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Parksook WW, Brown JM, Milks J, Tsai LC, Chan J, Moore A, Niebuhr Y, Honzel B, Newman AJ, Vaidya A. Saline suppression testing-induced hypocalcemia and implications for clinical interpretations. Eur J Endocrinol 2024; 191:241-250. [PMID: 39073780 PMCID: PMC11322817 DOI: 10.1093/ejendo/lvae099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 06/08/2024] [Accepted: 07/25/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Extracellular calcium critically regulates physiologic aldosterone production. Moreover, abnormal calcium flux and signaling are involved in the pathogenesis of the majority of primary aldosteronism cases. METHODS We investigated the influence of the saline suppression test (SST) on calcium homeostasis in prospectively recruited participants (n = 86). RESULTS During SST, 100% of participants had decreases in serum calcium, with 48% developing frank hypocalcemia. Serum calcium declined from 2.30 ± 0.08 mmol/L to 2.13 ± 0.08 mmol/L (P < .001) with parallel increases in parathyroid hormone from 6.06 ± 2.39 pmol/L to 8.13 ± 2.42 pmol/L (P < .001). In contrast, serum potassium and bicarbonate did not change, whereas eGFR increased and serum glucose decreased (P < .001). Lower body surface area (translating to greater effective circulating volume expansion during SST) was associated with greater reductions in (β = .33, P = .001), and absolutely lower, serum calcium levels (β = .25, P = .001). When evaluating clinically-relevant diagnostic thresholds, participants with post-SST aldosterone levels <138 pmol/L had lower post-SST calcium and 25-hydroxyvitamin D levels (P < .05), and higher post-SST parathyroid hormone levels (P < .05) compared with those with post-SST aldosterone levels >277 pmol/L. CONCLUSION SST uniformly decreases serum calcium, which is likely to be due to the combination of variable dilution, increased renal clearance, and vitamin D status. These acute reductions in bioavailable calcium are associated with lower post-SST aldosterone. Given the critical role of extracellular calcium in regulating aldosterone production, these findings warrant renewed inquiry into the validity of SST interpretations for excluding primary aldosteronism.
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Affiliation(s)
- Wasita W Parksook
- Center for Adrenal Disorders, Boston, MA 02115, United States
- Division of Endocrinology, Diabetes, and Hypertension, Boston, MA 02115, United States
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
- Department of Medicine (Division of Endocrinology and Metabolism, and Division of General Internal Medicine), Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Jenifer M Brown
- Center for Adrenal Disorders, Boston, MA 02115, United States
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
- Division of Cardiovascular Medicine, Boston, MA 02115, United States
| | - Julia Milks
- Center for Adrenal Disorders, Boston, MA 02115, United States
- Division of Endocrinology, Diabetes, and Hypertension, Boston, MA 02115, United States
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Laura C Tsai
- Center for Adrenal Disorders, Boston, MA 02115, United States
- Division of Endocrinology, Diabetes, and Hypertension, Boston, MA 02115, United States
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Justin Chan
- Center for Adrenal Disorders, Boston, MA 02115, United States
- Division of Endocrinology, Diabetes, and Hypertension, Boston, MA 02115, United States
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Anna Moore
- Center for Adrenal Disorders, Boston, MA 02115, United States
- Division of Endocrinology, Diabetes, and Hypertension, Boston, MA 02115, United States
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Yvonne Niebuhr
- Center for Adrenal Disorders, Boston, MA 02115, United States
- Division of Endocrinology, Diabetes, and Hypertension, Boston, MA 02115, United States
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Brooke Honzel
- Center for Adrenal Disorders, Boston, MA 02115, United States
- Division of Endocrinology, Diabetes, and Hypertension, Boston, MA 02115, United States
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Andrew J Newman
- Center for Adrenal Disorders, Boston, MA 02115, United States
- Division of Endocrinology, Diabetes, and Hypertension, Boston, MA 02115, United States
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Anand Vaidya
- Center for Adrenal Disorders, Boston, MA 02115, United States
- Division of Endocrinology, Diabetes, and Hypertension, Boston, MA 02115, United States
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
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2
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Abstract
Primary hyperparathyroidism (PHPT), the most common cause of hypercalcemia, is most often identified in postmenopausal women with hypercalcemia and parathyroid hormone (PTH) levels that are either frankly elevated or inappropriately normal. The clinical presentation of PHPT includes three phenotypes: target organ involvement of the renal and skeletal systems; mild asymptomatic hypercalcemia; and more recently, high PTH levels in the context of persistently normal albumin-corrected and ionized serum calcium values. The factors that determine which of these three clinical presentations is more likely to predominate in a given country include the extent to which biochemical screening is employed, the prevalence of vitamin D deficiency, and whether a medical center or practitioner tends to routinely measure PTH levels in the evaluation of low bone density or frank osteoporosis. When biochemical screening is common, asymptomatic primary hyperparathyroidism is the most likely form of the disease. In countries where vitamin D deficiency is prevalent and biochemical screening is not a feature of the health care system, symptomatic disease with skeletal abnormalities is likely to predominate. Finally, when PTH levels are part of the evaluation for low bone mass, the normocalcemic variant is seen. Guidelines for surgical removal of hyperfunctioning parathyroid tissue apply to all three clinical forms of the disease. If guidelines for surgery are not met, parathyroidectomy can also be an appropriate option if there are no medical contraindications to surgery. In settings where either the serum calcium or bone mineral density is of concern, and surgery is not an option, pharmacological approaches are available and effective. Referencing in this article the most current published articles, we review the different presentations of PHPT, with particular emphasis on recent advances in our understanding of target organ involvement and management.
