PTH Values Research Articles

SAT-367 A Case Series: Discovery of Parathyroid Carcinoma During Parathyroidectomy for Primary Hyperparathyroidism

Introduction: Parathyroid carcinoma is rare and represents <1% of patients diagnosed with hyperparathyroidism (1).Clinical Cases: We present two cases of incidentally diagnosed parathyroid carcinoma during parathyroidectomy for primary hyperparathyroidism.A 69-year-old female was referred for hypercalcemia of 10.7 mg/dL (normal range 8.4-10.2). She had bone pain, fatigue, and mild depression. She was taking triamterene-hydrochlorothiazide, vitamin D 2000 international units daily, and 1 caltrate daily. Her thiazide diuretic was discontinued, and a repeat calcium was 9.5 mg/dL with a PTH of 79 pg/mL (normal range 14-64). Vitamin D and renal function were normal. A 24 hour urine calcium was elevated at 706 mg/24 hours (normal range 100-321). A bone density revealed osteopenia.Based on the high urine calcium, a thyroid ultrasound was completed and showed an enlarged right parathyroid gland. Intraoperatively, the surgeon found a superior parathyroid gland adherent to the local soft tissues with recurrent laryngeal nerve entrapment. The right superior parathyroid and right thyroid lobe were resected. Pathology demonstrated an infiltrating parathyroid carcinoma. Postoperative monitoring has included: calcium, creatinine, PTH and neck ultrasound every six months without evidence of recurrence.A 79-year-old man was referred for an approximate 18-month history of hypercalcemia. He had a prior kidney stone and constipation. He was not on calcium supplementations or thiazides. On lab testing calcium was 11.0 mg/dl with prior levels of 11.7 mg/dl. PTH was 246 pg/ml and vitamin D was 20.1 ng/ml (normal range 30-80). Imaging was obtained for parathyroid localization. A neck ultrasound and nuclear medicine study showed a right inferior parathyroid adenoma. A bone density revealed osteoporosis. Intraoperatively, the surgeon found a bilobed parathyroid extending intrathyroidal and adherent to the recurrent laryngeal nerve. The right inferior parathyroid, right thyroid lobe, and isthmus were resected. Pathology was consistent with parathyroid carcinoma. The patient had recurrent laryngeal nerve damage with persistent hoarseness postoperatively.Clinical Lessons: Patients with parathyroid carcinoma typically present with symptomatic hypercalcemia with mean levels of 13.5-14 mg/dL and mean PTH values 8.7 times the upper limit of normal (1). Given the rarity of the condition, there are no guidelines for surveillance (1). These cases highlight atypical, mild, and early presentations of an unusual and typically aggressive disease and serve as an example of how to monitor for recurrence.Reference: 1- Stack BC, Bodenner DL. Medical and Surgical Treatment of Parathyroid Diseases An Evidence-Based Approach. Switzerland: Springer, Cham; 2017.http://link.springer.com/chapter/10.1007/978-3-319-26794-4_31#enumeration. Accessed November 3, 2019.

SAT-354 Isolated Hypoparathyroidism: A Rare Initial Manifestation of Hereditary Hemochromatosis (HH)

Background:We present a case of hypoparathyroidism diagnosed in a patient as initial manifestation of hereditary hemochromatosis. As per our literature search, it is very rarely reported as an isolated abnormality in HH.Case:A 27 year old male with history of seizure disorder, well controlled on Oxcarbazepine, referred for evaluation of chronic hypocalcemia. His PMH includes cerebral palsy, with good functional capacity and mild cognitive impairment. He denied muscle spasm, perioral numbness, bone pain, muscle weakness or fracture. He was taking calcium carbonate 600mg bid and vitamin D 50,000 IU q2monthly.There was no family history of any Ca disorders. Physical exam was unremarkable.Laboratory evaluation revealed Ca levels ranging from 7.6 to 8.5mg/dl with intact PTH values ranging from 11 to 22pg/ml. His ionized calcium was also low. Patient’s 24 hr urinary Ca was 122mg/24hrs. In this case, he did initially have hypomagnesemia and vitamin d deficiency, which could potentially explain low calcium. But even after supplementing Vitamin D and Mg, patient’s Ca remained low. His kidney function was normal. Hemoglobin was in range of 14-15g/dl. To further evaluate the cause of hypoparathyroidism, iron saturation and iron levels were also sent. His iron saturation % was high at 89% with iron level of 286 ug/dl. His ferritin was 224 ng/ml and TIBC was 265 ug/dl. A sample was sent for genetic analysis to rule out hemochromatosis. Homozygous mutations in C282Y gene were found. A diagnosis of hereditary hemochromatosis was made. His other entire hormonal axis was intact. In this case, patient’s hypoparathyroidism is likely an initial manifestation of his HH.Discussion:Hereditary Hemochromatosis (HH) is a genetic disease characterized by an excessive (unregulated) entry of iron into the bloodstream with increased iron deposition in the parenchymal cells of a variety of organs leading to their failure. A defect in the hemochromatosis gene (HFE) is the most common form of HH, also known as the classic form or type 1 HH, where the principal mutation is represented by a substitution of tyrosine for cysteine at position 282 of the HFE gene (C282Y) as seen in our case. According to the genetic forms, the clinical manifestation usually ranges from simple biochemical abnormalities to severe organ damage and disease such as liver cirrhosis, arthritis, DM, cardiomyopathy and hypogonadism.There are reports of hypoparathyroidism from iron overload seen in thalassemia patients and patients who receive long term blood transfusions. In our literature review, this is the first documented case of HH initially manifesting as hypoparathyroidism. As HH is not uncommon in Caucasians, the work up for hemochromatosis as a possible cause of endocrinopathies should be kept in the differential diagnosis. It will help in early diagnosis & treatment which can reverse the effects of the disease leading to better outcomes.

