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Misgar RA, Wani M, Qadir A, Chhabra A. Clinical, Biochemical and Surgical Outcomes of Primary Hyperparathyroidism in the Present Era: A Prospective Study From a Tertiary Care Hospital. Cureus 2024; 16:e60965. [PMID: 38910736 PMCID: PMC11193873 DOI: 10.7759/cureus.60965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/25/2024] Open
Abstract
Introduction Primary hyperparathyroidism (PHPT) has undergone a considerable change from being symptomatic to asymptomatic. This is the first large study from North India to study the clinical and biochemical features and surgical outcomes in the present era. Study design This is a cross-sectional study that was conducted in the Department of Endocrinology (SKIMS) from February 2021 to December 2022, in which 103 patients diagnosed with PHPT were included. Evaluation included measurement of total calcium, phosphorus, alkaline phosphate, intact parathyroid hormone, 25-hydroxy vitamin, 24-hour urinary calcium, radiological survey of hands and skull, Dual Energy X-ray absorptiometry, and ultrasonography (USG) of the abdomen. USG neck and technetium-99m sestamibi scans were used for preoperative localization; however, in cases of discordance between these investigations or suspicions of multi-glandular disease, four-dimensional computerized tomography of the neck was used. Patients were subjected to surgery according to the guidelines and monitored post-surgery for complications like hypocalcemia and hungry bone syndrome and to document the cure. Results The mean age of patients was 42.8±14.73 years, with a female-to-male ratio of 4.4:1. The mean eGFR of patients was 99.1±30.87 ml/min, with 55 (53.4%) of them having renal disease. Osteoporosis and fractures were present in 41 (39.8%) and 5 (4.8%) patients, respectively. Cholelithiasis and pancreatitis were present in 25 (24.3%) and 5 (4.9%) patients, respectively. Hypertension (HTN) and diabetes mellitus (DM) were the commonest comorbidities, which were present in 34 (33.1%) and 15 (14.5%) patients, respectively. Mean preoperative levels of calcium, phosphorus (PO4), alkaline phosphate (ALP), intact parathyroid hormone (iPTH), 25(OH)vitamin D, and 24-hour urinary calcium were 12.1 mg/dl, 2.35 mg/dl, 210.2 U/L, 332.9 pg/ml, 25.7 ng/ml, and 452.1 mg/day, respectively. The most common type was right inferior parathyroid adenoma, present in 45 cases (43.7%), followed by left inferior parathyroid adenoma in 31 cases (30.1%). A total of 75 patients (72.8%) underwent minimally invasive parathyroidectomy, with 68 patients (90.7%) achieving a biochemical cure. The mean adenoma weight was 3.19±2.25 g. There was no statistically significant correlation (r) between preoperative biochemical parameters and adenoma weight. Conclusion Despite improvements in imaging and the easy availability of immunoassays for early diagnosis, renal disease continued to be the most common presentation, followed by skeletal involvement in our population. In developing countries like India, any patient presenting with nephrolithiasis or nephrocalcinosis, low bone mass, or fragility fractures should be evaluated for PHPT.
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Affiliation(s)
- Raiz A Misgar
- Endocrinology and Metabolism, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Munir Wani
- General Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Ajaz Qadir
- Endocrinology and Metabolism, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Ankit Chhabra
- Endocrinology and Metabolism, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
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Viswanathan G, Mathew V, Jeeragi M, George B, Bantwal G, Ayyar V, Michael J. Emerging pattern of asymptomatic hyperparathyroidism in South India - a six-year retrospective study. Folia Med (Plovdiv) 2024; 66:221-226. [PMID: 38690817 DOI: 10.3897/folmed.66.e117637] [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: 12/20/2023] [Accepted: 03/30/2024] [Indexed: 05/03/2024] Open
Abstract
INTRODUCTION Primary hyperparathyroidism (PHPT) is a common endocrine disease with a variable presentation. There is a recent increase in the number of asymptomatic cases due to the use of multichannel automated analyzers.
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Affiliation(s)
| | - Vivek Mathew
- VPS Lakeshore Hospital and Research Centre, Kochi, India
| | | | | | | | - Vageesh Ayyar
- St John's Medical College Hospital, Bengaluru, India
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Rawat A, Grover M, Kataria T, Samdhani S, Mathur S, Sharma B. Minimally Invasive Parathyroidectomy as the Surgical Management of Single Parathyroid Adenomas: A Tertiary Care Experience. Indian J Otolaryngol Head Neck Surg 2023; 75:271-277. [PMID: 37275056 PMCID: PMC10234993 DOI: 10.1007/s12070-022-03236-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/11/2022] [Indexed: 06/07/2023] Open
Abstract
The aim of our study is to assess the feasibility, safety and adequacy of focused parathyroidectomy for single parathyroid adenoma accurately localized preoperatively by ultrasound neck and Tc99m sestamibi scan. The study was conducted in the department of Otorhinolaryngology of SMS Medical College and Hospital, Jaipur on 116 patients of primary hyperparathyroidism who underwent minimally invasive parathyroidectomy (MIP) for single gland adenoma localized by USG neck and tc99m sestamibi scans. S. Calcium and S. PTH followed up on day 1, 6th week and 6th month. Outcomes were determined on the basis of cure rate, duration of hospitalization, complication rates and disease persistence/recurrence rate. 82 (70.68%) females and 34 (29.31%) males belonging to the age group of 21-67 years (43.02 ± 14) formed the basis of our study. Skeletal (73.27%) and renal (62.93%) were the most common presentations. Accuracy of USG and sestamibi accurately was 93.10% and 96.55% respectively with combined accuracy of 100%. Preoperative serum calcium levels of 10.7-16.03 mg/dl (13.09 ± 2.11) and serum PTH 127-2196 pg/ml (846.57 ± 776.55) were observed. Cure rate of MIP was 99.13%. No permanent complications seen. MIP can be used as the surgical procedure of choice for PHPT caused by single gland adenoma aided by USG and sestamibi scan. The cure rates are equivalent to the bilateral neck exploration (> 95%) with minimal morbidity and complications. Hence, it is a more feasible, safe and effective treatment option.
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Affiliation(s)
- Anshu Rawat
- Department of Otorhinolaryngology and Head and Neck Surgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan 302004 India
| | - Mohnish Grover
- Department of Otorhinolaryngology and Head and Neck Surgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan 302004 India
- Jaipur, India
| | - Tanmaya Kataria
- Department of Otorhinolaryngology and Head and Neck Surgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan 302004 India
| | - Sunil Samdhani
- Department of Otorhinolaryngology and Head and Neck Surgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan 302004 India
| | - Sandeep Mathur
- Department of Endocrinology, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan 302004 India
| | - Balram Sharma
- Department of Endocrinology, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan 302004 India
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Patel YP, Patel SG, Patel SB, Parikh A, Soni S, Srivastava R, Raval C, Raval MA, Nand Pandey S, Ganpule AP, Desai MR. SPP1 and UMOD gene variants are synergistically associated with risk of renal stone disease. Gene 2023; 863:147264. [PMID: 36804854 DOI: 10.1016/j.gene.2023.147264] [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: 08/06/2022] [Revised: 12/23/2022] [Accepted: 02/06/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVE Calcium and oxalate are the most abundant metabolites present in the stone matrix. The SPP1 and UMOD gene has specific expression in kidneys and are involved in various stages of stone formation. Therefore, genetic variants in the SPP1 and UMOD genes may enhance the development of renal stone disease. This study has been designed to understand the association of genetic variants of SPP1 and UMOD genes with renal stone disease. MATERIALS AND METHOD A prospective study has been carried out, including 150 renal stone disease patients and 150 healthy individuals. Biochemical parameters were performed, including serum calcium levels, creatinine, parathyroid hormone, and 24-Hour urine metabolites. The genotyping of SPP1 (rs1126616) and UMOD (rs4293393) gene variants were performed using a customized TaqMan probe. T-test was used for continuous biochemical data analysis. The Chi-square test has been applied to assess the risk of a particular genotype associated with renal stone disease. In addition, correlation analysis for biochemical parameters and genetic variants with the renal stone disease has been performed using Shapley additive explanations (SHAP) values calculated with the help of the pycaret library. RESULT Renal stone patients had significantly higher levels of parathyroid hormone (93.37 ± 52.78 pg/ml vs 64.67 ± 31.50 pg/ml, P=<0.0001), serum creatinine (0.94 ± 0.38 mg/dl vs 0.77 ± 0.17 mg/dl, P=<0.0001) and 24hr urine metabolites in comparison to the healthy controls. Heterozygous (CT) variant of SPP1 and homozygous (GG) variant of UMOD genes were significantly associated with an increased risk of developing the renal stone disease (p = 0.0100, OR = 2.06, 95 %CI = 1.13-3.75; p=<0.0001, OR = 5.773, 95 % CI = 2.03-16.38, respectively). Individuals with hyperparathyroidism and CC (SPP1) and GG (UMOD) genotypes have a high risk (P = 0.0055, OR = 2.75, 95 %CI = 1.35-5.67; P = 0.0129, OR = 10.03, 95 %CI = 1.60-110.40, respectively) of developing a renal stone. In addition, individuals with hypercalciuria and TT genotype of SPP1 (P = 0.0112, OR = 2.92, 95 % CI = 1.33-6.35), AG genotype of UMOD (P=<0.0001, OR = 5.45, 95 %CI = 2.24-13.96) and GG genotype of UMOD (P=<0.0001, OR = 10.02, 95 %CI = 3.53-24.63) have high risk of developing renal stones. Moreover, Individuals with hyperoxaluria and AG + GG (UMOD) genotype have a greater risk (P=<0.0001, OR = 7.35, 95 % CI = 3.83-13.68) of developing a renal stone. The renal stone risk was persistent (P=<0.0002, OR = 2.44, 95 % CI = 1.52-3.86) when analyzed for the synergistic effect of risk genotypes of SPP1 (CT) and UMOD (GG) gene. Further, correlation analysis also confirmed the strong association between genetic variants and renal stone development. CONCLUSION Genetic variants of the SPP1 and UMOD genes were associated with renal stone disease. In the presence of risk genotype and hyperparathyroidism, hypercalciuria, and hyperoxaluria, the susceptibility to develop the renal stone disease risk gets modulated.
