Serum iPTH Levels Research Articles

Serum levels of intact parathyroid hormone on the first day after total thyroidectomy as predictor of permanent hypoparathyroidism

BackgroundPermanent hypoparathyroidism is the most common long-term complication after total thyroidectomy, causing significant morbidity and requiring long-term replacement therapy. Our study objective was to assess whether intact parathyroid hormone (iPTH) levels on the first day after total thyroidectomy are a good predictor of permanent hypoparathyroidism. Patients and methodsA retrospective observational study of all patients undergoing total thyroidectomy between January 2009 and December 2014. iPTH and calcium levels were measured the first day after surgery. Patients were followed up for at least one year after surgery. ResultsThe study group consisted of 481 patients with a mean age of 53±14 years, 82% of them females. The most common reason for thyroidectomy was multinodular goiter (75%), followed by papillary thyroid cancer (15%). Transient hypocalcemia was the most common early complication after total thyroidectomy (49%), and permanent hypoparathyroidism was the most common long-term complication (6%). ROC curve analysis showed that iPTH level on the first postoperative day was a good predictor of permanent hypoparathyroidism (area under the curve 0.87; 95% CI: 0.84–0.91). Cut-off iPTH levels of 5pg/mL had 95% sensitivity, 77% specificity, 21.6% positive predictive value, and 99.6% negative predictive value. ConclusionsiPTH level on the first day after total thyroidectomy is a useful predictor of permanent hypoparathyroidism because of its high negative predictive value. Serum iPTH levels >5pg/mL virtually exclude presence of permanent hypoparathyroidism.

Efficacy and safety of paricalcitol in patients undergoing hemodialysis: a meta-analysis.

BackgroundThe elevated calcium and phosphorus levels in patients undergoing hemodialysis may increase the risk of all-cause mortality. Paricalcitol, as a new vitamin D receptor activator (VDRA), seemed to be effective in reducing the calcium and phosphorus levels.ObjectivesThe aim of this study was to compare the efficacy and safety of paricalcitol with other VDRAs in patients undergoing hemodialysis.MethodsPubMed, Embase, and Web of Science database were systematically reviewed.Selection criteriaStudies that focused on the use of paricalcitol for hemodialysis patients were eligible for inclusion.Data collection and analysisTwo independent investigators performed the literature search, data extraction, and assessment of methodological quality. The outcomes were expressed with standard mean difference (SMD), HR, or risk ratio (RR) with 95% CI.ResultsThirteen studies involving 112,695 patients were included in this meta-analysis. Among these studies, four studies were cohort studies and nine studies were randomized controlled trials (RCTs). For cohort studies, they were regarded as being of high quality; for RCTs, only one was classified as being at low risk of bias; and the remaining eight studies were at being unclear risk of bias. Compared with other VDRAs, paricalcitol significantly improved the overall survival (HR =0.86, 95% CI: 0.80, 0.92; P<0.001) and reduced the intact parathyroid hormone (iPTH) (SMD =−0.53, 95% CI: −0.90, −0.17; P=0.004). Paricalcitol offered similar effect with other VDRAs in the control of calcium (SMD =0.32, 95% CI: −0.04, 0.67; P=0.078) and phosphorus (SMD =0.06, 95% CI: −0.26, 0.37; P=0.727) levels. However, the serum change in calcium phosphate product was greater in the paricalcitol group than in the other VDRA group (SMD =2.13, 95% CI: 0.19, 4.07; P=0.031). There was no significant difference in the incidence of adverse events between the two groups (RR =1.02, 95% CI: 0.93, 1.12; P=0.674).ConclusionParicalcitol was crucial in reducing the mortality in patients undergoing hemodialysis. Moreover, both paricalcitol and other VDRAs were effective in control of the serum iPTH, calcium, and phosphorus levels. Given the potential limitations in this study, more prospective large-scale, well-conducted RCTs are needed to confirm these findings.

Serum Calcium and Phosphorus Levels in Hemodialysis Patients: A Large Population-Based Multicenter Study

