of PHPT from a predominantly symptomatic to an asymptomatic disease, with its varied manifestations, has presented several challenges. Subclinical nephrolithiasis and vertebral fractures are common in patients with asymptomatic disease. The natural history of asymptomatic PHPT with no end organ damage at diagnosis is unclear. Some observational and cross-sectional studies continue to show associations between PHPT and cardiovascular and neuropsychological abnormalities, among the different disease phenotypes. Their causal relationship is uncertain. Limited new data are available on the natural history of skeletal, renal, cardiovascular, neuropsychological, and neuromuscular manifestations and quality of life. Normocalcemic PHPT (NPHPT) is often diagnosed without the fulfillment of rigorous criteria. Randomized clinical trials have not demonstrated a consistent long-term benefit of parathyroidectomy (PTX) versus observation on nonclassical manifestations. We propose further refining the definition of asymptomatic disease, into two phenotypes: one without and one with evidence of target organ involvement, upon the standard evaluation detailed in our recommendations. Each of these phenotypes can present with or without non-classical manifestations. We propose multiple albumin-adjusted serum calcium determinations (albumin-adjusted and ionized) and exclusion of all secondary causes of high parathyroid hormone (PTH) when establishing the diagnosis of NPHPT. Refining the definition of asymptomatic disease into the phenotypes proposed will afford insights into their natural history and response to interventions. This would also pave the way for the development of evidence-based guidance and recommendations. © 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)
- Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, World Health Organization (WHO) Collaborating Center (CC) for Metabolic Bone Disorders, Division of Endocrinology, American University of Beirut, Beirut, Lebanon
| | - Marlene Chakhtoura
- Calcium Metabolism and Osteoporosis Program, World Health Organization (WHO) Collaborating Center (CC) for Metabolic Bone Disorders, Division of Endocrinology, American University of Beirut, Beirut, Lebanon
| | - Cristiana Cipriani
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | - Richard Eastell
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
| | - Tatiana Karonova
- Clinical Endocrinology Laboratory, Department of Endocrinology, Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Jian-Min Liu
- Department of Endocrine and Metabolic Disease, Rui-jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | - Ambrish Mithal
- Institute of Endocrinology and Diabetes, Max Healthcare, New Delhi, India
| | - Carolina A Moreira
- Endocrine Division (SEMPR), Department of Internal Medicine, Federal University of Parana, Curitiba, Brazil
- Academic Research Center of Pro-Renal Institute, Curitiba, Brazil
| | - Munro Peacock
- Division of Endocrinology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marian Schini
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
| | - Barbara Silva
- Endocrinology Unit, Department of Medicine, Centro Universitario de Belo Horizonte (UNI BH), Felicio Rocho Hospital, Belo Horizonte, Brazil
- Endocrinology Unit, Santa Casa Hospital, Belo Horizonte, Brazil
| | - Marcella Walker
- Division of Endocrinology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ola El Zein
- Saab Medical Library, American University of Beirut, Beirut, Lebanon
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, Endocrine Unit 2, University Hospital of Pisa Chairman European Group on Graves' Orbitopathy Via Paradisa 2, University of Pisa Head, Pisa, Italy
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Al-Jehani A, Al-Ahmed F, Nguyen-Thi PL, Bihain F, Nomine-Criqui C, Demarquet L, Guerci B, Ziegler O, Brunaud L. Insulin resistance is more severe in patients with primary hyperparathyroidism. Surgery 2022; 172:552-558. [DOI: 10.1016/j.surg.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/05/2021] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
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Abstract
Sporadic primary hyperparathyroidism is a common endocrinopathy, particularly afflicting postmenopausal women and both African American men and women. Although classic signs and symptoms of the disease are well appreciated and described, because of the ease and availability and low threshold for screening, the disorder often is diagnosed in patients who are minimally symptomatic or asymptomatic. Surgery conducted by experienced endocrine surgeons has a high cure rate, particularly if guided by concordant imaging. In patients who cannot safely undergo surgery or who fail to be cured, medical therapy with the oral calcimimetic cinacalcet is a validated option for controlling serum calcium levels.
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Affiliation(s)
- Stephanie J Kim
- Division of Endocrinology and Metabolism, University of California, 400 Parnassus Avenue A549, San Francisco, CA 94143, USA.
| | - Dolores M Shoback
- Endocrine Research Unit - 111N, San Francisco Department of Veterans Affairs Medical Center, Division of Endocrinology and Metabolism, San Francisco VA Medical Center, University of California, 1700 Owens Street, 3rd floor Room 369, San Francisco, CA 94158, USA
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Turan U, Kilavuz H, Irkorucu O. CLINICAL FEATURES OF HYPERCALCEMIC CRISIS IN PRIMARY HYPERPARATHYROIDISM. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2021; 17:493-497. [PMID: 35747865 PMCID: PMC9206153 DOI: 10.4183/aeb.2021.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CONTEXT Primary hyperparathyroidism related hypercalcemic crisis (PHHC) is a condition that may result in fetal course. So, the early diagnosis and treatment of these patients are important. OBJECTIVE This study aimed to investigate the clinical features for hypercalcemic crisis (HC) by comparing the groups with and without primary hyperparathyroidism related calcemic crisis. DESIGN All patients operated with primary hyperparathyroidism (PH) diagnosis in a single clinic between March 2015 and March 2020 were included in this retrospective study. SUBJECTS AND METHODS 119 patients included the study.Patients with serum calcium (Ca) level > 14 mg/dl were regarded as HC and the patients were divided into two groups as HC and non-HC. These two groups were compared for demographic data, preoperative biochemical parameters, preoperative localization studies, histopathological assessment and postoperative results. RESULTS Serum Parathormone (PTH), Ca, Alkaline phosphatase (ALP) and creatinine values among preoperative biochemical parameters were higher in the HC group than the non-HC (p<0.005). The hyper-functional parathyroid size of the patients in the HC group was also bigger compared to non-HC (p<0.05). No difference was observed in the demographic and histopathological data, preoperative localization studies and postoperative results of the two groups (p>0.05). CONCLUSIONS PH is usually an elective operation and PHCC treatment should be relatively more urgent as it can be mortal. Higher HC occurrence possibility should be considered in PH patients with high serum PTH, ALP and creatinine values and large tumor diameters and those patients should be prioritized for treatment.