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Affiliation(s)
- Yash P Patel
- Department of Clinical Pharmacy, Ramanbhai Patel College of Pharmacy, Charotar University of Science and Technology, Changa, Anand, Gujarat 388421, India
| | - Samir G Patel
- Department of Pharmaceutical Chemistry and Analysis, Ramanbhai Patel College of Pharmacy, Charotar University of Science and Technology, Changa, Anand, Gujarat 388421, India
| | - Sandip B Patel
- Department of Pharmacology, L.M. College of Pharmacy, Ahmedabad, Gujarat 380009, India
| | - Aditya Parikh
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat 387001, India
| | - Shailesh Soni
- Department of Pathology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat 387001, India
| | - Ratika Srivastava
- School of Life Sciences, Department of Biotechnology, Babasaheb Bhimrao Ambedkar University (A Central University), Lucknow, UP 226025, India
| | - Chintal Raval
- Department of Information Technology, Devang Patel Institute of Advance Technology and Research, Charotar University of Science and Technology, Changa, Anand, Gujarat 388421, India
| | - Manan A Raval
- Department of Pharmacognosy and Phytochemistry, Ramanbhai Patel College of Pharmacy, Charotar University of Science and Technology, Changa, Anand, Gujarat 388421, India
| | - Sachchida Nand Pandey
- Department of Pathology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat 387001, India.
| | - Arvind P Ganpule
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat 387001, India
| | - Mahesh R Desai
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat 387001, India
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Ramalingam AK, Nellaiappar P, Hussain Z, Parvathy NA, Venkatesh NS. Sciatica masquerading parathyroid carcinoma. INTERNATIONAL JOURNAL OF ACADEMIC MEDICINE 2023. [DOI: 10.4103/ijam.ijam_53_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Chandran M, Bilezikian JP, Salleh NM, Ying H, Lau J, Lee J, deJong MC, Chan Maung A, Parameswaran R. Hungry bone syndrome following parathyroidectomy for primary hyperparathyroidism in a developed country in the Asia Pacific. A cohort study. Osteoporos Sarcopenia 2022; 8:11-16. [PMID: 35415277 PMCID: PMC8987324 DOI: 10.1016/j.afos.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/04/2022] [Accepted: 03/15/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives We sought to assess the incidence of hungry bone syndrome (HBS) following parathyroidectomy (PTX) for primary hyperparathyroidism (PHPT) in a cohort of multi-ethnic patients from a developed country in the Asia Pacific. Methods One hundred and sixty-four patients who underwent PTX for PHPT between 2012 and 2019 at the 2 largest public hospitals in Singapore were identified. HBS was defined as serum albumin-adjusted calcium ≤ 2.1 mmol/L with normal or raised serum intact parathyroid hormone (iPTH) levels, manifesting on or after the 3rd day, or persisting for more than 3 days post-operatively. Results Chinese constituted 73.8%, Malays 12.2%, Indians 9.8%, and other races 4.3%. HBS developed in 4 patients (2.4%) (95% CI, 0.8%–6.5%). HBS patients had significantly longer in-hospital stays; 20 days [IQR:15–22] vs 2 days [IQR:1–3]; P < 0.001in those who did not develop HBS. There was no difference in the incidence of HBS stratifying for age, sex, vitamin D status, or use of preoperative anti-resorptive medication use. For every 10 unit increase in iPTH and alkaline phosphatase (ALP) levels, the risk of HBS increased by 14% and 11%; RR (95% CI), 1.14 (1.05–1.21) and 1.11 (1.03–1.18), respectively. Conclusions The low incidence of HBS in multi-ethnic patients undergoing PTX by multiple surgeons for PHPT at the 2 largest public hospitals that see the most such patients in Singapore, a developed country, is consistent with the asymptomatic/milder form of presentation of PHPT in the developed world.
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Affiliation(s)
- Manju Chandran
- Osteoporosis and Complicated Metabolic Bone Disorders Unit, Department of Endocrinology, Singapore General Hospital, Singapore
- Corresponding author. Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, 20 College Road, ACADEMIA, 169856, Singapore.
| | - John P. Bilezikian
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | | | - Hao Ying
- National Public Health and Epidemiology Unit, National Centre for Infectious Diseases, Singapore
| | - Joel Lau
- Department of Endocrine Surgery, National University Hospital, Singapore
| | - James Lee
- Department of Endocrine Surgery, National University Hospital, Singapore
| | - Mechteld C. deJong
- Department of Endocrine Surgery, National University Hospital, Singapore
| | - Aye Chan Maung
- Department of Endocrinology, Singapore General Hospital, Singapore
- Department of Endocrinology, Ealing Hospital, London North West Healthcare NHS Trust, United Kingdom
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Boro H, Khatiwada S, Alam S, Kubihal S, Dogra V, Malla S, Kumar C. The spectrum of manifestations of primary hyperparathyroidism in children and adolescents. Pediatr Endocrinol Diabetes Metab 2022; 28:178-187. [PMID: 35942826 PMCID: PMC10214945 DOI: 10.5114/pedm.2022.118315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/27/2022] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Primary hyperparathyroidism (PHPT) is a rare disease in children and adolescents. Early recognition of this disease is important to prevent significant morbidity and mortality. MATERIAL AND METHODS We included 10 consecutive patients with PHPT aged 14 to 19 years of age and followed-up prospectively upto one year after parathyroidectomy. RESULTS Our cohort included 6 females and 4 males. The mean age of the patients was 16.7 ±1.8 years. The symptoms at presentation were musculoskeletal pain (90%), bone deformity (50%), fracture (30%), proximal myopathy (40%), renal stones (50%), reflux symptoms (40%), and pancreatitis (30%). The mean serum calcium was 3.1 ±0.5 mmol/l, mean serum inorganic phosphorus was 0.9 ±0.3 mmol/l and median serum alkaline phosphatase (ALP) was 1911.5 IU/l (IQR: 522.7-5702.3). The median serum intact parathyroid hormone was 133.5 pmol/l (IQR: 69.5 -178.7) while serum 25(OH)D was 47.7 nmol/l (IQR: 23.7-72.7). Hypercalciuria was observed in 7 patients. Hungry bone syndrome was observed in 4 (40%) patients after surgery. Typical parathyroid adenoma was found in 9 (90%) patients while one patient had atypical adenoma with high mitotic index. After one year of surgery, all patients had significant improvement in clinical and biochemical parameters with persistence of residual bone deformities. CONCLUSIONS Our study showed the spectrum of manifestations of PHPT in children and adolescents and outcomes of parathyroidectomy till one year. Long-term follow-up studies with bigger cohorts are required to understand the true nature of the disease in children and adolescents.
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Affiliation(s)
- Hiya Boro
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Saurav Khatiwada
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Sarah Alam
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Suraj Kubihal
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vinay Dogra
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Sundeep Malla
- Department of Radiodiagnosis, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Chitresh Kumar
- Department of Surgical Oncology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Arora S, Singh P, Verma R, Mittal N, Sood A, Kalra S, Shanthaiah D. Primary Hyperparathyroidism Masquerading as Acute Pancreatitis. Horm Metab Res 2021; 53:377-381. [PMID: 34154028 DOI: 10.1055/a-1495-5573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Acute pancreatitis as an initial manifestation of primary hyperparathyroidism (PHPT) is a rare occurrence and timely diagnosis of PHPT is crucial in preventing repeat attack of pancreatitis. The study aimed at evaluating the clinico-radiological profile of patients admitted with acute pancreatitis as the index presentation of PHPT and to determine the factors associated with development of severe pancreatitis. This series included retrospective analysis of medical records of 30 patients admitted with acute pancreatitis as initial manifestation of PHPT. Additionally, we analyzed the data of another 30 patients admitted with PHPT but without any evidence of pancreatitis, to serve as control group. The mean age of the subjects was 44.9±13.9 years with male to female ratio of 1.30. The mean serum calcium level was 12.24±2.79 mg/dl and five (16.6%) patients had normocalcemia at time of presentation. Presence of nephrolithiasis was significantly associated with severe pancreatitis. One patient had refractory hypercalcemia associated with renal failure and was successfully managed with denosumab. Patients with PHPT associated with acute pancreatitis had significantly higher calcium levels and lower frequency of skeletal involvement as compared to PHPT patients without pancreatitis. PHPT masquerading as acute pancreatitis is rare and high index of suspicion is required to diagnose this condition especially in the presence of normocalcemia at presentation. Patients with PHPT associated pancreatitis had male preponderance, higher calcium levels, and lower frequency of skeletal involvement as compared to PHPT patients without pancreatitis.
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Affiliation(s)
- Saurabh Arora
- Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana, Punjab, India
| | - Parminder Singh
- Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana, Punjab, India
| | - Rohit Verma
- Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana, Punjab, India
| | - Naveen Mittal
- Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana, Punjab, India
| | - Ajit Sood
- Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana, Punjab, India
| | - Sanjay Kalra
- Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana, Punjab, India
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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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Nouikes Zitouni S. Monocentric experience of primary hyperparathyroidism surgery in Algeria. Surg Open Sci 2021; 4:32-36. [PMID: 33748732 PMCID: PMC7966862 DOI: 10.1016/j.sopen.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 01/25/2021] [Accepted: 02/05/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Primary hyperparathyroidism (PHPT) remains a relatively underdiagnosed disease in developing countries. The aim of this study was to assess the demographic, pathological, biochemical, and surgical characteristics of patients with primary hyperparathyroidism in a university hospital department of otolaryngology in eastern Algeria. Materials and method We performed a retrospective analysis of the records of 62 patients operated in our department for primary hyperparathyroidism between January 2002 and December 2013. Results The mean age was 47.7 ± 15 years with a female preponderance (88.7%). The mode of discovery was during a biological assessment for bone syndrome in 42% of cases. The mean calcemia was 2.92 ± 0.6 mmol/L, and the intact serum parathyroid hormone was 867.78 ± 954.50 pmol/L. A total of 54.8% of patients had bilateral neck exploration, and 45.2% had minimally invasive open parathyroidectomy. Postoperative complications were dominated by severe hypocalcemia and hungry bone syndrome. Conclusion The diagnosis of primary hyperparathyroidism in our country is late, and management is often performed after the appearance of bone and renal complications. Primary hyperparathyroidism is an underdiagnosed disease in developing countries. The diagnosis is made after the appearance of bone and renal complications. Bone manifestations are the most common presenting symptoms. Biochemical profile is dominated by hypercalcemia and elevated serum parathyroid hormone levels. Average adenoma weight is very high, correlating with severe hyperparathyroidism. Hypocalcemia and hungry bone syndrome are the most common postoperative complications.
