Median Parathyroid Hormone Levels Research Articles

#1286 Utility of cinacalcet treatment in kidney transplant recipients with persistent hyperparathyroidism

Abstract Background and Aims Secondary hyperparathyroidism occurs in the majority of patients with chronic kidney disease (CKD). It may persist in up to 50-66% of patients despite the initial decrease in PTH levels after successful kidney transplantation (KT). Maintaining parathyroid hormone (PTH) levels within the normal range during the post-transplant period is crucial because it is related to hypercalcemia, hypophosphatemia, and reduced bone mass in KT recipients. Studies have already demonstrated that persistent hyperparathyroidism is associated with graft loss and all-cause mortality. Vitamin D, vitamin D analogs, and calcimimetics are most commonly used to manage hyperparathyroidism. However, studies about the long-term effect of calcimimetic therapy on the allograft are still limited. In this study, we aim to investigate the long-term allograft results of patients who received cinacalcet treatment for hyperparathyroidism. Method This study was conducted in Gazi University nephrology dialysis and transplantation unit with 312 patients who were transplanted between 1996 and 2019 and continued routine follow-up visits. Persistent hyperparathyroidism is defined as elevated PTH levels after the first year of KT (serum PTH>88 pg/mL). All patients without concurrent hypercalcemia were treated with vitamin D or analogs according to their vitamin D levels. Patients with non-functional allograft and parathyroidectomy after KT were excluded from this study. In addition, patients with rejection episodes, which could be confounding factor for allograft survival, were excluded to evaluate the isolated effect of cinacalcet on the allograft function. We identified 115 patients with persistent hyperparathyroidism, of whom were treated with cinacalcet (n = 21) or not (n = 94). We analyzed the baseline characteristics, comorbidities, and immunosuppressive treatments of the groups. Additionally, annual eGFR changes (Δ eGFR) calculated based on baseline (post-transplantation 6th month) eGFR after KT was also examined to evaluate the effect of cinacalcet on the graft. Results The mean age of the patients was 44.3 ± 12.6 years, and 47 (41%) were women. The median follow-up time of the patients was 87 (49-117) months. Twenty-nine patients (25%) underwent cadaveric transplantation, and 47 (41%) patients received anti-thymoglobulin (ATG) in induction therapy. While all patients were given glucocorticoids as maintenance immunosuppressive therapy, 93 (81%) of the patients received tacrolimus and, 9 (8%) cyclosporin as CNI, 78 (68%) received anti-metabolite therapy. Fifty-eight patients (19%) were used mTORi. A total of 21 patients with persistent hyperparathyroidism (21%) were treated with cinacalcet. Dialysis time is longer in the cinacalcet-treated group than in the patients not treated with cinacalcet (p < 0.001). The preemptive transplantation rate was lower (p = 0.03), and the delayed graft function was higher in the cinacalcet-treated group (p = 0.04). In the first year after KT, serum median PTH levels were 227 (167-341) pg/ml in the cinacalcet group and 110 (86-160) pg/ml in the other group, respectively (<0.001). Also, serum phosphate level is lower in the treatment group (2.7 ± 0.4 mg/dl vs. 3.1 ± 0.7 mg/dl, p = 0.03). At the last visit of patients, we observed similar median PTH levels between groups [141 (100-222) vs. 108 (73-159), p = 0.08]. During the follow-up, CMV episodes and BKV nephropathy diagnosis rates were similar between the groups (Table 1). Δ eGFRs in the first year (p = 0.7), second year (p = 0.2), third year (p = 0.4), and fifth year (p = 0.6) after KT were similar between both groups. Conclusion Our study suggests that cinacalcet treatment could be a safe and effective treatment for patients with persistent hyperparathyroidism. In long-term follow-up, there is no evidence of a reduction of kidney function. However, more trials are still required for other clinical outcomes such as fracture risk and cardiovascular morbidity and mortality.

Pediatric Fractures: Does Vitamin D Play a Role?

Vitamin D (25-OHD) deficiency and insufficiency are reported in about half of all children. The literature on low 25-OHD and pediatric fracture risk presents inconsistent results. This study evaluates the association between pediatric fractures and 25-OHD, parathyroid hormone (PTH), and calcium. This is a prospective case-control study in 2 urban pediatric emergency departments (2014-2017). Patients aged 1 to 17 requiring intravenous access were enrolled. Demographics, nutrition, and activity information were recorded and levels of 25-OHD, calcium, and PTH were measured. Two hundred forty-five subjects were enrolled: 123 fractures and 122 controls. Overall, the mean 25-OHD level was 23ng/mL±8.5: 52 (21%) of patients were 25-OHD sufficient; 193 (79%) were not. Ninety-six percent of patients with lower extremity fractures had low 25-OHD versus 77% of patients with upper extremity fractures (P=0.024). The fracture cohort was younger (P=0.002), included more males (P=0.020), and spent more time playing outdoor sports (P=0.011) than the control cohort. The 25-OHD level (fracture 22.8ng/mL±7.6 vs. nonfracture 23.5ng/mL±9.3, P=0.494) and median calcium level (fracture 9.8mg/dL vs. nonfracture 10.0mg/dL, P=0.054) were similar between cohorts. The median PTH level was higher in the fracture than the control cohort (33 vs. 24.5pg/mL; P<0.0005); PTH was elevated to hyperparathyroidism (>65pg/mL) in 13% of fractures and 2% of controls (P=0.006). Matched subgroup analysis of 81 fracture patients and 81 controls by age, gender, and race showed that PTH was the only variable independently associated with increased odds of fracture (odds ratio=1.10, 95% CI, 1.01-1.19, P=0.021) in a model adjusted for vitamin D sufficiency and time spent playing outdoor sports. Low 25-OHD is common in children with fractures but we found no difference in 25-OHD levels between fracture and nonfracture cohorts. This research can impact evidence-based guidelines on vitamin D level screening and/or supplementation after fracture. Diagnostic level IV-case-control study.

