Abnormal Parathyroid Hormone Research Articles

7337 High Parathyroid Hormone (PTH) Due To Immunoassay Interference

Abstract Disclosure: V.A. Mendpara: None. A.J. McShane: None. L.Z. Khan: None. Background: PTH levels are not always accurate. This case illustrates immunoassay interference in a female with markedly abnormal PTH values. Understanding immunoassay interference in diverse hormonal assessments can prevent diagnostic inaccuracies. Clinical Case: A 63-year-old female with osteopenia underwent serum parathyroid hormone (PTH) testing as part of a thorough bone evaluation. The initial PTH level revealed an abnormal level of 4008 pg/mL (normal range: 15 to 65 pg/mL). The follow-up PTH level with the same assay continued to result in elevated values of >5000 pg/mL. The medication list was negative for biotin use, which is a well-known interfering substance in the PTH assay. Clinical evaluation was negative for hyperparathyroidism symptoms, and thyroid/parathyroid ultrasound was normal, as were serum levels of phosphate, vitamin D, and calcium. No PTH values had been checked for patients in the past after an extensive review of prior records. The initial PTH testing used the Roche Elecsys PTH STAT assay. To investigate a potential immunoassay interference, the following studies were performed: First, the sample was diluted with polyethylene glycol (PEG) to precipitate large molecular weight proteins; second, the sample was treated with a commercial heterophilic blocking reagent (Scantibodies Laboratory); and lastly, the sample was assayed utilizing a different PTH vendor (Siemens Atellica, chemiluminescent immunoassay). The PEG and heterophilic blocking treatments resulted in significantly lower PTH concentrations of 895.6 and 40.7 pg/mL, respectively. We do not anticipate a change in PTH levels in samples supplemented with blocking reagents or PEG without interference. The result from Siemens’ assay was markedly lower at 43.4 pg/mL. Both the Siemens and Roche assays employ mouse antibodies; however, the antibodies are proprietary between the vendors. This results in potentially different anti-mouse antibody epitope targets. Due to a history of advanced ovarian cancer, the patient was taking Oregovomab, a murine monoclonal antibody, as therapy for her advanced disease. It is unclear if this medication resulted in assay interference, but it is possible. Discussion: In summary, the discrepancy in PTH assay results highlights the need to consider immunoassay interference, particularly in patients with a history of cancer on immunotherapy agents. Our case highlights the importance of the clinician’s review of medications when assessing patients. While prior PTH assays were not conducted before the patient started Oregovomab, the potential development of interfering antibodies warrants consideration. Clinicians should be vigilant for atypical results and collaborate closely with laboratory professionals, as detecting interfering substances can result in misdiagnosis. Presentation: 6/2/2024

Adefovir Dipivoxil-induced Osteomalacia: A Rare Case of Misdiagnosis due to Concurrent Thyroid Tumor

Background: Both the administration of adefovir dipivoxil and the elevation of primary parathyroid hormone can result in serum electrolyte abnormalities and the development of metabolic bone disease. Adefovir dipivoxil-induced osteomalacia is a clinical disease that is rarely seen and often leads to misdiagnosis. Case presentation: In this case, the patient developed osteomalacia due to renal tubular toxicity caused by chronic use of adefovir dipivoxil. The drug indirectly affected the secretion of parathyroid hormone (PTH). Coincidentally, the patient also had a tumor below the thyroid, leading to a misdiagnosis. Conclusion: Osteomalacia caused by adefovir dipivoxil is a clinically rare disease, and it is important not to overlook it as it may lead to misdiagnosis. Hence, in cases where laboratory tests reveal abnormal parathyroid hormone levels, it is crucial to inquire about the patient s detailed medication history. This is applicable even in situations where there is evidence suggesting primary hyperparathyroidism.

Impaired Quality of Life in Patients with Post-Surgical Hypoparathyroidism.

Hypoparathyroidism is characterized by chronic hypocalcemia with low or abnormal parathyroid hormone levels. Thyroid surgery remains a predominant cause of hypoparathyroidism, often preventable by partial thyroidectomy. Although hypoparathyroidism can impair quality of life (QOL), data remain limited for Latin America. We aimed to characterize clinical manifestations and QOL in patients with postsurgical hypoparathyroidism. This case-control study included patients (>18 years) who underwent total thyroidectomy (TT) for differentiated thyroid cancer (DTC) with postsurgical hypoparathyroidism (Group 1, Cases) and those with DTC who underwent TT without postsurgical hypoparathyroidism (Group 2, Controls). Clinical records were collected, and the SF-36v2 QOL survey and a structured symptom survey were applied. A logistic multivariate regression analysis was performed. This study included 106 subjects (Group 1, N=41; Group 2, N=65). Group 1 patients were younger, had a higher frequency of lymph node resection, and more frequently received Ι-131 than Group 2 patients (p<0.05). In the SF-36v2 survey, Group 1 had fewer physical-functioning scores (odds ratio, 3.8; 95% confidence interval, 1.2-11.7) and lower scores in mental and physical components than Group 2 and national records. Commonly reported symptoms include paresthesia, daily fatigue, and memory alterations. Treatment adherence rates were 56% and 71% for calcium and calcitriol, respectively. Furthermore, 24% of patients experienced one or more hypoparathyroidism drug-related adverse effects. Patients with postsurgical hypoparathyroidism had an impaired QOL, a high frequency of disease-associated symptoms, and limited treatment adherence. These results should be considered when deciding the best surgical alternative for DTC.

