[What's New in the CKD-BMD Therapy?]

The important advances in scientific knowledge have led to a notable enrichment of therapeutic offers in the field of CKD-MBD, which have allowed better control of the related biochemical parameters compared to the past. However, this has not corresponded to a tangible improvement in the clinical outcomes, both bone and cardiovascular, associated with CKD-MBD, nor has there been a significant drop in the number of pills that nephropathic patients must take, to keep the parameters controlled biochemicals, with the therapeutic cost of these interventions remaining high. All these unsatisfied needs continue to stimulate research to find new solutions that can improve one or more of these objectives not yet achieved. In this review of the most recent literature, we have tried to summarize what has been recently proposed in the therapeutic field of CKD-MBD, underlining the possible advantages of new drugs compared to already available therapies, with particular attention to unmet needs. We have also revisited the recent acquisitions relating to drugs that have already been in use for some time, reporting the most recent evidence that could change the approach to their use.

Factors associated with dysfunction of autogenous arteriovenous fistula in patients with secondary hyperparathyroidism after parathyroidectomy.

BACKGROUND: Secondary hyperparathyroidism (SHPT) is a prevalent chronic complication in patients undergoing hemodialysis. Parathyroidectomy (PTX) is crucial for reducing mortality and improving the prognosis in the treatment of refractory hyperparathyroidism. However, it is often associated with a number of postoperative complications such as postoperative hypotension, hyperkalemia, and hungry bone syndrome. A previous study demonstrated that low blood pressure influences the patency of autogenous arteriovenous fistulas (AVF). Few studies have examined AVF dysfunction following PTX. This study aimed to identify and describe the risk variables associated with AVF dysfunction after PTX. METHODS: Cases of AVF dysfunction after PTX between 2015 and 2021 were studied. Four controls were identified for each patient and were matched for sex and age. Biochemical parameters and blood pressure of the patients before and after PTX were recorded. Risk factors for AVF dysfunction after PTX were identified using conditional logistic regression analysis. RESULTS: Sixteen patients and 64 controls were included in this study. Baseline demographic and laboratory data were compared. Patients in the AVF dysfunction group had lower levels of postoperative calcium than the controls. After surgery, calcium levels decreased more in patients with AVF dysfunction than in the control group. The decrease in systolic blood pressure (ΔSBP) after PTX was greater in the AVF dysfunction group than that in the control group. For each 1 mmHg increment in ΔSBP, the risk of AVF dysfunction after surgery increased by 11.6% (OR = 1.116, 95% CI, 1.005-1.239, p = .040). The likelihood of developing AVF dysfunction after surgery was twelvefold higher in diabetic patients than in non-diabetic patients (OR = 12.506, 95% CI, 1.113-140.492, p = .041). Among patients with ΔSBP > 5.8 mmHg after PTX, the AVF failure rate was significantly greater in patients with diabetes than in those without diabetes. Patients with a history of AVF failure had a nine-fold higher risk of developing AVF dysfunction (OR = 9.143, 95% CI, 1.151-72.627, p = .036). Serum albumin, hemoglobin, ΔiPTH, and age were not independent predictors of AVF dysfunction. The cutoff value for SBP was 5.8 mmHg, as determined by the Youden index of the receiver operating characteristic curve. CONCLUSION: Decreased systolic blood pressure (ΔSBP) after PTX, diabetes, and AVF failure history were risk factors for AVF dysfunction following PTX in patients with SHPT. Diabetes patients with ΔSBP > 5.8 mmHg were more prone to AVF dysfunction after PTX.

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.

Lower Parathyroid Hormone Levels are Associated With Reduced Fracture Risk in Japanese Patients on Hemodialysis.

