Renal Secondary Hyperparathyroidism Research Articles

Tumoral Calcinosis of the Foot

Tumoral calcinosis is a disorder characterized by deposits of calcium phosphate in the subcutaneous tissues near large joints. While often resembling a neoplasm, the soft tissue deposits of tumoral calcinosis are benign in nature. The deposits can, however, cause significant morbidity to patients due to tissue pressure or impingement. The focus of this case report will include the presentation, radiographic examinations, clinical course, and treatment of a 90-year-old female patient presenting for evaluation of a painful plantar right foot soft tissue mass associated with chronic renal failure and secondary hyperparathyroidism.

Arm pain after syncope: Diagnosis

Quiz case

Cinacalcet may reduce arterial stiffness in patients with chronic renal disease and secondary hyperparathyroidism – results of a small-scale, prospective, observational study

This study evaluated the impact of cinacalcet on arterial stiffness, determined by pulse wave velocity (PWV), in patients with chronic renal disease and secondary hyperparathyroidism (SHPT). This prospective, observational study included, SHPT patients with chronic renal disease on dialysis undergoing cinacalcet treatment with a follow-up of 12 months. 21 patients, 62% males, with a mean age of 51.3 years (± 18.0) were included. Cinacalcet was given for at least a year with a mean daily dose of 35 mg (range 30-60 mg). Aortic PWV significantly decreased after 12 months of cinacalcet treatment (9.35 ± 1.83 m/sg vs. 8.66 ± 1.86 m/sg; p = 0.030). Additionally, there was a notable reduction trend in the left ventricular mass index (166.6 ± 39.4 g/m² vs. 156.1 ± 31.8 g/m²), although it did not achieve statistical significance (p = 0.063). Alkaline phosphatase and PTH were significantly decreased during the study. However, serum calcium, phosphorus and blood pressure remained stable. The results of this study support the possibility that cinacalcet reduces arterial stiffness of SHPT patients with chronic renal disease after 12 months of treatment. Prospective, randomized clinical trials are needed to confirm these preliminary findings.

Calcium–phosphorus homeostasis in cats with spontaneous chronic kidney disease and metabolic acidosis

The effect of metabolic acidosis on calcium–phosphorus homeostasis in cats with spontaneous chronic kidney disease (CKD) was studied. The cats were assigned into the clinically normal cats (n = 6), CKD (n = 9), and CKD with metabolic acidosis (12 cats). The CKD cats were cats with a blood urea nitrogen ≥50 mg/dl and creatinine level ≥2.1 mg/dl. A complete blood count, sodium, potassium, total calcium, adjusted calcium, ionized calcium, phosphorus, parathyroid hormone, and vitamin D levels were measured. The cats with spontaneous CKD had a significantly lower hemoglobin and pack cell volume than the clinically normal cats. The CKD cats with metabolic acidosis had mean creatinine levels of 7.12 ± 0.76 mg/dl (severe azotemic stage) and significantly increased levels of parathyroid hormone and plasma phosphorus levels which indicated the presence of renal secondary hyperparathyroidism.

Penile gangrene due to calcific uremic arteriopathy

Calcific uremic arteriopathy (CUA) is a rare but potentially life-threatening complication of end-stage renal disease (ESRD) and secondary hyperparathyroidism. It typically presents with ischemic necrosis involving areas of adiposity in the body mainly the trunk, buttocks, or proximal extremity. Patients can also present with digital ischemia and more rarely penile gangrene. The pathogenesis of CUA is not yet clear but several putative factors, mainly hyperparathyroidism and related metabolic abnormalities are implicated. A number of conditions can mimic CUA clinically and should be differentiated from it. We present in the current study, a patient who presented with progressive penile gangrene and skin necrosis due to CUA. We review the current understanding of the pathogenesis, diagnosis/differential diagnosis, and management of this rare but potentially life-threatening complication of ESRD.

Dr Penney Barber Awards

Penney Barber specialized in feline medicine and in particular, research into secondary renal hyperparathyroidism and hyperphosphataemia. The awards made in her name are given for studies into diseases of cats.

