Treatment Of Persistent Hyperparathyroidism Research Articles

Efficacy of Cinacalcet in the Treatment of Persistent Hyperparathyroidism in Late Kidney Transplantation

Efficacy of Cinacalcet in the Treatment of Persistent Hyperparathyroidism in Late Kidney Transplantation

Robotic thoracoscopic parathyroidectomy for ectopic mediastinal parathyroid adenoma

The publication presents the successful experience of using the DaVinci robotic system for the treatment of persistent hyperparathyroidism caused by mediastinal ectopic parathyroid adenoma in 62 years old female patient. The role of single photon emission computed tomography in diagnostics was demonstrated.

P1429EVALUATION OF PARATHYROIDECTOMY IN PERSISTENT HYPERARATHYROIDISM AFTER RENAL TRANSPLANTATION: A SINGLE-CENTER RETROSPECTIVE STUDY

Abstract Background and Aims To investigate the efficacy of parathyroidectomy (PTX) in the treatment of persistent hyperparathyroidism (PHPT) after renal transplantation and the effect of PTX on renal allograft function. Method This single-center retrospective study enrolled 31 patients who underwent PTX for the treatment of PHPT after renal transplantation in the Kidney Disease Center of the First Affiliated Hospital of Zhejiang University from May 2010 to Oct. 2018. The changes of serum calcium, serum phosphorus, alkaline phosphatase, parathyroid hormone(PTH), serum creatinine, and estimated glomerular filtration rate (eGFR) in the preoperative and postoperative periods (1w, 1m, 3m, 6m,12m) were compared. The operative successful rate (12 m) and postoperative complications were calculated. Results The serum calcium before PTX was (2.78±0.18) mmol/L, which decreased significantly to (2.19±0.34) mmol/L at 1 week postoperatively (P<0.01). The serum phosphorus before PTX was (0.76±0.16) mmol/L, which decreased significantly to (0.97±0.26) mmol/L at 1 week postoperatively (P<0.01). The PTH before PTX was (276.00±200.60) pg/mL, which decreased significantly to (46.62±104.36) pg/mL at 1 week postoperatively (P<0.01). The alkaline phosphatase before PTX was (261.59±236.95) U/L, which decreased significantly to (154.90±117.37) U/L at 3 months postoperatively (P<0.01). No significant difference was found in postoperative serum creatinine or eGFR levels compared with the baseline. The operative successful rate was 90.3% at 12 months postoperatively. The incidence rates of postoperative transient hypocalcemia, persistent hypoparathyroidism, and hoarseness were 35.5%, 3.2% and 3.2% respectively. No persistent hypocalcemia, incision hemorrhage, incision infection, or surgery-related death happened. Conclusion PTX can quickly and effectively alleviate high calcium, low phosphorus, high PTH and high alkaline phosphatase after renal transplantation. PTX is effective and safe in the treatment of PHPT after renal transplantation, and has no effect on renal allograft function.

Treatment of Persistent Hyperparathyroidism after Renal Transplant

Background Hyperparathyroidism is a frequent complication in chronic kidney disease and may persist after transplant in 20 to 50% of cases, manifest by hypercalcemia and hypophosphatemia. Persistent disease is associated with an increase in the incidence of cardiovascular events, fracture and death. Therapeutic options currently available are parathyroidectomy (PTX) and therapy with calcimimetic agent cinacalcet. Methods Single-center retrospective study including adult renal transplant recipients who developed hipercalcemia due to persistent hyperparathyroidism. Criteria for treatment: Elevated PTH with serum calcium > 11 mg/dL at any time after transplantation or serum calcium persistently higher than 10.2 mg/dl one year after transplantation. Patients treated with cinacalcet (n = 46) were compared to patients treated with parathyroidectomy (n = 30). The follow up period was 1 year. Demographic and laboratory data were analyzed. In the cinacalcet group, episodes of rejection and medication tolerance were also analyzed. Results PTX controlled the calcemia faster and reached significantly lower levels in the long term (p = 0.0073); PTX showed significantly higher levels of serum phosphate (p = 0.0012) and returned PTH to normal levels (p <0.0001). Cinacalcet, despite of controlling calcium and phosphorus in the long term, did not correct PTH. There was no difference in response to cinacalcet when subgroups were stratified by PTH (≤700 pg/ml vs. > 700 pg/ml). Patients treated with cinacalcet had better renal function (p = 0.0002). The drug was well tolerated and no rejection episode was detected. Conclusions The surgical treatment was superior to cinacalcet to correct the metabolic disorders of hyperparathyroidism; however, it was associated with worse renal function in the long term. Cinacalcet proved to be a safe and well tolerated drug.