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Affiliation(s)
- U. Turan
- Adana City Training and Research Hospital, Department of General Surgery, Adana, Turkey
| | - H. Kilavuz
- Adana City Training and Research Hospital, Department of General Surgery, Adana, Turkey
| | - O. Irkorucu
- University of Sharjah, College of Medicine, Clinical Sciences Department, Sharjah, United Arab Emirates
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Liang CC, Yeh HC, Lo YC, Chou CY, Yen TH, Tsai HC, Hsu SP, Kuo CC. Parathyroidectomy slows renal function decline in patients with primary hyperparathyroidism. J Endocrinol Invest 2021; 44:755-763. [PMID: 32729050 DOI: 10.1007/s40618-020-01369-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/18/2020] [Indexed: 01/09/2023]
Abstract
PURPOSE Primary hyperparathyroidism has deleterious effects on health and causes nephrolithiasis and osteoporosis. However, it remains unclear whether parathyroidectomy benefits kidney function among patients with primary hyperparathyroidism. METHODS In this retrospective study, patients with primary hyperparathyroidism receiving parathyroidectomy in a tertiary medical center between 2003 and 2017 were followed up until December 31 2017, death, or requiring renal replacement therapy. Impact of parathyroidectomy on kidney function was examined using longitudinal estimated glomerular filtration rate (eGFR) change scales: single, average, absolute difference, percent change, annual decline rate, and slope. We applied linear mixed-effect model to determine the effect of parathyroidectomy on kidney function. RESULTS During study period, 167 patients with primary hyperparathyroidism were identified from 498 parathyroidectomized patients, and finally, 27 patients fulfilled our stringent criteria. Median follow-up duration was 1.50 years (interquartile range 1.05-1.81) before surgery and 2.47 years (1.37-6.43) after surgery. Although parathyroidectomy did not affect amount of proteinuria and distribution of eGFR, parathyroidectomy significantly slowed decline rate of eGFR compared with that before surgery (- 1.67 versus - 2.73 mL/min/1.73 m2/year, p < 0.001). More importantly, parathyroidectomy made more beneficial effects on kidney function in patients with age < 65 years and those without chronic kidney disease or hypertension. CONCLUSIONS Our study showed that parathyroidectomy slows renal function decline irrespective of age or comorbidities, which offers novel insight into the revision of guidelines for surgical indications in primary hyperparathyroidism. Given small sample size, further large-scale controlled studies are warranted to confirm our findings.
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Affiliation(s)
- C-C Liang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - H-C Yeh
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Y-C Lo
- Big Data Center, China Medical University Hospital and China Medical University, Taichung, Taiwan
| | - C-Y Chou
- Division of Nephrology, Asia University Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Veterinary Medicine, Asia University, Taichung, Taiwan
| | - T-H Yen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - H-C Tsai
- Big Data Center, China Medical University Hospital and China Medical University, Taichung, Taiwan
| | - S-P Hsu
- College of Medicine, China Medical University, Taichung, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - C-C Kuo
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.
- College of Medicine, China Medical University, Taichung, Taiwan.
- Big Data Center, China Medical University Hospital and China Medical University, Taichung, Taiwan.
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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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Shariq OA, Strajina V, Lyden ML, McKenzie TJ, Wermers RA, Thompson GB, Dy BM. Parathyroidectomy improves hypercalciuria in patients with primary hyperparathyroidism. Surgery 2020; 168:594-600. [DOI: 10.1016/j.surg.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 01/21/2023]
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Physical Activity-Dependent Regulation of Parathyroid Hormone and Calcium-Phosphorous Metabolism. Int J Mol Sci 2020; 21:ijms21155388. [PMID: 32751307 PMCID: PMC7432834 DOI: 10.3390/ijms21155388] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/09/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022] Open
Abstract
Exercise perturbs homeostasis, alters the levels of circulating mediators and hormones, and increases the demand by skeletal muscles and other vital organs for energy substrates. Exercise also affects bone and mineral metabolism, particularly calcium and phosphate, both of which are essential for muscle contraction, neuromuscular signaling, biosynthesis of adenosine triphosphate (ATP), and other energy substrates. Parathyroid hormone (PTH) is involved in the regulation of calcium and phosphate homeostasis. Understanding the effects of exercise on PTH secretion is fundamental for appreciating how the body adapts to exercise. Altered PTH metabolism underlies hyperparathyroidism and hypoparathyroidism, the complications of which affect the organs involved in calcium and phosphorous metabolism (bone and kidney) and other body systems as well. Exercise affects PTH expression and secretion by altering the circulating levels of calcium and phosphate. In turn, PTH responds directly to exercise and exercise-induced myokines. Here, we review the main concepts of the regulation of PTH expression and secretion under physiological conditions, in acute and chronic exercise, and in relation to PTH-related disorders.