Correlation between biochemical parameters and 99 Tc m -MIBI SPECT/CT imaging in patients with hyperparathyropathy

Objective To explored the correlation between levels of serum calcium, phosphorus PTH and 99Tc m-MIBI in patients with hyperparathyropathy as well as to find cut off valve of serum calcium, phosphorus and PTH. Methods A total of 234 patients with hyperparathyroidism that confirmed by operation and pathology were collected from September 2017 to September 2019. Results The median PTH levels in PHPT group and SHPT group were 210.93 (122.60~529.20) pg/ml and 1 842.50 (1 342.50~2 345.00) pg/ml, respectively. There was significant difference between the two groups ( Z = −10.83, P = 0.000). SHPT group was significantly higher than that in PHPT group. The median of Ca level of PHPT group and SHPT group was 2.86 (2.65~3.15) mmol/L and 2.43 (2.32~2.58) mmol/L, respectively. There was significant difference between the two groups ( Z = −7.52, P = 0.000). The level of Ca in PHPT group was significantly higher than that in SHPT group. The median of P level in PHPT group and SHPT group was 0.80 (0.64~1.03) mmol/L and 2.26 (1.97~2.63) mmol/L respectively. There was significant difference between the two groups ( Z = −10.15, P = 0.000), and the PHPT group was significantly lower than the SHPT group. The age, gender, PTH and Ca and P value were taken as independent variables, and the results of MIBI imaging were used as dependent for logistic regression analysis. After screening, the influencing factor of PHPT group was PTH value ( OR: 1.012, 95% CI: 1.002~1.023), and correlation analysis showed that r = 0.60 ( P = 0.000). No related factors were found in SHPT group. ROC curves of 99Tc m-MIBI imaging results in PHPT group were drawn, corresponding to the areas under the maximum curve of 0.91, and the calculated cutoff value was 113.1 pg/mL. simple scatter plot of Ca value, P value and PTH value was drawn in PHPT group and SHPT group, and correlation analysis was performed. Tn PHPT group, Ca value and PTH value had moderate correlation ( r = 0.64, P = 0.000), P value and PTH value had low correlation ( r = −0.28, P = 0.032); in SHPT group: Ca value and PTH value had low correlation ( r = 0.17, P = 0.03), P value and PTH value had no correlation ( P = 0.15). Conclusion The serum PTH level of PHPT was moderately correlated with MIBI imaging results. The higher the serum PTH level, the higher the positive rate of MIBI imaging, and the corresponding cutoff value of MIBI imaging was 113.1 pg/mL. There was a moderate correlation between serum Ca level and serum PTH level in PHPT, while in SHPT group low correlation between serum Ca level and serum PTH level. 摘要： 目的 探讨甲状旁腺功能亢进症患者血清钙、磷、甲状旁腺激素 (PTH) 水平与 99Tc m-MIBI 显像的相关性, 计算 血清钙、磷和 PTH 的 Cut-off 值。 方法 回顾性分析 2017 年 9 月一2019 年 9 月经手术病理学确诊的甲状旁腺功能亢 进患者 234 例, 所有患者均于术前行甲氧基异丁基异腈 (MIBI) 显像和血清 PTH、钙、磷等生化检查。 结果 原发性 (PHPT) 和继发性 (SHPT) 甲状旁腺功能亢进者 PTH 水平中位数分别为 210.93(122.60~529.20) pg/mL 和 1 842.50 (1 342.50~2 345.00) pg/mL, 两组间差异有统计学意义 ( Z = −10.83, P = 0.000), SHPT 组显著高于 PHPT 组。PHPT 组和 SHPT 组血清钙水平中位数分别为 2.86(2.65~3.15) mmoL/L 和 2.43(2.32~2.58) mmoL/L, 两组间差异有统计学 意义 ( Z = −7.52, P = 0.000), PHPT 组显著高于 SHPT 组。PHPT 组和 SHPT 组血清磷水平中位数分别为 0.80(0.64~ 1.03) mmoL/L 和 2.26(1.97~2.63) mmoL/L, 两组间差异有统计学意义 ( Z = −10.15, P = 0.000), PHPT 组显著低于 SHPT 组。将年龄、性别、PTH 值、钙值、磷值作为自变量, MIBI 显像结果作为应变量, Logistic 回归分析得出 PTH 值 为 PHPT 组的影响因素 ( OR: 1.012, 95% CI: 1.002~1.023), 相关性分析得出 r = 0.60 ( P = 0.000); SHPT 组无相关因 素。绘制 PHPT 组 99Tc m-MIBI 影像显像结果 ROC 曲线, 对应最大曲线下面积 0.91, 计算 Cut-off 值为 113.1 pg/mL。 绘制 PHPT 组和 SHPT 组钙值、磷值与 PTH 值散点图, 相关性分析得出 PHPT 组：钙值与 PTH 值具有中度相关 ( r = 0.64, P = 0.000), 磷值与 PTH 值具有低度相关 ( r = −0.28, P = 0.032); SHPT 组:钙值与 PTH 值具有低度相关 ( r = 0.17, P = 0.03), 磷值与 PTH 值无相关性 ( P = 0.15)。 结论 PHPT 组血清 PTH 水平与 MIBI 显像结果具有中度相关 性, 血清 PTH 水平越高 MIBI 显像阳性率越高, MIBI 显像对应的分界值为 113.1 pg/ml。PHPT 组血清Ca水平与血清 PTH 水平具有中度相关性, 而 SHPT 组血清 Ca 水平与血清 PTH 水平具有低度相关性。

