iPTH Levels Research Articles

Surgical treatment of tertiary hyperparathyroidism: does one fit for all?

Tertiary hyperparathyroidism (3HPT) is defined as a condition of excessive autonomous excretion of intact parathyroid hormone (iPTH) with persistent hypercalcemia (>10.5 mg/dL) that lasts for more than 12 months after a successful kidney transplantation, in the context of a long course secondary hyperparathyroidism (2HPT). The chronic high levels of iPTH cause a worsening of graft function, accompanied by systemic symptoms of hypercalcemia. The only curative therapy is parathyroidectomy (PTX). It remains unclear whether total parathyroidectomy with autotransplantation (TPTX-AT) or subtotal parathyroidectomy (SPTX) lead to better outcomes. The aim of this retrospective, single-institution cohort study is to evaluate the rate of persistent or recurrent disease and postoperative calcium/iPTH disturbances in patients treated with TPTX-AT or SPTX for 3HPT. A single-center retrospective analysis of 3HPT patients submitted to TPTX-AT or SPTX between 2007-2020 with at least 24 months follow-up was conducted. The outcome parameters included persistence/recurrence of disease, incidence of transitory hypocalcemia, and temporary/permanent hypoparathyroidism. A cohort of 52 patients was analyzed and divided in two groups: 38 (73%) were submitted for TPTX-AT, and 14 patients (27%) were submitted for SPTX. The TPTX-AT population showed lower plasmatic calcium concentrations compared with the SPTX group during the entire follow-up period (p<0.001). There were eight cases (21%) of transitory hypocalcemia in the TPTX-AT group and none in the SPTX group, with p=0.065. Two cases (5%) of temporary hypoparathyroidism occurred in the TPTX-AT group and none in the SPTX group, with p= 0.530. There were no cases of permanent hypoparathyroidism and no cases of persistent disease. No statistical difference was assessed for the recurrence of 3HPT between the TPTX-AT group and the SPTX group (N=1, 3% vs N=1, 7%) (p=0.470). No significative difference was registered between the TPTX-AT and SPTX groups in terms of persistence/recurrence of disease, incidence of transitory hypocalcemia, and temporary/permanent hypoparathyroidism. Mean calcium levels iPTH values were statistically lower among the TPTX-AT group compared with the SPTX group while remaining always in the range of normality.

Efficacy of iguratimod on mineral and bone disorders after kidney transplantation: a preliminary study

Background Iguratimod has been shown to promote bone formation and inhibit bone resorption in rheumatoid arthritis patients. We aimed to explore its effect on bone metabolism and vascular calcification (VC) in kidney transplant recipients (KTRs). Methods A post hoc analysis was conducted among the subjects in our previous randomized clinical trial (NCT02839941). Forty-three KTRs completing bone metabolism 52 weeks after enrollment were selected for this analysis, among whom 27 patients received VC examinations. In the iguratimod group, iguratimod (25 mg twice daily) was added adjuvant to the traditional triple regimen. At the 52-week follow-up, the following parameters were assessed: serum calcium, phosphorus, 25-hydroxyvitamin D, intact parathyroid hormone (iPTH), bone alkaline phosphatase (BALP), osteocalcin, type I collagen N-terminal peptide (NTx), type I collagen C-terminal peptide (CTx), bone mineral density (BMD) of the femoral neck and lumbar spine, coronary artery calcification (CAC) and thoracic aortic calcification (TAC). Bone metabolic and VC indices were compared between the two groups using the independent samples t test and Wilcoxon nonparametric test. Results At 52 weeks after enrollment, the iguratimod group had lower osteocalcin (p = 0.010), BALP (p = 0.015), NTx (p = 0.007), CTx (p = 0.012), CAC (p = 0.080) and TAC scores (p = 0.036) than the control group. There was no significant difference in serum calcium, phosphorus, 25-hydroxyvitamin D, iPTH and BMD between the groups. Iguratimod could reduce bone turnover markers (BTMs) at both high and low iPTH levels. The adverse effect of iguratimod was mild and tolerable. Conclusion Iguratimod is safe, can reduce BTMs and may could attenuate VC in the first year after KT.

THU416 Trabecular Bone Score, Bone Mineral Density, And Fractures In Patients Of Chronic Kidney Disease With And Without Diabetes Mellitus