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Affiliation(s)
- Souad Nouikes Zitouni
- Faculty of Medicine, Badji Mokhtar Annaba University, Boulevard Mohamed Seddik Benyahia, Annaba, Algeria.,Department of Otolaryngology, Annaba University Hospital, Ibn Rochd, Seraidi Rd, Annaba, Algeria
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Abstract
Objectives. Hungry bone syndrome (HBS) is a severe and underdiagnosed complication of parathyroidectomy in the treatment of primary hyperparathyroidism (PHP) and secondary hyper-parathyroidism to chronic kidney disease (SHP-CKD).Methods. A longitudinal study was conducted to compare the postoperative outcomes of patients who developed HBS in two different time frames: before and after implementing a protocol with an intensive electrolytic monitoring and an algorithm regarding electrolytic supplementation.Results. Overall, 77 parathyroidectomies were included. In PHP, a protocol implementation led to an increased admission of patients in the Intermediate Care Unit for intensive electrolytic monitoring (p<0.001) and an increased rate of oral calcium replacement during hospital stay (p=0.013) compared to pre-protocol era. In SHP-CKD, duration of intravenous calcium replacement was reduced (p=0.010). The prevalence of HBS (9.8% in PHP and 58.3% in SHP-CKD) was similar between the two periods, although its diagnosis had an increased trend in PHP since the protocol implementation. None of the diagnosis of HBS was established due to hypocalcemic symptoms in the post-protocol era (contrary to pre-protocol period, p=0.021). Both hypocalcemia length and duration of surgical ward hospitalization were reduced (p=0.047 and p=0.042, respectively).Conclusions. An improved assessment of hyperparathyroidism and a decrease in HBS severity were noted in the post-protocol era. We strongly recommend the implementation of a standardized protocol with an intensive phosphocalcium monitoring in the high-risk patients who undergo parathyroidectomy due to hyperparathyroidism as it improves the health care and management of HBS.
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Rajan R, Paul I, Cherian KE, Korula A, Hephzibah J, Manipadam MT, Abraham DT, Kapoor N, Paul TV. Myelofibrosis and Pancytopenia Associated With Primary Hyperparathyroidism. AACE Clin Case Rep 2020; 7:69-71. [PMID: 33851024 PMCID: PMC7924162 DOI: 10.1016/j.aace.2020.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective Primary hyperparathyroidism (PHPT) has varied clinical presentations. Hematologic abnormalities secondary to PHPT have been described before. However, pancytopenia as the initial presentation has rarely been reported. We report a patient with PHPT who presented for evaluation of pancytopenia. Methods Histopathology of the bone marrow at presentation is described. Bone biochemistry results and the hematologic profile before and after curative parathyroidectomy are presented. Results A 48-year-old woman presented with pancytopenia (hemoglobin, 6.3 g/dL; total leucocyte count, 3000 cells/mm3; and platelet count, 60 000 cells/mm3), and her bone marrow study showed marrow fibrosis. Biochemical evaluation revealed hypercalcemia (15.5 mg/dL), hypophosphatemia (2.2 mg/dL), and elevated total alkaline phosphatase (4132 U/L). Bone mineral density assessment by dual-energy X-ray absorptiometry scan revealed osteoporosis at all 3 sites, which was more severe in the distal one third of the forearm. Further investigations confirmed the diagnosis of PHPT (serum parathyroid hormone, 2082 pg/mL). Following curative parathyroidectomy, in addition to normalization of calcium, there was restoration of all 3 hematologic cell lines at 3 months. Conclusion Pancytopenia may be a rare manifestation of PHPT. Thus, it may be prudent to evaluate the calcium profile in patients with chronic refractory anemia and pancytopenia.
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Affiliation(s)
- Remya Rajan
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, India
| | - Immanuel Paul
- Department of Pathology, Christian Medical College and Hospital, Vellore, India
| | - Kripa Elizabeth Cherian
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, India
| | - Anu Korula
- Department of Hematology, Christian Medical College and Hospital, Vellore, India
| | - Julie Hephzibah
- Department of Nuclear Medicine, Christian Medical College and Hospital, Vellore, India
| | | | - Deepak Thomas Abraham
- Department of Endocrine Surgery; Christian Medical College and Hospital, Vellore, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, India
| | - Thomas Vizhalil Paul
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, India
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Fatima T, Das B, Sattar S, Islam N. Primary Hyperparathyroidism: Experience from a Tertiary Care Centre in Pakistan. Pak J Med Sci 2020; 36:1199-1203. [PMID: 32968380 PMCID: PMC7501048 DOI: 10.12669/pjms.36.6.2572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Objective: To study the clinical, biochemical and radiological features and management outcomes of patients with primary hyperparathyroidism. Methods: This retrospective study was conducted at the Aga Khan University Hospital, Karachi, Pakistan and comprised data of patients with primary hyperparathyroidism from 2008 to 2017. Results: Out of 103 patients, 83(80.6%) were female. Overall mean age was 59.3±16.2 years. Musculoskeletal manifestations were seen in 60(58.3%) patients and renal manifestations in 28(27.2%). Ostieits fibrosa cystica was found in 04(3.88%) patients. Overall, Ultrasound neck and sestamibi scan localized the lesion in 66 (64.1%) and 77 (76.2%) patients respectively. Among 79 patients who underwent surgery, 67 (84.8%) patients had an adenoma, 05 (6.3%) had hyperplasia and 02(2.53%) patients had parathyroid carcinoma whereas histopathology was inconclusive in 5 (6.32%) out of the 79 surgically treated patients. Disease recurrence was seen in 13 out of 79(16.45%) patients who underwent surgery. Conclusion: Primary hyperparathyroidism is associated with significant morbidity in our population. Targeted measures like improving patient awareness, routine calcium screening, vitamin D supplementation and a high index of suspicion by the clinician may help in early diagnosis of the condition and thus reduce morbidity.
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Affiliation(s)
- Tehseen Fatima
- Dr. Tehseen Fatima, FCPS. Section of Endocrinology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Bhagwan Das
- Dr. Bhagwan Das, FCPS. Section of Endocrinology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Saadia Sattar
- Saadia Sattar, MSc. Section of Endocrinology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Najmul Islam
- Dr. Najmul Islam, FRCP. Section of Endocrinology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
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14
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Hui CC, Zhang X, Sun JR, Deng DT. Primary hyperparathyroidism in a woman with multiple tumors: A case report. World J Clin Cases 2019; 7:3132-3137. [PMID: 31624765 PMCID: PMC6795725 DOI: 10.12998/wjcc.v7.i19.3132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 06/25/2019] [Accepted: 07/03/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Parathyroid adenoma (PTA) is known as an adenomatous hyperparathyroidism syndrome. At earlier times, the major symptoms of this disease included high blood calcium and low phosphorus. PTA is a benign neuroendocrine neoplasm. We have reviewed the literature and found that it is rare for patients with hyperparathyroidism to have benign tumors with multiple organs at the same time. This report describes a patient with a PTA and four nonfunctional adenomas.
CASE SUMMARY We report a case of primary hyperparathyroidism in a 39-year-old woman with multiple organ tumors. The patient was admitted to hospital because of hypercalcemia. Laboratory, imaging, and histological examinations confirmed a left parathyroid neoplasm. Right thyroid adenoma was discovered during hospitalization. She had a medical history of uterine fibroids, right benign mammary gland tumor, and meningioma. The patient recovered after surgical and conservative treatments.
CONCLUSION Primary hyperparathyroidism with multiple organ tumors is uncommon, and further studies should be conducted to determine if there is genetic heterogeneity.
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Affiliation(s)
- Can-Can Hui
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Xue Zhang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
| | - Jian-Ran Sun
- Department of Endocrinology, The First Affiliated Hospital of USTC Anhui Provincial Hospital, Hefei 230001, Anhui Province, China
| | - Da-Tong Deng
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, China
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Yadav SK, Mishra SK, Mishra A, Mayilvagnan S, Chand G, Agarwal G, Agarwal A, Verma AK. Surgical Management of Primary Hyperparathyroidism in the Era of Focused Parathyroidectomy: A Study in Tertiary Referral Centre of North India. Indian J Endocrinol Metab 2019; 23:468-472. [PMID: 31741908 PMCID: PMC6844166 DOI: 10.4103/ijem.ijem_255_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Despite the benefits of focused parathyroidectomy (FPTx), few studies have questioned its durability with lower long-term cure rates than bilateral or conventional parathyroidectomy (CPTx). The objective of this study is to bring out the information on the type of surgical management versus cure rate, recurrence, and role of intra-operative parathyroid hormone (IOPTH) level monitoring of PHPT patients. MATERIAL AND METHODS This was a retrospective study of all PHPT patients treated at our center based on operative approach (CPTx vs FPTx) or use of IOPTH. Treatment failure was divided into persistent or recurrent disease, based on documentation of hypercalcemia in combination with an inappropriate PTH within 6 months or more of surgery, respectively. RESULTS Overall, 50.78% patients underwent CPTx and 49.32% FPTx. 29 FPTx were converted to CPTx. Intention to treat analysis between CPTx and FPTx showed that the persistence rate was not statistically different at 2.54% and 4%, respectively (P = 0.98). Furthermore, when the persistence rate was scrutinized by a treatment received (TR) instead of ITT analysis, the persistence rate was higher for the patients who underwent TR-CPTX than for the patients subjected to TR-FPTX (3.22% vs 1.08%) but not significant statistically. We further analyzed the outcome of FPTx with IOPTH (n = 213) and FPTx without IOPTH (n = 28). The outcome did not differ between two groups statistically. CONCLUSION FPTx yields a similar success rate as compared to CPTx even in symptomatic PHPT patients and can be performed safely even without intra-opeartive adjunct IOPTH in selected patients.