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Affiliation(s)
- Barbara C Silva
- Division of Endocrinology, Felicio Rocho and Santa Casa Hospital, Belo Horizonte, Brazil
| | - Natalie E Cusano
- Division of Endocrinology, Lenox Hill Hospital, New York, NY, USA
| | - John P Bilezikian
- Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
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Parksook WW, Heydarpour M, Brown JM, Turchin A, Mannstadt M, Vaidya A. Evaluating the clinical and mechanistic effects of eplerenone and amiloride monotherapy, and combination therapy with cinacalcet, in primary hyperparathyroidism: A placebo-controlled randomized trial. Clin Endocrinol (Oxf) 2023; 98:516-526. [PMID: 36316798 PMCID: PMC10006290 DOI: 10.1111/cen.14840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/23/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Human physiology and epidemiology studies have demonstrated complex interactions between the renin-angiotensin-aldosterone system, parathyroid hormone and calcium homeostasis. Several of these studies have suggested that aldosterone inhibition may lower parathyroid hormone (PTH) levels. The objective of this study was to assess the effect of 4 weeks of maximally tolerated mineralocorticoid receptor antagonist therapy with eplerenone on PTH levels in patients with primary hyperparathyroidism (P-HPT) when compared to amiloride and placebo. We also investigated the synergistic effect of these interventions when combined with cinacalcet for an additional 2 weeks. DESIGN Randomized, double-blinded, three parallel-group, placebo-controlled trial. PATIENTS Patients with P-HPT. RESULTS Most patients were women (83%) and White (76%). Maximally tolerated doses of eplerenone and amiloride induced significant reductions in blood pressure and increases in renin and aldosterone production; however, despite these physiologic changes, neither intervention induced significant changes in PTH or calcium levels when compared to the placebo. Both eplerenone and amiloride therapy induced significant reductions in procollagen type 1 N-terminal propeptide levels when compared to placebo. When cinacalcet therapy was added, PTH and calcium levels were markedly reduced in all groups; however, there was no significant difference in PTH or serum calcium reductions between groups. CONCLUSIONS Although maximally tolerated therapy with eplerenone and amiloride induced expected changes in renin, aldosterone and blood pressure, there were no meaningful changes in PTH or serum calcium levels in P-HPT patients. These results suggest that inhibition of aldosterone action does not have a clinically meaningful role in medical therapy for P-HPT.
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Affiliation(s)
- Wasita W. Parksook
- Center for Adrenal Disorders, Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Diabetes, and Hypertension, Harvard Medical School, Boston, MA, USA
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine (Division of Endocrinology and Metabolism, and Division of General Internal Medicine), Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Mahyar Heydarpour
- Division of Endocrinology, Diabetes, and Hypertension, Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Harvard Medical School, Boston, MA, USA
| | - Jenifer M. Brown
- Center for Adrenal Disorders, Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Harvard Medical School, Boston, MA, USA
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Turchin
- Division of Endocrinology, Diabetes, and Hypertension, Harvard Medical School, Boston, MA, USA
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Diabetes, and Hypertension, Harvard Medical School, Boston, MA, USA
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Giontella A, Lotta LA, Baras A, Minuz P, Gill D, Melander O, Fava C. Calcium, Its Regulatory Hormones, and Their Causal Role on Blood Pressure: A Two-Sample Mendelian Randomization Study. J Clin Endocrinol Metab 2022; 107:3080-3085. [PMID: 36062972 DOI: 10.1210/clinem/dgac501] [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: 06/03/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Vitamin D (Vit-D), parathyroid hormone (PTH), and fibroblast growth factor 23 (FGF23) are the major calciotropic hormones involved in the regulation of blood calcium levels from the intestine, kidney, and bone through a tight endocrine feedback loop system. Altered levels of calcium itself or through the effect of its regulatory hormones could affect blood pressure (BP), but the exact mechanisms remain unclear. OBJECTIVE To evaluate whether a causal relationship exists between serum calcium level and/or the regulatory hormones involved in its homeostasis with BP, we performed a two-sample Mendelian randomization (MR) study. METHODS From 4 large genome-wide association studies (GWAS) we obtained independent (r2 < 0.001) single nucleotide polymorphisms (SNPs) associated with serum calcium (119 SNPs), Vit-D (78 SNPs), PTH (5 SNPs), and FGF23 (5 SNPs), to investigate through MR their association with systolic BP (SBP) and diastolic BP (DBP) in a Swedish urban-based study, the Malmö Diet and Cancer study (n = 29 298). Causality was evaluated by the inverse variance weighted method (IVW) and weighted median, while MR Egger and MR-PRESSO were used as sensitivity analyses. RESULTS Genetically predicted serum calcium level was found to be associated with DBP (IVW: beta = 0.10, SE = 0.04, P = 0.007) and SBP (IVW: beta = 0.07, SE = 0.04, P = 0.04). Genetically predicted Vit-D and PTH showed no association with the traits, while FGF23 was inversely associated with SBP (IVW: beta = -0.11, SE = 0.04, P = 0.01), although this association lost statistical significance in sensitivity analysis. CONCLUSION Our study shows a direct association between genetically predicted calcium level and DBP, and a weaker association with SBP. No such clear association was found for genetically predicted calciotropic hormone levels. It is of interest to detect which target genes involved in calcium homeostasis mediate the effect of calcium on BP, particularly for improving personalized intervention strategies.