Introduction: Secondary hyperparathyroidism (SHPT) affects bone metabolism and may lead to bone fragility. However, there is conflicting evidence as to whether parathyroid hormone (PTH) levels are associated with fracture risk and whether the relationship is linear or U-shaped. Methods: We examined the association between PTH levels and the risk of any fracture and site-specific fractures in a nationwide cohort of 180,333 patients on hemodialysis. We also examined the association between the percent change in PTH levels during the preceding 1 year and subsequent fracture. Results: At baseline, the median intact PTH level was 141 pg/ml (interquartile range, 78-226 pg/ml). During 1 year of follow-up, there were a total of 3762 fractures requiring hospitalization (1361 hip, 551 vertebral, and 1850 other). In an adjusted analysis, higher baseline PTH levels were associated with an incrementally increased risk of any fracture (odds ratio [OR] per doubling of intact PTH, 1.06; 95% confidence interval, 1.03-1.09). The association between PTH levels and fracture risk was more pronounced for hip fractures but not found for vertebral fractures. The absolute risk difference associated with higher PTH levels appeared to be more pronounced in older individuals, females, and those with lower body mass index (BMI). Change in PTH levels was also associated with fracture risk: the adjusted OR for fracture decreased linearly with decreasing PTH levels over 1 year, regardless of the preceding PTH levels. Conclusion: Lower PTH levels are associated with a graded reduction in fracture risk. Further studies are needed to determine whether intensive PTH control reduces fracture risk.

The role of anatomical and functional orientation in identification of parathyroid glands for patients with parathyroidectomy.

Objective: To investigate diagnostic approaches for preoperative localization of secondary hyperparathyroidism, as well as to give surgeons with precise parathyroid gland localization and imaging so that surgery can be performed safely. Methods: The clinical data of 710 patients with secondary hyperparathyroidism who underwent surgery in our center from October 2009 to October 2023 were retrospectively analyzed. The changes in calcium, phosphorus, and parathyroid hormone levels were observed to ascertain the anatomical location and number of parathyroid glands. Results: Among the 710 patients, 55 underwent total parathyroidectomy, the others underwent total parathyroidectomy with autotransplantation. In total, 2,658 parathyroid glands were removed, with 43 glands being removed in 35 reoperation cases. The median parathyroid hormone level at 6 months postoperatively was 13.40 (interquartile range, 7.00-29.80) pg/mL. The detection rates of the parathyroid glands before first and repeat surgeries were higher using 99mTc-MIBI SPECT/CT fusion imaging than ultrasound (P<0.05). The sensitivity of combined preoperative 99mTc-MIBI SPECT/CT and ultrasound was 92.31%, higher than that of either 99mTc-MIBI SPECT/CT fusion imaging or ultrasound alone (P < 0.05). The incidence of ectopic parathyroid glands was 23.8%, and the incidence of ectopic left lower parathyroid glands was 13.2%. The left lower parathyroid gland was the most prone to ectopia. Conclusion: 99mTc-MIBI SPECT/CT fusion imaging, paired with high-frequency ultrasound, can be utilized to diagnose SHPT preoperatively. The most common ectopia site is the left lower parathyroid gland, which is located primarily in the thymus and superior mediastinum. Understanding the functional anatomical distribution of the parathyroid glands is critical for developing effective surgical methods for secondary hyperparathyroidism.

New calcimimetics for secondary hyperparathyroidism in CKD G5D: do they offer advantages?

Secondary hyperparathyroidism is one of the most frequent metabolic abnormalities found in patients with chronic kidney disease. The calcium-sensing receptor senses extracellular calcium and is the principal regulator of parathyroid hormone secretion. Cloning of the calcium-sensing receptor led to the development of calcimimetics, drugs that decrease parathyroid hormone secretion through the positive allosteric modulation of this receptor. Cinacalcet was the first oral calcimimetic approved by the US Food and Drug Administration (FDA) in 2004 for the treatment of secondary hyperparathyroidism in adult patients on dialysis. Although cinacalcet has demonstrated safety and effectiveness, it has two main problems: gastrointestinal side effects that result in poor adherence, and the inhibitory action on CYP2D6 with the possibility of interactions with commonly used medications. To address the problem of oral compliance, Etelcalcetide, a small synthetic polycationic peptide IV calcimimetic was introduced in 2017. This drug showed a 10% greater decrease in serum parathyroid hormone values compared to cinacalcet but no better gastrointestinal tolerance, with greater risk of hypocalcemia. Several structural modifications were introduced in cinacalcet to produce a new compound called evocalcet. This drug, which was introduced in Japan in 2018, has considerably enhanced bioavailability and decreased both the inhibitory effect on CYP2D6 and half of the gastrointestinal side effects of cinacalcet. Finally, a novel non-peptidic injectable calcimimetic agent, upacicalcet, became available in Japan in 2021. This agent has greater clearance by hemodialysis and shows no effect on gastric emptying. More studies are needed comparing the old calcimimetics to the new ones to establish their future role in the treatment of secondary hyperparathyroidism in chronic kidney disease (CKD) G5D.

