Latin-American consensus on the transition into adult life of patients with X-linked hypophosphatemia

INTRODUCTION

X-linked hypophosphatemia is an orphan disease of genetic origin and multisystem involvement. It is characterized by a mutation of the PHEX gene which results in excess FGF23 production, with abnormal renal and intestinal phosphorus metabolism, hypophosphatemia and osteomalacia secondary to chronic renal excretion of phosphate. Clinical manifestations include hypophosphatemic rickets leading to growth abnormalities and osteomalacia, myopathy, bone pain and dental abscesses. The transition of these patients to adult life continues to pose challenges to health systems, medical practitioners, patients and families. For this reason, the aim of this consensus is to provide a set of recommendations to facilitate this process and ensure adequate management and follow-up, as well as the quality of life for patients with X-linked hypophosphatemia as they transition to adult life.

MATERIALS AND METHODS

Eight Latin American experts on the subject participated in the consensus and two of them were appointed as coordinators. The consensus work was done in accordance with the nominal group technique in 6 phases: (1) question standardization, (2) definition of the maximum number of choices, (3) production of individual solutions or answers, (4) individual question review, (5) analysis and synthesis of the information and (6) synchronic meetings for clarification and voting. An agreement was determined to exist with 80% votes in favor in three voting cycles.

RESULTS AND DISCUSSION

Transition to adult life in patients with hypophosphatemia is a complex process that requires a comprehensive approach, taking into consideration medical interventions and associated care, but also the psychosocial components of adult life and the participation of multiple stakeholders to ensure a successful process. The consensus proposes a total of 33 recommendations based on the evidence and the knowledge and experience of the experts. The goal of the recommendations is to optimize the management of these patients during their transition to adulthood, bearing in mind the need for multidisciplinary management, as well as the most relevant medical and psychosocial factors in the region.

Hipopara-Red, Real Life Experience in 322 Patients With Hypoparathyroidism

Context

Hypoparathyroidism is a rare disease and, as such, its natural history, long-term complications, and correct clinical management remain unclear.

Objective

To describe the natural history and clinical characteristics of the disease.

Design and Setting

To present a retrospective observational analysis from 7 specialized centers in Buenos Aires, Argentina.

Patients

Chronic hypoparathyroid patients followed-up between 1985 and December 2018.

Main Outcome Measures

Data on demographics, etiology, clinical complications, biochemical parameters, dual-energy x-ray absorptiometry (DXA) values, and treatment doses were collected.

Results

A total of 322 subjects with chronic hypoparathyroidism were included; 85.7% were female, the mean age was 55.2 ± 16.8 years, and the mean age at diagnosis was 43.8 ± 16.8 years. Prevalence of surgical hypoparathyroidism was 90.7%, with the most common causes being thyroid carcinoma and benign thyroid disease. A history of hypocalcemia requiring hospitalization was present in 25.7% of the whole group and in 4.3% of patients who had a history of seizures. Overall, 40.9% of our patients had reported at least 1 neuromuscular symptom. Renal insufficiency was present in 22.4% of our patients and was significantly associated with age (P < 0.0001). Hyperphosphatemia was present in 42% of patients. A history of severe hypocalcemia, paresthesias, tetany, ganglia calcifications, seizures, and cataracts was significantly higher in nonsurgical patients.

Conclusion

Although these patients were followed-up by experienced physicians, clinical management was heterogeneous and probably insufficient to assess all the potential complications of this chronic disease. Almost 70% of the study’s group of patients met the experts’ indications for considering the use of rhPTH 1–84. Being aware of this fact is the 1^st step in improving our medical management of this disease in the future.

MON-LB090 Red-Hipopara, Real Life Experience in 322 Patients with Hypoparathyroidism in Argentina

Hypoparathyroidism (HPT) is a rare disorder characterized by hypocalcemia and absent or deficient PTH. Few data are available on the natural history and correct management of this disease. Aim: Describe clinical characteristics, treatment, and complications in a group of patients with hypoparathyroidism from 6 referral centers for endocrinological diseases. Secondary, describe how many patients reached guidelines recommendations for rhPTH (1-84) treatment (Brandi ML. JCEM. 2016). M & M: In this retrospective study patients with a diagnosis of HPT of ≥6 months were eligible for inclusion. Patients with pseudohypoparathyroidism were excluded. Demographics, etiology, management, hospitalizations, clinical manifestations and biochemical and DXA values were collected.Results:322 HPT patients were included; mean age was 55.2 ± 16.8 years, 85,7% were women. Mean ageat diagnosis was 43.8 ± 16.8 years and mean follow up time was 4.9 ± 5.1 years. Regarding etiology 90%were post-surgical (50.3% for thyroid cancer, 41% for multinodular goiter, 2.7% primary hyperparathyroidism;3.4% secondary hyperparathyroidism and 2.3% cervical cancer). Non-surgical etiology included: 5 DiGeorge Syndrome, 9 autoimmune and 16 idiopathic. Non-surgical patients were significantly younger (45 ± 19.5 vs.56.3 ± 16.1 years; p<0.01) and were younger at diagnosis (45.1 ± 15.9 vs. 31.4 ± 20.5 years;p<0.01).Treatment regimens were determined by the patients’ physician, per usual clinical practice, and most patients were receiving calcium supplementation (mean daily dose:2019 ± 1426 mg), vitamin D ( mean weekly dose 34.368 ± 55.278 UI) and calcitriol ( mean daily dose: 0.498 ± 0.279 mcg). 13 patients were receiving teriparatide ( 1-34 human parathyroid hormone). 25.7% had a history of hypocalcemia requiring hospitalization, 4.6% had fragility fracture history (wrist, hip, humerus, vertebra or tibia) and 4.3% has a history of seizures. Only 41.9% had a renal ultrasound done and 15.5 % had positive findings ( kidney stones and nephrocalcinosis). 54% had 24-hour urine calcium excretion measured and almost half of them had hypercalciuria confirmed (56.3%). Only 18,3% patients had central nervous system imaging performed,and 38.9% had basal ganglia calcification. Finally, 38.8% met criteria to rhPTH (1-84) treatment according to the guideline; most of them because their daily oral calcium requirements exceeded 2.5 g of calcium. Conclusion: Although these patients were followed by experienced physicians, clinical management and monitoring was heterogeneous and probably insufficient to assess all the potential complications of this chronic disease. Being aware of this situation is the first step to improve our medical management of HPT in the future Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