Background: Mineral bone disorder is one of the major factors affecting mortality and morbidity in dialysis patients, which is called chronic kidney disease-mineral and bone disorder (CKD-MBD). Objectives: This study aimed to evaluate the laboratory parameters of mineral bone disorder in hemodialysis patients in Iran and their relationship with malnutrition and inflammation. Methods: This multicenter observational study was conducted in 2016 in 58 dialysis centers in Iran. Data of a total number of 7191 chronic hemodialysis patients aged older than 18 years with a dialysis duration of > 3 months were collected. Idiopathic hypercalcemia and history of parathyroidectomy were considered as the exclusion criteria. The serum levels of calcium (Ca), phosphorus (P), and intact parathyroid hormone (iPTH) were measured over a period of three months, and the findings were compared with the K/DOQI (National Kidney Foundation Dialysis Outcomes Quality Initiative) guidelines. Moreover, the serum level of C-reactive protein (CRP) and nutritional status based on geriatric nutritional risk index (GNRI) were assessed. Results: The percentage of the patients who had a serum iPTH level of 300 pg/mL was 29.3%. Hypercalcemia and hyperphosphatemia were observed in 20.6% and 34.2% of the patients, respectively. Moreover, 51.7%, 61.3%, 24.7%, and 84.7% of the patients, respectively, reached the K/DOQI target range of Ca, P, iPTH, and Ca × P product. The percentages of mild-to-severe malnutrition based on GNRI in patients whose iPTH level was within, below, and above the recommended range of K/DOQI guidelines were 30.7%, 34.1%, and 25.9%, respectively (P < 0.001). Furthermore, the serum level of CRP was significantly higher in low-serum PTH patients than in the other two groups. In total, only could 8.3% of the patients reach the four KDOQI target levels of CKD-MBD. Conclusions: The findings showed a significant percentage of patients had a low serum PTH level, which might be attributed to inflammatory and nutritional factors. Only had a small percentage of patients reached all the K/DOQI targets. Therefore, the effects of inflammatory and nutritional factors should also be considered, particularly in developing countries.

Study on the Prevalence of Vascular Calcification in Different Types of Arteries and Influencing Factors in Maintenance Peritoneal Dialysis Patients

Objective: To investigate the occurrence of vascular calcification (VC) in different types of arteries in patients with maintenance peritoneal dialysis (PD) patients and its influencing factors. Methods: This study enrolled PD patients with stable status who has received PD treatment for more than 6 months in Peking University People’s Hospital. We used plain X-ray films of abdomen, pelvis, and hands to quantitatively evaluate VC of large artery (abdominal aorta, iliac artery), medium artery (femoral artery, radial artery), and small artery (finger arteries). Two radiologists read and scored radiographs blindly. Demographic data, clinical characteristics, Charlson comorbidity index (CCI), baseline and time-average laboratory indices including parameters of calcium phosphorus metabolism, serum albumin, PD adequacy were collected. A logistic regression model was used to estimate the influencing factors of different sites of VC. Results: (1) 154 PD patients were enrolled in this study: seventy-eight males, mean age was 60.4 ± 13.9 years, and median PD duration was 24 (16.39) months. The major primary disease was diabetic nephropathy (39%). (2) Among the 154 PD patients, the proportion of calcification of large artery was the highest (found in 100 patients, accounting for 64.9%); then the medium artery (66, 42.9%); and 15 of small artery, accounting for 9.7%. (3) Logistic regression showed that older age, longer dialysis duration, lower baseline serum intact parathyroid hormone (iPTH), and higher CCI scores were independent risk factors of large artery calcification (p < 0.05), and higher CCI scores, higher baseline serum triglycerides (TG), lower baseline serum iPTH, and time-average iPTH were independent risk factors of medium and small arteries. Conclusions: In PD patients, the occurrence of large artery calcification was higher than others. Among different sites of VC, the abdominal aortic calcification was most likely to occur, and the proportion of small artery calcification was low. Calcification of medium and small arteries can exist alone without calcification of large artery. Large artery calcification was more likely to occur in patients with older age, longer dialysis duration, lower baseline serum iPTH levels and higher CCI scores. Patients with higher CCI scores, higher baseline TG and lower baseline iPTH, and time-average iPTH were more likely to develop small and medium artery calcification.

Anemia and Iron Deficiency in Children with Chronic Kidney Disease (CKD): Data from the Know-Ped CKD Study.

Children with chronic kidney disease (CKD) are at high risk of anemia, an important risk factor for cardiovascular disease and poor quality of life. The present study used baseline data from the Korean cohort study for Outcome in patients With Pediatric Chronic Kidney Disease (KNOW-PedCKD). A Total of 437 patients was included in the analyses excluding missing data. The characteristics of patients with and without anemia and those of patients with and without iron deficiency were compared. Logistic regression analysis and Pearson correlation were conducted to evaluate associated risk factors and correlations in children with CKD. Anemia in children with CKD was associated with older age, low body weight and body mass index (BMI) z-score, birth age, preceding glomerulonephritis, decreased estimated glomerular filtration rate (eGFR), low levels of serum albumin and calcium, high levels of serum intact parathyroid hormone (iPTH), and serum phosphorus. Anemia was correlated positively with changes in the BMI z-score, body weight, and serum albumin and cholesterol levels, but correlated negatively with serum calcium, iPTH, ferritin levels, and transferrin saturation. Iron deficiency in children with CKD was associated with young age, low hemoglobin and serum ferritin levels, high BMI z-scores, and low levels of serum iPTH. This is the first nationwide cohort study of anemia in Korean children with CKD and the first prospective pediatric CKD cohort study in Asia. The study results demonstrated that anemia and iron deficiency are affected by various factors, including age, BMI, and levels of serum iPTH. To improve the retrospective outcome of affected children, it is important to understand the effect of each of these factors and to attempt an early intervention to prevent anemia and iron deficiency by regular measurement of these parameters in children at risk.