#3579 AN INITIAL LOW-DOSE ETELCALCETIDE APPROACH IS EFFECTIVE AND COST-SAVING IN HEMODIALYSIS PATIENTS WITH MODERATE SECONDARY HYPERPARATHYROIDISM

Abstract Background and Aims Etelcalcetide (ETC) is an intravenous calcimimetic approved for the management of secondary hyperparathyroidism (sHPT) in hemodialysis (HD) patients, with benefits in terms of reduction of FGF23 levels and prevention of progression of left ventricular hypertrophy. The label recommendation is a starting dose of 5 mg after HD, to be titrated every 4 weeks according to parathyroid hormone (PTH) and calcium levels. However, it remains unclear what dosage is best to start with and, thus, how this treatment can be implemented in a real-life setting. The aim of this study was to assess the efficacy and cost-effectiveness of ETC started at lower doses than those suggested by the manufacturer in patients with moderate sHPT. Methods This is a retrospective observational study comparing two different initial ETC dosing strategies, a “Low-dose approach” (LD, ETC starting dose&amp;lt;10 mg/week) and a “Classic approach” (CL, ETC starting dose≥10 mg/week), in terms of effects on CKD-MBD related biomarkers and costs during the first year of prescription. The study was conducted on HD patients with basal PTH between 500 and 1500 ng/l, treated with ETC for at least 3 months between 2018 and 2022 at ASST Spedali Civili di Brescia. Monthly monitoring of serum calcium, phosphorus and PTH was performed in both groups for dose adjustment. Results Overall, 53 patients were identified, 24 in the LD and 29 in the CL group. Both groups showed similar baseline characteristics (Table 1). Median follow-up was 52 weeks, during which 4 patients (one in the LD and three in the CL group) discontinued ETC (Table 1). At the end of follow-up, 92% of patients in the LD and 90% in the CL group achieved a decrease in PTH ≥30% compared to baseline, with median PTH levels of 282 (207 - 332) and 294 (151 – 382) ng/l, respectively (p = 0.825). Other CKD-MBD biochemical parameters were comparable between the two groups at all timepoints (Figure 1). The median of average ETC weekly doses per patient was 7.6 (6.2 – 10.2) mg in the LD and 10.6 (9.7 – 15) mg in the CL group (p&amp;lt;0.001). During follow-up, the median ETC dose remained stable in the LD group, while partially decreasing in the CL group (Figure 1). Use of paricalcitol was comparable in both groups. At cost analysis, the median of average ETC weekly costs per patient was €36.6 (29.6 – 50.0) in the LD and €50.5 (46.4 – 71.7) in the CL group (p&amp;lt;0.001). This translates into an average yearly cost per patient of €1909 and €2635 using the LD and CL approach, respectively, with a saving of €726 per patient-year in favour of the LD strategy. Conclusion In this retrospective study in HD patients with moderate sHPT, we showed that starting ETC at a lower dose than the one suggested by the manufacturer is as effective as the classic approach in terms of control of CKD-MBD parameters, with a significant reduction in treatment costs. Future prospective studies will be needed to validate the results in bigger cohorts, test whether these benefits can extend beyond the first year of treatment and assess the effects on FGF23 levels and other relevant clinical outcomes.

Parathyroidectomy for Normocalcemic Tertiary Hyperparathyroidism: A 19-Year Experience.

