RESUMEN
We present successful surgical treatment of a patient with chronic kidney disease (CKD) and hyperparathyroidism undergoing renal replacement therapy. At baseline, parathyroidectomy via cervical access was performed for parathyroid adenomas. After 6 years, clinical and laboratory relapse of disease required thoracoscopic resection of atypically located anterior mediastinal adenoma. This case demonstrates that this disease is one of the most difficult in modern medicine requiring a special approach in diagnosis and treatment. Patients with CKD and hyperparathyroidism need for follow-up, control of total and ionized serum calcium, inorganic phosphorus and parathormone, osteodensitometry, ultrasound and scintigraphy of thyroid and parathyroid glands, and, if necessary, CT or MRI of the neck and chest organs.
Asunto(s)
Adenoma , Neoplasias de las Paratiroides , Paratiroidectomía , Humanos , Neoplasias de las Paratiroides/cirugía , Neoplasias de las Paratiroides/complicaciones , Neoplasias de las Paratiroides/diagnóstico , Paratiroidectomía/métodos , Adenoma/cirugía , Adenoma/complicaciones , Adenoma/diagnóstico , Resultado del Tratamiento , Recurrencia Local de Neoplasia/cirugía , Glándulas Paratiroides/cirugía , Persona de Mediana Edad , Toracoscopía/métodos , Masculino , Femenino , Neoplasias del Mediastino/cirugía , Neoplasias del Mediastino/complicaciones , Neoplasias del Mediastino/diagnóstico , Hiperparatiroidismo Secundario/cirugía , Hiperparatiroidismo Secundario/etiología , Hiperparatiroidismo Secundario/diagnóstico , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/diagnóstico , Mediastino/cirugíaAsunto(s)
Hiperparatiroidismo Secundario , Fallo Renal Crónico , Humanos , Hiperparatiroidismo Secundario/etiología , Hiperparatiroidismo Secundario/complicaciones , Hiperparatiroidismo Secundario/diagnóstico , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/terapia , Síndrome , Masculino , Femenino , Diálisis Renal , Persona de Mediana EdadRESUMEN
Abdominal wall calcification in a peritoneal dialysis patient has not previously been reported. We describe a 40-year-old lady, a type 2 diabetic and hypertensive for the past 14 years, who did not have any history, clinical features or laboratory results suggesting autoimmune disease, and had not suffered from tuberculosis in the past, but who had been diagnosed with chronic kidney disease in 2016. She had initiated peritoneal dialysis in December 2018.
Asunto(s)
Pared Abdominal , Calcinosis , Hiperparatiroidismo Secundario , Fallo Renal Crónico , Diálisis Peritoneal , Femenino , Humanos , Adulto , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/terapia , Hiperparatiroidismo Secundario/diagnóstico , Diálisis Peritoneal/efectos adversos , Calcinosis/diagnóstico , Calcinosis/etiologíaRESUMEN
BACKGROUND: Normocalcemic hyperparathyroidism can occur, but surgery should not be considered until common etiologies for secondary hyperparathyroidism are comprehensively excluded. Calcium deficiency is an underrecognized cause of normocalcemic parathyroid hormone elevation, and we aim to determine if the implementation of a preoperative calcium challenge can be used to reduce unnecessary parathyroidectomy. METHODS: Consecutive patients referred for parathyroidectomy (1/21-6/22) with normocalcemia (serum calcium <10 mg/dL) and concurrently elevated parathyroid hormone levels were routinely treated with supplemental calcium and vitamin D3, and follow-up laboratory studies were assessed. RESULTS: A total of 29/314 (9%) patients had normocalcemic parathyroid hormone elevation with mean calcium, parathyroid hormone, and vitamin D 25OH levels of 9.5 ± 0.3 mg/dL, 109.9 ± 34.9 pg/mL, and 42.7 ± 23.8 ng/mL respectively. Confounding factors included estimated glomerular filtration rate <60 in 2, loop diuretic use in 4, and prior gastric bypass or gastric sleeve surgery in 4. Follow-up biochemical evaluation was available in 27 (92%); results were unchanged in 7 patients (26%); normalization of parathyroid hormone levels with persistently normal calcium levels occurred in 15 (55%), thus confirming secondary hyperparathyroidism and hypercalcemia with elevated parathyroid hormone levels (classic primary hyperparathyroidism) was diagnosed in 5 (19%). Parathyroid exploration has been completed for 3 of 5 patients with classic primary hyperparathyroidism to date. CONCLUSION: A preoperative calcium challenge was prospectively initiated in normocalcemic patients with parathyroid hormone elevation, and there was high compliance (92%). Short-interval calcium supplementation revealed â¼50% to have resolved secondary hyperparathyroidism due to insufficient calcium intake, which avoided unnecessary surgery. In contrast, classic patients were unveiled in 20%, allowing for prompt and correct surgical intervention.