Effects of Denosumab and Alendronate on Bone Health and Vascular Function in Hemodialysis Patients: A Randomized, Controlled Trial.

Mineral and bone disorders including osteoporosis are common in dialysis patients and contribute to increased morbimortality. However, whether denosumab and alendronate are effective and safe treatments in hemodialysis patients is not known. Thus, we conducted a prospective, three-center study of 48 hemodialysis patients who were diagnosed as having osteoporosis and had not received anti-osteoporotic agents previously. Participants were randomized to either denosumab or intravenous alendronate, and all subjects received elemental calcium and calcitriol during the initial 2 weeks. The primary endpoint was the percent change in lumbar spine bone mineral density (LSBMD) at 12 months of treatment. The secondary endpoints included the following: change in BMD at other sites; change of serum bone turnover markers (BTM), coronary artery calcium score (CACS), ankle-brachial pressure index (ABI), brachial-ankle pulse wave velocity (baPWV), flow mediated dilation (FMD), and intima-media thickness at the carotid artery (CA-IMT); change from day 0 to day 14 in serum levels of Ca and P; time course of serum calcium (Ca), phosphorus (P), and intact parathyroid hormone (i-PTH); new fractures; and adverse events. Initial supplementation with elemental calcium and calcitriol markedly ameliorated the decrease of serum corrected calcium (cCa) levels induced by denosumab during the first 2 weeks, whereas serum cCa levels in the alendronate group were increased. Denosumab and alendronate markedly decreased serum levels of BTM and increased LSBMD at 12 months compared with baseline. However, no significant differences were found in the changes in LSBMD between the two groups. The serum cCa, P, and i-PTH levels in the two groups were maintained within the appropriate range. In contrast to the anti-osteoporotic effects, no significant differences after 12 months of treatment were found in the CACS, CA-IMT, ABI, baPWV, and FMD compared with pretreatment in both groups. Denosumab and alendronate treatment improved LSBMD, reduced BTM, and appeared to be safe in hemodialysis patients with osteoporosis. © 2019 American Society for Bone and Mineral Research.

Correlation of serum intact parathyroid hormone and alkaline phosphatase in diabetic chronic kidney disease stage 3 to 5 patients with mineral bone disorders

Introduction: Chronic kidney disease (CKD) amongst diabetic patients is a worldwide public health problem. It is associated with cardiovascular disease and CKD mineral bone disorder (CKD-MBD). Cardiovascular and MBD are important contributors of morbidity and mortality in CKD patients. Serum intact parathyroid hormone (iPTH) and alkaline phosphatase (ALP) are two important markers to identify and mange CKD-MBD. This study was designed to evaluate the relationship between serum iPTH and alkaline phosphatase in diabetic CKD stages 3-5 patients with MBD.&#x0D; Methods: This cross-sectional study was conducted in BIRDEM General Hospital, Dhaka, Bangladesh from January 2013 to December 2014. Diabetic patients suffering from stage 3-5 CKD with MBD and not on dialysis, were consecutively and purposively included in this study. Along with base-line characteristics, clinical and laboratory data including serum alkaline phosphatase and iPTH levels were recorded for all patients. Data were analyzed by using SPSS version 20.0 and Pearson’s correlation test was applied to evaluate the relationship between iPTH and serum ALP.&#x0D; Results: Total patients were 306, of which 166 (54.2%) were males and 140 females (45.8%). Mean age of the study population was 56.5±11.3 years. Mean duration of diabetes mellitus (DM) and CKD were 12.8±7.6 and 2.9±1.7 years respectively. Among the study population, 49 (16.0%) were in CKD stage 3, 90 (29.4%) in stage 4 and rest 167 (54.6%) in stage 5. The mean HbA1c level did not differ significantly (p&gt;0.05 by ANOVA) amongst CKD-MBD stage 3, 4 and 5 cases. Mean±SE values of glycated haemoglobin (HbAlc %), serum creatinine (mg/dl), urea (mg/dl), calcium (mg/dl), phosphate (mg/dl), ALP (U/L) and iPTH (pg/ml) of total study population were 7.77±0.12, 6.8±0.17, 141.1±4.33, 8.1±0.07, 5.2±0.11, 164.1±7.74 and 229.7±8.64 respectively. Out of total cases, serum ALP was raised in only 53.9% CKD-MBD cases compared to 76.8% for iPTH. Serum iPTH level was found elevated in 79.6%, 83.3% and 72.5% CKD-MBD stage 3, 4 and 5 cases respectively while in comparison, serum ALP was found raised in 44.8%, 54.4% and 56.2% cases respectively. On correlation analysis between serum iPTH and ALP, the r values observed were 0.074, 0.231 and 0.046 for stage 3, 4 and 5 CKD-MBD cases respectively.&#x0D; Conclusion: The results of current study showed that most diabetic stage 3-5 pre-dialysis CKD-MBD patients had raised serum iPTH. In comparison, significantly low number of cases had raised serum ALP.&#x0D; IMC J Med Sci 2018; 12(2): 80-85