Parathyroidectomy is the standard management for patients with tertiary hyperparathyroidism (THPT) and hypercalcemia. However, a subset of patients with THPT have normal or mildly-elevated serum calcium levels in the setting of significantly elevated parathyroid hormone (PTH). The purpose of this study is to determine the effectiveness and safety of parathyroidectomy in normocalcemic THPT. Retrospective review of 212 consecutive patients with THPT who subsequently underwent parathyroidectomy between 2001 and 2020 was performed. Patients were categorized as normocalcemic, "mild" (Ca ≤ 10.4mg/dL) or hypercalcemic, "classic" THPT (Ca ≥ 10.5mg/dL) and clinical data are compared. 71 of 212 (34%) were normocalcemic with median pre-operative Ca and PTH levels of 9.7mg/dL and 225pg/mL, respectively and 141 of 212 (67%) were hypercalcemic with median preoperative Ca and PTH levels of 11mg/dL and 211pg/mL, respectively. The mean length of stay was shorter in normocalcemic patients (0.33 versus 0.50d; P=0.03). 10 of 71 (14%) normocalcemic patients underwent reoperative parathyroidectomy, more than double that of hypercalcemic patients (5.6%; P=0.06). Concomitant thymectomy was performed in 28.1% and 22.1% of normocalcemia and hypercalcemic patients, respectively (P=0.44). No patient in either group required intravenous calcium or had undetectable PTH levels, but permanent hypocalcemia was more frequent in normocalcemic compared to hypercalcemic patients (11.2% versus 1.4%; P=0.03). Parathyroidectomy for normocalcemic tertiary hyperthyroidism (HPT) can be performed safely. These data can help guide multidisciplinary discussions for earlier surgical referral and intervention. Future investigations are needed to evaluate the impact of parathyroidectomy on the renal allograft, bone health, and cardiovascular disease.

Parathyroid hormone and phosphate homeostasis in patients with Bartter and Gitelman syndrome: an international cross-sectional study.

Small cohort studies have reported high parathyroid hormone (PTH) levels in patients with Bartter syndrome and lower serum phosphate levels have anecdotally been reported in patients with Gitelman syndrome. In this cross-sectional study, we assessed PTH and phosphate homeostasis in a large cohort of patients with salt-losing tubulopathies. Clinical and laboratory data of 589 patients with Bartter and Gitelman syndrome were provided by members of the European Rare Kidney Diseases Reference Network (ERKNet) and the European Society for Paediatric Nephrology (ESPN). A total of 285 patients with Bartter syndrome and 304 patients with Gitelman syndrome were included for analysis. Patients with Bartter syndrome type I and II had the highest median PTH level (7.5pmol/L) and 56% had hyperparathyroidism (PTH>7.0pmol/L).Serum calcium was slightly lower in Bartter syndrome type I and II patients with hyperparathyroidism (2.42versus 2.49mmol/L; P=.038) compared to those with normal PTH levels and correlated inversely with PTH (rs -0.253; P=.009). Serum phosphate and urinary phosphate excretion did not correlate with PTH. Overall, 22% of patients had low serum phosphate levels (phosphate-standard deviation score < -2), with the highest prevalence in patients with Bartter syndrome type III (32%). Serum phosphate correlated with tubular maximum reabsorption of phosphate/glomerular filtration rate (TmP/GFR) (rs 0.699; P <.001), suggesting renal phosphate wasting. Hyperparathyroidism is frequent in patients with Bartter syndrome type I and II. Low serum phosphate is observed in a significant number of patients with Bartter and Gitelman syndrome and appears associated with renal phosphate wasting.

Double water-clear cell parathyroid adenoma: a case report and literature review

Water-clear cell parathyroid adenoma is an uncommon cause of primary hyperparathyroidism. Herein, we report an interesting case of a 56-year-old man who presented with weight loss, bone pain, fatigue, and a palpable right neck mass. Laboratory tests indicated hypercalcemia, elevated parathyroid hormone (PTH) levels, and normal thyroid function. Further examinations detected osteoporosis and kidney stones. The ultrasound of neck revealed bilateral extrathyroidal tumors, which were sestamibi-avid. The patient underwent resection of the large right inferior and left inferior parathyroid tumors. Histopathology revealed a double water-clear cell parathyroid adenoma. His serum calcium and PTH levels normalized after surgery. The literature review identified 37 cases of water-clear cell parathyroid adenoma between 1985 and 2021. The median age at diagnosis was 56 years. Classic complications were common, including nephrolithiasis in nine and skeletal presentations in 10 patients. Before surgery, the median calcium and PTH levels were 12.0 mg/dL and 290 pg/mL, respectively. Overall, 89% were localized on ultrasonography, and 60% were positive on scintigraphy. Four patients had double adenomas. The median maximum diameter was 3.8 cm, and the median weight of the resected adenoma was 5.27 g. In summary, water-clear cell parathyroid adenoma has certain unique features. These include larger tumor size, relatively indolent biochemical profile, high prevalence of complications and nonspecific symptoms, an isoechoic appearance on ultrasonography, and reduced scintigraphic sensitivity.