Parathormone Levels in a Middle-Eastern Healthy Population Using 2nd and 3rd Generation PTH Assays.

Background The purpose of the current study is to determine PTH reference values in vitamin-D-replete Lebanese adults using 2nd and 3rd generation PTH assays and to look at the factors that affect PTH variations. Methods Fasting PTH was measured using 2nd and 3rd generation Diasorin PTH assays in 339 vitamin-D-replete healthy subjects aged 18 to 63 years (230 men and 109 women) who have normal calcium levels and an eGFR ≥60 ml/mn. 25-OH vitamin D (25(OH)D) was measured using the Diasorin assay. Results For the 2nd PTH generation, median (IQR) levels were 48.9 (34.9–66.0) pg/ml, and its 2.5th–97.5th percentile values were 19.7–110.5 pg/ml for 25(OH)D values between 20 and 30 ng/ml, and 19.7–110.7 pg/ml for 25(OH)D values ≥30 ng/ml. For the 3rd PTH generation, the median (IQR) values were 23.9 (17.7–30.5) pg/ml, and its 2.5th–97.5th percentile values were, respectively, 9.2 and 50.2 pg/ml for 25(OH)D values between 20 and 30 ng/ml, and 8.4 and 45.4 pg/ml for 25(OH)D values ≥30 ng/ml. The median (IQR) serum 25(OH)D levels were 27.5 (23.8–32.7) ng/ml. 2nd and 3rd generation PTH values are strongly correlated (r = 0.96, p < 0.0001), but poorly concordant (Lin's concordance coefficient 0.365, 95% CI: 0.328–0.401) with observations beyond the 95% Bland–Altman limits of agreement. 2nd and 3rd generation PTH levels did not differ according to gender and were significantly correlated with age but not with 25(OH)D and serum calcium levels. Conclusion Lebanese adult healthy subjects have higher 2nd and 3rd generation PTH levels compared with the reference range provided by the manufacturer. The reference range was not influenced by changing the 25(OH)D cutoff. The clinical significance of the higher PTH levels in our population should be investigated.

"Intraoperative parathyroid hormone assay in patients with primary hyperparathyroidism"

Introduction: Currently, parathyroidectomy represents the elective surgical treatment and the only one curative that relieves the patient of metabolic complications and improves the quality of life of the patient. Intraoperative confirmation of PTH is required to reflect the fact that the correct parathyroid gland has been extracted. Material and method: The study is retrospective. The period on which the data was gathered over a period of 2 years. The values of the PTH assay were obtained from blood drawn from the ipsilateral cephalic vein of the hyperproductive parathyroid gland: 1. at the moment of anesthesia induction; 2. at identification; 3. at 10 minutes after the extraction; 4. at 20 minutes after extraction. Results: We identified a number of 25 patients operated for primary hyperparathyroidism. Preoperative values of PTH were 380pg/mL with a maximum value of 821 pg/mL. PTH values decreased by 55% at 5 min, 68% at 10 minutes and 74% at 15 minutes. A marked reduction in PTH values occurred after the first 5 minutes while the interval between 10-15minutes associated a variation of only 8-10% decrease. Conclusion: Intraoperative PTH assay is a useful technique to predict the success of the intervention. The technique is standard although some issues have been raised and are still under discussion.