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Affiliation(s)
- Sanjay K. Yadav
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Saroj K. Mishra
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Anjali Mishra
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Sabaretnam Mayilvagnan
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Gyan Chand
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Gaurav Agarwal
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Amit Agarwal
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Ashok K. Verma
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
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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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Jakubauskas M, Beiša V, Strupas K. Risk factors of developing the hungry bone syndrome after parathyroidectomy for primary hyperparathyroidism. Acta Med Litu 2018; 25:45-51. [PMID: 29928157 PMCID: PMC6008000 DOI: 10.6001/actamedica.v25i1.3703] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background. Around 13% of patients undergoing parathyroidectomy for primary hyperparathyroidism (PHPT) postoperatively develop a condition known as the hungry bone syndrome (HBS). Although the condition is quite prevalent, the research in this field is very limited. The aim of our study was to determine possible risk factors of developing HBS after parathyroidectomy for PHPT. Materials and methods. In this study we enrolled patients who underwent parathyroidectomy for PHPT from January 2005 to December 2016 and performed a retrospective analysis. We used the definition of HBS as hypocalcaemia with normal or elevated PTH values. Patients were divided into two groups by the postoperative HBS prevalence: patients with postoperative HBS and those without postoperative HBS. Results. In all, 94 patients were included into the final analysis. We found that patients who developed HBS more often underwent parathyroidectomies simultaneously with a thyroid surgery, underwent longer operations (73.9 ± 41.7 vs. 102.4 ± 44.8 minutes; p = 0.001), and had heavier parathyroid glands removed (0.6 (0.3–8.0) vs. 0.8 (0.15–14.0) g; p = 0.041). Also, these patients had higher preoperative PTH values (15.3 (6.1–63.7) vs. 22.4 (9.2–47.8) pmol/l; p = 0.003). From the ROC curve of the preoperative PTH values and the development of the hungry bone syndrome (AUC = 0.721 (95% CI 0.59–0.85); p = 0.003) we found a 45 pmol/l PTH cut-off value that shows a 90% tendency to develop postoperative HBS. Conclusions. Patients undergoing longer parathyroidectomies and those with heavier removed parathyroid glands tend to develop HBS. A preoperative PTH value higher than 45 pmol/l determines an over 90% risk of developing HBS.
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Affiliation(s)
| | - Virgilijus Beiša
- Faculty of Medicine Vilnius University, Vilnius, Lithuania.,Centre of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Kęstutis Strupas
- Faculty of Medicine Vilnius University, Vilnius, Lithuania.,Centre of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
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Mallikarjuna VJ, Mathew V, Ayyar V, Bantwal G, Ganesh V, George B, Hemanth GN, Vinotha P. Five-year Retrospective Study on Primary Hyperparathyroidism in South India: Emerging Roles of Minimally Invasive Parathyroidectomy and Preoperative Localization with Methionine Positron Emission Tomography-Computed Tomography Scan. Indian J Endocrinol Metab 2018; 22:355-361. [PMID: 30090727 PMCID: PMC6063170 DOI: 10.4103/ijem.ijem_445_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) is a common endocrine disease with a variable clinical presentation. PHPT is usually symptomatic at presentation in majority of the patients, especially in developing countries. As the accessibility to investigations, advanced imaging methods and surgical procedures are improving, the clinical profile of the patients with PHPT has undergone a palpable change compared to the earlier description. Hence we decided to look for a change in clinical, imaging and surgical outcomes of PHPT patients from South India. METHODS We collected the data on clinical presentation, biochemistry, radiological features and operative findings of patients with PHPT treated in our hospital from 2011-2015. Cases of PHPT were identified from the laboratory values using the biochemical criteria, after the exclusion of secondary and tertiary hyperparathyroidism cases. RESULTS Our study identified 54 patients (19 males and 35 females) with age ranging from 16 to 71 years. A Significant proportion(38.9%) of the patients were asymptomatic. Musculoskeletal symptoms (40.7%), renal manifestations (27.7%) and gastrointestinal system involvement (27.7%) constituted the other common modes of presentation. CNS involvement was seen in 3 patients. A palpable nodule in the neck was detected in 4 patients. Interestingly 4 patients were managed for parathyroid crisis at presentation. Biochemical features included hypercalcaemia (100%) and hypophosphatemia (59%) with a mean intact PTH level of 602.0±721.3 pg/ml. Sensitivity of Ultrasonography and Tc99M Sestamibi was 72% and 70.6% respectively for detecting a parathyroid adenoma. Sensitivity of C11 methionine PET-CT was 71.4% in those patients who were negative for other imaging modalities. Forty three patients (79.6%) underwent minimally invasive parathyroidectomy. CONCLUSION In South India we have a notable change in the clinical presentation of PHPT from a symptomatic to an asymptomatic state. C11 Methionine PET - CT is an emerging modality for preoperative localisation especially when other imaging modalities are negative and when a minimally invasive parathyroidectomy is desired.
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Affiliation(s)
- V. J. Mallikarjuna
- Department of Endocrinology, St. Johns Hospital and Medical College, Bengaluru, Karnataka, India
| | - Vivek Mathew
- Department of Endocrinology, St. Johns Hospital and Medical College, Bengaluru, Karnataka, India
| | - Vageesh Ayyar
- Department of Endocrinology, St. Johns Hospital and Medical College, Bengaluru, Karnataka, India
| | - Ganapathy Bantwal
- Department of Endocrinology, St. Johns Hospital and Medical College, Bengaluru, Karnataka, India
| | - V Ganesh
- Department of Endocrinologyst, Johns Hospital and Medical College, Bengaluru, Karnataka, India
| | - Belinda George
- Department of Endocrinology, St. Johns Hospital and Medical College, Bengaluru, Karnataka, India
| | - G. N. Hemanth
- Department of Surgical Oncology, St. Johns Hospital and Medical College, Bengaluru, Karnataka, India
| | - P. Vinotha
- Division of Epidemiology and Biostatistics, St John's Research Institute, Bengaluru, Karnataka, India
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Naik AH, Wani MA, Wani KA, Laway BA, Malik AA, Shah ZA. Intraoperative Parathyroid Hormone Monitoring in Guiding Adequate Parathyroidectomy. Indian J Endocrinol Metab 2018; 22:410-416. [PMID: 30090736 PMCID: PMC6063190 DOI: 10.4103/ijem.ijem_678_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Parathyroidectomy has been traditionally performed through bilateral neck exploration (BNE). However, with the use of intraoperative parathyroid hormone (IOPTH) assay along with preoperative localization studies, focused parathyroidectomy can be performed with good surgical success rate, multiglandular disease can be predicted, and hence recurrence and surgical failure can be prevented. Furthermore, it predicts eucalcemia in the postoperative period. The aim of this study was to evaluate the usefulness of IOPTH assay in guiding adequate parathyroidectomy in patients of primary hyperparathyroidism. MATERIALS AND METHODS Between year 2015 and 2017, 45 patients of primary hyperparathyroidism underwent parathyroidectomy with IOPTH assay employed as an intraoperative tool to guide the surgical procedure. Blood samples were collected: (1) at preincision time, (2) preexcision of gland, (3) 5-min postexcision of gland, and (4) 10-min postexcision of gland. On the basis of the Irvin criterion, an intraoperative PTH drop >50% from the highest either preincision or preexcision level after parathyroid excision was considered a surgical success. Otherwise, BNE was performed and search for other parathyroid glands done. RESULTS Ten-min postexcision PTH levels dropped >50% in 34 (75.6%) patients. True positive among them were 31 (68.8%), true negative 8 (17.7%), false positive 3 (6.6%), and false negative 3 (6.6%). We performed focused exploration at the outset in 40 (88.9%) patients and bilateral exploration for five patients as guided by preoperative localizing studies. Hence, IOPTH was helpful in guiding further exploration in 8 (17.7%) patients and prevented further exploration in 32 (71.1%) patients and also was able to predict eucalcemia in 97.7% patients at 6 months. Thus, IOPTH was able to obviate or to ask for additional procedure in 88.8% of patients. However, in three (6.6%) patients, IOPTH would guide unnecessary exploration and in equally, that is, three (6.6%) patients may require reoperation for unidentified parathyroids. CONCLUSION IOPTH in adjunct with other localizing studies is very helpful for carrying out successful parathyroidectomy in uniglandular disease and predicting postoperative eucalcemia. However, more importantly, its role is valuable in equivocal imaging, in such cases, it prevents unnecessary exploration or helps in adequate parathyroidectomy.
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Affiliation(s)
| | - Munir Ahmad Wani
- Department of General and Minimal Access Surgery, SKIMS, Srinagar, Jammu and Kashmir, India
| | | | | | - Ajaz Ahmad Malik
- Department of General and Minimal Access Surgery, SKIMS, Srinagar, Jammu and Kashmir, India
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Changing Profile of Primary Hyperparathyroidism Over Two and Half Decades: A Study in Tertiary Referral Center of North India. World J Surg 2018; 42:2732-2737. [DOI: 10.1007/s00268-018-4575-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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21
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Bhadada SK, Arya AK, Mukhopadhyay S, Khadgawat R, Sukumar S, Lodha S, Singh DN, Sathya A, Singh P, Bhansali A. Primary hyperparathyroidism: insights from the Indian PHPT registry. J Bone Miner Metab 2018; 36:238-245. [PMID: 28364324 DOI: 10.1007/s00774-017-0833-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/03/2017] [Indexed: 02/05/2023]
Abstract
The presentation of primary hyperparathyroidism (PHPT) is variable throughout the world. The present study explored retrospective data submitted to the Indian PHPT registry ( http://www.indianphptregistry.com ) between July 2005 and June 2015 from 5 centres covering four different geographical regions. The clinical, biochemical, radiological and histopathological characteristics of PHPT patients across India were analysed for similarity and variability across the centres. A total of 464 subjects (137 men and 327 women) with histopathologically proven PHPT were analysed. The mean age was 41 ± 14 years with a female:male ratio of 2.4:1. The majority (95%) of patients were symptomatic. Common clinical manifestations among all the centres were weakness and fatigability (58.7%), bone pain (56%), renal stone disease (31%), pancreatitis (12.3%) and gallstone disease (11%). Mean serum calcium, parathyroid hormone and inorganic phosphorus levels were 11.9 ± 1.6 mg/dL, 752.4 ± 735.2 pg/mL and 2.8 ± 0.9 mg/dL, respectively. Sestamibi scanning had better sensitivity than ultrasonography in the localisation of parathyroid adenoma; however, when these two modalities were combined, 93% of the cases were correctly localised. Mean parathyroid adenoma weight was 5.6 ± 6.5 g (0.1-54 g). It was concluded that the majority of PHPT patients within India are still mainly symptomatic with >50% of patients presenting with bone disease and one-third with renal impairment. Compared to Western countries, Indian patients with PHPT are younger, biochemical abnormalities are more severe, and adenoma weight is higher. As our observation is largely derived from a tertiary care hospital (no routine screening of serum calcium level), the results do not reflect racial differences in susceptibility to PHPT.
