Decreased Serum Parathyroid Hormone Research Articles

Nanocarbon tracer applied to explore the relationship between the number of exposed parathyroid glands and parathyroid function

After nanocarbon tracer was applied to thyroidectomy, we aimed to investigate the risk factors of hypoparathyroidism and the relationship between the number of exposed parathyroid glands and parathyroid function. This study retrospectively collected clinical data of patients who underwent thyroidectomy at Haining People’s Hospital from January 2019 to December 2022. Levels of parathyroid hormone (PTH) and blood calcium were observed before surgery, 1 day after surgery, and one month after surgery to assess the occurrence of postoperative parathyroid hypofunction. Patients were grouped based on their postoperative PTH levels. Furthermore, basic patient data and surgical data were collected to analyze the risk factors associated with hypoparathyroidism after thyroidectomy using single factor analysis. ANOVA analysis was used to compare the correlation between intraoperative parathyroid exposure and postoperative PTH and blood calcium levels. This study involved 80 patients. On the first day after surgery, the serum PTH and blood calcium levels of patients decreased, and 59 patients (73.75%) had normal serum PTH level after surgery, which was the normal group. Twenty-one patients (26.25%) developed hypoparathyroidism after operation and were divided into hypoparathyroidism group. Single factor analysis showed that the main risk factors of postoperative hypoparathyroidism were lesion location, lymph node dissection, nano carbon, number of lymph node metastasis, intraoperative parathyroid exposure, and inaccurate parathyroidectomy. ANOVA analysis showed that the more parathyroid exposure during operation was accompanied by the more decrease of serum PTH and blood calcium levels after operation. Therefore, the location of thyroid lesions, lymph node dissection, nano-carbon, number of lymph node metastases, intraoperative parathyroid exposure, and parathyroidectomy are risk factors for transient hypoparathyroidism after thyroid surgery. Moreover, intraoperative parathyroid exposure significantly affected serum PTH and blood calcium levels. Performing more accurate thyroidectomy and reducing parathyroid exposure help reduce the occurrence of postoperative hypoparathyroidism and hypocalcemia.

Bidirectional control of parathyroid hormone and bone mass by subfornical organ

Parathyroid hormone (PTH) is one of the most important hormones for bone turnover and calcium homeostasis. It is unclear how the central nervous system regulates PTH. The subfornical organ (SFO) lies above the third ventricle and modulates body fluid homeostasis. Through retrograde tracing, electrophysiology, and invivo calcium imaging, we identified the SFO as an important brain nucleus that responds to serum PTH changes in mice. Chemogenetic stimulation of GABAergic neurons in SFO induces decreased serum PTH followed by a decrease in trabecular bone mass. Conversely, stimulation of glutamatergic neurons in the SFO promoted serum PTH and bone mass. Moreover, we found that the blockage of different PTH receptors in the SFO affects peripheral PTH levels and the PTH's response to calcium stimulation. Furthermore, we identified a GABAergic projection from the SFO to the paraventricular nucleus, which modulates PTH and bone mass. These findings advance our understanding of the central neural regulation of PTH at cellular and circuit level.

Bone and mineral metabolism in patients with primary aldosteronism: A systematic review and meta-analysis.

Patients with primary aldosteronism (PA) tend to exhibit a high prevalence of osteoporosis (OP) that may vary by whether PA is unilateral or bilateral, and responsive to PA treatment. To explore relationships between bone metabolism, PA subtypes, and treatment outcomes, we performed a systematic review and meta-analysis. The PubMed, Embase, and Cochrane databases were searched for clinical studies related to PA and bone metabolism markers. Articles that met the criteria were screened and included in the systematic review; the data were extracted after evaluating their quality. R software (ver. 2022-02-16, Intel Mac OS X 11.6.4) was used for the meta-analysis. A total of 28 articles were subjected to systematic review, of which 18 were included in the meta-analysis. We found that PA patients evidenced a lower serum calcium level (mean difference [MD] = -0.06 mmol/L, 95% confidence interval [CI]: -0.10 ~ -0.01), a higher urine calcium level (MD = 1.29 mmol/24h, 95% CI: 0.81 ~ 1.78), and a higher serum parathyroid hormone (PTH) level (MD = 2.16 pmol/L, 95% CI: 1.57 ~ 2.75) than did essential hypertension (EH) subjects. After medical treatment or adrenal surgery, PA patients exhibited a markedly increased serum calcium level (MD = -0.08 mmol/L, 95% CI: -0.11 ~ -0.05), a decreased urine calcium level (MD = 1.72 mmol/24h, 95% CI: 1.00 ~ 2.44), a decreased serum PTH level (MD = 2.67 pmol/L, 95% CI: 1.73 ~ 3.62), and an increased serum 25-hydroxyvitamin D (25-OHD) level (MD = -6.32 nmol/L, 95% CI: -11.94 ~ -0.70). The meta-analysis showed that the ser um PTH level of unilateral PA patients was significantly higher than that of bilateral PA patients (MD = 0.93 pmol/L, 95% CI: 0.36 ~ 1.49) and the serum 25-OHD lower than that of bilateral PA patients (MD = -4.68 nmol/L, 95% CI: -7.58 ~ 1.77). There were, however, no significant differences between PA and EH patients of 25-OHD, or BMD of femoral neck and lumbar spine. BMDs of the femoral neck or lumbar spine did not change significantly after treatment. The meta-analytical results were confirmed via sensitivity and subgroup analyses. Excess aldosterone was associated with decreased serum calcium, elevated urinary calcium, and elevated PTH levels; these effects may be enhanced by low serum 25-OHD levels. The risks of OP and fracture might be elevated in PA patients, especially unilateral PA patients, but could be reduced after medical treatment or adrenal surgery. In view, however, of the lack of BMD changes, such hypothesis needs to be tested in further studies.