Asunto(s)
Hiperparatiroidismo Primario , Hiperparatiroidismo Secundario , Humanos , Calcio , Hiperparatiroidismo Primario/complicaciones , Hiperparatiroidismo Primario/diagnóstico , Hiperparatiroidismo Primario/cirugía , Hormona Paratiroidea , Glándulas Paratiroides , Hiperparatiroidismo Secundario/diagnóstico , Hiperparatiroidismo Secundario/etiología , Hiperparatiroidismo Secundario/cirugía , ParatiroidectomíaRESUMEN
O hiperparatireoidismo nutricional secundário é uma deficiência comum em répteis de cativeiro, podendo ocorrer pelo déficit de cálcio, o que leva, neste caso, ao sequestro desse mineral dos ossos para a manutenção do metabolismo. No geral, essa deficiência acontece devido ao manejo ambiental e alimentar incorretos, como a falta de cálcio na dieta ou falta de exposição à radiação ultravioleta, não permitindo a bioativação da vitamina D e, consequentemente, impedindo a absorção de cálcio na alimentação. Este estudo relata um caso de um gecko-leopardo, atendido no Consultório Veterinário Ilha Animal., na cidade do Rio de Janeiro RJ. Na anamnese foi relatado que o paciente sofria de apatia, postura cifótica e andar incoordenado, além dos citados erros de manejo. Foi realizado exame radiográfico, onde foi observado redução da densidade e deformidade óssea, o que permitiu o diagnóstico de osteodistrofia metabólica, considerando também os sinais clínicos e a anamnese. Com o tratamento oral, houve melhoras do animal.(AU)
Secondary nutritional hyperparathyroidism is a common deficiency in captive reptiles. It can occur due to a calcium deficit, which leads, in this case, to the sequestration of this mineral from the bones to maintain metabolism. In general, this deficiency occurs due to incorrect environmental and food management, such as a lack of calcium in the diet or lack of exposure to ultraviolet radiation, not allowing the bioactivation of vitamin D and, consequently, preventing the absorption of calcium in the diet. This study reports a case of a leopard gecko, seen at the Ilha Animal Veterinary Clinic. In the anamnesis it was reported that the patient suffered from apathy, kyphotic posture and uncoordinated walking, in addition to the aforementioned handling errors. A radiographic examination was performed, where a reduction in bone density and deformity was observed, which allowed the diagnosis of metabolic osteodystrophy, also considering clinical signs and anamnesis. With oral treatment, the animal improved. The objective of the work is to report the clinical case and review the literature on secondary nutritional hyperparathyroidism.(AU)
El hiperparatiroidismo nutricional secundario es una deficiencia común en reptiles en cautiverio que puede ocurrir debido a un déficit de calcio, lo que lleva, en este caso, al secuestro de este mineral de los huesos para mantener el metabolismo. En general, esta deficiencia se produce por un incorrecto manejo ambiental y alimentario, como la falta de calcio en la dieta o la falta de exposición a la radiación ultravioleta, no permitiendo la bioactivación de la vitamina D y, en consecuencia, impidiendo la absorción del calcio en la dieta. Este estudio reporta un caso de gecko leopardo, visto en la Clínica Veterinaria Animal Ilha. En la anamnesis se informó que el paciente padecía apatía, postura cifótica y descoordinación en la marcha, además de los errores de manejo antes mencionados. Se realizó examen radiográfico, donde se observó reducción de la densidad ósea y deformidad, lo que permitió el diagnóstico de osteodistrofia metabólica, considerando además los signos clínicos y la anamnesis. Con el tratamiento oral el animal mejoró. El objetivo del trabajo es reportar el caso clínico y revisar la literatura sobre hiperparatiroidismo nutricional secundario.(AU)
Asunto(s)
Animales , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/veterinaria , Hiperparatiroidismo Secundario/diagnóstico , Lagartos/fisiología , BrasilRESUMEN
Chronic kidney disease (CKD) is a prevalent pathological condition worldwide. Parathyroid hormone (PTH) is an important index related to bone metabolism in CKD patients and has not received enough attention. This study was performed to investigate the incidence and diagnostic rate of CKDin hospital as well as PTH testing and treatment for secondary hyperparathyroidism (SHPT) in patients with stage 3 to 5 CKD. The data of patients who visited Zhejiang Provincial People's Hospital from February 2006 to April 2022 were retrieved from the hospital database. All data were divided into three subgroups using PTH testing and SHPT treatment as major comparative indicators for analysis. The data were then analyzed for overall PTH testing, CKD incidence, and diagnostic rate. Among 5,301,391 patients, the incidence of CKD was 13.14%. The missed diagnosis rate for CKD was 65.76%. The total PTH testing rate was 1.22%, of which 15.37% of PTH testing was performed in patients with stage 3 to 5 CKD. The overall diagnosis rate of SHPT in patients with stage 3 to 5 CKD was 31.0%. The prophylactic medication rate was 7.4%, and the rate of post-diagnostic drug therapy was 22.2% in patients who underwent SHPT treatment. The high misdiagnosis rate and low PTH testing rate of CKD requires prompt attention from clinicians. SHPT treatment should be considered especially in patients with stage 3 to 5 CKD.
