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Hyperparathyroidism
Kinds of Hyperparathyroidism Selected AbstractsHN08P AUDIT OF 115 CONSECUTIVE PARATHYROIDECTOMIES IN PATIENTS WITH RENAL HYPERPARATHYROIDISMANZ JOURNAL OF SURGERY, Issue 2007T. H. Low Objectives To review the characteristics and outcomes of patients undergoing parathyroidectomy for renal (secondary and tertiary) hyperparathyroidism. Methods Review of prospectively collected data from a dedicated head and neck database at RPAH between 1988 and 2004. A total of 115 patients underwent exploratory parathyroidectomy. Results Common indications for parathyroidectomy included hypercalcaemia, renal osteodystrophy, calciphylaxis and calcinosis, bone or joint pain, and pruritus. Sixty-nine patients had subtotal parathyroidectomy (STP), 47 had total parathyroidectomy (TP) of which 4 had total parathyroidectomy with autotransplant (TPA). Ten patients required re-exploration for recurrent hyperparathyroidism at a median time to reoperation of 55 months. Of those, 8 had STP, 1 had TP, and 1 had TPA. Predictors of recurrent hyperparathyroidism included higher post operative PTH level (median of 22.5 pmol/L vs 3.4 pmol/L) and higher total parathyroid weight (median of 7.75 gm vs 2.9 gm). 97% of patients reported resolution of symptoms on follow-up. The average length of hospital admission was 4.4 days. Morbidity of this series included wound infection (0.8%), temporary vocal cord paralysis (0.8%), seizure due to severe hypocalcaemia (0.8%) and neck haematomas requiring evacuation (0.8%). Conclusions Parathyroidectomy is effective in the management of renal hyperparathyroidism. Subtotal parathyroidectomy is associated with a higher re-exploration rate. Predictors for recurrent hyperparathyroidism include total parathyroid weight and post-operative PTH level. [source] Heterogeneity in Serum 25-Hydroxy-Vitamin D Response to Cholecalciferol in Elderly Women with Secondary Hyperparathyroidism and Vitamin D DeficiencyJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2010Andrea Giusti MD OBJECTIVES: To compare the effects on parathyroid hormone (PTH) and 25-hydroxy-vitamin D (25(OH)D) of two dosing regimens of cholecalciferol in women with secondary hyperparathyroidism (sHPTH) and hypovitaminosis D and to investigate variables affecting 25(OH)D response to cholecalciferol. DESIGN: Randomized-controlled trial with 6-month follow-up. SETTING: Two osteoporosis centers in northern Italy. PARTICIPANTS: Sixty community-dwelling women aged 65 and older with sHPTH and hypovitaminosis D, creatinine clearance greater than 65 mL/min and without diseases or drugs known to influence bone and vitamin D metabolism. INTERVENTION: Cholecalciferol 300,000 IU every 3 months, once at baseline and once at 3 months (intermittent D3 group) or cholecalciferol 1,000 IU/day (daily D3 group). MEASUREMENTS: Serum PTH, 25(OH)D, calcium, bone-specific alkaline phosphatase, ,-C-terminal telopeptide of type I collagen, phosphate, 24-hour urinary calcium excretion. RESULTS: The two groups had similar baseline characteristics. All participants had vitamin D deficiency [25(OH)D<20 ng/mL)], and 36 subjects (60%) had severe deficiency (<10 ng/mL), with no difference between the groups (severe deficiency: intermittent D3 group, n=18; daily D3 group, n=18). After 3 and 6 months, both groups had a significant increase in 25(OH)D and a reduction in PTH. Mean absolute increase±standard deviation of 25(OH)D at 6 months was higher in the intermittent D3 group (22.7±11.8 ng/mL) than in the daily D3 group (13.7±6.7 ng/mL, P<.001), with a higher proportion of participants in the intermittent D3 group reaching desirable serum concentration of 25(OH)D , 30 ng/mL (55% in the intermittent D3 group vs 20% in the daily D3 group, P<.001). Mean percentage decrease of PTH in the two groups was comparable, and at 6 months, a similar proportion of participants reached normal PTH values. 25(OH)D response to cholecalciferol showed a wide variability. In a logistic regression analysis, body mass index and type of treatment appeared to be significantly associated with normalization of 25(OH)D values. CONCLUSION: Cholecalciferol 300,000 IU every 3 months was more effective than 1,000 IU daily in correcting vitamin D deficiency, although the two groups achieved similar effects on PTH at 6 months. Only 55% of the higher-dose intermittent group reached desirable concentrations of 25(OH)D, suggesting that yet-higher doses will be required for adequate vitamin D repletion. [source] Surveillance for Early Detection of Aggressive Parathyroid Disease: Carcinoma and Atypical Adenoma in Familial Isolated Hyperparathyroidism Associated With a Germline HRPT2 Mutation,,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 10 2006Thomas G Kelly Abstract Familial hyperparathyroid syndromes involving mutations of HRPT2 (also CDC73), a tumor suppressor, are important to identify because the relatively high incidence of parathyroid malignancy associated with such mutations warrants a specific surveillance strategy. However, there is a dearth of reports describing experience with surveillance and early detection informed by genetic insight into this disorder. Introduction: Familial isolated hyperparathyroidism (FIHP) is a rare cause of parathyroid (PT) tumors without other neoplasms or endocrinopathies. Germline mutations in CASR, MEN1, and rarely, HRPT2 have been identified in kindreds with FIHP. HRPT2 mutations may be enriched in FIHP families with PT carcinoma, underscoring the importance of identifying causative mutations. Materials and Methods: A 13-year-old boy, whose father had died of PT carcinoma, developed primary hyperparathyroidism. A left superior PT mass was identified by ultrasonography and removed surgically. Aggressive histological features of the boy's tumor included fibrous trabeculae, mitoses, and microscopic capsular infiltration. Two years later, under close biochemical surveillance, primary hyperparathyroidism recurred 5 months after documentation of normocalcemia and normal parathyroid status. Ultrasound and MRI identified a newly enlarged right superior PT gland