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Balawender K, Łuszczki E, Mazur A, Wyszyńska J. The Multidisciplinary Approach in the Management of Patients with Kidney Stone Disease-A State-of-the-Art Review. Nutrients 2024; 16:1932. [PMID: 38931286 PMCID: PMC11206918 DOI: 10.3390/nu16121932] [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] [Received: 05/21/2024] [Revised: 06/15/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
Kidney stone disease has a multifactorial etiology, and evolving dietary habits necessitate continuous updates on the impact of dietary components on lithogenesis. The relationship between diseases influenced by lifestyle, such as obesity and diabetes, and kidney stone risk underscores the need for comprehensive lifestyle analysis. Effective management of kidney stones requires a multidisciplinary approach, involving collaboration among nutritionists, urologists, nephrologists, and other healthcare professionals to address the complex interactions between diet, lifestyle, and individual susceptibility. Personalized dietary therapy, based on each patient's unique biochemical and dietary profile, is essential and necessitates comprehensive nutritional assessments. Accurate dietary intake evaluation is best achieved through seven-day, real-time dietary records. Key factors influencing urinary risk include fluid intake, dietary protein, carbohydrates, oxalate, calcium, and sodium chloride. Personalized interventions, such as customized dietary changes based on gut microbiota, may improve stone prevention and recurrence. Current research suggests individualized guidance on alcohol intake and indicates that tea and coffee consumption might protect against urolithiasis. There is potential evidence linking tobacco use and secondhand smoke to increased kidney stone risk. The effects of vitamins and physical activity on kidney stone risk remain unresolved due to mixed evidence. For diseases influenced by lifestyle, conclusive evidence on targeted interventions for nephrolithiasis prevention is lacking, though preliminary research suggests potential benefits. Management strategies emphasize lifestyle modifications to reduce recurrence risks, support rapid recovery, and identify predisposing conditions, highlighting the importance of these changes despite inconclusive data.
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Affiliation(s)
- Krzysztof Balawender
- Institute of Medical Sciences, Medical College of Rzeszow University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland;
- Clinical Department of Urology and Urological Oncology, Municipal Hospital, Rycerska 4, 35-241 Rzeszow, Poland
| | - Edyta Łuszczki
- Institute of Health Sciences, Medical College of Rzeszow University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland; (E.Ł.); (J.W.)
| | - Artur Mazur
- Institute of Medical Sciences, Medical College of Rzeszow University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland;
| | - Justyna Wyszyńska
- Institute of Health Sciences, Medical College of Rzeszow University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland; (E.Ł.); (J.W.)
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Karaca MO, Özyıldıran M, Savran MD, Başarır K, Yıldız HY. Brown tumors: Retrospective analysis of 26 cases. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05372-9. [PMID: 38795187 DOI: 10.1007/s00402-024-05372-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 05/07/2024] [Indexed: 05/27/2024]
Abstract
INTRODUCTION Brown tumors are reactive osteolytic lesions caused by hyperparathyroidism. These rare lesions are non-neoplastic processes that result from bone resorption. The purpose of this study was to retrospectively review a 34-year experience with brown tumors in our institution. MATERIALS AND METHODS We retrospectively analyzed the records of 26 consecutive patients with brown tumor who were treated in our institution between May 1988 and October 2020, with a mean follow-up of 36,1 months. RESULTS 17 male (65,4%) and 9 female (34,6%) patients with a mean age of 41,6 were included in the study. Localized bone pain was present in 13 cases (50,0%) as the first presenting symptom. 3 patients (11,5%) presented with diffuse bone pain. 7 patients (26,9%) were diagnosed with brown tumor while being investigated for pathological fractures. The other 3 patients (11,5%) were diagnosed while being evaluated for hypercalcemia symptoms. 7 patients (26,9%) had solitary lesions, while 19 patients (73,1%) had multiple lesions. Pelvis, femur, ribs, tibia, proximal humerus and mandible were the most common sites of localization. 23 patients (88,5%) were diagnosed with primary hyperparathyroidism, while the other 3 patients (11,5%) had secondary hyperparathyroidism. A total of the 65 lesions, 23 (35.4%) underwent orthopedic surgery, and 42 (64.6%) were followed up conservatively after parathyroidectomy. Orthopedic surgery was performed in 21 of 26 patients, the other 5 cases were followed up conservatively. Intralesional curettage was performed in 19 cases (82,6%). The resulting cavity was filled with bone cement in 11 cases (47,8%). Bone grafting was applied in 8 cases (34,8%). No recurrence was observed in any of the patients. CONCLUSION The diagnosis of brown tumor begins with clinical suspicion. Endocrinology and general surgery consultation is important before surgery. Treatment of brown tumors requires a multidisciplinary approach.
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Affiliation(s)
- Mustafa Onur Karaca
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
| | - Mustafa Özyıldıran
- Department of Orthopedics and Traumatology, Sandıklı State Hospital, Afyonkarahisar, Turkey.
| | - Merve Dursun Savran
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
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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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Mifsud S, Montanaro G, Craus S, Mifsud EL, Gruppetta M. Thiazide diuretics and primary hyperparathyroidism. Br J Hosp Med (Lond) 2023; 84:1-8. [PMID: 38153014 DOI: 10.12968/hmed.2023.0228] [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: 12/29/2023]
Abstract
Thiazide diuretics exert a natriuretic and diuretic effect by inhibiting sodium reabsorption in the distal convoluted tubule. Furthermore, thiazide diuretics affect renal calcium handling by increasing calcium reabsorption, leading to hypocalciuria. The effect that thiazide diuretics exert on parathyroid hormone secretion is controversial. Some studies found parathyroid hormone levels were suppressed with the use of thiazide diuretics, while others found that thiazides were associated with initial parathyroid hormone suppression followed by raised parathyroid hormone levels. This makes the relationship between thiazide diuretics and primary hyperparathyroidism interesting. If a patient is taking thiazide diuretics, this may make it harder to establish the aetiology of hypercalcaemia and may unmask normocalcaemic or mild primary hyperparathyroidism. Thiazide diuretics may have a beneficial role in the diagnosis of patients with concomitant hyperparathyroidism and hypercalciuria by distinguishing secondary hyperparathyroidism caused by hypercalciuria from normocalcaemic primary hyperparathyroidism. In addition, thiazide diuretics may have a role in managing patients with primary hyperparathyroidism who have an indication for parathyroidectomy in view of significant hypercalciuria, but are unfit for surgery.
