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Amjad W, Ginzberg SP, Passman JE, Heintz J, Kelz RR, Wachtel H. Predictive Risk Score for Postparathyroidectomy Hungry Bone Syndrome in Patients With Secondary Hyperparathyroidism. J Clin Endocrinol Metab 2024; 109:603-610. [PMID: 37897423 DOI: 10.1210/clinem/dgad636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/03/2023] [Accepted: 10/25/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE Secondary hyperparathyroidism (SHPT) frequently affects patients with end-stage renal disease. Hungry bone syndrome (HBS) is a common complication among patients who undergo parathyroidectomy for SHPT and may cause prolonged hospitalization or require intensive care. The objective of this study is to develop a scoring system to stratify patients according to their risk of developing HBS. METHODS A retrospective cohort study was performed using the US Renal Data System (2010-2021). Univariable and multivariable logistic regression models were developed and weighted β-coefficients from the multivariable model were used to construct a risk score for the development of HBS. Positive and negative predictive values were assessed. RESULTS Of 17 074 patients who underwent parathyroidectomy for SHPT, 19.4% developed HBS. Intensive care unit admission was more common in patients who developed HBS (33.5% vs 24.6%, P < .001). On multivariable logistic regression analysis, younger age, renal osteodystrophy, longer duration of dialysis, longer duration of kidney transplant, and higher Elixhauser score were significantly associated with HBS. A risk score based on these clinical factors was developed, with a total of 6 possible points. Rates of HBS ranged from 8% in patients with 0 points to 44% in patients with 6 points. The risk score had a poor positive predictive value (20.3%) but excellent negative predictive value (89.3%) for HBS. CONCLUSION We developed a weighted risk score that effectively stratifies patients by risk for developing HBS after parathyroidectomy. This tool can be used to counsel patients and to identify patients who may not require postoperative hospitalization.
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Affiliation(s)
- Wajid Amjad
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Sara P Ginzberg
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Jesse E Passman
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Jonathan Heintz
- Biostatistics Analysis Center, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Rachel R Kelz
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Heather Wachtel
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Udyavar NR, Ahn J, Crepeau P, Morris-Wiseman LF, Thompson V, Chen Y, Segev DL, McAdams-DeMarco M, Mathur A. Black patients are more likely to undergo parathyroidectomy for secondary hyperparathyroidism. Surgery 2023; 173:111-116. [PMID: 36195501 PMCID: PMC10443691 DOI: 10.1016/j.surg.2022.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/22/2022] [Accepted: 05/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Prior studies have demonstrated racial disparities in the severity of secondary hyperparathyroidism among dialysis patients. Our primary objective was to study the racial and socioeconomic differences in the timing and likelihood of parathyroidectomy in patients with secondary hyperparathyroidism. METHODS We used the United States Renal Data System to identify 634,428 adult (age ≥18) patients who were on maintenance dialysis between 2006 and 2016 with Medicare as their primary payor. Adjusted multivariable Cox regression was performed to quantify the differences in parathyroidectomy by race. RESULTS Of this cohort, 27.3% (173,267) were of Black race. Compared to 15.4% of White patients, 23.1% of Black patients lived in a neighborhood that was below a predefined poverty level (P < .001). The cumulative incidence of parathyroidectomy at 10 years after dialysis initiation was 8.8% among Black patients compared to 4.3% among White patients (P < .001). On univariable analysis, Black patients were more likely to undergo parathyroidectomy (adjusted hazard ratio = 1.83; 95% confidence interval, 1.74-1.93). This association persisted after adjusting for age, sex, cause of end-stage renal disease, body mass index, comorbidities, dialysis modality, and poverty level (adjusted hazard ratio = 1.35; 95% confidence interval, 1.27-1.43). Therefore, patient characteristics and socioeconomic status explained 26% of the association between race and likelihood of parathyroidectomy. CONCLUSION Black patients with secondary hyperparathyroidism due to end-stage renal disease are more likely to undergo parathyroidectomy with shorter intervals between dialysis initiation and parathyroidectomy. This association is only partially explained by patient characteristics and socioeconomic factors.
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Affiliation(s)
- N Rhea Udyavar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - JiYoon Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Philip Crepeau
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Valerie Thompson
- Department of Surgery, New York University, Grossman School of Medicine and Langone Health, New York, NY
| | - Yusi Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, New York University, Grossman School of Medicine and Langone Health, New York, NY
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University, Grossman School of Medicine and Langone Health, New York, NY
| | - Aarti Mathur
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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[Evolution of the incidence and results at 12 months of parathyroidectomy: 40 years of experience in a dialysis center with two successive surgical departments]. Nephrol Ther 2022; 18:616-626. [PMID: 36328900 DOI: 10.1016/j.nephro.2022.07.400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 05/18/2022] [Accepted: 07/19/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Secondary hyperparathyroidism remains the main complication of mineral and bone metabolism in patients with chronic kidney disease. In case of resistance to medical treatment (native and active vitamin D, calcium and calcimimetics), surgical parathyroidectomy is indicated. The aim of this retrospective study is to show the evolution of the incidence and results of surgical parathyroidectomy in our center between 1980 and 2020 as patient characteristics, diagnostic and therapeutic strategies have changed. PATIENTS AND METHODS We collected data from dialysis patients who had a first surgical parathyroidectomy between 2000 and 2020 (period 2) in the same surgical department and compared them with historical data between 1980 and 1999 (period 1) operated in one other center. RESULTS In period 1, 53 surgical parathyroidectomy were performed (2.78/year, 0 to 5, 8.5/1000 patients-year) vs.56 surgical parathyroidectomy in period 2 (2.8/year, 0 to 9, 8/1000 patients-year). The patients of the 2 periods were comparable except for the higher dialysis vintage in period 1 (149±170 vs.89±94 months; P=0.02). In comparison with dialysis patients not requiring surgical parathyroidectomy during the same period, patients who had surgical parathyroidectomy were younger, had higher dialysis vintage and lower diabetes prevalence, but more frequently carriers of glomerulopathy or polycystosis. Systematically performed in period 2, cervical ultrasound identified at least one visible gland in 78.6% of cases while the scintigraphy, performed only in 66% of cases, found at least one gland in 81% of cases. Twelve months after surgery, PTH > 300 pg/mL (marker of secondary hyperparathyroidism recurrence or surgery failure) was present in 30% of patients in period 1 vs. 5.3% in period 2. Hypoparathyroidism was also more frequently observed in period 2 (35.7 vs. 18.8%). Surgical complications were also higher in period 1. CONCLUSION Despite therapeutic and strategic advances, severe secondary hyperparathyroidism is still as common as ever. It is favored by excessively high PTH targets, by suboptimal prevention before dialysis and poor tolerance of calcimimetics. The surgical parathyroidectomy is effective and safe in the hands of a specialized team with an ultrasound and scintigraphic preoperative assessment.
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Parathyroidectomy Versus Cinacalcet for the Treatment of Secondary Hyperparathyroidism in Hemodialysis Patients. World J Surg 2022; 46:813-819. [PMID: 35022799 PMCID: PMC8885484 DOI: 10.1007/s00268-022-06439-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2021] [Indexed: 11/30/2022]
Abstract
Background Secondary hyperparathyroidism in patients with end stage renal disease on dialysis is associated with bone pain and fractures in addition to cardiovascular morbidity. Cinacalcet is the most commonly used drug to treat such patients, but it has never been compared to surgery. The goal of this study is to compare the long-term outcomes and survival between cinacalcet and parathyroidectomy in the treatment of secondary hyperparathyroidism in hemodialysis patients. Methods Adult patients on hemodialysis who were treated with cinacalcet or parathyroidectomy in the United States Renal Data System were included. Patients treated with surgery (n = 2023) were compared using 1:1 propensity score matching ratio to a cohort of patients treated with cinacalcet. A Cox regression analysis was conducted to compare the overall mortality. Results The propensity score matching successfully created two groups with similar demographics. Patients in the surgery group had a higher mean peak PTH level prior to therapy (2066.8 vs 1425.4, P < 0.001). No difference was observed in the development of new-onset coronary artery disease (7.7% vs 7.9%, P = 0.8) or cerebrovascular disease (7% vs 6.7%, P = 0.8). Surgical patients had a higher rate of pathologic fractures (27.8% vs 24.9%, P = 0.04). Survival analysis showed that patients undergoing surgery had a better 5-year survival (65.6% vs 57.8%) and were less likely to die within the study period (HR 0.77, 95% CI 0.7–0.85, P < 0.0001). Conclusions Patients on dialysis undergoing parathyroidectomy for the treatment of secondary hyperparathyroidism have a better overall survival than those treated with cinacalcet.
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Clinical and Economical Outcomes Associated with Parathyroidectomy: A 5-Year Population-Based Study in a Middle-Income Country with Universal Health Coverage. Int J Nephrol 2020; 2020:7250250. [PMID: 32411463 PMCID: PMC7204171 DOI: 10.1155/2020/7250250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 01/04/2020] [Accepted: 01/07/2020] [Indexed: 11/18/2022] Open
Abstract
Parathyroidectomy (PTX) is one of the most frequently performed surgeries in chronic kidney disease (CKD) patients. The objective of this study was to determine the intensive care unit (ICU) admission, mortality and hospital readmission rates within the 30-day postoperative period, and the total cost of the care episode and to determine possible prognostic factors in end-stage renal disease (ESRD) adult patients taken to PTX in the Colombian contributory health system. Methods. Retrospective cohort study of ESRD adult patients affiliated to the Colombian contributory health system, on dialysis for at least 3 months, undergoing PTX between January 1, 2012, and November 30, 2016. The clinical outcomes evaluated were rehospitalization at 30 days, hospital stay, and ICU requirement. The costs associated with the hospitalization event in which the PTX was performed from the perspective of the third payer were estimated. Results. The study included 478 patients. The mortality rate was 2.09 per 100 surgeries, the ICU admission rate was 32.64 per 100 surgeries, the 30-day hospital readmission percentage of the postoperative period was 16.74%, and the average length of hospital stay was 5.02 days. The median total costs of care for the entire procedure was USD $ 7,814.27 (p25-p75: 3,922.03-9,372.68), with significant regional differences. The geographical region was shown as a prognostic factor associated with clinical outcomes and the cost of care. Conclusions. There are large regional differences in readmission, ICU admission and mortality rates, and costs of dialysis ESRD patients undergoing PTX belonging to the Colombian contributory regime. The geographic region behaves as an independent predictor of clinical outcomes and costs.