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Affiliation(s)
- Sanjay Kumar Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Ashutosh Kumar Arya
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Satinath Mukhopadhyay
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India
| | - Rajesh Khadgawat
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Suja Sukumar
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Sailesh Lodha
- Department of Endocrinology, Fortis Hospital, Jaipur, India
| | | | - Anjali Sathya
- Vijaya Hospital/MMM Hospital, Chennai, Tamilnadu, India
| | - Priyanka Singh
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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22
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Mayilvaganan S, Bothra S. Radio-guided Minimally Invasive Parathyroidectomy: A Descriptive Report of the Experience from Tertiary Center. Indian J Nucl Med 2017; 32:383. [PMID: 29142370 PMCID: PMC5672774 DOI: 10.4103/ijnm.ijnm_92_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Sabaretnam Mayilvaganan
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sapana Bothra
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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23
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Kuchay MS, Kaur P, Mishra SK, Mithal A. The changing profile of hypercalcemia in a tertiary care setting in North India: an 18-month retrospective study. ACTA ACUST UNITED AC 2017; 14:131-135. [PMID: 29263720 DOI: 10.11138/ccmbm/2017.14.1.131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This retrospective study was undertaken to determine the profile of hypercalcemia in all patients who presented to Medanta-The Medicity, a tertiary care hospital in North India. A total of 255,830 patients presented to the hospital during 1st January 2014 till 30th June 2015 (18 months). Among them calcium measurement was done in 26,297 (10.2%) patients. A total of 552 patients was found to have hypercalcemia. Among them, 15 (2.7%) patients had transient hypercalcemia and 537 (97.3%) had sustained hypercalcemia. The incidence of hypercalcemia was 2.09%, being transient in 0.05% and sustained in 2.04%. The most common causes in the sustained group were malignancy (23.1%) followed by primary hyperparathyroidism (PHPT, 21.9%). Most cases of PHPT were asymptomatic. Interestingly, we found emergence of two unusual groups of hypercalcemia, namely hypercalcemia of advanced chronic liver disease (n = 34) and vitamin D toxicosis (n = 21) in the non-parathyroid group of hypercalcemia. This changing pattern of hypercalcemia should be kept in mind while evaluating a patient of hypercalcemia in a hospital setting.
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Affiliation(s)
- Mohammad Shafi Kuchay
- Division of Endocrinology and Diabetes, Medanta-The Medicity, Sector 38, Gurgaon, Haryana, India
| | - Parjeet Kaur
- Division of Endocrinology and Diabetes, Medanta-The Medicity, Sector 38, Gurgaon, Haryana, India
| | - Sunil Kumar Mishra
- Division of Endocrinology and Diabetes, Medanta-The Medicity, Sector 38, Gurgaon, Haryana, India
| | - Ambrish Mithal
- Division of Endocrinology and Diabetes, Medanta-The Medicity, Sector 38, Gurgaon, Haryana, India
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Gaurav K, Mishra SK. Management of hyperparathyroidism - Influence of patient and disease factors. Am J Surg 2017; 216:176. [PMID: 28662772 DOI: 10.1016/j.amjsurg.2017.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 01/02/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Kushagra Gaurav
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
| | - Saroj Kanta Mishra
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
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The Changing Profile of Hypercalcemia in Hospital Populations. Clin Rev Bone Miner Metab 2017. [DOI: 10.1007/s12018-017-9231-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Mayilvaganan S, Vijaya Sarathi HA, Shivaprasad C. Preoperative zoledronic acid therapy prevent hungry bone syndrome in patients with primary hyperparathyroidism. Indian J Endocrinol Metab 2017; 21:76-79. [PMID: 28217502 PMCID: PMC5240085 DOI: 10.4103/2230-8210.196023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Hungry bone syndrome is a common complication of surgery for primary hyperparathyroidism in India which often leads to prolonged hospitalization. There are varying reports on the use and efficacy of bisphosphonates in the prevention of hungry bone syndrome. METHODS We retrospectively analyzed the effect of preoperative bisphosphonate therapy on rates of hungry bone syndrome in our patients with primary hyperparathyroidism. A total of 19 patients underwent surgery for primary hyperparathyroidism at our institute between January 2013 and June 2015 among whom eight did not receive preoperative bisphosphonates and 11 received intravenous zoledronic acid 4 mg, 24-48 h preoperatively. RESULTS There was no significant difference between the two groups with respect to age, gender, duration of symptoms, preoperative serum calcium, phosphorus, parathyroid hormone, alkaline phosphatase, and the presence of radiological evidence of hyperparathyroid bone disease also did not differ between the groups. Three out of the eight patients who did not receive preoperative zoledronic acid therapy had hungry bone syndrome but none in the zoledronic acid group. The prevalence of hungry bone syndrome tended to be lower in the zoledronic acid group (P = 0.058). The need for intravenous calcium and duration of postoperative hospital stay were significantly lesser in the zoledronic acid group. CONCLUSION Preoperative intravenous zoledronic acid significantly reduces the need for intravenous calcium therapy and duration of postoperative hospital stay and seems a promising option to reduce the rate of hungry bone syndrome in patients with primary hyperparathyroidism.
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Affiliation(s)
- Sabaretnam Mayilvaganan
- Department of Endocrine and Breast Surgery, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India
| | - H. A. Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India
| | - C. Shivaprasad
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India
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Misgar RA, Dar PM, Masoodi SR, Ahmad M, Wani KA, Wani AI, Bashir MI. Clinical and laboratory profile of primary hyperparathyroidism in Kashmir Valley: A single-center experience. Indian J Endocrinol Metab 2016; 20:696-701. [PMID: 27730083 PMCID: PMC5040053 DOI: 10.4103/2230-8210.190560] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although primary hyperparathyroidism (PHPT) has become an asymptomatic disease in the West, in India, PHPT is still an uncommonly diagnosed, overtly symptomatic disease with skeletal, muscular, and renal manifestations. AIMS To describe the profile and surgical outcome of 78 consecutive PHPT patients over a period of two decades at a single center. MATERIALS AND METHODS All patients who underwent evaluation and surgery for PHPT from January 1996 to December 2015 were included. Evaluation included measurement of serum total calcium, inorganic phosphorus, alkaline phosphatase, intact parathyroid hormone, 25-hydroxy Vitamin D, 24 hour urinary calcium and radiological survey. Ultrasonography neck and technetium-99m sestamibi scan were used for preoperative localization. RESULTS A total of 78 patients were identified during the two decades of whom 29 patients were studied retrospectively and 49 patients prospectively. Mean age of patients was 44.72 ± 12.46, and male:female ratio was 1:6. The most common presenting features were nephrolithiasis and/or nephrocalcinosis (64.10%), bone pain (44.1%), abdominal pain (39%), constipation (26%), and myopathy (14.10%). Fractures were present only in 10.25%, and brown tumors in 6.41% patients. The cure rate in our series was 96.15%. The mean parathyroid gland weight was 2.05 ± 3.03 g. None of the 41 patients in whom long-term follow-up was available, had recurrence of PHPT. CONCLUSIONS The profile of PHPT is changing with older age at presentation, and emergence of renal stone disease and decline in overt skeletal disease as common presentation. The parathyroid weight in our study resembles that reported from developed countries.
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Affiliation(s)
- Raiz Ahmad Misgar
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Parvez Mohiuddin Dar
- Department of General Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Shariq Rashid Masoodi
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Munir Ahmad
- Department of General Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Khursheed Alam Wani
- Department of General Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Arshad Iqbal Wani
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Mir Iftikhar Bashir
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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Nair CG, Babu MJC, Jacob P, Menon R, Mathew J. Is intraoperative parathyroid hormone monitoring necessary in symptomatic primary hyperparathyroidism with concordant imaging? Indian J Endocrinol Metab 2016; 20:512-516. [PMID: 27366718 PMCID: PMC4911841 DOI: 10.4103/2230-8210.183451] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Symptomatic primary hyperparathyroidism (PHPT) is still seen frequently in referral centers all over India. These patients require parathyroidectomy and this study aimed to assess the roll of intraoperative parathyroid hormone (PTH) assay when concordant results of two localization studies were available. STUDY DESIGN We analyzed the case records of patients who underwent parathyroidectomy for PHPT from January 2005 to June 2015. RESULTS Of 143 patients included in the study, technetium 99m methoxyisobutylisonitrate dual phase scintigraphy showed true positive images in 93.7% and high definition ultrasonography in 84.6% of patients. Concordance in localization studies was observed in 121 (84.6%) patients, successful parathyroidectomy was done in 117 (96.7%) patients with concordant localization studies. Intraoperative PTH monitoring showed 97.84% sensitivity and 75% specificity and predicted failure in 2 patients with concordant imaging. However, re-exploration was not successful in these patients. CONCLUSION When concordant result is available between parathyroid scintigraphy and anatomical imaging surgical cure rate is high in trained hands. Re-exploration is unlikely to be successful since these patients require higher imaging.
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Affiliation(s)
- C. Gopalakrishnan Nair
- Department of Endocrine Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Misha J. C. Babu
- Department of Endocrine Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Pradeep Jacob
- Department of Endocrine Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Riju Menon
- Department of Endocrine Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Jimmy Mathew
- Department of Endocrine Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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Shah VN, Bhadada SK, Bhansali A, Behera A, Mittal B. Changes in clinical & biochemical presentations of primary hyperparathyroidism in India over a period of 20 years. Indian J Med Res 2014; 139:694-9. [PMID: 25027078 PMCID: PMC4140033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND & OBJECTIVES With the advent of serum chemistry autoanalyzer and routine estimation of serum calcium as a part of annual physical examination, there has been a dramatic change in the presentation of primary hyperparathyroidism (PHPT) from symptomatic to asymptomatic disease in the United States. However, such trend has not been documented from India. We carried out this retrospective study to analyse the changes in clinical presentations of PHPT patients over a period of two decades in a tertiary care centre in north India. METHODS This retrospective study included patients with PHPT treated at a single centre of north India between March 1990 and October 2010. Two decades were divided into four different time periods, i.e. 1990 to 1994, 1995 to 1999, 2000 to 2004 and 2005 to 2010. Clinical presentations, biochemical parameters and surgical outcomes were compared between different time periods using appropriate statistical methods. RESULTS Data of 202 patients with PHPT with male: female ratio of 3:7 were analyzed. There was a rise in the number of cases of PHPT diagnosed in the last decade compared to the previous decade (28 cases vs 174 cases, P<0.001). Change in the mean age, male: female ratio, lag time for the diagnosis of PHPT and clinical presentations of PHPT (predominance of bone and stone symptoms) did not differ across different time periods. Non-significant decrease in serum calcium levels at the time of diagnosis of PHPT and a significant, decline in the serum alkaline phosphatase levels (P<0.01) were found in the last decade, however, iPTH levels were higher in the last decade ( P <0.05). There was no change in the site and size of parathyroid adenoma in the two decades, however, postoperative symptomatic hypocalcemia was less frequent in the last decade. INTERPRETATION & CONCLUSIONS The findings of this retrospective analysis show that the PHPT still remains symptomatic disease with increasing awareness over the last two decades in our center. There was not much change in the clinical presentation, in the past two decades.