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Affiliation(s)
- Simon Mifsud
- Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta
| | | | - Sarah Craus
- Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta
| | - Emma L Mifsud
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Mark Gruppetta
- Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta
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Gronemeyer K, Fuss CT, Hermes F, Plass A, Koschker AC, Hannemann A, Völzke H, Hahner S. Renal complications in chronic hypoparathyroidism - a systematic cross-sectional assessment. Front Endocrinol (Lausanne) 2023; 14:1244647. [PMID: 38027217 PMCID: PMC10654620 DOI: 10.3389/fendo.2023.1244647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/02/2023] [Indexed: 12/01/2023] Open
Abstract
Context Although renal long-term complications are acknowledged in chronic hypoparathyroidism (HPT), standardized investigations are scarce. Objective To systematically investigate renal complications and their predictors in hypoparathyroid patients compared to matched individuals. Design Prospective observational study in 161 patients with chronic HPT. Methods Patients received renal ultrasound, clinical and laboratory assessments. An individual 1:3 matching with participants from the German population-based Study of Health in Pomerania was performed. Results Of 161 patients (92% postoperative HPT), prevalence of eGFR <60ml/min/1.73m2 was 21%, hypercalciuria 41%. Compared to healthy individuals, HPT patients had a significantly lower eGFR (74.2 vs. 95.7 ml/min/1.73m², p<0.01). Renal ultrasound revealed calcifications in 10% (nephrocalcinosis in 7% and calculi in 3%). Patients with renal calcifications had higher levels of 24-hour urine calcium excretion (8.34 vs. 5.08 mmol/d, p=0.02), spot urine calcium excretion (4.57 vs. 2.01 mmol/L, p=0.01) and urine calcium-to-creatinine ratio (0.25 vs. 0.16, p<0.01) than patients without calcifications. Albumin-corrected calcium, phosphate, calcium-phosphate product, 25-hydroxyvitamin D in serum, eGFR, daily calcium intake or disease duration were not significantly different between these two groups. Including patients receiving rhPTH therapy, a lower serum phosphate concentration (odds ratio 1.364 [95% confidence interval (CI) 1.049-1.776], p<0.05) and a longer disease duration of HPT (odds ratio 1.063 [95% CI 1.021-1.106], p<0.01) were significant predictors for renal calcifications. Excluding patients receiving rhPTH therapy, a higher 24-hour urine calcium excretion (odds ratio 1.215 [95% CI 1.058-1.396], p<0.01) was a significant predictor for renal calcifications but not serum magnesium or disease duration. Conclusions Prevalence of impaired renal function among patients with chronic HPT is increased and independent from visible renal calcifications. Depending on exclusion of patients with rhPTH therapy, regression analysis revealed disease duration and serum phosphate or disease duration and 24-hour urinary calcium excretion as predictors for renal calcifications. Clin Trials Identifier NCT05585593.
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Affiliation(s)
- Karen Gronemeyer
- Department of Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Carmina Teresa Fuss
- Department of Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Franca Hermes
- Department of Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Armin Plass
- Department of Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Ann-Cathrin Koschker
- Department of Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Anke Hannemann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
- German Centre for Cardiovascular Research, Partner Site Greifswald, Greifswald, Germany
| | - Henry Völzke
- German Centre for Cardiovascular Research, Partner Site Greifswald, Greifswald, Germany
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Stefanie Hahner
- Department of Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
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Chen J, Tang G, Peng Y, Cheng H. Parathyroid adenoma with rare severe pathological osteolytic lesion: a case report and literature review. Front Oncol 2023; 13:1218863. [PMID: 37601648 PMCID: PMC10435972 DOI: 10.3389/fonc.2023.1218863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023] Open
Abstract
Parathyroid adenomas are benign proliferative disorders of parathyroid glands. Patients typically exhibit hyperparathyroidism and elevated serum calcium levels due to elevated levels of parathyroid hormone (PTH). We report a newly diagnosed case of a rare pathological osteolytic lesion. Radiological evaluation revealed multiple bony lesions in multiple parts of the pelvis, vertebral body, and spinous process, suggesting hematological neoplasms or bone marrow metastatic carcinoma. The morphology revealed many abnormal cells in the bone marrow smear. Furthermore, serum calcium and PTH levels were significantly increased compared to normal levels. Doppler color ultrasound showed a thyroid mass (left), suspected parathyroid adenoma, thyroid, and isthmus nodular goiter (right). The patient underwent bilateral neck exploration with parathyroidectomy, and serum calcium and PTH levels significantly decreased on the second day after surgery and had a surgical cure.
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Affiliation(s)
- Jia Chen
- Department of Hematology, Naval Military Medical University, First Affiliated Hospital, Shanghai, China
| | - Gusheng Tang
- Department of Hematology, Naval Military Medical University, First Affiliated Hospital, Shanghai, China
| | - Ye Peng
- Department of Nuclear Medicine, Naval Military Medical University, First Affiliated Hospital, Shanghai, China
| | - Hui Cheng
- Department of Hematology, Naval Military Medical University, First Affiliated Hospital, Shanghai, China
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Pappachan JM, Lahart IM, Viswanath AK, Borumandi F, Sodi R, Metzendorf MI, Bongaerts B. Parathyroidectomy for adults with primary hyperparathyroidism. Cochrane Database Syst Rev 2023; 3:CD013035. [PMID: 36883976 PMCID: PMC9995748 DOI: 10.1002/14651858.cd013035.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT), a disorder in which the parathyroid glands produce excessive amounts of parathyroid hormone, is most common in older adults and postmenopausal women. While most people with PHPT are asymptomatic at diagnosis, symptomatic disease can lead to hypercalcaemia, osteoporosis, renal stones, cardiovascular abnormalities and reduced quality of life. Surgical removal of abnormal parathyroid tissue (parathyroidectomy) is the only established treatment for adults with symptomatic PHPT to prevent exacerbation of symptoms and to be cured of PHPT. However, the benefits and risks of parathyroidectomy compared to simple observation or medical therapy for asymptomatic and mild PHPT are not well established. OBJECTIVES To evaluate the benefits and harms of parathyroidectomy in adults with PHPT compared to simple observation or medical therapy. SEARCH METHODS We searched CENTRAL, MEDLINE, LILACS, ClinicalTrials.gov and WHO ICTRP from their date of inception until 26 November 2021. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing parathyroidectomy with simple observation or medical therapy for the treatment of adults with PHPT. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. cure of PHPT, 2. morbidity related to PHPT and 3. serious adverse events. Our secondary outcomes were 1. all-cause mortality, 2. health-related quality of life and 3. hospitalisation for hypercalcaemia, acute renal impairment or pancreatitis. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS We identified eight eligible RCTs that included 447 adults with (mostly asymptomatic) PHPT; 223 participants were randomised to parathyroidectomy. Follow-up duration varied from six months to 24 months. Of the 223 participants (37 men) randomised to surgery, 164 were included in the analyses, of whom 163 were cured at six to 24 months (overall cure rate 99%). Parathyroidectomy compared to observation probably results in a large increase in cure rate at six to 24 months follow-up: 163/164 participants (99.4%) in the parathyroidectomy group and 0/169 participants in the observation or medical therapy group were cured of their PHPT (8 studies, 333 participants; moderate certainty). No studies explicitly reported intervention effects on morbidities related to PHPT, such as osteoporosis, osteopenia, kidney dysfunction, urolithiasis, cognitive dysfunction or cardiovascular disease, although some studies reported surrogate outcomes for osteoporosis and cardiovascular disease. A post-hoc analysis revealed that parathyroidectomy, compared to observation or medical therapy, may have little or no effect after one to two years on bone mineral density (BMD) at the lumbar spine (mean difference (MD) 0.03 g/cm2,95% CI -0.05 to 0.12; 5 studies, 287 participants; very low certainty). Similarly, compared to observation, parathyroidectomy may have little or no effect on femoral neck BMD after one to two years (MD -0.01 g/cm2, 95% CI -0.13 to 0.11; 3 studies, 216 participants; very low certainty). However, the evidence is very uncertain for both BMD outcomes. Furthermore, the evidence is very uncertain about the effect of parathyroidectomy on improving left ventricular ejection fraction (MD -2.38%, 95% CI -4.77 to 0.01; 3 studies, 121 participants; very low certainty). Four studies reported serious adverse events. Three of these reported zero events in both the intervention and control groups; consequently, we were unable to include data from these three studies in the pooled analysis. The evidence suggests that parathyroidectomy compared to observation may have little or no effect on serious adverse events (RR 3.35, 95% CI 0.14 to 78.60; 4 studies, 168 participants; low certainty). Only two studies reported all-cause mortality. One study could not be included in the pooled analysis as zero events were observed in both the intervention and control groups. Parathyroidectomy compared to observation may have little or no effect on all-cause mortality, but the evidence is very uncertain (RR 2.11, 95% CI 0.20 to 22.60; 2 studies, 133 participants; very low certainty). Three studies measured health-related quality of life using the 36-Item Short Form Health Survey (SF-36) and reported inconsistent differences in scores for different domains of the questionnaire between parathyroidectomy and observation. Six studies reported hospitalisations for the correction of hypercalcaemia. Two studies reported zero events in both the intervention and control groups and could not be included in the pooled analysis. Parathyroidectomy, compared to observation, may have little or no effect on hospitalisation for hypercalcaemia (RR 0.91, 95% CI 0.20 to 4.25; 6 studies, 287 participants; low certainty). There were no reported hospitalisations for renal impairment or pancreatitis. AUTHORS' CONCLUSIONS In accordance with the literature, our review findings suggest that parathyroidectomy, compared to simple observation or medical (etidronate) therapy, probably results in a large increase in cure rates of PHPT (with normalisation of serum calcium and parathyroid hormone levels to laboratory reference values). Parathyroidectomy, compared with observation, may have little or no effect on serious adverse events or hospitalisation for hypercalcaemia, and the evidence is very uncertain about the effect of parathyroidectomy on other short-term outcomes, such as BMD, all-cause mortality and quality of life. The high uncertainty of evidence limits the applicability of our findings to clinical practice; indeed, this systematic review provides no new insights with regard to treatment decisions for people with (asymptomatic) PHPT. In addition, the methodological limitations of the included studies, and the characteristics of the study populations (mainly comprising white women with asymptomatic PHPT), warrant caution when extrapolating the results to other populations with PHPT. Large-scale multi-national, multi-ethnic and long-term RCTs are needed to explore the potential short- and long-term benefits of parathyroidectomy compared to non-surgical treatment options with regard to osteoporosis or osteopenia, urolithiasis, hospitalisation for acute kidney injury, cardiovascular disease and quality of life.