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Zou BS, Liu JS, Li H, Xu Z, Li H, Li HY, Wu KN, Kong LQ. Clinical study on the status of transient thyrotoxicosis after surgery for secondary hyperparathyroidism patients with end-stage renal disease and normal thyroid function. Eur J Med Res 2020; 25:7. [PMID: 32183885 PMCID: PMC7079515 DOI: 10.1186/s40001-020-00405-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 02/18/2020] [Indexed: 11/28/2022] Open
Abstract
Objective Secondary hyperparathyroidism (SHPT) is a common complication of end-stage renal disease (ESRD), and part of SHPT patients need receive parathyroidectomy (PTX). However, as an important postoperative complication of SHPT, thyrotoxicosis has received little attention. Therefore, in this article, we aimed to study the status of transient thyrotoxicosis after PTX for SHPT patients with ESRD and normal thyroid function. Methods A total of 24 SHPT patients with preoperative normal thyroid function, normal thyroglobulin (Tg) and normal thyroid antibodies receiving PTX were enrolled from the Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, from January 2017 to January 2019. Tg, high sensitivity thyrotropin stimulating hormone (sTSH), triiodothyronine (T3), free triiodothyronine (fT3), thyroxine (T4) and free thyroxine (fT4) were evaluated the day before PTX and on day 1, 3 and 5 after PTX. Besides, all enrolled patients were evaluated whether there are symptoms associated with thyrotoxicosis. Results Among the 24 SHPT patients, 1 case (4.2%), 8 cases (33.3%) and 13 cases (54.2%) had suffered thyrotoxicosis at the first, third and fifth day after surgery, respectively. Serum FT4 level increased significantly from pre-operation (0.68 ± 0.15 ng/dl, normal range 0.59–1.25 ng/dl) to the third day after operation (1.91 ± 0.97 ng/dl, p<0.001) and then gradually decline. The frequencies of serum sTSH lower than the normal level gradually increased from the first day (8.3%) to fifth day (66.7%) after surgery. Conclusion Transient thyrotoxicosis is a common postoperative complication of parathyroidectomy for SHPT patients with ESRD and normal thyroid function, and it is necessary for clinicians to evaluate the perioperative thyroid function to make early diagnosis and appropriate prevention and treatment of thyrotoxicosis.
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Affiliation(s)
- Bao-Shan Zou
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 You Yi Rd, Chongqing, 400016, China
| | - Jia-Shuo Liu
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 You Yi Rd, Chongqing, 400016, China
| | - Hong Li
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 You Yi Rd, Chongqing, 400016, China
| | - Zhou Xu
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 You Yi Rd, Chongqing, 400016, China
| | - Hao Li
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 You Yi Rd, Chongqing, 400016, China
| | - Hong-Yuan Li
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 You Yi Rd, Chongqing, 400016, China
| | - Kai-Nan Wu
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 You Yi Rd, Chongqing, 400016, China
| | - Ling-Quan Kong
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 You Yi Rd, Chongqing, 400016, China.
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Bures C, Skachko T, Dobrindt EM, Pratschke J, Uluk D, Mogl MT. Is There a Gender Difference in Clinical Presentation of Renal Hyperparathyroidism and Outcome after Parathyroidectomy? Visc Med 2020; 36:34-40. [PMID: 32110655 DOI: 10.1159/000505501] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/17/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction Gender has been proven to influence the pathophysiology and treatment of numerous diseases, including kidney diseases and hormonal dysfunction like hyperparathyroidism. Thus, higher parathormone levels have been demonstrated in women with end-stage kidney disease, when compared to men. Objectives We questioned whether female gender is associated with an increased risk for parathyroid nodular hyperplasia and necessary parathyroidectomy in dialysis patients and assessed demographics as well as outcome data for women and men undergoing parathyroidectomy for renal hyperparathyroidism. Patients and Methods One hundred and thirty patients (men = 75, female = 55) with end-stage renal disease on chronic dialysis and advanced secondary hyperparathyroidism who underwent parathyroidectomy between 2008 and 2014 at our center were analyzed retrospectively. Perioperative characteristics and short-term outcome were evaluated with respect to biological gender. Results No differences could be demonstrated for patient demography, comorbidities and the perioperative course between males and females. Only preoperative calcium levels were lower in female than in male patients (2.3 ± 0.19 vs. 2.3 ± 0.26, p = 0.04). There were more women, however, with cerebrovascular complications during follow-up (p = 0.04). There was no postoperative mortality, and all complications and comorbidities with exception of cerebrovascular diseases were equally distributed between female and male patients. Conclusion Overall, we could not demonstrate many significant differences between male and female patients with end-stage renal diseases, chronic dialysis and operated secondary hyperparathyroidism. Only preoperative electrolyte levels were higher in male than in female patients, and cerebrovascular complications developed more often in females than in males during long-term follow-up.
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Affiliation(s)
- Claudia Bures
- Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Tatjana Skachko
- Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Eva M Dobrindt
- Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Deniz Uluk
- Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martina T Mogl
- Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Chu TP, Yang PS, Lee JJ, Wu CJ, Cheng SP. Increasing Age Hinders the Decline in B-Type Natriuretic Peptide Following Parathyroidectomy in Dialysis Patients. In Vivo 2019; 33:1691-1696. [PMID: 31471425 DOI: 10.21873/invivo.11657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND/AIM Parathyroidectomy has beneficial effects on all-cause and cardiovascular mortality in patients with uncontrolled hyperparathyroidism. B-Type natriuretic peptide (BNP) correlates with the severity of heart failure. We aimed to investigate whether parathyroidectomy modulates the BNP levels in dialysis patients. PATIENTS AND METHODS Patients who underwent surgical intervention for hyperparathyroidism were included. The serum BNP levels were determined before parathyroidectomy and during follow-up. RESULTS The preoperative and postoperative BNP levels were 499±561 and 453±442 pg/ml, respectively (p=0.82). The baseline BNP level was positively correlated with weakness and headache, but not biochemical parameters. In multivariate analysis, age (odds ratio=0.837) and preoperative symptom score (odds ratio=0.935) were independent predictors for the postoperative decline in BNP levels Conclusion: The serum BNP levels may increase or decrease after parathyroidectomy. Younger age and lower symptom burden are associated with decline in BNP levels.
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Affiliation(s)
- Tun-Pang Chu
- Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan, R.O.C
| | - Po-Sheng Yang
- Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan, R.O.C
| | - Jie-Jen Lee
- Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan, R.O.C
| | - Chih-Jen Wu
- Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan, R.O.C.,Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, R.O.C
| | - Shih-Ping Cheng
- Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan, R.O.C. .,Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, R.O.C
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Cardiovascular and Cerebrovascular Events After Parathyroidectomy in Patients on Renal Replacement Therapy. World J Surg 2019; 43:1981-1988. [PMID: 31087130 DOI: 10.1007/s00268-019-05020-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND A majority of patients with end-stage renal disease suffer from secondary hyperparathyroidism, which is associated with osteoporosis and cardiovascular disease. Parathyroidectomy (PTX) is often necessary despite medical treatment. However, the effect of PTX on cardio- and cerebrovascular events (CVE) remains unclear. Data on the effect of PTX from population-based studies are scarce. Some studies have shown decreased incidence of CVE after PTX. The aim of this study was to evaluate the effect of PTX on risk of CVE in patients on renal replacement therapy. METHODS We performed a nested case-control study within the Swedish Renal Registry (SRR) by matching PTX patients on dialysis or with functioning renal allograft with up to five non-PTX controls for age, sex and underlying renal disease. To calculate time to CVE, i.e., myocardial infarct, stroke and transient ischemic attack, control patients were assigned the calendar date (d) of the PTX of the case patient. Crude and adjusted proportional hazards regressions with random effect (frailty) were used to calculate hazard ratios for CVE. RESULTS The study cohort included 20,056 patients in the SRR between 1991 and 2009. Among these, 579 patients had undergone PTX, 423 during dialysis and 156 during time with functioning renal allograft. These patients were matched with 1234 dialysis and 736 transplanted non-PTX patients. The adjusted hazard ratio (HR) with 95% confidence interval (CI) of CVE after PTX was 1.24 (1.03-1.49) for dialysis patients compared with non-PTX patients. Corresponding results for patients with renal allograft at d were HR (95% CI) 0.53 (0.34-0.84). CONCLUSIONS PTX patients on dialysis at d had a higher risk of CVE than patients without PTX. Patients with renal allograft at d on the other had a lower risk after PTX than patients without PTX.
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Kakani E, Sloan D, Sawaya BP, El-Husseini A, Malluche HH, Rao M. Long-term outcomes and management considerations after parathyroidectomy in the dialysis patient. Semin Dial 2019; 32:541-552. [PMID: 31313380 DOI: 10.1111/sdi.12833] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Parathyroidectomy (PTX) remains an important intervention for dialysis patients with poorly controlled secondary hyperparathyroidism (SHPT), though there are only retrospective and observational data that show a mortality benefit to this procedure. Potential consequences that we seek to avoid after PTX include persistent or recurrent hyperparathyroidism, and parathyroid insufficiency. There is considerable subjectivity in defining and diagnosing these conditions, given that we poorly understand the optimal PTH targets (particularly post PTX) needed to maintain bone and vascular health. While lowering PTH after PTX decreases bone turnover, long-term changes in bone activity have been poorly explored. High turnover bone disease, usually present at the time a PTX is considered, often swings to a state of low turnover in the setting of sufficiently low PTH levels. It remains unclear if all low bone turnover equate with disease. However, such changes in bone turnover appear to predispose to vascular calcification, with positive calcium balance after PTX being a potential contributor. We know little of how the post-PTX state resets calcium balance, how calcium and VDRA requirements change or what kind of adjustments are needed to avoid calcium loading. The current consensus cautions against excessive reduction of PTH although there is insufficient evidence-based guidance regarding the management of chronic kidney disease - mineral bone disease (CKD-MBD) parameters in the post-PTX state. This article aims to compile existing research, provide an overview of current practice with regard to PTX and post-PTX chronic management. It highlights gaps and controversies and aims to re-orient the focus to clinically relevant contemporary priorities in CKD-MBD management after PTX.
