Cardiovascular and fracture events analysis and intervention strategies in patients undergoing parathyroidectomy with secondary hyperparathyroidism.

Background: Chronic kidney disease (CKD), especially end-stage renal disease (ESRD), is the most common cause of secondary hyperparathyroidism (SHPT), and SHPT is the most severe complication of ESRD. This study aimed to analyze the influencing factors of cardiovascular and fracture events in patients with SHPT which are the leading causes of death in patients with CKD, and provide a reference for selecting patients for whom surgery is more suitable. Methods: Patients who underwent parathyroidectomy (PTX) for SHPT at The First Affiliated Hospital, Zhejiang University School of Medicine from September 2021 to April 2024 were selected as the study object, with the inclusion and exclusion criteria as followed. They were divided into rural and urban residents for comparison as a cross-sectional study. The study evaluated the comorbidities, socioeconomic status, and postoperative complications diagnosed by radiography of patients undergoing surgery for SHPT. Results: A total of 119 patients were included, among whom, 71 were from rural areas and 48 were from urban areas. Compared with urban residents, rural residents had poorer economic conditions, a longer interval from disease onset to PTX, and a higher incidence of cardiovascular and fracture events and concurrent nephrolithiasis, all of which were statistically significant. Multivariate analysis indicated that place of residence, age, and duration of uremia were independent risk factors of cardiovascular/fracture events. Conclusions: Medical staff in ESRD outpatient clinics should pay attention to patients with SHPT. ESRD patients should have better surveillance especially for rural, elder and poor phosphorus control patients, and promptly assess surgical intervention measures.

A basidomycetous hydroxynaphthalene-prenylating enzyme exhibits promiscuity toward prenyl donors.

The fungal prenyltransferase ShPT from Stereum hirsutum was believed to prenylate 4-hydroxybenzyl alcohol and thereby be involved in the vibralactone biosynthesis. In this study, we demonstrate that hydroxynaphthalenes instead of benzyl alcohol or aldehyde were accepted by ShPT for regular C-prenylation in the presence of both dimethylallyl and geranyl diphosphate. Although the natural substrate of ShPT remains unknown, our results provide one additional prenyltransferase from basidiomycetes, which are less studied, in comparison to those from other sources. Furthermore, this study expands the chemical toolbox for regioselective production of prenylated naphthalene derivatives. KEY POINTS: •Basidiomycetous prenyltransferase •Biochemical characterization •A DMATS prenyltransferase prenylating hydroxynaphthalene derivatives.

Comparative Effectiveness of MRI, 4D-CT and Ultrasonography in Patients with Secondary Hyperparathyroidism.

Objective: Accurate preoperative localization of abnormal parathyroid glands is crucial for successful surgical management of secondary hyperparathyroidism (SHPT). This study was conducted to compare the effectiveness of preoperative MRI, 4D-CT, and ultrasonography (US) in localizing parathyroid lesions in patients with SHPT. Methods: We performed a retrospective review of prospectively collected data from a tertiary-care hospital and identified 52 patients who received preoperative MRI and/or 4D-CT and/or US and/or 99mTc-MIBI and subsequently underwent surgery for SHPT between May 2013 and March 2020. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of each imaging modality to accurately detect enlarged parathyroid glands were determined using histopathology as the criterion standard with confirmation using the postoperative biochemical response. Results: A total of 198 lesions were identified intraoperatively among the 52 patients included in this investigation. MRI outperformed 4D-CT and US in terms of sensitivity (P < 0.01), specificity (P = 0.455), PPV (P = 0.753), and NPV (P = 0.185). The sensitivity and specificity for MRI, 4D-CT, and US were 90.91%, 88.95%, and 66.23% and 58.33%, 63.64%, and 50.00%, respectively. The PPV of combined MRI and 4D-CT (96.52%) was the highest among the combined 2 modalities. The smallest diameter of the parathyroid gland precisely localized by MRI was 8×3 mm, 5×5 mm by 4D-CT, and 5×3 mm by US. Conclusion: MRI has superior diagnostic performance compared with other modalities as a first-line imaging study for patients undergoing renal hyperparathyroidism, especially for ectopic or small parathyroid lesions. We suggest performing US first for diagnosis and then MRI to make a precise localization, and MRI proved to be very helpful in achieving a high success rate in the surgical treatment of renal hyperparathyroidism in our own experience.

RNA-Seq-based transcriptomics analysis during the photodynamic therapy of primary cells in secondary hyperparathyroidism.