Iron Indices Mediate but Not Modify Association of Parathyroid Hormone with Erythropoietin Resistance in Hemodialysis Patients

Introduction: Disordered iron balance and abnormal parathyroid hormone (PTH) concentrations, both prevalent in hemodialysis patients, are risk factors of erythropoietin (EPO) resistance. Few studies have evaluated the correlation between iron indices and PTH and the potential role of iron markers on the association of PTH with EPO resistance in hemodialysis population. Methods: In this cross-sectional study of 71 maintenance hemodialysis patients, iron indices including hepcidin, ferritin, reticulocyte hemoglobin content (CHr), and transferrin saturation (TSAT) were examined. EPO responsiveness was measured as EPO resistance index (ERI). Lowess regression curves were performed to explore the correlations of iron indices, PTH, and ERI. The association between PTH and ERI was modeled using linear regressions. Potential role of iron indices on this association was examined using stratified analyses and mediation analyses. Results: The average ERI value was 10.3 ± 5.3 IU w−1 kg−1 (g/dL) −1. ERI was correlated to PTH, hepcidin, CHr, and TSAT (all p < 0.05). Hepcidin and PTH were closely correlated with each other (r = 0.28, p = 0.020). Analysis by PTH categories yielded a total association effect of 2.53 (95% CI: 0.27–4.85, p = 0.027) for high PTH subgroup versus the reference low subgroup. No clinically significant interaction between iron indexes and PTH was identified. Hepcidin appeared to mediate about one-third of the total association between PTH and ERI in hemodialysis population (33.6%, p = 0.025). Conclusion: Iron indices and PTH levels were related to ERI values. Hepcidin appeared to be closely correlated to PTH and partly mediate the association between PTH and ERI in hemodialysis population.

Rare genetic disorders that impair parathyroid hormone synthesis, secretion, or bioactivity provide insights into the diagnostic utility of different parathyroid hormone assays.

Parathyroid hormone (PTH) is the major peptide hormone regulator of blood calcium homeostasis. Abnormal PTH levels can be observed in patients with various congenital and acquired disorders, including chronic kidney disease (CKD). This review will focus on rare human diseases caused by PTH mutations that have provided insights into the regulation of PTH synthesis and secretion as well as the diagnostic utility of different PTH assays. Over the past years, numerous diseases affecting calcium and phosphate homeostasis have been defined at the molecular level that are responsible for reduced or increased serum PTH levels. The underlying genetic mutations impair parathyroid gland development, involve the PTH gene itself, or alter function of the calcium-sensing receptor (CaSR) or its downstream signaling partners that contribute to regulation of PTH synthesis or secretion. Mutations in the pre sequence of the mature PTH peptide can, for instance, impair hormone synthesis or intracellular processing, while amino acid substitutions affecting the secreted PTH(1-84) impair PTH receptor (PTH1R) activation, or cause defective cleavage of the pro-sequence and thus secretion of a pro- PTH with much reduced biological activity. Mutations affecting the secreted hormone can alter detection by different PTH assays, thus requiring detailed knowledge of the utilized diagnostic test. Rare diseases affecting PTH synthesis and secretion have offered helpful insights into parathyroid biology and the diagnostic utility of commonly used PTH assays, which may have implications for the interpretation of PTH measurements in more common disorders such as CKD.

International variations in serum PTH and calcium levels and their mortality associations in peritoneal dialysis patients: Results from PDOPPS.