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Affiliation(s)
- Elijah Kakani
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - David Sloan
- Division of Endocrine Surgery, University of Kentucky, Lexington, KY, USA
| | - B Peter Sawaya
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Hartmut H Malluche
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Madhumathi Rao
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
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Nyssen L, Fillet M, Cavalier E, Servais A. Highly sensitive and selective separation of intact parathyroid hormone and variants by sheathless CE‐ESI‐MS/MS. Electrophoresis 2019; 40:1550-1557. [DOI: 10.1002/elps.201800507] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/28/2019] [Accepted: 02/22/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Laurent Nyssen
- Department of Clinical ChemistryCenter for Interdisciplinary Research on Medicines (CIRM)University of Liège Liège Belgium
- Laboratory for the Analysis of Medicines (LAM)Center for Interdisciplinary Research on Medicines (CIRM)University of Liège Liège Belgium
| | - Marianne Fillet
- Laboratory for the Analysis of Medicines (LAM)Center for Interdisciplinary Research on Medicines (CIRM)University of Liège Liège Belgium
| | - Etienne Cavalier
- Department of Clinical ChemistryCenter for Interdisciplinary Research on Medicines (CIRM)University of Liège Liège Belgium
| | - Anne‐Catherine Servais
- Laboratory for the Analysis of Medicines (LAM)Center for Interdisciplinary Research on Medicines (CIRM)University of Liège Liège Belgium
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Naylor KL, Kim SJ, McArthur E, Garg AX, McCallum MK, Knoll GA. Mortality in Incident Maintenance Dialysis Patients Versus Incident Solid Organ Cancer Patients: A Population-Based Cohort. Am J Kidney Dis 2019; 73:765-776. [PMID: 30738630 DOI: 10.1053/j.ajkd.2018.12.011] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 12/03/2018] [Indexed: 12/30/2022]
Abstract
RATIONALE & OBJECTIVE The mortality rate is high among dialysis patients, but how this compares with other diseases such as cancer is poorly understood. We compared the survival of maintenance dialysis patients with that for patients with common cancers to enhance the understanding of the burden of end-stage kidney disease. STUDY DESIGN Population-based cohort study. SETTING & PARTICIPANTS 33,500 incident maintenance dialysis patients in Ontario, Canada, and 532,452 incident patients with cancer (women: breast, colorectal, lung, or pancreas; men: prostate, colorectal, lung, or pancreas) from 1997 to 2015 using administrative health care databases. EXPOSURE Incident kidney failure treated with maintenance dialysis versus incident diagnoses of cancer. OUTCOME All-cause mortality. ANALYTICAL APPROACH Kaplan-Meier product limit estimator was used to describe the survival of subgroups of study participants. Extended Cox regression with a Heaviside function was used to compare survival between patients with incident kidney failure treated with maintenance dialysis and individual diagnoses of various incident cancers. RESULTS In men, dialysis had worse unadjusted 5-year survival (50.8%; 95% CI, 50.1%-51.6%) compared with prostate (83.3%; 95% CI, 83.1%-83.5%) and colorectal (56.1%; 95% CI, 55.7%-56.5%) cancer, but better survival than lung (14.0%; 95% CI, 13.7%-14.3%) and pancreas (9.1%; 95% CI, 8.5%-9.7%) cancer. In women, dialysis had worse unadjusted 5-year survival (49.8%; 95% CI, 48.9%-50.7%) compared with breast (82.1%; 95% CI, 81.9%-82.4%) and colorectal (56.8%; 95% CI, 56.3%-57.2%) cancer, but better survival than lung (19.7%; 95% CI, 19.4%-20.1%) and pancreas (9.4%; 95% CI, 8.9%-10.0%) cancer. After adjusting for clinical characteristics, similar results were found except when examining men and women with lung and pancreas cancer, for which dialysis patients had a higher rate of death 4 or more years after diagnosis. Women and men 70 years and older with incident kidney failure treated with maintenance dialysis had unadjusted 10-year survival probabilities that were comparable to pancreas and lung cancer. LIMITATIONS Cancer stage could be obtained for only a subpopulation. CONCLUSIONS Survival in incident dialysis patients was lower than in patients with several different solid-organ cancers. These results highlight the need to develop interventions to improve survival on dialysis therapy and can be used to aid advance care planning for elderly patients beginning treatment with maintenance dialysis.
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Affiliation(s)
- Kyla L Naylor
- ICES, London, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - S Joseph Kim
- ICES, London, Ontario, Canada; Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Amit X Garg
- ICES, London, Ontario, Canada; Division of Nephrology, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | | | - Gregory A Knoll
- Division of Nephrology, Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada; Kidney Research Centre and Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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13
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Chou FF, Chen JB, Huang SC, Chan YC, Chi SY, Chen WT. Changes in serum FGF23 and Klotho levels and calcification scores of the abdominal aorta after parathyroidectomy for secondary hyperparathyroidism. Am J Surg 2018; 218:609-612. [PMID: 30594298 DOI: 10.1016/j.amjsurg.2018.12.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Changes of calcification scores of the abdominal aorta (CSAA) after total parathyroidectomy plus autotransplantation (TPX + AT) for symptomatic secondary hyperparathyroidism (SSHP) have never been reported. METHODS Forty-nine patients who successfully underwent TPX + AT for SSHP were enrolled; 13 patients who had regular hemodialysis were enrolled as controls. Preoperatively, patients' age, gender, and duration of dialysis were recorded. Serum Ca, P, alkaline phosphatase (Alk-ptase), intact parathyroid hormone (iPTH), vitamin D, FGF23, and Klotho levels, and CSAA were measured. One year postoperatively, these data were measured again. In the control group, these data were recorded and measured before and one year later. RESULTS Serum iPTH, Alk-ptase and FGF23 levels and CSAA of the study group were significantly higher than those of the control group. One year postoperatively, serum Ca, P, Alk-ptase, iPTH, and FGF23 levels and CSAA were significantly lower than those before surgery. Except for FGF23 levels, other items of the control group did not change significantly one year later, whereas the study group decreased CSAA more than the control group. CONCLUSION One year postoperatively, CSAA decreased.
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Affiliation(s)
- Fong-Fu Chou
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, 123, Ta pei Rd, Niao Sung District, Kaohsiung City, Taiwan
| | - Jin-Bor Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, 123, Ta pei Rd, Niao Sung District, Kaohsiung City, Taiwan
| | - Shun-Cheng Huang
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, 123, Ta pei Rd, Niao Sung District, Kaohsiung City, Taiwan
| | - Yi-Chai Chan
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, 123, Ta pei Rd, Niao Sung District, Kaohsiung City, Taiwan
| | - Shun-Yu Chi
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, 123, Ta pei Rd, Niao Sung District, Kaohsiung City, Taiwan.
| | - Wei-Ting Chen
- Department of Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, 123, Ta pei Rd, Niao Sung District, Kaohsiung City, Taiwan
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14
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Ferreira D, Vilayur E, Gao M, Sankoorikal C, Bendinelli C. Calcitriol loading before total parathyroidectomy with autotransplant in patients with end-stage kidney disease: does it prevent postoperative hypocalcaemia? Intern Med J 2018; 49:886-893. [PMID: 30552793 DOI: 10.1111/imj.14209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 11/16/2018] [Accepted: 12/12/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hungry bone syndrome (HBS) is one of the most serious complications following parathyroidectomy for severe hyperparathyroidism. There is a lack of literature informing the treatment and risk factors for this condition and the ideal pre-operative strategy for prevention. AIMS The primary aims were to examine the incidence of HBS with pre-operative calcitriol loading for 10 days and to determine the risk factors for HBS. The secondary aims were to determine the rate of intravenous calcium replacement in those with HBS and to assess whether cinacalcet removal has increased rates of parathyroidectomy in the end-stage kidney disease population. METHODS We performed a retrospective study from 2011 to 2018 on 45 patients with end-stage kidney disease undergoing total parathyroidectomy with autotransplantation for severe hyperparathyroidism. This was based at the John Hunter and Newcastle Private Hospitals in New South Wales. RESULTS 28.3% of patients with calcitriol loading undergoing parathyroidectomy fulfilled criteria for HBS. Pre-operative variables that were associated with HBS were elevated parathyroid hormone (P = 0.028) and longer duration of renal replacement therapy (P = 0.033). Rates of total parathyroidectomy were higher after the removal of calcimimetics from the Pharmaceutical Benefits Scheme (P = 0.0024). CONCLUSIONS HBS remains a common complication of parathyroidectomy, even with prolonged high-dose calcitriol loading. This emphasises the need for further trials investigating other targeted therapies, such as bisphosphonates, to prevent HBS. Those most at risk of HBS are patients with high bone turnover and prolonged renal replacement therapy.
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Affiliation(s)
- David Ferreira
- Department of Nephrology, Medical and Interventional Services, John Hunter Hospital, School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Eswari Vilayur
- School of Epidemiology and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Michael Gao
- Department of Nephrology, Medical and Interventional Services, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Christy Sankoorikal
- Endocrinology Department, Medical and Interventional Services, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Cino Bendinelli
- Endocrine and General Surgery, Department of Surgery, John Hunter Hospital and Newcastle Private Hospital, Newcastle, New South Wales, Australia
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15
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Preoperative calcitriol reduces postoperative intravenous calcium requirements and length of stay in parathyroidectomy for renal-origin hyperparathyroidism. Surgery 2018; 165:151-157. [PMID: 30413326 DOI: 10.1016/j.surg.2018.03.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/21/2018] [Accepted: 03/29/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patients undergoing subtotal parathyroidectomy for renal-origin hyperparathyroidism often develop postoperative hypocalcemia, requiring calcitriol and intravenous calcium (Postop-IVCa). We hypothesized that in subtotal parathyroidectomy for renal-origin hyperparathyroidism, preoperative calcitriol treatment reduces the use of postoperative administration of intravenous calcium. METHODS A retrospective chart review compared subtotal parathyroidectomy for renal-origin hyperparathyroidism patients who received preoperative calcitriol treatment with those patietns who did not receive preoperative calcitriol treatment at one institution. Preoperative calcitriol treatment loading doses were 0.5 mcg twice daily for 5 days. All patients received postoperative calcitriol and oral calcium carbonate. Postoperative administration of intravenous calcium was given for symptoms, calcium <7.0 mg/dL, or surgeon preference. The Fisher exact test was used to compare proportions. The Wilcoxon test was used to compare continuous data. Multivariable logistic regression adjusted for confounders. RESULTS Included were 81 patients who received subtotal parathyroidectomy for renal-origin hyperparathyroidism (41 patients who received preoperative calcitriol treatment, 40 patients who did not receive preoperative calcitriol treatment). Preoperative calcitriol treatment use increased over time (0% 2004-2010, 69% 2011-2016). Groups who received preoperative calcitriol treatment and groups who did not receive preoperative calcitriol treatment were similar in preoperative serum calcium, vitamin D, parathyroid hormone, and median age (P > .05 for all). Patients who received preoperative calcitriol treatment less often required postoperative administration of intravenous calcium (34% vs 90% of patients who did not receive preoperative calcitriol treatment, P < .001). Median length of stay was 2.0 days shorter for patients who received preoperative calcitriol treatment versus patients who did not receive preoperative calcitriol treatment patients (P < .001). Factors associated with postoperative administration of intravenous calcium included not receiving preoperative calcitriol treatment, low preoperative calcium, and high preoperative parathyroid hormone. After multivariable adjustment, preoperative calcitriol treatment remained independently associated with reduced postoperative administration of intravenous calcium (OR 0.02, P < .001). CONCLUSION Preoperative calcitriol therapy lowered use of postoperative administration of intravenous calcium by 56% and length of stay by 50% in subtotal parathyroidectomy for renal-origin hyperparathyroidism patients. We believe preoperative calcitriol treatment should become standard of care for subtotal parathyroidectomy for renal-origin hyperparathyroidism.
