Average Parathyroid Hormone Research Articles

#1736 Correlation between chronic kidney disease-mineral and bone disorder parameters and clinical events in hemodialysis patients

Abstract Background and Aims Patients with chronic kidney disease experience mineral and bone metabolism alterations, collectively known as Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD), linked to elevated cardiovascular mortality. A significant biochemical change is the development of secondary hyperparathyroidism—an adaptive response to uremic conditions that, when surpassing critical thresholds, becomes maladaptive, heightening clinical risk. Presently, optimal parathyroid hormone (PTH) values for hemodialysis (HD) patients lack a clear definition, with recent evidence challenging international guideline limits. This study aimed to evaluate the impact of PTH values on mortality in a population of patients in HD. Method A prospective observational study involving chronic hemodialysis patients commenced in January 2020, with a 40-month follow-up for mortality recording. Exclusion criteria comprised parathyroidectomy, primary hyperparathyroidism evidence, prior kidney transplant, or transplant plans within three months. Clinical and biochemical data, aligned with the 2017 KDIGO guidelines for PTH, calcium (Ca), and phosphorus (Ps) target values, were recorded. Our laboratory PTH values ranged from 25 to 88 pg/ml, and stable PTH values within 180 to 700 pg/ml were deemed adequate in HD patients. Patients were categorized based on the average of three values over 12 months for PTH, Ca, and Ps parameters. Results One hundred patients (average age: 71 ± 13.59) were enrolled. Seventy-seven percent achieved PTH targets (180-700 pg/ml), 73% for Ca, and 19% for phosphorus (Table 1). During follow-up, 36 deaths (36%) occurred. While percentages of target achievement were similar between survivor and non-survivor groups, non-survivor patients exhibited higher PTH values (423.08 ± 277 vs. 360.44 ± 214.92; p = 0.05) without differences in Ca and Ps levels between the two groups (Table 2). Stratifying based on the median PTH value (330 pg/ml) revealed higher mortality in patients with PTH > 330 pg/ml (Log-rank test p = 0.05) (Fig. 1). Conclusion Despite comparable target achievements for PTH, Ca, and Ps, deceased patients had elevated average PTH values, especially those exceeding 330 pg/ml, indicating a higher risk of death during our follow-up. In line with recent literature, these findings underscore PTH's role as a uremic toxin, suggesting a revaluation of current PTH targets for hemodialysis patients

Correlation of serum vitamin D level before surgery with hypocalcemia after total thyroidectomy

Background. Hypocalcemia is a common complication of total thyroidectomy. It has many consequences for the health of patients and negatively affects the patient’s quality of life. The purpose of this study was to investigate the predictive role of vitamin D serum levels before total thyroidectomy in the occurrence of hypocalcemia. Methods. This cross-sectional study was conducted on 82 patients who were candidates for total thyroidectomy surgery and referred to 5 Azar Hospital in Gorgan in 2022. Demographic information, laboratory variables, and clinical symptoms of hypocalcemia before surgery, and 24 hours and two weeks after surgery were collected using a checklist. Data were analyzed with SPSS18 software, independent t-tests, U-Man-Whitney, Wilcoxon, paired t-tests, and a Chi-square test at a significance level of 0.05. Results. The mean serum calcium level was significantly reduced 24 hours and two weeks after surgery. The average serum level of phosphorus also decreased significantly 24 hours after surgery. About 32.9% showed symptoms of hypocalcemia 24 hours after surgery. Hypocalcemia was not related to the serum vitamin D level. The mean serum calcium level was significantly lower in patients with hypocalcemic symptoms. The average parathyroid hormone one day after surgery was significantly higher in patients with normal calcium levels. Conclusion. Vitamin D serum level before total thyroidectomy is not related to hypocalcemia after total thyroidectomy. Serum levels of parathyroid hormone and phosphorus are related to serum calcium changes after surgery. Practical Implications. Serum vitamin D levels before thyroidectomy cannot predict hypocalcemia after total thyroidectomy. Serum levels of parathyroid hormone and phosphorus are related to serum calcium changes after surgery. Therefore, long-term follow-up of calcium, vitamin D, parathyroid hormone, and phosphorus levels is recommended for these patients.