BACKGROUND: The aim of this study was to identify changes in gene expression before and after 5-aminolevulinic acid-mediated photodynamic therapy (5-ALA-PDT) and to investigate the potential mechanism of 5-ALA-PDT based on ribonucleic acid sequencing (RNA-Seq) analysis. METHODS: Secondary hyperparathyroidism (SHPT) primary cells were isolated from surgically excised specimens and exposed to laser light. The transcription profiles of SHPT primary cells were identified through RNA-Seq. Differentially expressed genes (DEGs) were identified. Enrichment of functions and signaling pathway analysis were performed based on Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses. Quantitative real-time polymerase chain reaction (RT-qPCR) and western blot analysis were used to validate genes based on RNA-Seq results. RESULTS: In total, 1320 DEGs were identified, of which 1019 genes were upregulated and 301 genes were downregulated. GO and KEGG pathway analyses identified significantly enriched pathways in DEGs, including TGF beta in extracellular matrix (ECM), negative regulation of triglyceride biosynthetic process, protein heterodimerization activity, systemic lupus erythematosus, ECM-receptor interaction, focal adhesion and protein digestion and absorption. Protein-protein interaction (PPI) network analyses identified potential heat shock protein (HSP) interactions among the DEGs. Eight HSP genes were also identified that were most likely involved in 5-ALA-PDT, which were further validated by RT-qPCR and western blotting. CONCLUSIONS: The findings of this descriptive study reveal changes in the transcriptome profile during 5-ALA-PDT, suggesting that gene expression and mutation, signaling pathways, and the molecular network are altered in SHPT primary cells. The above findings provide new insight for further studies on the mechanisms underlying 5-ALA-PDT in SHPT.

Effectiveness and Safety of Ultrasound-Guided Local Paricalcitol Injection in Treating Secondary Hyperparathyroidism in ESRD: A Retrospective Study.

PURPOSE: To compare the safety and efficacy of percutaneous paricalcitol injection with intravenously administered paricalcitol in treating parathyroid hyperplasia in patients with secondary hyperparathyroidism (SHPT). METHODS: This study was approved by the Ethics Committee of our institution. We retrospectively collected data on patients who received percutaneous paricalcitol injection (24 patients) and intravenously administered paricalcitol (22 patients) based on their intact parathyroid hormone (iPTH) level. Serum iPTH, calcium, phosphorus, and the volume of the parathyroid gland were measured at several indicated time points after treatment, and adverse events associated with the two treatments were evaluated. RESULTS: After 6 months of follow-up, we found that patients from the percutaneous injection group had significantly decreased levels of iPTH (from 1887.81 ± 726.81 pg/mL to 631.06 ± 393.06 pg/mL), phosphate (from 1.94 ± 0.36 mmol/L to 1.71 ± 0.34 mmol/L), and volume of the parathyroid gland (from 0.87 ± 0.50 cm3 to 0.60 ± 0.36 cm3), with relief from ostealgia within 48-72 h. In the intravenously administered group, the levels of iPTH decreased from 686.87 ± 260.44 pg/mL to 388.47 ± 167.36 pg/mL; while there was no significant change in phosphate levels, the volume of the parathyroid gland and ostealgia relief were observed at the end of follow-up. The serum calcium level did not significantly change, and no severe complications were observed in both groups. In vitro fluorescence-activated single cell sorting (FACS) analysis indicated that paricalcitol induced parathyroid cell apoptosis in a dose-dependent manner. CONCLUSIONS: Percutaneous paricalcitol injection is a selective treatment for SHPT in ESRD.

A Systematic Review and Meta-analysis of Efficacy and Safety of Calcimimetic Agents in the Treatment of Secondary Hyperparathyroidism in Patients with Chronic Kidney Disease.