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16
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Jovanovich A, Kendrick J. Personalized Management of Bone and Mineral Disorders and Precision Medicine in End-Stage Kidney Disease. Semin Nephrol 2018; 38:397-409. [PMID: 30082059 PMCID: PMC6615060 DOI: 10.1016/j.semnephrol.2018.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Chronic kidney disease mineral bone disorder (CKD-MBD) is common in end-stage renal disease and is associated with an increased risk of cardiovascular morbidity and mortality. Mainstays of treatment include decreasing serum phosphorus level toward the normal range with dietary interventions and phosphate binders and treating increased parathyroid hormone levels with activated vitamin D and/or calcimimetics. There is significant variation in serum levels of mineral metabolism markers, intestinal absorption of phosphorus, and therapeutic response among individual patients and subgroups of patients with end-stage renal disease. This variation may be partly explained by polymorphisms in genes associated with calcium and phosphorus homeostasis such as the calcium-sensing receptor gene, the vitamin D-binding receptor gene, and genes associated with vascular calcification. In this review, we discuss how personalized medicine may be used for the management of CKD-MBD and how it ultimately may lead to improved clinical outcomes. Although genetic variants may seem attractive targets to tailor CKD-MBD therapy, complete understanding of how these polymorphisms function and their clinical utility and applicability to personalized medicine need to be determined.
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MESH Headings
- Bone Diseases, Metabolic/etiology
- Bone Diseases, Metabolic/genetics
- Bone Diseases, Metabolic/metabolism
- Bone Diseases, Metabolic/therapy
- Calcium/metabolism
- Cardiovascular Diseases
- Humans
- Hyperparathyroidism, Secondary/etiology
- Hyperparathyroidism, Secondary/metabolism
- Hyperparathyroidism, Secondary/therapy
- Intestinal Absorption
- Kidney Failure, Chronic/complications
- Kidney Failure, Chronic/metabolism
- Kidney Failure, Chronic/therapy
- Parathyroid Hormone/metabolism
- Phosphorus/metabolism
- Polymorphism, Genetic
- Precision Medicine
- Receptors, Calcium-Sensing/genetics
- Vascular Calcification/etiology
- Vascular Calcification/metabolism
- Vitamin D/metabolism
- Vitamin D-Binding Protein/genetics
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Affiliation(s)
- Anna Jovanovich
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO.; VA Eastern Colorado Healthcare System, Denver, CO
| | - Jessica Kendrick
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO..
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17
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Isaksson E, Ivarsson K, Akaberi S, Muth A, Sterner G, Karl-Göran P, Clyne N, Almquist M. The Effect of Parathyroidectomy on Risk of Hip Fracture in Secondary Hyperparathyroidism. World J Surg 2018; 41:2304-2311. [PMID: 28341917 PMCID: PMC5544797 DOI: 10.1007/s00268-017-4000-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background
Secondary hyperparathyroidism increases the risk for fractures. Despite improvement in medical therapy, surgical parathyroidectomy (PTX) often becomes necessary, but its effect on risk of fractures is not clear. Our aim was to study the effect of parathyroidectomy on the risk of hip fractures in patients on dialysis or with a functioning renal graft at time of parathyroidectomy.
Design In a cohort of 20,056 patients on dialysis or with functioning renal allograft, we identified 590 patients who underwent parathyroidectomy between 1991 and 2009. Of these, 579 were matched with 1970 non-PTX patients on age, sex, cause of renal disease and functioning renal allograft or not at the time of PTX or at the corresponding time for non-PTX patients (t). We calculated the risk for hip fracture after PTX using crude and adjusted Cox proportional hazards regressions, adjusting for time in renal replacement therapy before t, time with functioning renal allograft before and after t, comorbidity at t and a hip fracture before t. Results The adjusted hazard ratio (95% confidence interval) for hip fracture was 0.40 (0.18–0.88) for PTX patients, compared to non-PTX patients. When analyses were performed separately for sex, only women had a lower risk of hip fracture after PTX compared to non-PTX patients. The risk of hip fracture after PTX was similar in patients with or without functioning renal allograft at time for PTX. Conclusion Parathyroidectomy is associated with a lower risk of hip fracture in female patients with secondary hyperparathyroidism.
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Affiliation(s)
- Elin Isaksson
- Department of Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Sweden. .,Department of Urology, Lund University, Skåne University Hospital, Malmö, Sweden.
| | - Kerstin Ivarsson
- Department of Child and Adolescent Psychiatry, Lund University, Lund, Sweden.,Department of Clinical Sciences, Faculty of Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| | - Shahriar Akaberi
- Department of Nephrology, Lund University, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Faculty of Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| | - Andreas Muth
- Endocrine and Sarcoma Surgery, Department of Surgery, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gunnar Sterner
- Department of Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Sweden.,Department of Nephrology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Prütz Karl-Göran
- Department of Internal Medicine, Helsingborg Hospital, Helsingborg, Sweden
| | - Naomi Clyne
- Department of Nephrology, Lund University, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Faculty of Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| | - Martin Almquist
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Skåne University Hospital, Lund, Sweden.,Department of Surgery Section of Endocrine and Sarcoma, Lund University, Skåne University Hospital, Lund, Sweden
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18
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Tayyebi-Khosroshahi H, Farnood F, Ghorbanian M, Karkon-Shayan F, Naghavi-Behzad M. Persistent hypocalcemia and hungry bone syndrome after parathyroidectomy and renal transplantation in a patient with end-stage renal disease. Niger Med J 2017; 58:50-52. [PMID: 29238129 PMCID: PMC5715567 DOI: 10.4103/0300-1652.218416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hungry bone syndrome (HBS) defines as persistent and severe hypocalcemia after parathyroidectomy surgery. It is treated by oral or venous discrimination of calcium carbonate. The present treatment is mostly effective. Hereby, we describe a 60-year-old man who had developed hyperparathyroidism secondary to end-stage renal disease and then parathyroidectomy was performed for him twice before renal transplantation. Up to 500 vials of calcium gluconate (100 mg/ml calcium gluconate 10%) were administered for him to control serum calcium level after parathyroidectomy and renal transplantation. Furthermore, high-dose calcium carbonate was administered for his outpatient care. Therefore, HBS, which was resistant to standard treatment, was detected for him.
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Affiliation(s)
| | - Farahnoush Farnood
- Chronic Renal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maryam Ghorbanian
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farid Karkon-Shayan
- Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Naghavi-Behzad
- Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.,Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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19
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Impact of surgical parathyroidectomy on chronic kidney disease-mineral and bone disorder (CKD-MBD) - A systematic review and meta-analysis. PLoS One 2017; 12:e0187025. [PMID: 29107998 PMCID: PMC5673225 DOI: 10.1371/journal.pone.0187025] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 09/06/2017] [Indexed: 01/11/2023] Open
Abstract
For more than 6 decades, many patients with advanced chronic kidney disease (CKD) have undergone surgical parathyroidectomy (sPTX) for severe secondary hyperparathyroidism (SHPT) mainly based historical clinical practice patterns, but not on evidence of outcome.We aimed in this meta-analysis to evaluate the benefits and harms of sPTX in patients with SHPT. We searched MEDLINE (inception to October 2016), EMBASE and Cochrane Library (through Issue 10 of 12, October 2016) and website clinicaltrials.gov (October 2016) without language restriction. Eligible studies evaluated patients reduced glomerular filtration rate (GFR), below 60 mL/min/1.73 m2 (CKD 3–5 stages) with hyperparathyroidism who underwent sPTX. Reviewers working independently and in duplicate extracted data and assessed the risk of bias. The final analysis included 15 cohort studies, comprising 24,048 participants. Compared with standard treatment, sPTX significantly decreased all-cause mortality (RR 0.74 [95% CI, 0.66 to 0.83]) in End Stage Kidney Disease (ESKD) patients with biochemical and / or clinical evidence of SHPT. sPTX was also associated with decreased cardiovascular mortality (RR 0.59 [95% CI, 0.46 to 0.76]) in 6 observational studies that included almost 10,000 patients. The available evidence, mostly observational, is at moderate risk of bias, and limited by indirect comparisons and inconsistency in reporting for some outcomes (eg. short term adverse events, including documented voice change or episodes of severe hypocalcaemia needing admission or long-term adverse events, including undetectable PTH levels, risk of fractures etc.). Taken together, the results of this meta-analysis would suggest a clinically significant beneficial effect of sPTX on all-cause and cardiovascular mortality in CKD patients with SHPT. However, given the observational nature of the included studies, the case for a properly conducted, independent randomised controlled trial comparing surgery with medical therapy and featuring many different outcomes from mortality to quality of life (QoL) is now very strong.
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20
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The role of parathyroidectomy in the management of secondary hyperparathyroidism. Curr Opin Nephrol Hypertens 2017; 26:516-522. [DOI: 10.1097/mnh.0000000000000365] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Lim CTS, Kalaiselvam T, Kitan N, Goh BL. Clinical course after parathyroidectomy in adults with end-stage renal disease on maintenance dialysis. Clin Kidney J 2017; 11:265-269. [PMID: 29644069 PMCID: PMC5887517 DOI: 10.1093/ckj/sfx086] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/19/2017] [Indexed: 12/28/2022] Open
Abstract
Background Parathyroidectomy (PTX) is done in cases of secondary hyperparathyroidism from chronic kidney disease to improve renal osteodystrophy. Despite this widespread practice, clinical outcomes regarding the benefits of this procedure are still lacking. Most studies in the literature have opted to report the laboratory outcome instead. Our study aimed to evaluate the postoperative clinical course for patients who had undergone total PTX without autoimplantation. Methods and results All patients who underwent PTX between January 2010 and February 2014 in a tertiary referral center were included in this study and followed up for 12 months. Laboratory outcome parameters include various preoperative and postoperative serial measurements of laboratory parameters. Patients’ hospitalizations and mortality records post-PTX were also retrieved and recorded. In all, 90 patients were included in this study. The mean age was 48 ± 18 years. The majority of the patients (54.4%) were male and 90% were on hemodialysis. The mean duration of dialysis was 8.0 ± 5.0 years. Indications for PTX were symptomatic bone pain (95.6%), fractures (3.3%) and calciphylaxis (1.1%). Mean preoperative values for serum calcium, phosphate, alkaline phosphatase and intact parathyroid hormone (iPTH) were 2.40 ± 0.23mmol/L, 1.92 ± 0.51 mmol/L, 689.60 ± 708.50 U/L and 311.90 ± 171.94 pmol/L, respectively. The majority (92.2%) had all four glands removed and 92.2% of the glands showed hyperplasic changes. One year after PTX, 90 patients (100%) had serum iPTH <8 pmol/L and 28 patients (31%) had unmeasurable iPTH levels. A total of 15% of patients had hospitalizations for various reasons and of these, 50% were within 90 days. The mean hospital stay was 14.4 ± 18.6 days. The mortality rate was 4.4% and of these, 25% were in first 30 days. Causes of death were mainly from sepsis (75%) and acute coronary syndrome (25%). One patient (1.1%) had a relapse. Conclusions Even though PTX markedly reduces postoperative serum iPTH levels, it carries with it significant risk of morbidity and mortality.