Asunto(s)
Hiperparatiroidismo Secundario , Hipoparatiroidismo , Insuficiencia Renal Crónica , Humanos , Hormona Paratiroidea , Diagnóstico Erróneo , Bases de Datos Factuales , Hiperparatiroidismo Secundario/diagnóstico , Hiperparatiroidismo Secundario/epidemiología , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/epidemiologíaRESUMEN
Secondary hyperparathyroidism (SHPT) is a major problem for patients with chronic kidney disease and can cause many complications, including osteodystrophy, fractures, and cardiovascular diseases. Treatment for SHPT has changed radically with the advent of calcimimetics; however, parathyroidectomy (PTx) remains one of the most important treatments. For successful PTx, removing all parathyroid glands (PTGs) without complications is essential to prevent persistent or recurrent SHPT. Preoperative imaging studies for the localization of PTGs, such as ultrasonography, computed tomography, and 99mTc-Sestamibi scintigraphy, and intraoperative evaluation methods to confirm the removal of all PTGs, including, intraoperative intact parathyroid hormone monitoring and frozen section diagnosis, are useful. Functional and anatomical preservation of the recurrent laryngeal nerves can be confirmed via intraoperative nerve monitoring. Total or subtotal PTx with or without transcervical thymectomy and autotransplantation can also be performed. Appropriate operative methods for PTx should be selected according to the patients' need for kidney transplantation. In the case of persistent or recurrent SHPT after the initial PTx, localization of the causative PTGs with autotransplantation is challenging as causative PTGs can exist in the neck, mediastinum, or autotransplanted areas. Additionally, the efficacy and cost-effectiveness of calcimimetics and PTx are increasingly being discussed. In this review, medical and surgical treatments for SHPT are described.
Asunto(s)
Hiperparatiroidismo Secundario , Paratiroidectomía , Humanos , Paratiroidectomía/efectos adversos , Hiperparatiroidismo Secundario/etiología , Hiperparatiroidismo Secundario/cirugía , Hiperparatiroidismo Secundario/diagnóstico , Glándulas Paratiroides/cirugía , Glándulas Paratiroides/trasplante , Hormona Paratiroidea , CuelloRESUMEN
BACKGROUND: Parathyroidectomy (PTX), an effective treatment for refractory secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD) patients, still has a high persistent rate. This study aimed to analyze the predictive value of characteristics of resected parathyroid glands for postoperative persistent SHPT. METHODS: The clinical data of patients with persistent SHPT and successful PTX controls who had or underwent total parathyroidectomy with forearm autotransplantation (TPTX + AT) was retrospectively collected. The characteristics including the number, minimum weight, maximum weight and total weight of resected parathyroid glands from each patient were recorded. Characteristics and cutoff value of resected parathyroid glands for the prediction of persistent SHPT were analyzed. RESULTS: A total of 227 patients (62 persistent SHPT patients and 165 successful PTX controls) were enrolled in the study. Forty-one (66%) persistent SHPT cases related to supernumerary parathyroid and the remaining 21 (34%) cases related to residual undetected parathyroid. In addition, ectopic parathyroid was found in 8 patients (13%) before PTX. The average number of resected glands in the persistent SHPT group and successful PTX group was 3.53 ± 0.72 and 3.93 ± 0.25 respectively (p < 0.001). There was significance in the number of patients with different resected parathyroid glands between two groups (p < 0.001). When the resected gland number was 4, minimum weight of the parathyroid was noted to be heavier in the persistent SHPT group than that in the successful PTX group (0.52 ± 0.31 g vs. 0.38 ± 0.19 g, p < 0.001). For persistent SHPT prediction, cutoff value of minimum weight was 0.535 g, with sensitivity of 46% and specificity of 82% (AUC = 0.611; p = 0.029). CONCLUSIONS: Major reason for the persistent SHPT is the existence of supernumerary parathyroid glands or resection of less than 4 glands. When 4 glands were resected, a minimum total parathyroid gland weight heavier than 0.535 g implied the potential presence of a missed supernumerary parathyroid gland, which also contributed to the persistent SHPT.