Abstract Disclosure: V. Suryadevara: None. R. Kg: None. A. Prasad: None. V. Sunthoju: None. P. Ps: None. R. Govindarajalou: None. J. Sahoo: None. S. Kamalanathan: None. D. Naik: None. Background and objectives: Chronic kidney disease-mineral bone disease (CKD-MBD) is a common yet neglected long-term complication of CKD. The primary objective of this study was to compare the proportion of patients with low trabecular bone score (TBS) in the CKD patients with diabetes mellitus (CKD-DM) and the CKD patients without DM (CKD-NDM). The secondary objectives were to compare bone mineral density (BMD) and morphometric vertebral fractures (VF) between the two groups. Methods: Patients of CKD with an estimated glomerular filtration rate (eGFR) &amp;lt; 60 mL/min/1.73m2, and not initiated on maintenance hemodialysis were recruited in the study. They were classified into the CKD-DM or the CKD-NDM group based on the presence of DM. Both groups were matched for age and gender. A detailed history was taken, and a physical examination was done to rule out secondary causes of osteoporosis. Serum creatinine, electrolytes, 25 hydroxy vitamin [25 (OH)D], and intact parathyroid hormone (iPTH) were analysed. Areal BMD was assessed using Hologic Discovery Wi dual-energy X-ray absorptiometer. TBS was estimated from spine BMD images using TBS iNsight software v 3.1.1 (Medimaps, Geneva). A dorsolumbar spine radiograph was performed to look for morphometric VFs. Results: 306 participants with CKD (153- diabetic and 153 non-diabetic) were included. The baseline characteristics were comparable between the two groups except for a higher BMI [24.13 (21.9-27.5) vs 21.86 (19.7-24.4) kg/m2], higher waist circumference [92.5 (85-99) vs 85 (80-93) cm], higher eGFR [31 (15.5-42.5) vs 25 (13-34) ml/min/1.73m2], lower magnesium [2 (1.8-2.2) vs 2.1 (1.8-2.4) mg/dl], and lower 25(OH)D [28.82 (21.3-38.6) vs 36.11 (28.4-47.3) ng/ml] in the CKD-DM group. The proportion of patients with low bone turnover (iPTH levels &amp;lt; 80 pg/ml) was higher in the CKD-DM group (34.2% vs 27.1%). The proportion of patients with low TBS was similar between the two groups (39.86% vs 41.83%; p=0.727). The BMD at lumbar spine (LS) [0.977 (0.877-1.128) vs 0.945 (0.814-1.148) g/cm2; p=0.219] and distal forearm (FA) [0.689 (0.618-0.736) vs 0.661 (0.576-0.731) g/cm2; p = 0.053] were also comparable between the two groups. However, BMD at femur neck (FN) [0.707 (0.624-0.798) vs 0.665 (0.586-0.768) g/cm2; p=0.012] and total hip (TH) [0.862 (0.760-0.951) vs 0.811 (0.713-0.916) g/cm2; p=0.006] were higher in the CKD-DM group. The prevalence of morphometric VF was similar between the two groups (8.5% vs 5.2%; p=0.258). Conclusion: In this cohort of pre-dialysis stage 3-5 CKD patients, the prevalence of low TBS, BMD at LS and distal FA were similar between the CKD-DM and the CKD-NDM groups. The BMD at FN and TH was higher in CKD with DM compared to CKD without DM. Presentation: Thursday, June 15, 2023

SAT229 Symptomatic Hypocalcemia In The Setting Of Crohn’s Disease With Severe Hypomagnesemia

Abstract Disclosure: K. Cuan: None. T. Reisman: None. Introduction: People with Crohn’s Disease (CD) are at risk for various nutritional deficiencies due to decreased oral intake, malabsorption, and increased intestinal losses. CD often causes a negative calcium balance, which does not usually cause hypocalcemia because the bones serve as a reservoir for calcium. However, symptomatic hypocalcemia may occur if a concurrent severe hypomagnesemic state is present. The factors resulting in hypocalcemia in patients with magnesium deficiency are impaired PTH secretion, PTH resistance, and vitamin D deficiency. Clinical Case: A 33-year-old man with CD and rheumatoid arthritis presented following a seizure with additional symptoms of hand cramping and facial twitching. He had previously undergone three small bowel resections and had a history of hypocalcemia due to malabsorption. Although this patient had previously been admitted due to a hypocalcemic seizure, he did not start oral calcium supplements at that time. No issues with magnesium were identified previously. On this encounter, he was found to have a corrected calcium (cCa) of 5.3 mg/dL, undetectably low magnesium at &amp;lt;0.7 mg/dL, normal phosphorus, 25-hydroxyvitamin D at 3.5 ng/mL, and an elevated intact PTH (iPTH) at 169 pg/mL. Aggressive intravenous calcium and magnesium repletion improved cCa to 7.4 mg/dL and magnesium to 2 mg/dL with no further seizure activity. He was discharged on calcium carbonate, calcitriol, and ergocalciferol. A month later, he presented to our endocrinology clinic asymptomatic but with a cCa of 6 mg/dL and magnesium at &amp;lt;0.7 mg/dL. Further biochemical workup revealed normal phosphorus, 25-hydroxyvitamin D at 7.9 ng/mL, and an inappropriately normal iPTH at 49 pg/mL. He was readmitted to the hospital where intravenous repletion improved cCa to 8.1 mg/dL and magnesium to 1.9 mg/dL. His recurrent hypomagnesemia was attributed to malabsorption. An increased dose of calcitriol and oral magnesium were added to his discharge medication regimen, in addition to his ergocalciferol and calcium carbonate. Three days later, he had a cCa level of 7.1 mg/dL as an outpatient. Conclusion: Patients with CD often have nutrient deficiencies, especially if they have had surgical resection within the intestinal tract. Our patient initially developed hypocalcemia from malabsorption, which was then exacerbated by the severely hypomagnesemic state. During his initial hospital encounter, the elevated iPTH level indicated PTH resistance. On his second encounter, the normal iPTH level suggested hypoparathyroidism. Given the relationship between magnesium and calcium homeostasis, addressing the hypomagnesemia eventually aided in achieving stabilization of serum calcium levels. Thus, in patients who are at risk for malabsorption and have recurrent symptomatic hypocalcemia, it is prudent to check magnesium levels as it can affect long term management of hypocalcemia. Presentation: Saturday, June 17, 2023