Vitamin D nutritional status in the adult population in Colombia – An analytical cross-sectional study

BackgroundThe key role of Vitamin D is to maintain an adequate calcium and phosphorus metabolism. Vitamin D plays an antagonistic role with the parathyroid hormone. 25 OH Vitamin D is the major circulating form and the best indicator to monitor Vitamin D levels. MethodsA cross-sectional study was conducted in 1339 individuals ≥18 years old. The main objective was to establish the nutritional status of Vitamin D and its association with PTH and ionized calcium levels. Other objectives were to compare the levels of 25 OH Vitamin D based on sun exposure habits, and to identify the minimum cut-off point for the levels of 25 OH Vitamin D that could give rise to a concomitant increase in PTH and ionized calcium levels. Results14.2% of participants presented Vitamin D deficiency, and 28.8% presented insufficiency; ≥89% of the participants with deficiency or insufficiency were exposed to sunlight <30 minutes per week. A value of 25 OH Vitamin D >30 ng/mL was associated with a more stable and “flat” PTH value. The median of 25 OH Vit-D associated with hypercalcemia was <10 ng/mL. ConclusionIn Colombia, low 25 OH Vitamin D values are highly prevalent; this may be accounted for by poor sun-exposure habits and frequent use of sunscreen. Just as in other similar trials, the lower the levels of 25 OH Vit-D, the higher the effect on PTH and ionized calcium elevation.

A Comparative Study of Vitamin D Levels and Some Biochemical Parameters between Healthy and Breast Cancer in Iraqi Females

Breast cancer is one of the most widespread cancers,depending on World Health Organization, cancer calculated for approximately 7.6 million incidences in 2008, whoever expected elevation in incidence is about 13.1 million in 2030. So that the current research investigates vitamin D role in the occurrence of this disease and explains if vitamin D has a positive effect on the incidence of disease, as well as measuring parathyroid hormone and estrogen levels. Three groups were included in this analysis: control healthy women, benign and malignant breast tumor women. All cases that were selected at the beginning of the disease diagnosis. According to statistical values vitamin D showed highly significant (P&lt;0.001) decrease in benign (3.74±2.33) ng/ml and malignant (4.38±3.12) ng/ml tumor patients compared with healthy group (24.96±7.24) ng/ml. Also a high significant increase was shown for PTH values in benign (208.37±132.5) pg/ml and malignant (133.9±60.02)pg/ml tumor patients compared with healthy group (67.04±25.6) pg/ ml. Furthermore, results revealed non-significant difference in estrogen levels between benign group (54.11±22.93) pg/ml, and control group (64.85±22.18)pg/ml, while there were a significant difference in levels of estrogen between control and malignant tumor groups (52.4±18. 09) pg/ml. As a results, we found that all patients had sever vitamin D deficiency compared with healthy group, as well as high levels of parathyroid hormone as evidence of vitamin D deficiency, while estrogen levels where within normal levels. We concluded that all patient groups were suffering from vitamin D deficiency and elevation in parathyroid hormone that gives evidence of the role of vitamin D as anti-cancer agent.

Evaluation of Serum parathyroid hormone level measurement in total thyroidectomy patients

Background: Postoperative hypoparathyroidism is a common complication after total thyroidectomy. It is necessary to diagnose hypoparathyroidism immediately after total thyroidectomy for minimizing complications.&#x0D; Objective: The objective of this study was to measure and to evaluate the serum parathyroid hormone level in total thyroidectomy patients.&#x0D; Methods: This prospective observational study was carried out in the Department of Clinical Pathology in collaboration with Department of Surgery &amp; Department of Otolaryngology of BSMMU and Department of Otolaryngology of DMCH, Dhaka, during the period of September 2010 to August 2011.&#x0D; Results: Total 65 patients were studied irrespective of age and sex. Decreased serum PTH was found in 9 cases and normal parathyroid hormone was found in 56 cases. Male was 16.0% and female was 84.0%. Females were predominant. The incidence of hypoparathyroidism was 41.5%. Asymptomatic hypoparathyroidism was found in 8 and symptomatic hypoparathyroidism was found in 1 cases. Decreased serum PTH was developed mostly in malignant thyroid diseases. In relation to preoperative PTH values, intraoperative PTH levels were lower from 5.48% to 90.0%, (mean±SD in percentage is 65.3±16.7, p=.001) which is significant in paired t test. The mean difference of intraoperative (20 minutes after total thyroidectomy), parathyroid hormone levels were statistically significant (p&lt;0.05) between patient with decreased parathyroid hormone and patient with normal parathyroid hormone in unpaired t-test.&#x0D; Conclusion: Serum parathyroid hormone level significantly decreased 20 minutes after total thyroidectomy. If clinical sign symptoms of hypoparathyroidism are not developed in postoperative period, patient is safe and can be discharged from hospital.&#x0D; Bangladesh J Otorhinolaryngol; April 2017; 23(1): 5-10