BACKGROUND: Some reports have pointed out that calcimimetics agents are effective in the treatment of secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD) patients, but there is no detailed description of the advantages and disadvantages of calcimimetics agents of SHPT in CKD patients. We tried to pool the published data to verify the effectiveness of calcimimetics agents and to compare the advantages and disadvantages of cinacalcet compared with control in the treatment of SHPT in CKD patients. METHODS: We included eligible studies of published papers from January 1st, 2000 to December 31st, 2020 in Medline, Pubmed and Web of science databases, and the data were extracted for this meta-analysis. RESULTS: Twenty-seven studies were eligible, and all the included studies were randomized controlled trials (RCT) including patients treated with long-term dialysis. The results indicated that calcimimetic agents can reduce the parathyroid hormone (PTH, pg/ml) level (WMD = -178.22, 95% CI: -238.57, -117.86, P < 0.00001), calcium (Ca, mg/dl) level (WMD = -0.71, 95% CI: -0.86, -0.55, P < 0.00001), phosphorus (P, mg/dl) level (WMD = -0.32, 95% CI: -0.55, -0.08, P = 0.008), calcium-phosphorus product level (WMD = -7.73, 95% CI: -9.64, -5.82, P < 0.00001). Calcimimetic agents increased the bone alkaline phosphatase (BSAP, ng/ml) levels and rate of achieving target PTH, and reduced osteocalcin levels and the rate of parathyroidectomy. Calcimimetic agents increased the total adverse events' rate, the rate of hypocalcemia and gastrointestinal side effects (nausea, vomiting, abdominal pain and diarrhea), but there was no significant difference in serious adverse events between the calcimimetic agent group and control group. CONCLUSION: Calcimimetic agents can reduce the PTH level, Ca level, P level, calcium-phosphorus product level and do not increase serious adverse events.

Modulation of cardiometabolic risk and CardioRenal syndrome by oral vitamin D3 supplementation in Black and White Southern Sahara residents with chronic kidney disease Stage 3: focus on racial and ethnic disparities.

OBJECTIVES: Several studies have shown that cholecalciferol supplementation (25OHD-S) in chronic kidney disease (CKD) improves kidney injury by reducing fibrosis-related vascular calcification and declining apoptosis-linked nephron damage. METHODS: The oral 25OHD-S was evaluated in 60,000 IU/month/36 weeks versus in 2000 IU/d/24 weeks in CKD Stage 3 with serum 25OHD level < 20 ng/mL. The study was undertaken on 156 black subjects and 150 white subjects Southern Sahara (SS). All biomarkers of cardiometabolic (CMet) and cardiorenal (CRenal) syndrome, Renin-angiotensin-aldosterone system (RAAS) profile, secondary hyperparathyroidism (SHPT), N-terminal pro B-type natriuretic peptide (NT-proBNP), Troponin T (cTnT) and atherogenicity risk were assessed by biochemical methods. Estimate glomerular filtration rate (eGFR) by chronic CKD-EPI equation formula. Total serum vitamin D by liquid chromatography-tandem mass spectrometry (MS). RESULTS: Vitamin D deficiency alters in the same manner CMet, CRenal, and others biomarkers in both groups SS; however, these disorders are more acute in blacks compared to whites SS. Oral 25OHD-S a highlighted improvement of eGFR drop, SHPT decrease, decline proteinuria, and cardiac failure risk (NT-proBNP and cTnT) attenuation. Concomitantly, 25OHD-S normalizes Renin, Aldosterone, and Angiotensin System (RAAS) activity. Nevertheless, homocysteine and Lp (a) do not modulate by 25OHD-S. CONCLUSIONS: The oral vitamin D3 supplementation, according the dose, and the treatment duration does not like in black-skinned people versus to white-skinned inhabitants, while the 02 groups are native to the same Saharan environment. It emerge that a high intermittent dose through an extensive supplementation (60,000 IU/36 weeks) was more effective in black subjects. At opposite, a lower dose during a short period supplementation is sufficient (2000 IU/24 weeks) in white subjects.

Prevalence and associated factors of secondary hyperparathyroidism after Roux-en-Y gastric bypass: A meta-analysis.

This study aimed to investigate the prevalence and factors associated with secondary hyperparathyroidism (SHPT) after Roux-en-Y gastric bypass (RYGB). We searched PubMed, EMBASE, and CENTRAL for relevant studies using search terms gastric bypass, RYGB and hyperparathyroidism. Thirty-four cohort studies with 4331 patients were incorporated into the final meta-analysis. Overall estimates of the prevalence of SHPT following RYGB were 39%. Subgroup analyses indicated the pooled prevalences of SHPT were 25%, 42%, 48%, and 54% for ≤1 year, >1 and ≤5 years, >5 and ≤10 years, and >10 years, respectively, after RYGB. Meta-regression showed that SHPT occurred was positively related to follow-up durations (p = 0.001). Additionally, SHPT prevalence was higher in studies in which calcium and vitamin D supplementation were considered inadequate than in those which were adequate (p = 0.002). SHPT is highly prevalent in individuals with obesity after RYGB. It seems to progress with time after surgery. Routine calcium and vitamin D supplementation post-RYGB together with targeted treatment of vitamin D deficiency, reasonable adjustment of the doses of supplementation with regular follow-up, and improved patient compliance, as well as long-term screening, are necessary to prevent the development of SHPT.