Measurement of Intact Serum Parathormone and Corrected Serum Calcium after Thyroid Surgery

Postoperative hypocalcemia is an important complication of thyroid surgery. The present study was undertaken to measure the serum levels of intact parathormone (iPTH) and corrected serum calcium (CSC) in the immediate postoperative period and then sequentially till 1 month after thyroid surgery. A total of 36 patients undergoing total thyroidectomy and 44 undergoing hemithyroidectomy had measurement of the level of iPTH and CSC at 1 hour, 1 day, 1 week, and 1 month after surgery. A mean drop of 9.3% in CSC, 40% in iPTH, and 10% in ionic calcium levels was noted 1 hour after total thyroidectomy. All the patients recovered to near preoperative levels at the 1-month follow-up. Among hemithyroidectomy patients, significant postsurgery drop in levels was not observed. The importance of the study is early recognition of a hypoparathyroid state at 1 hour after surgery and institution of calcium replacement, thereby sparing the patient from unpleasant symptoms of hypocalcemia. Furthermore, patients with a drop in the iPTH levels below the defined hypoparathyroidism levels should have careful evaluation of their thyroidectomy specimen for identification and possible autotransplantation of the parathyroid gland intraoperatively or in the immediate postoperative time frame.

Changes in Bone Mineral Density and Related Influencing Factors Assessed by Quantitative Computed Tomography in Maintenance Dialysis Patients.

To investigate the changes in volumetric bone mineral density (vBMD) assessed by quantitative computed tomography (QCT) in chronic kidney disease (CKD) patients on maintenance dialysis. Descriptive study. Place and Duration of the Study: Department of Radiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China, from March to July 2022. Maintenance dialysis patients were selected for this study, and parameters related to renal function and bone metabolism markers were recorded. Patients undergoing routine physical examination were age-matched with maintenance dialysis patients to serve as the control group. vBMD scans of the lumbar spine (L1-3) were obtained by QCT for all participants. Among the 141 maintenance dialysis patients, there were 67 patients with secondary hyperparathyroidism (SHPT) and 74 patients with non-secondary hyperparathyroidism (non-SHPT) with mean vBMDs of 145.99±55.13 mg/cm3 and 129.10±44.20 mg/cm3, respectively. The 159 individuals in the control group had mean age of 52.77±11.66 years and mean vBMD of 129.62±36.36 mg/cm3. The vBMD of the SHPT group was greater than that of both the non-SHPT group and the control group (all p<0.05). For dialysis patients, vBMD was positively correlated with calcium-phosphorus product and intact parathyroid hormone (iPTH) levels (r = 0.181, 0.214, respectively, p<0.05); vBMD was inversely correlated with age (r = -0.555, p<0.05). After adjusting for the covariates, vBMD remained positively correlated with iPTH (r = 0.184, p<0.05). Increased lumbar vertebral vBMD in maintenance dialysis patients may be associated with high iPTH, providing clinicians with a new understanding of the changes in bone mineral density in maintenance dialysis patients. Bone mineral density, Quantitative computed tomography, Chronic kidney disease, Maintenance dialysis.

Radiofrequency ablation for patients with recurrent or persistent secondary hyperparathyroidism after parathyroidectomy: initial experience.

Reoperation for recurrent or persistent secondary hyperparathyroidism (SHPT) after parathyroidectomy is challenging due to surgical scars and postoperative adhesions. Therefore, there is an increasing need to develop a new minimally invasive therapy. To analyze the efficacy of ultrasound (US)-guided radiofrequency ablation (RFA) in patients with recurrent or persistent SHPT after parathyroidectomy. From March 2013 to January 2022, 20 enlarged parathyroid glands in 10 patients with recurrent or persistent SHPT were treated with US-guided RFA. The levels of serum intact parathyroid hormone (iPTH), calcium (Ca), phosphorus (P), and alkaline phosphatase (ALP), as well as clinical symptoms, were compared before and after RFA. The ablation procedure-related complications were also evaluated. The target range for iPTH levels was approximately 2-9 times the upper limit of normal (130-585 pg/mL). The mean follow-up time was 49.6 ± 34.5 months (range from 6 to101 months). The levels of serum iPTH, Ca, and P decreased significantly one day post-ablation. Six months after RFA, 70% of patients reached the targets for iPTH, and 50% of patients reached targets at the end of follow-up. Two patients underwent repeat ablation at 9 months and 6 years after RFA, respectively, due to persistently elevated iPTH levels, and both had serum iPTH concentrations in the recommended range at the recent follow-up visit. The patients' clinical symptoms significantly improved after ablation. Major complications after RFA included hoarseness (2/10) and permanent hypoparathyroidism (1/10). Severe hypocalcemia occurred in four patients (4/10) after ablation. US-guided percutaneous RFA for recurrent or persistent SHPT is safe, efficacious, and repeatable, and can significantly improve hyperparathyroidism-related symptoms.