ODP133 Rare Case of Primary Hyperparathyroidism Causing Hypercalcemic crisis in Systemic Lupus Erythematosus (SLE)

Abstract Introduction Hyperparathyroid crisis is a rare endocrine emergency with a high mortality. Primary hyperparathyroidism (PHP) can present as severe hypercalcemia. There are very few cases documented in literature of patients with concomitant SLE and PHP. We present a case of hypercalcemic crisis in a patient with untreated primary hyperparathyroidism with a history of SLE. Case description A 46 year old woman was found to have hypercalcemia of 12.9 mg/dl on routine lab work. Her medical history is significant for SLE (diagnosed 9 years prior) and osteoarthritis. She had no physical complaints. Further workup confirmed primary hyperparathyroidism with PTH of 322.8 pg/ml and findings consistent with parathyroid adenoma on Sestamibi scintigraphy. Parathyroidectomy was strongly recommended however the patient refused. She was then offered medical management but did not show up for any follow up appointments. Two years later, she presented to the emergency department with altered mentation, lethargy, poor oral intake and abdominal pain for 2 days. She was found to have severe hypercalcemia with a serum calcium of > 24.8 mg/dl and was in acute renal failure. On admission, EKG changes suggestive of pseudoinfarct pattern from severe hypercalcemia were present. She was managed in the intensive care unit with intravenous hydration, calcitonin, zoledronic acid and hemodialysis. Shortly after initiation of hemodialysis, the patient succumbed to a cardiac arrest. Conclusion Hyperparathyroid crisis when untreated has a 100% mortality rate. Early management with surgical intervention is the only confirmed cure for PHP. There are only 18 cases reported in literature of hypercalcemia in SLE. Mechanisms involved are believed to be stimulatory PTH antibodies, PTHrP and osteoclastic activity due to inflammatory cytokines. To our best knowledge this is the 6th case report of a patient with concomitant SLE and PHP. A prospective study by Norman et. al 1 done in 10000 PHP patients demonstrated a Gaussian distribution with the average calcium concentration being 10.9 ± 0.6 mg/dL and the average parathyroid hormone concentration being 105.8 ± 48 pg/ml . Her baseline calcium at diagnosis was 13mg/dl and intact PTH was 322.8 pg/ml which is higher than seen in the normograms as per the study. In our patient, we believe SLE could have exacerbated the hypercalcemia caused by PHP. It is important to perform further studies to identify if any association exists between the two conditions. Physicians must recognize their concomitant occurrence as prompt management of hypercalcemia becomes even more crucial in these cases.

Calcimimetic use in US hemodialysis facilities in first 2 years after the launch of etelcalcetide: A descriptive analysis of real-world clinical practice and outcomes.

This study described control of parathyroid hormone (PTH), phosphorus, and corrected calcium in adults initiating calcimimetics in small dialysis organizations after the introduction of etelcalcetide. This retrospective study using Visonex Clarity electronic health records between October 1, 2017, and December 31, 2019, identified adults ≥ 18 years of age receiving in-center hemodialysis as either a cinacalcet or etelcalcetide initiator based on their first calcimimetic use in 2018 (index date) with no prior calcimimetic use in the 3months preindex date. Patients were stratified by PTH at index date and were followed for 15 months. Subcohorts of patients who were persistent on a single calcimimetic for 15 months and of patients who had their calcimimetic changed from cinacalcet to etelcalcetide were also analyzed. A total of 677 patients initiated cinacalcet and 711 initiated etelcalcetide. Mean PTH (pg/ml), phosphorus, and corrected calcium (mg/dl) at baseline were 864, 5.9, and 9.3 for cinacalcet and 804, 5.9, and 9.4 for etelcalcetide, respectively. During follow-up, the proportion of initiators considered in-target (monthly average PTH < 600) increased from 48% to 62% with cinacalcet and from 56% to 86% with etelcalcetide in the baseline PTH 600 to < 800 subgroup; increased from 30% to 64% with cinacalcet and 31% to 59% with etelcalcetide among those with baseline PTH 800 to < 1000; and increased from 14% to 41% with cinacalcet and 12% to 58% with etelcalcetide among those with baseline PTH ≥1000. A similar pattern was observed for persistent users (n=646). For patients changed from cinacalcet to etelcalcetide (n=183), the proportion of patients considered in-target increased from 22% in the month prior to the treatment change to 51% in Month 6 postchange. Patients initiating calcimimetics at lower baseline PTH had better biochemical control than patients starting at higher PTH. Patients changed from cinacalcet to etelcalcetide had improvements in PTH control postchange.

VITAMIN D STATUS OF INDOOR-HOUSED HOFFMANN'S TWO-TOED SLOTHS (CHOLOEPUS HOFFMANNI): A PILOT STUDY.