Differential diagnosis of hypercalcemia in a patient with CKD G5D

Patients with chronic kidney disease are characterized by the development of mineral disorders due to a decrease in the number of functioning nephrons. These changes manifest by the development of secondary hyperparathyroidism (the overproduction of intact parathyroid hormone (PTH) associated with the serum hypocalcemia, hyperphosphatemia), dysfunctional vitamin D metabolism, bone mineralization and also extraosseous calcifications. Decreased serum PTH levels associated with hypercalcemia are suspicious for adynamic bone disease, but at the same time requires an extended differential diagnostic search (e.g. metastatic processes). One of the rare causes of hypercalcemia is a defect in 24-hydroxylase (CYP24A1). We present a case of a patient on hemodialysis with atypical secondary hyperparathyroidism and an established CYP24A1 defect.

Опыт использования парентерального кальцимиметика для лечения критических минерально-костных нарушений при тяжелом гиперпаратиреозе. Клиническое наблюдение

Secondary hyperparathyroidism (SHPT) leads to bone disorders and cardiovascular complications in long-term dialysis patients. SHPT is caused by hyperphosphatemia. Abnormalities of calcium-sensing receptor (CaSR) are associated with the pathogenesis of SHPT. Clinical trials have shown that calcimimetics significantly reduce the risks of parathyroidectomy, bone fracture and cardiovascular hospitalization among long-term dialysis patients with SHPT. Etelcalcetide, a novel calcimimetic compound, acts as a direct CaSR agonist, restores the sensitivity of the CaSR in parathyroid cells, and decreases serum parathyroid hormone without inducing hypercalcemia or hyperphosphatemia. Etelcalcetide's properties allow it to be administered intravenously thrice weekly at the end of a hemodialysis treatment session improving medication adherence.

Review of clinical practice guidelines for hypoparathyroidism

Hypoparathyroidism is a rare disorder characterized by the absent or inappropriately decreased serum parathyroid hormone in the parathyroid glands, which is accompanied by impaired calcium-phosphorus metabolism.The main etiology of hypoparathyroidism remains damage or removal of the parathyroid glands during neck surgery. In view of the incidence of thyroid cancer, primary hyperparathyroidism and other pathologies of the neck organs, which radical treatment can lead to the parathyroid gland impairment, an increased number of patients with hypoparathyroidism is expected. Autoimmune hypoparathyroidism is the second most common form of the disease, usually occurring as part of type 1 autoimmune polyglandular syndrome. Autoimmune hypoparathyroidism usually occurs in childhood and is characterized by a severe course of the disease, especially in the case of concomitant malabsorption syndrome.Chronic hypoparathyroidism of any etiology requires lifelong multicomponent therapy, as well as careful monitoring and an individual approach to choose the optimal treatment strategy. In the absence of adequate follow-up, the risks of long-term complications significantly increase, particularly in the renal, cardiovascular systems; in the soft tissues and in the brain, it could lead to visual disturbances; pathology of the musculoskeletal system with a decreased bone remodeling and a potential risk of fractures, as well as to the neurocognitive disorders and an impaired health-related quality of life.Timely diagnosis, rational medical therapy and management strategy may reduce the risks of short-term and long-term complications, frequency of hospitalizations and disability of patients, as well as improve the prognosis.This review covers the main issues of Russian guidelines for the management of chronic hypoparathyroidism, approved in 2021, including laboratory and instrumental evaluation, treatment approaches and follow-up. This guidelines also include the recommendations for special groups of patients: with acute hypocalcemia, hypoparathyroidism during pregnancy.