but indicated no recurrent disease in the left neck. Histologic features typical of a benign adenoma were evident after surgical extirpation of the gland. Results: Leukocyte DNA analysis revealed a frameshift mutation in exon 2 of HRPT2. The initial tumor manifested the expected germline HRPT2 mutation, plus a distinct somatic frameshift mutation, consistent with the Knudson "two hit" concept of biallelic inactivation of a classic tumor suppressor gene. Genetic screening of the patient's 7 asymptomatic and previously normocalcemic siblings revealed three with the same germline HRPT2 mutation. One of the siblings newly identified as mutation-positive was noted to be hypercalcemic at the time of the genetic screening. He was found to have a PT adenoma with aggressive features. Two of the five children of another mutation-positive sibling also carry the same HRPT2 mutation. Conclusions: Despite the reported rarity of HRPT2 mutations in FIHP, a personal or family history of PT carcinoma in FIHP mandates serious consideration of germline HRPT2 mutation status. This information can be used in diagnostic and management considerations, leading to early detection and removal of potentially malignant parathyroid tumors. [source] Chondrosarcoma in Association With Primary Hyperparathyroidism,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 7 2004Ajay Bhatia Abstract We describe two female patients, 66 and 36 years of age, with both primary hyperparathyroidism and chondrosarcoma. Case 1 had a chondrosarcoma of the right scapula, and case 2 had chondrosarcoma of the left proximal tibia. Both patients underwent surgical resection of their chondrosarcoma and subsequent parathyroid surgery. Histological analysis of the excised parathyroid in case 1 showed a parathyroid carcinoma and in case 2 showed a parathyroid adenoma. Including these two patients, there is now a total of six cases that have been reported in the literature describing the association between hyperparathyroidism and bone malignancy. We believe that this small number makes it unlikely that there is an association between these two conditions, although we speculate that there may be an underlying genetic basis. [source] Radioguided Parathyroidectomy for Recurrent Hyperparathyroidism Caused by Forearm Graft Hyperplasia,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 5 2003Rebecca S Sippel Abstract One of the surgical options for symptomatic secondary hyperparathyroidism is a total parathyroidectomy with forearm implantation. Recurrence can occur and is most likely caused by hyperplasia of the small fragments of parathyroid tissue implanted in the forearm muscle. Forearm graft hyperplasia can be detected using Tc-99m sestamibi scanning of the forearm, which can show abnormal enhancement at the former graft site. In this report, we present the case of a 49-year-old gentleman with recurrent hyperparathyroidism caused by hyperplasia of forearm graft fragments. Unfortunately, no sutures or clips were placed at his initial surgery to identify the location of the parathyroid tissue in the forearm. Thus, we describe the first reported use of radioguided techniques using Tc-99m sestamibi injection and intraoperative gamma probe to localize parathyroid fragments in the forearm muscle. During our initial exploration, we found that injection of the tracer in the operative arm leads to prohibitively high levels of background activity. During a second exploration, the tracer was injected in the lower extremity, minimizing the background in the forearm and allowing the gamma probe to clearly identify two areas of abnormal parathyroid tissue. The intraoperative radioprobe allowed quick identification and removal of the abnormal parathyroid tissue in a case that was made particularly challenging by the absence of marking sutures. [source] Hyperparathyroidism in dogs with hyperadrenocorticismJOURNAL OF SMALL ANIMAL PRACTICE, Issue 11 2005I. K. Ramsey Objectives: To assess the effect of canine hyperadrenocorticism (HAC) on parathyroid hormone (PTH), phosphate and calcium concentrations. Methods: PTH concentrations and routine biochemical parameters were measured in 68 dogs with HAC. Ionised calcium was measured in 28 of these dogs. The results obtained were compared with an age- and weight-matched group of 20 hospital patients that did not show signs of HAC. Results: There were significant differences between the PTH, phosphate, alkaline phosphatase, creatinine and albumin concentrations between the two groups. Total and ionised calcium concentrations were not significantly different. Most of the dogs (92 per cent) with HAC had PTH concentrations that were greater than the reference range (10 to 60 pg/ml), and in 23 dogs they were greater than 180 pg/ml. There were significant positive correlations between the PTH and basal cortisol, post-adrenocorticotropic hormone (ACTH) cortisol and alkaline phosphatase concentrations, and also the phosphate and post-ACTH cortisol concentrations. Clinical Significance: Adrenal secondary hyperparathyroidism is a cause of increased PTH concentrations and may be associated with abnormalities in calcium and phosphate metabolism in dogs with HAC. The findings of this study could explain why canine HAC may cause clinical signs such as calcinosis cutis that are associated with altered calcium metabolism. [source] Calcium and Phosphorus Homeostasis in Dogs with Spontaneous Chronic Kidney Disease at Different Stages of SeverityJOURNAL OF VETERINARY INTERNAL MEDICINE, Issue 1 2010O. Cortadellas Background: Studies in dogs with experimental chronic kidney disease (CKD) have demonstrated that abnormalities of calcium-phosphorus (Ca-P) homeostasis occur frequently and have a negative effect on kidney function and survival. However, the prevalence of these alterations in dogs with naturally occurring CKD at different stages of severity has not yet been investigated. Hypothesis: Abnormalities of Ca-P metabolism occur early in the course of CKD with an increased prevalence in more severe stages. Animals: Fifty-four dogs with CKD and 22 healthy dogs. Methods: Blood and urine samples were obtained