The importance of hypophosphatemia in the clinical management of primary hyperparathyroidism.

AIM: The levels of serum phosphorus (P) are low or low-normal in primary hyperparathyroidism (PHPT), and there is an inverse relationship between the levels of parathormone (PTH) and P. However, when considering the diagnostic and surgical indication criteria of PHPT, serum P levels are generally ignored. The aim of this study was to retrospectively evaluate the association of serum P levels with the clinical outcomes of PHPT. MATERIALS AND METHODS: A retrospective evaluation was made of the data of 424 consecutive patients (370 females, 54 males) with PHPT who presented at our centre. RESULTS: The mean age of the study population was 57 ± 11.68 years. The mean P was 2.57 ± 0.53 mg/dl. Asymptomatic disease was determined in 199 (47%) patients. Male patients had significantly lower levels of P. Symptomatic patients and patients with renal stones, vitamin D < 20 µg/l, calcium level ≥ 11.2 mg/dl, 24 h urinary calcium > 400 mg/day, or hypomagnesemia, were seen to have significantly lower levels of P (p < 0.05). Hypophosphatemia (hypoP) was found in 202 of 424 patients (47%), and these patients had a higher rate of symptomatic disease (63% to 44%, p < .0001). Of the 61 (88%) patients with moderate hypoP, 54 (88%) had at least one of the surgical criteria. A statistically significant increase in the incidence of hypoP was determined in symptomatic and male patients. In the patients with hypoP, serum PTH and urine calcium levels were found to be higher, and lumbar T-scores and serum vitamin D levels were lower. The patients with hypoP had higher rates of renal stones and osteoporosis (p < 0.05). CONCLUSIONS: The current study results show that hypoP is associated with a higher risk of osteoporosis and renal stones in PHPT patients. Even if patients are asymptomatic, moderate hypoP may be associated with poor outcomes of PHPT. Therefore, moderate hypoP may be a new criterion for parathyroidectomy, regardless of hypercalcemia level.

The prognostic significance of glutamic acid decarboxylase antibodies in patients with chronic pancreatitis undergoing total pancreatectomy with islet autotransplantation.

AIM: Islet autotransplantation (IAT) is considered a 'non-immune' model of islet transplant, with no risk for autoimmune-mediated beta cell loss, but we have previously observed de novo type 1 diabetes in one total pancreatectomy with islet autotransplantation (TPIAT) recipient. We aimed to investigate the clinical significance of glutamic acid decarboxylase antibodies (GADA), as a sensitive marker for autoimmune diabetes mellitus (DM), in patients with chronic pancreatitis undergoing TPIAT. METHODS: We identified 9 patients undergoing TPIAT with elevated GADA pre-TPIAT (8 non-diabetic and 1 with C-peptide positive DM), otherwise demographically similar to GADA negative TPIAT recipients (n=341). Metabolic and clinical measures related to islet cell function were recorded both before and after TPIAT. RESULTS: None of the 9 TPIAT patients achieved insulin independence after surgery, vs. 33% of GADA negative patients (n=318 with 1-yr follow-up). The two patients with the highest titters of GADA (>250 IU/mL) both experienced islet graft failure, despite normoglycaemia pre-TPIAT and high islet mass transplanted (5276 and 9378 IEQ per kg), with elevated HbA1c levels post-TPIAT (8.3%, 9.6%). The remaining 7 seven were insulin dependent with partial graft function and HbA1c levels <7%. CONCLUSION: Insulin dependence was more frequent in 9 patients with elevated GADA prior to TPIAT than in GADA negative TPIAT recipients, with graft failure in 2 cases. We speculate that beta-cell autoimmunity may occur in a small subset of TPIAT recipients and that beta cell antibody testing prior to TPIAT may be warranted to identify individuals at higher risk for insulin dependence.

Tear Film and Ocular Surface Evaluation in Gestational Diabetes Mellitus.

BACKGROUND: Dry eye syndrome is one of the complaints of diabetic patients. The aim of the present study was to evaluate the tear functions in pregnant women with gestational diabetes mellitus (GDM) using tests: Schirmer, tear break-up time (TBUT), and tear film osmolarity (TFO) tests and the Ocular Surface Disease Index score (OSDI). METHODS: Pregnant women with GDM (Group 1, n=46) and healthy pregnant women (Group 2, n=36) were enrolled. Initially, all participants were asked to answer the OSDI and then they underwent a detailed ophthalmic examination including Schirmer, TBUT, and TFO tests. The individuals with ocular or systemic disorders that might affect the tear function tests and who were using topical medications were excluded. RESULTS: The results of Schirmer, TBUT, TFO tests and OSDI scores were 11.20±4.93 mm, 5.59±2.16 sec, 309.65±14.80 mOsm/L, and 9.59 ± 9.69 in Group 1, respectively, and 12.33±5.33 mm, 5.67±2.68 sec, 308.36±16.00 mOsm/L, and 10.62±8.66 in Group 2, respectively. There was no significant difference in any of the tear function tests and OSDI scores between the study groups (p>0.05). CONCLUSION: GDM seems to have no negative effects on tear function tests. This may be due to a lack of duration of hyperglycemia long enough to affect the tear function tests of pregnant women.

The effects of blood glucose regulation on tear function tests in diabetic patients.