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Affiliation(s)
- Joseph M Pappachan
- Department of Endocrinology & Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- Faculty of Science, Manchester Metropolitan University, Manchester, UK
- University of Manchester Medical School, Manchester, UK
| | - Ian M Lahart
- Faculty of Education, Health and Wellbeing, University of Wolverhampton, Walsall, UK
| | | | - Farzad Borumandi
- Department of Oral and Maxillofacial Surgery, University Hospitals Sussex NHS Foundation Trust, St. Richard's Hospital, Chichester and Worthing Hospital, Worthing, UK
| | - Ravinder Sodi
- Biochemistry, Pathology Department, Broomfield Hospital, Mid & South Essex NHS Foundation Trust, Chelmsford, UK
| | - Maria-Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Brenda Bongaerts
- Institute of General Practice, Medical Faculty of the Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
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Gosavi V, Lila A, Memon SS, Sarathi V, Goroshi M, Jamale T, Thakare S, Phadte A, Patil V, Bandgar T. Spectrum of renal dysfunction after curative parathyroidectomy in symptomatic primary hyperparathyroidism. ANNALES D'ENDOCRINOLOGIE 2023; 84:14-20. [PMID: 36563936 DOI: 10.1016/j.ando.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/22/2022] [Accepted: 10/30/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The long-term renal consequences of curative parathyroidectomy (PTX) in symptomatic primary hyperparathyroidism (sPHPT) are not well characterized. We aimed to assess renal glomerular and tubular functions in an sPHPT cohort at ≥1 year's follow-up. DESIGN Retrospective-prospective study. METHODS sPHPT patients with preoperative eGFR ≥60mL/min/1.73m2 and in remission (normocalcemic) for ≥1 year after PTX underwent clinical and biochemical assessment (calcium profile, renal parameters). Ammonium chloride and bicarbonate loading tests were performed in patients with renal tubular dysfunction (RTD). RESULTS Forty-eight patients (31 females) with median plasma PTH 1,029 (338-1604) pg/mL and mean eGFR 109.2±26.0mL/min/1.73m2 at diagnosis were evaluated at 5.62±3.66 years after curative PTX. At follow-up, eGFR was <60mL/min/m2 in 5 patients (10.4%). Patients with >10% drop in eGFR (n=31) had significantly higher pre-PTX plasma PTH (1,137 vs. 687pg/mL), and longer time to post-PTX evaluation (6.8 vs. 3.4 years). RTD was seen in 11 patients (22.9%): urinary low molecular weight proteinuria (14.6%), distal renal tubular acidosis (12.5%), hypophosphatemia (8.3%), and hypokalemia (8.3%); RTD was associated with significantly lower post-PTX eGFR (72.7 vs. 95.4mL/min/m2). Five of the 7 RTD patients undergoing loading test had impaired urinary acidification, whereas none had impaired bicarbonate resorption. CONCLUSIONS Reduction in eGFR and subclinical RTD were prevalent at long-term follow-up in the present Asian-Indian cohort with cured sPHPT. Further studies are warranted to understand the clinical implications of these various renal abnormalities.
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Affiliation(s)
- Vikrant Gosavi
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, 103, 1st floor, OPD building, KEM Hospital Campus, Parel, Mumbai, Maharashtra 400012, India
| | - Anurag Lila
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, 103, 1st floor, OPD building, KEM Hospital Campus, Parel, Mumbai, Maharashtra 400012, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, 103, 1st floor, OPD building, KEM Hospital Campus, Parel, Mumbai, Maharashtra 400012, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
| | | | - Tukaram Jamale
- Department of Nephrology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Sayali Thakare
- Department of Nephrology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Aditya Phadte
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, 103, 1st floor, OPD building, KEM Hospital Campus, Parel, Mumbai, Maharashtra 400012, India
| | - Virendra Patil
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, 103, 1st floor, OPD building, KEM Hospital Campus, Parel, Mumbai, Maharashtra 400012, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, 103, 1st floor, OPD building, KEM Hospital Campus, Parel, Mumbai, Maharashtra 400012, India.
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9
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Frey S, Wargny M, Blanchard C, Caillard C, Hadjadj S, Cariou B, Figueres L, Mirallié E. Effects of parathyroidectomy on kidney function in patients with primary hyperparathyroidism: Results of a prospective study. Surgery 2023; 173:146-153. [PMID: 36167701 DOI: 10.1016/j.surg.2022.05.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Altered glomerular filtration rate is a controversial indication for parathyroidectomy in patients with primary hyperparathyroidism. The objective of this study was to evaluate the estimated glomerular filtration rate change 12 months after parathyroidectomy for primary hyperparathyroidism according to preoperative kidney function. METHOD Patients who underwent parathyroidectomy for primary hyperparathyroidism between 2016 and 2021 (n = 381) were enrolled in a monocentric prospective cohort. Patients without 1-year follow-up or with missing data were excluded (n = 135, 35%). Patients were dichotomized according to their baseline estimated glomerular filtration rate: <60 mL/min (group 1) and ≥60 mL/min (group 2). Parameters were measured before and then at 6 and 12 months after parathyroidectomy. RESULTS Out of 246 included patients, 27 (11%) were assigned to group 1 and 219 (89%) to group 2. The mean baseline estimated glomerular filtration rate was 46.8 ± 11.5 and 87.3 ± 14.7 mL/min in groups 1 and 2, respectively. Group 1 patients were older (P = .0006) and had a higher median serum parathyroid hormone level (P = .021). At 6 months postoperative, 224 patients (91%) were normocalcemic. The estimated glomerular filtration rate raw change after parathyroidectomy was significantly higher in group 1 than in group 2 (4.2 ± 7.8 vs -2.2 ± 9.1 mL/min, P = .0004). In group 1, 13/27 patients (48%) improved their chronic kidney disease stage after parathyroidectomy, including 6/13 (46%) with postoperative estimated glomerular filtration rate ≥60 mL/min, whereas 2/27 (7%) worsened. The baseline estimated glomerular filtration rate <60 mL/min and elevated serum calcium level were associated with postoperative estimated glomerular filtration rate improvement in multivariable analysis (P = .0023 and .039, respectively). CONCLUSION Parathyroidectomy for primary hyperparathyroidism is more likely to improve kidney function in patients with preoperative estimated glomerular filtration rate <60 mL/min. These results strengthen the current guidelines for surgery.