Ultrasound-guided microwave ablation for tertiary hyperparathyroidism in patients with renal transplantation

Objective To explore the safety and efficacy of ultrasound-guided microwave ablation (MWA) for tertiary hyperparathyroidism (THPT) in patients with renal transplantation (RT). Methods In total, fifteen patients with THPT after renal transplantation who underwent MWA were enrolled in the study. The pre- and post-MWA intact parathyroid hormone (iPTH), serum calcium, phosphorus, creatinine, urea nitrogen and estimated glomerular filtration rate (eGFR) values were compared. Results A total of 38 parathyroid hyperplastic nodules in 15 RT patients were treated with ultrasound-guided MWA. The mean (median, range) size of the hyperplastic parathyroid nodules was 11.5 mm (11 mm, 5–25 mm), and the average (median, range) ablation time was 163.5s (121 s, 44–406 s). The average levels of serum iPTH and calcium at 1 d, 7 d, 1 month, 3 months, 6 months, 1 year post-MWA and at the end of follow-up were significantly lower than those pre-MWA (all p < 0.05). Compared with the pre-MWA value (0.76 mmol/L), the serum phosphorus levels at 1 d post-MWA (0.63 mmol/L) were significantly decreased, and those at 7 d, 1 month, 3 months, 6 months, 1 year post-MWA and at the end of follow-up were significantly increased, but all were within the normal range. There was no significant difference in serum creatinine and eGFR pre-MWA and post-MWA. No major MWA-related complications occurred. Conclusion Ultrasound-guided MWA shows potential as a viable treatment for THPT in RT patients. However, further studies are required to confirm its safety and effectiveness in larger cohorts of longer duration.

Associations of calcium, phosphate and intact parathyroid hormone levels with mortality, residual kidney function and technical failure among patients on peritoneal dialysis.

Associations of calcium, phosphate and intact parathyroid hormone (iPTH) levels with outcomes may be different between patients on peritoneal dialysis (PD) and hemodialysis (HD). The aim of the study is to evaluate these associations among PD patients. In this prospective cohort study on the Japan Renal Data Registry, adults on PD at the end of 2009 were included. The observation period was until the end of 2018 and the data were censored at the time of transplantation or transition to HD. Exposures were time-averaged or time-dependent albumin-corrected calcium (cCa), phosphate and iPTH levels. Outcomes were all-cause and cardiovascular mortality, transition to HD and urine output. Data were analyzed using Cox regression models or linear mixed-effects models and the results were shown as cubic spline curves. Among 7393 patients, 590 deaths and 211 cardiovascular deaths were observed during a median follow-up of 3.0 years. Higher cCa and phosphate levels were associated with higher mortality. Lower cCa levels were associated with a faster decline, whereas lower phosphate was associated with a slower decline in urine output. Lower phosphate and iPTH levels were associated with a lower incidence of transition to HD. Among PD patients, the observed associations of cCa, phosphate and iPTH with mortality, residual kidney function and technical failure suggest that avoiding high cCa, phosphate and iPTH levels might improve outcomes.

Phase 2 study of upacicalcet in Japanese haemodialysis patients with secondary hyperparathyroidism: an intraindividual dose-adjustment study.

Upacicalcet is a novel small-molecule calcimimetic agent developed for intravenous injection. Here, we evaluated the long-term efficacy and safety of upacicalcet treatment via intraindividual dose adjustment in haemodialysis patients with secondary hyperparathyroidism (SHPT). A phase 2, multicentre, open-label, single-arm study was conducted. Upacicalcet was administered for 52weeks; the starting dose was 50μg thrice a week, and then adjusted to 25, 50, 100, 150, 200, 250, or 300μg, according to the dose-adjustment method set in the protocol. The primary endpoint was the percentage of patients with serum intact parathyroid hormone (iPTH) level achieving a target range of 60-240pg/mL (target achievement rate) at week 18. A total of 58 patients were administered upacicalcet. The target achievement rate of serum iPTH level at week 18 was 57.9%, which increased to 80.8% at week 52. The serum-corrected calcium (cCa) level decreased immediately after upacicalcet administration, but no further decrease was observed. Adverse events were observed in 94.8% of patients, and adverse drug reactions (ADRs) occurred in 20.7% of patients. The most common ADR was decreased adjusted calcium in eight patients; dizziness occurred as a serious ADR in one patient. The serum cCa level of patients who interrupted upacicalcet treatment at a serum cCa level of <7.5mg/dL recovered to ≥7.5mg/dL immediately after the interruption. In haemodialysis patients with SHPT, upacicalcet doses of 25-300μg for 52 weeks were found to be highly effective and well-tolerated, with minor safety concerns.