Disorders of calcium homeostasis have been reported with some frequency in two-toed sloths, yet little investigation has been performed on vitamin D and mineral metabolism in these species. This study evaluates biomarkers involved in vitamin D and calcium metabolism in a group of nine managed Hoffmann's two-toed sloths (Choloepus hoffmanni), correlated with diet analysis. Serum was analyzed for both vitamin D2 and D3 metabolites, minerals (calcium [Ca], phosphorus [P], and magnesium [Mg]), parathyroid hormone (PTH), and ionized calcium (iCa). The diet was analyzed for proximate nutrients, minerals and vitamins D2 and D3, and feed intake was estimated. Average values reported for D3 metabolites, including 25(OH)D3, 1,25(OH)2D3, and 24,25(OH)2D3, were 25.1 ng/ml, 52.23 pg/ml, and 7.65 ng/ml, respectively. Average PTH was 0.22 pmol/L while average iCa was 1.46 mmol/L. Values reported for Ca, P, Mg were within expected ranges. Dietary concentration of D3 was 6.7 ng/g and the average daily intake per sloth was 113.7 IU/kg body weight. No detectable levels of vitamin D2 metabolites 25(OH)D2, 1,25(OH)2D2, or 24,25(OH)2D2 were found in the diet or serum. These data will serve as a starting point for future investigations into the vitamin D metabolism and calcium homeostasis of two-toed sloths to improve the health in managed settings.

The Association Between Dietary Inflammatory Index and Parathyroid Hormone in Adults With/Without Chronic Kidney Disease.

Aims: We aimed to assess the association between dietary inflammation index (DII) with parathyroid hormone (PTH) and hyperparathyroidism (HP) in adults with/without chronic kidney disease (CKD).Methods: Data were obtained from the 2003–2006 National Health and Nutrition Examination Survey (NHANES). The participants who were <18 years old, pregnant, or missing the data of DII, PTH, and CKD were excluded. DII was calculated based on a 24-h dietary recall interview for each participant. Weighted multivariable regression analysis and subgroup analysis were conducted to estimate the independent relationship between DII with PTH and the HP in the population with CKD/non-CKD.Results: A total of 7,679 participants were included with the median DII of −0.24 (−2.20 to 1.80) and a mean PTH level of 43.42 ± 23.21 pg/ml. The average PTH was 45.53 ± 26.63 pg/ml for the participants in the highest tertile group compared with 41.42 ± 19.74 pg/ml in the lowest tertile group (P < 0.0001). The rate of HP was 11.15% overall, while the rate in the highest DII tertile was 13.28 and 8.60% in the lowest DII tertile (P < 0.0001). The participants with CKD tended to have higher PTH levels compared with their counterparts (61.23 ± 45.62 vs. 41.80 ± 19.16 pg/ml, P < 0.0001). A positive association between DII scores and PTH was observed (β = 0.46, 95% CI: 0.25, 0.66, P ≤ 0.0001), and higher DII was associated with an increased risk of HP (OR = 1.05, 95% CI: 1.02, 1.08, P = 0.0023). The results from subgroup analysis indicated that this association was similar in the participants with different renal function, gender, age, BMI, hypertension, and diabetes statuses and could also be appropriate for the population with CKD.Conclusions: Higher consumption of a pro-inflammatory diet appeared to cause a higher PTH level and an increased risk of HP. Anti-inflammatory dietary management may be beneficial to reduce the risk of HP both in the population with and without CKD.

PDB30 Calcimimetic Use in United States (US) Hemodialysis Facilities in First Two Years after Launch of Etelcalcetide

This study described control of parathyroid hormone (PTH), and corresponding corrected calcium (Ca) and phosphorous in adults initiating calcimimetics during 2018 in small dialysis organizations after the introduction of etelcalcetide. This retrospective study using Visonex® Clarity electronic health records between 10/1/2017 and 12/31/2019 identified adults ≥18 years of age receiving in-center hemodialysis as either a cinacalcet or etelcalcetide initiator based on their first calcimimetic use in 2018 (index date) with no prior calcimimetic use in the 3 months pre-index date. Patients were stratified by PTH at baseline and were followed for 15 months from index date. Sub-groups of patients who were persistent on a single calcimimetic for 15 months and of patients who switched from cinacalcet to etelcalcetide were also analyzed. 677 patients initiated cinacalcet and 711 initiated etelcalcetide. Mean PTH (pg/mL), phosphorus and Ca (mg/dL) at baseline were 864, 5.9 and 9.3 for cinacalcet and 804, 5.9 and 9.4 for etelcalcetide. Over 15 months of follow-up the proportion of initiators with baseline PTH 600-<800 considered “in-target” (monthly average PTH <600) increased from 48% to 62% with cinacalcet and from 56% to 86% with etelcalcetide; among those with baseline PTH 800-<1000, the proportion increased from 30% to 64% with cinacalcet and 31% to 59% with etelcalcetide; and among those with baseline PTH ≥1000 this proportion increased from 14% to 41% with cinacalcet and 12% to 58% with etelcalcetide. A similar pattern was observed for persistent users (n=646). For patients switching from cinacalcet to etelcalcetide (n=183), the proportion of patients considered “in-target” increased from 22% in the month prior to switch to 51% in month 6 post-switch. Patients initiating calcimimetics at higher baseline PTH had poorer biomarker control than patients starting at lower PTH. Patients switched from cinacalcet to etelcalcetide had improvements in PTH control post-switch.