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Affiliation(s)
- Samuel Frey
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France; Université de Nantes, France; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France. https://twitter.com/samuelfrey13
| | - Matthieu Wargny
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France; CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11: Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des Données, France
| | - Claire Blanchard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France; Université de Nantes, France; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Cécile Caillard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France
| | - Samy Hadjadj
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Bertrand Cariou
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Lucile Figueres
- Université de Nantes, France; Service de Néphrologie-Immunologie Clinique, CHU de Nantes, France
| | - Eric Mirallié
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France; Université de Nantes, France.
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10
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Nwosu IF, Ibeson CE, Olawoye A, Kyaw H, Kumar K, Odigwe C, Nwosu CA, Oshunsanya A. Interpretation of Parathyroid Hormone Levels in Renal Impairment. Cureus 2022; 14:e25819. [PMID: 35822143 PMCID: PMC9271268 DOI: 10.7759/cureus.25819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 12/02/2022] Open
Abstract
Distinguishing between acute kidney injury and chronic kidney disease (CKD) in an emergency setting may pose a conundrum for physicians, especially when a patient’s medical history and records are unknown. Parathyroid hormone (PTH) has proved valuable as a marker of CKD and is frequently assayed for this reason. The use of PTH as a sole marker of CKD may be misleading in certain conditions, and for this reason, physicians need to interpret PTH values with caution. In patients with no existing medical records, it is vital to consider their overall clinical picture, an accurate interpretation of urinalysis and urine microscopy, and the PTH values when making the initial management decisions.
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11
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Carrasco-Ruiz MF, Ruiz-Rivera A, Soriano-Ursúa MA, Martinez-Hernandez C, Manuel-Apolinar L, Castillo-Hernandez C, Guevara-Balcazar G, Farfán-García ED, Mejia-Ruiz A, Rubio-Gayosso I, Perez-Capistran T. Global longitudinal strain is superior to ejection fraction for detecting myocardial dysfunction in end-stage renal disease with hyperparathyroidism. World J Cardiol 2022; 14:239-249. [PMID: 35582470 PMCID: PMC9048274 DOI: 10.4330/wjc.v14.i4.239] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/07/2022] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The estimation of left ventricular ejection fraction (LVEF) by 2D echocardiography (2D-ECHO) is the most used tool to assess LV systolic function (LVSF). Global longitudinal strain (GLS) has recently been suggested as a superior method for several evaluations. This study explored the association and prevalence of LV systolic dysfunction (LVSD) by using these methods in patients with end-stage renal disease (ESRD) and severe hyperparathyroidism (SHPTH); both associated with cardiovascular events (CEs).
AIM To evaluate the myocardial function in patients with ESRD and SHPTH by using the GLS and LVEF measured through conventional 2D-ECHO.
METHODS In 62 patients with ESRD and SHPTH, asymptomatic, and without a history of CEs, LVSF was evaluated by 2D-ECHO, obtaining the EF, by the Simpson biplane method, and GLS by speckle tracking.
RESULTS The total patients with ESRD had a preserved LVEF (> 50%) but abnormal GLS (< 13.55%). Additionally, multivariate analysis showed an independent association of GLS and serum parathyroid hormone (PTH), LV mass index, and hemoglobin. Also, PTH was independently associated with lateral e' wave and tricuspid regurgitation velocity.
CONCLUSION In patients with SHPTH linked to ESRD, the use of GLS by 2D-ECHO is a more sensitive tool than LVEF for detecting LVSD.
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Affiliation(s)
- Maria Fernanda Carrasco-Ruiz
- Department of Physiology, Escuela Superior de Medicina, Instituto Politécnico Nacional, Ciudad de México 11340, Mexico
| | - Antonio Ruiz-Rivera
- Department of Cardiology, Instituto Mexicano del Seguro Social, Ciudad de México 06720, Mexico
| | - Marvin A Soriano-Ursúa
- Department of Physiology, Escuela Superior de Medicina, Instituto Politécnico Nacional, Ciudad de México 11340, Mexico
| | | | - Leticia Manuel-Apolinar
- Endocrine Research Unit, Instituto Mexicano del Seguro Social, Ciudad de México 06720, Mexico
| | - Carmen Castillo-Hernandez
- Department of Cardiovascular Pharmacology, Instituto Politécnico Nacional, Ciudad de México 11340, Mexico
| | - Gustavo Guevara-Balcazar
- Department of Cardiovascular Pharmacology, Instituto Politécnico Nacional, Ciudad de México 11340, Mexico
| | - Eunice D Farfán-García
- Department of Biochemistry, Escuela Superior de Medicina, Instituto Politécnico Nacional, Ciudad de México 11340, Mexico
| | - Ana Mejia-Ruiz
- Education Research, Comisión Nacional Para la Mejora Continua de la Educación, Ciudad de México 03900, Mexico
| | - Ivan Rubio-Gayosso
- Postgraduate Studies and Research Section,Escuela Superior de Medicina, Instituto Politécnico Nacional, Ciudad de México 11340, Mexico
| | - Teresa Perez-Capistran
- Department of Physiology, Escuela Superior de Medicina, Instituto Politécnico Nacional, Ciudad de México 11340, Mexico
- Department of Physiology, Instituto Politécnico Nacional, Mexico City 11340, Ciudad de México, Mexico
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12
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Das L, Bhadada SK, Arvindbhai SM, Dahiya D, Behera A, Dutta P, Bhansali A, Sood A, Singh P, Prakash M, Kumari P, Rao SD. Baseline renal dysfunction determines mortality following parathyroidectomy in primary hyperparathyroidism: analysis of Indian PHPT registry. J Bone Miner Metab 2022; 40:81-91. [PMID: 34392465 DOI: 10.1007/s00774-021-01256-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 07/21/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Primary hyperparathyroidism (PHPT) in India is mostly symptomatic with renal and skeletal complications. Evidence on mortality outcomes following parathyroidectomy from India, where the disease is predominantly symptomatic is limited. MATERIAL AND METHODS This was a prospective study to evaluate mortality outcomes in the Indian PHPT registry over the past 25 years (n = 464). Pre- and postoperative parameters and mortality data were obtained from medical records and/or by verbal autopsy, a method validated by WHO for data collection in settings where several deaths are noninstitutional. Patients were divided into survivor (SG) and nonsurvivor groups (NSG) to ascertain differences in presentation and the effect of parathyroidectomy. RESULTS The overall mortality was 8.8% at a median follow-up of 8 years (IQR 1-13) after parathyroidectomy. Chronic kidney disease was the most common background cause of death (43.5%), followed by pancreatitis (28.2%). NSG had significantly more frequent renal dysfunction (91.9% vs 73.9%), anaemia (50 vs 16.6%) and pancreatitis (24.3 vs 6.4%). PTH (61.9 vs 38.3 pmol/l) and baseline creatinine (97.2 vs 70.7 µmol/l) were significantly higher and eGFR lower (66.7 vs 90.7 ml/min/1.73m2) in the NSG than SG. By Cox proportional modelling, renal dysfunction [HR 2.88 (1.42-5.84)], anaemia [HR 2.45 (1.11-5.42)] and pancreatitis [HR 2.65 (1.24-5.66)] on univariate and renal dysfunction [HR 3.33 (1.13-9.77)] on multivariate analysis were significant for mortality. Survival curves demonstrated a significantly higher mortality with lower eGFR values. CONCLUSIONS Nonsurvivors in PHPT had greater prevalence and more severe baseline renal dysfunction than survivors. Survival after parathyroidectomy was significantly associated with estimated glomerular filtration rate at baseline.