Mineral bone disorder (MBD) in chronic kidney disease (CKD) is associated with high symptom burden, fractures, vascular calcification, cardiovascular disease and increased morbidity and mortality. CKD-MBD studies have been limited in peritoneal dialysis (PD) patients. Here, we describe calcium and parathyroid hormone (PTH) control, related treatments and mortality associations in PD patients. We used data from eight countries (Australia and New Zealand (A/NZ), Canada, Japan, Thailand, South Korea, United Kingdom, United States (US)) participating in the prospective cohort Peritoneal Dialysis Outcomes and Practice Patterns Study (2014-2022) among patients receiving PD for >3 months. We analysed the association of baseline PTH and albumin-adjusted calcium (calciumAlb) with all-cause mortality using Cox regression, adjusted for potential confounders, including serum phosphorus and alkaline phosphatase. Mean age ranged from 54.6 years in South Korea to 63.5 years in Japan. PTH and serum calciumAlb were measured at baseline in 12,642 and 14,244 patients, respectively. Median PTH ranged from 161 (Japan) to 363 pg/mL (US); mean calciumAlb ranged from 9.1 (South Korea, US) to 9.8 mg/dL (A/NZ). The PTH/mortality relationship was U-shaped, with the lowest risk at PTH 300-599 pg/mL. Mortality was nearly 20% higher at serum calciumAlb 9.6+ mg/dL versus 8.4-<9.6 mg/dL. MBD therapy prescriptions varied substantially across countries. A large proportion of PD patients in this multi-national study have calcium and/or PTH levels in ranges associated with substantially higher mortality. These observations point to the need to substantially improve MBD management in PD to optimise patient outcomes. Chronic kidney disease-mineral bone disorder (MBD) is a systemic condition, common in dialysis patients, that results in abnormalities in parathyroid hormone (PTH), calcium, phosphorus and vitamin D metabolism. A large proportion of peritoneal dialysis (PD) patients in this current multi-national study had calcium and/or PTH levels in ranges associated with substantially higher risks of death. Our observational study design limits our ability to determine whether these abnormal calcium and PTH levels cause more death due to possible confounding that was not accounted for in our analysis. However, our findings, along with other recent work showing 48-75% higher risk of death for the one-third of PD patients having high phosphorus levels (>5.5 mg/dL), should raise strong concerns for a greater focus on improving MBD management in PD patients.

Estimation of serum levels of Parathyroid hormone, Vitamin D, Calcium and Phosphorus to study their association with age, gender, disease duration, and severity of chronic plaque psoriasis: Results of a case control study

: Psoriasis is a chronic inflammatory disease characterized by rapid turnover of epidermal keratinocytes; presenting clinically as erythema, induration, and scaling Parathyroid hormone (PTH) is secreted by parathyroid glands and its elevated levels may be seen in psoriasis and several other disorders of keratinization. PTH/PTH-related peptide receptors are present in dermal fibroblasts &amp; regulate proliferation and maturation of fibroblasts and keratinocytes. Release of PTH is under the feedback regulation of serum Ca2+, Vit.D and PO: To assess the Parathyroid hormone levels in patients of Psoriasis along with Vitamin D, Serum Calcium and Serum Phosphorus levels.: Out of the 50 cases aged between 18 and 91 years majority of patients i.e 22 (44%) were in the age group of 18-40 years followed by 20 (40%) patients in 41-60 years age group. Eight (16%) patients were above &amp;#62;60 years. 32 (64%) patients who had psoriasis for less than ≤60 months while 18 (36%) patients had psoriasis for more than &amp;#62;60 months Serum PTH (normal 10–65pg/ml), Vitamin D(normal 20-50(ng/ml), calcium (normal 9-11mg/dl and phosphorus (normal 2.5-4.5mg/dl) levels were measured after overnight fasting. : A total of 50 psoriasis patients along with 50 non-psoriatic age and sex matched controls were recruited for the study. There were 28 males and 22 females in the patient group aged between 18 and 91 years (mean±SD 43.52±16.23 years). The mean age of controls was 47.12±16.29 years with 19(38%) subjects in 18-40 years age group and 21(42%) in 41-60 years age group. Amongst the cases, there were 10(20%) patients who had abnormal PTH levels (six had elevated levels of PTH and four patients with low PTH levels) while 40(80%) had normal levels (mean±SD 47.97±25.46 pg/ml). : The interpretation of our observation remains complex and any conclusion for the significance of these biochemical abnormalities remain conjectural. Moreover, association of psoriasis with abnormal biochemical parameters remains debatable in view of limited number of studies whether abnormal biochemical parameters can serve as markers of severity and their correction can lead to improvement in the disease needs confirmation with more well designed experimental and prospective clinical studies.

THU605 Impact Of Abnormal Circadian Cortisol Secretion On Bone Metabolism In Patients With Mild Autonomous Cortisol Secretion