Vitamin D and bone mineral density status among postmenopausal Bangladeshi women

Background and objectives: Low vitamin D is a global problem in all age groups as is osteoporosis in postmenopausal women. The present study was carried out in an urban hospital to assess serum 25-hydroxyvitamin D [25(OH)D] level and bone mineral density (BMD) in postmenopausal women (PMW) and to evaluate correlation between serum 25(OH)D levels and BMD.&#x0D; Methods: A single center cross-sectional study was conducted among 133 apparently healthy PMW aged 45 years and above with the history of complete cessation of menstruation over a period of more than 1 year. Serum 25(OH)D, BMD and serum intact parathyroid hormone (iPTH) were determined. Patients having both vitamin D and BMD values were analyzed for correlations. Similarly, correlation of vitamin D, iPTH and BMD were determined.&#x0D; Results: Among the study population, 63 (47.4%) had deficient (&lt;20 ng/ml), 46 (34.6%) had insufficient (20-30ng/ml) and 24(18%) had sufficient (30-100ng/ml) levels of serum 25(OH)D. Among the 121 patients whose BMD was done, 52 (43.0%) and 60 (49.6%) had osteoporosis and osteopenia respectively. Serum iPTH levels were normal in 34 (89.5%) patients. The proportion of osteopenia and osteoporosis in vitamin D deficient group were 44.1% and 50.8% and in insufficient group 47.5 and 45.0%, respectively. Age had significant negative correlation with BMD value (r=-0.246, p=.005) and significant positive correlation with serum iPTH (r=0.358, p=.024). There was no statistically significant influence of serum 25(OH)D or iPTH on occurrence of osteoporosis (P=0.322 and P=0.592 respectively).&#x0D; Conclusion: A large proportion of postmenopausal women had low vitamin D levels and as well as osteopenia and osteoporosis. Low vitamin D level coexisted with low BMD. However, there was no correlation between serum 25(OH)D levels and BMD status.&#x0D; IMC J Med Sci 2018; 12(2): 44-49

Bone Mineral Density is Decreased in Patients with Systemic Sclerosis and Correlates With Serum Intact Parathormone Levels: A Cross-Sectional Study

Objective: To study bone mineral density (BMD) in Indian patients with systemic sclerosis and objectively verify whether an association exists between osteoporosis and systemic sclerosis. Methods: Adult patients suffering from systemic sclerosis (as per the 2013 American College of Rheumatology classification criteria for systemic sclerosis) attending the rheumatology clinic at Post Graduate Institute of Medical Education and Research, Chandigarh, India were recruited. BMD was measured using dual energy x-ray absorptiometry (DXA) and serum Vitamin D and iPTH levels were estimated. The 10-year probability of sustaining an osteoporotic fracture was estimated using the World Health Organisation fracture risk assessment tool with the Indian population reference. Results: 100 patients were included (89 women). Interstitial lung disease and pulmonary arterial hypertension were seen in 48 and 18 patients, respectively. Median (range) serum 25 hydroxy Vitamin D level was 17 ng/ml (3.7-225.7 ng/ml). Mean serum iPTH level was 79.6±38.1 pg/ml. 55 patients were categorized as Vitamin D deficient, 24 as insufficient, and 21 as Vitamin D sufficient. 21 patients had iPTH values above 75 pg/ml. 28% had osteoporosis of the lumbar spine while 6% had osteoporosis of the femoral neck. Serum iPTH correlated inversely with low bone mass at the hip (P = 0.023, r2 = 0.121). Low bone mass did not correlate with age, postmenopausal status, low BMI, corticosteroid use, serum 25 hydroxy Vitamin D levels, disease duration, presence of interstitial lung disease or pulmonary arterial hypertension. Conclusion: Low bone mass is highly prevalent in patients with systemic sclerosis and is associated with elevated serum iPTH levels.

The impact of cinacalcet in the mineral metabolism markers of patients on dialysis with severe secondary hyperparathyroidism.