Serum biotin interference: A troublemaker in hormone immunoassays

ObjectivesBiotin therapy can affect the results of many immunoassay procedures. The present study investigates biotin’s interference on 25-hydroxy vitamin D (25-OHD), parathyroidhormone (PTH) and thyroid-stimulating hormone (TSH) tests using four different assay systems and biotin neutralization. Design and methodsEnrolled in the study were 50 children diagnosed with biotinidase deficiency (BTD) undergoing treatment with biotin (5–20 mg/day) who were subjected to a series of analyses involving 25-OHD (Roche Diagnostics assays, Beckman Coulter assays, HPLC, LC/MS-MS), TSH, PTH (Roche Diagnostics assays, Beckman Coulter assays) and biotin (LC/MS-MS), before and after biotin neutralization with Streptavidin-coated magnetic particles (SMP). ResultsThe median biotin concentration was found to be 175.2 [94.0–307.1] μg/L. There was no significant difference in the 25-OHD results before and after neutralization with the Beckman Coulter, HPLC and LC-MS/MS assays. In contrast, the median 25-OHD level was seen to decrease from 90.2 [35.9–105.3] ng/mL to 29.1 [22.6–37.6] ng/mL after neutralization with the Roche assay (p < 0.0001). While there was no statistically significant difference in the values recorded before and after neutralization in PTH analysis using Beckman assay, the median PTH levels increased from 7.8 [1.6–21.6] pg/mL to 28.2 [22.5–41.9] pg/mL after neutralization with the Roche assay (p < 0.0001). The cut-off values at which serum biotin interfered in the Roche assay PTH test, with 25-OHD levels determined as 51.4 μg/L and 62.9 μg/L, respectively. A significant increase was detected in the TSH levels analyzed with a Roche assay after neutralization (from 2.36 [1.85–3.00] mIU/L to 2.74 [1.93–3.70] mIU/L, p < 0.0001). ConclusionsThe PTH, 25-OHD and TSH results were found to be affected by high biotin concentrations in Roche assays, leading to a risk of misdiagnosis, although SMP neutralization can suppress any such interference efficiently.

Elderly patients with hip fracture and subnormal renal function have inadequate response to vitamin D supplementation

IntroductionAll Danish citizens aged >70 years are recommended to take vitamin D supplements. We hypothesized that renal insufficiency may impair the activation and effect of vitamin D supplements. We aimed to investigate the association between use of vitamin D supplements, and levels of 25-hydroxy-vitamin D and parathyroid hormone (PTH) in elderly patients according to estimated glomerular filtration rate (eGFR). MethodsThe study was a sub-analysis of 164 patients with 25-hydroxy-vitamin D levels measured in a cross-sectional study of 200 consecutive patients aged ≥65 years admitted to hospital with hip fracture. ResultsVitamin D supplement-users (n = 68) had significantly higher 25-hydroxy-vitamin D levels regardless of eGFR ≤ or>60 ml/min. In patients with eGFR>60 ml/min (n = 103), median PTH levels were significantly lower in vitamin D supplement-users compared to non-users (4.8 [4.2–6.7] vs 6.25 [4.9–8.3] pmol/l, P = 0.039), while there was no difference in patients with eGFR≤60 ml/min (9.5 [5.4–16.7] vs 9.8 [5.9–16.9] pmol/l, P = 0.66 (n = 61)). ConclusionsUse of vitamin D supplements was associated with increased levels of 25-hydroxy-vitamin D, but only associated with decreased levels of PTH in patients with eGFR>60 ml/min. Thus, renal function may be essential to gain effect of vitamin D supplements, and 25-hydroxy-vitamin D levels may not reflect active Vitamin D status in elderly vitamin D supplement-users with hip fracture and decreased renal function. In addition to current guidelines for prescription of vitamin D supplements, it may be considered to monitor PTH or active vitamin D in elderly patients with eGFR<60 ml/min and adjust dose accordingly.

A Retrospective Study of Ultrasonography in the Investigation of Primary Hyperparathyroidism: A New Perspective for Ultrasound Echogenicity Features of Parathyroid Nodules

ObjectiveTo identify and understand parathyroid lesions of patients with primary hyperparathyroidism (PHPT) more accurately under ultrasound. MethodsThis retrospective study involved 423 adult patients with PHPT with a single parathyroid nodule and positive parathyroid ultrasonography between 2018 and 2019. The clinical characteristics of the study patients and histopathologic sections were reviewed. ResultsAccording to the main grayscale echogenicity features of parathyroid nodules, 423 cases were divided into groups: iso-hyperechogenicity solid (61/423), hypoechogenicity solid (304/423), and mixed-echogenicity cyst-solid (58/423) groups. Comparison among the 3 groups showed that the iso-hyperechogenicity group included more asymptomatic patients with PHPT and fewer patients with severe symptoms like bone fractures (P < .05). The mixed-echogenicity group showed higher median serum parathyroid hormone (PTH) and serum calcium levels and larger lesion sizes (P < .05), and the iso-hyperechogenicity group showed the lowest median serum PTH level. No difference in lesion size was noted between the 2 solid groups, but the median serum PTH level in the hypoechogenicity group was higher than that in the iso-hyperechogenicity group (P < .05). According to histopathology, the hypoechogenic area of the samples may contain more functional components (chief cells), whereas the iso-hyperechogenic area has more nonfunctional components (eg, lipocytes and connective tissues). ConclusionThe PHPT nodules distinguished by ultrasound echogenicity features showed different histopathologic components, reflected by different clinical characteristics of the patients with PHPT.