Management of polycythemia vera by endoscopic parathyroidectomy

Polycythemia vera (PV) is a hemotologic disease. Majority of persons with PV, essential thrombocythemia and primary myelofibrosis show the Janus kinase (JAK) 2 gene– which is needed for the normal development of blood cells. PV is generally controlled with medication: hydroxyurea or pipobroman. Phlebotomy is the mainstay of therapy for PV. Association between hyperparathyroidism and PV has been very sparingly considered. Primary hyperparathyroidism may produce a growth factor, which induces pancytosis, especially in the presence of high levels of ionized calcium. It is found that parathyroid hormone levels (PTH) could influence hemopoiesis through a direct action on hemopoietic precursors. A 52-year-old female presented with complaints of fever associated with headache and generalized weakness. On evaluation, her hemoglobin value was found to be high (Hb– 18.8 g/dl) with leukocytosis. She was evaluated for polycythemia, which showed JAK-2 mutation positivity. She was started on Enteric Coated Aspirin. She was managed initially with twice-weekly venesection to keep packed cell volume <45. It was observed that she was having very high PTH– 569.9 pg/ml and low Vitamin D levels– 8.41 mg/ml. She underwent a Technetium 99M Sestamibi Scan (TcMIBI), which showed a large adenoma involving the left inferior parathyroid gland. She was taken up for endoscopic parathyroid removal through the left axillo-breast approach. Intraoperatively, PTH value had dropped from 569.9 pg/ml to 62 pg/ml. Hemoglobin level decreased to normalcy by the 2nd week of surgery without any medication or venesection. Patients with polycythemia must be screened for hyperparathyroidism. Early treatment of hyperparathyroidism by parathyroid removal will take care of polycythemia as well. Endoscopic parathyroidectomy is very feasible, safe, and well accepted by patients.

Treatment of hyperphosphatemia: the dangers of aiming for normal PTH levels.

Secondary hyperparathyroidism is part of the complex of chronic kidney disease-associated mineral and bone disorders (CKD-MBD) and is linked with high bone turnover, ectopic calcification, and increased cardiovascular mortality. Therefore, measures for CKD-MBD aim at lowering PTH levels, but there is no general consensus on optimal PTH target values. This manuscript is part of a pros and cons debate for keeping PTH levels within the normal range in children with CKD, focusing on the cons. We conclude that a modest increase in PTH most likely represents an appropriate adaptive response to declining kidney function in patients with CKD stages 2-5D, due to phosphaturic effects and increasing bone resistance. There is no evidence for strictly keeping PTH levels within the normal range in CKD patients with respect to bone health and cardiovascular outcome. In addition, the potentially adverse effects of PTH-lowering measures, such as active vitamin D and calcimimetics, must be taken into account. We suggest that PTH values of 1-2 times the upper normal limit (ULN) may be acceptable in children with CKD stage 2-3, and that PTH levels of 1.7-5 times UNL may be optimal in patients with CKD stage 4-5D. However, standard care of CKD-MBD in children relies on a combination of different measures in which the observation of PTH levels is only a small part of, and trends in PTH levels rather than absolute target values should determine treatment decisions in patients with CKD as recommended by the 2017 KDIGO guidelines.

Association between inflammatory markers and primary hyperparathyroidism

Aim: Primary hyperparathyroidism (PHP) is associated with systemic inflam-mation. The effect of parathyroidectomy (PTX) on inflammatory markers is contro-versial. The aim of our study was to investigate changes in inflammatory markers including C-reactive protein (hs-CRP), platelet-to-lymphocyte ratio (PLR), and red cell distribution width (RDW) before and after PTX. Patients and Methods: PHP patients (n=55) and age and sex matched healthy controls (n=50) were included in the study. The clinical and laboratory results of the PHP and control groups were compared before PTX and 6-months after PTX.Results: At baseline, serum hs-CRP (4.01±3.44 vs. 2.48±1.73 mg/L), PLR (127.21±25.77 vs. 103.63±32.52), RDW (15.50±2.53 % vs. 13.49±0.70 %) values were higher in the PHP group than in the control group (p&amp;lt;0.05). After PTX, hs-CRP (3.59±3.07 mg/L), PLR (123.03±31.94), RDW (14.25±1.51 %) values did not change (p&amp;gt;0.05). Post-PTX hs-CRP, PLR, and RDW values were higher in the PHP group than in the control group (p&amp;lt;0.05). PTH value was positively correlated with pre-PTX hs-CRP (r2=0.377, p=0.001), PLR (r2=0.234, p=0.023), RDW (r2=0.296, p=0.004).Conclusion: Before PTX, inflammatory markers were higher in PHP patients com-pared with healthy controls. After PTX, the inflammatory markers did not significantly decrease; however these postoperative markers were higher than controls. İnflam-mation occurs in PHP patients, and also shows a partial recovery from inflammation despite successful surgery.