Atypical Calciphylaxis in a Patient Receiving Warfarin Then Resolving With Cessation of Warfarin and Application of Hyperbaric Oxygen Therapy

Calciphylaxis is a rare, usually fatal vasculopathic disorder characterized by cutaneous ischemia and necrosis due to calcification of arterioles. Although calciphylaxis is most frequently associated with end-stage renal disease (ESRD) and secondary hyperparathyroidism, it has been reported infrequently among patients on warfarin. No standard treatment has been established for atypical calciphylaxis; however, a potentially beneficial treatment is hyperbaric oxygen therapy (HBOT). A high degree of clinical suspicion, early diagnosis, and understanding the pathophysiology of this disease promotes the optimal management of this extremely morbid and often fatal condition. We present a 63-year-old Polynesian woman with biopsy-proven calciphylaxis in the absence of ESRD or elevated serum calcium levels while taking warfarin. Therapeutic dose enoxaparin was substituted for warfarin and she received 40 sessions of HBOT during which lower extremity ulcers resolved. Warfarin has been implicated when calciphylaxis presents in an atypical fashion. No guidelines exist for treatment of atypical calciphylaxis in the setting of concomitant warfarin therapy. Up to 80% of calciphylaxis patients die within 1 year of diagnosis. Our patient was changed to low-molecular-weight heparin and received HBOT. We present what we believe is the first case of atypical calciphylaxis thought to be attributable to warfarin treated with a therapeutic substitution of anticoagulant and HBOT leading to resolution of cutaneous lesions.

Treatment Options for Hyperphosphatemia in Feline CKD: What's Out there?

Phosphorus is retained in chronic kidney disease (CKD), promoting renal secondary hyperparathyroidism and eventually resulting in hyperphosphatemia. Most agree that phosphate retention is a major contributor to the progression of CKD in many species and it is well known that hyperphosphatemia is associated with a significant mortality risk in humans with end-stage renal disease. Chronic kidney disease is a common ailment of geriatric cats. There is evidence in cats suggesting that the use of a phosphate-restricted diet in IRIS stage 2-3 disease has a beneficial effect on clinical outcome. However, despite the fact that intestinal phosphate binders are commonly used in veterinary practice for patients with CKD, there have been few published reports focusing on the safety and efficacy of these products in veterinary medicine. No phosphorus binders are licensed as medications for dogs or cats. This article draws on data from clinical trials in humans and studies in cats to discuss treatment goals and options for phosphate retention and hyperphosphatemia in feline CKD. With careful monitoring of serum phosphate and parathyroid hormone, and implementation of phosphate-restricted dietary management and intestinal phosphate binders, progression of CKD and the degree of hyperparathyroidism in cats may be reduced. Companion animal and feline practitioners are at the forefront in the management of CKD in cats.

Surgery of Renal Secondary Hyperparathyroidism

In most patients on long-term dialysis, an increase in secondary hyperparathyroidism (2(superscript nd) HPT) is noted due to hyper-phosphatemia, a deficit of calcitriol synthesis and hypocalcemia. Symptoms of bone pain, skin itching, general weakness and insomnia with high IPTH levels (＞ 650 pg/ml), hypercalcemia (＞ 10.1 mg/ml) and hyperphosphatemia (＞ 4.6 mg/dl) are indications for surgery. Total parathyroidectomy or subtotal parathyridectomy is a cost effective procedure to treat symptomatic 2nd HPT. Total parathryoidectomy plus subcutaneous autotransplantation is an easy method to perform and it can avoid long-life hypoparathyroidism, which total parathyroidectomy without autotransplantaion cannot. It is also easy to find and remove the parathyroid tissue if recurrent hyperparathyroidism at the transplantation site is found.

Outcome of parathyroidectomy for patients with renal disease and hyperparathyroidism: predictors for recurrent hyperparathyroidism