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Affiliation(s)
- Viral N. Shah
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sanjay Kumar Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research, Chandigarh, India,Reprint requests: Dr. Sanjay Kumar Bhadada, Associate Professor, Department of Endocrinology, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India e-mail:
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Arnanshu Behera
- Department of Surgery, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - B.R. Mittal
- Department of Surgery, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Shah VN, Bhadada SK, Bhansali A, Behera A, Bhattacharya A, Nahar U, Bhasin D, Vadera B. Effect of gender, biochemical parameters & parathyroid surgery on gastrointestinal manifestations of symptomatic primary hyperparathyroidism. Indian J Med Res 2014; 139:279-84. [PMID: 24718404 PMCID: PMC4001341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND & OBJECTIVES Information on gastrointestinal manifestations and then response after curative parathyroid surgery is scarce in symptomatic primary hyperparathyroidism (PHPT). This study was carried out to analyse gastrointestinal manifestations in patients with PHPT and their associations with biochemical parameters. METHODS This retrospective study included 153 patients with symptomatic primary hyperparathyroidism (PHPT). The signs and symptoms pertaining to gastrointestinal system were analyzed. The difference of symptoms between men and women and difference in biochemical parameters in presence of different symptoms were evaluated. The relationship between serum calcium, phosphate and parathyroid hormone (PTH) levels with presence of gallstone and pancreatitis was also studied. RESULT Of the 153 patients, 46 (30%) were men. The mean age was 39.2 ± 13.9 yr. Nearly 80 per cent of PHPT patients had at least one symptom/ sign related to gastrointestinal system. The most common gastrointestinal manifestations were abdominal pain 66 (43%), constipation 55 (36%), and nausea/or vomiting 46 (30%). Nearly one-fourth 34 (22%) of patients had a history of either gallstone disease or cholecystectomy or both. The prevalence of gallstone disease was higher in women (P<0.05). Imaging and biochemical evidence of pancreatitis was found in 27 (18%) patients. Pancreatitis was more common in men compared to women (P<0.05) despite the higher prevalence of gallstones in women. Serum calcium, phosphate or PTH levels were not associated with high risk for gallstone disease, however, serum calcium (P<0.05) was associated with 1.3 times higher risk of developing pancreatitis. In majority of patients, gastrointestinal manifestations resolved within three months of curative parathyroidectomy. Except two patients, none had recurrence of pancreatitis. INTERPRETATION & CONCLUSIONS The study revealed that the gastrointestinal symptoms were common in patients with symptomatic PHPT. There was not much gender difference in gastrointestinal symptoms except higher occurrence of gallstones in women and pancreatitis in men. There was no difference in biochemical profile between those who had and did not have gastrointestinal symptoms.
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Affiliation(s)
- Viral N. Shah
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sanjay Kumar Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research, Chandigarh, India,Reprint requests: Dr Sanjay Kumar Bhadada, Associate Professor, Department of Endocrinology, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India e-mail:
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - A. Behera
- Department of Surgery, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Anish Bhattacharya
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Uma Nahar
- Department of Pathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Deepak Bhasin
- Department of Gastroenterology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Bhavin Vadera
- Department of Preventive Medicine & Department of Biostatistics, M.P. Shah Medical College, Jamnagar, India
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Maskey R, Panchani R, Varma T, Goyal A. Primary hyperparathyroidism in India: A cocktail of contemporary and classical presentations: Lesson from 47 cases. Indian J Endocrinol Metab 2013; 17:S209-S211. [PMID: 24251161 PMCID: PMC3830307 DOI: 10.4103/2230-8210.119574] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Primary hyperparathyroidism (PHPT) is now the contemporary form of previously existing classical disease, which is increasingly diagnosed due to hypercalcemia with asymptomatic form predominant in developed countries, whereas symptomatic form predominant in developing countries. So, we highlighted important subtle features of PHPT, problems in diagnosis in day to day practice in patients with PHPT at our center.
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Affiliation(s)
- Robin Maskey
- Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India
| | - Roopal Panchani
- Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India
| | - Tarun Varma
- Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashutosh Goyal
- Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India
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Paruk IM, Esterhuizen TM, Maharaj S, Pirie FJ, Motala AA. Characteristics, management and outcome of primary hyperparathyroidism in South Africa: a single-centre experience. Postgrad Med J 2013; 89:626-31. [PMID: 23824345 DOI: 10.1136/postgradmedj-2012-131707] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Primary hyperparathyroidism (PHPT) is a common endocrine disorder characterised by hypercalcaemia and elevated parathyroid hormone (PTH) levels. However, it remains a relatively underdiagnosed disease in the developing world primarily due to a lack of routine blood chemistry screening. The aim of this analysis was to evaluate the characteristics, management and outcome of patients with PHPT at a tertiary referral clinic in South Africa. METHODS A retrospective analysis was undertaken on all patients with a diagnosis of PHPT attending the endocrinology clinic at a tertiary referral hospital in Durban, South Africa, between January 2003 and June 2009. Information on clinical presentation, past medical history, biochemistry, radiology, histology and surgical notes were recorded. Patients with multiple endocrine neoplasia were excluded. RESULTS A total of 28 case records of PHPT were reviewed. The mean age at presentation was 60±14.5 years with a female preponderance (78.6%). The mode of presentation included referral for investigation of an abnormal serum calcium (n: 23), referral from urologist with nephrolithiasis (n: 3) and for investigation of bone disease (n: 2). Symptomatic disease was found in 26 patients (92.9%), including bone pain (75%), fatigue (46.4%) and abdominal pain (32.1%). Mean serum calcium was 3.0+0.39 (normal 2.08-2.65) mmol/L, serum intact PTH 34.7±41.5 (normal 1.2-8.5) pmol/L and serum alkaline phosphatase 206.3±340.2 (normal 53-141) mIU/L. Sestamibi scan was performed on 24 patients and an adenoma was identified in 83.3%. Of the 19 (68%) patients who had parathyroidectomy, an adenoma was identified as the cause in all cases where histology was available (n:18). Surgery was successful in 18 patients with only one patient requiring repeat parathyroidectomy for persistent hypercalcaemia. Postoperative hypocalcaemia developed in eight patients (42.1%) including four patients who required intravenous calcium infusion for symptomatic hypocalcaemia. CONCLUSIONS PHPT is a treatable disorder with good surgical success. Asymptomatic disease was uncommon in this group of patients. This is compatible with the symptomatic pattern of presentation reported in other developing countries.
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Affiliation(s)
- Imran M Paruk
- Department of Diabetes & Endocrinology, University of KwaZulu-Natal, , Durban, South Africa
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Varshney S, Bhadada SK, Saikia UN, Sachdeva N, Behera A, Arya AK, Sharma S, Bhansali A, Mithal A, Rao SD. Simultaneous expression analysis of vitamin D receptor, calcium-sensing receptor, cyclin D1, and PTH in symptomatic primary hyperparathyroidism in Asian Indians. Eur J Endocrinol 2013; 169:109-16. [PMID: 23660642 DOI: 10.1530/eje-13-0085] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To explore underlying molecular mechanisms in the pathogenesis of symptomatic sporadic primary hyperparathyroidism (PHPT). MATERIALS AND METHODS Forty-one parathyroid adenomas from patients with symptomatic PHPT and ten normal parathyroid glands either from patients with PHPT (n=3) or from euthyroid patients without PHPT during thyroid surgery (n=7) were analyzed for vitamin D receptor (VDR), calcium-sensing receptor (CASR), cyclin D1 (CD1), and parathyroid hormone (PTH) expressions. The protein expressions were assessed semiquantitatively by immunohistochemistry, based on percentage of positive cells and staining intensity, and confirmed by quantitative real-time PCR. RESULTS Immunohistochemistry revealed significant reductions in VDR (both nuclear and cytoplasmic) and CASR expressions and significant increases in CD1 and PTH expressions in adenomatous compared with normal parathyroid tissue. Consistent with immunohistochemistry findings, both VDR and CASR mRNAs were reduced by 0.36- and 0.45-fold change (P<0.001) and CD1 and PTH mRNAs were increased by 9.4- and 17.4-fold change respectively (P<0.001) in adenomatous parathyroid tissue. PTH mRNA correlated with plasma PTH (r=0.864; P<0.001), but not with adenoma weight, while CD1 mRNA correlated with adenoma weight (r=0.715; P<0.001). There were no correlations between VDR and CASR mRNA levels and serum Ca, plasma intact PTH, or 25-hydroxyvitamin D levels. In addition, there was no relationship between the decreases in VDR and CASR mRNA expressions and the increases in PTH and CD1 mRNA expressions. CONCLUSIONS The expression of both VDR and CASR are reduced in symptomatic PHPT in Asian Indians. In addition, CD1 expression was greatly increased and correlated with adenoma weight, implying a potential role for CD1 in adenoma growth and differential clinical expression of PHPT.
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Affiliation(s)
- Shweta Varshney
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, 4th Floor, F-Block, Room No. 2, Chandigarh 160012, India
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Witteveen JE, van Thiel S, Romijn JA, Hamdy NAT. Hungry bone syndrome: still a challenge in the post-operative management of primary hyperparathyroidism: a systematic review of the literature. Eur J Endocrinol 2013; 168:R45-53. [PMID: 23152439 DOI: 10.1530/eje-12-0528] [Citation(s) in RCA: 172] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hungry bone syndrome (HBS) refers to the rapid, profound, and prolonged hypocalcaemia associated with hypophosphataemia and hypomagnesaemia, and is exacerbated by suppressed parathyroid hormone (PTH) levels, which follows parathyroidectomy in patients with severe primary hyperparathyroidism (PHPT) and preoperative high bone turnover. It is a relatively uncommon, but serious adverse effect of parathyroidectomy. We conducted a literature search of all available studies reporting a 'hungry bone syndrome' in patients who had a parathyroidectomy for PHPT, to identify patients at risk and address the pitfalls in their management. The severe hypocalcaemia is believed to be due to increased influx of calcium into bone, due to the sudden removal of the effect of high circulating levels of PTH on osteoclastic resorption, leading to a decrease in the activation frequency of new remodelling sites and to a decrease in remodelling space, although there is no good documentation for this. Various risk factors have been suggested for the development of HBS, including older age, weight/volume of the resected parathyroid glands, radiological evidence of bone disease and vitamin D deficiency. The syndrome is reported in 25-90% of patients with radiological evidence of hyperparathyroid bone disease vs only 0-6% of patients without skeletal involvement. There is insufficient data-based evidence on the best means to treat, minimise or prevent this severe complication of parathyroidectomy. Treatment is aimed at replenishing the severe calcium deficit by using high doses of calcium supplemented by high doses of active metabolites of vitamin D. Adequate correction of magnesium deficiency and normalisation of bone turnover are required for resolution of the hypocalcaemia which may last for a number of months after successful surgery. Preoperative treatment with bisphosphonates has been suggested to reduce post-operative hypocalcaemia, but there are to date no prospective studies addressing this issue.