Prevalence of vitamin D deficiency and persistent hyperparathyroidism in an Egyptian cohort of renal transplant recipients

Background Vitamin D metabolism might be influenced by impaired allograft function and by persistently elevated parathyroid hormone (PTH) and fibroblast growth factor 23 levels as well. Hyperparathyroidism is a frequent and sometimes severe complication following renal transplantation. Purpose The primary objective was to measure the prevalence of vitamin D deficiency in renal transplant recipients in a single center (Almowasah Hospital). The secondary objective was to determine predictors of low 25-hydroxyvitamin D levels using patient characteristics to identify patients at a higher risk of vitamin D deficiency. Patients and methods A retrospective cross-sectional study was conducted on 55 renal transplant recipients for whom 25-hydroxyvitamin D was measured. Intact PTH was measured as well and compared with pretransplant values. Results The majority of the patients, representing ∼81.8%, were vitamin D deficient, whereas 14.5% had insufficient serum vitamin D level. A minority of the patients (3.6%) showed sufficient vitamin D level. The mean vitamin D level was 15.13±7.03 ng/ml. Approximately 38.2% of the patients showed evidence of persistent hyperparathyroidism. The median PTH level was higher in the pretransplant period, with a value of 308.0 pg/ml, compared with the posttransplant period (121.0 pg/ml). The difference was statistically significant (P&lt;0.001). Serum PTH level showed a reduction in its level by ∼55.79% after transplantation. Conclusion Vitamin D deficiency is highly prevalent in renal transplant recipients. It is also more prevalent in early than late transplant recipients, and there is a statistically significant inverse correlation between vitamin D and PTH.

Acute and long-term kidney function after parathyroidectomy for primary hyperparathyroidism.

In kidney transplant patients, parathyroidectomy is associated with an acute decrease in renal function. Acute and chronic effects of parathyroidectomy on renal function have not been extensively studied in primary hyperparathyroidism (PHPT). This retrospective cohort study included 494 patients undergoing parathyroidectomy for PHPT. Acute renal changes were evaluated daily until day 4 post-parathyroidectomy and were stratified according to acute kidney injury (AKI) criteria. Biochemical assessment included serum creatinine, total and ionized calcium, parathyroid hormone (PTH), and 25-hydroxyvitamin D (25OHD). The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation. We compared preoperative and postoperative renal function up to 5 years of follow-up. A total of 391 (79.1%) patients were female, and 422 (85.4%) were non-African American. The median age was 58 years old. The median (first and third quartiles) preoperative serum creatinine, PTH and total calcium levels were 0.81 mg/dL (0.68-1.01), 154.5 pg/mL (106-238.5), and 10.9 mg/dL (10.3-11.5), respectively. The median (first and third quartiles) preoperative eGFR was 86 mL/min/1.73 m2 (65-101.3). After surgery, the median acute decrease in the eGFR was 21 mL/min/1.73 m2 (p<0.0001). Acutely, 41.1% of patients developed stage 1 AKI, 5.9% developed stage 2 AKI, and 1.8% developed stage 3 AKI. The acute eGFR decrease (%) was correlated with age and PTH, calcium and preoperative creatinine levels in univariate analysis. Multivariate analysis showed that the acute change was related to age and preoperative values of ionized calcium, phosphorus and creatinine. The change at 12 months was related to sex, preoperative creatinine and 25OHD. Permanent reduction in the eGFR occurred in 60.7% of patients after an acute episode. There was significant acute impairment in renal function after parathyroidectomy for PHPT, and almost half of the patients met the criteria for AKI. Significant eGFR recovery was observed during the first month after surgery, but a small permanent reduction may occur. Patients treated for PHPT seemed to present with prominent renal dysfunction compared to patients who underwent thyroidectomy.

Prevalence and risk factors of post-kidney transplant hyperparathyroidism: a single-center study

Objective:to assess the prevalence of hyperparathyroidism (HPT) and the factors affecting its development in kidney transplant recipients.Materials and methods. The single-center observational cohort study included 97 kidney transplant recipients – 40 men, 57 women, age 50 ± 9 years. Inclusion criteria: more than 12 months of post-transplant period, 3 months of stable renal transplant function. Non-inclusion criterion: therapy with vitamin D, with its alternatives or with cinacalcet. Dialysis ranged from 0 to 132 months (median 18); 46% of patients had pre-operative secondary HPT. A comprehensive laboratory study included evaluation of serum concentrations of parathyroid hormone (PTH), 25-OH vitamin D, calcium, phosphorus, magnesium, total alkaline phosphatase (ALP) activity, albumin, creatinine and daily proteinuria. At the dialysis stage, the target PTH range of 130–585 pg/ ml was used, in the post-transplant period – ≤130 pg/ml. Glomerular filtration rate (eGFR) was calculated using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) formula.Results.Patients were divided into two groups based on PTH threshold level (130 pg/ml): the first with HPT (PTH &gt;130 pg/ml, median 203), the second without HPT (PTH ≤130 pg/ml, median 101). Both groups were comparable in terms of gender, age, primary renal disease, dialysis modality, post-transplant follow-up, and immunosuppressive therapy regimen. In group 1 and group 2 recipients, dialysis therapy, pre-transplant median PTH level, incidence of reoperation and incidence of immediate renal graft function were 30 (14; 50) and 14 (6; 28) months (p = 0.004), 681 (538; 858) and 310 (182; 556) pg/ml (p &lt; 0.001), 17% and 2% (p = 0.028), 51% and 80% (p = 0.005), respectively. At the time of the study, 72% of group 1 recipients had eGFR &lt;60 ml/min, versus 36% of group 2 (p &gt;&lt; 0.001). Among HPT biochemical parameters, there were differences for ionized serum calcium (1.32 ± 0.07 versus 1.29 ± 0.04 mmol/l, p = 0.017) and ALP activity (113 ± 61 versus 75 ± 19 u/l, p = 0.021). Serum vitamin D in both groups reduced in equal measures – 14 ± 4 and 15 ± 6 ng/ml.Conclusion.Persistent HPT in the long-term post-transplant period reaches 48.5%. Risk factors for its development included dialysis for more than 18 months, pre-operative secondary HPT, repeated kidney transplantation, delayed graft function, and eGFR &lt;60 ml/min.