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Cipriani C, Bilezikian JP. Non-surgical management of primary hyperparathyroidism in the aging population. Maturitas 2020; 136:49-53. [PMID: 32386666 DOI: 10.1016/j.maturitas.2020.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/02/2020] [Accepted: 04/08/2020] [Indexed: 01/24/2023]
Abstract
Primary hyperparathyroidism (PHPT) is commonly observed in the aging population, and the average age at diagnosis has increased in the last 20 years. Parathyroidectomy, the only definitive cure for PHPT, is indicated in symptomatic and asymptomatic older PHPT patients with skeletal and renal disease. It is as effective in older patients as it is in younger patients. Nevertheless, older patients may present with comorbidities and greater frailty, leading to the possibility of more complications, higher morbidity and mortality after surgery. This review focuses on the non-surgical clinical management of PHPT in elderly patients. We also summarize the most recent literature regarding the pharmacological management of PHPT to reduce serum calcium levels, to improve bone mineral density or to do both in the aging population.
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Affiliation(s)
- Cristiana Cipriani
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - John P Bilezikian
- Division of Endocrinology, Columbia University College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, USA.
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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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Cipriani C, Pepe J, Colangelo L, Fassino V, Occhiuto M, Biondi P, Nieddu L, Minisola S. Investigating subtle kidney injury in primary hyperparathyroidism by means of sensitive and specific biomarkers. Clin Endocrinol (Oxf) 2019; 91:660-668. [PMID: 31309599 DOI: 10.1111/cen.14064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/24/2019] [Accepted: 07/12/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Kidney involvement is a common complication in primary hyperparathyroidism (PHPT). No study so far has assessed the prevalence of kidney injury developing before the reduction in glomerular filtration rate (GFR) in PHPT. The study was aimed at establishing the potential role of biomarkers of kidney injury in detecting subtle renal damage in patients with PHPT. DESIGN Cross-sectional study. PATIENTS A total of 69 postmenopausal patients with PHPT and 41 healthy age- and sex-matched subjects were studied. Exclusion criteria were as follows: GFR < 30 mL/min, chronic inflammatory disease, nephrotic syndrome, infection, malignancy, heart failure, recent exposure to iodinated contrast media or nonsteroidal anti-inflammatory drugs. MEASUREMENTS We measured a panel of sensitive biomarkers of kidney injury in PHPT vs controls. RESULTS Mean FGF23 and Klotho were higher in PHPT (72 ± 48 and 811 ± 366 pg/mL, respectively) than controls (53 ± 23.5 and 668.6 ± 17; P < .02 and P < .05). Urine KIM-1/uCr was significantly higher in PHPT (1.4-6 ± 1.3-6 ) than controls (9.2-7 ± 7-7 ; P < .05); this was particularly evident in the CrCl 60-89 mL/min category (1.36 ± 97 vs 8.2-7 ± 3.6-7 ; P < .02). Mean values of urine NGAL/uCr were higher in PHPT with (n = 28) compared to those without kidney stones (n = 35; 1.8-5 ± 1.4-5 and 1-5 ± 8-6 ; P < .0001). We found significant positive associations between urine NGAL/uCr and Ca (R = .292, P < .02) and urine KIM1/uCr and PTH (R = .329, P < .01). CONCLUSIONS We propose the utilization of these molecules, particularly urine KIM-1/uCr and urine NGAL/uCr ratios for the assessment of subtle kidney injury in patients with PHPT. These molecules are elevated in tubular necrosis and have potential role in the development of kidney damage in PHPT, according to the severity of the disease.
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Affiliation(s)
- Cristiana Cipriani
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
| | - Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
| | - Luciano Colangelo
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
| | - Valeria Fassino
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
| | - Marco Occhiuto
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
| | - Piergianni Biondi
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
| | | | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
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Coronary artery disease is more severe in patients with primary hyperparathyroidism. Surgery 2019; 167:149-154. [PMID: 31668778 DOI: 10.1016/j.surg.2019.05.094] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/27/2019] [Accepted: 05/22/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Primary hyperparathyroidism is associated with an increased cardiovascular mortality, but mechanisms underlying this association are unclear. The goal of this study was to evaluate coronary artery calcifications via the coronary calcification score in primary hyperparathyroidism patients, to compare with control subjects, and to identify risk factors for high to intermediate risk coronary calcification scores (coronary calcification score >100). METHOD Cross-sectional study of primary hyperparathyroidism patients without a history of coronary artery disease, diabetes, or severe, chronic kidney disease. Coronary calcification scores were compared with a cohort of population-based control subjects. RESULTS The mean coronary calcification score was 120 ± 344 in 130 primary hyperparathyroidism patients. The coronary calcification score was >100 in 27 patients (21%). When compared with control subjects, the percentage of positive coronary calcification scores was similar in primary hyperparathyroidism patients (53% vs 50%); however, positive coronary calcification scores were at the 67th percentile of the control subjects cohort (P < .001). In multivariable regression, patient age (1.1; 1.1-1.2; P < .001), patients in the mild normocalcemic primary hyperparathyroidism group (5.1; 1.1-22.6; P = .037), and the need for antihypertensive medications (6.1; 1.8-20.9; P < .001) remained independent predictors for a coronary calcification score >100. CONCLUSION Positive coronary calcification scores were greater in primary hyperparathyroidism patients than in population-based control subjects. These study data may provide new criteria for parathyroidectomy in patients with primary hyperparathyroidism.