A small group of patients with renal disease-related secondary or tertiary hyperparathyroidism require surgical parathyroidectomy. Among them, 5-20% require further re-exploration and excision of parathyroid tissue because of recurrent disease. The aims of the present study were to review the characteristics and outcomes of patients undergoing parathyroidectomy for renal disease related hyperparathyroidism and to identify the risk factors for recurrent hyperparathyroidism. Review of data from a dedicated head and neck database at Royal Prince Alfred Hospital between 1988 and 2004. There were 115 patients of whom 68 (59%) patients were treated with subtotal parathyroidectomy (STP), 43 (37%) were treated with total parathyroidectomy (TP) and 4 (3%) were treated with TP with autotransplant. Of those, 11 (9.6%) patients developed recurrent hyperparathyroidism (9 had STP, 1 had TP and 1 had TP with autotransplant). On re-exploration, persistent hyperplastic parathyroid tissue was located at the site of partially excised parathyroid gland (64%), autotransplanted parathyroid tissue (9%), anterior mediastinum (18%) and intrathyroidal parathyroid (9%). Predictors for recurrent hyperparathyroidism are STP (P= 0.049), preoperative symptom of calciphylaxis or calcinosis (P= 0.024), elevated preoperative calcium level (P= 0.007) and elevated post-operative PTH levels (P= 0.014). Post-operative PTH levels less than 10 pmol/L has a positive predictive value of 97.5% for cure (P= 0.02). More aggressive surgical approach could be indicated in patients with preoperative hypercalcaemia and calcinosis/calciphylaxis. Post-operative PTH can be utilized as a marker for cure after parathyroidectomy in hyperparathyroidism of renal disease.

Prevalence of radiological findings among cases of severe secondary hyperparathyroidism.

Patients with end stage renal disease (ESRD) and secondary hyperparathyroidism (HPT2) are prone to develop heterotopic calcifications and severe bone disease. Determination of the sites most commonly affected would decrease costs and patients' exposure to X-ray radiation. The aim here was to determine which skeletal sites produce most radiographic findings, in order to evaluate hemodialysis patients with HPT2, and to describe the most prevalent radiographic findings. This study was cross-sectional, conducted in one center, the Hospital Universitário Clementino Fraga Filho (HUCFF), in Rio de Janeiro, Brazil. Whole-body radiographs were obtained from 73 chronic hemodialysis patients with indications for parathyroidectomy due to severe HPT2. The regions studied were the skull, hands, wrists, clavicles, thoracic and lumbar column, long bones and pelvis. All the radiographs were analyzed by the same two radiologists, with great experience in bone disease interpretation. The most common abnormality was subperiosteal bone resorption, mostly at the phalanges and distal clavicles (94% of patients, each). 'Rugger jersey spine' sign was found in 27%. Pathological fractures and deformities were seen in 27% and 33%, respectively. Calcifications were presented in 80%, mostly at the forearm fistula (42%), abdominal aorta and lower limb arteries (35% each). Brown tumors were present in 37% of the patients, mostly on the face and lower limbs (9% each). The greatest prevalence of bone findings were found on radiographs of the hands, wrists, lateral view of the thoracic and lumbar columns and femurs. The most prevalent findings were bone resorption and ectopic calcifications.

Calcium-phosphorus homeostasis and changes in parathyroid hormone secretion in cats with various stages of spontaneous chronic renal failure

Feline chronic renal failure was recognized with increased frequency in Maine coon, Abyssinian, Siamese, Russian blue, and Burmese cats. The objective of this study was to investigate the relationship between parathyroid hormone (PTH) level, calcium, and phosphorus homeostasis and the development of various stages of the naturally occurring chronic renal failure (CRF) in cats. Thirty-two CRF cats without history of receiving special diet for renal diseases that were presented to the Small Animal Hospital, Faculty of Veterinary Science, Chulalongkorn University were studied. Nineteen CRF cats were followed prospectively for 60 days and divided into two groups: uremic group (11 cats) and end-stage group (eight cats). The control group (13 cats) were normal cats, which were brought for vaccination at the same hospital within the same period. CRF cats with blood urea nitrogen concentrations of more than 50 mg/dl, serum creatinine level of more than 2.1 mg/dl, and urine specific gravity of between 1.008 and 1.014 were included into the study. Completed blood count, blood chemistry, electrolytes, including sodium, potassium, total calcium, and phosphorus, and PTH levels were measured on days 0, 14, 30, and 60 after the first diagnosis. The results showed that cats with CRF had significantly lower red blood cells, hemoglobin, and pack cell volume than control cats (p < 0.01) on days 0, 14, 30, and 60. PTH levels on first day of diagnosis were 50.51 ± 19.65, 79.41 ± 28.12, and 183.37 ± 50.12 pg/ml in controls, uremic, and end-stage groups, respectively. Cats in end-stage group had significantly increased levels of PTH when compared to control (p < 0.01) and uremic groups (p < 0.05) on days 0, 14, and 30. Serum phosphorus levels also increased significantly in end-stage group (p < 0.001), indicating the presence of renal secondary hyperparathyroidism. This study reveals that PTH level is significantly increased in end-stage CRF cats who did not received special diet for renal diseases. The development of renal secondary hyperparathyroidism in end-stage CRF cats significantly decreased its survival rate.