Dietary supplementation with 25-hydroxycholecalciferol and phytase in growing-finishing pigs: II. Effects on intestinal antioxidant status, immunity and bone quality

The objective of this study was to determine the effects of dietary 25-hydroxycholecalciferol (25OHD3) and phytase supplementation alone and in combination on intestinal antioxidant status, immunity and bone quality in growing-finishing pigs fed low-phosphorus (P) diets. A total of 80 crossbred pigs with an initial body weight (BW) of 49.38 ± 0.54 kg were allotted to 4 diets with 5 replicate pens per treatment (2 barrows and 2 gilts per pen) according to BW and sex. The treatments were designed as a 2 × 2 factorial arrangement: low-P diet (C); low-P diet + 1,000 U phytase/kg diet (C + phytase); low-P diet +50 μg 25OHD3/kg diet (C + 25OHD3); low-P diet + 1,000 U phytase/kg diet +50 μg 25OHD3/kg diet (C + phytase + 25OHD3). The experiment consisted of 3 phases including phase 1 (days 1–28), phase 2 (days 29–60) and phase 3 (days 61–88). Dietary 25OHD3 supplementation deceased (P < 0.05) serum bone-specific alkaline phosphatase (BALP) level on days 60 and 88, and decreased serum parathyroid hormone (PTH) level on day 66. Phytase significantly decreased (P < 0.05) serum BALP level on day 88. 25OHD3 significantly increased glutathione peroxidase (GSH-Px) activity in duodenal mucosa and activities of catalase (CAT) and GSH-Px in ileal mucosa, as well as decreased tumour necrosis factor-α (TNF-α) level in jejunal mucosa. Phytase increased (P < 0.05) activities of CAT and GSH-Px in ileal mucosa, as well as decreased (P < 0.05) contents of interleukin-1β (IL-1β) and TNF-α in jejunal mucosa. The Ca content, bone mineral content (BMC) and breaking strength was higher (P < 0.05) as well as bone mineral density (BMD) and stiffness tended to be higher in the metacarpal bone of growing-finishing pigs fed with 25OHD3. Phytase increased (P < 0.05) Ca content, P content, BMC, BMD, breaking strength and stiffness in the metacarpal bone. 25OHD3 and phytase could help improve serum parameters, intestinal antioxidant capacity, immune function, and bone quality of growing-finishing pigs fed with low P diets.

ОБЗОР КЛИНИЧЕСКИХ РЕКОМЕНДАЦИЙ ПО ГИПОПАРАТИРЕОЗУ

Hypoparathyroidism is a rare disorder characterized by the absent or inappropriately decreased serum parathyroid hormone in the parathyroid glands, which is accompanied by impaired calcium-phosphorus metabolism. The main etiology of hypoparathyroidism remains damage or removal of the parathyroid glands during neck surgery. In view of the incidence of thyroid cancer, primary hyperparathyroidism and other pathologies of the neck organs, which radical treatment can lead to the parathyroid gland impairment, an increased number of patients with hypoparathyroidism is expected. Autoimmune hypoparathyroidism is the second most common form of the disease, usually occurring as part of type 1 autoimmune polyglandular syndrome. Autoimmune hypoparathyroidism usually occurs in childhood and is characterized by a severe course of the disease, especially in the case of concomitant malabsorption syndrome. Chronic hypoparathyroidism of any etiology requires lifelong multicomponent therapy, as well as careful monitoring and an individual approach to choose the optimal treatment strategy. In the absence of adequate follow-up, the risks of long-term complications significantly increase, particularly in the renal, cardiovascular systems; in the soft tissues and in the brain, it could lead to visual disturbances; pathology of the musculoskeletal system with a decreased bone remodeling and a potential risk of fractures, as well as to the neurocognitive disorders and an impaired health-related quality of life. Timely diagnosis, rational medical therapy and management strategy may reduce the risks of short-term and long-term complications, frequency of hospitalizations and disability of patients, as well as improve the prognosis. This review covers the main issues of Russian guidelines for the management of chronic hypoparathyroidism, approved in 2021, including laboratory and instrumental evaluation, treatment approaches and follow-up. This guidelines also include the recommendations for special groups of patients: with acute hypocalcemia, hypoparathyroidism during pregnancy.