Parathyroidectomy restored bone mineral density in a neglected femoral neck fracture with renal osteodystrophy: A case report.

BACKGROUND: This case report contributes to the medical literature by highlighting the successful management of a neglected femoral neck fracture in a patient with renal osteodystrophy and secondary hyperparathyroidism (SHPTH) who was on dialysis due to end-stage renal disease (ESRD). It underscores the efficacy of parathyroidectomy (PTX) in restoring bone mineral density (BMD) and promoting fracture healing, addressing a significant complication in ESRD patients. CASE SUMMARY: A 36-year-old female with renal osteodystrophy and on dialysis due to ESRD presented with a history of left patellar tendon rupture and later, a right achilles tendon avulsion fracture. Persistent right hip pain led to the discovery of a neglected right femoral neck fracture, which was initially overlooked due to the patient's complex medical history. Two months post-achilles tendon repair, the patient underwent PTX to manage the refractory SHPTH. The postoperative course included rehabilitation and weight-bearing exercises. Remarkably, 2 years after osteosynthesis, radiographic assessments indicated a solid union of the periprothesis fracture and significant improvement in BMD, showcasing the efficacy of the treatment approach. CONCLUSION: PTX, combined with appropriate rehabilitation, is crucial for improving BMD and fracture healing in ESRD patients with SHPTH.

Parathyroidectomy reduces the costs of medication in patients with secondary hyperparathyroidism.

INTRODUCTION: Subtotal Parathyroidectomy (S-PTx) and total Parathyroidectomy with immediate Autograft (PTx-AG) are well-established techniques for the treatment of refractory Secondary Hyperparathyroidism (SHPT), with comparable improvements in patients' quality of life and survival. However, the long-term costs after these operations may impact the choice of surgical technique. The objective of the study is to analyze the impact of surgical treatment on medication costs and whether there is any difference between medication use after each procedure, considering impacts on the health system. MATERIAL AND METHODS: Prospective and randomized study in patients with severe SHPT undergoing S-PTx and PTx-AG. Analysis of prescribed medication costs in the month before the postoperative period at 1-, 3-, 6-, 12-, and 18 months. Costs were estimated according to government payment system values. The medications of 65 patients after PTx-AG were compared with those of 24 patients after S-PTx. A comparison of the total costs of the period between 38 men and 51 women was also made. RESULTS: There were 89 evaluable cases. Surgery reduced medication costs after 12 months. The median of total drug costs in the analyzed period was R$ 8,375.00 per patient. There was no difference in costs per patient in the S-PTx group compared to the PTx-AG group. The median total costs were R$ 11,063.0 for men and R$ 7,651.0 for women (p = 0.0078). CONCLUSIONS: The type of parathyroidectomy did not impact costs after surgery. In the first year after surgery, the use of calcium and calcitriol was more significant than the use of other medications. In the following months, the use of sevelamer is responsible for the highest costs. Men have higher costs in outpatient follow-up after surgery.

Addressing the challenges of missed parathyroid glands in ultrasonography for secondary hyperparathyroidism: a retrospective observational study.

Purpose: Preoperative localization plays an important role in secondary hyperparathyroidism (SHPT) surgery. The advantages of neck ultrasound (US) include high availability and low cost. However, the reported sensitivity of US is 54%-76%, and the reason for missed parathyroid glands (PGs) on US has been rarely addressed. Methods: Fifty-four patients who were diagnosed with renal SHPT from September 2020 to March 2022 were included in this retrospective study. Preoperative localization included surgeon-oriented US and technetium 99m-sestamibi single-photon emission CT (SPECT)/CT. Results: A total of 212 PGs were pathologically confirmed, resulting in a success rate of 96.2% (52 of 54). Using echo, 193 PGs (91.0%) were accurately localized, while 19 glands (9.0%) were not identified, including those in ectopic positions (n = 12, at thymus or intrathyroid or others), of small size (<1 cm, n = 6), or overlapping with an ipsilateral PG (n = 1). US accurately detected 4 PGs in 36 (66.7%) patients, while SPECT/CT localized 4 glands in 19 patients (35.2%). Although the number of US-detectable PGs was not associated with success rate, it showed a significant negative correlation with surgical time (rs = -0.459, P = 0.002). Conclusion: US detected 4 glands in 66% of SHPT patients with a sensitivity of 90% for localization. Ectopic position and small size were the most common reasons for the failure to detect PG on US. Complete preoperative echo localization might shorten operating time.