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Affiliation(s)
- Liza Das
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sanjay Kumar Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Sapara Mohin Arvindbhai
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Divya Dahiya
- Department of General Surgery, PGIMER, Chandigarh, India
| | | | - Pinaki Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Anil Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashwani Sood
- Department of Nuclear Medicine, PGIMER, Chandigarh, India
| | - Priyanka Singh
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Poonam Kumari
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sudhaker D Rao
- Division of Endocrinology, Diabetes, and Bone & Mineral Disorders, Bone & Mineral Research Laboratory, Henry Ford Hospital, Detroit, MI, USA
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Nicoli F, Dito G, Guabello G, Longhi M, Corbetta S. Hypercalciuria in Postmenopausal Women With Reduced Bone Mineral Density Is Associated With Different Mineral Metabolic Profiles: Effects of Treatment With Thiazides and Anti-resorptives. Front Med (Lausanne) 2021; 8:780087. [PMID: 34977081 PMCID: PMC8714925 DOI: 10.3389/fmed.2021.780087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/15/2021] [Indexed: 11/21/2022] Open
Abstract
Hypercalciuria may represent a challenge during the workup for osteoporosis management. The present study aimed: (1) to describe the phenotype associated with hypercalciuria in vitamin D-sufficient (serum 25 hydroxyvitamin D (25OHD) > 20 ng/ml) patients with osteopenia/osteoporosis; (2) to analyze the effects of thiazides and anti-resorptive drugs on urine calcium excretion (UCa), mineral metabolic markers, and bone mineral density. Seventy-seven postmenopausal women with hypercalciuria (Uca > 4.0 mg/kg body weight/24 h on two determinations) were retrospectively evaluated in a real-life setting. Median UCa was 5.39 (4.75–6.70) mg/kg/24 h. Kidney stones occurred in 32.9% of patients, who had median UCa similar to that of patients without kidney stones. Clustering analysis considering the three variables, such as serum calcium, phosphate, and parathormone (PTH), identified two main clusters of hypercalciuric patients. Cluster 1 (n = 13) included patients with a primary hyperparathyroidism-like profile, suggesting a certain degree of autonomous PTH secretion from parathyroid glands. Within cluster 2 (n = 61), two subgroups were recognized, cluster 2A (n = 18) that included patients with relatively increased PTH and normophosphatemia, and cluster 2B (n = 43) that included patients with the normal mineral profile. After a follow-up of 33.4 ± 19.6 months, 49 patients treated with thiazidic diuretics (TZD) were reevaluated; 20 patients were treated with hydrochlorothiazide (HCT; 12.5–37.5 mg/day), 29 with indapamide (IND; 1.50–3.75 mg/day). Any significant difference could be detected in all the parameters both basal and treated conditions between patients treated with HCT or IND. TZD induced a mean 39% reduction in UCa and 63.3% of patients obtained Uca < 4.0 mg/kg/24 h, independent of their mineral metabolic profile. Moreover, TZD induced a significant decrease in PTH levels. TZD-treated patients normalizing UCa experienced an increase in bone mineral densities when concomitantly treated with anti-resorptives, while any gain could be observed in TZD-treated patients with persistent hypercalciuria. Finally, multiple regression analysis showed that UCa reduction was at least in part related to denosumab treatment. In conclusion, in postmenopausal osteoporotic women, hypercalciuria is associated with kidney stones in about one-third of patients and with a wide range of impaired PTH secretion, determining a diagnostic challenge. TZD efficiently reduces UCa and normalization contributes to increasing anti-resorptives positive effect on bone mineral density.
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Affiliation(s)
- Federico Nicoli
- Department of Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Endocrinology and Diabetology Service, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Giorgia Dito
- Endocrinology and Diabetology Service, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | | | - Matteo Longhi
- Rheumatology Unit, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Sabrina Corbetta
- Endocrinology and Diabetology Service, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
- *Correspondence: Sabrina Corbetta ; orcid.org/0000-0001-8140-3175
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14
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Sferopoulos NK. Primary Hyperparathyroidism in the Common Orthopaedic Practice. Open Orthop J 2021. [DOI: 10.2174/1874364102115010157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
An extensive review of the publications on primary hyperparathyroidism (pHPT) is presented in this report. It has strongly been emphasized in the literature that patients with pHPT may present either with the classical symptomatology or with asymptomatic disease, emerged due to biochemical screening. The clinical and epidemiological presentation of pHPT in western countries has changed profoundly during the past few decades, and bone disease is nowadays a distinct rarity. The introduction of serum calcium screening for osteoporosis and the technological advances in the laboratory assessment of parathyroid hormone have played important roles in early diagnosis. Subsequently, the disease is increasingly being detected as asymptomatic hypercalcaemia without guiding signs or symptoms. A third type of disease, the normocalcaemic variant, has been recently described in the literature. However, the potential diagnosis of pHPT should always be on the orthopaedics’ list of differential diagnoses in female or elderly patients with vertebral fractures and nephrolithiasis, either symptomatic or asymptomatic, as well as when solitary or multiple osteolytic lesions are encountered on the radiographs.
Additionally, a middle aged woman with parathyroid adenoma and subsequent brown tumors detected on the pelvic radiographs is reported. Her initial laboratory findings indicated a minimal increase of the serum calcium, a mild increase of the erythrocyte sedimentation rate, and a significant increase in total serum alkaline phosphatase. Finally, the detection of elevated parathyroid hormone levels indicated the diagnosis of pHPT and necessitated imaging studies of the parathyroid glands, which indicated a parathyroid adenoma. Following successful excision of the parathyroid adenoma, the patient suffered from the hungry bone syndrome. After a follow-up of 20 years, the patient had normal calcium, vitamin D, and parathyroid hormone serum levels, while a pelvic radiograph indicated no significant changes in the appearance of the brown tumors.
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15
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Sferopoulos NK. Primary Hyperparathyroidism in the Common Orthopaedic Practice. Open Orthop J 2021. [DOI: 10.2174/1874325002115010057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
An extensive review of the publications on primary hyperparathyroidism (pHPT) is presented in this report. It has strongly been emphasized in the literature that patients with pHPT may present either with the classical symptomatology or with asymptomatic disease, emerged due to biochemical screening. The clinical and epidemiological presentation of pHPT in western countries has changed profoundly during the past few decades, and bone disease is nowadays a distinct rarity. The introduction of serum calcium screening for osteoporosis and the technological advances in the laboratory assessment of parathyroid hormone have played important roles in early diagnosis. Subsequently, the disease is increasingly being detected as asymptomatic hypercalcaemia without guiding signs or symptoms. A third type of disease, the normocalcaemic variant, has been recently described in the literature. However, the potential diagnosis of pHPT should always be on the orthopaedics’ list of differential diagnoses in female or elderly patients with vertebral fractures and nephrolithiasis, either symptomatic or asymptomatic, as well as when solitary or multiple osteolytic lesions are encountered on the radiographs.