Relationship between the extent of central node dissection and parathyroid function preservation in thyroid cancer surgery.

The risk and effect of hypocalcemia following surgery of different magnitudes remains unclear. Thus, we assessed whether different extents of central lymph node dissection (CLND) and status of preserved parathyroid glands can influence parathyroid function in differentiated thyroid carcinoma (DTC) patients with initial surgical resection. Participants were categorized into 6 groups based on the extent of the surgical procedures, number of parathyroid glands preserved in situ, and parathyroid autotransplantation. The frequencies of hypocalcemia, serum calcium (Ca) levels, and parathyroid hormone (PTH) levels among the different groups were analyzed. The prevalence of hypocalcemia, number and status of parathyroid glands preserved in situ, and parathyroid autotransplantation were inversely related to extensive CLND (r=-0.18; P<0.05). The decrease of serum Ca and PTH was most severe on postoperative days (POD) 1-7. The incidence of hypocalcemia was higher in Group C than in Group B and A (P<0.05). The average postoperative serum Ca and PTH levels in Group C were significantly lower than group A on POD 1-7 (P<0.05). The incidence of hypocalcemia was obviously increased in Group D compared to Groups E and F (P<0.05). The mean serum Ca and PTH levels in Group D were significantly lower than in Group F (P<0.05), and the same results could be observed between Groups D and E (P<0.05). However, through parathyroid autotransplantation, there was no significant difference that could be found between Groups E and F on POD 1-7 (P>0.05). With the expansion of CLND scope, postoperative parathyroid function will be affected, increasing the risk of postoperative hypocalcemia. When at least 1-2 parathyroid glands were reserved in situ plus at least 1 parathyroid gland autotransplantation, there was little effect on postoperative parathyroid function.

Surgical treatment of patients with primary hyperparathyroidism with a risk of hypercalcaemic crisis.

The objective of the work was to evaluate the effectiveness of surgical treatment in patients with a high risk of hypercalcaemic crisis due to primary hyperparathyroidism (PHPT) and to determine the best time to undergo surgery. Between 2010 and 2019, 627 patients underwent surgery due to PHPT. Sixty-two patients (9.9%) (47 women and 15 men, aged 28-79 years, average 53.7 years) faced the threat of a parathyroid crisis. In these patients, the average parathyroid hormone (PTH) levels were 774.02 pg/mL (95% CI: 203-1246 pg/mL) and ionised calcium (iCa2+) 1.91 mmol/L (95% CI: 1.70-2.2 mmol/L). The PTH postoperative concentration averaged at 37.86 pg/mL (95% CI: 9.91-42.7 pg/mL) and iCa2 + 1.11 mmol/L (95% CI: 1.07-1.21 mmol/L). Bilateral neck exploration was performed in all patients with the removal of the affected parathyroid gland and biopsies of other parts. Histopathological examination revealed adenoma in 42 cases (67.7%), hyperplasia in 16 (25.7%), and parathyroid cancer in four of the patients (6.6%). Comparison of tests before and after surgery showed a statistically significant decrease in PTH (p < 0.001) and iCa (p < 0.001) in blood serum. A developing hypercalcaemic crisis in the course of hyperparathyroidism is an indication for preoperative intensive medical therapy, along with urgent surgical intervention and removal of diseased parathyroid glands. This type of surgery should be performed as soon as possible, even if there are no imaging tests, only based on an assessment of the general condition of the patient and their serum calcium levels.

Effects of Elevated Parathyroid Hormone Levels on Muscle Health, Postural Stability and Quality of Life in Vitamin D-Insufficient Healthy Women: A Cross-Sectional Study.

Independently of plasma 25-hydroxyvitamin D (P-25(OH)D) levels, elevated parathyroid hormone (PTH) levels may exert an adverse effect on muscle health, postural stability, well-being, and quality of life. Using a cross-sectional design, we investigated 104 healthy postmenopausal women with low P-25(OH)D (< 50nmol/l) levels, who had either secondary hyperparathyroidism (SHPT) with elevated PTH levels (> 6.9pmol/l, n = 52) or normal PTH levels (n = 52). The average PTH value in women with SHPT was 8.5 (interquartile range 7.5-9.7) pmol/l and 5.3 (4.4-6.3) pmol/l in women with normal PTH (p < 0.001). Plasma phosphate was significantly lower in women with SHPT than in women with normal PTH (1.01 ± 0.14 vs. 1.09 ± 0.13mmol/l; p < 0.01). In the total cohort, average level of 25(OH)D were 38 (31-45) nmol/l, with no differences between groups. SHPT was associated with impaired muscle strength as assessed by both maximum muscle strength and maximum force production at knee flexion with the knee fixed at 60° and 90° (pall < 0.05). Postural stability was impaired during semi tandem standing (p = 0.001). However, the two groups did not differ in terms of self-reported physical activity, muscle-related symptoms, quality of life, or lean muscle mass as assessed by dual-energy X-ray absorptiometry. Independently of 25(OH)D levels, mild to moderately elevated PTH levels are associated with adverse effects on muscle strength and postural stability. Why some individuals respond to vitamin D insufficiency with an elevated PTH and others do not need further elucidation, but elevated PTH itself seems to affect muscle function and postural stability.