PURPOSE: To investigate whether blood glucose regulation in patients with diabetes mellitus (DM) has an influence on the ocular surface disease index (OSDI) score and tear function tests such as tear film osmolarity (TFO), tear break-up time (TBUT) and Schirmer tests. METHODS: Fifty diabetic patients with a fasting blood glucose (FBG) level greater than 200mg/dL and HbA1c level greater than 10% were recruited for this prospective study. All of the patients underwent a detailed ophthalmic examination including OSDI questionnaire, TFO test, TBUT test and Schirmer test initially. All tests were repeated after obtaining regulation of patients' blood sugar (approximately 6 weeks later). RESULTS: The mean age of the diabetic patients in the study was 54.96±12.48 years. Initially, the mean FBG, postprandial blood glucose (PBG) and HbA1c levels were 301.40±79.11mg/dL, 431.06±74.47mg/dL and 12.31±1.67%, respectively. After blood glucose regulation; the levels of all parameters (153.78±59.32mg/dL, 252.32±88.34mg/dL and 9.67±1.60%, respectively) statistically significantly decreased (P<0.001). The mean levels of OSDI score, TFO measurement, TBUT test and Schirmer test were 28.38±16.46 points, 349.66±13.09 mOsm/L, 6.44±1.91s and 8.66±3.57mm initially, and 17.82±11.70 points, 314.14±12.80 mOsm/L, 6.62±2.03s and 9.02±3.68mm after blood glucose regulation, respectively. Although the improvements in TBUT and Schirmer test values were not statistically significant (P>0.05), statistically significant reduction was obtained in OSDI scores and TFO levels (P<0.001, for each). CONCLUSION: DM, which is a hyperosmolar disorder, appears to cause elevation in OSDI score and increase in TFO level, especially if blood glucose is poorly regulated.

Bone health and vitamin D status in alcoholic liver disease.

Alcohol consumption is harmful to many organs and tissues, including bones, and it leads to osteoporosis. Hepatic osteodystrophy is abnormal bone metabolism that has been defined in patients with chronic liver disease (CLD), including osteopenia, osteoporosis, and osteomalacia. Decreased bone density in patients with CLD results from decreased bone formation or increased bone resorption. The prevalence of osteopenia in alcoholic liver disease (ALD) patients is between 34 % and 48 %, and the prevalence of osteoporosis is between 11 % and 36 %. Cirrhosis is also a risk factor for osteoporosis. The liver has an important role in vitamin D metabolism. Ninety percent of patients with alcoholic liver cirrhosis have vitamin D inadequacy (<80 nmol/L). The lowest serum vitamin D levels were observed in patients with Child-Pugh class C. Bone densitometry is used for the definitive diagnosis of osteoporosis in ALD. There are no specific controlled clinical studies on the treatment of osteoporosis in patients with ALD. Alcohol cessation and abstinence are principal for the prevention and treatment of osteoporosis in ALD patients, and the progression of osteopenia can be stopped in this way. Calcium and vitamin D supplementation is recommended, and associated nutritional deficiencies should also be corrected. The treatment recommendations of osteoporosis in CLD tend to be extended to ALD. Bisphosphonates have been proven to be effective in increasing bone mineral density (BMD) in chronic cholestatic disease and post-transplant patients, and they can be used in ALD patients. Randomized studies assessing the management of CLD-associated osteoporosis and the development of new drugs for osteoporosis may change the future. Here, we will discuss bone quality, vitamin D status, mechanism of bone effects, and diagnosis and treatment of osteoporosis in ALD.

Frequency of metabolic syndrome and 25-hydroxyvitamin D3 levels in patients with non-alcoholic fatty liver disease.

AIM: It is known that insulin resistance has an important role in the pathogenesis of non-alcoholic fatty liver disease (NAFLD) and that serum 25-hidroksivitamin D3 [25-(OH)D] levels are found low in the presence of insulin resistance. Metabolic syndrome (MetS) is characterized by insulin resistance. The purpose of the present study was to determine the levels of 25-(OH)D and the frequency of MetS in patients with NAFLD, and to evaluate the association of 25-(OH)D with the histology of NAFLD and metabolic parameters. METHOD: Sixty-three patients with NAFLD confirmed by liver biopsy (29 females and 34 males, mean age 42.70±9.82 years) and 46 healthy controls (16 females and 30 males, mean age 37.54±8.56 years) were included in the study. International Diabetes Federation criteria were used for MetS diagnosis. Insulin resistance was determined according to the Homeostasis Model of Assessment (HOMA-IR) method. The groups were compared for 25-(OH)D levels and MetS frequencies. Correlation analysis was used to evaluate relationships between 25-(OH)D and metabolic parameters and/or NAFLD histology. RESULTS: 25-(OH)D levels were lower in the NAFLD group compared to the control group (36.06±13.07 ng/mL vs. 51.19±23.45 ng/mL, respectively, P<0.01), while MetS frequency was higher (66.7% vs. 15.2%, P<0.01). In the NAFLD group, 25-(OH)D levels were negatively correlated with non-alcoholic steatohepatitis scores and HOMA-IR (r=-0.317, P=0.011 and r=-0.437, P=0.001, respectively). CONCLUSION: The present study demonstrated higher frequency of MetS and lower levels of 25-(OH)D in patients with NAFDL, and a negative association of 25-(OH)D levels with non-alcoholic steatohepatitis scores and insulin resistance.