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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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ÇALIŞKAN M, KIZILGÜL M, BEYSEL S, UÇAN B, AKCAN F, TAKIR M, ÖZBEK M, ÇAKAL E. Factors associated with glomerular filtration rate variation in primary hyperparathyroidism after parathyroidectomy. Turk J Med Sci 2019; 49:295-300. [PMID: 30761868 PMCID: PMC7350870 DOI: 10.3906/sag-1806-181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background/aim Prolonged hypercalcemia impairs renal function, and a reduced glomerular filtration rate (GFR) is typical in advanced primary hyperparathyroidism (PHPT). There are scarce data related to predictors of renal impairment in patients with PHPT. Hence, we aimed to evaluate changes in kidney function in PHPT patients after parathyroidectomy (PTX) and identify factors associated with GFR variation in these patients. Materials and methods One hundred and twenty-five patients with PHPT who underwent surgery between 2012 and 2014 were enrolled in the study. Patients were divided into two groups according to GFR values: patients whose GFR was lower than 60 mL/min/1.73 m2 and higher than 60 mL/min/1.73 m2. Demographic and laboratory parameters were compared before and 6 months after parathyroidectomy. Results Prevalence of antihypertensive drug users and patients with renal cysts and parathormone (PTH) and alkaline phosphatase levels were higher in patients with GFR of ≥60 than in GFR of <60 mL/min/1.73 m2 (P < 0.05). Systolic BP, uric acid, and magnesium were decreased in patients with GFR of ≥60, but GFR did not change in the two groups after parathyroidectomy. After parathyroidectomy, calcium and PTH decreased but 25(OH)D3 and phosphorus increased in the two groups. In multiple regression analysis, age, calcium, and baseline GFR were independent predictors of GFR variation. Parathyroid adenoma volume and urinary calcium were not independent predictors of GFR change. Conclusion Older age, higher preoperative calcium, and GFR were factors associated with GFR increase in PHPT patients after parathyroidectomy. Further renal impairment was prevented by parathyroidectomy in PHPT patients.
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Affiliation(s)
- Mustafa ÇALIŞKAN
- Department of Endocrinology and Metabolism, University of Health Sciences,Dışkapı Training and Research Hospital, AnkaraTurkey
| | - Muhammed KIZILGÜL
- Department of Endocrinology and Metabolism, University of Health Sciences,Dışkapı Training and Research Hospital, AnkaraTurkey
- * To whom correspondence should be addressed. E-mail:
| | - Selvihan BEYSEL
- Department of Endocrinology and Metabolism, University of Health Sciences,Dışkapı Training and Research Hospital, AnkaraTurkey
| | - Bekir UÇAN
- Department of Endocrinology and Metabolism, University of Health Sciences,Dışkapı Training and Research Hospital, AnkaraTurkey
| | - Fatih AKCAN
- Department of Otorhinolaryngology, School of Medicine, Düzce University, DüzceTurkey
| | - Mümtaz TAKIR
- Department of Endocrinology and Metabolism, Medeniyet University, Göztepe Training and Research Hospital, İstanbulTurkey
| | - Mustafa ÖZBEK
- Department of Endocrinology and Metabolism, University of Health Sciences,Dışkapı Training and Research Hospital, AnkaraTurkey
| | - Erman ÇAKAL
- Department of Endocrinology and Metabolism, University of Health Sciences,Dışkapı Training and Research Hospital, AnkaraTurkey
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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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Green P, Zagzag J, Patel D, Weinstein LS, Simonds WF, Blau J, Marx S, Kebebew E, Perrier N, Nilubol N. High prevalence of chronic kidney disease in patients with multiple endocrine neoplasia type 1 and improved kidney function after parathyroidectomy. Surgery 2018; 165:124-128. [PMID: 30414705 DOI: 10.1016/j.surg.2018.04.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/04/2018] [Accepted: 04/10/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Because chronic kidney disease is an important comorbidity associated with primary hyperparathyroidism, we sought to evaluate the prevalence of chronic kidney disease and effects of parathyroidectomy on kidney function in patients with multiple endocrine neoplasia type 1-associated primary hyperparathyroidism. METHODS We performed a retrospective analysis of 112 patients with multiple endocrine neoplasia type 1-associated primary hyperparathyroidism who had at least 1 operation for primary hyperparathyroidism at 2 tertiary referral centers. The preoperative and postoperative estimated glomerular filtration rates were compared. The prevalence of chronic kidney disease stage 3 or worse (estimated glomerular filtration rates less than 60 mL/min/1.73m2) in this cohort was compared to the rates in the US population reported by the Centers for Disease Control and Prevention. RESULTS The median age at the time of parathyroidectomy was 36.5 years (range: 12-76 years). A total of 99 patients had biochemical remission. The rate of chronic kidney disease stage 3 or worse in patients with multiple endocrine neoplasia type 1-associated primary hyperparathyroidism was greater than that observed in the US population for ages 20-39 and 40-59 (5% [n = 2/44] vs 0.39% [n = 18/4565], P = .015 and 10% [n = 4/40] vs 2.31% (n = 89/3848), P = .015, respectively). We observed improved estimated glomerular filtration rates in those with chronic kidney disease stage 3 or worse postoperatively (48 vs 57 mL/min/1.73m2, P = .047). A successful parathyroidectomy normalized all 24-hour urine calcium excretion. CONCLUSION An indication for early parathyroidectomy should include estimated glomerular filtration rates less than 60mL/min/1.73m2 in patients with multiple endocrine neoplasia type 1-associated primary hyperparathyroidism.