The rate, cost and outcomes of parathyroidectomy in the united states dialysis population from 2016-2018.

BACKGROUND: In end-stage kidney disease, patients may undergo parathyroidectomy if secondary hyperparathyroidism cannot be managed medically. This study was designed to estimate the parathyroidectomy rate in the United States (US) and to quantify changes in costs and other outcomes after parathyroidectomy. METHODS: This was a retrospective observational cohort study using US Renal Data System data for 2015-2018. Parathyroidectomy rates were estimated for adult hemodialysis and peritoneal dialysis patients alive at the beginning of 2016, 2017, and 2018 who were followed for a year or until parathyroidectomy, death, or transplant. Incremental differences in economic and clinical outcomes were compared before and after parathyroidectomy in adult hemodialysis and peritoneal dialysis patients who received a parathyroidectomy in 2016 and 2017. RESULTS: The rate of parathyroidectomy per 1,000 person-years decreased from 6.5 (95% CI 6.2-6.8) in 2016 to 5.3 (95% CI 5.0-5.6) in 2018. The incremental increase in 12-month cost after versus before parathyroidectomy was $25,314 (95% CI $23,777-$27,078). By the second month after parathyroidectomy, 58% of patients had a corrected calcium level < 8.5 mg/dL. In the year after parathyroidectomy (versus before), hospitalizations increased by 1.4 per person-year (95% CI 1.3-1.5), hospital days increased by 12.1 per person-year (95% CI 11.2-13.0), dialysis visits decreased by 5.2 per person-year (95% CI 4.4-5.9), and office visits declined by 1.3 per person-year (95% CI 1.0-1.5). The incremental rate per 1,000 person years for hematoma/bleed was 224.4 (95% CI 152.5-303.1), for vocal cord paralysis was 124.6 (95% CI 59.1-232.1), and for seroma was 27.4 (95% CI 0.4-59.0). CONCLUSIONS: Parathyroidectomy was a relatively uncommon event in the hemodialysis and peritoneal dialysis populations. The incremental cost of parathyroidectomy was mostly attributable to the cost of the parathyroidectomy hospitalization. Hypocalcemia occurred in over half of patients, and calcium and phosphate levels were reduced. Clinicians, payers, and patients should understand the potential clinical and economic outcomes when considering parathyroidectomy.

Predictors of hyperkalemia after total parathyroidectomy in patients with drug-refractory secondary hyperparathyroidism.

Background: The purpose of this retrospective study was to explore the primary possible risk factors for the development of postoperative hyperkalemia after total parathyroidectomy with autotransplantation (TPTX + AT) in patients with drug-refractory secondary hyperparathyroidism (SHPT). Methods: The clinical data of 149 patients receiving maintenance dialysis for drug-refractory SHPT, who underwent TPTX + AT, were reviewed and analyzed. Demographic data, dialysis status, and laboratory test indices were collected from enrolled patients. According to the postoperative serum potassium level >5.3 mmol/L or not, they were divided into hyperkalemia group and non-hyperkalemia group. The differences in general clinical data and laboratory indicators between the two groups were compared; logistic regression analysis was performed to analyze the risk factors affecting the development of postoperative hyperkalemia in patients; receiver operating characteristic (ROC) subject workup curves were analyzed for the threshold values of postoperative hyperkalemia. Results: Of the 149 participants, 25 (16.78%) developed postoperative hyperkalemia after TPTX + AT. Univariate analysis suggested that dialysis duration, SHPT duration, dialysis modality, and preoperative alkaline phosphatase, blood potassium, and blood calcium levels were independently associated with the development of hyperkalemia after TPTX + AT. Univariate logistic analysis suggested that dialysis duration [odds ratio (OR) 1.18, 95% confidence interval (CI): 1.03, 1.35, P=0.014], preoperative blood potassium (OR 4.95, 95% CI: 2.05, 11.96, P<0.001), and preoperative blood calcium (OR 16.17, 95% CI: 1.36, 191.58, P=0.027) were 3 factors that predicted hyperkalemia after TPTX + AT. According to ROC curve analysis, the optimal cutoff point for dialysis duration was 8.5 years, the optimal cutoff level for preoperative blood potassium was 4.57 mmol/L, and the optimal cutoff level for preoperative blood calcium was 2.31 mmol/L. Of these 3 factors, preoperative blood potassium had a more balanced sensitivity, specificity, and optimal diagnostic efficacy. Conclusions: Patients with drug-refractory SHPT are prone to hyperkalemia after TPTX + AT. Duration of dialysis and preoperative blood potassium and blood calcium levels can help predict the development of postoperative hyperkalemia.