Introduction:Treating secondary hyperparathyroidism (SHPT), a common condition associated with death in patients with chronic kidney disease, is a challenge for nephrologists. Calcimimetics have allowed the introduction of drug therapies no longer based on phosphate binders and active vitamin D. This study aimed to assess the safety and effectiveness of cinacalcet in managing chronic dialysis patients with severe SHPT. Methods: This retrospective study included 26 patients [age: 52 ± 12 years; 55% females; time on dialysis: 54 (4-236) months] on hemodialysis (N = 18) or peritoneal dialysis (N = 8) with severe SHPT (intact parathyroid hormone (iPTH) level > 600 pg/mL) and hyperphosphatemia and/or persistent hypercalcemia treated with cinacalcet. The patients were followed for 12 months. Their serum calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), and iPTH levels were measured at baseline and on days 30, 60, 90, 180, and 365. Results: Patients with hyperphosphatemia (57.7%), hypercalcemia (23%), or both (19.3%) with iPTH > 600 pg/mL were prescribed cinacalcet. At the end of the study, decreases were observed in iPTH (1348 ± 422 vs. 440 ± 210 pg/mL; p < 0.001), Ca (9.5 ± 1.0 vs. 9.1 ± 0.6 mg/dl; p = 0.004), P (6.0 ± 1.3 vs. 4.9 ± 1.1 mg/dl; p < 0.001), and ALP (202 ± 135 vs. 155 ± 109 IU/L; p = 0.006) levels. Adverse events included hypocalcemia (26%) and digestive problems (23%). At the end of the study, 73% of the patients were on active vitamin D and cinacalcet. Three (11.5%) patients on peritoneal dialysis did not respond to therapy with cinacalcet, and their iPTH levels were never below 800 pg/mL. Conclusion: Cinacalcet combined with traditional therapy proved safe and effective and helped manage the mineral metabolism of patients with severe SHPT.

The effectiveness of cinacalcet: a randomized, open label study in chronic hemodialysis patients with severe secondary hyperparathyroidism

Background: Secondary hyperparathyroidism (SHPT) is associated with high incidences of cardiovascular disease, bone fracture, and mortality. This study was conducted to demonstrate the effectiveness of cinacalcet treatment on chronic kidney disease-mineral bone disorder (CKD-MBD) markers in chronic hemodialysis patients with severe SHPT.Methods: In phase 1, 30 adult HD patients were randomized to cinacalcet or control groups for 12 weeks to explore the achievement of >30% reduction of iPTH. In phase 2, 45 patients were participated to further explore the effect of cinacalcet on CKD-MBD parameters for 24-week follow up and 12 additional weeks after cinacalcet discontinuation.Results: In phase 1, the baseline serum iPTH levels were not different [1374 (955, 1639) pg/mL in the control group vs. 1191 (1005, 1884) pg/mL in the cinacalcet group], the percentage of patients achieving iPTH target were significantly higher in the treatment group [80% vs. 13%, p = .001]. In phase 2, the significant reductions of iPTH, FGF-23, tartrate-resistant acid phosphatase 5b, and slightly decreased size of parathyroid gland and stabilized vascular calcification were observed at 24-week follow up and markedly rebounded after discontinuation of cinacalcet.Conclusions: The effectiveness of cinacalcet were still obviously demonstrated even in chronic HD patients with severe SHPT. In addition, the improvements of bone markers and FGF-23, and stabilization of vascular calcification were observed. Therefore, cinacalcet can provide salutary effects on CKD-MBD in severe SHPT and might be an initially effective PTH-lowering therapy prior to surgical parathyroidectomy as well as an alternative treatment in the patients unsuitable for surgery.Clinical trial registration: ClinicalTrials.gov: NCT02056730. Date of registration: February 4, 2014.

Effect of Ronghuang Granule on serum FGF23, FGFRs and Klotho in non-dialysis patients with CKD-MBD and kidney deficiency and damp-heat syndrome

To observe the effect of Ronghuang granule on serum fibroblast growth factor 23 (FGF23), fibroblast growth factor receptor (FGFRs) and Klotho protein levels in non-dialysis patients with chronic kidney disease-mineral and bone disorder (CKD-MBD) and kidney deficiency and damp heat syndrome. Seventy non-dialysis CKD-MBD patients with kidney deficiency and dampness-heat syndrome were randomized into control group (n=35) and treatment group (n=35). All the patients were given routine treatment combined with traditional Chinese medicine retention enema, and the patients in the treatment group received additional Ronghuang granule treatment (3 times a day). After the 12-week treatments, the patients were examined for changes of TCM syndromes. Serum levels of Ca, P, parathyroid hormone (iPTH), FGF23, FGFRs and Klotho proteins were detected before and after treatment. These parameters were also examined in 20 healthy volunteers. Sixty-five patients completed the study, including 33 in the control group and 32 in the treatment group. The patients in the treatment group showed significantly better treatment responses than those in the control group (P &lt; 0.05 or 0.01). At 4, 8, and 12 weeks of treatment, the patients in the treatment group had significantly lowered scores of TCM syndromes compared with the score before treatment (P &lt; 0.05 or 0.01), while in the control group, significant reduction of the scores occurred only at 12 weeks (P &lt; 0.05); at each of the time points, the treatment group had significantly greater reductions in the score than the control group (P &lt; 0.01). Significant improvements in serum Ca, P and iPTH levels were observed at 4, 8, and 12 weeks in the treatment group (P &lt; 0.05) but only at 12 weeks in the control group (P &lt; 0.05). The patients in the control and treatment groups all showed elevated serum levels of FGF23, FGFRs and Klotho protein compared with the normal subjects (P &lt; 0.01); FGF23, FGFRs and Klotho levels were significantly reduced in the treatment group (P &lt; 0.05) but remained unchanged in the control group (P&gt;0.05), showing significant differences between the two groups. Ronghuang granule improves the clinical symptoms of non-dialysis CKD-MBD patients with kidney deficiency and dampness heat syndrome by reducing serum levels of FGF23, FGFRs and Klotho, improving calcium and phosphorus metabolism disorder, and inhibiting secondary hyperparathyroidism.