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Affiliation(s)
- Patience Green
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jonathan Zagzag
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Dhaval Patel
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Lee S Weinstein
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - William F Simonds
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Jenny Blau
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Stephen Marx
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Electron Kebebew
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Nancy Perrier
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Naris Nilubol
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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Abusahmin H, Geen J, Das G. Subclinical urolithiasis in patients with asymptomatic primary hyperparathyroidism. Ther Adv Endocrinol Metab 2018; 9:325-327. [PMID: 30349660 PMCID: PMC6194929 DOI: 10.1177/2042018818788201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Hussam Abusahmin
- Department of Endocrinology, Prince Charles
Hospital, Cwm Taf University Health Board, Merthyr Tydfil, Mid Glamorgan,
UK
| | - John Geen
- Department of Clinical Biochemistry, Prince
Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, Mid
Glamorgan, UK Faculty of Life Sciences and Education, University of South
Wales, Pontypridd, UK
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Ejlsmark-Svensson H, Bislev LS, Rolighed L, Sikjaer T, Rejnmark L. Predictors of Renal Function and Calcifications in Primary Hyperparathyroidism: A Nested Case-Control Study. J Clin Endocrinol Metab 2018; 103:3574-3583. [PMID: 29955845 DOI: 10.1210/jc.2018-00923] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/22/2018] [Indexed: 01/14/2023]
Abstract
CONTEXT Some patients with primary hyperparathyroidism (PHPT) develop renal calcifications. Investigation of urinary and nonurinary risk factors are essential. OBJECTIVE We aimed to study the prevalence and potential biochemical predictors of renal calcifications. DESIGN Nested case-control study. SETTING University hospital. PARTICIPANTS We identified 792 patients with PHPT from 2005 to 2015. We used biochemical data to validate the diagnosis of PHPT. MAIN OUTCOME MEASURES The prevalence of renal calcifications defined as nephrolithiasis or nephrocalcinosis assessed by a routine CT scan at the time of diagnosis. RESULTS A total of 792 patients with PHPT were identified among whom 617 patients (78%) had a CT scan preformed. We found a prevalence of renal calcifications of 23%, equally frequent between sexes. A total of 76 patients (12%) had nephrolithiasis and 75 patients (12%) had nephrocalcinosis where 7 patients (1%) had both nephrolithiasis and nephrocalcinosis. Compared with patients without renal calcifications, patients with renal calcifications had significantly higher levels of ionized calcium, parathyroid hormone, and 24-hour calcium excretion (Pall < 0.01). Patients with nephrocalcinosis had higher plasma levels of phosphate and a higher calcium-phosphate product compared with patients with nephrolithiasis (Pall < 0.05). Impaired renal function (estimated glomerular filtration rate <60 mL/min) was observed in 12% of patients. However, no differences in renal function were observed between those with and without renal calcifications. CONCLUSION Renal calcifications are frequent in patients with PHPT and are associated with the severity of the disease. Impaired renal function is also common in PHPT, but renal function was not associated with renal calcifications.
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Affiliation(s)
- Henriette Ejlsmark-Svensson
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Lise Sofie Bislev
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Lars Rolighed
- Department of Otorhinolaryngology, Head, and Neck Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - Tanja Sikjaer
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Lars Rejnmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus N, Denmark
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Tay YKD, Liu M, Bandeira L, Bucovsky M, Lee JA, Silverberg SJ, Walker MD. Occult urolithiasis in asymptomatic primary hyperparathyroidism. Endocr Res 2018; 43:106-115. [PMID: 29400579 PMCID: PMC6042842 DOI: 10.1080/07435800.2018.1431275] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Recent international guidelines suggest renal imaging to detect occult urolithiasis in all patients with asymptomatic primary hyperparathyroidism (PHPT), but data regarding their prevalence and associated risk factors are limited. We evaluated the prevalence and risk factors for occult urolithiasis. METHODS Cross-sectional analysis of 96 asymptomatic PHPT patients from a university hospital in the United States with and without occult nephrolithiasis. RESULTS Occult urolithiasis was identified in 21% of patients. Stone formers had 47% higher 24-hour urinary calcium excretion (p = 0.002). Although available in only a subset of patients (n = 28), activated vitamin D [1,25(OH)2D] was 29% higher (p = 0.02) in stone formers. There was no difference in demographics, BMI, calcium or vitamin D intake, other biochemistries, renal function, BMD, or fractures. Receiver operating characteristic curves indicated that urinary calcium excretion and 1,25(OH)2D had an area under the curve of 0.724 (p = 0.003) and 0.750 (p = 0.04), respectively. A urinary calcium threshold of >211mg/day provided a sensitivity of 84.2% and a specificity of 55.3% while a 1,25(OH)2D threshold of >91pg/mL provided a sensitivity and specificity of 62.5% and 90.0% respectively for the presence of stones. CONCLUSION Occult urolithiasis is present in about one-fifth of patients with asymptomatic PHPT and is associated with higher urinary calcium and 1,25(OH)2D. Given that most patients will not have occult urolithiasis, targeted imaging in those most likely to have occult stones rather than screening all asymptomatic PHPT patients may be useful. The higher sensitivity of urinary calcium versus 1,25(OH)2D suggests screening those with higher urinary calcium may be an appropriate approach.