Asunto(s)
Hiperparatiroidismo Secundario , Glándulas Paratiroides , Humanos , Glándulas Paratiroides/cirugía , Paratiroidectomía , Estudios Retrospectivos , Hiperparatiroidismo Secundario/diagnóstico , Hiperparatiroidismo Secundario/etiología , Hiperparatiroidismo Secundario/cirugía , Resultado del Tratamiento , Hormona ParatiroideaAsunto(s)
Hiperparatiroidismo Secundario , Fallo Renal Crónico , Nefrología , Humanos , Hiperparatiroidismo Secundario/diagnóstico , Hiperparatiroidismo Secundario/tratamiento farmacológico , Hiperparatiroidismo Secundario/etiología , Paratiroidectomía , Fallo Renal Crónico/terapia , Hormona ParatiroideaRESUMEN
BACKGROUND: Differential diagnosis between the normocalcemic primary hyperparathyroidism (nPHPT) and secondary hyperparathyroidism (SHPT) due to hypercalciuria remains a challenge. AIM: The aim of this study was to investigate the capability of short test with hydrochlorothiazide for the differential diagnosis of nPHPT and SHPT. MATERIALS AND METHODS: A retrospective study was conducted with the participation of 28 patients who underwent a functional test with thiazide diuretics during hospitalization in the Department of parathyroid glands pathology and mineral disorders of the Endocrinology Research Centre, Russia. Parameters of mineral metabolism were evaluated before and 3-5 days after taking hydrochlorothiazide 50 mg/day. RESULTS: According to baseline and dynamic biochemical evaluation patients were divided into 3 groups. Group 1 (n=21) included patients with confirmed PHPT, who reached hypercalcemia accompanying with an elevated level of iPTH (n=19) or an increased level of iPTH accompanying with normocalcemia (n=2). In group 1, baseline Caadj. was 2.48 mmol/l [2.47; 2.52], iPTH 107.5 pg/ml [86.8; 133.0], after short test - 2.63 mmol/l [2.59; 2.66] and 102.1 pg/ml [95,7; 124,1]. Group 2 included only one who was diagnosed with SHPT, a normal value of iPTH with concomitant normocalcemia was achieved after 4 days of hydrochlorothiazide therapy (baseline Caadj. 2.35 mmol/l, iPTH 74.5 pg/ml vs at 2.27 mmol/l and 50.7 pg/ml respectively). Patients with doubtful results of the test entered in group 3 (n=6), they did not achieve significant changes in the calcium and iPTH levels, so it was recommended to continue the test on an outpatient basis (baseline Caadj. 2.39 mmol/l [2.33;2.45], iPTH 97.0 pg/ml [83.1;117.0]); after short test - 2.47 mmol/l [2.42; 2.48] and 91.3 pg/ml [86.9; 124.0] respectively). Groups with PHPT and SHPT and doubtful results significantly differed from each other in Caadj (Ñ=0.003, U-test, Bonferroni correction Ð 0=0.006), but not in iPTH, daily calciuria, eGFR, and phosphorus. There were no significant differences in the incidence of classical complications of PHPT. CONCLUSION: The diagnosis of PHPT was confirmed in 21/28 patients 3-5 days after taking hydrochlorothiazide 50 mg/day. The obtained results are significant for the differential diagnosis in hospitalized patients with an unspecified genesis of hyperparathyroidism.