Efficacy and safety of intravenous paricalcitol treatment in Chinese hemodialysis patients: a real-world database analysis.

BACKGROUND: The aim of this retrospective observational study based on real-world data was to evaluate the efficacy and safety profile of paricalcitol in Chinese hemodialysis (HD) patients with secondary hyperparathyroidism (SHPT) in routine clinical practice. METHODS: From the Better Life for Future database, a total of 668 Chinese hemodialysis patients from 104 dialysis centers between January 2015 and May 2019 were included in the analysis set. Intact parathyroid hormone (iPTH), total serum calcium (Ca), phosphate (P), dosage of intravenous (IV) paricalcitol (Zemplar®) were analyzed and discussed via retrospective analysis of the database during the treatment. RESULTS: Patients were divided into five groups according to the duration of follow-up. Median iPTH levels decreased from 1,183 pg/mL at baseline to 676 pg/mL at the final visit, or 30.88% (P<0.0001). A total of 56.14% of patients had a ≥30% decrease and 29.34% of patients had a ≥50% decrease in iPTH level. Serum Ca levels shown significantly increased in the group of Month 12-24 (P=0.0479). Serum phosphate levels remained stable in all follow-up groups. The average dose of paricalcitol was 20±9 µg/week. The total dose of paricalcitol and baseline iPTH were negatively correlated with the decrease in iPTH levels. CONCLUSIONS: This is the first national retrospective real-world observational study since intravenous paricalcitol is available in China since 2014. This study demonstrates the use of paricalcitol as an effective and well-tolerated treatment for the control of PTH during its use in routine practice.

Ultrasound-Guided Radiofrequency Ablation: A New Attempt to the Treatment of Refractory Hyperparathyroidism Secondary to Chronic Kidney Disease.

INTRODUCTION: To evaluate clinical application value of radiofrequency ablation (RFA) in refractory hyperparathyroidism secondary to chronic kidney disease (CKD) by comparing the safety and effectiveness of RFA with parathyroidectomy with autotransplantation (PTX + AT). METHODS: A retrospective study was conducted on 80 patients with CKD with refractory hyperparathyroidism who underwent RFA or PTX + AT between January 2018 and February 2021. Serum parathyroid hormone (PTH), calcium, and phosphorus levels, complications, clinical symptoms, visual analogue scale (VAS) scores, hospital stay duration, and postoperative recurrence rate were compared between the 2 groups. RESULTS: Serum PTH, phosphorous, and calcium levels and the VAS scores improved significantly after RFA and PTX + AT (P < 0.05). Significant differences were observed between the 2 groups in postoperative (day 1 and week 1) levels of serum PTH and postoperative day 1 of serum calcium and phosphorus levels (P < 0.05), with more pronounced reduction after PTX + AT. Although the incidence of recurrent laryngeal nerve (RLN) injury was slightly higher in the RFA group compared with the PTX + AT group (26.67% vs. 16.67%; P > 0.05), RFA markedly decreased the risk of severe hypocalcemia (SH) (20% vs. 46.67%; P < 0.05) and shortened hospital stay (7.53 ± 2.67 days vs. 12.13 ± 3.86 days; P < 0.05). The 6-month recurrence rate was 23.3% (7 of 30) in the RFA group and 30% (9 of 30) in the PTX + AT group (P > 0.05). CONCLUSION: RFA can treat refractory secondary hyperparathyroidism (SHPT) with similar clinical efficacy as surgery and achieve faster recovery and a lower incidence of postoperative SH.

Uremic leontiasis ossea: distinctive imaging features allow differentiation from other clinical causes of leontiasis ossea.

Skeletal changes are a common complication in patients with chronic kidney disease and traditionally labelled as renal osteodystrophy. Uremic leontiasis ossea is a rare and severe form of renal osteodystrophy with characteristic overgrowth of the craniofacial bones. Imaging, in particular computed tomography, is valuable for the diagnosis and management of such rare condition. Uremic leontiasis ossea has distinctive imaging features with significant overgrowth of the jaw and characteristic internal serpiginous tunneling. The recognition of its radiological appearance and abrupt management are essential to avoid its devastating esthetic and functional impairments.

Etelcalcetide Utilization, Dosing Titration, and Chronic Kidney Disease-Mineral and Bone Disease (CKD-MBD) Marker Responses in US Hemodialysis Patients.