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Affiliation(s)
- Christopher Thiam Seong Lim
- Department of Nephrology, Serdang Hospital, Malaysia.,Department of Medicine, Faculty of Medicine, Universiti Putra Malaysia, Malaysia
| | - Thevandra Kalaiselvam
- Department of Nephrology, Serdang Hospital, Malaysia.,Department of Medicine, Faculty of Medicine, Universiti Putra Malaysia, Malaysia
| | | | - Bak Leong Goh
- Department of Nephrology, Serdang Hospital, Malaysia.,Clinical Research Center, Serdang Hospital, Malaysia
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22
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Ribeiro C, Penido MGMG, Guimarães MMM, Tavares MDS, Souza BDN, Leite AF, de Deus LMC, Machado LJDC. Parathyroid ultrasonography and bone metabolic profile of patients on dialysis with hyperparathyroidism. World J Nephrol 2016; 5:437-447. [PMID: 27648407 PMCID: PMC5011250 DOI: 10.5527/wjn.v5.i5.437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 04/12/2016] [Accepted: 06/29/2016] [Indexed: 02/07/2023] Open
Abstract
AIM To evaluate the parathyroid ultrasonography and define parameters that can predict poor response to treatment in patients with secondary hyperparathyroidism due to renal failure.
METHODS This cohort study evaluated 85 patients with chronic kidney disease stage V with parathyroid hormone levels above 800 pg/mL. All patients underwent ultrasonography of the parathyroids and the following parameters were analyzed: Demographic characteristics (etiology of chronic kidney disease, gender, age, dialysis vintage, vascular access, use of vitamin D), laboratory (calcium, phosphorus, parathyroid hormone, alkaline phosphatase, bone alkaline phosphatase), and the occurrence of bone changes, cardiovascular events and death. The χ2 test were used to compare proportions or the Fisher exact test for small sample frequencies. Student t-test was used to detect differences between the two groups regarding continuous variables.
RESULTS Fifty-three patients (66.4%) had parathyroid nodules with higher levels of parathyroid hormone, calcium and phosphorus. Sixteen patients underwent parathyroidectomy and had higher levels of phosphorus and calcium × phosphorus product (P = 0.03 and P = 0.006, respectively). They also had lower mortality (32% vs 68%, P = 0.01) and lower incidence of cardiovascular or cerebrovascular events (27% vs 73%, P = 0.02). Calcium × phosphorus product above 55 mg2/dL2 [RR 1.48 (1.06, 2.08), P = 0.03], presence of vascular calcification [1.33 (1.01, 1.76), P = 0.015] and previous occurrence of vascular events [RR 2.25 (1.27, 3.98), P < 0.001] were risk factors for mortality in this population. There was no association between the occurrence of nodules and mortality.
CONCLUSION The identification of nodules at ultrasonography strengthens the indication for parathyroidectomy in patients with secondary hyperparathyroidism due to renal failure.
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23
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Chen JB, Chou FF, Yang CH, Hua MS. Association between clinical variables and mortality after parathyroidectomy in maintenance hemodialysis patients. Am J Surg 2016; 213:140-145. [PMID: 27469221 DOI: 10.1016/j.amjsurg.2016.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND We investigated factors associated with all-cause mortality and cardiovascular disease (CVD)-associated mortality after parathyroidectomy (PTX) in patients on maintenance hemodialysis (HD). METHODS Our study population consisted of 161 consecutive HD patients who underwent PTX before 2009 and 354 consecutive HD patients without PTX as controls from those visiting the Kaohsiung Chang Gung Memorial Hospital, Taiwan between 2009 and 2013. All-cause and CVD mortality with clinical variables were compared in PTX and non-PTX HD patients. RESULTS PTX patients had significantly lower all-cause and CVD mortality than controls. Multivariate logistic regression analyses showed PTX patients had a lower odds ratio for all-cause mortality than those without (odds ratio = .35, 95% confidence interval = .16 to .74). Association analysis based on clinical variables revealed patients with higher hemoglobin, albumin, creatinine, and HD adequacy index-Kt/V levels had significantly decreased risk of all-cause mortality. CONCLUSIONS PTX in HD patients reduces the risk of death.
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Affiliation(s)
- Jin-Bor Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Fong-Fu Chou
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Song District, Kaohsiung, Taiwan.
| | - Cheng-Hong Yang
- Department of Electronic Engineering, National Kaohsiung University of Applied Sciences, Kaohsiung, Taiwan
| | - Moi-Sin Hua
- Department of Electronic Engineering, National Kaohsiung University of Applied Sciences, Kaohsiung, Taiwan
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Affiliation(s)
- James B Wetmore
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota; and Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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Kim SM, Long J, Montez-Rath ME, Leonard MB, Norton JA, Chertow GM. Rates and Outcomes of Parathyroidectomy for Secondary Hyperparathyroidism in the United States. Clin J Am Soc Nephrol 2016; 11:1260-1267. [PMID: 27269300 PMCID: PMC4934842 DOI: 10.2215/cjn.10370915] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 03/08/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Secondary hyperparathyroidism is common among patients with ESRD. Although medical therapy for secondary hyperparathyroidism has changed dramatically over the last decade, rates of parathyroidectomy for secondary hyperparathyroidism across the United States population are unknown. We examined temporal trends in rates of parathyroidectomy, in-hospital mortality, length of hospital stay, and costs of hospitalization. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, a representative national database on hospital stay regardless of age and payer in the United States, we identified parathyroidectomies for secondary hyperparathyroidism from 2002 to 2011. Data from the US Renal Data System reports were used to calculate the rate of parathyroidectomy. RESULTS We identified 32,971 parathyroidectomies for secondary hyperparathyroidism between 2002 and 2011. The overall rate of parathyroidectomy was approximately 5.4/1000 patients (95% confidence interval [95% CI], 5.0/1000 to 6.0/1000). The rate decreased from 2003 (7.9/1000 patients; 95% CI, 6.2/1000 to 9.6/1000), reached a nadir in 2005 (3.3/1000 patients; 95% CI, 2.6/1000 to 4.0/1000), increased again through 2006 (5.4/1000 patients; 95% CI, 4.4/1000 to 6.4/1000), and remained stable since that time. Rates of in-hospital mortality decreased from 1.7% (95% CI, 0.8% to 2.6%) in 2002 to 0.8% (95% CI, 0.1% to 1.6%) in 2011 (P for trend <0.001). In-hospital mortality rates were significantly higher in patients with heart failure (odds ratio [OR], 4.23; 95% CI, 2.59 to 6.91) and peripheral vascular disease (OR, 4.59; 95% CI, 2.75 to 7.65) and lower among patients with prior kidney transplantation (OR, 0.20; 95% CI, 0.06 to 0.65). CONCLUSIONS Despite the use of multiple medical therapies, rates of parathyroidectomy of secondary hyperparathyroidism have not declined in recent years.
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Affiliation(s)
| | - Jin Long
- Division of Nephrology, Department of Medicine
- Division of Pediatric Nephrology, Department of Pediatrics, and
| | | | - Mary B. Leonard
- Division of Nephrology, Department of Medicine
- Division of Pediatric Nephrology, Department of Pediatrics, and
| | - Jeffrey A. Norton
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
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Nemeth EF, Goodman WG. Calcimimetic and Calcilytic Drugs: Feats, Flops, and Futures. Calcif Tissue Int 2016; 98:341-58. [PMID: 26319799 DOI: 10.1007/s00223-015-0052-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 08/10/2015] [Indexed: 01/28/2023]
Abstract
The actions of extracellular Ca(2+) in regulating parathyroid gland and kidney functions are mediated by the extracellular calcium receptor (CaR), a G protein-coupled receptor. The CaR is one of the essential molecules maintaining systemic Ca(2+) homeostasis and is a molecular target for drugs useful in treating bone and mineral disorders. Ligands that activate the CaR are termed calcimimetics and are classified as either agonists (type I) or positive allosteric modulators (type II); calcimimetics inhibit the secretion of parathyroid hormone (PTH). Cinacalcet is a type II calcimimetic that is used to treat secondary hyperparathyroidism in patients receiving dialysis and to treat hypercalcemia in some forms of primary hyperparathyroidism. The use of cinacalcet among patients with secondary hyperparathyroidism who are managed with dialysis effectively lowers circulating PTH levels, reduces serum phosphorus and FGF23 concentrations, improves bone histopathology, and may diminish skeletal fracture rates and the need for parathyroidectomy. A second generation type II calcimimetic (AMG 416) is currently under regulatory review. Calcilytics are CaR antagonists that stimulate the secretion of PTH. Several calcilytic compounds have been evaluated as orally active anabolic therapies for postmenopausal osteoporosis but clinical development of all of them has been abandoned because they lacked clinical efficacy. Calcilytics might be repurposed for new indications like autosomal dominant hypocalcemia or other disorders beyond those involving systemic Ca(2+) homeostasis.
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Affiliation(s)
- E F Nemeth
- MetisMedica, 13 Poplar Plains Road, Toronto, ON, M4V 2M7, Canada.
| | - W G Goodman
- , 22102 Palais Place, Calabasas, CA, 91302, USA
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Kayalar AO, Basturk T, Koc Y, Yilmaz F, Caglayan FB, Sakaci T, Ahbap E, Ünsal A. Comparison of Long-term Complications in Patients on Haemodialysis and Peritoneal Dialysis Longer than 10 Years. J Clin Diagn Res 2016; 10:OC05-8. [PMID: 27042493 DOI: 10.7860/jcdr/2016/15279.7172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 11/22/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Depending on developments in dialysis techniques and new treatment strategies for comorbid diseases, life expectancy has increased. As a result, dialysis related long term complications could be seen more frequently. We investigated and compared long term complications of the Haemodialysis (HD) and Peritoneal Dialysis (PD) in patients with history if either mode at least 10years. MATERIALS AND METHODS A 13HD & 16PD patients were included to the study. Basic demographic parameters and prevalence of cardiovascular diseases (CVD), uraemic peripheral neuropathy (PNP), parathyroid adenoma, parathyroidectomy and acquired cystic disease (ACD) were assessed. RESULTS HD patients were older than PD patients (p=0.035) and duration of dialysis was longer in HD patients (p=0.001). CVD was present in 18 patients (9 HD, 9 PD). There was no difference in presence of CVD between HD and PD patients (p=0.455). Valvular diseases (n=15), diastolic dysfunction (n=8), left ventricular hypertrophy (n=5), ischemic heart disease (n=3) and congestive heart failure (n=1) were investigated. Uraemic peripheral neuropathy was observed in 14 of the patients (8 HD, 6 PD patients). Eight patients had mixed type sensory motor neuropathy and 3 patients had mixed type sensorial neuropathy, 2 patients had demyelinating PNP, 1 patient had axonal PNP and 3 of them had CTS related to peripheral neuropathy. Parathyroid adenoma was detected in 4 patients (2 HD, 2 PD) and 3 patients (1 HD, 2 PD) had history of parathyroidectomy. Serum phosphate and iPTH levels were higher in HD patients (p=0.003, p=0.04, respectively). ACD was detected in 14 patients (7 HD, 7 PD). There was no difference between PD and HD patients (p=0.75). CONCLUSION HD patients were older than PD patients and had longer duration of dialysis. The prevalence of long term complications was similar in HD and PD modalities. CVD especially valvular diseases were common complication in both modalities.