Additionally, a middle aged woman with parathyroid adenoma and subsequent brown tumors detected on the pelvic radiographs is reported. Her initial laboratory findings indicated a minimal increase of the serum calcium, a mild increase of the erythrocyte sedimentation rate, and a significant increase in total serum alkaline phosphatase. Finally, the detection of elevated parathyroid hormone levels indicated the diagnosis of pHPT and necessitated imaging studies of the parathyroid glands, which indicated a parathyroid adenoma. Following successful excision of the parathyroid adenoma, the patient suffered from the hungry bone syndrome. After a follow-up of 20 years, the patient had normal calcium, vitamin D, and parathyroid hormone serum levels, while a pelvic radiograph indicated no significant changes in the appearance of the brown tumors.
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16
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Dandurand K, Ali DS, Khan AA. Primary Hyperparathyroidism: A Narrative Review of Diagnosis and Medical Management. J Clin Med 2021; 10:jcm10081604. [PMID: 33918966 PMCID: PMC8068862 DOI: 10.3390/jcm10081604] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/26/2021] [Accepted: 04/06/2021] [Indexed: 12/13/2022] Open
Abstract
Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia in the outpatient setting. Symptomatic presentation includes non-specific signs and symptoms of hypercalcemia, skeletal fragility, nephrolithiasis and nephrocalcinosis. The majority of individuals present at an asymptomatic stage following routine biochemical screening, without any signs or symptoms of calcium or parathyroid hormone (PTH) excess or target organ damage. Indications for surgery have recently been revised as published in recent guidelines and consensus statements. Parathyroidectomy is advised in patients younger than 50 years old and in the presence of either significant hypercalcemia, impaired renal function, renal stones or osteoporosis. Surgery is always appropriate in suitable surgical candidates, however, medical management may be considered in those with mild asymptomatic disease, contraindications to surgery or failed previous surgical intervention. We summarized the optimal medical interventions available in the care of PHPT patients not undergoing parathyroidectomy. Calcium and vitamin D intake should be optimized. Antiresorptive therapy may be used for skeletal protection in patients with an increased fracture risk. Cinacalcet, a calcimimetic agent, has been shown to effectively lower serum calcium and PTH levels. The effect of medical treatment on the reduction in fracture risk is unknown and should be the focus of future research.
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17
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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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18
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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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19
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Ni W, Yuan Y, Chu X, Chen G, Han X, Li J, Wu X, Wang J, Liu C, Xu S. Bone Turnover Markers in Response to Ultrasound-Guided Microwave Ablation for Primary Hyperparathyroidism. Front Endocrinol (Lausanne) 2021; 12:782050. [PMID: 34925241 PMCID: PMC8672162 DOI: 10.3389/fendo.2021.782050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/15/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To assess the efficacy and safety of ultrasound-guided microwave ablation (MWA) in the treatment of primary hyperparathyroidism (PHPT), and to investigate whether MWA can improve the bone turnover and renal function. METHODS A total of 20 consecutive PHPT patients with 21 parathyroid lesions treated with MWA in our center from May 2019 to March 2021 were recruited in this study. Serum parathyroid hormone (PTH), calcium and phosphorus levels before MWA and at 20 minutes, 4 hours, 1 day, 3 months, 6 months and 12 months after MWA were measured. Bone turnover biomarkers, renal function and lesion volume with volume reduction rate (VRR) before MWA and at the last follow-up were compared. Any complication related with MWA was evaluated. The technical and clinical success rates of MWA in the treatment of PHPT were calculated. Clinical success was defined as normal serum PTH and calcium without PHPT-associated manifestations at more than 6 months after ablation. Technical success was defined as complete ablation indicated by immediate postoperative contrast-enhanced ultrasound. RESULTS The serum PTH, calcium and phosphorus levels at their respective follow-up time points dropped significantly after MWA (P <0.05). The volume of parathyroid lesions at the final examination was significantly reduced, compared with pre-ablation volume (P <0.001), with a median VRR reaching 89%. The technical and clinical success rates were 100% and 63.6%, respectively. Substantial changes of bone turnover biomarkers were observed before and after MWA (P <0.05), but the differences in renal function were not statistically significant. No major complications were reported in all cases. Pre-MWA serum PTH, lesion volume, maximum diameter of lesion and ablation time were significantly different between patients with successful and failed MWA. CONCLUSIONS PHPT can be effectively and safely treated by ultrasound-guided MWA, as proven by drop in serum PTH and reduction in the volume of parathyroid adenomas. Besides, MWA can impede bone remodeling to suppress hyperparathyroidism in the condition of PHPT.
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Affiliation(s)
- Wenjing Ni
- Endocrine and Diabetes Center, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yue Yuan
- Endocrine and Diabetes Center, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Xiaoqiu Chu
- Endocrine and Diabetes Center, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Guofang Chen
- Endocrine and Diabetes Center, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Key Laboratory of TCM Syndrome & Treatment of Yingbing of State Administration of Traditional Chinese Medicine, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Xue Han
- Endocrine and Diabetes Center, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jie Li
- Department of Ultrasound, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Xinping Wu
- Department of Ultrasound, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jianhua Wang
- Department of General Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Chao Liu
- Endocrine and Diabetes Center, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Key Laboratory of TCM Syndrome & Treatment of Yingbing of State Administration of Traditional Chinese Medicine, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
- *Correspondence: Chao Liu, ; Shuhang Xu,
| | - Shuhang Xu
- Endocrine and Diabetes Center, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- *Correspondence: Chao Liu, ; Shuhang Xu,
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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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Verdelli C, Tavanti GS, Corbetta S. Intratumor heterogeneity in human parathyroid tumors. Histol Histopathol 2020; 35:1213-1228. [PMID: 32468569 DOI: 10.14670/hh-18-230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Parathyroid tumors are the second most common endocrine neoplasia after thyroid neoplasia. They are mostly associated with impaired parathormone (PTH) synthesis and release determining the metabolic and clinical condition of primary hyperparathyroidism (PHPT). PHPT is the third most prevalent endocrine disorder, mainly affecting postmenopausal women. Parathyroid benign tumors, both adenomas of a single gland or hyperplasia involving all the glands, are the main histotypes, occurring in more than 95% of PHPT cases. The differential diagnosis between benign and malignant parathyroid lesions is a challenge for clinicians. It relies on histologic features, which display significant overlap between the histotypes with different clinical outcomes. Parathyroid adenomas and hyperplasia have been considered so far as a unique monoclonal/polyclonal entity, while accumulating evidence suggest great heterogeneity. Intratumor parathyroid heterogeneity involves tumor cell type, as well as tumor cell function, in terms of PTH synthesis and secretion, and of expression patterns of membrane and nuclear receptors (calcium sensing receptor, vitamin D receptor, α-klotho receptor and others). Intratumor heterogeneity can also interfere with cell molecular biology, in regard to clonality, oncosuppressor gene expression (such as MEN1 and HRPT2/CDC73), transcription factors (GCM2, TBX1) and microRNA expression. Such heterogeneity is likely involved in the phenotypic variability of the parathyroid tumors, and it should be considered in the clinical management, though at present target therapies are not available, with the exception of the calcium sensing receptor agonists.