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Affiliation(s)
- Yu-Kwang Donovan Tay
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York
- Department of Medicine, Sengkang Health, Singapore
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore
| | - Minghao Liu
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York
| | - Leonardo Bandeira
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York
| | - Mariana Bucovsky
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York
| | - James A. Lee
- Department of Endocrine Surgery, Columbia University, New York, USA
| | - Shonni J. Silverberg
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York
| | - Marcella D. Walker
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York
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Abstract
In this Review, we describe the pathogenesis, diagnosis and management of primary hyperparathyroidism (PHPT), with a focus on recent advances in the field. PHPT is a common endocrine disorder that is characterized by hypercalcaemia and elevated or inappropriately normal serum levels of parathyroid hormone. Most often, the presentation of PHPT is asymptomatic in regions of the world where serum levels of calcium are routinely measured. In addition to mild hypercalcaemia, PHPT can manifest with osteoporosis and hypercalciuria as well as with vertebral fractures and nephrolithiasis, both of which can be asymptomatic. Other clinical forms of PHPT, such as classical disease and normocalcaemic PHPT, are less common. Parathyroidectomy, the only curative treatment for PHPT, is recommended in patients with symptoms and those with asymptomatic disease who are at risk of progression or have subclinical evidence of end-organ sequelae. Parathyroidectomy results in an increase in BMD and a reduction in nephrolithiasis. Various medical therapies can increase BMD or reduce serum levels of calcium, but no single drug can do both. More data are needed regarding the neuropsychological manifestations of PHPT and the pathogenetic mechanisms leading to sporadic PHPT, as well as on risk factors for complications of the disorder. Future work that advances our knowledge in these areas will improve the management of the disorder.
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Affiliation(s)
- Marcella D Walker
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA
| | - Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA
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Parathyroid hormone, aldosterone-to-renin ratio and fibroblast growth factor-23 as determinants of nocturnal blood pressure in primary hyperparathyroidism: the eplerenone in primary hyperparathyroidism trial. J Hypertens 2017; 34:1778-86. [PMID: 27379537 DOI: 10.1097/hjh.0000000000001004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The high prevalence of arterial hypertension in primary hyperparathyroidism (pHPT) is largely unexplained. Apart from parathyroid hormone (PTH), the mineral hormones fibroblast growth factor (FGF)-23 and aldosterone-to-renin ratio (ARR) are upregulated in pHPT. We aimed to determine whether nocturnal blood pressure (BP) is related with PTH, FGF-23 or ARR in a relatively large sample of pHPT patients. METHODS Cross-sectional data of the single-center "Eplerenone in Primary Hyperparathyroidism" trial were used. All patients with a biochemical diagnosis of pHPT who had both available 24-h ambulatory BP monitoring and valid laboratory data were included. RESULTS Full data were available in 136 patients (mean age 67 ± 10 years, 78% women). Median PTH was 99 (interquartile range: 82-124) pg/ml and mean calcium was 2.63 ± 0.15 mmol/l. ARR, but not PTH or FGF-23, was significantly and directly related with nocturnal SBP (Pearson's r = 0.241, P < 0.01) and DBP (r = 0.328, P < 0.01). In multivariate regression analyses, with adjustment for age, sex, PTH, FGF-23, traditional cardiovascular risk factors, antihypertensive medication and parameters of calcium metabolism ARR remained significantly and directly related with nocturnal BP (SBP: adjusted β-coefficient = 0.289, P < 0.01; DBP: β = 0.399, P < 0.01). The relationship between ARR and nocturnal SBP was exclusively present in patients with PTH levels above the median of 99 pg/ml. CONCLUSION ARR, but not FGF-23 or PTH, was independently and directly related with nocturnal BP parameters in patients with pHPT, and this relationship was dependent on pHPT disease severity. Inappropriately, elevated aldosterone may partially explain the high prevalence of arterial hypertension in pHPT.
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Primary hyperparathyroidism, hypercalciuria, and bone recovery after parathyroidectomy. Surgery 2017; 162:429-436. [DOI: 10.1016/j.surg.2017.02.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 01/29/2017] [Accepted: 02/15/2017] [Indexed: 11/20/2022]
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Verdelli C, Corbetta S. MECHANISMS IN ENDOCRINOLOGY: Kidney involvement in patients with primary hyperparathyroidism: an update on clinical and molecular aspects. Eur J Endocrinol 2017; 176:R39-R52. [PMID: 27601015 DOI: 10.1530/eje-16-0430] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/12/2016] [Accepted: 09/02/2016] [Indexed: 12/27/2022]
Abstract
Primary hyperparathyroidism (PHPT) is the third most common endocrine disease. Kidney is a target of both chronic elevated PTH and calcium in PHPT. The classic PHPT complications of symptomatic kidney stones and nephrocalcinosis have become rare and the PHPT current presentation is asymptomatic with uncertain and long-lasting progression. Nonetheless, the routine use of imaging and of biochemical determinations have revealed the frequent occurrence of asymptomatic kidney stones, hypercalciuria and reduced kidney function in asymptomatic PHPT patients. Though the pathogenesis is far from being elucidated, PHPT is associated with reduced renal function, in terms of estimated glomerular filtration rate, and related increased morbidity and mortality. In the last decade, the effort of the Kidney Disease: Improving Global Outcomes (KDIGO) panel of experts highlighted that even mild reduction of kidney function is associated with increased risk of cardiovascular disease. These considerations provided the basis for the Fourth Workshop recommendations of a more extensive diagnostic workout about kidney features and of wider criteria for parathyroid surgery including asymptomatic kidney disease. Moreover, kidney involvement in PHPT is likely to be affected by variants of genes coding the key molecules regulating the calcium and ions renal handling; these features might have clinical relevance and should be considered both during diagnostic workout and follow-up. Finally, the effects of parathyroid surgery and of medical treatment on kidney involvement of PHPT are reviewed.