The Relation between Vitamin D Status and Anemia in Patients with End Stage Renal Disease on Regular Hemodialysis

Abstract Background Anemia is a common complication in end stage renal disease patients on regular hemodialysis (HD). several factors are linked to the pathogenesis of anemia in this population. There has been a lot of interest in the non-classical effects of vitamin D, including its association with erythropoiesis and anemia pathogenesis. Objectives To establish whether there is an association between anemia and the status of 25 OH (Hydroxy) vitamin D level in dialysis patients Methods This study is a cross sectional study that enrolled 90 patients on regular hemodialysis. Laboratory tests included Serum calcium, phosphorus, 25(OH) vitamin D and intact parathyroid hormone (iPTH) levels, Hemoglobin level, ferritin level, serum iron, total iron binding capacity and calculation of transferrin saturation. 25(OH) vitamin D level was measured by ELISA (Calbiotech. USA, REF: VD2208. Vitamin D status was classified into deficient (&amp;lt; 20 ng/ml), insufficient (20-30 ng/ml) and sufficient (&amp;gt;30 ng/ml). Results The level of Vitamin D measured in the patients ranged between 3.5 to 66 ng/ml with median 16.35 (8 – 34). 24 patients had vitamin D deficiency (vitamin D levels &amp;lt; 20 ng/dl), Patients with insufficient levels (vitamin D levels 20-30 ng/dl) were 32 patients, while patients with sufficient (&amp;gt; 30 ng/dl) levels were 34 patients. there were no statistically significant relations between vitamin D levels and the gender of the patients (p = 0.536), their age (p = 0.973), duration of HD (p = 0.600), Diabetes mellitus (p = 0.064) and hypertension (p = 0.249). There were statistically significant positive correlations between Vitamin D levels and the level of hemoglobin of the patients (P = 0.000), serum calcium levels (P = 0.000) and serum PO4 levels (P = 0.023). However, significant negative correlation between Vitamin D levels and serum iPTH levels (p = 0.000), serum iron (p = 0.019) and Transferrin saturation (%) (p = 0.012). Using Spearman correlation coefficient, there were highly significant positive correlations between vitamin D3 levels in all patients and both hemoglobin levels (p = 0.000) and serum calcium levels (p = 0.000). Meanwhile, there were highly significant negative correlations between vitamin D3 levels in all patients and serum iPTH levels (p = 0.000) and T.SAT of the patients (p = 0.003). Conclusion There was a significant association between the status of vitamin D and the level of hemoglobin in dialysis population who were studied, other associations with hemoglobin levels included PTH level and calcium.

Observation of the efficacy of parathyroidectomy for secondary hyperparathyroidism in hemodialysis patients: a retrospective study

PurposeParathyroidectomy (PTX) is commonly performed as a treatment for secondary hyperparathyroidism (SHPT) in patients with end-stage renal disease (ESRD). We aimed to evaluate the efficacy of PTX in patients with SHPT who underwent hemodialysis.MethodsThis retrospective study analyzed the clinical treatment of 80 hemodialysis patients with SHPT who underwent either total PTX with forearm auto transplantation (TPTX + AT) or subtotal parathyroidectomy (SPTX). We compared the changes in biochemical indices before and after surgery as well as the attenuation of intact parathyroid hormone (iPTH) in the TPTX and SPTX groups. We also evaluated clinical symptoms and quality of life using the Visual Analog Scale (VAS) and the Short Form-36 Questionnaire (SF-36) before and at 3, 6, and 12 months after surgery.ResultsSerum iPTH and serum phosphorus levels decreased significantly after surgery in 80 patients with SHPT (P < 0.05). Within one month of surgery, there was a difference in iPTH levels between the TPTX + AT and SPTH groups, but there was no difference over time. Patients experienced significant improvement in their clinical symptoms of restless leg syndrome, skin itching, bone pain, and joint pain at 1 week post operation (P < 0.001). Quality of life significantly improved after surgery, as assessed by SF-36 scores (P < 0.05). Hypocalcemia was the most common postoperative complication, occurring in 35% of patients. Within the first 12 months post surgery, 5 patients had a recurrence.ConclusionPTX is effective in rapidly reducing iPTH levels, improving calcium and phosphorus metabolism disorders, and enhancing patients’ quality of life by safely and effectively relieving clinical symptoms.

Incidence and risk factors of hypoparathyroidism and hypocalcemia after hemithyroidectomy.