MO952EFFECT OF KIDNEY TRANSPLANTATION ON PARATHYROID GLANDS FUNCTION

Abstract Background and Aims The normalization of the function of the parathyroid glands after successful kidney transplantation does not occur in all patients. The aim of our study was to determine of parathyroid function, patient factors that would be predictive of achieving a normal serum PTH in the first months after surgery and prevalence of hyperparathyroidism (HPT) in patients after kidney transplantation (KT) at various stages of the post-transplant period. Method The observational cross-retrospective study included 230 kidney graft recipients. Inclusion criteria: the duration of the post-transplant period is more than 12 months and stable kidney transplant function for 6 months. The median of the pre-transplant stage was 18 months (Q1-Q3: 9; 35), post-transplant period - 42 months (Q1-Q3: 21; 73). Serum concentrations of parathyroid hormone (PTH), calcium, phosphorus, total alkaline phosphatase activity, albumin, and creatinine were determined using standard methods. HPT was diagnosed with PTH&amp;gt;130 pg/ml. Retrospective analysis of parameters in three months after surgery it was performed in 197 patients. Estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI formula, stratification of chronic kidney disease (CKD) stages was carried out according to the eGFR. Results Patients had different kidney transplant function: eGFR 117-15 ml/min, median 51 (Q1-Q3: 39;65): CKD 1(КT) st. was in 3.5%, CKD 2(КT) st. - in 33.9%, CKD 3(КT) st. - in 49.1% and CKD 4(КT) st. – in 13.5% patients. Serum PTH levels were 27-670 pg/ml, median 120 pg/ml (Q1-Q3: 87; 182). The median PTH of blood in patients was 99 pg/ml (Q1-Q3: 76; 120), 98 pg/ml (Q1-Q3: 79; 123), 120 pg/ml (Q1-Q3: 89; 180) and 267 pg/ml (Q1-Q3: 170; 328), respectively, with CKD 1(КT), CKD 2(КT), CKD 3(T) and CKD 4(КT) st. The frequency of HPT was 38.7%: 19.8% in patients with eGFR≥60 ml/min, 38.1% and 93.5% in patients with CKD 3(КT) and CKD 4(КT) st. (p&amp;lt;0.001) (Fig. 1). HPT was equally frequently diagnosed in the second, third, fourth and fifth years after kidney transplantation and amounted to 30.3% in the first five years. In patients with a post-transplant period of more than 5 years, HPT was 54.7% (p&amp;lt;0.001). In the same group, the proportion of patients with eGFR&amp;lt;60 ml/min was also higher - 55.5% (p=0.002) (Fig. 2). An inverse relationship was established between serum PTH and eGFR and a direct relationship between serum PTH and serum creatinine (p&amp;lt;0.001). A retrospective analysis showed that 3 months after kidney transplantation, the median PTH was 178 pg/ml (Q1-Q3: 120; 250), HPT was recorded in 65.5% of patients. Serum PTH decreased by 6-92%, median 50%. Kidney graft function was worse in patients with a decrease in serum PTH ≤50% (n = 100) versus patients with a decrease in serum PTH &amp;gt;50% (n = 97). Minimal blood creatinine was recorded in the early postoperative period, respectively, on (median) 7 and 5 days (p = 0.015), the median eGFR by the end of the third month was 59 and 63 ml/min, respectively (p=0.044). We found that preoperative PTH&amp;gt;585 pg/ml (p&amp;lt;0.0001 OR 2.93 95% CI 1.78; 5.05), delayed kidney graft function (p=0.005 OR 1.57 95% CI 1.58; 9.87), and eGFR&amp;lt;60 ml/min (p&amp;lt;0.0005 OR 2.01 95% CI 1.36; 3.09) were predictive of HPT in patients in the early stages after kidney transplantation. Conclusion Hyperparathyroidism in patients after kidney transplantation continues to be an ongoing problem. It occurs in a third of patients in the first five postoperative years and in half patients in subsequent years. Preoperative secondary hyperparathyroidism, delayed and suboptimal kidney graft function prevent the restoration of parathyroid glands function after kidney transplantation.

Morbidity and mortality associated with thyroid surgery - retrospective analysis 19912010.

The incidence of thyroid disorders has been rising worldwide. Unlike the incidence, mortality associated with malignant thyroid cancer shows only amodest increase. Between 1979 and 2009, mortality in Czech women increased from 1.21 to 1.31 and in Czech men from 0.54 to 0.74 cases per 100,000 individuals. Methods: Aretrospective statistical analysis was performed in patients undergoing thyroid surgery at the Department of Otorhinolaryngology and Head and Neck Surgery of the 1st Faculty of Medicine, Charles University and University Hospital Motol, and at the Department of Otorhinolaryngology of the Institute for Postgraduate Medical Education in Prague from 1991 to 2010 (twenty years). In this period, 11,005 procedures were done for thyroid disease. The study analysed the incidence, morbidity, mortality, surgical complications and lethality. The study group included surgeries in 1588 male and 9417 female patients. The male/female ratio was 1:5.93. Benign thyroid tumours - mean patient age is 54.7 years; recurrent nerve morbidity is 1.37% (calculated from exposed nerves). Hypocalcaemia incidence is low, 5.4% of permanent hypocalcaemia or hypoparathyroidism, respectively, based on decreased serum parathyroid hormone (PTH) levels. Temporary hypocalcaemia is much more frequent, occurring in almost 15% cases depending on age, season of the year, and nutritional status. Hypoparathyroidism was demonstrated based on laboratory serum PTH levels only in 0.3% patients. In total, 442 patients were operated for the mechanic syndrome (alarge goitre). The mean thyroid volume was 493 ml±136 ml; however, the maximum volume was 980 ml and weight 1115 g. The incidence of recurrent nerve injury occurs in 4.5%, i.e. the morbidity is 2 times higher compared to surgeries for other diagnoses. The incidence of hypoparathyroidism is not higher compared to other surgeries. Revision surgeries were indicated more commonly in malignant thyroid diseases, particularly in papillary and follicular carcinomas. Cervical lymph nodes procedures comprise another large segment in tumour treatment. Our analysis supports selective neck dissections while preserving non-lymphatic structures. As arule, mortality associated with thyroid surgery is divided as mortality in the perioperative period (within 24 hours after the procedure) and early postoperative mortality (within 120 hours after the procedure). Surgery-related mortality was never classified as perioperative or within 24 hours after the procedure. Despite that, we believe that perioperative mortality within 120 hours after the procedure, which occurred in 7 cases, is very important. Mortality of the group was 0.007%. Each surgery procedure is associated with complications, morbidity and mortality. Experience of endocrine surgeons of all disciplines leads to avery low incidence of recurrent nerve and parathyroid gland injuries while at the same time achieving sufficient radicality. This, in cooperation with other medical fields such as endocrinologists, nuclear medicine specialists and oncologists, supports asafe and effective management of all thyroid disorders, including agood prognosis of patients with most types of cancer. Key word: thyroid surgery - complications recurrent nerve - hypoparathyroidism lethality.