Parathyroidectomy in the Management of Secondary Hyperparathyroidism.

Secondary hyperparathyroidism develops in CKD due to a combination of vitamin D deficiency, hypocalcemia, and hyperphosphatemia, and it exists in nearly all patients at the time of dialysis initiation. There is insufficient data on whether to prefer vitamin D analogs compared with calcimimetics, but the available evidence suggests advantages with combination therapy. Calcium derangements, patient adherence, side effects, and cost limit the use of these agents. When parathyroid hormone level persists >800 pg/ml for >6 months, despite exhaustive medical interventions, monoclonal proliferation with nodular hyperplasia is likely present along with decreased expression of vitamin D and calcium-sensing receptors. Hence, surgical parathyroidectomy should be considered, especially if concomitant disorders exist, such as persistent hypercalcemia or hyperphosphatemia, tissue or vascular calcification including calciphylaxis, and/or worsening osteodystrophy. Parathyroidectomy is associated with 15%-57% greater survival in patients on dialysis, and it also improves hypercalcemia, hyperphosphatemia, tissue calcification, bone mineral density, and health-related quality of life. The parathyroidectomy rate in the United States declined to approximately seven per 1000 dialysis patient-years between 2002 and 2011 despite an increase in average parathyroid hormone levels, reflecting calcimimetics introduction and uncertainty regarding optimal parathyroid hormone targets. Hospitalization rates are 39% higher in the first postoperative year. Hungry bone syndrome occurs in approximately 25% of patients on dialysis, and profound hypocalcemia requires high doses of oral and intravenous calcium along with calcitriol supplementation. Total parathyroidectomy with autotransplantation carries a higher risk of permanent hypocalcemia, whereas risk of hyperparathyroidism recurrence is higher with subtotal parathyroidectomy. Given favorable long-term outcomes from observational parathyroidectomy cohorts, despite surgical risk and postoperative challenges, it is reasonable to consider parathyroidectomy in more patients with medically refractory secondary hyperparathyroidism.

Measurement of serum parathyroid hormone during the early postoperative period as a predictor of clinical hypocalcaemia

Aim – to assess the risk of postoperative hypoparathyroidism and hypocalcaemia depending on the parathyroid hormone (PTH) blood levels in the early postoperative period in patients underwent thyroid surgery of different volume. Materials and methods. The results of serum PTH and ionized calcium (Ca++) levels in 305 patients operated on thyroid gland were analyzed. They included: thyroidectomy for Graves' disease (76 patients), hemithyroidectomy for nodular goiter (12 patients), hemithyroidectomy with lymphadenectomy for suspected cancer (19 patients), thyroidectomy for multinodular goiter (24 patients), thyroidectomy with lymphadenectomy for multinodular goiter, suspected or proven thyroid cancer (174 patients). According to the degree of clinical manifestations of hypocalcaemia, patients were divided into 4 groups: 1 – absence of obvious clinical manifestations, 184 (60.33%), 2 – mild form, 62 (20.33%), 3 – medium severity, 36 (11.8%), 4 – severe form, 23 (7.54%). Results and Discussion. The increase in the degree of clinical manifestations of hypocalcaemia correlated with the decrease in mean level of PTH and Ca++ in serum. Thus, patients of group 1 (184) had an average PTH level of 25.86 pg/ml (range: 14.23 – 51.39 pg/ml), and the mean level of Ca++ blood was 1.16 mmol/l (1.0 – 1.26 mmol/l). Patients of 2 group demonstrated the average level of PTH 12.92 pg/ml (8.12 – 16.36 pg/ml), and the average level of Ca++ 0.98 mmol/l (0.92 – 1.05 mmol/l). Patients of 3 group had average PTH levels of 7.67 pg/ml (4.54 – 11.19 pg/ml), Ca++ 0.84 mmol/l (0.78 – 0.97 mmol/l); and patients with severe form – PTH 3.42 pg/ml (0.2 – 6.38 pg/ml), Ca++ 0.68 mmol/l (0.62 – 0.83 mmol/l). The mean blood levels of PTH and Са++ decrease depending on the degree of clinical manifestations of hypocalcaemia. With an increase in the volume of surgical intervention, the number of cases of iatrogenic hypoparathyroidism and hypocalcaemia increased: hemithyroidectomy with lymphadenectomy resulted with hypocalcaemia in 4 patients (21.05%), thyroidectomy for multinodular goiter – in 8 (33.3%), thyroidectomy with lymphadenectomy – in 73 (41.95%), and thyroidectomy for Graves' disease – in 36 cases (47.36%). All patients of group 1 (184 patients) who had no clinical manifestations of hypoparathyroidism demonstrated PTH at lower border of normal figures (14.23 pg/ml and higher), and were candidates for safe early discharge from the hospital (2-3 day). Conclusions. Measurement of PTH level in the early postoperative period helps to identify patients with a high risk of postoperative hypoparathyroidism. The more than 15 pg/ml level of PTH in such patients allows to exclude the development of hypocalcaemia and shorten the patient's stay in the hospital, contributes to safe discharge.