Abstract Disclosure: J. Saini: None. R. Nathani: None. S. Singh: None. V. Fell: None. E. Atkinson: None. S. Achenbach: None. S. Khosla: None. I. Bancos: None. Background: Previous studies reported that both cortisol secretion and bone metabolism biomarkers follow a circadian pattern of secretion. Patients with mild autonomous cortisol secretion (MACS) demonstrate an increased risk of fractures. As most patients with MACS do not have increased cortisol production, we hypothesized that abnormal circadian cortisol secretion is associated with impaired bone metabolism. Objective: To compare the circadian secretory pattern of bone metabolism biomarkers in relation to cortisol circadian secretion in patients with MACS versus referent subjects. Methods: We conducted a pilot cross-sectional study of patients with MACS and referent subjects. MACS was diagnosed in patients with adrenal adenomas based on an abnormal 1 mg dexamethasone suppression test (cortisol &amp;gt;1.8 mcg/dL). Referent subjects with available abdominal imaging within 5 years and adrenal disorder were recruited from the community. Participants were admitted to the clinical research unit for blood sampling every 2 hours over 24h period. Measurements included total and free cortisol, calcium, parathyroid hormone (PTH), osteocalcin, amino-terminal propeptide type 1 collagen (PINP), and carboxy-terminal telopeptide of type 1 collagen (CTX). Subjects with disorders or medication affecting bone metabolism were excluded. Time periods of blood draw were categorized into the morning (6 to 12 hours), afternoon (14-18 hours) and night (20-2 hours). Delta (morning measurements/afternoon measurements) was calculated. Results: Subjects included 12 patients with MACS (median age 57, IQR 48-67, 83% women) and 10 referent subjects (median age 57, IQR 50-63, 80% women). The 24-hour area under the curve for total (10342 vs 9090 mcg/dL, p=0.468) and free cortisol (437 vs 329 mcg/dL, p=0.086) was no different between patients with MACS and referent subjects. However, the mean night total (6.7 vs 4.3 mcg/dL, p=0.056) and free cortisol (0.2 vs 0.1 mcg/dL, p=0.035) was higher in MACS vs referent subjects. The area under the curve for calcium, phosphorus, CTX, osteocalcin and PINP were similar between patients and referent subjects, however, the area under the curve for PTH was higher in patients vs referent subjects (mean 64179 vs 42602 pg/mL, p=0.021). Both delta total cortisol (mean 8.6 vs 5.5, p=0.01) and delta PTH (mean -1.5 vs 4.2, p=0.051) was higher in referent subjects vs patients with MACS. Conclusion: When compared to referent subjects, patients with MACS have similar 24-hour cortisol production but demonstrate an increase in night-time cortisol secretion and a blunting of diurnal cortisol (lower morning/afternoon cortisol). Patients with MACS have higher PTH production overall, as well as an abnormal diurnal PTH secretion. Noted abnormalities in PTH may contribute to the MACS-associated impairment in bone health. Presentation: Thursday, June 15, 2023

A-090 Impact of Changing Total Calcium Methodology on Observed Hypercalcemia Prevalence at an Academic Health System

Abstract Background The UC Davis Health clinical chemistry laboratory implemented a new total laboratory automation (Roche Diagnostics, Indianapolis, IN) system in February 2022—replacing a prior system (Beckman Coulter, Brea, CA) that was in place since 2007. In August 2022, primary care and endocrinology providers contacted laboratory leadership to report an increase in patients with calcium values flagged as abnormally elevated, resulting in increased communications from patients to primary care providers and increased referrals to endocrinology. This change in testing methodology produced a shift in the upper reference interval limit from 10.5 mg/dL to 10.0 mg/dL. The new testing methodology determined total calcium photometrically vs by indirect potentiometry via the outgoing method. We hypothesize photometric-based total calcium measurements to be more sensitive. Methods We conducted a retrospective study to investigate the reported increase in hypercalcemic values—our electronic health system’s (EHR) EPIC’s self-service reporting tool (“SlicerDicer”) was utilized for data acquisition and visualization. Although the reference interval had already been verified prior to implementation, a “normal study” study was conducted to re-confirm manufacturer derived intervals. One hundred thirty-six samples from apparently healthy adults (age ≥ 18 years) were banked for this study. Parathyroid hormone (PTH) values were then measured to confirm levels were within normal limits. Additional observational data was also collected for PTH levels pre- and post-new automation line implementation. Quality control (QC) and proficiency testing (PT) data was also reviewed during this time. Results In the four months preceding implementation of the new automation line, 1211 patients had total calcium values flagged as elevated, compared to 5146 patients during a similar post implementation time period (302.8/month vs 1286.5/month), or an increase of 324.9%. During these same time periods, patients with abnormal PTH were observed at 270.8/month pre-implementation compared to 393/month post (45.2% increase). An increase in patients with concurrently performed calcium and PTH was also observed (30.3%; 583.8/month vs 760.8/month), though a greater increase was seen in patients with concurrently elevated calcium and abnormal PTH (294.5%; 22.8/month vs 89.8/month). One hundred twenty samples with normal PTH values were included in the total calcium normal study, which reported a mean (SD) value of 9.3 (0.33) mg/dL, confirming the manufacturer-derived intervals of 8.7–10 mg/dL. No biases, shifts, or trends were observed in PT or QC data in the four months preceding and post analyzer change. Conclusion Increased hypercalcemic events post-automation line implementation is likely not due to analytical error or inappropriate reference intervals, but rather due to increased sensitivity of methodology. Hypercalcemic cases determined by our new methodology were corroborated by corresponding abnormal PTH values. The perceived increased sensitivity could be due to known limitations of indirect potentiometry (i.e., lack of selectivity, difficulty detecting all forms of calcium, etc.). Further investigation is warranted to determine the overall impact of changing this one assay on the health system.