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Affiliation(s)
- Arzu Ozdemir Kayalar
- Fellow in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital , Istanbul-Turkey
| | - Taner Basturk
- Associate Professor in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital , Istanbul-Turkey
| | - Yener Koc
- Associate Professor in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital , Istanbul-Turkey
| | - Figen Yilmaz
- Associate Professor in Physical treatment and rehabilitation, Department of Physical Treatment and Rehabilitation, Sisli Etfal Research and Education Hospital , Istanbul-Turkey
| | - Feyza Bayraktar Caglayan
- Fellow in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital , Istanbul-Turkey
| | - Tamer Sakaci
- Specialist in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital , Istanbul-Turkey
| | - Elbis Ahbap
- Specialist in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital , Istanbul-Turkey
| | - Abdulkadir Ünsal
- Professor in Nephrology, Department of Nephrology, Sisli Etfal Research and Education Hospital , Istanbul-Turkey
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Indications for Parathyroidectomy in End-Stage Renal Disease and After Renal Transplantation. Updates Surg 2016. [DOI: 10.1007/978-88-470-5758-6_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ivarsson KM, Akaberi S, Isaksson E, Reihnér E, Rylance R, Prütz KG, Clyne N, Almquist M. The effect of parathyroidectomy on patient survival in secondary hyperparathyroidism. Nephrol Dial Transplant 2015; 30:2027-33. [PMID: 26374600 PMCID: PMC4832998 DOI: 10.1093/ndt/gfv334] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 08/18/2015] [Accepted: 08/18/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Secondary hyperparathyroidism is a common condition in patients with end-stage renal disease and is associated with osteoporosis and cardiovascular disease. Despite improved medical treatment, parathyroidectomy (PTX) is still necessary for many patients on renal replacement therapy. The aim of this study was to evaluate the effect of PTX on patient survival. METHODS A nested index-referent study was performed within the Swedish Renal Registry (SRR). Patients on maintenance dialysis and transplantation at the time of PTX were analysed separately. The PTX patients in each of these strata were matched for age, sex and underlying renal diseases with up to five referent patients who had not undergone PTX. To calculate survival time and hazard ratios, indexes and referents were assigned the calendar date (d) of the PTX of the index patient. The risk of death after PTX was calculated using crude and adjusted Cox proportional hazards regressions. RESULTS There were 20 056 patients in the SRR between 1991 and 2009. Of these, 579 (423 on dialysis and 156 with a renal transplant at d) incident patients with PTX were matched with 1234/892 non-PTX patients. The adjusted relative risk of death was a hazard ratio (HR) of 0.80 [95% confidence interval (CI) 0.65-0.99] for dialysis patients at d who had undergone PTX compared with matched patients who had not. Corresponding results for the patients with a renal allograft at d were an HR of 1.10 (95% CI 0.71-1.70). CONCLUSIONS PTX was associated with improved survival in patients on maintenance dialysis but not in patients with renal allograft.
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Affiliation(s)
| | - Shahriar Akaberi
- Department of Nephrology and Transplantation, Skane University Hospital Lund, Skåne, Sweden
| | | | - Eva Reihnér
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecca Rylance
- National Registry Centre, Skane University Hospital Lund, Skåne, Sweden
| | - Karl-Göran Prütz
- Department of Internal Medicine, Helsingborg Hospital, Helsingborg, Sweden
| | - Naomi Clyne
- Department of Nephrology and Transplantation, Skane University Hospital Lund, Skåne, Sweden
| | - Martin Almquist
- Department of Surgery Section of Endocrine and Sarcoma, Skane University Hospital, Lund, Skåne, Sweden
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Influence of dialysis modalities on patients undergoing parathyroidectomy for renal hyperparathyroidism. FORMOSAN JOURNAL OF SURGERY 2015. [DOI: 10.1016/j.fjs.2015.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Messa P. Parathyroidectomy and patient survival in CKD patients. Nephrol Dial Transplant 2015; 30:1944-6. [PMID: 26275892 DOI: 10.1093/ndt/gfv286] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 06/29/2015] [Indexed: 12/13/2022] Open
Affiliation(s)
- Piergiorgio Messa
- Department of Medicine and Medical Specialties, Unit of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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Cunningham J, Floege J, London G, Rodriguez M, Shanahan CM. Clinical outcomes in secondary hyperparathyroidism and the potential role of calcimimetics. NDT Plus 2015; 1:i29-i35. [PMID: 25983954 PMCID: PMC4421154 DOI: 10.1093/ndtplus/sfm042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Accepted: 09/10/2007] [Indexed: 12/26/2022] Open
Abstract
Cinacalcet, a type II calcimimetic agent that interacts with the calcium-sensing receptor on the parathyroid gland and increases its sensitivity to calcium, has proved an effective therapy for the treatment of the biochemical derangements that comprise uraemic secondary hyperparathyroidism. These patients experience high cardiovascular attrition with evidence that this is associated with vascular calcification, arterial stiffening and increased pulse wave velocity, and with some of the disturbances of bone and mineral metabolism in uraemia. Thus, it is possible that improved biochemical control in calcimimetic-treated patients might lead to better clinical outcomes. This hypothesis was investigated by retrospective analyses of randomized placebo-controlled phase 3 studies. The addition of cinacalcet to standard therapy with active vitamin D and phosphate binders was found to result in a 93% reduction in the rate of parathyroidectomy, a 54% reduction in fracture rate and 39% reduction in the rate of cardiovascular hospitalization, as well as improvements in some measures of quality of life. These encouraging results point to the need for a more robust assessment of the impact of cinacalcet on cardiovascular and skeletal outcomes.
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Affiliation(s)
- John Cunningham
- The Royal Free and University College Medical School , London , UK
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Florescu MC, Islam KM, Plumb TJ, Smith-Shull S, Nieman J, Mandalapu P. Calcium supplementation after parathyroidectomy in dialysis and renal transplant patients. Int J Nephrol Renovasc Dis 2014; 7:183-90. [PMID: 24868170 PMCID: PMC4027938 DOI: 10.2147/ijnrd.s56995] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Data on the risk factors and clinical course of hungry bone syndrome are lacking in dialysis and renal transplant patients who undergo parathyroidectomy. In this study, we aimed to assess the risks and clinical course of hungry bone syndrome and calcium repletion after parathyroidectomy in dialysis and renal transplant patients. Methods We performed a retrospective review of parathyroidectomies performed at The Nebraska Medical Center. Results We identified 41 patients, ie, 30 (73%) dialysis and eleven (27%) renal transplant patients. Dialysis patients had a significantly higher pre-surgery intact parathyroid hormone (iPTH, P<0.001) and a larger iPTH drop after surgery (P<0.001) than transplant recipients. Post-surgery hypocalcemia in dialysis patients was severe and required aggressive and prolonged calcium replacement (11 g) versus a very mild hypocalcemia requiring only brief and minimal replacement (0.5 g) in transplant recipients (P<0.001). Hypophosphatemia was not detected in the dialysis group. Phosphorus did not increase immediately after surgery in transplant recipients. The hospital stay was significantly longer in dialysis patients (8.2 days) compared with transplant recipients (3.2 days, P<0.001). Conclusion The clinical course of hungry bone syndrome is more severe in dialysis patients than in renal transplant recipients. Young age, elevated alkaline phosphatase, elevated pre-surgery iPTH, and a large decrease in post-surgical iPTH are risk factors for severe hungry bone syndrome in dialysis patients.
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Affiliation(s)
| | | | | | - Sara Smith-Shull
- Department of Pharmacy, The Nebraska Medical Center, Omaha, NE, USA
| | - Jennifer Nieman
- Department of Pharmacy, The Nebraska Medical Center, Omaha, NE, USA
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Akaberi S, Clyne N, Sterner G, Rippe B, Reihnér E, Wagner P, Rylance R, Prütz KG, Almquist M. Temporal trends and risk factors for parathyroidectomy in the Swedish dialysis and transplant population - a nationwide, population-based study 1991 - 2009. BMC Nephrol 2014; 15:75. [PMID: 24886448 PMCID: PMC4041342 DOI: 10.1186/1471-2369-15-75] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 05/01/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Many patients on renal replacement therapy (RRT) require parathyroidectomy (PTX). Trends and current rates of PTX on a national level are not known. Furthermore, it is not completely clear which factors influence rates of PTX. Thus, our aim was to investigate the incidence, regional distribution and factors associated with PTX as well as possible temporal changes, in the Swedish RRT population. METHODS From the Swedish Renal Registry we extracted data on 20 015 patients on RRT between 1991 and 2009. In these, 679 incident PTX (3.4%) were identified by linkage with the National Inpatient Registry, and the Scandinavian Quality Registry for Thyroid Parathyroid and Adrenal Surgery. Poisson models were used to estimate rates per calendar year, adjusted for risk factors such as gender, age, time with renal transplant, and underlying cause of renal disease. RESULTS The PTX rate was 8.8/1 000 person-years. There was a significant increase 2001-2004 after which the rate fell, as compared with year 2000. Female gender, non-diabetic cause of renal disease and age between 40-55 were all associated with an increased frequency of PTX. CONCLUSION The rise in PTX rates after year 2000 might reflect increasing awareness of the potential benefits of PTX. The introduction of calcimimetics and paricalcitol might explain the decreased rate after 2005.