Bone mineral disturbances in patients with chronic kidney disease stage 5 not yet on dialysis.

This retrospective study evaluates the success of a treatment strategy for secondary hyperparathyroidism in our cohort of patients with chronic kidney disease stage 5 who were not yet on dialysis. 81 predialysis patients from the outpatient clinic of the Department of Nephrology, University Medical Center Ljubljana were reviewed. We focused on serum markers for bone mineral metabolism including intact parathyroid hormone (PTH), phosphate, corrected calcium, and the usage of phosphate-binding agents and vitamin D analogs. Results of intact PTH and phosphorus and calcium concentrations were related to treatment options for secondary hyperparathyroidism. The average intact PTH concentration was 198.8±162.5 ng/L, serum phosphate was 1.52±0.35 mmol/L, and corrected calcium was 2.23±0.2 mmol/L. Phosphate-binding agents were prescribed in 62% patients, 44% of these patients were on calcium-containing phosphate binders. Active vitamin D or synthetic vitamin D analogs were given to 65% of patients, and 48% of all received a combination of active vitamin D derivate and inactive vitamin D supplementation. Serum intact PTH was between 150 and 300 ng/L in 30%, under 150 ng/L in 46%, and over 300 ng/L in 24% of patients, respectively. Our data show that 76% of our patients with CKD stage 5 not yet on dialysis achieved adequate control of secondary hyperparathyroidism. Marked reduction of intact PTH levels in a significant proportion of our patients prompt us to assess the administration of excessive amounts of calcium and/or vitamin D supplements to prevent over-suppression of PTH, which can induce adynamic bone disease. .

The Relationship between Vitamin D and Coronary Artery Ectasia in Subjects with a Normal C-Reactive Protein Level.

Background and ObjectivesVitamin D is generally known to be closely related to inflammation. The effects of vitamin D on coronary artery disease (CAD) are not fully explained. Nowadays, coronary artery ectasia (CAE) cases are common and are regarded as being a kind of CAD. We aimed to investigate, in a case-control study, the relationship between vitamin D and CAE without an associated inflammatory process.Subjects and MethodsThis study population included 201 patients (CAE group, 121 males; mean age, 61.2±6.4 years) with isolated CAE; and 197 healthy individuals (control group, 119 males; mean age, 62.4±5.8 years), comprising the control group, who had normal coronary arteries. These participants concurrently underwent routine biochemical tests, tests for inflammatory markers, and tests for 25-OH vitamin D in whole-blood draws. These parameters were compared.ResultsThere are no statistical significance differences among the groups for basic clinical characteristics (p>0.05). Inflammatory markers were recorded and compared to exclude any inflammatory process. All of them were similar, and no statistical significance difference was found. The average parathyroid hormone (PTH) level of patients was higher than the average PTH level in controls (41.8±15.1 pg/mL vs. 19.1±5.81 pg/mL; p<0.001). Also, the average 25-OH vitamin D level of patients was lower than the average 25-OH vitamin D level of controls (14.5±6.3 ng/mL vs. 24.6±9.3 ng/mL; p<0.001). In receiver operating characteristic curve analysis, the observed cut-off value for vitamin D between the control group and patients was 10.8 and 85.6% sensitivity and 75.2% specificity (area under the curve: 0.854, 95% confidence interval: 0.678-0.863).ConclusionWe found that there is an association between vitamin D and CAE in patients who had no inflammatory processes. Our study may provide evidence for the role of vitamin D as a non-inflammatory factor in the pathophysiology of CAE.