The incidence and risk factors for hypoparathyroidism after total thyroidectomy is well-known. However, the characteristics of hypoparathyroidism and hypocalcemia after hemithyroidectomy have not been investigated well. In this study, we aimed to evaluate the incidence, characteristics, and risk factors of hypoparathyroidism and hypocalcemia after hemithyroidectomy. We retrospectively analyzed the medical data of 321 patients who underwent hemithyroidectomy, with or without central neck dissection, from January 2012 to April 2019. We analyzed the serum intact parathyroid hormone (iPTH), calcium, and ionized calcium (iCa) levels serially (preoperatively and postoperatively on the operation day; days 1 and 3; and months 1, 3, 6, and 12) and evaluated risk factors for postoperative hypoparathyroidism and hypocalcemia. The mean iPTH and calcium levels decreased significantly after hemithyroidectomy on the operation day and postoperative days 1 and 3, and returned to the preoperative level at the postoperative 1-month follow-up. The mean iCa level decreased significantly on the operation day and postoperative day 1. Transient hypoparathyroidism and transient hypocalcemia occurred in 16 (5%) and 250 (78%) participants, and they recovered to normal levels postoperatively by 1month. Eight (2.5%) patients had mild symptoms of hypocalcemia necessitating oral calcium supplementation. No permanent hypoparathyroidism or hypocalcemia was observed. Preoperatively low serum iPTH and calcium levels were associated with transient hypoparathyroidism and hypocalcemia after hemithyroidectomy. Approximately 5% and 2.5% of participants showed transient hypoparathyroidism and mild symptomatic hypocalcemia after hemithyroidectomy. The risk factors for transient hypoparathyroidism and hypocalcemia include preoperative low serum iPTH and calcium levels.

Pharmacological profile of upacicalcet, a novel positive allosteric modulator of calcium-sensing receptor, in vitro and in vivo

Upacicalcet (formerly SK-1403/AJT240) is a novel non-peptide calcimimetic agent that acts as a calcium-sensing receptor (CaSR) agonist for the treatment of secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD). We compared upacicalcet with other calcimimetics (etelcalcetide or cinacalcet) and examined its in vitro and in vivo characteristics in terms of its human CaSR agonistic activity, its efficacy in normal and CKD rats after a single administration, and its effect on gastric emptying in rats. Upacicalcet activated human CaSR depending on the extracellular calcium (Ca2+) concentration without exhibiting an agonistic action when the extracellular Ca2+ level was below the physiological level. On the other hand, etelcalcetide had an agonistic activity even in the absence of physiological levels of extracellular Ca2+. The intravenous administration of upacicalcet to normal and double-nephrectomized rats dose-dependently (0.03–3mg/kg and 0.3–30mg/kg, respectively) decreased the serum intact parathyroid hormone (iPTH) and serum Ca2+ levels; however, the effect of upacicalcet on the reduction in serum Ca2+ disappeared at extracellular Ca2+ levels below the physiologically range, even when administered at a dose higher (100-fold) than the effective dose. Furthermore, upacicalcet did not affect gastric emptying in normal rats when administered up to a dose of 10mg/kg (300-fold higher than the dose affecting serum iPTH levels), while the administration of cinacalcet significantly slowed gastric emptying by approximately 50%. These findings suggest that upacicalcet has potential as an alternative calcimimetic agent with good pharmacological properties and a lower risk of hypocalcemia and gastrointestinal complications.

Efficacy of Radiofrequency Ablation/Microwave Ablation Technology for Treatment of Chronic Kidney Disease Complicated with Secondary Hyperparathyroidism

It aimed to investigate the efficacy and safety (EAS) of radiofrequency ablation (RFA)/microwave ablation (MWA) in treating patients with chronic kidney disease (CKD) and secondary hyperparathyroidism (SHPT). PubMed, EMbase, Medline, CBM, CNKI, Cochrane Online Library, and Web of Science were searched for randomized controlled or cohort studies of parathyroidectomy (PTX), RFA, or MWA for CKD with SHPT. After quality assessment, RevMan 5.3 was employed for meta-analysis. Results revealed that seven articles were retrieved and included, including 842 patients, with 435 in the RFA/MWA group and 407 in the PTX group. Based on the PTX group, intact parathyroid hormone (IPTH) at 1 day (MD = 145.87, 95% CI = 49.20–242.54, Z = 2.96, P = 0.003) and iPTH at 3 months (SMD = 1.32, 95% CI = 0.38–2.25, Z=2.75, P =0.006) in the RFA/MWA group were markedly increased, the length of hospital stay (LOS) (MD=−3.24, 95% CI=−4.55–1.92, Z = 4.83, P &lt;0.00001) was remarkably shorter, and the hematoma rate (OD = 0.27, 95% CI = 0.08–0.91, Z = 2.10, P = 0.04) and hypocalcemia rate (OD = 0.43, 95% CI = 0.22–0.85, Z = 2.43, P = 0.02) were markedly decreased. However, no great difference was observed in serum calcium (Ca) and phosphorus (P) levels or hoarseness rate between the PTX group and the RFA/MWA group at three months after the operation. In short, the blood iPTH level of patients after RFA or MWA treatment was markedly increased, the rate of adverse events (AEs) was lower, and the length of LOS was shortened.

Effects of running a marathon on sclerostin and parathyroid hormone concentration in males aged over 50.