RATIONALE & OBJECTIVE: Clinical trial data have demonstrated the efficacy of etelcalcetide for reducing parathyroid hormone (PTH) levels in hemodialysis (HD) patients. We provide a real-world summary of etelcalcetide utilization, dosing, effectiveness, and discontinuation since its US introduction in April 2017. STUDY DESIGN: New-user design within prospective cohort. SETTING & PARTICIPANTS: 2,596 new users of etelcalcetide from April 2017 through August 2019 in a national sample of adult maintenance HD patients in the US Dialysis Outcomes and Practice Patterns Study (DOPPS). PREDICTORS: Baseline PTH, prior cinacalcet use, initial etelcalcetide dose. OUTCOME: Trajectories of etelcalcetide dose, chronic kidney disease-mineral and bone disease (CKD-MBD) medications, and levels of PTH, serum calcium, and phosphorus in the 12 months after etelcalcetide initiation. ANALYTICAL APPROACH: Cumulative incidence methods for etelcalcetide discontinuation and linear generalized estimating equations for trajectory analyses. RESULTS: By August 2019, etelcalcetide prescriptions increased to 6% of HD patients from their first use in April 2017. Starting etelcalcetide dose was 15 mg/wk in 70% of patients and 7.5 mg/wk in 27% of patients; 49% of new users were prescribed cinacalcet in the prior 3 months. Etelcalcetide discontinuation was 9%, 17%, and 27% by 3, 6, and 12 months after initiation. One year after etelcalcetide initiation, mean PTH levels declined by 40%, from 948 to 566 pg/mL, and the proportion of patients with PTH within target (150-599 pg/mL) increased from 33% to 64% overall, from 0 to 60% among patients with baseline PTH ≥ 600 pg/mL, and from 30% to 63% among patients with prior cinacalcet use. The proportion of patients with serum phosphorus > 5.5 mg/dL decreased from 55% to 45%, while the prevalence of albumin-corrected serum calcium < 7.5 mg/dL remained at 1%-2%. There were increases in use of active vitamin D (from 77% to 87%) and calcium-based phosphate binders (from 41% to 50%) in the 12 months after etelcalcetide initiation. LIMITATIONS: Data are unavailable for provider dosing protocols, dose holds, or reasons for discontinuation. CONCLUSIONS: In the 12 months after etelcalcetide initiation, patients had large and sustained reductions in PTH levels. These results support the utility of etelcalcetide as an effective therapy to achieve the KDIGO-recommended guidelines for CKD-MBD markers in HD patients.

Predictive markers for severe hypocalcemia in dialysis patients with secondary hyperparathyroidism after near-total parathyroidectomy.

BACKGROUND: Secondary hyperparathyroidism (SHPT) is common in dialysis patients with end-stage renal disease (ESRD). Parathyroidectomy (PTX) is an effective treatment for SHPT. Postoperative severe hypocalcemia (SH) is a common and severe complication after PTX. This study aimed to investigate the potential predictive markers of SH in dialysis ESRD patients with SHPT after near-total PTX (near-tPTX) without autotransplantation (AT). METHODS: A retrospective analysis involving 131 dialysis patients with SHPT who were treated with near-tPTX without AT between January and August 2018 was performed. Demographic characteristics (age, gender, type of dialysis modality, etc.) and perioperative laboratory parameters [serum calcium, phosphorus, alkaline phosphatase (ALP), intact parathyroid hormone (iPTH), and bone metabolism markers] were collected and analyzed. Postoperative serum calcium level <1.875 mmol/L (7.5 mg/dL) was defined as postoperative SH. RESULTS: Among the 131 patients, 73 (55.7%) had postoperative hypocalcemia and 43 (32.8%) had postoperative SH. Univariate analysis showed that values of preoperative serum iPTH, calcium, ALP, bone-specific alkaline phosphatase (BAP), and osteocalcin (OC) were significantly different between the SH and non-SH groups. In the multivariate logistic regression model, preoperative serum ALP was an independent risk predictor of postoperative SH. The receiver operating characteristic (ROC) curve for preoperative serum ALP was 277 U/L. The sensitivity of preoperative serum ALP was 73.8% and the specificity was 63.2%. CONCLUSIONS: The incidence rates of postoperative hypocalcemia and SH in dialysis patients with SHPT after near-tPTX without AT were 55.7% and 32.8%, respectively. Preoperative serum ALP was an independent predictor for the occurrence of postoperative SH, and dialysis patients with SHPT were susceptible to postoperative SH when preoperative serum ALP level was >277 U/L. Hence, we recommend that preoperative serum ALP be utilized to complement clinical protocols for postoperative SH management of dialysis ESRD patients with SHPT after near-tPTX without AT.