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Affiliation(s)
- C Verdelli
- Laboratory of Experimental EndocrinologyIRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - S Corbetta
- Laboratory of Experimental EndocrinologyIRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Endocrinology ServiceDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Renal dysfunction in primary hyperparathyroidism; effect of Parathyroidectomy: A retrospective Cohort Study. Int J Surg 2016; 36:383-387. [DOI: 10.1016/j.ijsu.2016.11.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/02/2016] [Indexed: 01/16/2023]
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"Silent" kidney stones in "asymptomatic" primary hyperparathyroidism-a comparison of multidetector computed tomography and ultrasound. Langenbecks Arch Surg 2016; 402:289-293. [PMID: 27734157 PMCID: PMC5346427 DOI: 10.1007/s00423-016-1520-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 10/02/2016] [Indexed: 12/02/2022]
Abstract
Purpose The purpose of this study was to demonstrate the high number of kidney stones in primary hyperparathyroidism (PHPT) and the low number of in fact “asymptomatic” patients. Methods Forty patients with PHPT (28 female, 12 male; median age 58 (range 33–80) years; interquartile range 17 years [51–68]) without known symptoms of kidney stones prospectively underwent multidetector computed tomography (MDCT) and ultrasound (US) examinations of the urinary tract prior to parathyroid surgery. Images were evaluated for the presence and absence of stones, as well as for the number of stones and sizes in the long axis. The MDCT and US examinations were interpreted by two experienced radiologists who were blinded to all clinical and biochemical data. Statistical analysis was performed using the Wilcoxon signed-rank test. Results US revealed a total of 4 kidney stones in 4 (10 %) of 40 patients (median size 6.5 mm, interquartile range 11.5 mm). MDCT showed a total of 41 stones (median size was 3 mm, interquartile range 2.25 mm) in 15 (38 %) of 40 patients. The number of kidney stones detected with MDCT was significantly higher compared to US (p = 0.00124). Conclusions MDCT is a highly sensitive method for the detection of “silent” kidney stones in patients with PHPT. By widely applying this method, the number of asymptomatic courses of PHPT may be substantially reduced. MDCT should be used primarily to detect kidney stones in PHPT and to exclude asymptomatic PHPT.
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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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Ermetici F, Filopanti M, Verga U, Passeri E, Dito G, Malavazos AE, Mapelli C, Raggi ME, Spada A, Corbetta S. Estimated glomerular filtration rate by serum cystatin C correlates with cardiometabolic parameters in patients with primary hyperparathyroidism. Eur J Endocrinol 2015; 173:441-6. [PMID: 26194503 DOI: 10.1530/eje-15-0341] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 07/20/2015] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Patients with primary hyperparathyroidism (PHPT) are at risk of chronic kidney disease (CKD). Cystatin C (Cys-C) is considered a more reliable tool to assess glomerular filtration rate (GFR) than creatinine. The study aimed to assess circulating Cys-C and its relationships with biochemical PHPT and cardiometabolic parameters. DESIGN AND METHODS The present cross-sectional study was performed in academic endocrine units on PHPT patients (n=190) and non-hypertensive, non-diabetic, age- and sex-matched healthy controls (n=135) with no established CKD. The main outcomes were creatinine by alkaline picrate method, Cys-C by immunonephelometry and calculation of estimated GFR based on creatinine and Cys-C (eGFRcr-cys) using the CKD-EPI equation. RESULTS In PHPT patients, circulating Cys-C ranged 0.45-3.13 mg/l and correlated with creatinine, age and BMI. Mean Cys-C level was higher in PHPT patients than in controls (0.93±0.02 vs 0.78±0.14 mg/l; P=0.03). Cys-C levels in PHPT patients were predicted by age, BMI, ionized calcium, hypertension and HDL-cholesterol, the most significant determinant being ionized calcium. Cys-C positively correlated with cardiovascular disease (CVD) occurrence. Overall, 18.4% of PHPT patients with eGFRcr >60 ml/min per 1.73 m(2) (n=169) had Cys-C levels higher than the 95th percentile in controls (1.03 mg/l), consistent with a preclinical CKD, which was associated with hypertension and insulin resistance. Considering eGFRcr-cys, CKD (stages G3a, G3b, 4) was diagnosed in 13.7% of PHPT patients. Estimated GFRcr-cys, but not eGFR based on creatinine, was predicted by insulin resistance and hypertension and positively correlated with CVD. CONCLUSIONS Elevated Cys-C levels were associated with ionized calcium, cardiometabolic risk factors and CVD, and identified preclinical CKD in PHPT patients.