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Affiliation(s)
- Alice Giontella
- Department of Medicine, University of Verona, Verona 37124, Italy
- Department of Clinical Sciences, Clinical Research Center, Lund University, Malmö 21428, Sweden
| | - Luca A Lotta
- Regeneron Genetics Center, Tarrytown, NY 10591, USA
| | - Aris Baras
- Regeneron Genetics Center, Tarrytown, NY 10591, USA
| | - Pietro Minuz
- Department of Medicine, University of Verona, Verona 37124, Italy
| | - Dipender Gill
- Department of Epidemiology and Biostatistics, Imperial College London, London SW72AZ, UK
- Novo Nordisk Research Centre Oxford, Old Road Campus OX37FZ, UK
| | - Olle Melander
- Department of Clinical Sciences, Clinical Research Center, Lund University, Malmö 21428, Sweden
- Department of Emergency and Internal Medicine, Skåne University Hospital, Malmö 21428, Sweden
| | - Cristiano Fava
- Department of Medicine, University of Verona, Verona 37124, Italy
- Department of Clinical Sciences, Clinical Research Center, Lund University, Malmö 21428, Sweden
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Hassani S, Afkhamizadeh M, Teimouri A, Najaf Najafi M, Vazifeh Mostaan L, Mohebbi M. Evaluation of Serum Level of FGF23 and 1,25(OH) 2D 3 in Primary Hyperparathyroidism Patients Before and After Parathyroidectomy. Int J Gen Med 2020; 13:289-295. [PMID: 32606893 PMCID: PMC7295333 DOI: 10.2147/ijgm.s253246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/28/2020] [Indexed: 12/29/2022] Open
Abstract
Purpose Parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23) play critical roles in phosphate homeostasis. To the best of our knowledge, there are limited data on the impact of FGF23 and PTH on serum calcium, 1,25(OH)2D3, and phosphate in patients with primary hyperparathyroidism (PHPT). We examined these parameters and their correlations in PHPT patients before and after parathyroidectomy (PTX). Patients and Methods In this prospective cohort study, 29 PHPT patients who met the inclusion criteria were selected. The patient’s blood samples were taken three times: before the operation, 24 h after the operation, and 1 week after the operation. The concentrations of serum calcium, FGF23, 1,25(OH)2D3, phosphate, PTH, and alkaline phosphatase were measured in a referral laboratory at each of the three steps. Moreover, 25(OH)D was primarily measured just before the surgery. Results Of 29 patients included in this study with a mean age of 52.37±12.3 years, majority were females (75.8%). Serum FGF23 and 1,25(OH)2D3 levels were high before PTX and decreased after the operation; however, the difference was not statistically significant. FGF23 levels were significantly correlated with 1,25(OH)2D3 at each of the three steps (r=0.964, P <0.01; r=0.985, P <0.0; and r=0.976, P <0.05). The variations in calcium, phosphate, creatinine, and PTH were preoperatively and postoperatively significant. Conclusion Although 1,25(OH)2D3 and FGF23 levels were preoperatively higher in PHPT, their variations were not meaningful. There was a statistically direct significant relationship between 1,25(OH)2D3 and FGF23 preoperatively and postoperatively; however, the correlations between FGF23 and calcium, phosphate, and PTH were not significant.