SAT-387 Testing for Parathyroid Hormone: Performances of a Novel Fully Chemiluminescent Automated Assay

Background: Parathyroid hormone (PTH) is one of the key regulators of the bone and mineral metabolism. Testing for PTH is essential for the management of hyper- or hypo calcemia. Measurement of PTH is also an important tool for the monitoring of patient with chronic kidney diseases. Our study objective was to determine the performances of a novel fully automated chemiluminescent assay for testing of intact PTH. Methods: We evaluated the Maglumi® (Snibe) PTH assay a fully automated two-sites immunoluminometric method based on a solid-phase, paramagnetic microbeads, coated with a monoclonal antibody targeting PTH epitopes. Assay imprecision was assessed with two levels of control materials. Reference values were determined with samples of 24 healthy volunteers. Method comparison was performed with an electrochemiluminescent immunoassay (ECLIA) (Roche diagnostics) with 24 patients’ samples. Results: The between-run coefficients of variation of the Maglumi® PTH assay were 5.1 and 3.7 % for concentrations of 33 and 992 pg/mL, respectively. The median PTH levels were 121 pg/mL (range: 18 - 369) with the Maglumi assay and 117 pg/mL with the ECLIA method (range: 10 - 482). The upper limit of the reference interval in the healthy volunteers was 63 pg/mL. The correlation between the both methods was good (r=0.87, p<0,001). Passing-Bablok regression analysis showed a slope of 0.96 (95% confidence interval (CI): 0.83 to 1.35) and an intercept of -2.14 (95% CI: -20.49 to -10.47). Bland-Altman plot evidenced a bias between the methods with a mean bias of 4.6 pg/mL. Conclusions: Our preliminary data showed excellent concordance and analytical performances for the PTH fully automated immunoassay associated to perspectives of automation and reduction of turn-around time of analysis.

Perioperative Nursing of Patients with Reoperation of Recurrent Parathyroid Carcinoma Invading the Upper Digestive or Respiratory Tract.

Objective The aim of this study was to summarize the perioperative nursing care of patients with recurrent parathyroid carcinoma. Methods A retrospective analysis of 10 patients with recurrent parathyroid carcinoma was performed. The clinical data, diagnosis, treatment process, and nursing process (including clinical nursing intervention of various complications) were analyzed. The nursing experience and methods were discussed, summarized, and analyzed. Results A total of 10 patients were reviewed (male : female 7 : 3; aged 48.6 ± 14.60 years). The mean interval between the initial operation and reoperation was 2.23 ± 1.65 years. The mean number of operations was 4.00 ± 1.41. Invasion of the trachea or esophagus was evident in 7 patients, larynx in 6 patients, recurrent laryngeal nerve in 1 patient, and cyclic cartilage in 2 patients. Serum calcium range was 3.20–4.68 mmol/L, and parathyroid hormone (PTH) range was 860–2830 pg/ml at admission. 6 patients underwent prophylactic tracheostomy, 2 patients underwent partial laryngectomy, and 2 patients underwent total laryngectomy. 1 patient experienced temporary water-electrolyte disorder and hypoproteinemia. The median serum calcium was 2.28 mmol/L (1.66–3.18 mmol/L) and median PTH level was 82.60 pg/ml (63.70–900.00 pg/ml) postoperatively. Serum PTH and calcium were still higher than the upper limit of normal in 2 patients after surgery. 2 of the other 8 patients relapsed within 8–11 months, and 6 patients remained normal for 11–40 months. Conclusion For patients with reoperation of recurrent parathyroid carcinoma, high-quality, reasonable, and careful perioperative nursing ensured a successful operation and optimized outcome.

The Australian Calciphylaxis Registry: reporting clinical features and outcomes of patients with calciphylaxis.