Asunto(s)
Hiperparatiroidismo Primario , Hiperparatiroidismo Secundario , Diagnóstico Diferencial , Hospitalización , Humanos , Hidroclorotiazida/efectos adversos , Hiperparatiroidismo Secundario/diagnóstico , Hiperparatiroidismo Secundario/tratamiento farmacológico , Hiperparatiroidismo Secundario/epidemiología , Pacientes Internos , Minerales , Hormona Paratiroidea , Diálisis Renal/efectos adversos , Estudios RetrospectivosRESUMEN
AIM: Recently, we demonstrated the efficacy of etelcalcetide in the control of secondary hyperparathyroidism (SHPT). This post hoc analysis aimed to evaluate changes in fibroblast growth factor-23 (FGF23) and calciprotein particles (CPPs) after treatment with calcimimetics. METHODS: The DUET trial was a 12-week multicenter, open-label, parallel-group, randomized (1:1:1) study with patients treated with etelcalcetide plus active vitamin D (E + D group; n = 41), etelcalcetide plus oral calcium (E + Ca group; n = 41), or control (C group; n = 42) under maintenance haemodialysis. Serum levels of FGF23 and CPPs were measured at baseline, and 6 and 12 weeks after the start. RESULTS: In the linear mixed model, serum levels of FGF23 in etelcalcetide users were significantly lower than those in non-users at week 6 (p < .001) and week 12 (p < .001). When compared the difference between the E + Ca group and the E + D group, serum levels of FGF23 in the E + Ca group were significantly lower than those in the E + D group at week 12 (p = .017). There were no significant differences in the serum levels of CPPs between etelcalcetide users and non-users at week 6 and week 12, while CPPs in the E + Ca group were significantly lower than those in the E + D group (p < .001) at week 12. CONCLUSION: Etelcalcetide may be useful through suppression of FGF23 levels among haemodialysis patients with SHPT. When correcting hypocalcaemia, loading oral calcium preparations could be more advantageous than active vitamin D for the suppression of both FGF23 and CPPs.
Asunto(s)
Factor-23 de Crecimiento de Fibroblastos , Hiperparatiroidismo Secundario , Calcio , Factores de Crecimiento de Fibroblastos , Humanos , Hiperparatiroidismo Secundario/diagnóstico , Hiperparatiroidismo Secundario/tratamiento farmacológico , Hiperparatiroidismo Secundario/etiología , Hormona Paratiroidea , Péptidos , Diálisis Renal/efectos adversos , Vitamina DRESUMEN
Hypocalcemia is a common complication found in patients with secondary hyperparathyroidism (SHPT) who undergo parathyroidectomy. This study aimed to construct a predictive risk score for the occurrence of hypocalcemia after parathyroidectomy in patients with SHPT who underwent chronic renal replacement therapy (RRT). This 22-year retrospective cohort study enrolled 179 patients with SHPT who had their first parathyroidectomy. Eighty-two percent of patients developed hypocalcemia within 16.9 (95% CI 14.5-19.5) h after parathyroidectomy. This study demonstrated four factors as independent risk factors for post-parathyroidectomy hypocalcemia, including duration of RRT, preoperative serum phosphate, preoperative serum alkaline phosphatase (ALP) and mean difference of serum intact parathyroid hormone (iPTH). By using logistic regression analysis, this study demonstrated cut-off points for these four risk factors for the diagnosis of hypocalcemia after parathyroidectomy: 5 years for the duration of RRT, 5 mg/dL for serum phosphate, 387 U/L for serum ALP, and 97% for the mean difference of serum iPTH. Finally, the predictive risk score was constructed by assigning a score of one to each factor. With a total score of at least 2, the proposed predictive risk score has an AuROC of 0.755 with a sensitivity of 78.2%, a specificity of 71.4%, and an accuracy of 76.9%.