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Affiliation(s)
- Solmaz Hassani
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mozhgan Afkhamizadeh
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Teimouri
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mona Najaf Najafi
- Clinical Research Development Unit, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Masoud Mohebbi
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Bayomy O, Zaheer S, Williams JS, Curhan G, Vaidya A. Disentangling the Relationships Between the Renin-Angiotensin-Aldosterone System, Calcium Physiology, and Risk for Kidney Stones. J Clin Endocrinol Metab 2020; 105:5803967. [PMID: 32163150 PMCID: PMC7185954 DOI: 10.1210/clinem/dgaa123] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/05/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT Complex relationships between aldosterone and calcium homeostasis have been proposed. OBJECTIVE To disentangle the influence of aldosterone and intravascular volume on calcium physiology. DESIGN Patient-oriented and epidemiology studies. SETTING Clinical research center and nationwide cohorts. PARTICIPANTS/INTERVENTIONS Patient-oriented study (n = 18): Participants were evaluated after completing a sodium-restricted (RES) diet to contract intravascular volume and after a liberalized-sodium (LIB) diet to expand intravascular volume. Cross-sectional studies (n = 3755): the association between 24h urinary sodium and calcium excretion and risk for kidney stones was assessed. RESULTS Patient-oriented study: compared to a RES-diet, a LIB-diet suppressed renin activity (LIB: 0.3 [0.1, 0.4] vs. RES: 3.1 [1.7, 5.3] ng/mL/h; P < 0.001) and plasma aldosterone (LIB: 2.0 [2.0, 2.7] vs. RES: 20.0 [16.1, 31.0] vs. ng/dL; P < 0.001), but increased calciuria (LIB: 238.4 ± 112.3 vs. RES: 112.9 ± 60.8 mg/24hr; P < 0.0001) and decreased serum calcium (LIB: 8.9 ± 0.3 vs. RES: 9.8 ± 0.4 mg/dL; P < 0.0001). Epidemiology study: mean urinary calcium excretion was higher with greater urinary sodium excretion. Compared to a urinary sodium excretion of < 120 mEq/day, a urinary sodium excretion of ≥220 mEq/day was associated with a higher risk for having kidney stones in women (risk ratio = 1.79 [95% confidence interval 1.05, 3.04]) and men (risk ratio = 2.06 [95% confidence interval 1.27, 3.32]). CONCLUSIONS High dietary sodium intake suppresses aldosterone, decreases serum calcium, and increases calciuria and the risk for developing kidney stones. Our findings help disentangle the influences of volume from aldosterone on calcium homeostasis and provide support for the recommendation to restrict dietary sodium for kidney stone prevention.
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Affiliation(s)
- Omar Bayomy
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, US
| | - Sarah Zaheer
- Division of Endocrinology and Metabolism, Department of Medicine, Duke University, Durham, NC, US
| | - Jonathan S Williams
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, US
| | - Gary Curhan
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, US
| | - Anand Vaidya
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, US
- Correspondence and Reprint Requests: Anand Vaidya, MD MMSc, Division of Endocrinology, Diabetes, and Hypertension, 221 Longwood Ave, Boston, MA 02115. E-mail:
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Abstract
Although untreated primary hyperparathyroidism is associated with increased cardiovascular mortality, controversy exists regarding the therapeutic effects of parathyroidectomy on cardiovascular health. This review will examine the evidence linking primary hyperparathyroidism (PHPT) and cardiovascular disease, specifically hypertension, and evaluate the available literature regarding the natural history of hypertension after successful parathyroidectomy.
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Affiliation(s)
- Sarah B Fisher
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nancy D Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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8
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Abstract
BACKGROUND Primary hyperparathyroidism (PHPT), the most common cause of hypercalcemia, is most often identified in postmenopausal women. The clinical presentation of PHPT has evolved over the past 40 years to include three distinct clinical phenotypes, each of which has been studied in detail and has led to evolving concepts about target organ involvement, natural history, and management. METHODS In the present review, I provide an evidence-based summary of this disorder as it has been studied worldwide, citing key concepts and data that have helped to shape our concepts about this disease. RESULTS PHPT is now recognized to include three clinical phenotypes: overt target organ involvement, mild asymptomatic hypercalcemia, and high PTH levels with persistently normal albumin-corrected and ionized serum calcium values. The factors that determine which of these clinical presentations is more likely to predominate in a given country include the extent to which biochemical screening is used, vitamin D deficiency is present, and whether parathyroid hormone levels are routinely measured in the evaluation of low bone density or frank osteoporosis. Guidelines for parathyroidectomy apply to all three clinical forms of the disease. If surgical guidelines are not met, parathyroidectomy can also be an appropriate option if no medical contraindications are present. If either the serum calcium or bone mineral density is of concern and surgery is not an option, pharmacological approaches are available and effective. CONCLUSIONS Advances in our knowledge of PHPT have guided new concepts in diagnosis and management.