Calciphylaxis is a rare disease, predominantly affecting patients with chronic kidney disease (CKD) and associated with significant morbidity and mortality due to progressive cutaneous calcification, necrotic ulceration and infection. Clinical registries have been established to better understand the risk factors, optimal treatments and disease outcomes of calciphylaxis. We established a prospective, Internet-based clinical registry for the online notification of calciphylaxis cases in Australia. Seven institutions participated, with data recorded on patient characteristics, biochemical parameters, treatments and disease outcomes. Between 2014 and 2019, 47 cases of calciphylaxis were registered. The mean patient age was 66 ± 11 years and body mass index was 35 ± 9 kg/m2, with a higher proportion of females (51%). Eighty-seven percent of patients had end-stage kidney disease (ESKD), with 61% on hemodialysis or hemodiafiltration, with a median dialysis vintage of 4.8 [interquartile range (IQR) 1.7-7.4)] years. Five patients had CKD not requiring dialysis and two were kidney transplant recipients. Diabetes was present in 76% of patients and the cause of ESKD in 60%; 34% received vitamin K antagonists (VKAs) before diagnosis. The median parathyroid hormone level at diagnosis was 32 (IQR 14-50) pmol/L. The most common site of calciphylaxis was the lower limbs (63%), with 19% of patients having more than one area involved. Ten patients (22%) had a resolution of calciphylaxis and 25 died, with 50% mortality at a median of 1.6 (IQR 0.2-2.5) years from diagnosis. The Australian Calciphylaxis Registry highlights risk factors for calciphylaxis, including diabetes, obesity and VKA use. Resolution of calciphylaxis is uncommon despite multimodal therapy and mortality from calciphylaxis in the first year following diagnosis remains high.

SAT-536 Vitamin D Status in an Ambulatory Cohort of Women undergoing Screening Mammography

INTRODUCTION: Controversy exists over possible ethnic differences in 25-OH-vitamin D (25OHD) levels among healthy individuals, such as blacks having lower levels than whites. The extent to which these possible differences reflect physiologic deficiency is unclear. We utilized data from women undergoing routine mammography and measures of mineral metabolism to examine 25OHD levels and its relationship to parathyroid hormone (PTH) levels by race/ethnicity. METHODS: Data were obtained from an observational cohort study examining breast arterial calcification in women aged 60-79 years where laboratory measures also included calcium, PTH, 25OHD, and creatinine to estimate glomerular filtration rate (eGFR). For this study, we identified women without hypercalcemia (Ca >10.3) and free of chronic kidney disease (eGFR<60). Analyses included the distribution of 25OHD level and whether low 25OHD was associated with higher PTH. Sensitivity analyses were conducted excluding those with use of calcium (>3x/week) or vitamin D (>1x/week) supplements because of the potential impact of supplement use on 25OHD level. RESULTS: Among 3544 women (62.2% white, 11.0% black, 10.0% Hispanic, 15.4% Asian, 1.4% other/unknown), 25OHD varied by race/ethnicity, with mean ± SD and median (interquartile range, IQR) values as follows: white 37.5 ± 12.7 and 36 (IQR 30-44); black 29.8 ± 12.7 and 30 (IQR 20-38); Hispanic 32.1 ± 11.5 and 30 (24-39); and Asian 35.0 ± 12.0 and 34 (27-42) ng/mL. The proportion of women with 25OHD <20 ng/mL also varied by race/ethnicity: white (5.4%), black (24.0%), Hispanic (11.6%) and Asian (7.9%). The median PTH level for these same subgroups with low 25OHD level were: white 46 (IQR 34-63), black 62 (46-79), Hispanic 43 (30-61), and Asian 41 (36-59) pg/mL (p<0.01 for black vs each of the other race/ethnicities). When restricted to the 1277 women without regular use of calcium or vitamin D supplements, (57.7% white, 15.1% black, 11.9% Hispanic, 13.5% Asian, 1.8% other/unknown), 25OHD mean ± SD and median (IQR) values were somewhat lower: white 30.5 ± 10.1 and 30 (IQR 24-36); black 24.0 ± 10.8; 23 (IQR 15-31), Hispanic 25.8 ± 9.3 and 25 (19-31); and Asian 27.0 ± 9.5 and 26 (20-33) ng/mL. Among these 1277 women, the proportions with 25OHD <20 ng/mL were: white (13.4%), black (39.4%), Hispanic (25.7%) and Asian (22.7%). The median PTH level for these subgroups with low 25OHD level were: white 45 (IQR 33-61), black 61 (45-81), Hispanic 43 (30-61) and Asian 41 (38-60) pg/mL (p<0.01 for black vs each of the other race/ethnicities). CONCLUSIONS: Compared to white women, black and Hispanic women have about 20% lower 25OHD levels. Compared to white, black women also have significantly higher PTH (about one-third higher) when 25OHD is low. We hypothesize that in black women (with lower 25OHD level), PTH elevation maintains adequate mineral balance and may contribute to their greater skeletal mass.