Asunto(s)
Hiperparatiroidismo Secundario , Hipocalcemia , Calcio , Humanos , Hiperparatiroidismo Secundario/diagnóstico , Hiperparatiroidismo Secundario/etiología , Hiperparatiroidismo Secundario/cirugía , Hipocalcemia/diagnóstico , Hipocalcemia/etiología , Hormona Paratiroidea , Paratiroidectomía/efectos adversos , Fosfatos , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: The risk of postoperative hungry bone syndrome after parathyroidectomy for secondary hyperparathyroidism of renal origin may alter the course of treatment, including the hospital length of stay and readmission rates. We sought to identify additional patient or hospital factors that might contribute to hungry bone syndrome after parathyroidectomy in patients with secondary hyperparathyroidism of renal origin. METHODS: Patients who underwent a parathyroidectomy for secondary hyperparathyroidism of renal origin were identified in a geographically diverse, 10-state, discharge data set. Covariates included demographic data, payer status, 31 comorbidities, and hospital characteristics. The primary outcome variable of interest was hospital length of stay. Secondary outcomes were complications and 30-day readmission. RESULTS: Of 796 patients studied, 164 patients (20.6%) were diagnosed with hungry bone syndrome. There were no differences in the rates of hungry bone syndrome by race or number of comorbidities. The average age of hungry bone syndrome patients (45.7 years ± 13.9) was younger than that of non-hungry bone syndrome patients (50.7 ± 14.8; P < .001). Hungry bone syndrome was more common among obese patients than nonobese patients (25.0% vs 15.8%; P < .001). Parathyroid autotransplant was performed at similar rates in hungry bone syndrome and non-hungry bone syndrome patients (23.8% vs 23.1%; P = .821). Median length of stay was significantly longer for hungry bone syndrome patients (6 days, interquartile range: [4, 8] versus 3 days, interquartile range: [2-6]; P < .001). Similar 30-day readmission rates were observed (hungry bone syndrome: 41 (25%) versus non-hungry bone syndrome: 147 (23%); P = .640). CONCLUSION: Hungry bone syndrome occurs in 1 of 5 patients after parathyroidectomy for secondary hyperparathyroidism of renal origin. Patients should be informed of the possibility of a relatively long (6 days) length of stay after surgery as well as the moderate possibility (>20%) of another hospitalization within the 30-day postdischarge period.
Asunto(s)
Consejo , Hiperparatiroidismo Secundario/cirugía , Hipocalcemia/epidemiología , Paratiroidectomía/efectos adversos , Complicaciones Posoperatorias/epidemiología , Insuficiencia Renal Crónica/complicaciones , Adulto , Toma de Decisiones , Femenino , Humanos , Hiperparatiroidismo Secundario/diagnóstico , Hiperparatiroidismo Secundario/etiología , Hipocalcemia/etiología , Hipocalcemia/prevención & control , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Readmisión del Paciente , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Medición de Riesgo/estadística & datos numéricos , Factores de RiesgoRESUMEN
Parathyroidectomy has been the mainstay of treatment of severe hyperparathyroidism in patients with kidney failure until the introduction of calcimimetic. Several large observational studies demonstrated the improvement in patient outcomes after parathyroidectomy. The benefit of parathyroidectomy on vascular calcification remains largely unexplored. AIM: To examine the association between parathyroidectomy and the progression of vascular calcification as well as overall survival in maintenance haemodialysis patients. METHOD: This is a matched case-control study undertaken between 2012 and 2020. Patients who underwent parathyroidectomy were identified and matched 1:1 to non-parathyroidectomized (non-PTX) haemodialysis patients using propensity score matching method resulting in 120 patients in each arm. Aortic arch calcification (AoAC) score was determined annually in the posteroanterior chest x-ray. The average follow-up period was 38 months. RESULTS: Baseline demographic, laboratory data and AoAC score were comparable among the two groups of patients. The prevalence of AoAC was 59% in the PTX group and 54% in the non-PTX group (p = .43). Progression of AoAC occurred in 33% in the PTX group and 47% in the non-PTX group (p = .04). Multivariate generalized linear model revealed parathyroidectomy as an independent protective factor [ß (95% CI) -1.04 (-1.68, -0.41)] and increased serum calcium as a potentiating factor [ß (95% CI) 0.62 (0.25, 0.1)] for progression of AoAC. Linear mixed models revealed an increase in AoAC score in both groups but between group comparisons indicated substantially slower progression in the PTX group. Rapid progression of AoAC was also observed more frequently among non-PTX patients. Death occurred in 7 and 16% in the PTX and non-PTX groups, respectively. Kaplan-Meier survival curve revealed better survival associated with parathyroidectomy (p = .01). More rapid progression of AoAC also correlated with worse survival. CONCLUSION: Parathyroidectomy was associated with slow progression of vascular calcification in maintenance haemodialysis patients.