Uso del valor de la hormona paratiroidea intacta en el primer día postoperatorio tras tiroidectomía total como predictor de hipoparatiroidismo permanente

BackgroundPermanent hypoparathyroidism is the most common long-term complication after total thyroidectomy, causing significant morbidity and requiring long-term replacement therapy. Our study objective was to assess whether intact parathyroid hormone (iPTH) levels on the first day after total thyroidectomy are a good predictor of permanent hypoparathyroidism. Patients and methodsA retrospective observational study of all patients undergoing total thyroidectomy between January 2009 and December 2014. iPTH and calcium levels were measured the first day after surgery. Patients were followed up for at least one year after surgery. ResultsThe study group consisted of 481 patients with a mean age of 53±14 years, 82% of them females. The most common reason for thyroidectomy was multinodular goiter (75%), followed by papillary thyroid cancer (15%). Transient hypocalcemia was the most common early complication after total thyroidectomy (49%), and permanent hypoparathyroidism was the most common long-term complication (6%). ROC curve analysis showed that iPTH level on the first postoperative day was a good predictor of permanent hypoparathyroidism (area under the curve 0.87; 95% CI: 0.84-0.91). Cut-off iPTH levels of 5pg/mL had 95% sensitivity, 77% specificity, 21.6% positive predictive value, and 99.6% negative predictive value. ConclusionsiPTH level on the first day after total thyroidectomy is a useful predictor of permanent hypoparathyroidism because of its high negative predictive value. Serum iPTH levels >5pg/mL virtually exclude presence of permanent hypoparathyroidism.

Association of serum mineral parameters with mortality in hemodialysis patients: Data from the Korean end-stage renal disease registry.

BackgroundWe investigated the associations between mineral metabolism parameters and mortality to identify optimal targets in Korean hemodialysis patients.MethodsAmong hemodialysis patients registered in the end-stage renal disease registry of the Korean Society of Nephrology between March 2012 and June 2017, those with serum calcium, phosphorus, and intact parathyroid hormone (iPTH) measured at enrollment were included. Association of serum levels of calcium, phosphorus, and iPTH with all-cause mortality was analyzed.ResultsAmong 21,433 enrolled patients, 3,135 (14.6%) died during 24.8 ± 14.5 months of follow-up. After multivariable adjustment, patients in the first quintile of corrected calcium were associated with lower mortality (hazard ratio [HR], 0.84; 95% confidence interval [95% CI], 0.71–0.99; P = 0.003), while those in the fifth quintile were associated with higher mortality (HR, 1.39; 95% CI, 1.20–1.61; P < 0.001) compared with those in the third quintile. For phosphorus, only the lowest quintile was significantly associated with increased mortality (HR, 1.24; 95% CI, 1.08–1.43; P = 0.003). The lowest (HR, 1.18; 95% CI, 1.02–1.36; P = 0.026) and highest quintiles of iPTH (HR, 1.24; 95% CI, 1.05–1.46; P = 0.013) were associated with increased mortality. For target counts achieved according to the Kidney Disease Outcomes Quality Initiative guideline, patients who did not achieve any mineral parameter targets hadhigher mortality than those who achieved all three targets (HR, 1.37; 95% CI, 1.12–1.67; P = 0.003).ConclusionIn Korean hemodialysis patients, high serum calcium, low phosphorus, and high and low iPTH levels were associated with increased all-cause mortality.

Comparison of Initial Clinical Presentations between Primary Hyperparathyroidism Patients from New Brunswick and Changsha.

Purpose To compare the initial clinical features, laboratory values, and bone mineral density among patients with primary hyperparathyroidism (PHPT) in Changsha (China) and New Brunswick (USA). Methods In this retrospective study, we reviewed 169 PHPT patients who presented at Robert Wood Johnson University Hospital and 133 PHPT patients who presented at the Second Xiangya Hospital of Central South University in the same time period. The following characteristics were compared between the groups: age, gender, BMI, serum calcium, alkaline phosphatase (AKP), albumin, intact PTH (iPTH), 25-hydroxyvitamin D (25 (OH) D), fasting blood glucose levels, and bone mineral density (BMD). All these parameters were also compared according to gender and menopausal status. iPTH associations were also assessed along with several other parameters. Results PHPT patients from Changsha had higher serum calcium, iPTH, and AKP levels but lower 25 (OH) D levels than the patients from New Brunswick (p < 0.05). Patients in Changsha had lower T-scores and Z-scores in both the lumbar spine and hip regions than those in New Brunswick (p < 0.05). Patients in New Brunswick had lower percentages of parathyroid adenoma and kidney stones. Serum iPTH level was positively correlated with serum calcium and serum AKP levels in both Changsha and New Brunswick (p < 0.05). Conclusions There are distinct biochemical and clinical differences between patients with PHPT in China and the United States. Our study revealed that Asian PHPT patients from Changsha presented more severe PHPT profiles, lower bone mineral density, and higher incidence of renal stones.