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Affiliation(s)
- John P Bilezikian
- Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
- Correspondence and Reprint Requests: John P. Bilezikian, MD, Department of Medicine, College of Physicians and Surgeons, University of Columbia, 630 West 168th Street, New York, New York 10032. E-mail:
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9
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Abstract
Primary hyperparathyroidism (PHPT), the most common cause of hypercalcemia, is most often identified in postmenopausal women with hypercalcemia and parathyroid hormone (PTH) levels that are either frankly elevated or inappropriately normal. The clinical presentation of PHPT includes three phenotypes: target organ involvement of the renal and skeletal systems; mild asymptomatic hypercalcemia; and more recently, high PTH levels in the context of persistently normal albumin-corrected and ionized serum calcium values. The factors that determine which of these three clinical presentations is more likely to predominate in a given country include the extent to which biochemical screening is employed, the prevalence of vitamin D deficiency, and whether a medical center or practitioner tends to routinely measure PTH levels in the evaluation of low bone density or frank osteoporosis. When biochemical screening is common, asymptomatic primary hyperparathyroidism is the most likely form of the disease. In countries where vitamin D deficiency is prevalent and biochemical screening is not a feature of the health care system, symptomatic disease with skeletal abnormalities is likely to predominate. Finally, when PTH levels are part of the evaluation for low bone mass, the normocalcemic variant is seen. Guidelines for surgical removal of hyperfunctioning parathyroid tissue apply to all three clinical forms of the disease. If guidelines for surgery are not met, parathyroidectomy can also be an appropriate option if there are no medical contraindications to surgery. In settings where either the serum calcium or bone mineral density is of concern, and surgery is not an option, pharmacological approaches are available and effective. Referencing in this article the most current published articles, we review the different presentations of PHPT, with particular emphasis on recent advances in our understanding of target organ involvement and management.
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Affiliation(s)
- Barbara C Silva
- Division of Endocrinology, Felicio Rocho and Santa Casa Hospital, Belo Horizonte, Brazil; Department of Medicine, Centro Universitario de Belo Horizonte (UNIBH), Brazil
| | - Natalie E Cusano
- Division of Endocrinology, Lenox Hill Hospital, New York, NY, USA
| | - John P Bilezikian
- Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
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Srivastava T, Jafri S, Truog WE, Sebestyen VanSickle J, Manimtim WM, Alon US. Successful Reversal of Furosemide-Induced Secondary Hyperparathyroidism With Cinacalcet. Pediatrics 2017; 140:peds.2016-3789. [PMID: 29192005 DOI: 10.1542/peds.2016-3789] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2017] [Indexed: 11/24/2022] Open
Abstract
Secondary hyperparathyroidism (SHPT) is a rare complication of furosemide therapy that can occur in patients treated with the loop diuretic for a long period of time. We report a 6-month-old 28-weeks premature infant treated chronically with furosemide for his bronchopulmonary dysplasia, who developed hypocalcemia and severe SHPT, adversely affecting his bones. Discontinuation of the loop diuretic and the addition of supplemental calcium and calcitriol only partially reversed the SHPT, bringing serum parathyroid hormone level down from 553 to 238 pg/mL. After introduction of the calcimimetic Cinacalcet, we observed a sustained normalization of parathyroid hormone concentration at 27 to 63 pg/mL and, with that correction, of all biochemical abnormalities and healing of the bone disease. No adverse effects were noted. We conclude that in cases of SHPT due to furosemide in which traditional treatment fails, there may be room to consider the addition of a calcimimetic agent.
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Affiliation(s)
| | - Shahryar Jafri
- Sections of Nephrology, Bone and Mineral Disorder Clinic, and
| | - William E Truog
- Neonatology, The Children's Mercy Hospitals and Clinics, University of Missouri at Kansas City, Kansas City, Missouri
| | | | - Winston M Manimtim
- Neonatology, The Children's Mercy Hospitals and Clinics, University of Missouri at Kansas City, Kansas City, Missouri
| | - Uri S Alon
- Sections of Nephrology, Bone and Mineral Disorder Clinic, and
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12
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Vaidya A, Curhan GC, Paik JM, Wang M, Taylor EN. Body Size and the Risk of Primary Hyperparathyroidism in Women: A Cohort Study. J Bone Miner Res 2017; 32:1900-1906. [PMID: 28488734 PMCID: PMC5555811 DOI: 10.1002/jbmr.3168] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/26/2017] [Accepted: 05/08/2017] [Indexed: 01/05/2023]
Abstract