Sustained Reduction of Elevated Intact Parathyroid Hormone Concentrations with Extended-Release Calcifediol Slows Chronic Kidney Disease Progression in Secondary Hyperparathyroidism Patients.

INTRODUCTION: Chronic kidney disease (CKD) drives onerous human and healthcare costs, underscoring an urgent need to avert disease progression. Secondary hyperparathyroidism (SHPT) develops as CKD advances, and persistently elevated parathyroid hormone (PTH) may be nephrotoxic and associated with earlier dialysis onset. This study examines, for the first time, the hypothesis that sustained reduction of elevated intact PTH (iPTH) with extended-release calcifediol (ERC) reduces the nephrotoxic impact of SHPT and forestalls renal decline. METHODS: Changes in estimated glomerular filtration rate (eGFR) were analyzed post hoc in 126 adults with SHPT, stage 3-4 CKD, and low serum 25-hydroxyvitamin D (25D) treated for 1 year with ERC in pivotal trials. ERC was administered at 30 µg/day increasing, as needed, to 60 µg/day to achieve ≥30% reductions in iPTH. Calcium, phosphorus, 25D, 1,25-dihydroxyvitamin D (1,25D), iPTH, eGFR, fibroblast growth factor-23 (FGF23), bone turnover markers (BTMs), and urine albumin-to-creatinine ratio (uACR) were measured at baseline and regular intervals. Participants were categorized by achievement (or not) of sustained ≥30% iPTH reductions over the last 2 quarters of treatment to evaluate differences in eGFR decline. RESULTS: For all participants, 25D increased 58.5 ± 2.3 (SE) ng/mL (p < 0.001) by the end of treatment (EOT), 1,25D increased 10.1 ± 1.8 pg/mL (p < 0.001), iPTH decreased from 143.8 ± 5.8 pg/mL to 108.8 ± 7.2 (p < 0.001), BTMs improved (p < 0.01), and eGFR declined 2.2 ± 0.5 mL/min/1.73 m2 (p < 0.001). The rate of eGFR decline was >5-fold higher (p = 0.014) in participants who did not achieve sustained iPTH reductions of ≥30% (3.2 ± 0.7; 12.7 ± 2.2%) than in those who did (0.6 ± 0.8; 2.9 ± 2.4%). It was highest in the 30 participants who did not exhibit an iPTH lowering response in both of the last 2 quarters of treatment (5.4 ± 0.9; 20.9 ± 3.4%). Duration of iPTH reduction had no impact on safety parameters. Degree of iPTH reduction at EOT was also associated with slower CKD progression. CONCLUSION: Sustained reduction of elevated iPTH with ERC treatment was associated with slower rates of eGFR decline in patients with SHPT and stage 3-4 CKD without raising safety concerns. A prospective trial is warranted to confirm this finding.

Persistent uncertainties in optimal treatment approaches of secondary hyperparathyroidism and hyperphosphatemia in patients with chronic kidney disease.

PURPOSE OF REVIEW: This review is a critical analysis of treatment results obtained in clinical trials conducted in patients with chronic kidney disease (CKD) and secondary hyperparathyroidism (SHPT), hyperphosphatemia, or both. RECENT FINDINGS: Patients with CKD have a high mortality rate. The disorder of mineral and bone metabolism (CKD-MBD), which is commonly present in these patients, is associated with adverse outcomes, including cardiovascular events and mortality. Clinical trials aimed at improving these outcomes by modifying CKD-MBD associated factors have most often resulted in disappointing results. The complexity of CKD-MBD, where many players are closely interconnected, might explain these negative findings. We first present an historical perspective of current knowledge in the field of CKD-MBD and then examine potential flaws of past and ongoing clinical trials targeting SHPT and hyperphosphatemia respectively in patients with CKD.