Decrease in serum calcitriol (but not free 25-hydroxyvitamin D) concentration in hip fracture healing.

To assess the decrease in serum calcitriol concentrations after hip fracture. Serum concentrations of calcitriol, 25(OH)D, parathyroid hormone (PTH), directly measured free 25(OH)D, and indices of bone formation were measured in elderly patients with hip fracture (HF) and patients with elective hip replacement (EHR) at admission and after 7weeks. A total of 45 patients with HF and 17 patients with EHR completed this prospective study. Baseline serum calcitriol levels were ≤ 60pmol/l in 26% of the HF patients. After 7weeks, they significantly decreased (p < 0.001). In patients with EHR, serum calcitriol was within the reference range in all but one patient and did not change during the 7-week recovery phase. Seven weeks after HF, a significant positive relationship was observed between the change in calcitriol and serum 25(OH)D concentration (r = 0.385, p = 0.009) and free 25(OH)D (r = 0.296, p = 0.048), and a decrease in calcitriol during recovery was associated with a decrease in serum PTH (p = 0.038). Seven weeks after HF, changes in both serum PTH and serum 25(OH)D concentrations contributed to the prediction of changes in serum calcitriol (R2 = 0.190, p = 0.012). Unlike patients with EHR, subjects with HF had low serum 25(OH)D and low free 25(OH)D concentrations at admission, while their serum 1,25D levels were relatively elevated. Decreases in circulating calcitriol levels in the 7weeks following hip surgery were associated with a resolution of secondary hyperparathyroidism and low availability of free 25(OH)D.

EFFICACY OF DOUBLE DOSE VERSUS STANDARD DOSE ERGOCALCIFEROL ON VITAMIN D STATUS AMONG PATIENTS WITH CHRONIC KIDNEY DISEASE

Background: Patients with chronic kidney disease (CKD) have an exceptionally high rate of 25-hydroxyvitamin D (25-OHD) deficiency. Modest supplementation with ergocalciferol to raise serum 25-OH-D levels might improve bone and mineral disorders in CKD. Limited evidence is available regarding dosage of ergocalciferol supplement in CKD populations.&#x0D; Objectives: The study aimed to examine the effectiveness of double-dose ergocalciferol on serum 25-OHD, serum intact parathyroid hormone (PTH) levels and mineral and safety profiles compared with standard-dose ergocalciferol among CKD subjects.&#x0D; Methods: The study employed a 12-week open labeled, randomized, controlled design among patients with CKD at stages III-IV and serum 25-OHD &lt;30 ng/mL. Patients were randomized in 2 groups: standard dose treated with ergocalciferol as recommended by K/DOQI guidelines or double dose of ergocalciferol from recommendations. Serum testing including 25-OHD, intact PTH, phosphate and calcium was performed at baseline and week 12.&#x0D; Results: Sixty-three patients were included [standard-dose group (N=30) and double-dose group (N=34)]. At the end of the 12 weeks, 20 (58.8%) patients in the double dose ergocalciferol group achieved sufficiency compared with 6 (20%) patients in the standard dose ergocalciferol group (p&lt;0.05). A significant increase in serum 25-OHD levels (13.6±9.9 vs. 8.5±6.8 ng/mL, p=0.030) and decrease in serum PTH level group (-16.8±26.4 vs. -0.3±26.8 pg/mL, p=0.030) was found in the double-dose group compared with the standard-dose group. No adverse effect was associated with the treatment.&#x0D; Conclusion: The study demonstrated that high dose oral ergocalciferol had higher efficacy to increase serum 25-OHD and decrease serum PTH levels among patients with CKD than standard-dose ergocalciferol after 12 weeks of treatment.