for a CBC, biochemistry, determination of parathyroid hormone (PTH), calcitriol, and ionized calcium concentrations and urinalysis. Based on urine protein/creatinine ratio and serum creatinine concentration, dogs were grouped according to the IRIS classification for CKD. Results: Hyperparathyroidism (HPTH) (PTH , 48 pg/mL) was diagnosed in 41 (75.9%) dogs with CKD. Its prevalence increased from 36.4% (stage 1) to 100% (stage 4). Hyperphosphatemia (P > 5.5 mg/dL) was present in 37 (68.5%) dogs; increasing in prevalence from 18% (stage 1) to 100% (stage 4). Receiver-operating characteristic curve analysis showed that serum phosphorus concentration in the 4.5,5.5 mg/dL range correctly identified the presence of HPTH in most dogs. Calcitriol concentration progressively decreased in dogs with CKD and differences became statistically significant by stage 3. Conclusion and Clinical Relevance: HPTH and hyperphosphatemia occur frequently in dogs with naturally occurring CKD, even at early stages of CKD in some dogs. These findings highlight the importance of monitoring these parameters early in the course of CKD. [source] Primary Hyperparathyroidism and Monoclonal Gammopathy in a DogJOURNAL OF VETERINARY INTERNAL MEDICINE, Issue 1 2009G. Benchekroun First page of article [source] Early and Severe Hyperparathyroidism Associated with Hypercalcemia After Renal Transplant Treated with CinacalcetAMERICAN JOURNAL OF TRANSPLANTATION, Issue 10 2006N. Leca Bone disease is a common clinical problem following renal transplantation. In renal transplant recipients, multiple underlying factors determine the extent of bone loss and the subsequent risk of fractures. In addition to the well-recognized risk to bone disease posed by steroids, calcineurin inhibitors and pre-existing bone disease, persistent hyperparathyroidism (HPT) contributes to post-transplant bone loss. HPT is usually treated with vitamin D supplements combined with calcium. Patients whose HPT is associated with hypercalcemia pose a difficult therapeutic dilemma which often requires parathyroidectomy. Cinacalcet, a calcium mimetic agent, offers a unique pharmacologic approach to the treatment of patients with post-transplant hypercalcemia and HPT. In this paper, we describe the clinical course and biochemical changes in 10 renal transplant recipients with hypercalcemia and severe HPT early after renal transplantation treated with cinacalcet. Cinacalcet therapy corrected hypercalcemia and decreased parathyroid hormone (PTH) levels in all cases. A transient rise in the level of alkaline phosphatase was noted following initiation of cinacalcet therapy. In this patient population, correction of HPT was not permanent as discontinuing cinacalcet therapy led to a rapid rise in PTH level. [source] Insulin resistance is not coupled with defective insulin secretion in primary hyperparathyroidismDIABETIC MEDICINE, Issue 10 2009F. Tassone Abstract Aims, An increased frequency of both impaired glucose tolerance and Type 2 diabetes mellitus (DM) has been reported in primary hyperparathyroidism (pHPT), thus we sought to investigate insulin sensitivity and insulin secretion in a large series of pHPT patients. Subjects and methods, One hundred and twenty-two consecutive pHPT patients without known DM were investigated [age (mean ± sd) 59.3 ± 13.6 years, body mass index (BMI) 25.7 ± 4.2 kg/m2; serum calcium 2.8 ± 0.25 mmol/l; PTH 203.2 ± 145.4 ng/l]. Sixty-one control subjects were matched, according to the degree of glucose tolerance, in a 2 : 1 patient:control ratio. Fasting- and oral glucose tolerance test-derived estimates of insulin sensitivity and secretion were determined by means of the quantitative insulin sensitivity check index (QUICKI) and the insulin sensitivity index (ISI) composite. Results, Both the QUICKI and ISI composite were lower in pHPT patients than control subjects (P < 0.03 and P < 0.05, respectively) after adjusting for age, systolic blood pressure and BMI. Conversely, all insulin secretion estimates were significantly increased in pHPT patients than in control subjects (P < 0.04 and P < 0.03, respectively) and after adjusting for age, systolic blood pressure and BMI. Log serum calcium levels were negatively associated with the QUICKI and log ISI composite (R = ,0.30, P = 0.001; R = ,0.23, P = 0.020, respectively) in pHPT patients. Serum calcium levels significantly and independently contributed to impaired insulin sensitivity in multivariate analysis (QUICKI as dependent variable: , = ,0.31, P = 0.004, R2 = 0.15; log ISI composite as dependent variable: , = ,0.29, P = 0.005, R2 = 0.16). Conclusions, Our study confirms a reduction in both basal and stimulated insulin sensitivity in primary hyperparathyroidism, in spite of increased insulin secretion. Moreover, our data show for the first time a significant relationship between hypercalcaemia and insulin sensitivity in this condition. [source] Cytopathologist-performed ultrasound-guided fine-needle aspiration of parathyroid lesions,DIAGNOSTIC CYTOPATHOLOGY, Issue 5 2010David Lieu M.D., M.B.A. Abstract The gold standard to determine the cause of primary hyperparathyroidism (PHPT) is bilateral neck exploration. As most cases are caused by parathyroid adenoma, there is a movement toward preoperative localization of the abnormal gland by ultrasound and/or Tc99 -sestamibi scan and minimally invasive parathyroidectomy. Nonpalpable thyroid nodules are common and cannot be differentiated from parathyroid lesions by imaging alone. This study examines cytopathologist-performed ultrasound-guided fine-needle aspiration (UG-FNA) in diagnosis of parathyroid lesions. Between January 1, 2007 and December 31, 2008, seven patients with PHPT or other parathyroid lesions with one or more sonographically-visible thyroid masses underwent cytopathologist-performed UG-FNA with immediate cytological evaluation (ICE). One mass was palpable and nine were nonpalpable. Three parathyroid adenomas, two benign colloid nodules, one papillary carcinoma, three parathyroid cysts, and one thyroid cyst were diagnosed. The nodules in three patients with parathyroid adenomas were identified as follicular lesion/neoplasm on ICE. Additional UG-FNA passes were made to obtain tissue for immunohistochemistry stains, which confirmed parathyroid origin. Two of these patients had a separate benign colloid nodule and one had a thyroid cyst diagnosed by UG-FNA. The PHPT patient with papillary carcinoma on UG-FNA had the malignancy confirmed at surgery and a sonographically occult parathyroid adenoma. The three patients with thyroid cysts identified by radiology were suspected of being parathyroid cysts on the basis of real-time sonographic features at the biopsy table. The clear cyst fluid obtained by UG-FNA had markedly elevated PTH. Cytopathologist-performed UG-FNA can distinguish between parathyroid and thyroid nodules in patients with suspected parathyroid lesions. Diagn. Cytopathol. 