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Affiliation(s)
- J E Witteveen
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Leiden, The Netherlands.
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Selvan B, Paul MJ, Seshadri MS, Thomas N, Paul T, Abraham D, Oommen R, Shandhly N, John S, Rajaratnam S, Therese MM, Nair A, Kumar Samuel P. High Index of Clinical Suspicion With Optimal Surgical Techniques and Adjuvant Radiotherapy Is Critical to Reduce Locoregional Disease Progression in Parathyroid Carcinoma. Am J Clin Oncol 2013; 36:64-9. [DOI: 10.1097/coc.0b013e31823a4924] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- Anil Bhansali
- Department of Endocrinology, PGIMER, Chandigarh, India
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Bhadada SK, Agrawal A, Shah VN, Bhansali A, Behera A, Bhattacharya A, Nahar U. Pulmonary function tests in patients with primary hyperparathyroidism. Indian J Endocrinol Metab 2012; 16:414-416. [PMID: 22629510 PMCID: PMC3354851 DOI: 10.4103/2230-8210.95685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
CONTEXT There is limited information on respiratory muscle functions in patients with primary hyperparathyroidism (PHPT). AIM To assess respiratory muscle dysfunction in patients with PHPT. SETTING AND DESIGN This prospective study was carried between January 2005 and December 2006 by the Department of Endocrinology at the Postgraduate Institute of Medical Education and Research, Chandigarh. MATERIALS AND METHODS PHPT was defined as elevated parathyroid hormone in the presence of hypercalcemia. Spirometry was performed using a dry rolling seal spirometer and spirometric indices like forced vital capacity (FVC), forced expiratory volume in first second (FEV(1)), and FEV(1)/FVC ratio were measured using standard guidelines. RESULTS Thirty patients were studied with a mean age of 37.1 ± 2.4 years and 18 were women. The most common presenting symptoms were fatigue (75.0%) and bone pain (60.70%). The mean (±SD) of percentage predicted FVE(1), FVC, FEV(1)/FVC ratio, PEF, and FEF were 98.7 ± 16.1, 93.9 ± 14.7, 84.5 ± 3.4, 89.3 ± 22.5, and 99.7 ± 33.6, respectively. Two had obstructive lung disease and two had restrictive lung disease. We did not find correlation with preoperative serum calcium, phosphate, and PTH with FVE(1), FVC, FEV(1)/FVC ratio, PEF, and FEF. CONCLUSION Elevated calcium, low phosphate, and elevated PTH levels in patients with moderate to severe PHPT do not significantly affect respiratory muscle functions.
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Affiliation(s)
- Sanjay Kumar Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh (UT), India
| | - Ahutosh Agrawal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh (UT), India
| | - Viral N. Shah
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh (UT), India
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh (UT), India
| | - Arnanshu Behera
- Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh (UT), India
| | - Anish Bhattacharya
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh (UT), India
| | - Uma Nahar
- Department of Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh (UT), India
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Lila AR, Sarathi V, Jagtap V, Bandgar T, Menon PS, Shah NS. Renal manifestations of primary hyperparathyroidism. Indian J Endocrinol Metab 2012; 16:258-262. [PMID: 22470864 PMCID: PMC3313745 DOI: 10.4103/2230-8210.93745] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Primary hyperparathyroidism (PHPT) is associated with nephrolithiasis and nephrocalcinosis. Hypercalciuria is one of the multiple factors that is implicated in the complex pathophysiology of stone formation. The presence of a renal stone (symptomatic or asymptomatic) categorizes PHPT as symptomatic and is an indication for parathyroid adenomectomy. Progression of nephrocalcinosis is largely reversible after successful surgery, but the residual risk persists. PHPT is also associated with declining renal function. In case of asymptomatic mild PHPT, annual renal functional assessment is advised. Guidelines suggest that an estimated glomerular filtration rate (eGFR) < 60 ml / minute / 1.73 m(2) is an indication for parathyroid adenomectomy. This article discusses how to monitor and manage renal stones and other related renal parameters in case of PHPT.
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Affiliation(s)
- Anurag Ranjan Lila
- Department of Endocrinology, Seth G. S. Medical College, Parel, Mumbai, India
| | - Vijaya Sarathi
- Department of Endocrinology, Seth G. S. Medical College, Parel, Mumbai, India
| | - Varsha Jagtap
- Department of Endocrinology, Seth G. S. Medical College, Parel, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth G. S. Medical College, Parel, Mumbai, India
| | - Padma S. Menon
- Department of Endocrinology, Seth G. S. Medical College, Parel, Mumbai, India
| | - Nalini Samir Shah
- Department of Endocrinology, Seth G. S. Medical College, Parel, Mumbai, India
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The Detection and Management of Primary Hyperparathyroidism in Patients with Urolithiasis. Urolithiasis 2012. [DOI: 10.1007/978-1-4471-4387-1_93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Chakraborty D, Mittal BR, Harisankar CNB, Bhattacharya A, Bhadada S. Spectrum of single photon emission computed tomography/computed tomography findings in patients with parathyroid adenomas. INDIAN JOURNAL OF NUCLEAR MEDICINE : IJNM : THE OFFICIAL JOURNAL OF THE SOCIETY OF NUCLEAR MEDICINE, INDIA 2011; 26:52-5. [PMID: 21969785 PMCID: PMC3180727 DOI: 10.4103/0972-3919.84618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Primary hyperparathyroidism results from excessive parathyroid hormone secretion. Approximately 85% of all cases of primary hyperparathyroidism are caused by a single parathyroid adenoma; 10–15% of the cases are caused by parathyroid hyperplasia. Parathyroid carcinoma accounts for approximately 3–4% of cases of primary disease. Technetium-99m-sestamibi (MIBI), the current scintigraphic procedure of choice for preoperative parathyroid localization, can be performed in various ways. The “single-isotope, double-phase technique” is based on the fact that MIBI washes out more rapidly from the thyroid than from abnormal parathyroid tissue. However, not all parathyroid lesions retain MIBI and not all thyroid tissue washes out quickly, and subtraction imaging is helpful. Single photon emission computed tomography (SPECT) provides information for localizing parathyroid lesions, differentiating thyroid from parathyroid lesions, and detecting and localizing ectopic parathyroid lesions. Addition of CT with SPECT improves the sensitivity. This pictorial assay demonstrates various SPECT/CT patterns observed in parathyroid scintigraphy.
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Affiliation(s)
- Dhritiman Chakraborty
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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41
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Chopra S, Cherian D, Jacob JJ. The thyroid hormone, parathyroid hormone and vitamin D associated hypertension. Indian J Endocrinol Metab 2011; 15 Suppl 4:S354-60. [PMID: 22145139 PMCID: PMC3230087 DOI: 10.4103/2230-8210.86979] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Thyroid disorders and primary hyperparathyroidism have been known to be associated with increases in blood pressure. The hypertension related to hypothyroidism is a result of increased peripheral resistance, changes in renal hemodynamics, hormonal changes and obesity. Treatment of hypothyroidism with levo-thyroxine replacement causes a decrease in blood pressure and an overall decline in cardiovascular risk. High blood pressure has also been noted in patients with subclinical hypothyroidism. Hyperthyroidism, on the other hand, is associated with systolic hypertension resulting from an expansion of the circulating blood volume and increase in stroke volume. Increased serum calcium levels associated with a primary increase in parathyroid hormone levels have been also associated with high blood pressure recordings. The mechanism for this is not clear but the theories include an increase in the activity of the renin-angiotensin-aldosterone system and vasoconstriction. Treatment of primary hyperparathyroidism by surgery results in a decline in blood pressure and a decrease in the plasma renin activity. Finally, this review also looks at more recent evidence linking hypovitaminosis D with cardiovascular risk factors, particularly hypertension, and the postulated mechanisms linking the two.
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Affiliation(s)
- Sandeep Chopra
- Department of Cardiology, Christian Medical College, Ludhiana, India
| | - Davis Cherian
- Department of Cardiology, Christian Medical College, Ludhiana, India
| | - Jubbin J. Jacob
- Endocrine and Diabetes Unit, Department of Medicine, Christian Medical College, Ludhiana, India
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Mshelia DS, Hatutale AN, Mokgoro NP, Nchabaleng ME, Buscombe JR, Sathekge MM. Correlation between serum calcium levels and dual-phase 99mTc-sestamibi parathyroid scintigraphy in primary hyperparathyroidism. Clin Physiol Funct Imaging 2011; 32:19-24. [DOI: 10.1111/j.1475-097x.2011.01048.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kamalanathan SC, Mahesh DM, Vignesh G, Halanaik D. Symptomatic primary hyperparathyroidism in Indians. Indian J Endocrinol Metab 2011; 15:229-230. [PMID: 21897907 PMCID: PMC3156550 DOI: 10.4103/2230-8210.83413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - D. M. Mahesh
- Department of Endocrinology, JIPMER, Puducherry, India
| | - G. Vignesh
- Department of Endocrinology, JIPMER, Puducherry, India
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Pradeep PV, Jayashree B, Mishra A, Mishra SK. Systematic review of primary hyperparathyroidism in India: the past, present, and the future trends. Int J Endocrinol 2011; 2011:921814. [PMID: 21747854 PMCID: PMC3124672 DOI: 10.1155/2011/921814] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Revised: 01/16/2011] [Accepted: 03/29/2011] [Indexed: 12/18/2022] Open
Abstract
Primary hyperparathyroidism (PHPT) has become an asymptomatic disease in the Western world with the introduction of routine calcium screening. However, the same phenomenon is not observed in India. We have now systematically reviewed the status of PHPT in India. While there is a paucity of literature on PHPT from India when compared to Western countries, some information can be gleaned upon. Most patients present with symptomatic disease whereas very few are screen-detected cases (bone disease 77%, renal disease 36%, and 5.6% asymptomatic). Mean calcium, parathyroid hormone (PTH), and alkaline phosphate levels are high while Vitamin D levels are low. The average parathyroid gland weight is large and the majority being parathyroid adenomas (89.1%). Hungry bone syndrome (HBS) is common in the postoperative period. The disease-related mortality rate is 7.4%, recurrence 4.16%, and persistent disease 2.17%. We suggest that dedicated efforts are needed to pick up asymptomatic disease in India by methods like incorporating calcium estimation in the routine health check-up programs.