Evaluation of Long-Term Nutrition Outcomes After Duodenal Switch: A Systematic Review and Meta-Analysis.

Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective and durable metabolic and bariatric surgery to achieve a target weight loss. However, many surgeons are hesitant to adopt BPD-DS due to a lack of training, technical complexity, and long-term nutrition deficiencies. This meta-analysis aimed to investigate long-term nutrition outcomes after primary BPD-DS in the management of obesity. Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to February 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42023391316). From 834 studies screened, 8 studies met the eligibility criteria, with a total of 3443 patients with obesity undergoing primary BPD-DS. At long-term follow-up (≥5years), 25.4% of patients had vitamin A deficiency (95% CI: -.012, .520, I2 = 94%), and 57.3% had vitamin D deficiency (95% CI: .059, 1.086, I2 = 86%). Calcium deficiency was observed in 125 patients (22.2%, 95% CI: .061, .383, I2 = 97%), and 69.7% had an abnormal parathyroid hormone level (95% CI: .548, .847, I2 = 78%). Ferritin level was abnormal in 30 patients (29.0%, 95% CI: .099, .481, I2 = 79%). Despite displaying comparable nutrition-related outcomes to mid-term follow-up, our study demonstrated that BPD-DS could result in a high level of long-term nutrition deficiency after BPD-DS for selected patients. However, further randomized controlled studies with standardized supplementation regimens and improvement in compliance are necessary to evaluate and prevent long-term nutritional deficiencies after BPD-DS.

Monocyte-to-lymphocyte ratio correlates with parathyroid hormone concentration in patients with severe symptomatic aortic stenosis

PurposeThe normal healthy valve is devoid of inflammatory cells, however background of aortic stenosis (AS) may include inflammatory processes. Moreover, the link between hyperparathyroidism and heart failure is postulated. Simple whole blood analysis with indices is a beneficial tool in cardiovascular diseases’ assessment. The purpose of the study was to evaluate correlation between parathyroid hormone (PTH) and simple blood parameters in severe AS. Material and methodsThe study included 62 patients with severe AS. Patients with inflammatory or autoimmune co-morbidities were excluded. Blood samples were collected, and clinical and demographic data were analyzed. ResultsThe final study group comprised 55 patients (31 females, 56.4%; mean age 77.13 (SD 6.76)). In 23 patients (41.8%), PTH concentration was markedly increased. The study group was divided into two subgroups according to the PTH concentration. Patients from both groups did not differ significantly in terms of age and co-morbidities. PTH concentration correlated positively with monocyte-lymphocyte ratio (MLR) (p ​= ​0.008, Spearman rho 0.356) and platelet-lymphocyte ratio (PLR) (p ​= ​0.047, Spearman rho 0.269), creatinine level (p ​= ​0.001, Spearman rho 0.425) and glomerular filtration rate (GFR-MDRD) (p ​= ​0.009, Spearman rho −0.349).The multivariable logistic regression with backward analysis revealed MLR (p ​= ​0.029) and GFR (p ​= ​0.028) as independent significant predictors of abnormal PTH values.The receiver operator characteristics (ROC) curve was performed for the model of MLR and GFR-MDRD (AUC ​= ​0.777), yielding the sensitivity of 60.9% and specificity of 90.6%. ConclusionsPTH concentration correlates with monocyte-to-lymphocyte and platelet-to-lymphocyte ratios in calcified AS.

Hypoparathyroidism Risk After Total Endoscopic Thyroidectomy for Papillary Thyroid Cancer: A Comparison of the Transoral Vestibular and Breast Approaches.

BackgroundThis study aimed to compare the risk of hypoparathyroidism between the transoral vestibular approach (TOVA) and the breast approach (BA) in patients undergoing total endoscopic thyroidectomy (TET) for papillary thyroid carcinoma (PTC).MethodsThe medical records of 121 PTC patients (all women) who underwent total TET from January 2015 to January 2021 were retrospectively analyzed. Patients were grouped according to surgical approach (BA or TOVA). Clinical status and concentrations of parathyroid hormone (PTH) and calcium were monitored in the perioperative period and 1, 6, and 12 months after surgery.ResultsThe BA and TOVA groups comprised 101 and 20 patients, respectively. Clinicopathologic and characteristics and surgical data were comparable between the groups. Incidence of transient hypoparathyroidism was significantly lower in the TOVA group than the BA group (10% vs 63.4%; p <0.01). Incidence of permanent hypoparathyroidism was comparable (5% vs 6.9%). Two days after TET, mean PTH concentration was significantly higher and incidence of abnormal PTH was significantly lower in the TOVA group. The incidence of abnormal calcium concentration 2 days after surgery was significantly lower in the TOVA group. One month after surgery, the mean calcium concentration was significantly higher in the TOVA group. Univariate and multivariate Cox regression analysis suggested that patients who underwent TOVA had a lower risk of transient hypoparathyroidism (hazard ratio 0.05, 95% confidence interval, 0.01–0.23; p<0.01). No clinicopathological factors examined were significantly associated with permanent hypoparathyroidism.ConclusionIn patients undergoing TET for PTC, the incidence of transient hypoparathyroidism may be lower with the TOVA than the BA. Surgeons should be aware of the relatively high risk of transient hypoparathyroidism when performing the BA.