2010. © 2009 Wiley-Liss, Inc. [source] Fine-needle aspiration of brown tumor of bone: Cytologic features with radiologic and histologic correlationDIAGNOSTIC CYTOPATHOLOGY, Issue 2 2009Ph.D., Sasha Pavlovic M.D. Abstract We report the case of a 40-year-old man with tertiary hyperparathyroidism due to end stage renal disease who initially presented with acute-onset paraplegia, elevated serum parathyroid hormone, and multiple bone abnormalities, including a large extradural intraspinal mass seen by magnetic resonance imaging. In contrast with imaging features, fine-needle aspiration cytology showed numerous benign-appearing multinucleated osteoclast-type giant cells that are the characteristics of either brown tumor or benign giant cell tumor of bone. Sheets of mononuclear spindled stromal cells were also noted. A core-needle biopsy confirmed the diagnostic features of brown tumor of hyperparathyroidism. Diagn. Cytopathol. 2009. © 2008 Wiley-Liss, Inc. [source] Vitamin D Levels and Bone Turnover in Epilepsy Patients Taking Carbamazepine or OxcarbazepineEPILEPSIA, Issue 3 2006Scott Mintzer Summary:,Purpose: Evidence suggests that enzyme-inducing antiepileptic drugs (AEDs) may decrease serum 25-hydroxyvitamin D (25-OHD) levels and increase bone turnover. We sought to determine whether these are affected by treatment with carbamazepine (CBZ) or oxcarbazepine (OXC). Methods: We measured serum levels of 25-OHD, parathyroid hormone (PTH), osteocalcin (OCLN), bone alkaline phosphatase (BAP), and urinary N-telopeptides of type I collagen cross-links (NTX) in normal controls (n = 24) and in epilepsy patients taking CBZ (n = 21) or OXC (n = 24) in monotherapy. CBZ patients were subsequently switched overnight to OXC monotherapy, and after 6 weeks, the tests were repeated. Results: 25-OHD levels were lower in each drug-treated group (OXC, 19.4 ± 2.3 pg/ml; CBZ, 20.4 ± 2.4) than in the controls (27.5 ± 2.8) (ANOVA, p = 0.052). This difference was significant for the OXC group (p < 0.05). PTH, BAP, and NTX did not differ significantly among groups. OCLN levels were somewhat elevated in the OXC group (2.79 ± 0.47 ng/ml) and more clearly and significantly elevated in the CBZ group (3.63 ± 0.36) compared with controls (2.38 ± 0.41) (p = 0.053). Because the data were very similar between OXC and CBZ groups, they were combined to increase statistical power. The combined drug-treatment group had significantly higher BAP (p = 0.02) and lower 25-OHD (p = 0.015) than did controls. The latter remained significant even after accounting for the confounding effects of age on 25-OHD levels (p < 0.05). No significant differences were found after CBZ patients were switched to OXC. Conclusions: Epilepsy patients taking OXC or CBZ have significantly lower 25-OHD than do normal controls, with a pattern of changes in other bone biomarkers suggestive of secondary hyperparathyroidism. It may be prudent for patients taking CBZ or OXC to be prescribed 25-OHD replacement. [source] Validation and clinical utility of a novel immunoradiometric assay exclusively for biologically active whole parathyroid hormone in the horseEQUINE VETERINARY JOURNAL, Issue 3 2003J. C. ESTEPA Summary Reasons for performing study: Parathyroid hormone (PTH) plays a critical role in the regulation of mineral metabolism in mammals. Until recently, the standard method for PTH measurement has been the 2nd generation intact-PTH (I-PTH) assay. Current evidence indicates that the I-PTH assay binds to the PTH molecule and to an inactive N-terminally truncated PTH fragment that tends to accumulate in the blood of uraemic patients. Therefore, a new 3rd generation PTH assay that detects only the whole PTH molecule (W-PTH; cyclase-activating PTH [CAP]) has been developed. Objectives: To validate this more specific W-PTH assay for measurement of equine PTH and evaluate its clinical utility. Methods: W-PTH and I-PTH were measured in plasma samples from normal horses (adults and foals) and horses with nutritional secondary hyperparathyroidism (N2HPT) and with chronic renal failure (CRF). Replicate measurements and dilutional paralellism were used for assay validation. Changes in blood ionized calcium were induced by EDTA and CaCl2 administration. Results: Performance of the W-PTH assay (accuracy, sensitivity, specificity and ability to detect changes in PTH in response to changes in calcium) was similar to that of the I-PTH assay. Surprisingly, the relative W-PTH concentration in normal horses and foals was higher than the relative I-PTH concentration. W-PTH values remained higher than I-PTH during acute hypo- and hypercalcaemia. An increase in both W-PTH and I-PTH concentrations was found in horses with N2HPT. In horses with CRF, W-PTH and I-PTH values were very low and no increase in I-PTH was observed. Conclusions: The W-PTH assay can be used for measurement of equine PTH. Potential relevance: The use of W-PTH assay is likely to improve the diagnosis of mineral metabolism in horses. [source] Neurofibromatosis type 1: should we screen for other genetic syndromes?EUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 9 2009A case report of co-existence with multiple endocrine neoplasia 2A Abstract Background, NF 1 is a genetic disorder with an autosomal dominant pattern of inheritence. It is associated with neoplastic disorders mainly derived from the neural