The aim of our study was to verify whether running a marathon (32nd Wroclaw Marathon) was associated with changes in sclerostin and intact PTH (iPTH) concentration in middle-aged males. We enrolled 33 males who completed the marathon race. Blood samples were taken 60 minutes before (V1), immediately after (V2), and 7 days after the run (V3). The mean serum sclerostin concentration was 42.4 ± 10.8 pmol/L at V1, increased to 62.9 ± 12.6 pmol/L at V2 (t= -11.206; p < 0.001) and returned to baseline in V3 (t = 8.344; p < 0.001, V3 vs. V2). A similar trend was recorded for iPTH (t= -7.440; p < 0.001, for V2 vs. V1; t = 6.229; p < 0.001, for V3 vs. V2), at V3, iPTH levels remained significantly higher than V1 (t= -2.759; p = 0.010). The results of our study suggest that, in middle-aged males, running a marathon affects skeletal metabolism by activating two counteracting mechanisms, although temporarily overlapping: first, by a sudden inhibition of bone formation, through induction sclerostin expression and, secondly, by a long-lasting induction of PTH, which also guarantees the maintenance of adequate circulating levels of calcium. The net effect would be the maintenance of adequately high levels of circulating calcium to be used for neuromuscular activity and muscle contraction.

Chronic dialysis patient with severe secondary hyperparathyroidism undergoing parathyroidectomy in Indonesia: a case series

Link of Video Abstract: https://youtu.be/d196XKGsPekBackground: Parathyroidectomy is a method of treating secondary hyperparathyroidism associated with Chronic Kidney Disease (CKD), which has been largely abandoned in developed countries due to the existence of calcimimetic drugs which are reported to be effective in treating secondary hyperparathyroidism in this population. However, in developing countries like Indonesia, the availability of Calcimimetic drugs is still rare and expensive, so that parathyroidectomy can be an option. The study aimed to present four case reports of chronic HD patients with SHPT accompanied by clinical symptoms. As far as our knowledge goes, this is the first case series reported from Indonesia. Case Presentation: This research is a multicenter case series study. All patients had undergone dialysis for five years and complained of body aches. All calcium levels were within the normal range, while three patients had hyperphosphatemia and one patient had normal phosphate levels. All patients had iPTH levels &gt;1000 pg/ml in the last six months. Before the surgery, all patients had received long-term phosphate-binding drugs, including calcium-based and non-calcium-based drugs and vitamin D3 agonists. All patients underwent total parathyroidectomy with autotransplantation of parathyroid tissue in the right antebrachial regions, except for the second patient who received the transplant in the left antebrachial region due to an AV fistula in the right arm. Conclusion: In dialysis patients, especially in developing countries, approximately 10.7% of them experience SHPT with PTH levels &gt;1,000 pg/mL, and one study in Indonesia showed that around 35% of patients undergoing chronic hemodialysis had PTH levels &gt;200 pg/ml, making parathyroidectomy a highly possible option considering that medications such as cinacalcet are more expensive and not widely available.

Negative impact on bone homeostasis in postmenopausal women with non-metastatic breast cancer during cytotoxic chemotherapy.

The burden and mechanisms of endocrine therapy-related bone loss are well known, while there are limited data on chemotherapy-induced bone resorption. The study aimed to evaluate the effect of cytotoxic chemotherapy on bone homeostasis among postmenopausal women with non-metastatic breast cancer. Early and locally advanced postmenopausal non-metastatic breast cancer patients aged 45 to 65 planned for three cycles of anthracycline and four cycles of taxane chemotherapy administered along with dexamethasone (cumulative dose-256mg) as an antiemetic from June 2018 to December 2021 were included. Bone mineral density (BMD), bone turnover markers, calciotropic hormones, pro-inflammatory cytokines, oxidative stress, and total antioxidant levels (TAS) were measured. We recruited 109 patients, with early 34 (31.2%) and locally advanced breast cancer 75 (68.8%) with median age 53 (45-65) years. There was a significant decrease in the % BMD at the lumbar spine, neck of the femur, and total hip post-chemotherapy. There was a significant increase in serum C-terminal telopeptide of type I collagen (CTX) and procollagen type I N-terminal propeptide (PINP) levels post-chemotherapy. PINP/CTX ratio significantly decreased post-chemotherapy. Serum 25-OH vitamin D was significantly reduced with a compensatory increase in plasma iPTH levels. The change in CTX, PINP/CTX ratio, 25-OH vitamin D, iPTH, and oxidative stress index was more pronounced during anthracycline as taxane chemotherapy. There were no significant changes in pro-inflammatory cytokine levels. Chemotherapy and dexamethasone as antiemetic resulted in significant bone loss, as evidenced by bone turnover markers. Further studies are required to understand the mechanism of chemotherapy-induced bone loss and the need for bone-strengthening agents during chemotherapy.