Asunto(s)
Hiperparatiroidismo Secundario , Fallo Renal Crónico , Calcificación Vascular , Estudios de Casos y Controles , Humanos , Hiperparatiroidismo Secundario/diagnóstico , Hiperparatiroidismo Secundario/etiología , Hiperparatiroidismo Secundario/cirugía , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/diagnóstico , Fallo Renal Crónico/terapia , Paratiroidectomía/efectos adversos , Puntaje de Propensión , Diálisis Renal/efectos adversos , Calcificación Vascular/complicaciones , Calcificación Vascular/diagnóstico por imagenRESUMEN
Chronic kidney disease (CKD) is defined as an abnormality of the kidney's structure or function that is present for more than 3 months. Secondary hyperparathyroidism is a consequence of CKD, which eventuates with a decrease in the glomerular filtration rate. This study aimed to evaluate the effectiveness of alternate-day cinacalcet in noncompliant dialysis patients compared with a daily dose. The effects on the levels of intact parathyroid hormone (iPTH), calcium, and phosphorus were measured, and the compliance of patients with our protocol was observed. We followed the patients' (n = 134) iPTH levels every 3 months and their serum calcium and phosphorous monthly for 6 months and compared the results with 6 months of data from patients receiving daily doses of cinacalcet. The patients' mean age was 49.54 ± 16.17 years, the mean duration of dialysis was 6.44 ± 5.10 years, and 37.3% had diabetic nephropathy. The mean dose of alternate-day cinacalcet was 61.92 ± 26.59 mg. The level of iPTH before and after the change was 924.63 ± 474.132 pg/mL and 787.87 ± 496.49 pg/mL, respectively (P = 0.001), and the mean serum calcium level before and after was 8.56 ± 1.91 mg/dL and 8.85 ± 1.25 mg/dL, respectively (P = 0.035). The level of serum phosphorous before and after the change was 4.81 ± 1.32 mg/dL and 5.08 ± 2.3 mg/dL, respectively (P = 0.204). Cinacalcet produced significant reductions in iPTH with intermittent (three times per week) doses and thus was more cost-effective and had better compliance.
Asunto(s)
Hiperparatiroidismo Secundario , Insuficiencia Renal Crónica , Humanos , Adulto , Persona de Mediana Edad , Anciano , Cinacalcet/efectos adversos , Calcio , Naftalenos , Hiperparatiroidismo Secundario/diagnóstico , Hiperparatiroidismo Secundario/tratamiento farmacológico , Hiperparatiroidismo Secundario/etiología , Diálisis Renal/efectos adversos , Hormona Paratiroidea , Fósforo , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/terapiaRESUMEN
A 9-yr-old female black-footed African penguin (Spheniscus demersus) was presented for necropsy after a history of reproductive abnormalities, paresis of limbs, weakness, and sudden death. Postmortem examination revealed soft keel, collapsed rib cage with beading of the ribs, and bilateral parathyroid enlargement. Classic histologic lesions of fibrous osteodystrophy with osteomalacia were observed in the ribs, vertebrae, and to a lesser extent in the femur and tibiotarsus associated with hyperplasia of parathyroid glands. This represents the first report of nutritional secondary hyperparathyroidism in birds of the order Spheniciformes, most likely caused by low levels of calcium supplementation during egg laying. The reproductive abnormalities observed in this penguin and others from the same group (asynchronous egg-laying cycles, abnormal breeding behavior) were most likely exacerbated by the lack of an adequate photoperiod mimicking the natural daylight pattern.
Reporte de casoHiperparatiroidismo secundario nutricional y osteodistrofia fibrosa en un pingüino africano (Spheniscus demersus) en cautiverio similar a la osteomalacia observada en de aves de corral. Una hembra de pingüino africano de patas negras (Spheniscus demersus) de nueve años fue sometida a necropsia después de un historial de anomalías reproductivas, paresia de extremidades, debilidad y muerte súbita. El examen post mortem reveló que la quilla del esternón estaba blanda, la caja torácica colapsada, se observaron "perlas raquíticas" en las costillas y agrandamiento bilateral de las paratiroides. Se observaron lesiones histológicas clásicas de osteodistrofia fibrosa con osteomalacia en las costillas, vértebras y en menor medida, en el fémur y tibiotarsus asociadas con hiperplasia de glándulas paratiroides. Esto representa el primer informe de hiperparatiroidismo secundario nutricional en un ave del orden Spheniciformes, muy probablemente causado por un bajo nivel de suplementos de calcio durante la producción de huevos. Las anomalías reproductivas observadas en este pingüino y otros del mismo grupo (ciclos de puesta de huevos asincrónicos, comportamiento de reproducción anormal) probablemente se vieron exacerbadas por la falta de un fotoperíodo adecuado que imitara el patrón de luz natural.