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Affiliation(s)
- P. V. Pradeep
- Narayana Medical College and Superspeciality Hospitals, Nellore, Andhra Pradesh, India
| | - B. Jayashree
- Narayana Medical College and Superspeciality Hospitals, Nellore, Andhra Pradesh, India
| | - Anjali Mishra
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - S. K. Mishra
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Brooks JK, Rivera-Ramirez LE, Errington LW, Scheper MA. Synchronous Paget disease of bone and hyperparathyroidism: report of a case with extensive craniofacial involvement. ACTA ACUST UNITED AC 2011; 111:e19-24. [PMID: 21333565 DOI: 10.1016/j.tripleo.2010.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 11/01/2010] [Accepted: 11/02/2010] [Indexed: 11/17/2022]
Abstract
Paget disease of bone (PDB) and hyperparathyroidism (HPT) are metabolic osseous disorders which affect ≥2% of the population. As these diseases may share clinical, radiographic, biochemical, and histopathologic features, knowledge of their phenotypic overlap may provide diagnostic utility and improve clinical outcome. Scant information is available in the dental literature regarding patients concurrently affected with both pathologies. We present an unusual case report of a 63-year-old woman coaffected with primary HPT, attributed to a functional oxyphilic parathyroid adenoma, and PDB. Bone scintigraphy revealed pagetoid lesions of the skull, humeral head, spine, sacrum, and hemipelvis. Salient craniofacial features noted were bony involvement of the calvarium and midface, resulting in extensive maxillary overgrowth, hearing loss, telecanthus and consequent visual impairment, nasal deformity, and leontiasis ossea. The patient underwent a partial parathyroidectomy and bisphosphonate administration was to be initiated upon extraction of the remaining dentition.
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Affiliation(s)
- John K Brooks
- Department of Oncology and Diagnostic Sciences, University of Maryland Dental School, Baltimore, MD 21201-1586, USA.
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Chen HH, Chen YW, Wu CJ. Primary hyperparathyroidism in Taiwan: clinical features and prevalence in a single-center experience. Endocrine 2010; 37:373-8. [PMID: 20960277 DOI: 10.1007/s12020-010-9315-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Accepted: 02/19/2010] [Indexed: 12/31/2022]
Abstract
In Taiwan, urolithiasis remains a common manifestation of primary hyperparathyroidism (PHPT). We designed this study to estimate the prevalence of PHPT in asymptomatic adults and to assess the complications already present when the disease was diagnosed. In the first phase of the study, we retrospectively reviewed 50 patients diagnosed with surgically or biochemically proven PHPT between April 1995 and April 2007. In the second phase, we reviewed the records of 4,359 asymptomatic subjects who had undergone a health examination between August 2002 and January 2007. Of the 50 patients reviewed in the first phase, hypercalcemia was the presenting complication in 33 patients (64%) followed by symptomatic recurrent solitary urolithiasis in 10 patients (20%). Of the 43 patients who underwent urologic imaging, 29 (67%) had urolithiasis and 7 (16%) had nephrocalcinosis, indicating that urinary stone disease is common. In the second phase, 28 of the 4,359 asymptomatic adults (0.64%) were found to have hypercalcemia; of these 28, 4 (0.092%) were diagnosed with PHPT. In Taiwan, PHPT remains underdiagnosed, and complications manifest in most patients upon admission. Although still relatively uncommon, screening serum calcium levels helps diagnose PHPT at an asymptomatic stage.
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Affiliation(s)
- Han-Hsiang Chen
- Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei City, Taiwan, ROC.
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Muthukrishnan J, Hari Kumar KVS, Jha R, Jha S, Modi KD. Distal renal tubular acidosis due to primary hyperparathyroidism. Endocr Pract 2009; 14:1133-6. [PMID: 19158053 DOI: 10.4158/ep.14.9.1133] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To present 4 cases of distal renal tubular acidosis (RTA) in patients with primary hyperparathyroidism (PHPT) and discuss their possible etiopathogenetic correlation. METHODS We diagnosed distal RTA in 4 patients with symptomatic primary PHPT on the basis of the baseline biochemical variables and the results of the ammonium chloride loading test. Complete resolution of distal RTA was documented after surgical cure of PHPT by removal of a parathyroid adenoma. RESULTS All our patients presented with symptomatic bone disease and metabolic myopathy. One patient presented with recurrent renal stones. Inappropriately alkaline fasting urine (pH >5.5) in association with a normal anion gap metabolic acidosis suggested the diagnosis of distal RTA. All cases were confirmed by an ammonium chloride loading test. Three patients responded to surgical cure of PHPT by normalization of the acid-base status. CONCLUSION Hypercalciuria in PHPT can lead to nephrocalcinosis and renal tubular dysfunction, which manifests as distal RTA. Cure of distal RTA after surgical treatment of PHPT establishes PHPT as the primary cause of distal RTA in these cases.
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Bhadada SK, Bhansali A, Ahluwalia J, Chanukya GV, Behera A, Dutta P. Anaemia and marrow fibrosis in patients with primary hyperparathyroidism before and after curative parathyroidectomy. Clin Endocrinol (Oxf) 2009; 70:527-32. [PMID: 18727711 DOI: 10.1111/j.1365-2265.2008.03346.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the relationship between anaemia and myelofibrosis in patients with symptomatic primary hyperparathyroidism (PHPT) and to assess the effect of curative parathyroidectomy on anaemia and marrow fibrosis. DESIGN AND METHODS In this prospective follow-up study of 28 consecutive patients with symptomatic PHPT from January 2005 to June 2006, 15 patients were diagnosed with anaemia (haemoglobin < 130 g/l in males and < 120 g/l in females), eight (53%) of whom were finally recruited for the study. Complete blood cell count, serum calcium, phosphorus, alkaline phosphatase, intact PTH and 25-hydroxyvitamin D and bone marrow examination were performed both before and after parathyroidectomy in all (n = 8) patients, but bone marrow examination after surgery was performed only in those who had marrow fibrosis at baseline (n = 6). RESULTS Anaemia was observed in 15 (53.3%) of the 28 patients with symptomatic PHPT. Normocytic normochromic anaemia that is characteristic of PHPT was found in 14 (50%) patients. Eight of the 15 patients with anaemia had a bone marrow examination and marrow fibrosis was observed in six (75%). Both anaemia and marrow fibrosis improved after successful parathyroidectomy, but improvement in anaemia was significant (P = 0.02) only in those with marrow fibrosis at baseline. Marrow fibrosis did not correlate with duration of the disease (P = 0.17), degree of hypercalcaemia (P = 0.53) or serum levels of intact PTH (P = 0.60). CONCLUSIONS Anaemia is common in patients with symptomatic PHPT, and was associated with marrow fibrosis in the majority of the patients who underwent bone biopsy. Both anaemia and marrow fibrosis improved after curative parathyroidectomy, but improvement in anaemia was noticeable only in those who had marrow fibrosis at presentation.
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Affiliation(s)
- Sanjay K Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Bhansali A, Shanmugasundar G, Bhadada SK, Walia R, Ravikumar P. Worsening of bone disease after curative surgery in primary hyperparathyroidism. BMJ Case Rep 2009; 2009:bcr12.2008.1357. [PMID: 21686353 DOI: 10.1136/bcr.12.2008.1357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe the case of a 33-year-old woman who underwent surgery successfully 3 years earlier for primary hyperparathyroidism, and subsequently presented with severe bone disease due to secondary hyperparathyroidism associated with chronic kidney disease and vitamin D deficiency.
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Affiliation(s)
- Anil Bhansali
- Endocrinology, Postgraduate Institute of Medical and Educational Research, Chandigarh, 160012, India
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Shukla S, Kaushal M, Shukla SK. Primary hyperparathyroidism: retrospective 10-year study of 32 cases. Indian J Surg 2008; 70:169-74. [PMID: 23133051 PMCID: PMC3452778 DOI: 10.1007/s12262-008-0047-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Accepted: 08/10/2008] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Parathyroid glands are endocrine glands that regulate calcium metabolism. Usually four in number, they lie mostly on the posterior aspect of thyroid glands. Primary hyper-parathyroidism (PHPT) refers to a condition wherein they secrete an excess of parathyroid hormone leading to signs and symptoms of hypercalcemia. PATIENTS AND METHODS Thirty-two patients of primary hyper-parathyroidism were seen by us in the ten years. Majority of patients were below 40 years of age (88%). Male: female ratio was 1:4. The diagnosis was made incidentally in patients who reported for various signs and symptoms not responding to treatment. High serum calcium pointed to the diagnosis of primary parathyroid hyperplasia. It was confirmed by high level of serum parathyroid hormone and localization of enlarged parathyroid glands by USG / MRI and / or Tc-99 Technetium scan. Of the 32 patients examined, 43 parathyroid glands were excised, five cases had two glands excised; out of these 4 cases underwent parathyroid reimplantation in neck/forearm muscles. One unusual case underwent operation for giant-cell tumor of the head of humerus. This patient presented with excessive vomiting not responding standard medical management in post-operative period. RESULTS During investigations serum calcium was found to be very high, the diagnosis was confirmed by finding high parathyroid hormone and corroborated by T(99) Technetium scan. Parathyroidectomy was done in all cases, of which 59% (18 cases) developed mild to severe tetany due to hypocalcaemia. CONCLUSION Primary hyperplasia of thyroid gland is the most important cause of hypercalcemia. Hypercalcemia is found in all cases of PHPT in our series with high parathyroid hormone levels. Majority of our cases have one gland involvement and hypocalcaemia in our series is unusually high following excision of involved gland.
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Affiliation(s)
- Sumit Shukla
- MGM Medical College and M.Y. Group of Hospital, Indore, India
| | - Manish Kaushal
- MGM Medical College and M.Y. Group of Hospital, Indore, India
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