Greater body weight and fat mass have been associated with higher serum parathyroid hormone levels and a higher prevalence of primary hyperparathyroidism (P-HPTH) in women. However, prospective studies to evaluate whether greater body size associates with a higher incidence of developing P-HPTH have not been reported. We investigated whether greater body size was independently associated with a higher risk for developing P-HPTH in women. We conducted a prospective cohort study of 85,013 female participants in the Nurses' Health Study I followed for up to 26 years. Body size was measured via multiple metrics: weight, body mass index (BMI), and waist circumference (WC). Weight and BMI were assessed every 2 years from 1986 to 2012, and WC was assessed in 1986, 1996, and 2000. Detailed dietary and demographic exposures were quantified via validated biennial questionnaires. Incident cases of P-HPTH were confirmed by individual medical record review. Cox proportional hazards models were used to evaluate whether WC, weight, and BMI were independent risk factors for developing P-HPTH. Models were adjusted for demographic variables, comorbidities, medications, intakes of calcium and vitamin D, and exposure to ultraviolet light. We confirmed 491 incident cases of P-HPTH during 2,128,068 person-years of follow-up. The multivariable-adjusted relative risks for incident P-HPTH increased across quartiles of WC: Q1, ref; Q2, 1.34 (0.97, 1.86); Q3, 1.70 (1.24, 2.31); Q4, 2.27 (1.63, 3.18); p trend < 0.001. Similarly, the multivariable-adjusted risks for incident P-HPTH increased across quartiles of weight: Q1, ref; Q2, 1.23 (0.92, 1.65); Q3, 1.63 (1.24, 2.14); Q4, 1.65 (1.24, 2.19); p trend < 0.001. A similar but statistically non-significant trend was observed across quartiles of BMI (p trend = 0.07). In summary, body size may be an independent and modifiable risk factor for developing P-HPTH in women. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Anand Vaidya
- Division of Endocrinology, Diabetes, and Hypertension
- Brigham and Women's Hospital
- Harvard Medical School
| | - Gary C. Curhan
- Division of Renal Medicine
- Channing Division of Network Medicine
- Brigham and Women's Hospital
- Harvard Medical School
- Department of Epidemiology, Harvard T.H. Chan School of Public Health
| | - Julie M. Paik
- Division of Renal Medicine
- Channing Division of Network Medicine
- Brigham and Women's Hospital
- Harvard Medical School
- Department of Epidemiology, Harvard T.H. Chan School of Public Health
| | - Molin Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health
| | - Eric N. Taylor
- Channing Division of Network Medicine
- Brigham and Women's Hospital
- Division of Nephrology and Transplantation, Maine Medical Center
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13
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Abstract
Primary hyperparathyroidism (PHPT) is the most common cause of chronic hypercalcemia. With the advent of routine calcium screening, the classic presentation of renal and osseous symptoms has been largely replaced with mild, asymptomatic disease. In hypercalcemia caused by PHPT, serum parathyroid hormone levels are either high, or inappropriately normal. A single-gland adenoma is responsible for 80% of PHPT cases. Less frequent causes include 4-gland hyperplasia and parathyroid carcinoma. Diminished bone mineral density and nephrolithiasis are the major current clinical sequelae. Parathyroidectomy is the only definitive treatment for PHPT, and in experienced hands, cure rates approach 98%.
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Affiliation(s)
- Kyle A Zanocco
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Avenue, 72-182 CHS, Los Angeles, CA 90095, USA
| | - Michael W Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Avenue, 72-250 CHS, Los Angeles, CA 90095, USA.
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14
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Parathyroid hormone reflects adiposity and cardiometabolic indices but not bone density in normal men. BONEKEY REPORTS 2016; 5:852. [PMID: 28018585 DOI: 10.1038/bonekey.2016.85] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/02/2016] [Indexed: 12/12/2022]
Abstract
Hyperparathyroidism may be associated with skeletal and cardiovascular abnormalities, but it is unclear whether these associations exist for high-normal levels of parathyroid hormone (PTH). We assessed relationships between PTH and anthropometric, skeletal and cardiometabolic indices in normal men. Body composition, blood pressure, biochemistry and bone mineral density (BMD) were evaluated in 151 healthy men. BMD was reassessed at 2 years, and coronary artery calcium (CAC) was measured at 3.5 years. Relationships between PTH and other baseline characteristics, CAC scores and change in BMD were evaluated. PTH correlated positively with baseline body mass index, fat mass, diastolic blood pressure, triglycerides, total and low-density lipoprotein (LDL) cholesterol, (r=0.19-0.25, P=0.02-0.002), and with category of CAC score. Relationships between PTH and cardiometabolic indices remained significant after adjustment for age, 25-hydroxyvitamin D and estimated glomerular filteration rate. Men in the top PTH tertile (⩾4.4 pmol l-1, n=51) were more likely to have LDL cholesterol ⩾3.5 mmol l-1, diastolic blood pressure ⩾85 mm Hg, and CAC score >0 than men in lower tertiles. PTH was not associated with history of fracture, baseline BMD, or change in BMD over 2 years. In summary, in this cohort of healthy men, PTH levels are linearly related to adiposity and to cardiometabolic indices, but not to BMD or bone loss. These findings suggest that adiposity should be considered as an independent cause of secondary hyperparathyroidism, and they may be relevant to patients with normocalcemic hyperparathyroidism, in whom high PTH levels may be a marker of adiposity and cardiometabolic risk rather than always indicating parathyroid autonomy.