NF-κB activation contributes to parathyroid cell proliferation in chronic kidney disease.

Secondary hyperparathyroidism is characterized by parathyroid gland (PG) hyperplasia, and excessive synthesis and secretion of parathyroid hormone (PTH). Reduced vitamin D receptor (VDR) density has shown to play an essential role in PG hyperplasia progression; nevertheless, its exact mechanism remains unclear. VDR has shown to suppress the inflammation mediator NF-κB-mediated gene transcription. The aim of this study is to examine whether NF-κB is involved in the pathogenesis of parathyroid hyperplasia. 35 PGs was obtained from 10 maintenance hemodialysis patients who underwent parathyroidectomy surgery. 5/6-nephrectomized rats fed with a high-phosphate diet were divided into four groups: (1) Nx + vehicle group, treated with vehicle; (2) Nx + PDTC prevention group, treated with NF-κB inhibitor PDTC for 2months; (3) Nx + PDTC therapy group, treated with PDTC for 1month; (4) Nx + calcitriol group, treated with activated vitamin D calcitriol for 1month. Ten sham-operated rats fed with normal-phosphate diet were used as a control group. Serum calcium, phosphorus, creatinine, Blood urea nitrogen (BUN), intact PTH and PG size in rats were measured. Proliferating cell nuclear antigen (PCNA), VDR, NF-κB of PGs were examined using immunohistochemistry and western blot. The activation of NF-κB pathway in the nodular hyperplasia gland was significantly increased compared with the diffuse hyperplasia gland found in hemodialysis patients. Markedly higher serum creatinine, BUN, phosphorus levels, serum iPTH levels and larger PGs were found in Nx rats fed with a high-phosphate diet compared to sham-operated rats. Also, PCNA levels and activation of NF-κB pathway in PGs were higher compared with the sham group, meanwhile the VDR levels decreased. Contrary, treating rats with PDTC and calcitriol notably reduced serum iPTH, expression of PCNA and activation of NF-κB pathway, and decreased the enlargement of PGs in those animals. NF-κB plays an important role in PG hyperplasia progression. VDR deficiency may be involved in the parathyroid gland hyperplasia through the activation of NF-κB pathway.

Higher dialysate calcium concentration is associated with incident myocardial infarction among diabetic patients with low bone turnover: a longitudinal study

This is a longitudinal study on 53,560 hemodialysis patients from the Japan Renal Data Registry. Predictor was D[Ca] ≥3.0 vs 2.5 mEq/L. Outcomes were the first CV events during 1-year observation period. Association of D[Ca] with CV events and effect modifications were tested using multivariate logistic regression analyses. Diabetes mellitus (DM) was a significant effect modifier for association of higher D[Ca] and myocardial infarction (MI) (OR: 1.26 (1.03–1.55) among DM and 0.86 (0.72–1.03) among non-DM, p for interaction <0.01). The effect size was not affected by further adjustment for serum albumin-corrected Ca or intact parathyroid hormone (iPTH) levels, but was attenuated by adjustment for intradialytic change in serum Ca concentration (ΔCa) (1.16 [0.89–1.51]). Among DM, D[Ca] ≥3.0 mEq/L was significantly associated with MI in the first tertile of corrected Ca or iPTH ≤60 pg/ml (p for interaction 0.03 and 0.03, respectively). In conclusion, higher D[Ca] was associated with incident MI in DM, especially with low serum Ca or iPTH levels. Attenuation of the effect size by adjustment for ΔCa and stratified analyses suggest that larger Ca influx during dialysis with higher D[Ca] in patients suggestive of low bone turnover leads to vascular calcification and subsequent MI in DM.

Sequential parathyroidectomy under cervical plexus anesthesia for secondary hyperparathyroidism with renal function failure

Objective: To summarize the strategy of sequential parathyroidectomy for secondary hyperparathyroidism. Methods: Between January 2009 and December 2017, 32 patients with secondary hyperparathyroidism underwent parathyroidectomy in Department of General Surgery, Peking Union Medical College Hospital. There were 11 male and 21 female patients with a mean age of 51.3 years. Eleven of them underwent bilateral neck exploration under general anesthesia, while the rest of them underwent sequential parathyroidectomy. For the patients with sequential parathyroidectomy, a unilateral neck exploration was performed in the initial operation under cervical plexus blocking anesthesia. Second operation for contralateral parathyroid lesions was performed if the serum intact parathyroid hormone (iPTH) was still higher than 1 000 ng/L or related symptoms were not relieved significantly 6 months later after initial surgery. Fisher exact test was used to compare the date between the 2 groups. Results: In the bilateral exploration group, the serum iPTH level gradually exceeded above 1 000 ng/L in 5 patients during follow-up, and reoperation were performed in 3 patients of them. In the group with sequential parathyroidectomy, the serum iPTH level after initial operation exceeded above 1 000 ng/L in 15 patients. Eleven of them underwent contralateral parathyroidectomy, which decreases the serum iPTH levels to less than 1 000 ng/L in 10 patients. Compared with the sequential parathyroidectomy group (1/11), more patients needed to be treated in the intensive care unit after operation in bilateral exploration group (6/11), although the difference was statistically insignificant (P=0.063). Conclusions: Sequential parathyroidectomy strategy is feasible for the secondary hyperparathyroidism with severe complications. Prospective controlled observation with large sample size is needed to confirm its effect.