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Affiliation(s)
- Shahriar Akaberi
- Department of Nephrology, Clinical Sciences Lund, Lund University, Alwallhuset, Barngatan 2A, Lund 221 85, Sweden
| | - Naomi Clyne
- Department of Nephrology, Clinical Sciences Lund, Lund University, Alwallhuset, Barngatan 2A, Lund 221 85, Sweden
| | - Gunnar Sterner
- Department of Nephrology, Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Bengt Rippe
- Department of Nephrology, Clinical Sciences Lund, Lund University, Alwallhuset, Barngatan 2A, Lund 221 85, Sweden
| | - Eva Reihnér
- Department of Molecular Medicine and Surgery, Karolinska Institute, Section of Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
- Scandinavian Quality Register for Thyroid Parathyroid and Adrenal Surgery, Helsingborg, Sweden
| | - Philippe Wagner
- National Registry Centre, Skane University Hospital, Lund, Sweden
| | - Rebecca Rylance
- National Registry Centre, Skane University Hospital, Lund, Sweden
| | - Karl Göran Prütz
- Department of Internal Medicine, Helsingborg Hospital, Helsingborg, Sweden
- Swedish Renal Registry, Ryhov Hospital, Jönköping, Sweden
| | - Martin Almquist
- Section of Endocrine and Sarcoma Surgery, Department of Surgery, Skane University Hospital, Lund, Sweden
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Prospective analysis of coronary calcium in patients on dialysis undergoing a near-total parathyroidectomy. Surgery 2013; 154:1315-21; discussion 1321-2. [DOI: 10.1016/j.surg.2013.06.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/25/2013] [Indexed: 11/19/2022]
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Cheng SP, Lee JJ, Liu TP, Yang TL, Chen HH, Wu CJ, Liu CL. Parathyroidectomy improves symptomatology and quality of life in patients with secondary hyperparathyroidism. Surgery 2013; 155:320-8. [PMID: 24035616 DOI: 10.1016/j.surg.2013.08.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 08/12/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The parathyroidectomy assessment of symptoms (PAS) score was designed initially for primary hyperparathyroidism to provide a specific symptom assessment and was validated later in secondary and tertiary hyperparathyroidism. The aim of our study was to evaluate changes in the PAS scores and quality of life before and after parathyroidectomy for secondary hyperparathyroidism. METHODS This prospective study included 49 consecutive patients who underwent parathyroidectomy for secondary hyperparathyroidism. The PAS and Short Form (SF)-36 questionnaires were completed before parathyroidectomy and at 12 months postoperatively. RESULTS All 13 symptoms included in the PAS score improved significantly. The mean ± standard deviation PAS score decreased from 545 ± 263 to 284 ± 201 (P < .0001) after parathyroidectomy. Quality of life was enhanced in both physical (40.3 ± 17.1 to 59.0 ± 14.9; P < .0001) and mental (47.6 ± 17.1 to 63.7 ± 13.0; P < .0001) components. The PAS score was inversely correlated with the SF-36 global score preoperatively and postoperatively (r(2) = 0.48 and 0.25; P < .001). The change in PAS score also correlated with the change in SF-36 global score (r(2) = 0.29; P < .001). Multiple linear regression analysis showed that preoperative PAS score and bone mineral density T-score were predictors of the decrease in PAS score. Preoperative SF-36 global score and intact parathyroid hormone levels were predictors of the increment in SF-36 score. CONCLUSION The symptom burden of secondary hyperparathyroidism has a negative impact on a patient's quality of life. Parathyroidectomy is associated with a marked improvement in symptoms and quality of life.
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Affiliation(s)
- Shih-Ping Cheng
- Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medical College, New Taipei City, Taiwan; Department of Pharmacology and Graduate Institute of Medical Sciences, Taipei Medical University, Taipei, Taiwan
| | - Jie-Jen Lee
- Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medical College, New Taipei City, Taiwan; Mackay Medicine, Nursing and Management College, Taipei, Taiwan; Department of Pharmacology and Graduate Institute of Medical Sciences, Taipei Medical University, Taipei, Taiwan
| | - Tsang-Pai Liu
- Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medical College, New Taipei City, Taiwan; Mackay Medicine, Nursing and Management College, Taipei, Taiwan
| | - Tsen-Long Yang
- Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Han-Hsiang Chen
- Department of Nephrology, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medical College, New Taipei City, Taiwan; Mackay Medicine, Nursing and Management College, Taipei, Taiwan
| | - Chih-Jen Wu
- Department of Nephrology, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medical College, New Taipei City, Taiwan; Department of Pharmacology and Graduate Institute of Medical Sciences, Taipei Medical University, Taipei, Taiwan
| | - Chien-Liang Liu
- Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medical College, New Taipei City, Taiwan; Mackay Medicine, Nursing and Management College, Taipei, Taiwan.
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Latus J, Roesel M, Fritz P, Braun N, Ulmer C, Steurer W, Biegger D, Alscher MD, Kimmel M. Incidence of and risk factors for hungry bone syndrome in 84 patients with secondary hyperparathyroidism. Int J Nephrol Renovasc Dis 2013; 6:131-7. [PMID: 23882155 PMCID: PMC3709645 DOI: 10.2147/ijnrd.s47179] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Introduction Secondary hyperparathyroidism develops in nearly all patients with end-stage renal disease. Parathyroidectomy is often performed when medical therapy fails. The most common postoperative complication, hungry bone syndrome (HBS), requires early recognition and treatment. Materials and methods A total of 84 patients who underwent parathyroidectomy because of secondary hyperparathyroidism were investigated. Detailed analysis of laboratory parameters (calcium, phosphate, parathyroid hormone, hemoglobin, and urea levels) and baseline characteristics (age at time of surgery, duration of renal replacement therapy, and medication) was performed to detect preoperative predictors for the development of HBS. Results Average overall follow-up of the cohort was 4.7 years. Within this time frame, 13 of 84 patients had to undergo a second surgery because of recurrent disease, and HBS occurred in 51.2%. Only decreased preoperative calcium levels and younger age at time of surgery were significant predictors of HBS. Minimal levels of calcium were detected 3 weeks after surgery. Preoperative vitamin D therapy could not prevent HBS and could not shorten the duration of intravenous calcium supplementation. Conclusion HBS is a very common complication after parathyroidectomy. Younger patients and patients with low preoperative calcium levels were at higher risk for the development of HBS. Remarkably, preoperative vitamin D therapy could not prevent HBS and had no impact on the length of intravenous calcium supplementation. Intensive monitoring of calcium levels must be performed for at least 3 weeks after surgery.
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Affiliation(s)
- Joerg Latus
- Department of Internal Medicine, Division of Nephrology, Robert Bosch Hospital, Stuttgart, Germany
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Lafrance JP, Cardinal H, Leblanc M, Madore F, Pichette V, Roy L, Le Lorier J. Effect of cinacalcet availability and formulary listing on parathyroidectomy rate trends. BMC Nephrol 2013; 14:100. [PMID: 23642012 PMCID: PMC3648401 DOI: 10.1186/1471-2369-14-100] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 04/18/2013] [Indexed: 01/19/2023] Open
Abstract
Background Recent trends in parathyroidectomy rates are not known. Our objective was to investigate the trend in parathyroidectomy rates between 2001 and 2010, and to evaluate if the availability and reimbursement of cinacalcet modified that trend. Methods Using a provincial administrative database, we included all adult patients receiving chronic dialysis treatments between 2001 and 2010 (incident and prevalent) in a time series analysis. The effect of cinacalcet availability on parathyroidectomy bimonthly rates was modeled using an ARIMA intervention model using different cut-off dates: September 2004 (Health Canada cinacalcet approval), January 2005, June 2005, January 2006, June 2006 (date of cinacalcet provincial reimbursement), and January 2007. Results A total of 12 795 chronic dialysis patients (mean age 64 years, 39% female, 82% hemodialysis) were followed for a mean follow-up of 3.3 years. During follow-up, 267 parathyroidectomies were identified, translating to an average rate of 7.0 per 1000 person-years. The average parathyroidectomy rate before cinacalcet availability was 11.4 /1000 person-years, and 3.6 /1000 person-years after cinacalcet public formulary listing. Only January 2006 as an intervention date in the ARIMA model was associated with a change in parathyroidectomy rates (estimate: -5.58, p = 0.03). Other intervention dates were not associated with lower parathyroidectomy rates. Conclusions A reduction in rates of parathyroidectomy was found after January 2006, corresponding to cinacalcet availability. However, decreased rates may be due to other factors occurring simultaneously with cinacalcet introduction and further studies are needed to confirm these findings.
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Postoperative hungry bone syndrome in patients with secondary hyperparathyroidism of renal origin. World J Surg 2012; 36:1314-9. [PMID: 22399154 DOI: 10.1007/s00268-012-1560-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hungry bone syndrome (HBS) is a postoperative condition of severe hypocalcemia that can be seen in patients who have undergone parathyroidectomy (PTX) for secondary hyperparathyroidism (2HPT) of renal origin. This study examines HBS in patients after PTX for 2HPT. METHODS Prospectively collected data was retrospectively reviewed in patients who underwent PTX for 2HPT of renal origin at a single institution. HBS was defined as the need for additional days of hospitalization or readmission for intravenous calcium supplementation due to clinical symptoms of hypocalcemia, including tingling, muscle spasms, and bone pain and/or immediate postoperative low serum calcium ≤7.5 mg/dl. RESULTS Of 79 patients who underwent PTX for 2HPT, 27.8% (n = 22) experienced HBS. Young age (≤45 years, p = 0.02) was the only preoperative variable that predicted HBS. Most patients developed HBS within 18 h after surgery and required a prolonged hospital stay (19/22) compared to those requiring hospital readmission within the first 7 days (3/22). Initial postoperative serum calcium levels within 18 h of surgery were significantly lower in those patients who developed HBS (7.1 vs. 8.3 mg/dl, p = 0.001), and those patients also had a greater absolute decrease in serum calcium (2.8 vs. 3.5 mg/dl, p = 0.04). CONCLUSION HBS develops in a significant proportion of patients generally within the first 18 h after subtotal PTX for 2HPT. The only identifiable preoperative risk factor for HBS was young age. Additionally, low initial calcium levels and greater absolute decrease in serum calcium may help identify those patients that will develop HBS requiring judicious calcium supplementation.