Differences in primary hyperparathyroidism characteristics between children and adolescents

BackgroundIn children and adolescents, primary hyperparathyroidism (pHPT) is rare, associated with severe morbidity, and has different clinical characteristics than in adults. The aim of this study was to analyze differences in clinical and laboratory characteristics between children and adolescents with pHPT. MethodsA retrospective cohort study was conducted to analyze pHPT characteristics in young patients, who have been operated at our institution. All patients were divided into two groups: group of patients ≤15 years (children) and group of patients >15 and ≤20 years (adolescents). ResultsOut of 1363 pHPT patients surgically treated during the study period, 14 patients (1%) were younger than 20 years: 6 children and 8 adolescents. Male-to-female ratio in children was 2:1, and in adolescents 1:1.7. Kidney stones were found in 62.5% of the adolescents and in none of the children patients. Bone form of the disease was the most frequent in children (in 83.1%), while in adolescents the kidney form was the most frequent (in 50%). Only 16.7% of children and 25% of adolescents did not have classical symptoms. All adolescent patients had single parathyroid adenoma, while 4 children patients had single parathyroid adenoma, one patient had hyperplasia, and one had parathyroid carcinoma. Both preoperative serum calcium and PTH levels were higher in children than in adolescents (3.87 mmol/L vs. 3.17 mmol/L; 812 ng/mL vs. 392 ng/mL, respectively). In all patients vitamin D level was low. All patients had normal postoperative values of serum calcium and PTH. ConclusionThere is a significant difference in clinical and biochemical characteristics between children and adolescent pHPT patients. Therefore, these two groups should be analyzed and treated separately. Type of StudyRetrospective comparative study. Level of EvidenceLevel III.

The Impact of Smoking on Bone Metabolism, Bone Mineral Density and Vertebral Fractures in Postmenopausal Women

Background: Smoking is recognized among the risk factors for osteoporosis, but only few studies have comprehensively explored its influence on bone metabolism and strength. We aimed to evaluate smoking effects on calcium-phosphate metabolism, bone mineral density (BMD) and fracture risk in postmenopausal women. Methods: Our sample included 1067 postmenopausal women who arrived to our osteoporosis outpatient clinic. Anamnestic data, smoking habits (categorized as never, former, and current; and by smoking intensity and duration), biochemical parameters, lumbar/femoral BMD, and presence of vertebral fractures were recorded. In a subsample of 357 women, the changes in BMD after a 2-yr follow-up period were also assessed. Results: Current smokers had shorter reproductive age, lower body mass index, and higher prevalence of heavy alcohol consumption than former/never smokers. They also had lower PTH values and weaker linear association between serum vitamin D and parathyroid hormone (current β = −0.11[SE = 0.004]; former β = −0.14[SE = 0.01]; never β = −0.20[SE = 0.003]; p < 0.01 for all). Baseline BMD did not reflect differences based on smoking habits, duration or intensity. However, after 2 years, only current smokers significantly worsened in femural BMD. After adjustment for confounders, the chance of having sustained vertebral fractures at the first evaluation increased by 74% (95% confidence interval:1.07–2.83) in current compared with never smokers, especially among heavy smokers. Conclusions: Smoking may negatively affect bone by inhibiting vitamin D-parathyroid hormone axis, reducing estrogen exposure, promoting risky health behaviors, and accelerating bone loss, especially at the femur. No significant differences were observed in these outcomes among former smokers, suggesting that quitting smoking has beneficial effects on bone health.

Clinical Guidelines and PTH Measurement: Does Assay Generation Matter?

PTH is an important regulator of calcium and phosphate homeostasis and bone remodeling. It is metabolized into PTH fragments, which are measured to a different extent by PTH assays of different generations because of differences in fragments recognized and lack of assay standardization. PTH is measured in the workup of several conditions, and clinical guidelines provide recommendations concerning these measurements. This review provides an overview of the impact of differences between PTH assays, applying distinct clinical guidelines for primary and secondary hyperparathyroidism and perioperative use of PTH measurements. Guidelines deal with PTH measurement in different ways, recommending either trend monitoring, the use of a fold increase of the upper reference limit, or an absolute PTH cutoff value. For classic primary hyperparathyroidism (PHPT), the type of PTH assay used will not affect diagnosis or management because the precise concentration of PTH is less relevant. In chronic kidney disease, the guideline recommends treating secondary hyperparathyroidism above a twofold to ninefold PTH increase, which will result in different clinical decisions depending on the assay used. For patients after bariatric surgery, guidelines state absolute cutoff values for PTH, but the impact of different generation assays is unknown because direct comparison of PTH assays has never been performed. During parathyroid surgery, PTH measurements with a third-generation assay reflect treatment success more rapidly than second-generation assays. Increased awareness among clinicians regarding the complexity of PTH measurements is warranted because it can affect clinical decisions.

Circulating 25-hydroxycholecalciferol in Relationship to Central Dual-Energy X-Ray Absorptiometry Assesses. A clinical study

The aim of the research was to realize a clinical study on menopausal patients, focused on 25-hydroxyvitamin D (25OHD) assays versus Dual-Energy X-Ray Absorptiometry (DXA) categories. This transversal, observational, real-life study was effectuated on Caucasian Romanian females. A total of 60 subjects were grouped according to lumbar T-score: normal T-score (N=28), osteopenia (N=22), and osteoporosis (N=10). The lowest average value of 25OHD is found in patients with osteoporosis, which is statistically significant lower than in patients with osteopenia. The average values of PTH were within normal levels for each group. 25OHD did not correlate with PTH or lumbar BMD. Overall the mean values of 25OHD are in deficient ranges regardless osteoporosis, osteopenia or normal DXA.