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Affiliation(s)
- C Verdelli
- Laboratory of Experimental Endocrinology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - G S Tavanti
- Laboratory of Experimental Endocrinology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - S Corbetta
- Endocrinology and Diabetology Service, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.,Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
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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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Singh P, Manohar S, Erickson S. Abdominal Pain in a Patient with Hypercalcemia. KIDNEY360 2020; 1:223-224. [PMID: 35368627 PMCID: PMC8809260 DOI: 10.34067/kid.0000262019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Prince Singh
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Sandhya Manohar
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Stephen Erickson
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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Paja-Fano M, Martínez-Martínez AL, Monzón-Mendiolea A. Diagnostic and treatment delay in primary hyperparathyroidism. A pending issue. ACTA ACUST UNITED AC 2020; 67:357-363. [PMID: 31982385 DOI: 10.1016/j.endinu.2019.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Primary hyperparathyroidism (PHPT) remains underdiagnosed among patients with hypercalcemia, potentially causing increased morbidity. OBJECTIVE To identify in surgically operated patients the presence of overlooked hypercalcemia and patients with criteria for surgery (CFS) for PHPT at least one year prior to referral to Endocrinology, and to determine whether this diagnostic delay leads to increased morbidity. METHODS An observational study was carried out in 116 consecutive patients. We evaluated electronic medical records registered at least 12 months prior to referral and divided them in four groups: hypercalcemia with CFS (group 1), hypercalcemia without CFS (group 2), normocalcemia (group 3), and cases without previous biochemical evaluation (group 4). RESULTS A total of 84 patients (72.4%) had a previous measurement of serum calcium at a time interval of ≥ 12 months. Sixty-six (56.9%) had hypercalcemia and 43 of them (37%) had ≥ 1 CFS, with an average delay of 57 months in receiving proper evaluation. Almost half of the calcemia measurements in group 1 had been made in the emergency room. Patients from group 1 were younger, and had a greater frequency of nephrolithiasis and renal impairment than patients in group 4. The serum calcium values at referral were similar in both groups and higher than the values found in patients from the other two groups. DISCUSSION In patients with PHPT and CFS, referral to an endocrinologist is made with an average delay of almost 5 years. The identified causes of this delay, which conditions more kidney disease, are unrecognized hypercalcemia and/or unawareness of the surgical criteria, while calcium elevations promote referral. Interventions are needed to avoid this delay in the diagnosis and resolution of PHPT.
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Affiliation(s)
- Miguel Paja-Fano
- Hospital Universitario Basurto. Servicio de Endocrinología, Osakidetza, OSI Bilbao-Basurto, Bilbao, España.
| | | | - Andoni Monzón-Mendiolea
- Hospital Universitario Basurto. Servicio de Endocrinología, Osakidetza, OSI Bilbao-Basurto, Bilbao, España
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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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Hassan-Smith ZK, Criseno S, Gittoes NJL. Mild primary hyperparathyroidism-to treat or not to treat? Br Med Bull 2019; 129:53-67. [PMID: 30576424 DOI: 10.1093/bmb/ldy042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/20/2018] [Accepted: 11/26/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The presentation of primary hyperparathyroidism (PHPT) has shifted from a disease characterized by renal and skeletal complications to a mild or asymptomatic condition. Modern imaging allows localization of a surgical target in the majority of cases. SOURCES OF DATA Data were collected from literature searches of online databases including PUBMED, MEDLINE and Cochrane. A narrative review was performed. AREAS OF AGREEMENT Parathyroidectomy is the only therapy with curative potential with good outcomes and low risk of complications in experienced hands. Current guidelines advocate that surgery is offered in all symptomatic cases and in those who meet criteria depending on age, serum calcium concentration, skeletal and renal parameters. A structured monitoring approach should be offered to those who do not undergo surgery. AREAS OF CONTROVERSY Thresholds for intervention to improve skeletal and renal outcomes are debatable. In addition, controversy persists over the benefit of surgery for non-skeletal/renal outcomes. GROWING POINTS The role of medical management of PHPT using agents such as bisphosphonates, denosumab and cinacalcet are discussed. AREAS TIMELY FOR DEVELOPING RESEARCH In summary, further data on the natural history and effects of treatment of mild and asymptomatic PHPT are required to determine thresholds for surgery. In particular, further investigations of non-skeletal and non-renal parameters, such as neurocognitive quality of life and cardiovascular disease are required. Data on normocalcaemic PHPT are lacking. Large-scale randomized controlled trials would be welcome in these areas, however in view of the cost implications a more pragmatic approach may be to develop collaborative multi-centre registries.
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Affiliation(s)
- Zaki K Hassan-Smith
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Sherwin Criseno
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Neil J L Gittoes
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
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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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Lombardi G, Ziemann E, Banfi G. Physical Activity and Bone Health: What Is the Role of Immune System? A Narrative Review of the Third Way. Front Endocrinol (Lausanne) 2019; 10:60. [PMID: 30792697 PMCID: PMC6374307 DOI: 10.3389/fendo.2019.00060] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/22/2019] [Indexed: 12/12/2022] Open
Abstract
Bone tissue can be seen as a physiological hub of several stimuli of different origin (e.g., dietary, endocrine, nervous, immune, skeletal muscle traction, biomechanical load). Their integration, at the bone level, results in: (i) changes in mineral and protein composition and microarchitecture and, consequently, in shape and strength; (ii) modulation of calcium and phosphorous release into the bloodstream, (iii) expression and release of hormones and mediators able to communicate the current bone status to the rest of the body. Different stimuli are able to act on either one or, as usual, more levels. Physical activity is the key stimulus for bone metabolism acting in two ways: through the biomechanical load which resolves into a direct stimulation of the segment(s) involved and through an indirect load mediated by muscle traction onto the bone, which is the main physiological stimulus for bone formation, and the endocrine stimulation which causes homeostatic adaptation. The third way, in which physical activity is able to modify bone functions, passes through the immune system. It is known that immune function is modulated by physical activity; however, two recent insights have shed new light on this modulation. The first relies on the discovery of inflammasomes, receptors/sensors of the innate immunity that regulate caspase-1 activation and are, hence, the tissue triggers of inflammation in response to infections and/or stressors. The second relies on the ability of certain tissues, and particularly skeletal muscle and adipose tissue, to synthesize and secrete mediators (namely, myokines and adipokines) able to affect, profoundly, the immune function. Physical activity is known to act on both these mechanisms and, hence, its effects on bone are also mediated by the immune system activation. Indeed, that immune system and bone are tightly connected and inflammation is pivotal in determining the bone metabolic status is well-known. The aim of this narrative review is to give a complete view of the exercise-dependent immune system-mediated effects on bone metabolism and function.