Post-Thyroidectomy Hypocalcemia: Incidence, Prediction, and Outpatient Management Strategies Based on PTH and Calcium Levels

PTH measurement has been proposed to predict transient and permanent postoperative hypocalcemia. There is no standard cut-off point or time for sampling. To report the incidence of post-thyroidectomy hypocalcemia in a high-volume surgical group and propose an outpatient management protocol according to postoperative (PO) calcium levels, iPTH (normal, low, or undetectable), and symptoms. Furthermore, determine postoperative PTH values as predictors of hypocalcemia. In 106 patients with total thyroidectomy between 2019 and 2021, pre-and postoperative levels of calcium, magnesium, phosphorus, and iPTH were measured. Transient (< 12 months) and permanent (> 12 months) hypocalcemia was observed in 29% and 1%. Cut-off points to predict hypocalcemia were PTH < 8.8 pg/mL and < 80% decrease in % PTH (d% PTH) the day after surgery. With the proposed management, early discharge is indicated (an average of 1.05 days), and the prescription cost is limited. There is no significant association between PO hypomagnesemia and hyperphosphatemia with PO hypocalcemia. The most widely used treatment is exclusive calcium carbonate (schemes I and II). Patients remain with mild symptoms at two weeks PO in 5% and discontinue oral treatment in 93% in this period. Protocols for measuring PTH as a hypocalcemia predictor vary. Each center must know and establish its management protocols. With this experience, we demonstrate the usefulness and safety of a management scheme based on calcium, PTH (normal, low, or undetectable), and symptoms with an indication of prophylactic treatment for all patients and a safe outpatient setting at a lower cost than prolonged hospitalization.

#5653 MEASURABLE IMPROVEMENT IN ABD WITH SMALL CHANGE IN HD SETTING

Abstract Background and Aims Majority of the patients with chronic kidney disease on hemodialysis (CKD HD) have various bone-related pathologies covered under one clinical entity chronic kidney disease – mineral bone disorders (CKD-MBD). One of the most common is the adynamic bone disease (ABD).1 Published data are showing that changes of calcium level in HD fluid might improve the ABD.2,3 Our aim was to assess whether the lowering of the calcium in dialysis fluid will improve the ABD in our HD patients. Method Prospective study was conducted in a single HD centre in a period of 12 months (01.10.2020 until 30.09.2021), with further 6 months follow up. One hundred thirty three HD patients were screened, 64 patients of them had ABD (iPTH &amp;lt;150 ng/ml). 53 patients were enrolled who met the inclusion criteria (age &amp;gt;18 years, and HD vintage &amp;gt;90 days) and 50 completed the study, during which the only phosphate binder used was calcium based. The calcium level content in the dialysis fluid was changed from various calcium content level (1.5 mmol/L; 1.75 mmol/L) and set to 1.25 mmol/L in the enrolled patients. Laboratory parameters were followed each month and the level of iPTH trimonthly. Results Data from 50 patients was collected and analysed, 50.9% (n=27) males. The average age of the cohort was 69.31 years (±12.49), average HD vintage was 51.94 months (±43.82). Average HD time was 254.8 minutes (±14.71) with average blood pump 393.4 ml/min (±44.38). At study end, the iPTH level was significantly changed (p=.00001), from 67.48 ng/ml (±32.85) to 150.38 ng/ml (±92.96). 24 out of 50 patients (48%) had iPTH level &amp;gt;150 ng/ml, p=.00001. Calcium level changed slightly from 2.27 mmol/L (±0.15) to 2.25 mmol/L (±0.18), p=.25. The phosphate level changed from 1.29 mmol/L (±0.49) to 1.55 mmol/L (±0.48), p=.004. The alkaline phosphatase level significantly changed (p=.00002), from 82.61 IU/L (±49.5) to 118.71 IU/L (±50.23). Patients who had iPTH level &amp;gt;150 ng/ml at the study end had level of calcium of 2.2 mmol/L (±0.16), p=.17 compared to patients who had iPTH level &amp;lt;150 ng/ml (level of calcium of 2.31 mmol/L ±0.18; p= .43). There was improvement in the level of phosphate and alkaline phosphatase; 1.31 mmol/L (±0.46) vs. 1.6 mmol/L (±0.46), p=.002 and 82.57 IU/L (±57.22) vs. 130.83 IU/L (±60.24), p= .004, accordingly. Diabetes mellitus (DM) had insignificant impact on ABD in the patient cohort. 66.7% of the patients with DM (n=10) and 40% of the patients without DM (n=14) reached iPTH &amp;gt;150 ng/ml at study end. Intergroup comparison showed significance only in the level of calcium, DM group calcium=2.16 mmol/L (±0.1); non DM group calcium=2.29 mmol/L (±0.1); p=.01. Additionally, at study end, Karnofsky score was higher in patients with iPTH &amp;gt;150 ng/ml, 76.09% (±13.05); p=.009. Patients who did not reach iPTH &amp;gt;150 ng/ml (n=26) were further followed up for 6 months, and 10 of them reached iPTH &amp;gt;150 ng/ml. Conclusion Indirectly minor change in HD setting, as lowering the calcium level in dialysis fluid in a period of more than 12 months, might improve the adynamic bone disease. Presence of diabetes did not showed significant impact on ABD. However, Karnofsky score showed significant improvement, and exercise may also improve ABD in HD patients. These findings might be used as recommendation in low and middle-income countries in which pharmacological treatments for ABD are limited and/or unavailable.