seath. However, the co-existence of NF1 with the full spectrum of MEN 2A has rarely been reported. The aim of the study was to investigate the presence of secondary neoplasias in a patient with diagnosed NF1, and in particular the presence of hyperparathyroidism and the possible co-existence with another pheochromocytoma-related syndrome. Methods, We report a case of a 70 years old female patient who had NF1. The patient was referred to our center and was diagnosed with an isolated pheochromocytoma of the right adrenal gland for which she underwent right adrenalectomy. We further investigated for the presence of another pheochromocytoma-related syndrome and in particular for the presence of hyperparathyroidism and medullary thyroid cancer. Molecular screening for germline mutations of the genes NF1, RET and VHL has also been performed. Results, The patient was further diagnosed with hyperparathyroidism and medullary thyroid cancer, having the full spectrum of the clinical picture of the MEN2A syndrome. The genetic testing revealed the germline mutation for NF1 but not for the RET proto-oncogene which is generally found in MEN2A cases. Conclusion, To our knowledge this is a rare case of co-existence of two pheochromocytoma-related genetic syndromes, and generates the question of whether all patients with these syndromes should undergo a thorough clinical and laboratory investigation for the possibility of another co-existing pheochromocytoma-related genetic syndrome. [source] The role of calcimimetics in the treatment of hyperparathyroidismEUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 12 2007R. P. Wüthrich Abstract Calcimimetics reduce serum levels of parathyroid hormone (PTH) and calcium, with a leftward shift in the set-point for calcium-regulated PTH secretion. The aim of this publication is to review the data available for calcimimetics in primary, secondary and tertiary hyperparathyroidism (HPT). Parathyroidectomy (PTX) is currently the only curative treatment for primary HPT, and recommended for patients with moderate-to-severe disease, as defined by a 2002 National Institute's of Health summary statement. In general, patients with primary HPT not meeting these surgical criteria, as well as those with contraindication or refusal for surgery, are monitored for signs and symptoms of primary HPT. There are currently no non-surgical therapies approved for use in primary HPT, although bisphosphonates are used in some patients, in an effort to control serum calcium levels. Calcimimetics decrease PTH and calcium levels and are a potential alternative for patients contraindicated for PTX, or who have failed previous PTX and have recurrent primary HPT. Secondary HPT develops early in chronic kidney disease and is present virtually in all patients with end-stage renal disease (ESRD). Secondary HPT is a progressive disease and is associated with several systemic complications, including renal osteodystrophy, soft tissue and vascular calcifications, and adverse cardiovascular outcomes. In ESRD patients, calcimimetics were shown to simultaneously reduce PTH, calcium, phosphate and calcium × phosphate product. In addition, observational analyses of use of calcimimetics in the ESRD population have shown a reduction of important clinical outcomes. In renal allograft recipients with tertiary HPT and hypercalcaemia, calcimimetics are a promising treatment option to control the parameters of calcium phosphate metabolism and may be a valid alternative to PTX. Based on its unique mechanism of action, the calcimimetic cinacalcet may play a role in the medical treatment of primary and tertiary forms of HPT, in addition to the registered indication for the treatment of secondary HPT. [source] Mineral metabolism disturbances in patients with chronic kidney diseaseEUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 8 2007B. Kestenbaum Abstract Background Kidney disease, especially chronic kidney disease (CKD), is a worldwide public health problem with serious adverse health consequences for affected individuals. Secondary hyperparathyroidism, a disorder characterized by elevated serum parathyroid hormone levels, and alteration of calcium and phosphorus homeostasis are common metabolic complications of CKD that may impact cardiovascular health. Materials and methods Here, we systematically review published reports from recent observational studies and clinical trials that examine markers of altered mineral metabolism and clinical outcomes in patients with CKD. Results Mineral metabolism disturbances begin early during the course of chronic kidney disease, and are associated with cardiovascular disease and mortality in observational studies. Vascular calcification is one plausible mechanism connecting renal-related mineral metabolism with cardiovascular risk. Individual therapies to correct mineral metabolism disturbances have been associated with clinical benefit in some observational studies; clinical trials directed at more comprehensive control of this problem are warranted. Conclusions There exists a potential to improve outcomes for patients with CKD through increased awareness of the Bone Metabolism and Disease guidelines set forth by the National Kidney Foundation,Kidney Disease Outcomes Quality Initiative. Future studies may include more aggressive therapy with a combination of agents that address vitamin D deficiency, parathyroid hormone and phosphorus excess, as well as novel agents that modulate circulating promoters and inhibitors of calcification. [source] Dihydropyridine- and voltage-sensitive Ca2+ entry in human parathyroid cellsEXPERIMENTAL PHYSIOLOGY, Issue 7 2009Keitaro Yokoyama Patch-clamp and fluorescence measurements of cytoplasmic Ca2+ concentration ([Ca2+]i) were performed to directly detect extracellular Ca2+ entry into cultured parathyroid cells from patients with secondary hyperparathyroidism. Cells loaded with fluo-3 AM or fluo-4 AM showed a transient increase in fluorescence (Ca2+ transient) following 10 s exposure to 150 mm K+ solution in the presence of millimolar concentrations of external Ca2+. The Ca2+ transient was completely