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Affiliation(s)
- Giovanni Lombardi
- Laboratory of Experimental Biochemistry & Molecular Biology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Department of Physiology and Pharmacology, Faculty of Rehabilitation and Kinesiology, Gdansk University of Physical Education and Sport, Gdansk, Poland
- *Correspondence: Giovanni Lombardi
| | - Ewa Ziemann
- Department of Physiology and Pharmacology, Faculty of Rehabilitation and Kinesiology, Gdansk University of Physical Education and Sport, Gdansk, Poland
| | - Giuseppe Banfi
- Laboratory of Experimental Biochemistry & Molecular Biology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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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: 41] [Impact Index Per Article: 6.8] [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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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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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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Perez AA, Schneider DF, Long KL, Pitt SC, Sippel RS. Timely Evaluation and Management of Primary Hyperparathyroidism in Patients With Kidney Stones. J Surg Res 2018; 232:564-569. [PMID: 30463775 DOI: 10.1016/j.jss.2018.07.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 06/19/2018] [Accepted: 07/11/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Nephrolithiasis is a classic, treatable manifestation of primary hyperparathyroidism (PHPT). We examined predictors of kidney stone formation in PHPT patients and determined how efficiently the diagnosis of PHPT is made in patients whose initial presentation is with stones. MATERIALS AND METHODS We performed a retrospective analysis of surgically treated PHPT patients, comparing 247 patients who were kidney stone formers and 1047 patients with no kidney stones. We also analyzed 51 stone-forming patients whose stone evaluation and treatment were completed within our health system before PHPT diagnosis. RESULTS Stone-forming patients had higher 24-h urinary calcium (342 versus 304 mg/d, P = 0.005), higher alkaline phosphatase (92 versus 85 IU/L, P = 0.012), and were more likely to be normocalcemic (26.6% versus 16.9%, P = 0.001). Surprisingly, 47.3% of stone formers had normal urinary calcium levels (<300 mg/d). Of the 51 stone-forming patients treated at our institution, serum calcium was measured within 6 mo of stone diagnosis in 37 (72.5%) patients. Only 16 (31.4%) of these patients had elevated calcium levels, and only 10 (62.5%) of these 16 had a serum parathyroid hormone ordered within the following 3 mo. These patients had a significantly shorter time from their first stone to surgical treatment compared to other patients (median 8.5 versus 49.1 mo, P = 0.001). CONCLUSIONS Elevated serum and urinary calcium levels are not evaluated in the majority of PHPT patients presenting with kidney stones. In nephrolithiasis patients, provider consideration of PHPT with prompt serum calcium and parathyroid hormone evaluation significantly reduces time to treatment.
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Affiliation(s)
- Alberto A Perez
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - David F Schneider
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kristin L Long
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Susan C Pitt
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Rebecca S Sippel
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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35
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Pappachan JM, Sodi R, Viswanath AK, Lahart IM. Parathyroidectomy for adults with primary hyperparathyroidism. Cochrane Database Syst Rev 2018; 2018:CD013035. [PMCID: PMC6494479 DOI: 10.1002/14651858.cd013035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of parathyroidectomy for adults with PHPT. We will also compare the effects of different types of parathyroidectomy on people with PHPT.
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Affiliation(s)
- Joseph M Pappachan
- University Hospitals of Morecambe Bay NHS Foundation TrustEndocrinologyAshton RoadLancasterUKLA1 4RP
| | - Ravinder Sodi
- University Hospitals of Morecambe Bay NHS Foundation TrustClinical SciencesAshton RoadLancasterUKLA1 4RP
| | - Ananth K Viswanath
- New Cross HospitalEndocrinologyWolverhampton RoadWolverhamptonUKWV10 0QP
| | - Ian M Lahart
- University of WolverhamptonFaculty of Education, Health and WellbeingGorway RoadWalsallUKWS1 3BD
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Yuan P, Zheng X, Li M, Ke Y, Fu Y, Zhang Q, Wang X, Feng W. Two Sulfur Glycoside Compounds Isolated from Lepidium apetalum Willd Protect NRK52e Cells against Hypertonic-Induced Adhesion and Inflammation by Suppressing the MAPK Signaling Pathway and RAAS. Molecules 2017; 22:molecules22111956. [PMID: 29137154 PMCID: PMC6150345 DOI: 10.3390/molecules22111956] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 01/06/2023] Open
Abstract
Lepidium apetalum Willd has been used to reduce edema and promote urination. Cis-desulfoglucotropaeolin (cis-DG) and trans-desulfoglucotropaeolin (trans-DG) were isolated from Lepidium apetalum Willd, and caused a significant increase in cell viability in a hypertonic model in NRK52e cells. In the hypertonic model, cis-DG and trans-DG significantly promoted the cell viability of NRK52e cells and inhibited the elevation of Na+ in the supernatant, inhibited the renin-angiotensin-aldosterone (RAAS) system, significantly reduced the levels of angiotensin II (Ang II) and aldosterone (ALD), and lowered aquaporin-2 (AQP2) and Na+–K+ ATP content in renal medulla. After treatment with cis-DG and trans-DG, expression of calcineurin (CAN) and Ca/calmodulin-dependent protein kinase II (CaMK II) was decreased in renal tissue and Ca2+ influx was inhibited, thereby reducing the secretion of transforming growth factor-β (TGFβ), reversing the increase in adhesion and inflammatory factor E-selectin and monocyte chemotactic protein 1 (MCP-1) induced by high NaCl, while reducing oxidative stress status and decreasing the expression of cyclooxygenase-2 (COX2). Furthermore, inhibition of protein kinase C (PKC) expression also contributed to these improvements. The cis-DG and trans-DG reduced the expression of p-p44/42 MAPK, p-JNK and p-p38, inhibited the phosphorylation of the MAPK signaling pathway in NRN52e cells induced by high salt, decreased the overexpression of p-p38 and p-HSP27, and inhibited the overactivation of the p38-MAPK signaling pathway, suggesting that the p38-MAPK pathway may play a vital role in the hypertonic-induced adhesion and inflammatory response. From the results of this study, it can be concluded that the mechanism of cis-DG and trans-DG may mainly be through inhibiting the p38-MAPK signaling pathway, inhibiting the excessive activation of the RAAS system, and thereby reducing adhesion and inflammatory factors.
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Affiliation(s)
- Peipei Yuan
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China.
- Collaborative Innovation Center for Respiratory Disease Diagnosis and Treatment & Chinese Medicine Development of Henan Province, Zhengzhou 450046, China.
| | - Xiaoke Zheng
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China.
- Collaborative Innovation Center for Respiratory Disease Diagnosis and Treatment & Chinese Medicine Development of Henan Province, Zhengzhou 450046, China.
| | - Meng Li
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China.
- Collaborative Innovation Center for Respiratory Disease Diagnosis and Treatment & Chinese Medicine Development of Henan Province, Zhengzhou 450046, China.
| | - Yingying Ke
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China.
- Collaborative Innovation Center for Respiratory Disease Diagnosis and Treatment & Chinese Medicine Development of Henan Province, Zhengzhou 450046, China.
| | - Yang Fu
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China.
| | - Qi Zhang
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China.
| | - Xiaolan Wang
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China.
- Collaborative Innovation Center for Respiratory Disease Diagnosis and Treatment & Chinese Medicine Development of Henan Province, Zhengzhou 450046, China.
| | - Weisheng Feng
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China.
- Collaborative Innovation Center for Respiratory Disease Diagnosis and Treatment & Chinese Medicine Development of Henan Province, Zhengzhou 450046, China.
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Chiara V, Sabrina C. Epigenetics of human parathyroid tumors. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2017. [DOI: 10.2217/ije-2017-0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Parathyroid tumors are common endocrine neoplasia associated with primary hyperparathyroidism, a metabolic disorder sustained by parathormone hypersecretion. The epigenetic scenario in parathyroid tumors is beginning to be decoded. Here, main findings are reviewed: hypermethylation of specific DNA CpG islands has been described, despite global DNA promoter hypomethylation was not detectable; embryonic-related miRNAs, belonging to the C19MC and miR‐371-373 clusters, and miR‐296, are deregulated; expression of histone H1.2 and H2B is increased; expression of histone methyltransferase EZH2, BMI1 and RIZ1 is impaired; the tumor suppressor HIC1, MEN1 and CDC73 gene products, key molecules in parathyroid tumorigenesis, may be involved in epigenetic aberrant changes. Epigenetic changes are more frequent and more consistent in parathyroid malignancies, and positively correlated with severity of primary hyperparathyroidism.
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Affiliation(s)
- Verdelli Chiara
- Laboratory of Experimental Endocrinology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Corbetta Sabrina
- Endocrinology Unit, Department of Biomedical Sciences for Health, University of Milan, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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