Secondary hyperparathyroidism in chronic kidney disease: A narrative review focus on therapeutic strategy.

Chronic kidney disease (CKD) affects over 10% of the global population. One crucial complication of CKD is secondary hyperparathyroidism (SHPT), marked by elevated parathyroid hormone levels due to hyperphosphataemia, hypocalcaemia, and low active vitamin D from impaired renal function. SHPT increases risks of bone deformities, vascular calcification, cardiovascular events and mortality. This review examines SHPT treatment strategies in patients with CKD. First-line treatments include phosphate binders, vitamin D receptor activators and calcimimetics. When these fail, invasive options like parathyroidectomy (PTX) and thermal ablation are considered. PTX effectively reduces symptoms and improves radiological outcomes, outperforming medical treatment alone in reducing cardiovascular risk and mortality. Thermal ablation techniques, such as microwave, radiofrequency, laser or high-intensity focused ultrasound, offer less invasive alternatives with promising results. Future research should explore the molecular mechanisms of parathyroid gland hyperplasia and evaluate various treatments' impacts.

Intradialytic serum phosphate variations are associated with low PTH levels.

BACKGROUND: Numerous studies have explored the role of kidney replacement therapy (KRT) in phosphorus (P) control among prevalent hemodialysis (HD) patients. However, whether the reduction of P achieved during KRT affects parathyroid hormone (PTH) levels is still a matter of debate. METHODS: We conducted a retrospective observational study on the prevalent HD population at the Division of Nephrology, University Hospital of Verona, from January to December 2022. We Included clinically stable adult patients undergoing HD for over 6 months, with multiple recorded visits during the follow-up. Demographic, clinical, laboratory, and medication data were collected. Time-varying variables were updated at each study visit. The primary outcome of interest was PTH levels. The absolute intra-HD change in P (intra-HD ∆P), defined as the difference between pre- and post-HD P levels, served as the main exposure. Multivariable adjusted linear mixed models were used to investigate the relationship between intra-HD ∆P and PTH levels. RESULTS: A total of 211 patients contributed to 904 study visits. A significant and positive relationship was observed between intra-HD ∆P and pre-HD P (ß = 0.76, 95% CI 0.75, 0.78, p < 0.001) and urea reduction ratio (ß = 0.38, 95% CI 0.35, 0.41; p < 0.001). An increase in intra-HD ∆P was significantly and independently associated with low PTH levels (ß = - 0.16, 95% CI - 0.30, -0.03; p = 0.020). CONCLUSIONS: The extent of intra-HD P reduction significantly correlates with low PTH levels. Strategies focused on optimizing or enhancing depurative efficiency in KRT can exert a substantial impact on managing positive phosphorus balance and secondary hyperparathyroidism. The assessment of intra-HD P reduction may play a pivotal role in the management and follow-up of secondary hyperparathyroidism in HD patients.

Sagliker Syndrome: A Case Report of Facial Deformities and Renal Osteodystrophy Secondary to Hyperparathyroidism in End-Stage Renal Disease.

Sagliker syndrome (SS) is a rare but distinctive form of renal osteodystrophy associated with poorly managed secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD). We present a case of a 28-year-old male with end-stage CKD on hemodialysis for 10 years, who exhibited progressive facial deformities and maxillofacial bone pain. Physical examination revealed bilateral expansion of the maxillary and mandibular bones and facial asymmetry. Radiological findings included diffuse bone thickening and multilocular cysts in the maxillofacial bones, while laboratory tests showed decreased levels of calcium and elevated parathyroid hormone, confirming SHPT. Despite multidisciplinary management involving nephrology, endocrinology, and maxillofacial surgery, the patient's condition deteriorated and he manifested community-acquired pneumonia leading to cardiopulmonary arrest and death. This case underscores the challenges in managing severe HPT in CKD and emphasizes the importance of early assessment and comprehensive multidisciplinary care to prevent irreversible complications.

Impact of successful secondary hyperparathyroidism treatment on cardiovascular morbidity in patients with chronic kidney disease KDIGO stages G3b-5.