Parathyroidectomy for patients with secondary hyperparathyroidism in a changing landscape for the management of end-stage renal disease

BackgroundThe landscape of patients with end-stage renal disease is changing with the increasing availability of kidney transplantation. In the near future, a less aggressive approach to treat secondary hyperparathyroidism might be beneficial. We report outcomes of parathyroidectomy for end-stage renal disease–related hyperparathyroidism comparing the outcomes of limited, subtotal, and total parathyroidectomy. MethodsWe performed a retrospective analysis of prospectively collected data. Patients were divided into 3 parathyroidectomy subgroups: limited (<3 glands removed), subtotal (3–3.5 glands), and total (4 glands) parathyroidectomy. Primary outcome was serum levels of parathyroid hormone. Secondary endpoints were serum levels of calcium, phosphate, and alkaline phosphatase, postoperative complications, and persistent or recurrent disease rates. ResultsIn total, 195 patients were included for analysis of whom 13.8% underwent limited parathyroidectomy, 46.7% subtotal parathyroidectomy, and 39.5% total parathyroidectomy. Preoperative parathyroid hormone levels (pg/mL) were 471 (210–868), 1,087 (627–1,795), and 1,070 (475–1,632) for the limited, subtotal, and total parathyroidectomy groups, respectively (P < .001). A decrease in serum parathyroid hormone was seen in all groups; however, postoperative levels remained greater in the limited parathyroidectomy group compared to the subtotal and total parathyroidectomy groups (P < .001). Serum calcium, phosphate, and alkaline phosphatase levels decreased in all groups to within the reference range. In the limited parathyroidectomy group, persistent disease and recurrence occurred more frequently (P = .02 and P = .07, respectively). ConclusionSubtotal parathyroidectomy is the optimal strategy in an era with an increasing availability of kidney transplantation and improved regimens of dialysis. In this changing practice, the approach to parathyroid surgery, however, might shift to a less aggressive and patient-tailored approach.

Efficacy and safety of cinacalcet compared with other treatments for secondary hyperparathyroidism in patients with chronic kidney disease or end-stage renal disease: a meta-analysis

BackgroundIt is controversial for the effect and safety between cinacalcet and other treatments in treating secondary hyperparathyroidism for patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD).MethodsEmbase, PubMed, and Cochrane Library were searched through Feb 2017. 21 randomized controlled trials were included. We calculated the pooled mean difference (MD), relative risk (RR) and corresponding 95% confidence interval (CI).ResultPatients received calcimimetic agents had significantly decreased serum parathyroid hormone (MD = − 259.24 pg/mL, 95% CI: − 336.23 to − 182.25), calcium (MD = − 0.92 mg/dL, 95% CI: − 0.98 to − 0.85) and calcium phosphorus product (MD = − 5.97 mg2/dL2, 95% CI: − 9.77 to − 2.16) concentration compared with control treatment. However, the differences in cardiovascular mortality and all-cause mortality between calcimimetics agents and control group were not statistically significant. The incidence of nausea (RR = 2.13, 95% CI: 1.62 to 2.79), vomiting (RR = 1.99, 95% CI: 1.78 to 2.23) and hypocalcemia (RR = 10.10, 95% CI: 7.60 to 13.43) in CKD patients with calcimimetics agents was significantly higher than that with control treatment.ConclusionCinacalcet improved the biochemical parameters in CKD patients, but did not improve all-cause mortality and cardiovascular mortality. Moreover, cinacalcet can cause some adverse events.

Serum PTH is not a good marker for defining a threshold for vitamin D deficiency.

ObjectiveIn addition to its skeletal effects, vitamin D may also be important for health in general. It is uncertain what level of serum 25-hydroxyvitamin D (25(OH)D), marker of vitamin D status, is sufficient for these effects. With decreasing serum 25(OH)D levels there is an increase in serum PTH. The point at which this occurs has been considered as a threshold for vitamin D sufficiency. The thresholds found have varied widely and have mainly been based on observational studies. However, to truly establish a threshold for vitamin D effects, this has to be based on randomized controlled trials (RCTs).MethodsThe study included 2803 subjects from a general health survey, the Tromsø study, and pooled individual person data from five vitamin D intervention studies (n = 1544). Serum parathyroid hormone (PTH) and change in PTH after vitamin D supplementation were related to serum 25(OH)D levels in steps of 25 nmol/L (<24, 25–49, 50–74, 75–99, and >99 nmol/L).ResultsIn the Tromsø study, in the females there was a gradual decrease in serum PTH with increasing serum 25(OH)D with no apparent plateau, whereas in the males the decrease in PTH in subjects with serum 25(OH)D >74 nmol/l was marginal. In pooled RCTs, there was a significant reduction in serum PTH by vitamin D supplementation regardless of baseline serum 25(OH)D level.ConclusionsThe use of the serum PTH–25(OH)D relation from observational studies to determine a threshold for vitamin D sufficiency is highly questionable.

4D-Dynamic Contrast-Enhanced MRI for Preoperative Localization in Patients with Primary Hyperparathyroidism.