Cinacalcet in the treatment of persistent hyperparathyroidism after kidney transplantation

Secondary hyperparathyroidism persists in 30 - 50% of patients after a successful kidney transplant and it is the most frequent cause of hypercalcemia after transplant, contributing to graft loss and mortality. Several medical therapies have been studied for the treatment of this condition without clear benefit. Recently, interest has grown in the use of cinacalcet in kidney transplant recipients. We describe the efficacy of cinacalcet in 18 kidney transplant patients with persistent hyperparathyroidism and progressive hypercalcemia treated for a period of 12-months. We analyzed serum calcium, phosphorus and parathyroid hormone levels every 6 months, and cinacalcet was titrated if necessary. Statistical analysis was performed using ANOVA. With therapy, all patients exhibited significant reduction in parathyroid hormone levels, from a mean value of 242.04 ± 105.82 pg/ml to a mean value of 145.62 ± 54.99 pg/ml (p < 0.001) 12 months later. In addition, serum calcium levels normalized during the study period, from 11.16 mg/d to 9.95 mg/dl (mean values) (p < 0.001). No significant change in serum creatinine was found in this group of patients. Cinacalcet was well tolerated, with no side effects documented. This preliminary experience suggests that cinacalcet may be useful in the treatment of persistent hyperparathyroidism after kidney transplant. In addition, cinacalcet controlled hypercalcemia, which has well known adverse effects after transplant. This was accomplished with no evidence of declining kidney function or limiting side effects.

Treatment of Persistent Hyperparathyroidism in Renal Transplant Patients With Cinacalcet Improves Control of Blood Pressure

Persistent hyperparathyroidism is observed in 17% to 50% of patients at 1 year after renal transplantation. In 10% of these patients, hypercalcemia is also present. This condition increases the risk of vascular calcification, correlating with inferior graft function among patients with interstitial calcification in the renal allograft. Hypertension is appears in 60% to 90% of patients after transplantation, favoring progressive graft dysfunction. Hypercalcemia per se causes hypertension. Parathyroid hormone can potentiate the pressor effects of hypercalcemia. Fourteen renal transplant recipients were included based upon: total serum calcium > 10.0 mg/dL, intact parathyroid hormone levels > 70 pg/mL, graft function > 6 months, creatinine clearance > 50 mL/min, and stable immunosuppressive therapy. We also examined blood pressure and antihypertensive treatment. Initially patients received 30 mg of cinacalcet once a day. The follow-up was up to 6 months. The mean cinacalcet dose was 40 mg/24 h. Five patients received 60 mg/24 h. Both serum calcium and iPTH decreased significantly from 10.6 (DE 0.4) to 9.8 (DE Both serum calcium and iPTH decreased significantly from 10.6 (DE 0.4)to 9.8 (DE 0.6) mg/dL (P < .001) and from 195.0 (DE 140.0) to 118.62 (DE 102.2; P < .0001). There were no significant changes in renal function, proteinuria, or tacrolimus levels. Mean blood pressure diminished from 94.1 (DE 12.0) to 88.0 (DE 7.5) mm Hg (P < .019) with no changes in antihypertensive treatment. Cinacalcet was suspended in one patient because of gastrointestinal discomfort and in another one because the iPTH was reduced to 51 pg/mL. Cinacalcet is an effective treatment for persistent hyperparathyroidism associated with hypercalcemia among renal transplant patients and may be helpful for hypertension control.