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Sharma J, Raggi P, Kutner N, Bailey J, Zhang R, Huang Y, Herzog CA, Weber C. Improved long-term survival of dialysis patients after near-total parathyroidectomy. J Am Coll Surg 2012; 214:400-7; discussion 407-8. [PMID: 22463880 DOI: 10.1016/j.jamcollsurg.2011.12.046] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 12/20/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Severe secondary hyperparathyroidism, which is associated with life-threatening complications, can develop in dialysis-dependent end-stage renal disease patients. The aim of this study was to compare short- and long-term mortality in dialysis patients who underwent near-total parathyroidectomy (NTPTX) and matched nonoperated controls. STUDY DESIGN We identified 150 dialysis patients who underwent NTPTX (1993-2009) at our institution and compared them with 1,044 nonoperated control patients identified in the US Renal Data System registry, matched for age, sex, race, diabetes as cause of kidney failure, years on dialysis, and dialysis modality. Survival outcomes were estimated using multivariable Cox proportional hazards models with stratification on the matching sets, adjusted for cardiovascular comorbidities, smoking, inability to ambulate/transfer, and payor status. RESULTS During a follow-up of a mean of 3.6 years (range 0.1 month to 16.4 years), NTPTX patients had a significant reduction in the long-term risk of all-cause death (hazard ratio = 0.68; 95% CI, 0.52-0.89; p = 0.006) compared with controls. Thirty-day mortality rates for NTPTX patients and controls were 246 vs 105 per 1,000 person-years (p = 0.21). In adjusted analyses, NTPTX patients had a 37% reduced risk of all-cause death and a 33% reduced risk of cardiovascular death compared with controls. A durable reduction in mean parathyroid hormone was observed after NTPTX; from 1,776 ± 1,416.6 pg/mL to 301 ± 285.7 pg/mL (p < 0.0001). CONCLUSIONS In our center, NTPTX in dialysis patients was associated with a significant reduction in long-term risk of death compared with matched control patients, without a significantly increased short-term risk.
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Affiliation(s)
- Jyotirmay Sharma
- Department of Surgery, Emory University, Atlanta, GA 30322, USA.
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Gender Differences Among Patients with Secondary Hyperparathyroidism Undergoing Parathyroidectomy. J Surg Res 2011; 168:82-7. [DOI: 10.1016/j.jss.2009.07.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 06/17/2009] [Accepted: 07/21/2009] [Indexed: 11/23/2022]
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Ritz D, Nourrit-Poirette F. Les effets délétères de la parathormone sur le coeur. Nephrol Ther 2011; 7:H13-6. [DOI: 10.1016/s1769-7255(11)70006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Li S, Chen YW, Peng Y, Foley RN, St Peter WL. Trends in parathyroidectomy rates in US hemodialysis patients from 1992 to 2007. Am J Kidney Dis 2010; 57:602-11. [PMID: 21186072 DOI: 10.1053/j.ajkd.2010.10.041] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 10/01/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Parathyroidectomy rates in hemodialysis patients increased from 1992 to 2002, when medication choices to manage secondary hyperparathyroidism expanded. STUDY DESIGN Retrospective follow-up registry study. SETTING & PARTICIPANTS We evaluated annual cohorts of point-prevalent US hemodialysis patients with Medicare as primary payer for 1992-2007 (n = 1,063,258 for 1992-1999; 757,207 for 2000-2003; 902,119 for 2004-2007). PREDICTOR Comorbid conditions, vitamin D use, previous kidney transplant, and parathyroid hormone testing were assessed in the previous year. Available bone and mineral disorder treatment patterns were evaluated. OUTCOMES We examined incidence rate trends and patient characteristics through 2007 to estimate the association between parathyroidectomy and patient factors. Follow-up was from January 1 of each study year to the earliest in the same year of parathyroidectomy, death, or December 31. MEASUREMENTS We used χ(2) analysis to compare patient characteristics in 3 time frames. Unadjusted and adjusted parathyroidectomy rates were calculated. Cox regression was used to test the association of parathyroidectomy and covariates. RESULTS Adjusted parathyroidectomy rates increased from 1998 (7.0/1,000 patient-years; 1,045 events), peaked in 2002 (12.8/1,000 patient-years; 2,229 events), decreased through 2005 (5.4/1,000 patient-years; 1,078 events), and increased in 2006 (8.6/1,000 patient-years; 1,743 events) and 2007 (8.8/1,000 patient-years; 1,832 events). Vitamin D use, virtually undetectable in 1991, subsequently steadily increased; >80% of patients received vitamin D in 2006. LIMITATIONS The study was not designed to provide causal explanations for observed changes; oral medication use trend data were limited to one large dialysis provider and may not reflect use patterns in all dialysis facilities; because Medicare is not the primary payer for all US hemodialysis patients, results do not describe the entire US hemodialysis population; parathyroid hormone values are lacking in the database. CONCLUSIONS Adjusted parathyroidectomy rates varied substantially from 1992 through 2007. Rates were highest in 1994 and 2002 and lowest in 1998 and 2005, likely influenced by changing medication use patterns and guideline publication.
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Affiliation(s)
- Suying Li
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South 8th Street, Minneapolis, MN 55404, USA
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Zitt E, Rix M, Ureña Torres P, Fouque D, Jacobson SH, Pétavy F, Dehmel B, Ryba M. Effectiveness of cinacalcet in patients with recurrent/persistent secondary hyperparathyroidism following parathyroidectomy: results of the ECHO study. Nephrol Dial Transplant 2010; 26:1956-61. [PMID: 20947534 DOI: 10.1093/ndt/gfq641] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Progressive secondary hyperparathyroidism (sHPT) is characterized by parathyroid gland hyperplasia which may ultimately require parathyroidectomy (PTX). Although PTX is generally a successful treatment for those patients subjected to surgery, a significant proportion develops recurrent sHPT following PTX. ECHO was a pan-European observational study which evaluated the achievement of KDOQI(TM) treatment targets with cinacalcet use in patients on dialysis. Previously published results showed that cinacalcet plus flexible vitamin D therapy lowered serum PTH, phosphorus and calcium in the clinical practice with similar efficacy as seen in phase III trials. METHODS This subgroup analysis of ECHO describes the real-world cinacalcet treatment effect in patients with recurrent or persistent sHPT after PTX (n = 153) compared to sHPT patients without prior history of PTX (n = 1696). RESULTS Both groups of patients had substantially elevated serum PTH with comparable sHPT severity at baseline. After 12 months of cinacalcet treatment, 20.3% (26/128) of patients with prior PTX and 18.2% (253/1388) of patients without prior PTX achieved serum PTH and Ca × P values within the recommended KDOQI(TM) target ranges. CONCLUSIONS Our data support the successful use of cinacalcet in patients with recurrent/persistent sHPT after PTX.
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Affiliation(s)
- Emanuel Zitt
- Department of Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria.
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Chu KH, Cheuk A, Lee W, Yim KF, Tang HL, Fung KS, Lee KC, Tong KL, Chan HWH. Renal Bone Disease: 25-year Experience From a Single Center. Int J Organ Transplant Med 2010. [DOI: 10.1016/s1561-5413(10)60012-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Dumasius V, Angelos P. Parathyroid Surgery in Renal Failure Patients. Otolaryngol Clin North Am 2010; 43:433-40, x-xi. [DOI: 10.1016/j.otc.2010.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
PURPOSE OF REVIEW At all stages of chronic kidney disease (CKD) cardiovascular death is the most prominent cause of mortality. Current treatment options are still not completely satisfactory in this group of high cardiovascular risk patients. Experimental data and clinical observations suggest a role of secondary hyperparathyroidism, hyperphosphatemia, and hypercalcemia in the genesis of cardiovascular complications of CKD. The ubiquitous expression of the calcium-sensing receptor, which is targeted by calcimimetics and the pleiotropic effects of calcimimetics, make this class of drugs potential candidates for cardiovascular intervention. RECENT FINDINGS Recent experimental studies suggest that calcimimetics interfere with the development of vascular abnormalities in CKD and to some extent even reverse them. The effects of calcimimetics on the vasculature are, at least partially, independent of their effects on calcemia, phosphatemia, and parathyroid hormone concentration. The beneficial effects of calcimimetics on vascular calcification, arteriolar thickening, atherogenesis, and myocardial capillarization are well documented. In addition they have hypotensive and renoprotective actions. SUMMARY Experimental models suggest beneficial effects of calcimimetics on cardiovascular disease. Although prospective clinical data are still lacking, retrospective data suggest cardiovascular benefit of calcimimetics even in humans. Clinical trials with calcimimetics evaluating hard cardiovascular end-points would be desirable.
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Parathyroid scintigraphy findings in chronic kidney disease patients with recurrent hyperparathyroidism. Eur J Nucl Med Mol Imaging 2009; 37:623-34. [DOI: 10.1007/s00259-009-1313-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2009] [Accepted: 10/21/2009] [Indexed: 10/20/2022]
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Thompson M, Schiller B. Mysterious PTH values after parathyroidectomy in a patient on maintenance dialysis. Hemodial Int 2009; 13:543-6. [PMID: 19732173 DOI: 10.1111/j.1542-4758.2009.00375.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 25-year-old patient with end-stage renal disease on maintenance peritoneal dialysis underwent parathyroidectomy when his secondary hyperparathyroidism did not respond to medical management. However, over the subsequent months he developed extremely raised parathyroid hormone (PTH) levels. When surgical removal of the autotransplant was considered, preoperative work-up revealed a PTH level within the target range. It became apparent that the very high PTH values were due to the location of the blood draw close to the autotransplant, thus measuring a local rather than the systemic PTH value. The multiple causes of varying PTH measurements other than clinical and physiological reasons are reviewed.
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Affiliation(s)
- Marla Thompson
- Satellite Healthcare, WellBound, Mountain View, California, USA
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Trikalinos TA, Siebert U, Lau J. Decision-Analytic Modeling to Evaluate Benefits and Harms of Medical Tests: Uses and Limitations. Med Decis Making 2009; 29:E22-9. [DOI: 10.1177/0272989x09345022] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The clinical utility of medical tests is measured by whether the information they provide affects patient-relevant outcomes. To a large extent, effects of medical tests are indirect in nature. In principle, a test result affects patient outcomes mainly by influencing treatment choices. This indirectness in the link between testing and its downstream effects poses practical challenges to comparing alternate test-and-treat strategies in clinical trials. Keeping in mind the broader audience of researchers who perform comparative effectiveness reviews and technology assessments, the authors summarize the rationale for and pitfalls of decision modeling in the comparative evaluation of medical tests by virtue of specific examples. Modeling facilitates the interpretation of test performance measures by connecting the link between testing and patient outcomes, accounting for uncertainties and explicating assumptions, and allowing the systematic study of tradeoffs and uncertainty. The authors discuss challenges encountered when modeling test-and-treat strategies, including but not limited to scarcity of data on important parameters, transferring estimates of test performance across studies, choosing modeling outcomes, and obtaining summary estimates for test performance data.
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Affiliation(s)
- Thomas A. Trikalinos
- Tufts Evidence-based Practice Center and Center for Clinical Evidence Synthesis, Tufts Medical Center, Boston, Massachusetts,
| | - Uwe Siebert
- Department of Public Health, Medical Decision Making and Health Technology Assessment UMIT-University for Health Sciences, Medical Informatics and Technology, Hall I. T., Austria, Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical, School and Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
| | - Joseph Lau
- Tufts Evidence-based Practice Center and Center for Clinical Evidence Synthesis, Tufts Medical Center, Boston, Massachusetts
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