Our aim was to test the hypothesis that our recently introduced 4D-dynamic contrast-enhanced MR imaging with high spatial and temporal resolution has equivalent accuracy to 4D-CT for preoperative gland localization in primary hyperparathyroidism without requiring exposure to ionizing radiation. Inclusion criteria were the following: 1) confirmed biochemical diagnosis of primary hyperparathyroidism, 2) preoperative 4D-dynamic contrast-enhanced MR imaging, and 3) surgical cure with >50% decrease in serum parathyroid hormone intraoperatively. 4D-dynamic contrast-enhanced studies were reviewed independently by 2 neuroradiologists to identify the side, quadrant, and number of abnormal glands, and compared with surgical and pathologic results. Fifty-four patients met the inclusion criteria: 37 had single-gland disease, and 17, multigland disease (9 with double-gland hyperplasia; 3 with 3-gland hyperplasia; and 5 with 4-gland hyperplasia). Interobserver agreement (κ) for the side (right versus left) was 0.92 for single-gland disease and 0.70 for multigland disease. Interobserver agreement for the quadrant (superior versus inferior) was 0.70 for single-gland disease and 0.69 for multigland disease. For single-gland disease, the gland was correctly located in 34/37 (92%) patients, with correct identification of the side in 37/37 (100%) and the quadrant in 34/37 (92%) patients. For multigland disease, the glands were correctly located in 35/47 (74%) patients, with correct identification of the side in 35/47 (74%) and the quadrant in 36/47 (77%). The proposed high spatial and temporal resolution 4D-dynamic contrast-enhanced MR imaging provides excellent diagnostic performance for preoperative localization in primary hyperparathyroidism, with correct gland localization of 92% for single-gland disease and 74% in multigland disease, superior to 4D-CT studies.

Effectiveness of the Gamma Probe in Childhood Parathyroidectomy: Retrospective Study.

BackgroundThere are few reports about parathyroidectomy due to secondary hyperparathyroidism in patients with end-stage renal failure in the literature. We aimed to evaluate the surgical treatment methods and the results of patients who were operated for secondary hyperparathyroidism with end-stage renal disease in our center.MethodSixteen patients with the diagnosis of secondary hyperparathyroidism were treated surgically in our center. Demographical data, laboratory findings, and imagining methods were all examined. The effect of the Technetium 99m methoxyisobutylisonitrile (Tc-99m-MIBI) probe sensitive to gamma rays detection was also evaluated to locate and identify all the parathyroid glands during the operation.ResultsEleven of the patients underwent intravenous (IV) Tc-99m MIBI preoperatively and a gamma probe was detected during surgery. The gamma probe was not used in five patients. Four parathyroid glands were removed in eight (72.7%) out of 11 patients with gamma probes and three parathyroid glands were found in three patients. Total parathyroidectomy and parathyroid autoimplantation were made to eight patients who had removed four glands, subtotal parathyroidectomy was done for the other patients. On a comparison of laboratory findings before and after the surgery, there was a significant relationship between the decrease of serum parathyroid hormone and calcium levels (p<0.05).ConclusionTotal parathyroidectomy and parathyroid autoimplantation is the most efficient and safe mode of management for secondary parathyroidism patients. During the surgery, using a probe sensitive to gamma rays detection may also help the surgeon. Thus, unnecessary dissections to prevent the presence of atypical parathyroid glands are prevented.

Cathepsin K-deficient osteocytes prevent lactation-induced bone loss and parathyroid hormone suppression.

Lactation induces bone loss to provide sufficient calcium in the milk, a process that involves osteoclastic bone resorption but also osteocytes and perilacunar resorption. The exact mechanisms by which osteocytes contribute to bone loss remain elusive. Osteocytes express genes required in osteoclasts for bone resorption, including cathepsin K (Ctsk), and lactation elevates their expression. We show that Ctsk deletion in osteocytes prevented the increase in osteocyte lacunar area seen during lactation, as well as the effects of lactation to increase osteoclast numbers and decrease trabecular bone volume, cortical thickness and mechanical properties. In addition, Ctsk deletion in osteocytes increased bone Parathyroid Hormone related Peptide (PTHrP), prevented the decrease in serum Parathyroid Hormone (PTH) induced by lactation, but amplified the increase in serum 1,25(OH)2D. The net result of these changes is to maintain serum and milk calcium levels in the normal range, ensuring normal offspring skeletal development. Our studies confirm the fundamental role of osteocytic perilacunar remodeling in physiological states of lactation and provides genetic evidence that osteocyte-derived Ctsk contributes not only to osteocyte perilacunar remodeling, but also to the regulation of PTH, PTHrP, 1,25-Dyhydroxyvitamin D (1,25(OH)2D), osteoclastogenesis and bone loss in response to the high calcium demand associated with lactation.