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15
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Zaheer S, de Boer I, Allison M, Brown JM, Psaty BM, Robinson-Cohen C, Ix JH, Kestenbaum B, Siscovick D, Vaidya A. Parathyroid Hormone and the Use of Diuretics and Calcium-Channel Blockers: The Multi-Ethnic Study of Atherosclerosis. J Bone Miner Res 2016; 31:1137-45. [PMID: 26748479 PMCID: PMC5424889 DOI: 10.1002/jbmr.2779] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/21/2015] [Accepted: 01/04/2016] [Indexed: 01/05/2023]
Abstract
Thiazide diuretic (TZ) use is associated with higher bone mineral density, whereas loop diuretic (LD) use is associated with lower bone density and incident fracture. Dihydropyridine-sensitive calcium channels are expressed on parathyroid cells and may play a role in parathyroid hormone (PTH) regulation. The potential for diuretics and calcium-channel blockers (CCBs) to modulate PTH and calcium homeostasis may represent a mechanism by which they influence skeletal outcomes. We hypothesized that the use of LD and dihydropyridine CCBs is associated with higher PTH, and TZ use is associated with lower PTH. We conducted cross-sectional analyses of participants treated for hypertension in the Multi-Ethnic Study of Atherosclerosis who did not have primary hyperparathyroidism or chronic kidney disease (n = 1888). We used adjusted regression models to evaluate the independent association between TZ, LD, and CCB medication classes and PTH. TZ use was associated with lower PTH when compared with non-TZ use (44.4 versus 46.9 pg/mL, p = 0.02), whereas the use of LD and CCBs was associated with higher PTH when compared with non-users of each medication class (LD: 60.7 versus 45.5 pg/mL, p < 0.0001; CCB: 49.5 versus. 44.4 pg/mL, p < 0.0001). Adjusted regression models confirmed independent associations between TZ use and lower PTH (β = -3.2 pg/mL, p = 0.0007), and LD or CCB use and higher PTH (LD: β = +12.0 pg/mL, p < 0.0001; CCB: +3.7 pg/mL, p < 0.0001). Among CCB users, the use of dihydropyridines was independently associated with higher PTH (β = +5.0 pg/mL, p < 0.0001), whereas non-dihydropyridine use was not (β = +0.58 pg/mL, p = 0.68). We conclude that in a large community-based cohort with normal kidney function, TZ use is associated with lower PTH, whereas LD and dihydropyridine CCB use is associated with higher PTH. These associations may provide a mechanistic explanation linking use of these medications to the development of skeletal outcomes. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Sarah Zaheer
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ian de Boer
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Matthew Allison
- Division of Preventive Medicine, University of California, San Diego, CA, USA
| | - Jenifer M Brown
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Bruce M Psaty
- Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle, WA, USA
| | - Cassianne Robinson-Cohen
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
- Kidney Research Institute, University of Washington, Seattle, WA, USA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California, San Diego, CA, USA
| | - Bryan Kestenbaum
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
- Kidney Research Institute, University of Washington, Seattle, WA, USA
| | | | - Anand Vaidya
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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16
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Abstract
Primary hyperparathyroidism (PHPT) is a common disorder in which parathyroid hormone (PTH) is excessively secreted from one or more of the four parathyroid glands. A single benign parathyroid adenoma is the cause in most people. However, multiglandular disease is not rare and is typically seen in familial PHPT syndromes. The genetics of PHPT is usually monoclonal when a single gland is involved and polyclonal when multiglandular disease is present. The genes that have been implicated in PHPT include proto-oncogenes and tumour-suppressor genes. Hypercalcaemia is the biochemical hallmark of PHPT. Usually, the concentration of PTH is frankly increased but can remain within the normal range, which is abnormal in the setting of hypercalcaemia. Normocalcaemic PHPT, a variant in which the serum calcium level is persistently normal but PTH levels are increased in the absence of an obvious inciting stimulus, is now recognized. The clinical presentation of PHPT varies from asymptomatic disease (seen in countries where biochemical screening is routine) to classic symptomatic disease in which renal and/or skeletal complications are observed. Management guidelines have recently been revised to help the clinician to decide on the merits of a parathyroidectomy or a non-surgical course. This Primer covers these areas with particular attention to the epidemiology, clinical presentations, genetics, evaluation and guidelines for the management of PHPT.