Changes in bone and mineral metabolism in kidney transplant patients with chronic kidney disease

Recently, the Foundation has proposed new definitions KDIGO to refer to the alterations of bone - mineral metabolism in patients with chronic renal disease (CRD), relegating the traditional term of renal osteodystrophy (ODR). RECOMMEND: The term ODR exclusively to define alterations in bone morphology and architecture characteristic of the ERC. - And the term of bone-mineral alteration associated with the CRD to describe biochemical changes, and skeletal calcifications that occur as a result of alterations in mineral metabolism in the CRD. The different metabolic abnormalities are secondary to the progressive loss of renal mass and renal function that leads to retention of phosphorus and a decrease in the levels of calcitriol which are responsible for the skeletal resistance to the action of PTH. The main clinical manifestations of abnormal bone mineral metabolism are posttransplantation osteoporosis and osteopenia producing an increase in fractures, osteonecrosis, and bone pain. Biochemical parameters (calcium, phosphorus, PTH, 25 hydroxyvitamin D), X-ray bone densitometry and bone biopsy. (Evidence B). THERAPEUTIC ALTERNATIVES: It is recommended for the treatment and prevention of osteopenia - osteoporosis in transplant patients based on data from clinical evidence available from other study populations, such as in patients with chronic kidney disease. In addition to specific treatment, we must take into account the preventive measures to reduce the risk of fractures. Treatment includes specific measures for the prevention of bone loss (active metabolite of vitamin D analogues and bisphosphonates) and the treatment of persistent hyperparathyroidism (calcimiméticos). (Evidence B).

Potential future uses of calcimimetics in patients with chronic kidney disease.

Cinacalcet has proven effective in the treatment of secondary hyperparathyroidism (SHPT) in dialysis patients, and it may also have benefits in stage 3 and 4 chronic kidney disease (CKD). The efficacy of cinacalcet in the treatment of SHPT was investigated in a study of 54 patients with stage 3 and 4 CKD not receiving dialysis. A significant number of these patients achieved at least a 30% reduction in parathyroid hormone (PTH) from baseline with cinacalcet therapy compared with placebo (56% versus 19%; P = 0.006). Another potential use of cinacalcet is in the treatment of persistent hyperparathyroidism (HPT) after kidney transplantation. The pathophysiologic considerations for persistent HPT in patients who have undergone renal transplantation are different from those in stage 3 and 4 CKD. Post-transplant patients with normal graft function often present with hypercalcaemia, low serum phosphorus and persistently elevated levels of PTH. In eight small open-label studies including a total of 83 patients with persistent HPT after successful kidney transplantation, cinacalcet treatment effectively corrected hypercalcaemia and significantly reduced elevated PTH levels. These studies suggest that cinacalcet therapy is an effective therapy in controlling hyperparathyroidism in patients with stage 3 and 4 CKD and in post-transplant patients with persistent hyperparathyroidism.

The calcimimetic cinacalcet normalizes serum calcium in renal transplant patients with persistent hyperparathyroidism

Treatment of persistent hyperparathyroidism in renal transplant patients resistant to calcium and vitamin D sterols is limited and often requires parathyroidectomy. Given the potential hazards linked to surgery, an alternative approach to manage excess parathyroid hormone (PTH) secretion is needed. Calcimimetics inhibit PTH secretion by modulating the calcium-sensing receptor in the parathyroid. Lowering of the serum calcium concentration with the calcimimetic cinacalcet has previously been demonstrated in patients with primary hyperparathyroidism or with secondary hyperparathyroidism on dialysis. Here we present the first clinical observations of a calcimimetic in patients with persistent hyperparathyroidism. A 30 mg dose of cinacalcet was prescribed once daily for 3 months to seven female and seven male stable renal transplant patients, aged 23-65 years, 7 months to 14 years after transplantation, with a serum creatinine ranging from 89 to 229 micromol/l and persistent hyperparathyroidism. Concomitant medication included cyclosporin and low-dose prednisone in all patients. On cinacalcet, serum calcium decreased and normalized in all but two patients (baseline 2.72+/-0.03 mmol/l; 1 month 2.42+/-0.04 mmol/l, P<0.001), whereas serum PTH and phosphate levels did not change significantly. A slight reduction in renal function, as assessed by serum creatinine concentration, was observed at months 2 and 3 (P<0.05). An immunoglobulin-deficient patient developed colitis after 1 week of treatment and cinacalcet was withdrawn. No patient stopped cinacalcet because of other presumed side effects. Calcimimetics are a promising therapy in renal transplant patients with persistent hyperparathyroidism. Prospective controlled studies must now be designed focusing on functionally relevant musculo-skeletal end-points and allowing the exclusion of negative effects on long-term renal and general outcome of such patients.