Primary hyperparathyroidism in Saudi Arabia revisited: a multi-centre observational study.

PurposePrimary hyperparathyroidism (PHPT) is a common cause of hypercalcemia and remains understudied within the Arabian population. The present study, the largest of its kind within the Gulf Cooperation Council (GCC) countries, aims to determine the demographics and clinical presentation of PHPT in Saudi Arabia.MethodsIn this multi-center retrospective study involving three tertiary hospitals in different geographic locations of Saudi Arabia namely, Riyadh, Al Ahsa and Jeddah, a total of 205 out of 243 confirmed PHPT cases aged 16 to 93 years old were included (N = 96 from Riyadh; N = 59 from Al Ahsa and N = 50 from Jeddah). Demographics, clinical manifestations and surgical outcomes were recorded as well as laboratory and radiologic investigations including serum parathyroid hormone (PTH), 25(OH)D, adjusted calcium, estimated glomerular filtration rate (eGFR) and nuclear scan outcome.ResultsPHPT cases appeared to increase over time when compared to other local studies published so far, with 12.8 cases per 100,000 hospital population. Females outnumber males (3:1) with 86% seen as out-patients. The average age was 59.8 ± 15.5 years. Abnormal PTH scan was seen in 171 patients (83.4%). Kidney stones was the most common renal manifestation (32 cases, 15.6%) and osteoporosis was the most common skeletal manifestation (67 cases, 32.7%). Al Ahsa had the highest prevalence of multiple comorbidities at 54% and the highest prevalence of obesity as a single comorbidity (17%) compared to other regions (p < 0.05). Jeddah recorded the highest prevalence of osteoporosis with bone and joint pains (30%) (p < 0.05).ConclusionComparison of present data with previous local studies suggest an increasing trend in PHPT cases in Saudi Arabia. Regional variations in the clinical presentation of PHPT were observed and warrant further investigation.

Health status of patients with β-thalassemia in the West Bank: a retrospective study

BackgroundThe management of β-thalassemia in developing countries is challenging due to few treatments being available other than recurrent transfusions. We assessed the haematological, biochemical, and hormonal findings among patients with β-thalassemia in the West Bank, occupied Palestinian territory. MethodsThis retrospective study was done between Jan 1, 2017, and Dec 31, 2018. Data on haematological, biochemical, and hormonal tests were collected from medical files of patients with β-thalassemia in eight primary health-care clinics, nine emergency departments, and eleven Palestinian Ministry of Health hospitals across the West Bank. Additionally, we collected data on demographics and the use of iron chelation. The study was approved by the research ethics committee at Al-Quds University and the Palestinian Ministry of Health (reference 162/1075/2019). The data had no identifying information and, therefore, informed consent from patients was waived for this study. Findings309 patients with β-thalassemia were included in the study (154 men and 155 women), with an average age of 23·4 (SD 10·4) years. 202 (79%) patients had pretransfusion haemoglobin concentrations lower than 9 g/dL (mean 8·4 [SD 1·4]). Additionally, 185 (73%) had iron overload, with the mean ferritin concentration in serum being 3175·8 μg/L (SD 3378·8). Concentrations of alanine aminotransferase and aspartate aminotransferase were high in 91 (38%) and 145 (61%) patients, respectively, and correlated positively with serum ferritin concentrations (r=0·527 and r=0·254, respectively; both p<0·0001). Kidney function tests (serum creatinine and blood urea nitrogen) did not correlate with serum ferritin (p=0·553 and 0·280, respectively). Deferoxamine was used for iron chelation in 63 (27%), and these patients had significantly higher ferritin concentrations in serum than patients receiving deferasirox (175 [74%], p=0·009). A small proportion of patients had endocrine function data that indicated abnormal total tri-iodothyronine, free thyroxine, and thyroid-stimulating hormone levels in 24 (34%), 29 (37%), and 24 (15%) patients, respectively, in addition to abnormal parathyroid hormone levels in 25 (50%) patients. However, these findings were not sufficient to diagnose or interpret endocrinopathies. InterpretationOur findings showed a lack of adherence to international guidelines in the management of β-thalassemia, which was reflected by the low pretransfusion haemoglobin and high serum ferritin concentrations. This study highlights the importance of establishing patient-tailored comprehensive assessment and follow-up protocols for the management of β-thalassemia with an emphasis on blood transfusion and iron chelation practices. FundingNone.

Abstract #1178603: Persistently High Parathyroid Hormone: Could it be drug-induced?