INTRODUCTION: Chronic kidney disease is common, with a projected increase to 5.4 million people in need of kidney replacement therapy by 2030. As many as 61.7% of patients on hemodialysis have secondary hyperparathyroidism (SHPT). This has been associated with high cardiovascular morbidity. The present study investigates the effect of SHPT treatment success on cardiovascular morbidity in patients with CKD KDIGO stages G3b, 4, and 5. METHODS: A retrospective single center analysis of 211 chronic kidney disease stages G3b-5 patients undergoing computed tomography for coronary artery calcium (CAC) scoring at the University Hospital of Zurich between 2015 and 2019 was performed. The presence of and control of SHPT was assessed at the timepoint of CAC scoring and 6-12 months prior. Information on left ventricular ejection fraction (LVEF), left ventricular hypertrophy (LVH), and left ventricular myocardial mass index (LVMMI) were calculated from echocardiography values obtained at the timepoint of CAC scoring. Occurrence of major acute cardiovascular events, including acute coronary syndrome (ACS), within 1 year of CAC scoring was drawn from the charts. Independent predictive factors for ACS and LVH were assessed by multivariable analysis. RESULTS: Thirty-four percent (n=72) of the patients had uncontrolled SHPT, whereas 66% (n=139) had either no (n=18%, n=39) or a controlled SHPT (n=48%, n=100). The CKD stage G3b-5 patients with uncontrolled SHPT had a significantly lower LVEF (p=0.028) and significantly more pronounced LVH (p=0.003) and a higher LVMMI (p=0.002) than the group with either no SHPT or well-controlled SHPT. Uncontrolled SHPT in the observed CKD cohort had a significantly higher risk for developing ACS (p=0.011, HR 2.76, 95%CI 1.26-6.05) compared to no or controlled SHPT patients (41.7% vs 31.7%). While patients with uncontrolled SHPT showed a median CAC score of 290 (IQR 18-866), those with no or controlled SHPT had a lower median CAC score of 194 (IQR 14-869), although not significant (p=0.490). Patients with CAC scores >400 displayed a significantly higher incidence of ACS (56.8% vs 33.1%, p=0.010). CONCLUSIONS: SHPT is common (82%) in advanced CKD (≥G3b) patients and insufficiently controlled in one-third of patients. Insufficient control of SHPT is associated with higher cardiovascular morbidity, lower LVEF, increased LVH, and a higher incidence of ACS. Thus, increased focus on SHPT control in CKD patients may have a beneficial impact on cardiovascular outcomes.

Brown Tumor of the Dorsal Spine With Hemorrhage Causing Acute Neurological Deterioration: A Rare Presentation of Secondary Hyperparathyroidism.

Brown tumor due to secondary hyperparathyroidism in chronic kidney disease is a well-established entity. Brown tumor of the spine with hemorrhage causing acute neurological deficit is a rare entity. A 35-year-old gentleman, with chronic kidney disease (CKD) on dialysis, presented with acute paraplegia and loss of lower limb sensation and bowel and bladder control. Imaging revealed a T8 vertebral body expansile lytic lesion with collapse, exaggerated kyphosis, and cord compression. He underwent an emergency decompressive laminectomy and transpedicular corpectomy of T8, with posterior stabilization. Histopathology revealed lobular clusters of osteoclast-like multinucleated giant cells with background of which was possibly the reason for acute neurological deterioration in this case. Brown tumors of the spine can mimic lytic lesions of the spine like myeloma and metastasis. Suspicion must be raised given in the setting of CKD and hyperparathyroidism. They can present with hemorrhage and acute neurological deficit, which warrants urgent surgical intervention for optimal outcomes.

Construction and validation of a risk prediction model for early hungry bone syndrome in maintenance hemodialysis patients post-parathyroidectomy. / ç»´æŒæ€§è¡€æ¶²é€æžæ‚£è€ ç”²çŠ¶æ—è ºåˆ‡é™¤æœ¯åŽæ—©æœŸéª¨é¥¥é¥¿ç»¼åˆå¾é£Žé™©é¢„æµ‹æ¨¡åž‹çš„æž„å»ºä¸ŽéªŒè¯.