Asunto(s)
Enfermedades de las Aves/diagnóstico , Hiperparatiroidismo Secundario/veterinaria , Osteomalacia/veterinaria , Spheniscidae , Animales , Animales de Zoológico , Enfermedades de las Aves/etiología , Enfermedades de las Aves/patología , Resultado Fatal , Femenino , Hiperparatiroidismo Secundario/diagnóstico , Hiperparatiroidismo Secundario/etiología , Hiperparatiroidismo Secundario/patología , Osteomalacia/diagnóstico , Osteomalacia/etiología , Osteomalacia/patologíaRESUMEN
Secondary hyperparathyroidism (SHPT) is characterized by excessive serum parathyroid hormone levels in response to decreasing kidney function, and tertiary hyperparathyroidism (THPT) is often the result of a long-standing SHPT. To date, several genes have been associated with the pathogenesis of primary hyperparathyroidism (PHPT). However, the molecular genetic mechanisms of uremic hyperparathyroidism (HPT) remain uncharacterized. To elucidate the differences in genetic alterations between PHPT and SHPT/THPT, the targeted next-generation sequencing of genes associated with HPT was performed using DNA extracted from parathyroid tissues. As a result, 26 variants in 19 PHPT or SHPT/THPT appeared as candidate pathogenic mutations, which corresponded to 9 (35%) nonsense, 8 (31%) frameshift, 6 (23%) missense, and 3 (11%) splice site mutations. The MEN1 (23%, 6/26), ASXL3 (15%, 4/26), EZH2 (12%, 3/26), and MTOR (8%, 2/26) genes were frequently mutated. Sixteen of 25 patients with PHPT (64%) had one or more mutations, whereas 3 (21%) of 21 patients with SHPT/THPT had only 1 mutation (p = 0.001). Sixteen of 28 patients (57%) with parathyroid adenoma (PA) had one or more mutations, whereas 3 of 18 patients (17%) with parathyroid hyperplasia (PH) had just one mutation (p = 0.003). Known driver mutations associated with parathyroid tumorigenesis such as CCND1/PRAD1, CDC73/HRPT2, and MEN1 were identified only in PA (44%, 7/16 with mutations). Our results suggest that molecular genetic abnormalities in SHPT/THPT are distinct from those in PHPT. These findings may help in analyzing the molecular pathogenesis underlying uremic HPT development.
Asunto(s)
Hiperparatiroidismo Primario/diagnóstico , Hiperparatiroidismo Secundario/diagnóstico , Adulto , Edad de Inicio , Anciano , Análisis Mutacional de ADN/métodos , Diagnóstico Diferencial , Secuenciación de Nucleótidos de Alto Rendimiento , Humanos , Hiperparatiroidismo Primario/epidemiología , Hiperparatiroidismo Primario/etiología , Hiperparatiroidismo Primario/genética , Hiperparatiroidismo Secundario/epidemiología , Hiperparatiroidismo Secundario/etiología , Hiperparatiroidismo Secundario/genética , Persona de Mediana Edad , Mutación , República de Corea/epidemiologíaRESUMEN
Rising levels of parathyroid hormone (PTH) are common in patients with chronic kidney disease (CKD) not on dialysis and are associated with an elevated risk of morbidity (including progression to dialysis) and mortality. However, there are several challenges for the clinical management of secondary hyperparathyroidism (SHPT) in this population. While no recognised target level for PTH currently exists, it is accepted that patients with non-dialysis CKD should receive early and regular monitoring of PTH from CKD stage G3a. However, studies indicate that adherence to monitoring recommendations in non-dialysis CKD may be suboptimal. SHPT is linked to vitamin D [25(OH)D] insufficiency in non-dialysis CKD, and correction of low 25(OH)D levels is a recognised management approach. A second challenge is that target 25(OH)D levels are unclear in this population, with recent evidence suggesting that the level of 25(OH)D above which suppression of PTH progressively diminishes may be considerably higher than that recommended for the general population. Few therapeutic agents are licensed for use in non-dialysis CKD patients with SHPT and optimal management remains controversial. Novel approaches include the development of calcifediol in an extended-release formulation, which has been shown to increase 25(OH)D gradually and provide a physiologically-regulated increase in 1,25(OH)2D that can reliably lower PTH in CKD stage G3-G4 without clinically meaningful increases in serum calcium and phosphate levels. Additional studies would be beneficial to assess the comparative effects of available treatments, and to more clearly elucidate the overall benefits of lowering PTH in non-dialysis CKD, particularly in terms of hard clinical outcomes.