Calcium metabolism is one of the most complex and amazing physiologic mechanism of our system. Various factors are needed to maintain adequate calcium homeostasis but the most important one is Parathyroid Hormone (PTH). PTH responds efficiently to disturbances of calcium levels to keep calcium in the normal range. When PTH values are not consistent with expected physiology we must consider other etiologies and now things get even more exciting. Here we present a case of abnormal PTH levels in absence of expected changes and propose a suspected etiology.

Mineral Bone Disorders in Hemodialysis Patients in the West of Libya

Background and Objectives: Chronic kidney disease (CKD) is affecting 5%–10% of the world population. As kidney function declines, there is progressive deterioration in minerals homeostasis manifesting as disruption of serum and tissue concentrations of phosphorus, calcium (Ca), and parathyroid hormone (PTH). CKD-mineral bone disorder (CKD-MBD) is a systemic disorder of mineral and bone metabolism manifested by any or a combination of the following: abnormalities of Ca, phosphorus, PTH, Vitamin D metabolism, abnormalities of bone turnover, and vascular or soft-tissue calcification, associated with fractures, cardiovascular disease, and mortality in CKD patients. The study aims to identify the prevalence and pattern of CKD-MBD among hemodialysis patients in the west of Libya. Patients and Methods: A cross-sectional study was carried out on 186 regular hemodialysis patients from five hemodialysis centers in the west of Tripoli-Libya District. All patients were investigated for complete blood count, blood sugar, serum albumin, blood urea, serum creatinine, total Ca level, serum phosphate, serum alkaline phosphatase, and serum intact PTH (iPTH) level. Results: According to the Kidney Disease Outcomes Quality (KDOQ) iPTH level guideline, 88.10% of the studied patients had metabolic bone disorders, and 39.80% showed low bone turnover. About 48.40% were high bone turnover; only 11.80% of studied patients were within the target range according to the KDOQ Initiative guidelines. About 40.36% of studied patients had low calcium levels (below 8.5 mg%), and 35.48% had high phosphorus levels (more than 5.5 mg%). About 61.10% of high bone turnover patients complain of bone pain and 50.50% complain of muscle weakness. Among low bone turnover patients, 36.48% had no symptoms, and 28.38% were complaining of both muscle weakness and bone pain. Conclusions: The prevalence of MBDs among studied patients with abnormal PTH levels is 87.6%, distributed as 39.2% in abnormal low PTH (low bone turnover), and 48.4% in abnormal high PTH (high bone turnover).

Effectiveness and safety of ultrasound-guided microwave ablation for the treatment of primary hyperparathyroidism in 12 patients with parathyroid adenoma

To investigate the effectiveness and safety of ultrasound-guided microwave ablation (MWA) in treatment of primary hyperparathyroidism (PHPT). A total of 12 PHPT patients with parathyroid adenoma were treated with MWA in Nanjing University of Chinese Medicine Affiliated Hospital of Integrated Traditional Chinese and Western Medicine from May 2019 to February 2021. The patients were followed up once every 3 months for 3-12 months. Levels of serum parathyroid hormone (PTH), calcium and phosphorus were detected before and 20 min, 4h and 1day after ablation, and during follow-up period. The volume and volume reduction rate of parathyroid lesion were compared before the treatment and at the end of follow-up. The technical and clinical success of MWA were assessed as well. At the end of follow-up, median serum PTH [66.60 (42.21,80.03) ng/L vs.169.90 (89.01,396.50) ng/L] and calcium [2.39 (2.32,2.49) mmol/L vs. 2.75 (2.57,2.96) mmol/L] levels in 12 patients decreased significantly (all P<0.05). A complete response in terms of PTH and calcium levels was achieved in 6 of the 12 patients, while 4 of the patients had slightly elevated PTH levels just above the upper limit of normal reference range, and 2 of the patients remained abnormal PTH and calcium levels. The clinical cure rate was 50%. The volumes of all lesion after ablation were significantly decreased (P<0.05), with the technical success rate reaching 92.3%. No serious complications were observed. Ultrasound-guided MWA, thus, is safe and effective in the treatment of PHPT.

MO792CONTEMPORARY MINERAL AND BONE DISORDER MARKERS AND TREATMENT AMONG HEMODIALYSIS PATIENTS IN THE EUROPEAN DIALYSIS OUTCOMES AND PRACTICE PATTERNS STUDY (DOPPS)*