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Affiliation(s)
- Federica Ermetici
- Diabetology and Metabolic Disease UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyEndocrine and Diabetology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyClinical Pathology LaboratoryIRCCS E. Medea, Bosisio Parini, Lecco, ItalyEndocrine and Diabetology UnitDepartment of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | - Marcello Filopanti
- Diabetology and Metabolic Disease UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyEndocrine and Diabetology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyClinical Pathology LaboratoryIRCCS E. Medea, Bosisio Parini, Lecco, ItalyEndocrine and Diabetology UnitDepartment of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | - Uberta Verga
- Diabetology and Metabolic Disease UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyEndocrine and Diabetology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyClinical Pathology LaboratoryIRCCS E. Medea, Bosisio Parini, Lecco, ItalyEndocrine and Diabetology UnitDepartment of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | - Elena Passeri
- Diabetology and Metabolic Disease UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyEndocrine and Diabetology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyClinical Pathology LaboratoryIRCCS E. Medea, Bosisio Parini, Lecco, ItalyEndocrine and Diabetology UnitDepartment of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | - Giorgia Dito
- Diabetology and Metabolic Disease UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyEndocrine and Diabetology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyClinical Pathology LaboratoryIRCCS E. Medea, Bosisio Parini, Lecco, ItalyEndocrine and Diabetology UnitDepartment of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | - Alexis Elias Malavazos
- Diabetology and Metabolic Disease UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyEndocrine and Diabetology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyClinical Pathology LaboratoryIRCCS E. Medea, Bosisio Parini, Lecco, ItalyEndocrine and Diabetology UnitDepartment of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | - Chiara Mapelli
- Diabetology and Metabolic Disease UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyEndocrine and Diabetology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyClinical Pathology LaboratoryIRCCS E. Medea, Bosisio Parini, Lecco, ItalyEndocrine and Diabetology UnitDepartment of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | - Maria Elisabetta Raggi
- Diabetology and Metabolic Disease UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyEndocrine and Diabetology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyClinical Pathology LaboratoryIRCCS E. Medea, Bosisio Parini, Lecco, ItalyEndocrine and Diabetology UnitDepartment of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | - Anna Spada
- Diabetology and Metabolic Disease UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyEndocrine and Diabetology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyClinical Pathology LaboratoryIRCCS E. Medea, Bosisio Parini, Lecco, ItalyEndocrine and Diabetology UnitDepartment of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | - Sabrina Corbetta
- Diabetology and Metabolic Disease UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyEndocrine and Diabetology UnitFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitIRCCS Policlinico San Donato, San Donato Milanese, Milan, ItalyClinical Pathology LaboratoryIRCCS E. Medea, Bosisio Parini, Lecco, ItalyEndocrine and Diabetology UnitDepartment of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Milan, ItalyEndocrinology UnitDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
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Macfarlane DP, Yu N, Leese GP. Asymptomatic and mild primary hyperparathyroidism. ANNALES D'ENDOCRINOLOGIE 2015; 76:120-7. [DOI: 10.1016/j.ando.2015.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
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Brown TC, Healy JM, McDonald MJ, Hansson JH, Quinn CE. Heart block and acute kidney injury due to hyperparathyroidism-induced hypercalcemic crisis. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2014; 87:563-7. [PMID: 25506288 PMCID: PMC4257040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We describe a patient who presented with multi-system organ failure due to extreme hypercalcemia (serum calcium 19.8 mg/dL), resulting from primary hyperparathyroidism. He was found to have a 4.8 cm solitary atypical parathyroid adenoma. His course was complicated by complete heart block, acute kidney injury, and significant neurocognitive disturbances. Relevant literature was reviewed and discussed. Hyperparathyroidism-induced hypercalcemic crisis (HIHC) is a rare presentation of primary hyperparathyroidism and only a small minority of these patients develop significant cardiac and renal complications. In cases of HIHC, a multidisciplinary effort can facilitate rapid treatment of life-threatening hypercalcemia and definitive treatment by surgical resection. As such, temporary transvenous cardiac pacing and renal replacement therapy can provide a life-saving bridge to definitive parathyroidectomy in cases of HIHC.
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Affiliation(s)
- Taylor C. Brown
- Department of Surgery, Section of Endocrine Surgery, Yale School of Medicine, New Haven, Connecticut
| | - James M. Healy
- Department of Surgery, Section of Endocrine Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Mary J. McDonald
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Joni H. Hansson
- Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, New Haven, Connecticut
| | - Courtney E. Quinn
- Department of Surgery, Section of Endocrine Surgery, Yale School of Medicine, New Haven, Connecticut,To whom all correspondence should be addressed: Courtney E. Quinn, MD, MS, Assistant Professor of Surgery, Department of Surgery, Section of Endocrine Surgery, Yale School of Medicine, 330 Cedar St., FMB 130, Box 208062, New Haven, CT 06520; Tele: 203-737-2036; Fax: 203-785-2498;
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Cipriani C, Bilezikian JP. Commentary on silent renal stones in primary hyperparathyroidism: prevalence and clinical features. Endocr Pract 2014; 20:1231-3. [PMID: 25297666 DOI: 10.4158/ep14313.co] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Cristiana Cipriani
- College of Physicians and Surgeons, Columbia University, New York, New York Department of Internal Medicine and Medical Disciplines, "Sapienza" University of Rome, Italy
| | - John P Bilezikian
- College of Physicians and Surgeons, Columbia University, New York, New York
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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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