Effects of Short Term Alendronate Administration on Bone Mineral Density in Patients with Chronic Kidney Disease.

Abstract Background: Osteoporosis is highly prevalent in CKD patients and is characterized by low bone mass leading to decreased bone strength. It is associated with an increased risk of fracture, thus increasing morbidity and mortality. Bisphosphonate administration decreases fracture risk in postmenopausal females with osteoporosis. There are limited studies showing effects of short term alendronate administration on BMD in predialysis osteoporotic patients with CKD. Methods: This study was conducted on fifty adult patients with chronic kidney disease. Patients were divided into two groups. Group A consisted of seventeen patients with CKD stage 3 (eGFR 45-30 ml/min/1.73m2) and Group B comprised thirty three patients with CKD stage 4 (eGFR 30-15 ml/min/1.73m2). The study included male patients between age 18-75 years and premenopausal non pregnant females older than 18 years of age. All the patients were osteoporotic having T score &lt; −2.5 on DEXA scan. The patients were administered 70 mg alendronate tablet once a week for 6 weeks. Renal parameters, parathyroid hormone, calcium, phosphorous and alkaline phosphatase levels were assayed at baseline for 6 months. Serum (iPTH) level (pg/ml) was measured by chemiluminescent immune assay (CLIA) method and serum 25 Hydroxy Vitamin D level (ng/ml) was measured by enzyme linked immunosorbent assay (ELISA) method. Bone Mineral Density (BMD) was measured at baseline for 6 months, by dual energy x-ray absorptiometry at lumbar spine and neck of femur and lowest values were included. The results were obtained for T score, Z score and bone mineral density (g/cm2). Results: The BMD, T score and Z score increased in both groups after 6 months with a statistically significant difference in the treatment group. In Group A, T score, Z score and BMD (g/cm2) increased from −2.60±0.086, −2.13±0.28, and 0.80±0.008 at baseline to −2.57±0.097, −2.11±0.26 and 0.81±0.008 after six months. In Group B, the T score, Z score and BMD (g/cm2) increased from −3.17±0.24, −2.82±0.33 and 0.738±0.03 to −3.16±0.25, −2.66±0.95 and 0.743±0.03 after six months with a statistically significant difference. eGFR decreased in both groups but the difference was statistically non-significant (P&gt;0.05). The serum iPTH levels increased after 6 months in both groups with a statistically insignificant difference. There was an increase in serum calcium and decrease in serum phosphate levels after six months, however the difference was statistically insignificant (p&gt;0.05). The SAP values decreased in both groups after six months with a statistically insignificant difference. The main side-effect in the alendronate group was the occurrence of gastroesophageal reflux symptoms in two subjects. Conclusion: Low-dose alendronate, administered for a limited duration, appears to be well tolerated in CKD patients. The BMD increased in both groups suggesting a bone-preserving effect of alendronate.

The intervention effect of zuogui pill on chronic kidney disease-mineral and bone disorder regulatory factor

Chronic kidney disease-mineral and bone disorder (CKD-MBD) play a critical role in the pathogenesis of cardiovascular complications in patients with chronic kidney disease (CKD). Zuogui pill as a traditional Chinese herbal drug has been used for nourish kidney essence improve bone malnutrition of renal bone disease by regulating the metabolism of calcium and phosphorus and participating in osteoblast metabolism. In the present study, 5/6 nephrectomy rat model was used to reveal the mechanism of zuogui pill in treatment of CKD-MBD. Compared with sham rats, the levels of serum phosphorus, PTH, iPTH and creatinine were significantly decreased, while the serum calcium level was significantly increased, and the Cbfa1 protein level was significantly decreased and FGF23 protein level was significantly increased by Zuogui pill treatment. Compared with model rats, the BMD of rat was significantly increased by Zuogui pill treatment. Histological analysis revealed that the kidney injury of rats with CKD was significantly reduced by zuogui pill treatment. Compared with model rats, the CYP27B1 mRNA level was significantly increased, and the PTH mRNA level and NaPiIIa protein level were significantly decreased in the kidney by zuogui pill treatment. We inferred that zuogui pill exhibited potential therapeutic effects on CKD-MBD in the rats by regulating bone metabolism and nourish kidney.