Preoperative vitamin D levels do not relate with the risk of hypocalcemia following total thyroidectomy. A cohort study.

Hypocalcemia is the most common complication following total thyroidectomy. Few factors may relate with increased risk of postoperative hypocalcemia. Preoperative vitamin D values have been evaluated in few studies, but reports present conflicting data. Aim of our study is to evaluate the association of preoperative vitamin D values and hypocalcemia following total thyroidectomy. A retrospective analysis of patients undergoing total thyroidectomy in our department of endocrine surgery between November 2012 and November 2015 was performed. Mean age of patients was 56.2 years (±14.0) and sex ratio (F:M) was 4.3:1. Sixty-four patients (17.4%) had preoperative vitamin D insufficiency (x<25 nmol/L), 138 patients (37.5%) vitamin D deficiency (25<x<50 nmol/L) and 166 patients (45.1%) vitamin D sufficiency (x>50 nmol/L). Following total thyroidectomy for both benign and malignant pathology, 66 patients (17.9%) had symptomatic hypocalcemia (x<2.0 mmol/L) requiring medical treatment (group 1), 64 patients (17.4%) biochemical hypocalcemia (2<x<2.1 mmol/L) not requiring treatment (group 2) and 238 patients (64.7%) had normal levels (x>2.1 mmol/L, group 3). Mean postoperative PTH value was 25.4 pg/ml (range 2-61). No statistical correlation between postoperative serum calcium and preoperative vitamin D values (R=-0.001, P=0.9849) was found nor associations were found regarding age, sex, type of thyroid disease or BMI. In our cohort of patients, preoperative vitamin D levels were not associated with a higher risk of hypocalcemia following total thyroidectomy. Postoperative PTH appears to be the most sensible item to predict the risk of postoperative symptomatic hypocalcemia.

Factors Affecting Bone Mineral Density in Hemodialysis Patients

Objective: Disorders of mineral metabolism and bone density are common complications in chronic kidney disease and are an important cause of morbidity. Recently used definition is chronic kidney disease-mineral and bone disorder (CKD-MBD). The aim of our study was to evaluate the correlation between bone mineral density and influencing factors in patients with end-stage renal failure undergoing hemodialysis.Material and Methods: In our study, cases were evaluated by being divided into 3 groups depending on bone mineral density (BMD). Our study included 124 cases and was designed as a cross-sectional observational study. The demographic data of the cases were recorded separately for each case. Routine biochemical analyses were studied. Results: The median vit D value of the patients with osteoporosis participated in the study was 14.44 mg/dl in the osteopenic group and the median value of the patients without osteoporosis was 20.14 mg/dl. The lowest and highest vit D values of the patients with osteoporosis were 3 mg/dl and 34.77 mg/dl, respectively. There was a statistically significant difference between all 3 groups for the age variable (p=0.002). There was a statistically significant difference between all 3 groups for the BMI variable (p=0.011). For 3 groups divided according to BMD measurements, statistically significant results were found in the PTH, Ferritin, Hgb, CRP, ALP, Albumin, e-GFR, hip and lumbar BMD values, respectively (p&amp;lt;0.001, p=0.001, p=0.004, p=0.001, p=0.003,p=0.005, p=0.001, p&amp;lt;0.001, p&amp;lt;0.001). Conclusion: In conclusion, our study revealed that the most important risk factor associated with osteoporosis in patients undergoing hemodialysis was PTH elevation and low vitamin D levels. For this purpose, BMD measurements and biochemical parameters of CKD patients undergoing hemodialysis should be studied in appropriate periods by adhering to the guidelines. Vit D replacement should not be neglected in order to avoid osteoporosis and to treat the detected cases.

Effects of Parathyroidectomy on Plasma iPTH and (1-84) PTH Levels in Patients with Stage 5 Chronic Kidney Disease.