Bone Mineral Density and Bone Remodeling in Tunisian Patients with Inflammatory Bowel Disease

Background:A high prevalence of osteopenia and osteoporosis is observed in patients with Inflammatory Bowel Disease (IBD).Objective:The aim of our study was to investigate the prevalence of bone loss, bone remodeling and risk factors in Tunisian patient with IBD.Patients and Methods:The study included 40 patients with IBD and 32 age- and sex-matched healthy controls subjects. All participants underwent bone densitometry by dual energy X-ray absorptiometry at the femoral neck and lumbar spine. Serum levels of 25-hydroxy vitamin D (25(OH)D), parathyroid hormone (PTH), osteocalcin(OC), and urinary degradation products of C-terminal telopeptide of type I collagen (CTXI) were measured in all participants to assess the bone metabolism status.Results:Twelve (30%) patients were normal, 32.5% were osteopenic and 37.5% were osteoporotic. Osteoporosis was more frequent in IBD patients than controls (p=0.0001). Age and inflammation were associated with low bone mineral density (BMD). Mean calcium, phosphorus and alkaline phosphatase levels were similar in both groups. Median 25(OH) D levels were significantly lower in IBD patients compared with controls (p=0.0001). Median urinary CTXI levels were significantly higher in IBD patients compared with healthy controls (p=0.007). No significant differences between IBD patients and controls concerning the median serum OC and PTH levels were found.Conclusion:In our study, there is a high prevalence of low BMD in IBD patients and an increase in bone resorption without a change of bone formation. Low BMI and hypovitaminoses D were identified as risk factors for low BMD.

Sequential vitamin D and parathyroid hormone measurement in patients with septic shock: Could they be prognostic marker in septic shock

Aim: Hypocalcemia is a common clinical problem in critically-ill patients and it is associated with increased morbidity and mortality. The aim of this study was to investigate serum calcium, vitamin D and parathyroid hormone (PTH) levels in surviving and non-surviving septic shock patients Method: Patients with septic shock criteria and who were older than 18 years of age were included, whereas patients with diseases influencing calcium homeostasis were excluded. Demographic and laboratory parameters were recorded prospectively. Results: 41 patients, 20 of which were male were included in the study. The median (min-max) age of study population was 67 (19-88) years. Frequency of hypocalcemia in the study population was 29.2% and 68.2% according to corrected calcium and ionized calcium, respectively. On the day septic shock was diagnosed (day 1), median vitamin D levels of survivors and non-survivors were 8.7 ng/ml (4.3-30.4) and 5.3 ng/ml (1.0-21.7), respectively (p=0.05). On the same day, median PTH levels of survivors and non-survivors were 94 ng/L (16.9-1746) and 49 ng/L (6.6-339), respectively (p=0.042). Although vitamin D levels were suppressed and PTH levels were elevated in non-survivors at day 5, this change was not statistically significant (p=0.19 and p=0.187). Conclusion: Hypocalcemia is frequent in septic shock patients, whereas vitamin D levels were low and PTH levels were high in the diagnosis day. These results suggest that vitamin D is suppressed by septic shock at non-surviving patients during course of septic shock. Parathyroid hormone may be a marker for worse outcome in critically ill patients.

The Results of PArathyroid Hormone Assay in Parathyroid Aspirates in Pre-Operative Localization of Parathyroid Adenomas for Focused Parathyroidectomy in Patients With Negative or Suspicious Technetium-99M-Sestamibi Scans

This study aimed to evaluate the results of parathyroid hormone (PTH) assay in parathyroid aspirates to determine uniglandular disease by an endocrinologist-performed ultrasound (US) in patients with discordant or negative technetium-sestamibi scans and to evaluate whether this procedure increases the number of focused parathyroidectomies (FPs). We analyzed the data of 65 patients who underwent an endocrinologist-performed US-guided parathyroid fine-needle aspiration (FNA) with PTH wash-out, retrospectively. The results of PTH wash-out procedure and the reports of parathyroid surgery and pathology were reviewed. Of 65 patients, 54 had positive PTH wash-out results. The median serum PTH level of patients with positive and negative PTH wash-out results was 143 (25 and 75% interquartile range [IQR], 114 to 197) versus 154 (IQR, 115 to 255) pg/mL (P = .45), and the median PTH in FNA was 3,533 (IQR, 1,481 to 3,534) versus 6.0 (IQR, 1 to 6) pg/mL (P<.001), respectively. Forty-five patients underwent surgery. Of the operated patients, 42 had positive PTH wash-out results and had successful FP. Four patients with redo surgery had positive PTH wash-out results and were successfully re-operated with FP. Of 11 patients with negative PTH wash-out results, 3 had bilateral neck exploration (BNE) surgery and 2 patients were successfully operated, while surgery was unsuccessful in 1 patient, despite BNE. Our study results suggest that endocrinologist-performed US and parathyroid FNA with PTH wash-out increases the number and success of FPs. In particular, patients with redo surgery may benefit from this procedure. 4D-CT = four-dimensional computed tomography BNE = bilateral neck exploration FNA = fine-needle aspiration FNAB = fine-needle aspiration biopsy FP = focused parathyroidectomy IQR = 25 and 75% inter-quartile range PHPT = primary hyperparathyroidism PPV = positive predictive value PTH = parathyroid hormone 99mTc = technetium US = ultrasound.

56 High serum parathyroid hormone level is independently associated with carotid intima-media thickness in older patients undergoing invasive management of non-st elevation myocardial infarction

IntroductionSerum parathyroid hormone (PTH) levels, which are intimately linked to vitamin D status, are associated with an increased risk of cardiovascular events and mortality and may directly influence atherogenesis. Elevated...