SAT-514 The Decrease in Serum Parathyroid Hormone on Vitamin D Treatment Is Similar When Comparing Increases in Serum Free or Total 25 Hydroxyvitamin D in White and Black Women

Background: Recent advances in measurement of total serum 25OHD (T25D) led to development of free 25OHD (F25D) assays. The free hormone hypothesis states that only F25D which is about 0.02% of T25D is available for conversion to the active metabolite 1,25(OH)2D, the rest is bound to D binding protein (DBP) and albumin. In a previous paper (J Int Med 2018 Aug 23 online)we did not find a change in BMD or bone markers compared to F25D or T25D. A one month vitamin D study reported F25D was more highly correlated than T25D with serum PTH. If confirmed then F25D measurement would be clinically important. Methods: In two 12 month vitamin D placebo/dosing studies in young, old white and black women, serum T25D, F25D and PTH were measured at baseline and 12 months. The main inclusion criteria was vitamin D insufficiency (Diasorin serum T25D ≤ 20ng/ml). Serum T25D was remeasured by LCMS and F25D was measured by Elisa (Future Diagnostics). Serum PTH was measured by immunoassay (Diasorin). Group means were compared by t-test. Linear regression was used to assess percent change in T25D and F25D on percent change in PTH, accounting for age (young, old), race (Caucasians, African Americans) and interactions. Results: In the older women, there were 109 Caucasians and 79 African Americans with baseline measurements of F25D, T25D and PTH. Mean age (± SD) was 69 (± 7.3) years. In the younger women, there were 81 Caucasians and 31 African Americans, mean age 37 (± 5.6) years. In older women, serum T25D was similar in black compared to white women 18.70(±5.57) and 19.63(±5.19) ng/ml, p=0.24. Serum F25D was lower in older African Americans compared to Caucasians 3.38(±1.21) vs 3.73(±1.39) pg/mL (p=0.075). In younger women T25D was significantly lower in blacks 14.33(±4.13) compared to 22.09 (±5.45)ng/ml in whites, p<0.001. F25D was lower in blacks 3.55(±1.17) versus 4.64(±1.25) pg/ml p<0.001. Baseline mean serum PTH was higher in the older black women 44(±21) compared to whites 38 (±14)pg/ml (p=0.03). In young black women serum PTH was higher 44(±18) than white women 31(±10)(p<0.01). Serum PTH decreased on vitamin D. The decrease in PTH compared to levels of serum F25D was similar in young and old, black and white women. The decrease in PTH was 6% for each 1% increase in F25D. The slope for the regression of PTH on serum T25D was steeper in blacks than whites (p<0.01) but did not differ by age. The percent decrease in PTH was 13% in blacks and 5% in whites for each 1% increase in T25D. Summary: The percent decrease in serum PTH after vitamin D was related to increasing free and total 25D in young and old, black and white women. However, black women showed a significantly larger decrease in PTH with T25D, possibly because of more secondary hyperparathyroidism. Because the parathyroid gland has the megalin and cubilin receptors mechanism for uptake of DBP it may not be unexpected that the correlations between serum PTH and free and total 25(OH)D are so similar.

Is hepcidin related with anemia and bone mineral metabolism in children with non-dialysis chronic kidney disease?

Aim:Functional iron deficiency seco ndary to inflammation and increased serum hepcidin lead to erythropoietin-resistant anemia in children with chronic kidney disease. Vitamin D deficiency, parathyroid hormone, and phosphate can also participate in chronic inflammation and anemia. The aim of this study was to evaluate the association between hepcidin, bone mineral metabolism, and anemia in non-dialysis pediatric patients with chronic kidney disease.Material and Methods:Thirty-five patients with stage 2–4 chronic kidney disease and 35 healthy subjects were enrolled in the study. Serum creatinine, blood urea nitrogen, uric acid, C-reactive protein, interleukin-6, hepcidin, complete blood count, ferritin, calcium, phosphorus, parathyroid hormone, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and fibroblast growth factor-23 levels were compared between the groups.Results:Ferritin, C-reactive protein, interleukin-6, blood urea nitrogen, creatinine, uric acid levels, and percentages of reticulocytes were significantly higher than in the controls (p<0.05). The mean serum hepcidin levels in the chronic kidney disease and control groups were 9.6±5.2 (range, 2.15–25.3) and 9.7±4.3 (range, 3.4–22.2) ng/mL and were not significantly different in either group. There were no differences in terms of serum phosphorus, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D and fibroblast growth factor-23 levels between the groups (p>0.05). Serum hepcidin levels were not correlated with anemia parameters, serum fibroblast growth factor-23, phosphorus, uric acid, C-reactive protein, parathyroid hormone, and 25-hydroxyvitamin D levels (p>0.05). However, serum hepcidin levels were correlated with 1,25-dihydroxyvitamin D and interleukin-6 levels (p=0.013 and p=0.002, respectively).Conclusion:Serum hepcidin levels may not increase significantly in non-dialysis pediatric patients with chronic kidney disease despite high levels of inflammatory markers such as C-reactive protein and interleukin-6. The increase of serum hepcidin levels may be inhibited by effective treatment of anemia with iron supplementation and erythropoietin, and the treatment of secondary hyperparathyroidism with phosphate binders and the active form of vitamin D, which decrease serum parathyroid hormone and fibroblast growth factor-23 levels, and control inflammation to some extent.