Abstract Background and Aims Chronic kidney disease mineral and bone disorder (CKD-MBD) is characterized by abnormalities in serum calcium, phosphorus, and parathyroid hormone (PTH) and associated with morbidity and mortality. Previous publications from the Dialysis Outcomes and Practice Patterns Study (DOPPS) have demonstrated country differences in the prevalence and treatment of CKD-MBD among hemodialysis patients in participating European countries. We aim to compare the distribution of CKD-MBD related labs and treatments across countries in a contemporary population of European hemodialysis patients. Method DOPPS is an international prospective cohort study of hemodialysis patients ≥18 years of age. Patients are enrolled randomly from a representative sample of dialysis facilities within each nation at the start of each study phase. The current analysis includes n=1,701 patients from 91 facilities in the initial prevalent cross section of Europe DOPPS phase 7 (2019-present; Belgium, Germany, Italy, Spain, Sweden, UK). Results from Belgium should be considered preliminary as initial questionnaire completion is ongoing. Results The % of patients with a high PTH (&amp;gt;600 pg/mL) ranged from 6% in Italy to 24% in the UK, with 12-17% having high PTH in all other countries. Mean serum total calcium ranged from 8.7 in Germany to 9.1 mg/dL in the UK (Table). Mean serum phosphorus varied from 4.5 in Belgium to 5.3 mg/dL in Germany. Dialysate calcium of 2.5 mEq/L was predominant in Germany, Sweden, and the UK while 3.0 mEq/L was the most common prescription in Belgium, Italy, and Spain. Calcimimetic prescription ranged from 13% in the UK to 32% in Spain. Etelcalcetide prescription ranged from 1% in the UK to 12% in Spain and 14% in Italy. Active vitamin D prescription ranged from 27% in Belgium to 75% in Sweden. Nearly all vitamin D prescriptions were administered intravenously in Spain versus about half in Italy; in all other countries, the route of active vitamin D administration was primarily oral. Patient age and dialysis vintage varied by country, potentially contributing to some of the observed country differences in MBD marker levels and treatment practices. Conclusion CKD-MBD related abnormalities in PTH, serum phosphorus and calcium remain common in European dialysis patients, with prevalence varying considerably by country. Substantial international variation in CKD-MBD treatments was also observed in prescription of vitamin D and calcimimetics. Uptake of the relatively new calcimimetic, etelcalcetide, varied considerably by country. A detailed understanding of the effect of treatment variation on CKD-MBD marker levels and patient outcomes is needed to provide important insights for the European HD community in optimizing management of secondary hyperparathyroidism.

Race and Gender Disparities in Access to Parathyroidectomy: A Need to Change Processes for Diagnosis and Referral to Surgeons.

Hyperparathyroidism substantially impairs quality of life, and effective treatment depends on timely referral to surgeons. We hypothesized that there would be race and gender disparities in the time from initial diagnosis of hyperparathyroidism to treatment with parathyroidectomy. We reviewed administrative data on 2289 patients with hypercalcemia (calcium > 10.5mg/dL) and abnormal parathyroid hormone levels who were seen at a tertiary referral center from 2011 to 2016. We used two-phase parametric hazard modeling to identify predictors of time from index abnormal calcium until parathyroidectomy. The median age of our cohort was 63years, and 1685 (74%) were women. Of the total patients, 1301 (57%) were Caucasian, and 946 (41%) were African-American. Only 490 (21%) patients underwent parathyroidectomy. Among patients undergoing surgery, time from index high calcium to surgical treatment was longest for African-American men, who waited a median of 13.6months (interquartile range IQR 2-28), compared with 2.9months (IQR 1-8) for Caucasian males (p < 0.05). African-American women waited a median of 6.7months (IQR 2-16) versus 3.5months (IQR 2-14) for Caucasian women (p < 0.05). At 1year after the index abnormal calcium, only 6% of black men underwent surgery compared with 20% of white males (p < 0.05). Similarly, 13% of black women underwent surgery versus 20% of white women (p < 0.05). These differences remained significant after adjusting for age, calcium levels, insurance, and comorbidities. African-Americans face substantial delays in access to parathyroidectomy after diagnosis with hyperparathyroidism that could impair quality of life and increase health care costs. We must improve systems of diagnosis and referral to ensure timely treatment of hyperparathyroidism.

Primary hyperparathyroidism.

Primary hyperparathyroidism (PHPT) is a condition that affects calcium metabolism due to parathyroid hormone (PTH) hypersecretion leading to hypercalcemia. Manifestations have changed over time, from a symptomatic disease with bone pain, fractures, nephrolithiasis, and muscle weakness, to a condition that is mainly asymptomatic (80-90%). Typical symptoms and signs occur in the bones and kidneys and atypical manifestations are cardiovascular, neuropsychiatric and cognitive, neuromuscular, rheumatological, and gastrointestinal. Diagnosis occurs, in most cases, in asymptomatic patients by a routine calcium measurement with corrected high total calcium associated with high or inappropriately abnormal PTH. If indicated, a search for the location of the involved parathyroid gland should be performed with ultrasound, scintigraphy, or 4D CT. Parathyroidectomy is the gold standard treatment. If surgery cannot be performed, clinical management is indicated. Surgical indications are osteoporosis, hypercalciuria, spine fractures, age <50 years, calcemic values above 1.0mg/dL threshold value, creatinine clearance ≤60mL/min, and nephrolithiasis or nephrocalcinosis.