inactivated after 30,40 s exposure to the high-K+ solution, was reduced by dihydropyridine antagonists and was enhanced by FPL-64176, an L-type Ca2+ channel agonist. The electrophysiological and pharmacological properties of the whole-cell Ca2+ and Ba2+ currents were similar to those of L-type Ca2+ channels. The Ca2+ transients induced by 10 s exposure to 3.0 mm extracellular Ca2+ concentration ([Ca2+]o) were inhibited by dihydropyridine antagonists and were partly inactivated following 30,40 s exposure to the high-K+ solution. These results demonstrate, for the first time, that human parathyroid cells express L-type-like Ca2+ channels that are possibly involved in the [Ca2+]o -induced change in [Ca2+]i. This Ca2+ entry system might provide a compensatory pathway for the negative feedback regulation of parathyroid hormone secretion, especially in hyperplastic conditions in which the Ca2+ -sensing receptor is poorly expressed. [source] Elderly patient presenting with severe thyrotoxic hypercalcemiaGERIATRICS & GERONTOLOGY INTERNATIONAL, Issue 4 2006Reiko Kikuchi An 81-year-old woman with Graves' disease and osteoporosis was referred to the hospital because of anorexia over one month and impaired consciousness. She also presented with low-grade fever and emaciation. Laboratory tests revealed marked hypercalcemia (corrected serum calcium level of 12.4 mg/dL), which was initially suspected to result from vitamin D toxicity, because she had been taking vitamin D3 (alphacalcidol of 0.5 µg/day) for the treatment of osteoporosis. However, discontinuation of vitamin D3 and fluid infusion did not ameliorate hypercalcemia one week later. After excluding hyperparathyroidism and malignancy-related hypercalcemia, hypercalcemia was considered to be attributable to the exacerbation of hyperthyroidism (free T4 of 6.69 ng/dL, free T3 of 13.27 pg/mL and thyroid stimulating hormone (TSH) <0.015 µIU/mL) with increased bone resorption. Finally, the increased dose of thiamazole (30 mg/day) normalized serum calcium level and thyroid function three months later. Laboratory tests suggested that normal bone formation in spite of increased bone resorption contributed to hypercalcemia in hyperthyroid state. [source] Endocrinological aspects of aging: Adaptation to and acceleration of aging by the endocrine systemGERIATRICS & GERONTOLOGY INTERNATIONAL, Issue 1 2006Kiyoshi Hashizume Endocrinological functions of aging subjects deviate from those of young subjects during the aging process. There are two types of deviation expressed as: (i) an adaptation to the aging process; and (ii) an acceleration of aging. The former includes hyperparathyroidism, hyperglycemia and hyperinsulinemia. The latter includes growth hormone resistance and low-T3 syndrome. Excess adaptation promotes the metabolic syndrome. Excess acceleration of aging easily leads subjects to mental disorder and death. In order to prevent subjects from both excess adaptation to and excess acceleration of aging, endocrinological intervention is required. [source] Usefulness of the combination of ultrasonography and 99mTc-sestamibi scintigraphy in the preoperative evaluation of uremic secondary hyperparathyroidismHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 9 2010Carlo Vulpio MD Abstract Background. The usefulness of the combination of technetium-99m-methoxyisobutylisonitrile (99mTc-MIBI) parathyroid scintigraphy and ultrasonography to detect parathyroid glands (PTGs) in secondary hyperparathyroidism (SHPT) is still controversial. Methods. In all, 21 patients with SHPT underwent parathyroidectomy. The sensitivity and specificity of ultrasonography and scintigraphy related to site, size, hyperplasia type of PTG, concomitant thyroid disease, and the frequency of intraoperative frozen sections were determined. Results. The sensitivities of scintigraphy and ultrasonography were 62% and 55%, and the specificity was 95% for both procedures. The sensitivity of combined techniques was 73%. The scintigraphy detected 7/9 (78%) ectopic PTGs, whereas ultrasonography was always negative. A PTG maximum longitudinal diameter <8 mm, the presence of diffuse hyperplasia, the upper localization of glands, and the presence of concomitant thyroid disease reduced the sensitivity and specificity of imaging techniques. In cases of positive imaging, the rate of intraoperative frozen sections was significantly lower. Conclusions. The ultrasonography and sestamibi scintigraphy, which showed a higher sensitivity than that of either ultrasonography or scintigraphy alone, led to a reduction of intraoperative frozen sections and to preoperative diagnosis of ectopic (29%) or supernumerary PTGs (10%) and concomitant nodular thyroid disease (24%). © 2010 Wiley Periodicals, Inc. Head Neck, 2010 [source] Accuracy and definitive interpretation of preoperative technetium 99m sestamibi imaging based on the discipline of the reader,HEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 5 2009Ayesha N. Khalid MD Abstract Background. Technetium 99m sestamibi scans have become a principal means of localizing parathyroid adenomas. Its accuracy and reliability has allowed for the proliferation of minimal access parathyroidectomy. Localizing interpretation of these scans often drives referral of hyperparathyroid patients for surgery. Interpretation of these scans may differ between nuclear medicine physicians and surgeons. Methods. We reviewed patients (N = 65) with digital images from an academic medical center with the diagnosis of primary hyperparathyroidism. We assessed the willingness to define an adenoma's location, the interrater reliability, and the accuracy of technetium (Tc-99m) sestamibi read by a surgeon and a nuclear medicine physician. Results. There was poor correlation between both readers for assessment of quality of images (k = 0.54, 0.07) but very good correlation for adenoma location (k = 0.81). Conclusion. Both readers had good accuracy in predicting the location of the parathyroid adenoma. The surgeon was more likely to call a scan positive. © 2008 Wiley Periodicals, Inc. Head Neck, 2009 [source] Comparison of perioperative management and outcome