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17
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Vaidya A, Curhan GC, Paik JM, Wang M, Taylor EN. Physical Activity and the Risk of Primary Hyperparathyroidism. J Clin Endocrinol Metab 2016; 101:1590-7. [PMID: 26812691 PMCID: PMC4880164 DOI: 10.1210/jc.2015-3836] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT Primary hyperparathyroidism (P-HPTH) is relatively common and predominantly affects women. Prior studies have shown that physical activity (PA) can lower PTH levels. OBJECTIVE Our objective was to evaluate the hypothesis that lower PA is a risk factor for developing P-HPTH. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study included 69 621 female participants in the Nurses' Health Study I followed for 22 years. EXPOSURES PA and other dietary and demographic exposures were quantified via detailed, and validated, biennial questionnaires. OUTCOMES Incident P-HPTH was confirmed by medical record review after initial assessment by questionnaire. Adjusted Cox proportional hazards models were used to evaluate whether PA was an independent risk factor for developing P-HPTH. We also evaluated the risk of developing P-HPTH when combining low PA (<16 metabolic equivalent hours/week) with a previously identified independent risk factor for developing P-HPTH: low calcium intake (<800 mg/day). The relation between PA and PTH levels was evaluated in 625 participants. RESULTS We confirmed 302 incident cases of P-HPTH during 1 474 993 person-years of follow-up. Participants in the highest quintile (Q) of PA had a 50% lower risk of developing P-HPTH: age-adjusted relative risks and 95% confidence intervals for incident P-HPTH by lowest to highest of PA were Q1 = 1.0 (reference); Q2 = 0.83 (0.60–1.15); Q3 = 0.84 (0.61–1.15); Q4 = 0.50 (0.34–0.74); Q5 = 0.50 (0.35–0.73); P for trend <.001. Extensive multivariable adjustments did not materially change these findings. The adjusted relative risk for developing P-HPTH among participants with the combination lower PA and lower calcium intake was 2.37-fold (1.60–3.51) higher than in participants with higher PA and higher calcium intake. PA was inversely correlated with serum PTH (ρ = −0.09, P = .03); the mean adjusted serum PTH in Q 2–5 of PA was lower than in Q 1 (36.3 vs 39.1 pg/mL, P = .02). CONCLUSION Low physical activity may be a modifiable risk factor for developing P-HPTH in women.
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Affiliation(s)
- Anand Vaidya
- Division of Endocrinology, Diabetes, and Hypertension (A.V.), Division of Renal Medicine (G.C.C., J.M.P.), Channing Division of Network Medicine (G.C.C., J.M.P., E.N.T.), Brigham and Women's Hospital (A.V., G.C.C., J.M.P., E.N.T.), Boston, Massachusetts; Harvard Medical School (A.V., J.M.P.), Boston, Massachusetts; Department of Epidemiology (G.C.C. J.M.P., M.W.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of Nephrology and Transplantation (E.N.T.), Maine Medical Center, Portland, Maine 02115
| | - Gary C Curhan
- Division of Endocrinology, Diabetes, and Hypertension (A.V.), Division of Renal Medicine (G.C.C., J.M.P.), Channing Division of Network Medicine (G.C.C., J.M.P., E.N.T.), Brigham and Women's Hospital (A.V., G.C.C., J.M.P., E.N.T.), Boston, Massachusetts; Harvard Medical School (A.V., J.M.P.), Boston, Massachusetts; Department of Epidemiology (G.C.C. J.M.P., M.W.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of Nephrology and Transplantation (E.N.T.), Maine Medical Center, Portland, Maine 02115
| | - Julie M Paik
- Division of Endocrinology, Diabetes, and Hypertension (A.V.), Division of Renal Medicine (G.C.C., J.M.P.), Channing Division of Network Medicine (G.C.C., J.M.P., E.N.T.), Brigham and Women's Hospital (A.V., G.C.C., J.M.P., E.N.T.), Boston, Massachusetts; Harvard Medical School (A.V., J.M.P.), Boston, Massachusetts; Department of Epidemiology (G.C.C. J.M.P., M.W.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of Nephrology and Transplantation (E.N.T.), Maine Medical Center, Portland, Maine 02115
| | - Molin Wang
- Division of Endocrinology, Diabetes, and Hypertension (A.V.), Division of Renal Medicine (G.C.C., J.M.P.), Channing Division of Network Medicine (G.C.C., J.M.P., E.N.T.), Brigham and Women's Hospital (A.V., G.C.C., J.M.P., E.N.T.), Boston, Massachusetts; Harvard Medical School (A.V., J.M.P.), Boston, Massachusetts; Department of Epidemiology (G.C.C. J.M.P., M.W.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of Nephrology and Transplantation (E.N.T.), Maine Medical Center, Portland, Maine 02115
| | - Eric N Taylor
- Division of Endocrinology, Diabetes, and Hypertension (A.V.), Division of Renal Medicine (G.C.C., J.M.P.), Channing Division of Network Medicine (G.C.C., J.M.P., E.N.T.), Brigham and Women's Hospital (A.V., G.C.C., J.M.P., E.N.T.), Boston, Massachusetts; Harvard Medical School (A.V., J.M.P.), Boston, Massachusetts; Department of Epidemiology (G.C.C. J.M.P., M.W.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of Nephrology and Transplantation (E.N.T.), Maine Medical Center, Portland, Maine 02115
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