The Determinants of Hemoglobin Variability in Hemodialysis Patients

Abstract Introduction. Factors that have been reported to affect erythropoietin (EPO) responsiveness in hemodialysis (HD) patients include iron deficiency, chronic inflammation, secondary hyperparathyroidism, malnutrition and inadequate HD dose. The aim of the study was to analyze the deteminants of hemoglobin variability in HD patients. Methods. The study encompassed 526 patients (197 F and 329 M). According to HD vintage at the beginning of the study the patients were divided into two groups: group-1 encompassed 153 patients with HD vintage bellow 24 months, and group-2 encompassed 329 patients with HD vintage over 24 months. Over a period of 21 months after admission the following parameters were analyzed: hemoglobin (Hb), EPO dose, iron dose, HD dose (eKT/V), transferrin saturation (TSAT), C-reactive protein (CRP), ferritin and serum albumin at 3 months and parathyroid hormone (PTH) at 6 months. Results. The percentage of patients with Hb&gt;=105g/L significantly improved, and the average Hb level significantly increased in both groups over a period of 21 months. The average EPO and iron dose significantly decreased, but TSAT and ferritin levels significantly increased over a period of 21 months. The average eKT/V and s-albumin values significantly increased, but the average CRP and PTH levels significantly decresead over a period of 21 months. In group-1 EPO dose and CRP, but in group-2 EPO dose, ferritin, HD vintage, and iron dose were statistically significant predictors of the Hb level 9 months after admission. Conclusions. Insufficient EPO therapy, iron deficiency and chronic inflammation were the main factors of inadequate correction of anemia in HD patients before admission.

Fractal properties of the trabecular pattern of the mandible in chronic renal failure.

The purpose of this study was to evaluate fractal analysis as a tool to quantitatively determine the mandibular trabecular bone changes in patients with chronic renal failure (CRF). In the present study, fractal analysis was performed using ImageJ (National Institutes of Health, Bethesda, MD) program with box-counting method over panoramic radiographs of 25 patients (14 females and 11 males) with CRF and 26 healthy individuals (14 females and 12 males) as a control group. The fractal dimension (FD) values of the patients and healthy individuals were compared. In addition, average biochemical parameters [parathyroid hormone (PTH), calcium (Ca), phosphorus (P), product of Ca and P levels (CaxP), alkaline phosphatase (ALP), vitamin D] of the patients with CRF, as measured during the 3 months before the panoramic radiographs, were compared with FD values. According to the results, FD values of the patients with CRF were found to be statistically lower than the control group (p < 0.05). The average PTH levels of the patients with CRF were 416.16 ± 310.3 pg ml(-1); average Ca levels were 8.94 ± 1.2 mg dl(-1); average P levels were 5.76 ± 1.7 mg dl(-1); average CaxP values were 51.12 ± 15.03; average ALP levels were 83.44 ± 36.8 U l(-1); and the average vitamin D values were 19.43 ± 9.7 ng ml(-1). In addition, there was no significant correlation between FD values and the biochemical parameters of the patients, and there was no correlation between age, gender and FD. The FD values of the patients with CRF were lower than those of the controls. This finding suggests that FD analysis might be a promising simple and cost-effective tool for evaluating trabecular bone structure.

Endoscopic thyroidectomy along with bilateral central neck dissection (ETBC) increases the risk of transient hypoparathyroidism for patients with thyroid carcinoma.

Increasing number of patients with thyroid carcinoma, especially young female patients, prefer to choose endoscopic thyroidectomy with bilateral central neck dissection (ETBC) for perfect cosmetic effects. However, the incidence of hypoparathyroidism after ETBC has not been well studied. Ninety six patients with papillary thyroid carcinoma were enrolled. All patients, including 49 ETBC and 47 open surgery patients, underwent total thyroidectomy with bilateral central neck dissection (CND). Some patients also underwent lateral neck dissection simultaneously. The incidence of hypoparathyroidism and parathyroid hormone (PTH) level were examined. Patients in the open surgery group had more advanced lesions, with larger tumor (p=0.000), older age (p=0.000), and more serious local involvement. The dissection extent of the open group was significantly larger than that of the ETBC group (p=0.006). In contrast, the ETBC group with less dissection extent showed a significantly higher incidence of transient hypoparathyroidism than the open group (59.2 vs. 29.6%, p=0.004). The average PTH decline of the ETBC group was significantly higher than that of the open group on postoperative day 1 (POD1) (32.1 vs. 21.6pg/ml, p=0.010). Furthermore, the ETBC group had a significantly higher portion of patients with a PTH <10pg/ml on POD1 (p=0.001). One patient in the ETBC group developed permanent hypoparathyroidism. Autotransplantation and inadvertent removal rates of parathyroid did not differ between the two groups. Although generally considered a safe method for patients with thyroid carcinoma, ETBC may increase the risk of transient hypoparathyroidism compared with conventional open surgery.

Accentuated hyperparathyroidism in type II Bartter syndrome.