Active vitamin D increases the risk of hypercalcaemia in non-dialysis chronic kidney disease patients with secondary hyperparathyroidism: a systematic review and meta-analysis.

BACKGROUND: This study evaluates the effects of active (1α-hydroxylated) vitamin D (AVD) therapy on hypercalcaemia in patients with non-dialysis chronic kidney disease (ND-CKD) and secondary hyperparathyroidism (SHPT). METHODS: A systematic search of the PubMed, Embase and Cochrane Library databases (up to 14 May 2020) was performed to identify randomized, placebo-controlled trials of single-agent, oral AVD therapies in adults with ND-CKD and SHPT. Only studies with ≥30 participants per arm and ≥6 weeks in duration were eligible. The outcome of interest was the number of subjects with an episode of hypercalcaemia. A meta-analysis of eligible studies was conducted using Comprehensive Meta-Analysis software (version 3.0). RESULTS: Six studies (five evaluating paricalcitol, one evaluating alfacalcidol) involving 799 patients were identified. Treatment durations ranged from 16 weeks to 2 years. The weekly doses of paricalcitol administered were 7 (three studies) and 14 µg (two studies); the weekly dose of alfacalcidol was 1.75-7.0 µg. Across all studies, rates of hypercalcaemia were 1.1-43.3% with AVD versus 0-3.4% with placebo. Meta-analysis of the six studies showed that AVD was associated with a 6.6-fold greater probability of hypercalcaemia versus placebo (odds ratio: 6.63, 95% confidence interval: 2.37, 18.55; P < 0.001). Two separate sensitivity analyses (one excluded a study identified as having a high risk of bias; the second excluded two studies that accounted for a large proportion of observed hypercalcaemia events) indicated the primary meta-analysis findings were robust. CONCLUSIONS: Compared with placebo, AVD significantly increased the risk of hypercalcaemia among ND-CKD patients with SHPT.

Changes in bone microarchitecture following parathyroidectomy in patients with secondary hyperparathyroidism.

BACKGROUND: Secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD) has a significant effect on bone, affecting both trabecular and cortical compartments. Although parathyroidectomy results in biochemical improvement in mineral metabolism, changes in bone microarchitecture as evaluated by high-resolution imaging modalities are not known. Magnetic resonance imaging (MRI) provides in-depth three-dimensional assessment of bone microarchitecture, as well as determination of mechanical bone strength determined by finite element analysis (FEA). METHODS: We conducted a single-centre longitudinal study to evaluate changes in bone microarchitecture with MRI in patients with SHPT undergoing parathyroidectomy. MRI was performed at the distal tibia at baseline (time of parathyroidectomy) and at least 12 months following surgery. Trabecular and cortical topological parameters as well as bone mechanical competence using FEA were assessed. RESULTS: Fifteen patients with CKD (12 male, 3 female) underwent both MRI scans at the time of surgery and at least 12 months post-surgery. At baseline, 13 patients were on dialysis, one had a functioning kidney transplant, and one was pre-dialysis with stage 5 CKD. Seven patients received a kidney transplant following parathyroidectomy prior to follow-up MRI. MRI parameters in patients at follow up were consistent with loss in trabecular and cortical bone thickness (p = 0.006 and 0.03 respectively). Patients who underwent a kidney transplant in the follow-up period had reduction in trabecular thickness (p = 0.05), whereas those who continued on dialysis had reduction in cortical thickness (p = 0.04) and mechanical bone strength on FEA (p = 0.03). CONCLUSION: Patients with severe SHPT requiring parathyroidectomy have persistent changes in bone microarchitecture at least 12 months following surgery with evidence of ongoing decline in trabecular and cortical thickness.

Application of nanocarbon negative imaging technology in surgery for secondary hyperparathyroidism.