of parathyroidectomy between older and younger patientsHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 11 2008Gideon Bachar MD Abstract Background. The aim of this study was to compare the clinical status, surgical course, and outcomes of patients with primary hyperparathyroidism (PHPT), over the age of 70, with younger patients. Methods. Between 1996 and 2006, 951 patients underwent parathyroidectomies for PHPT, of whom 190 were over the age of 70. Patient data were collected from chart reviews and a computerized database. Results. Fewer older patients were asymptomatic at presentation. No between-group differences in serum calcium were seen; however, parathyroid hormone (PTH) levels were higher in the older group. Hospitalization time was longer for the elderly. Duration of surgery, surgical success rates, and postoperative complications were similar between the 2 groups. Conclusion. Surgical treatment of PHPT has both physiological benefits and helps to preserve quality of life. Our findings suggest that there is no practical difference in perioperative management and surgical outcomes for older patients. Surgeons should consider parathyroidectomy in PHPT patients regardless of age. © 2008 Wiley Periodicals, Inc. Head Neck, 2008 [source] Evolution of maxillofacial brown tumors after parathyroidectomy in primary hyperparathyroidismHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 11 2008Jaime Alonso Reséndiz-Colosia MD Abstract Background. Brown tumor occasionally affects the facial bones. Clinically, these lesions can be mistaken for a neoplasm. Opinions are divided on the course of management of the bony lesions once parathyroidectomy has been carried out. Methods. We treated 22 patients with primary hyperparathyroidism and osteitis fibrosa cystica and observed their clinical and biochemical recovery. Results. Fifteen patients (68.2%) had brown tumors in mandible, and 7 (31.8%) in maxilla. After parathyroidectomy, 21 patients had normal total serum calcium values. All brown tumors presented a spontaneous progressive regression; in 18cases, regression was total, with a mean time period of 10months. Two patients had partial regression after nearly 2years. Another 2 patients were lost to follow-up. Conclusions. After successful parathyroid surgery, the bony lesions tended to regress spontaneously, either partially or completely. However, if the lesion is disfiguring or symptomatic, surgical excision may be indicated. © 2008 Wiley Periodicals, Inc. Head Neck, 2008 [source] Clinical and operative management of persistent hyperparathyroidism after renal transplantation: A single-center experienceHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 11 2007Hanna Gilat MD Abstract Background. Persistent (tertiary) hyperparathyroidism (TH) after renal transplantation may cause considerable morbidity and necessitate parathyroidectomy. This study investigated the characteristics of this patient subgroup. Methods. The medical data and pathology specimens of 20 kidney transplant recipients who underwent parathyroidectomy for TH in 2001 to 2004 were reviewed. Results. Treatment consisted of subtotal resection of 3.5 glands in 13 patients, resection of 3 to 3.5 glands under intraoperative parathyroid hormone monitoring (iPTH) in 5 patients, and selective resection in 2 patients with markedly asymmetric gland enlargement. Eighteen patients had hyperplasia,diffuse in 10, nodular in 4, or both in 2; 2 patients had 1 large nodule in every gland. Six patients had postoperative complications. Follow-up of 2 years revealed recurrent hypercalcemia in 1 patient and a high level of PTH (>60 pg/mL) in 12. Conclusion. Subtotal resection for TH may be insufficient. The use of iPTH monitoring is recommended. Renal transplant recipients have distinctive characteristics and require special perioperative attention. © 2007 Wiley Periodicals, Inc. Head Neck, 2007 [source] Spontaneous remission of primary hyperparathyroidism: A case report and meta-analysis of the literatureHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 1 2006Christopher T. Wootten MD Abstract Background. In a minority of patients, primary hyperparathyroidism spontaneously remits either by autoinfarction or by hemorrhage into or around the adenoma. We describe a case of autoparathyroidectomy occurring in a 63-year-old man 9 years after three parathyroid glands were removed during a total thyroidectomy. This case is compared with 50 previously reported cases of autoparathyriodectomy, and a meta-analysis is performed. Methods. Case report, literature review, and meta-analysis were done using statistical software (SigmaStat 2.0, SPSS, Chicago). Results. Fifty cases of autoparathyroidectomy were summarized according to the three etiologies. The greatest biochemical aberration was found in the acute intracapsular hemorrhage group, with [Ca++] falling from a mean 15.1 mg/dL to 8.9 mg/dL. The average drop in parathyroid hormone was 69% across all groups, comparing favorably to surgical resection. Conclusions. Autoparathyroidectomy is a rare but described outcome of unoperated primary hyperparathyroidism that may delay or supplant operative management. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX,XXX, 2005 [source] Preoperative evaluation of patients with parathyroid adenoma: Role of high-resolution ultrasonography,HEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 1 2002David Ulanovski MD Abstract Background Unilateral parathyroid exploration with adenoma removal and identification of a normal parathyroid gland is a controversial surgical approach to the treatment of primary hyperparathyroidism. The aim of this study was to evaluate the ability of high-resolution ultrasonography to localize adenomas preoperatively and to assess the effect of such localization on operative time. Methods One hundred twenty consecutive previously non-operated patients with primary hyperparathyroidism underwent ultrasonography before surgery, which consisted of unilateral neck exploration. The procedure was changed to bilateral exploration when justified by the surgical findings. Results The sensitivity and positive