Evaluación prospectiva de paratiroidectomías en el tratamiento del hiperparatiroidismo secundario

Parathyroidectomy for secondary hyperparathyroidism in chronic renal failure Background: Parathyroidectomy is indicated in patients with chronic renal failure and secondary hyperparathyroidism that is persistent and refractory to treatment. Aim: To assess the effects of parathyroidectomy in patients with chronic renal failure and symptomatic hyperparathyroidism. Patients and Methods: Prospective evaluation of 33 patients (20 females), aged between 23 and 78 years, with chronic renal failure and secondary hyperparathyroidism that were subjected to a total parathyroidectomy and autotrasplantation. Patients were followed for six months measuring parathormone (PTH), calcium and phosphorus. Results: In the postoperative period, one patient had a cervical hematoma that had to be operated. Mean serum PTH levels at the moment of hospital discharge and at six months, were 832 and 212 pg/ml respectively. All patients that had bone pain experienced a notable reduction of this symptom on the morning after surgery. One patient had a relapse of her hyperparathyroidism. Conclusions: Para- thyroidectomy is safe and effective for secondary hyperparathyroidism in patients with chronic renal failure.

Multiple brown tumors of the orbital walls: case report

We report the case of a 40-year-old woman with chronic renal failure and secondary hyperparathyroidism that presented with slowly progressive proptosis of the right eye and mass sensation in the temporal and frontal orbital margins. Computerized tomography scan revealed two separate hyperdense and well-circumscribed lesions in the right orbital walls. A biopsy followed by histopathologic study revealed a dense lesion, with fibrous proliferation associated with osseous metaplasia and osteoclastic activity in the tumor, compatible with the diagnosis of brown tumor. The patient was submitted to surgical removal of the parathyroid glands that resulted in marked improvement in her condition and regression of the orbital tumors. Although the occurrence of more than one separate bone lesion in the orbit usually suggests metastasis, our case shows that brown tumors should also be included in the differential diagnosis of such lesions, particularly in patients with hyperparathyroidism.

Blockage of the Renin-Angiotensin System Attenuates Mortality but Not Vascular Calcification in Uremic Rats: Sevelamer Carbonate Prevents Vascular Calcification

Background/Aims: Hyperphosphatemia is associated with vascular calcification and increased cardiovascular morbidity and mortality. Angiotensin-converting enzyme inhibitors are beneficial in suppressing the progression of kidney and cardiovascular disease. The present studies explore the influence of enalapril and sevelamer carbonate on renal function, vascular calcification and mortality in long-term experimental uremia. Methods: Normal and 5/6 nephrectomized rats were fed a high-phosphorus diet for 4 months and treated with enalapril or the combination of both enalapril and sevelamer carbonate. Results: The rats treated with enalapril alone or both enalapril and sevelamer had less deterioration in renal function compared to uremic control as seen by lower serum creatinine (1.6, 1.6 vs. 2.1 mg/dl, respectively, p < 0.05) and higher creatinine clearance. They also exhibited attenuated mortality (23.5, 12.5 vs. 75%, respectively, p < 0.01) and inhibition of myocardial hypertrophy. Enalapril alone did not suppress secondary hyperparathyroidism or vascular calcification. Combination therapy with both enalapril and sevelamer carbonate ameliorated secondary hyperparathyroidism and vascular calcification (calcium content: 854 ± 40 vs. 1,735 ± 479 μg/g wet tissue) compared to uremic controls. Conclusion: In these experiments, animal mortality and myocardial hypertrophy were significantly reduced by both enalapril alone and enalapril in combination with sevelamer. In addition, sevelamer carbonate induced beneficial effects on renal dysfunction, secondary hyperparathyroidism and vascular calcification.