OBJECTIVES: Parathyroidectomy (PTX) is an effective treatment for refractory secondary hyperparathyroidism (SHPT), but it can lead to hungry bone syndrome (HBS), significantly threatening the health of maintenance haemodialysis (MHD) patients. While previous studies have analyzed the risk factors for HBS post-PTX, the predictive performance and clinical applicability of these risk models need further validation. This study aims to construct and validate a risk prediction model for HBS in MHD patients with SHPT post-PTX. METHODS: A retrospective analysis was conducted on 368 MHD patients with SHPT who underwent PTX at Changsha Jieao Nephrology Hospital from January 2020 to December 2021. Patients were divided into a HBS group and a non-HBS group based on the occurrence of HBS. General data, surgical information, and biochemical indicators were compared between the 2 groups. Multivariate logistic regression was used to identify factors influencing HBS, and a risk prediction model was established. The model's performance was evaluated using receiver operator characteristic (ROC) curves, decision curves, and calibration curves. External validation was performed on 170 MHD patients with SHPT who underwent PTX at the Third Xiangya Hospital of Central South University from January to December 2022. RESULTS: The incidence of HBS post-PTX in MHD patients with SHPT was 60.60%. Logistic regression analysis identified preoperative bone involvement (OR=3.908, 95% CI 2.179 to 7.171), preoperative serum calcium (OR=7.174, 95% CI 2.291 to 24.015), preoperative intact parathyroid hormone (iPTH) (OR=1.001, 95% CI 1.001 to 1.001), preoperative alkaline phosphatase (ALP) (OR=1.001, 95% CI 1.000 to 1.001), and serum calcium on the first postoperative day (OR=0.006, 95% CI 0.001 to 0.038) as independent risk factors for HBS (all P<0.01). The constructed risk prediction model demonstrated good predictive performance in both internal and external validation cohorts. The internal validation cohort showed an accuracy of 0.821, sensitivity of 0.890, specificity of 0.776, Youden index of 0.666, and area under the curve (AUC) of 0.882 (95% CI 0.845 to 0.919). The external validation cohort showed an accuracy of 0.800, sensitivity of 0.806, specificity of 0.799, Youden index of 0.605, and AUC of 0.863 (95% CI 0.795 to 0.932). CONCLUSIONS: Preoperative bone involvement, serum calcium, iPTH, ALP, and serum calcium on the first postoperative day are influencing factors for HBS in MHD patients with SHPT post-PTX. The constructed risk prediction model based on these factors is reliable.

Parathyroid carcinoma in a dialysis patient definitively diagnosed after parathyroidectomy for uncontrolled secondary hyperparathyroidism.

Secondary hyperparathyroidism (SHPT) is a well-known complication in chronic kidney disease patients undergoing maintenance dialysis. In 2006, the Japanese Society for Dialysis Therapy recommended parathyroidectomy (PTx) for medically resistant SHPT cases, resulting in an increase in the performance of PTx. However, after calcimimetics were added to the treatment options in 2008, the number of cases requiring PTx has decreased. Presented here is the case of a dialysis patient with SHPT under medical treatment with calcimimetics, who was normocalcemic but showed persistently high levels of parathyroid hormone (PTH), suggesting the possibility of parathyroid carcinoma. Parathyroid carcinoma is a very rare endocrine malignancy characterized by hypercalcemia and increased PTH level. With appropriately performed PTx at the proper time, the definitive diagnosis was made and the patient has not developed any recurrences or metastases to date. In cases of SHPT refractory to medical therapy, the possibility of parathyroid carcinoma should be considered as an alternative. We report a case in which parathyroid carcinoma was diagnosed after appropriate conversion from medical therapy to PTx with reference to ultrasonographic images.

Role of thymectomy in surgical treatment of renal hyperparathyroidism.