Currently, the second-generation intact parathyroid hormone (iPTH) assay is commonly used for measuring PTH levels. The iPTH assay detects both full-length (1-84)PTH and (7-84)PTH fragments, which have antagonistic effects on (1-84)PTH in bones and kidneys. The third-generation PTH assay is specific for (1-84)PTH. This study examined the features of different PTH fragments in stage 5 chronic kidney disease (CKD) and the effects of parathyroidectomy (PTX) on the above markers in severe secondary hyperparathyroidism (SHPT) patients. The cross-sectional study included 262 stage 5 CKD patients and 90 controls. A prospective follow-up study was then conducted in 34 PTX patients. Second- and third-generation assays were used to measure plasma iPTH and (1-84)PTH levels, respectively. Circulating (7-84)PTH levels were calculated by subtracting the (1-84)PTH value from the iPTH value. Different plasma PTH fragments were higher, and (1-84)PTH/iPTH was lower in CKD patients than in controls. Plasma (1-84)PTH and (7-84)PTH concentrations increased as iPTH levels increased, and (7-84)PTH increased more evidently. Plasma iPTH, (1-84)PTH and (7-84)PTH levels were 1530.5 (885.0-2111.5) pg/ml, 683.1 (431.4-1018.0) pg/ml, and 739.3 (452.6-1261.0) pg/ml, respectively, in PTX patients. Plasma iPTH, (1-84)PTH and (7-84)PTH concentrations decreased considerably, and the (1-84)PTH/iPTH ratio increased after PTX (median follow-up interval: 10.9 months). Stage 5 CKD patients had higher plasma levels of different PTH fragments, and lower (1-84)PTH/iPTH ratio. PTX could significantly reverse these abnormalities in severe SHPT patients. The iPTH assay overestimated the function of the parathyroid glands; thus, the third-generation PTH assay is likely better for the management of CKD patients.

Experiencia con paratiroidectomía quirúrgica en pacientes con enfermedad renal crónica e hiperparatiroidismo terciario

Introducción: el hiperparatiroidismo terciario es la consecuencia final de las alteraciones del metabolismo calcio-fósforo en pacientes con enfermedad renal crónica. Aquellos pacientes que no logran controlarlo con el tratamiento médico, requieren paratiroidectomía. &#x0D; Objetivo: describir la evolución clínica y paraclínica en pacientes con enfermedad renal crónica y diagnóstico de hiperparatiroidismo terciario, que fueron llevados a paratiroidectomía.&#x0D; Metodología: estudio prospectivo, que incluyó pacientes con hiperparatiroidismo terciario llevados a paratiroidectomía entre los años 2006 y 2015. Se realizaron estudios bioquímicos pre y post quirúrgicos y se evaluó la presencia y progresión de síntomas. &#x0D; Resultados: se incluyeron 32 pacientes, 68.8% mujeres, con media de edad de 46.2 años. Se identificaron diferencias estadísticamente significativas en el cambio en los valores de calcio, fósforo y PTH pre y post quirúrgicos. El 81.5% de los pacientes reportaron presencia de síntomas. El 34.6, 26.9, y 23% presentaron mejoría total de dolor óseo, dolor articular y prurito, respectivamente. El 28% presentaron hipocalcemia sintomática post operatoria. No hubo casos de muerte durante el seguimiento. &#x0D; Conclusiones: la paratiroidectomía se constituye en un alternativa segura y confiable para los pacientes con hiperparatiroidismo terciario, mejorando significativamente los síntomas y las alteraciones en el metabolismo óseo y mineral. Vigilar los niveles de calcio en el post operatorio es importante para evitar las complicaciones del síndrome de hueso hambriento

The Impact of Immunosuppression on Mineral Metabolism One Year after Kidney Transplantation

Introduction After kidney transplantation, a substantial amount of patients still suffer from Mineral Bone Disorder (MBD). However, the role of immunosuppressive therapy on mineral metabolism in transplanted patients is largely unknown. The aim of this study is to compare the effect of two common immunosuppressive schedules on MBD-related biomarkers 1 year after transplantation. Both schedules were tacrolimus- and prednisone-based and patients received either micofenolate or an mTOR inhibitor according to the ongoing protocol. Methods Longitudinal 1-year long retrospective study on patients transplanted from June 2013 to May 2016 at Hospital Clínic, Barcelona, who were treated continuously either with mycophenolate (MP) (n=186) or an mTOR inhibitor (mTORi) (n=122) during the first year after kidney transplantation. These two drugs were always combined with both tacrolimus and prednisone. Patients who died within the first year, lost at the follow-up, with graft failure and those who changed immunosuppression during the first year were discarded from the final analysis (25.7% of original population). Results Patients with the mTORi regimen were older and received more likely a graft from a cadaveric donor. There was no difference in renal function at 1 year between groups (creatinine 1.37 ± 0.52 vs 1.43 ± 0.57 for MP and mTORi group respectively, p=0.273). Patients who were doing mTORi experienced a less significant decrease in PTH values 1 year after transplantation (PTH -211.56 ± 270.22 pg/mL vs -136.75 ± 286.06 pg/mL for difference between 1-year and basal values in the MP and mTORi groups, respectively). Alkaline phosphatase decreased significantly in the MP group, while it did not substantially change in the mTORi group (-32.13 ± 89.51 U/L for MP vs +1.66 ± 104.66U/L for mTORi, p=0.009). There was a trend towards lower phosphate levels in the mTORi group (p=0.078), while total calcium was not affected (p=0.373). Conclusion an mTOR inhibitor-based regimen is associated with higher PTH and alkaline phosphatase values 1 year after kidney transplantation when compared to a mycophenolate-based regimen, along with a standard tacrolimus and prednisone immunosuppression.