Cost-Effectiveness of Early versus Late Cinacalcet Treatment in Addition to Standard Care for Secondary Renal Hyperparathyroidism in the USA

Objectives The objective of this research was to estimate lifetime cost-effectiveness of treating patients with cinacalcet early (when parathyroid hormone [PTH] levels are in the range of 300–500 pg/ml) versus delaying treatment with cinacalcet (cinacalcet initiated when PTH levels are >800 pg/ml) in patients with secondary hyperparathyroidism (SHPT) in the US setting. Methods A Markov model was developed to simulate the effects of early versus delayed use of cinacalcet (plus standard of care). Four different PTH ranges (≤300 pg/ml; 301–500 pg/ml; 501–800 pg/ml; >800 pg/ml) were used to represent four different health states within the Markov model. Associated with each Markov state (PTH range) were varying risks of major SHPT complications, including cardiovascular disease (CVD), fracture (Fx), and parathyroidectomy (PTx). Baseline cohort characteristics and risks of CVD, Fx, and PTx by PTH category were derived from a large US renal database and published sources. Costs were estimated from the US Renal Data System database and reported in 2006 US Dollars ($). Clinical and economic outcomes were discounted at 3.0% per annum. Results Early treatment was projected to improve quality-adjusted life years (QALYs) by 0.337 years compared to delaying treatment. The incremental cost-effectiveness ratio was $17,275 per QALY gained. Conclusions Early treatment with cinacalcet was associated with improvements in QALYs and would represent good value for money compared to delaying treatment with cinacalcet.

Use of Cinacalcet HCl to Achieve the Recommended Targets of Bone Metabolism in a Patient With Therapy-Resistant Renal Hyperparathyroidism

We report on a patient with end-stage renal disease and severe progressive secondary hyperparathyroidism, whose condition failed to respond to conventional pharmacologic or surgical interventions. Although immunotherapy produced a partial response, it failed to decrease serum parathyroid hormone to the levels recommended by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative clinical practice guidelines. Treatment with a new calcimimetic agent, cinacalcet HCl (Mimpara, Amgen, Munich, Germany), resulted in a rapid decline in elevated parathyroid hormone levels, near normalization of other laboratory markers of bone metabolism, improvement in mobility and skeletal pain caused by renal osteodystrophy, and an increase in body weight.

Fracture mandibulaire chez un Lhassa Apso avec hyperparathyroïdie secondaire rénale

A Lhassa Apso is presented in emergency after having been injured by another dog. It was suffering from a mandibular fracture. The clinical exam revealed generalized and excessive mobility of the whole dentition. Radiographs showed generalized jaw bone demineralisation. A blood sample was analysed and revealed chronic renal disease. We came to the conclusion that this dog was suffering from secondary renal hyperparathyroidism. The hypocalcified bone was so thin that a slight trauma induced the mandibular fracture.

Survival after Parathyroidectomy in Patients with End‐stage Renal Disease and Severe Hyperparathyroidism

Patients with end-stage renal disease (ESRD) and secondary hyperparathyroidism (SHPT) are at high risk of mortality. Whether an increased risk of death persists after a parathyroidectomy (PTX) is not clearly established. The survival of 40 patients with ESRD and SHPT who underwent PTX was compared with that of 664 ESRD patients. From first dialysis, a lower mortality rate was found in the group of patients who underwent PTX than in the nonoperated ESRD group (hazard ratio: 0.23; 95% CI: 0.14-0.37). The patients who underwent PTX were younger, had a longer time on dialysis, and had a higher prevalence of kidney transplantation. The mean number of comorbidities was lower (Charlson score 4.2 +/- 2.1 versus 6.4 +/- 2.9, p < 0.001). Then, we randomly selected two matched controls for each PTX case (80 controls, 40 PTX) who had at least an equivalent mean duration of dialysis between the first dialysis and PTX of the PTX group. In a univariate model, there was a trend for PTX being associated with prolonged survival. The mortality was higher both among those at an advanced age and those with a high Charlson score. Adjustments for these covariates made the effect of PTX no more significant. The risk of death of patients with severe SHPT leading to PTX differed from that of nonoperated subjects. The apparent differences in survival may be related to the number and severity of associated comorbidities. ESRD patients who undergo PTX may represent a subset of healthier subjects.

Complicações cardiovasculares em criança com insuficiência renal crônica

This is the report of an 11-year-old boy with chronic renal disease and secondary hyperparathyroidism. The child had been on dialysis, calcitriol, calcium carbonate, and presented dyslipidemia and calcified thrombi in various vessels and organs in the course of his condition. Pathological examination showed ischemic cerebral necrosis, calcification in coronary arteries, and myocardial infarction.