INTRODUCTION: The role for routine thymectomy in patients with secondary or tertiary hyperparathyroidism (SHPT, THPT) is unclear. We aim to compare rates of recurrence and complications in patients who underwent subtotal parathyroidectomy with and without thymectomy. METHODS: Patients who underwent surgery for renal HPT at a tertiary endocrine surgery center between 2010 and 2022 were reviewed. Presence of parathyroid tissue in resected tissue was identified through pathology reports. A multivariate logistic regression was used to compare baseline characteristics, recurrence rates and complications between those who did and did not undergo thymectomy. RESULTS: Of 107 patients who underwent subtotal parathyroidectomy, 29 (27.1 â€‹%) underwent concomitant thymectomy. Recurrence occurred in 15 patients (14 â€‹%). Thymectomy did not affect recurrence (OR: 0.33, 95%CI: 0.06-1.28, p â€‹= â€‹0.14), but was associated with permanent hypoparathyroidism (OR: 4.62, 95%CI: 1.67-13.18, p â€‹= â€‹0.003). Fewer parathyroid specimens increased the odds of thymectomy (p â€‹= â€‹0.04). Parathyroid glands were found in 6 thymectomy samples (20.7 â€‹%). CONCLUSION: Thymectomy at the time of subtotal parathyroidectomy for renal HPT was not associated with disease recurrence, but increased likelihood of permanent hypoparathyroidism.

Effects of active vitamin D analogs and calcimimetic agents on PTH and bone mineral biomarkers in hemodialysis patients with SHPT: a network meta-analysis.

OBJECTIVE: Active vitamin D analogs and calcimimetic agents are primary drugs for patients with secondary hyperparathyroidism. Due to the different pharmacological mechanisms, they have different effects on the level of parathyroid hormone, serum calcium, phosphorus, and bone turnover biomarkers. This study aimed to evaluate the active vitamin D analogs and calcimimetic agents in hemodialysis patients with secondary hyperparathyroidism. METHODS: We included randomized clinical trials of hemodialysis patients with secondary hyperparathyroidism, comparing active vitamin D analogs to calcimimetic agents or placebo/control. The primary outcome was the change of PTH level from baseline to end-up. The secondary outcome was the change in serum calcium, phosphorus, calcium-phosphorus product, and bone turnover biomarkers. A network meta-analysis method was applied to complete this study. The forest plots reflected statistical differences in the outcomes between active vitamin D analogs and calcimimetic agents. The SUCRA result presented the ranking of impact on the outcomes. RESULTS: Twenty-one randomized clinical trials with 4653 patients were included in this network meta-analysis. Global and splitting-node inconsistencies provided no evidence of inconsistency in this study. There was no statistical difference between two active vitamin D analogs and three calcimimetic agents in the PTH, and phosphorus levels changed. Considering serum calcium level, compared with placebo, calcitriol (9.73, 3.09 to 16.38) and paricalcitol (9.74, 3.87 to 15.60) increase serum calcium. However, cinacalcet (- 1.94, - 3.72 to - 0.15) and etelcalcetide (- 7.80, - 11.80 to - 3.80) reduced the serum calcium, even a joint use of cinacalcet with active vitamin D analogs (- 5.83, - 9.73 to - 1.93). Three calcimimetic agents decreased calcium levels much more than calcitriol and paricalcitol. The same type of drugs was not distinct, with each one affecting the change in calcium level. Cinacalcet reduced calcium-phosphorus product much more than paricalcitol (- 3.66, - 6.72 to - 0.60). Evocalcet decreased calcium-phosphorus product more than cinacalcet (- 5.64, - 8.91 to - 2.37), calcitriol (- 9.36, - 14.81 to - 3.92), and paricalcitol (- 9.30, - 13.78 to - 4.82). Compared with paricalcitol, cinacalcet significantly increases the level of ALP (24.50, 23.05 to 25.95) and bALP (0.67, 0.03 to 1.31). The incidence of gastrointestinal disorders in cinacacet (29.35, 1.71 to 504.98) and etelcalcetide (20.92, 1.20 to 365.68) was notably higher than in paricalcitol. Etelcalcetide (0.71, 0.53 to 0.96) and evocalcet (0.46, 0.33 to 0.64) presented a lower rate of gastrointestinal disorders than cinacalcet. Cinacalcet ranked first in adverse gastrointestinal, nervous, and respiratory reactions. CONCLUSION: The same kinds of agents perform similar efficacy on the level of PTH, serum calcium, phosphorus, and calcium-phosphorus product. Paricalcitol did not lead to more hypercalcemia than calcitriol. The calcium decrease induced by cinacalcet was not settled even by associating it with active vitamin D analogs. Cinacalcet and evocalcet were superior to calcitriol and paricacitol in reducing calcium-phosphorus product. Calcimimetics induced more gastrointestinal disorders than active vitamin D analogs, especially cinacalcet.