[Recommendations of the Infectious Diseases Work Group (GTEI) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Infections in Critically Ill Patients Study Group (GEIPC) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) for the diagnosis and treatment of influenza A/H1N1 in seriously ill adults admitted to the Intensive Care Unit]

The diagnosis of influenza A/H1N1 is mainly clinical, particularly during peak or seasonal flu outbreaks. A diagnostic test should be performed in all patients with fever and flu symptoms that require hospitalization. The respiratory sample (nasal or pharyngeal exudate or deeper sample in intubated patients) should be obtained as soon as possible, with the immediate start of empirical antiviral treatment. Molecular methods based on nucleic acid amplification techniques (RT-PCR) are the gold standard for the diagnosis of influenza A/H1N1. Immunochromatographic methods have low sensitivity; a negative result therefore does not rule out active infection. Classical culture is slow and has low sensitivity. Direct immunofluorescence offers a sensitivity of 90%, but requires a sample of high quality. Indirect methods for detecting antibodies are only of epidemiological interest. Patients with A/H1N1 flu may have relative leukopenia and elevated serum levels of LDH, CPK and CRP, but none of these variables are independently associated to the prognosis. However, plasma LDH> 1500 IU/L, and the presence of thrombocytopenia <150 x 10(9)/L, could define a patient population at risk of suffering serious complications. Antiviral administration (oseltamivir) should start early (<48 h from the onset of symptoms), with a dose of 75 mg every 12h, and with a duration of at least 7 days or until clinical improvement is observed. Early antiviral administration is associated to improved survival in critically ill patients. New antiviral drugs, especially those formulated for intravenous administration, may be the best choice in future epidemics. Patients with a high suspicion of influenza A/H1N1 infection must continue with antiviral treatment, regardless of the negative results of initial tests, unless an alternative diagnosis can be established or clinical criteria suggest a low probability of influenza. In patients with influenza A/H1N1 pneumonia, empirical antibiotic therapy should be provided due to the possibility of bacterial coinfection. A beta-lactam plus a macrolide should be administered as soon as possible. The microbiological findings and clinical or laboratory test variables may decide withdrawal or not of antibiotic treatment. Pneumococcal vaccination is recommended as a preventive measure in the population at risk of suffering severe complications. Although the use of moderate- or low-dose corticosteroids has been proposed for the treatment of influenza A/H1N1 pneumonia, the existing scientific evidence is not sufficient to recommend the use of corticosteroids in these patients. The treatment of acute respiratory distress syndrome in patients with influenza A/H1N1 must be based on the use of a protective ventilatory strategy (tidal volume <10 ml / kg and plateau pressure <35 mmHg) and positive end-expiratory pressure set to high patient lung mechanics, combined with the use of prone ventilation, muscle relaxation and recruitment maneuvers. Noninvasive mechanical ventilation cannot be considered a technique of choice in patients with acute respiratory distress syndrome, though it may be useful in experienced centers and in cases of respiratory failure associated with chronic obstructive pulmonary disease exacerbation or heart failure. Extracorporeal membrane oxygenation is a rescue technique in refractory acute respiratory distress syndrome due to influenza A/H1N1 infection. The scientific evidence is weak, however, and extracorporeal membrane oxygenation is not the technique of choice. Extracorporeal membrane oxygenation will be advisable if all other options have failed to improve oxygenation. The centralization of extracorporeal membrane oxygenation in referral hospitals is recommended. Clinical findings show 50-60% survival rates in patients treated with this technique. Cardiovascular complications of influenza A/H1N1 are common. Such problems may appear due to the deterioration of pre-existing cardiomyopathy, myocarditis, ischemic heart disease and right ventricular dysfunction. Early diagnosis and adequate monitoring allow the start of effective treatment, and in severe cases help decide the use of circulatory support systems. Influenza vaccination is recommended for all patients at risk. This indication in turn could be extended to all subjects over 6 months of age, unless contraindicated. Children should receive two doses (one per month). Immunocompromised patients and the population at risk should receive one dose and another dose annually. The frequency of adverse effects of the vaccine against A/H1N1 flu is similar to that of seasonal flu. Chemoprophylaxis must always be considered a supplement to vaccination, and is indicated in people at high risk of complications, as well in healthcare personnel who have been exposed.