BACKGROUND: Our objective is to evaluate the application values and effects of nanocarbon negative imaging technology in surgery for patients with the fifth stage of chronic kidney disease complicated with secondary hyperparathyroidism (SHPT). METHODS: Eighty-nine patients with SHPT in the fifth stage of chronic kidney disease admitted to the Department of Thyroid and Breast Surgery at the Affiliated Hospital of Nantong University between January 2018 and August 2020 were selected. All patients underwent total parathyroidectomy (tPTX) and were randomly divided into a group receiving nanocarbon (observation group; group A) and a control group (group B). Patients were followed up for 6 months after surgery and several observation indexes were compared and analyzed. RESULTS: Compared with the control group, the parathyroid glands in the observation group treated with nanocarbon were more clearly exposed, and better performances were seen in the operation time, blood loss, and recovery rate of bone pain (P<0.05). The postoperative follow-up blood intact parathyroid hormone level (iPTH) and recurrence rate control were also improved in the observation group and the differences were statistically significant (P<0.05). CONCLUSIONS: In the fifth stage of chronic kidney disease with SHPT, the application of nanocarbon negative imaging technology can significantly reduce the recurrence rate of hyperparathyroidism, improve the surgical effect, and improve the long-term quality of life and survival rate of patients.

Cephalometric craniofacial features of patients with Sagliker syndrome: a primary analysis of our experience.

BACKGROUND: Sagliker syndrome (SS) is characterized by a severe uglifying facial appearance resulting from untreated or inadequately treated secondary hyperparathyroidism (SHPT). To date, the craniofacial morphology of patients with SS has yet to be analyzed. The present research sought to cephalometrically evaluate the craniofacial features of patients with SS and to perform an in-depth analysis of their serum biochemical parameters, with the aim of furthering the theoretical basis for the early diagnosis and prevention of SS. METHODS: A retrospective chart review of 9 patients who fulfilled the diagnostic criteria for SS were included in this study, and their serum biochemical parameters were collected. After subjecting standard lateral cephalometric radiographic images to correction for distortions caused by magnification followed by digitization, we conducted a cephalometric analysis. Student's two-tailed t tests or Mann-Whitney U tests were used to analyze the data. Thirty-three patients with patients with SHPT alone were also included as controls. RESULTS: The lower anterior facial height (ANS-ME) and total anterior facial height (N-Me) measurements of patients with SS were significantly increased compared to those of the controls. The angles between the Frankfort horizontal, palatal, and occlusal planes and the mandibular plane, were greater in the SS group than in the control group, as was the gonial angle. Patients with SS also exhibited a significantly larger maxillary protrusion angle and relative position of the maxilla to the mandible. Most patients with SS had class II malocclusion, whereas most of the controls exhibited normal occlusion. Soft tissue largely followed the same pattern as craniofacial changes. Our investigation also showed that among patients with SHPT, female sex, longer duration of dialysis, and higher serum levels of alkaline phosphatase and intact parathyroid hormone were associated with development to SS. CONCLUSIONS: Patients with SS show facial and biochemical differences compared to patients with SHPT. Female sex, long dialysis duration, and high serum levels of intact parathyroid hormone and alkaline phosphatase may be potential risk factors for SS.

Relationship between intraoperative measured parameters of parathyroid gland and pathological patterns in patients with secondary hyperparathyroidism.

BACKGROUND: The hyperplastic patterns of parathyroid glands (PTGs) in secondary hyperparathyroidism (SHPT) are critical for surgical indication and deciding on the approach. Earlier histopathological investigations have suggested the occurrence of an initial increase in the parathyroid cells, with a normal lobular structure (diffuse hyperplasia, DH). After this, the PTGs become hyperplastic with some nodules (nodular hyperplasia, NH). The current study aimed to explore the relationship between the intraoperative measurements of weight, volume, and maximal diameter of dissected PTGs and the histopathological diagnosis of SHPT patients with end-stage renal disease. METHODS: A total of 182 SHPT patients who received parathyroidectomy (PTX) were retrospectively enrolled. Altogether 21 patients were selected as having at least one diffuse polyclonal hyperplasia PTG. Intraoperative measurements of weight, volume, and maximal diameter of dissected PTGs were compared between tissues with DH and NH. RESULTS: Intraoperative dissected PTGs were verified histologically. The differences in the intraoperative measurements of weight, volume, maximal diameter, and the combination of the three measurements between the DH and the NH PTGs groups were significant (P=0.000), and the values of area under the ROC curve (AUCs) were 0.824 (95% CI: 0.731-0.918), 0.812 (95% CI: 0.716-0.908), 0.746 (95% CI: 0.633-0.860), and 0.851 (95% CI: 0.768-0.935), respectively, with cut-off values of the three parameters being 0.19 g, 206.3 mm3, and 10.5 mm, respectively. CONCLUSIONS: The measurement of weight, volume, and maximal diameter of dissected PTGs is a possible alternative to assess the hyperplasia patterns of the dissected PTGs. It is a promising reference for the ultrasound prediction of pathological patterns of PTGs.