Bartter syndrome (BS) may be associated with different degrees of hypercalciuria, but marked parathyroid hormone (PTH) abnormalities have not been described. We compared clinical and laboratory data of patients with either ROMK-deficient type II BS (n = 14) or Barttin-deficient type IV BS (n = 20). Only BS-IV patients remained mildly hypokalemic in spite of a higher need for potassium supplementation. Estimated glomerular filtration rate (eGFR) was mildly decreased in only four BS-IV patients. Average PTH values were significantly higher in BS-II (160.6 ± 85.8 vs. 92.5 ± 48pg/ml in BS-IV, p = 0.006). In both groups, there was a positive correlation between age and log(PTH). Levels of 25(OH) vitamin D were not different. Total serum calcium was lower (within normal limits) and age-related serum phosphate (Pi)-SDS was increased in BS-II (1.19 ± 0.71 vs. 0.01 ± 1.04 in BS-IV, p < 0.001). The GFR threshold for Pi reabsorption was higher in BS-II (5.63 ± 1.25 vs. 4.36 ± 0.98, p = 0.002). Spot urine calcium/creatinine ratio and nephrocalcinosis rate (100 vs. 16%) were higher in the BS-II group. PTH, serum Pi levels, and urinary threshold for Pi reabsorption are significantly elevated in type II vs. type IV BS, suggesting a PTH resistance state. This may be a response to more severe long-standing hypercalciuria, leading to a higher rate of nephrocalcinosis in BS-II.

Fracture Burden and Risk Factors in Childhood CKD: Results from the CKiD Cohort Study.

Childhood chronic kidney disease (CHD) poses multiple threats to bone accrual; however, the associated fracture risk is not well characterized. This prospective cohort study included 537 CKD in Children (CKiD) participants. Fracture histories were obtained at baseline, at years 1, 3, and 5 through November 1, 2009, and annually thereafter. We used Cox regression analysis of first incident fracture to evaluate potential correlates of fracture risk. At enrollment, median age was 11 years, and 16% of patients reported a prior fracture. Over a median of 3.9 years, 43 males and 24 females sustained incident fractures, corresponding to 395 (95% confidence interval [95% CI], 293-533) and 323 (95% CI, 216-481) fractures per 10,000 person-years, respectively. These rates were 2- to 3-fold higher than published general population rates. The only gender difference in fracture risk was a 2.6-fold higher risk in males aged ≥15 years (570/10,000 person-years, adjusted P=0.04). In multivariable analysis, advanced pubertal stage, greater height Z-score, difficulty walking, and higher average log-transformed parathyroid hormone level were independently associated with greater fracture risk (all P≤0.04). Phosphate binder treatment (predominantly calcium-based) was associated with lower fracture risk (hazard ratio, 0.37; 95% CI, 0.15-0.91; P=0.03). Participation in more than one team sport was associated with higher risk (hazard ratio, 4.87; 95% CI, 2.21-10.75; P<0.001). In conclusion, children with CKD have a high burden of fracture. Regarding modifiable factors, higher average parathyroid hormone level was associated with greater risk of fracture, whereas phosphate binder use was protective in this cohort.

Abnormalities in renal tubular phosphate handling in children with sickle cell disease.

The mechanisms responsible for the hyperphosphatemia in patients with sickle cell disease (SCD) and preserved glomerular filtration rate (GFR) are not fully understood. The role of fibroblast growth factor 23 (FGF23), a phosphaturic hormone has not been investigated in SCD. Hence, we evaluated parameters of renal tubular phosphorus handling and their relation to prevailing FGF23 levels in a cohort of young SCD patients. Renal tubular phosphate handling and circulating levels of various analytes including FGF23 and parathyroid hormone (PTH) were measured in 24 children with SCD and normal estimated GFR in a cross sectional study. Correlation and regression analysis were employed to derive relationships between serum phosphorus and several variables. Most children showed elevated age- adjusted serum phosphorus (5.1 ± 0.7 mg/dl) levels. Tubular re-absorption of phosphorus(TRP) (96.3 ± 2.1%) and tubular maximum re-absorption of phosphorus per unit volume of GFR (TMP/GFR) (4.9 ± 0.6 mg/dl) were both elevated. Plasma intact FGF23 concentrations were elevated (81 ± 38 pg/ml) while the average PTH values were normal in most patients (50 ± 27 pg/ml). Univariate analysis showed significant correlations of serum phosphorus with TMP/GFR, alkaline phosphatase, age, lactate dehydrogenase (LDH), and log intact FGF23. TMP/GFR correlated with log intact FGF23 (r = 0.5, P< or = 0.01) but not with PTH. Multiple regression analysis yielded an independent relationship of serum phosphorus with TMP/GFR. The elevated serum phosphorus concentrations with simultaneously increased TMP/GFR and elevated FGF23 levels collectively suggest that patients with SCD display proximal tubular resistance to the action of FGF23 before any decline in GFR.