predictive value of the ultrasonographic examinations were 89% and 98%, respectively. These results were obtained regardless of the size of the adenoma. No significant difference was found in the presence of thyroid multinodular disease (p = .2). A positive sonographic examination decreased the operative time to an average of 59 minutes. The average size of the adenomas was 19 mm (range, 4,55 mm). A positive and highly statistically significant correlation was found between adenoma size and both preoperative calcium level (p = .01) and parathyroid hormone level (p = .0001). Conclusions In experienced hands, high-resolution ultrasonography can be a cost-effective means of localizing parathyroid adenomas when unilateral neck exploration is considered the acceptable surgical approach. © 2002 John Wiley & Sons, Inc. Head Neck 24: 1,5, 2002. [source] Comparison between different dialysate calcium concentrations in nocturnal hemodialysisHEMODIALYSIS INTERNATIONAL, Issue 2 2007Nigel D. TOUSSAINT Abstract Benefits of dialysate with greater calcium (Ca) concentration are reported in nocturnal hemodialysis (NHD) to prevent Ca depletion and subsequent hyperparathyroidism. Studies with patients dialyzing against 1.25 mmol/L Ca baths demonstrate increases in alkaline phosphatase (ALP) and parathyroid hormone (PTH) and increasing dialysate Ca subsequently corrects this problem. However, whether 1.5 or 1.75 mmol/L dialysate Ca is most appropriate for NHD is yet to be determined, and differences in the effect on mineral metabolism of daily vs. alternate daily NHD have also not been well defined. We retrospectively analyzed mineral metabolism in 48 patients, from 2 institutions (30 at Monash and 18 at Geelong), undergoing home NHD (8 hr/night, 3.5,6 nights/week) for a minimum of 6 months. Thirty-seven patients were dialyzed against 1.5 mmol/L Ca bath and 11 patients against 1.75 mmol/L. We divided patients into 4 groups, based on dialysate Ca and also on the hours per week of dialysis, <40 (1.5 mmol/L, n=29 and 1.75 mmol/L, n=8) or ,40 (n=4 and 7). We compared predialysis and postdialysis serum markers, time-averaged over a 6-month period, and the administration of calcitriol and Ca-based phosphate binders between 1.5 and 1.75 mmol/L Ca dialysate groups. Baseline characteristics between all groups were similar, with a slightly longer, but nonsignificant, duration of NHD in both 1.75 mmol/L dialysate groups compared with 1.5 mmol/L. The mean predialysis Ca, phosphate, and Ca × P were similar between the 1.5 and 1.75 mmol/L groups, regardless of NHD hr/week. Postdialysis Ca was significantly greater, with 1.75 vs. 1.5 mmol/L in those dialyzing <40 hr/week (2.64±0.19 vs. 2.50±0.12 mmol/L, p=0.046), but postdialysis Ca × P were similar (2.25±0.44 vs. 2.16±0.29 mmol2/L2, p=0.60). Parathyroid hormone was also lower with 1.75 vs. 1.5 mmol/L baths in the <40 hr/week groups (31.99±26.99 vs. 14.47±16.36 pmol/L, p=0.03), although this difference was not seen in those undertaking NHD ,40 hr/week. Hemoglobin, ALP, and albumin were all similar between groups. There was also no difference in vitamin D requirement when using 1.75 mmol/L compared with the 1.5 mmol/L dialysate. Multivariate analysis to determine independent predictors of postdialysis serum Ca showed a statistically significant positive association with predialysis Ca, dialysate Ca, and total NHD hr/week. An elevated dialysate Ca concentration is required in NHD to prevent osteopenia but differences in serum markers of mineral metabolism between 1.5 and 1.75 mmol/L Ca dialysate in NHD in our study were few. This was similar for patients undertaking NHD <40 or ,40hr/week, although differences in the frequency of NHD may also be as important as dialysate Ca with regard to serum Ca levels. With concerns that prolonged higher Ca levels contribute to increased cardiovascular mortality, the optimal Ca dialysate bath is still unknown and further studies addressing bone metabolism with larger NHD numbers are required. [source] Modification of cardiovascular risk in hemodialysis patients: An evidence-based reviewHEMODIALYSIS INTERNATIONAL, Issue 1 2007David W. JOHNSON Abstract Cardiovascular disease accounts for 40% to 50% of deaths in dialysis populations. Overall, the risk of cardiac mortality is 10-fold to 20-fold greater in dialysis patients than in age and sex-matched controls without chronic kidney disease. The aim of this paper is to review critically the evidence that cardiac outcomes in dialysis patients are modified by cardiovascular risk factor interventions. There is limited, but as yet inconclusive controlled trial evidence that cardiovascular outcomes in dialysis populations may be improved by antioxidants (vitamin E or acetylcysteine), ensuring that hemoglobin levels do not exceed 120 g/L (especially in the setting of known cardiovascular disease), prescribing carvedilol in the setting of dilated cardiomyopathy, and by using cinacalcet in uncontrolled secondary hyperparathyroidism. Similarly, there are a number of negative controlled trials, which have demonstrated that statins, high-dose folic acid, angiotensin-converting enzyme inhibitors, multiple risk factor intervention via multidisciplinary clinics, and high-dose or high-flux dialysis are ineffective in preventing cardiovascular disease. Although none of these studies could be considered conclusive, the negative trials to date should raise significant concerns about the heavy reliance of current clinical practice guidelines on extrapolation of findings from cardiovascular intervention trials in the general population. It may be that cardiovascular disease in dialysis populations is less amenable to intervention, either because of the advanced stage of chronic kidney disease or because the pathogenesis of cardiovascular disease in dialysis patients is different from that in the general population. Large, well-conducted, multicenter randomized-controlled trials in this area are urgently required. [source] Metastatic pulmonary calcification in a dialysis patient: Case report and a reviewHEMODIALYSIS INTERNATIONAL, Issue S2 2006Christoph H. EGGERT Abstract A 19-year-old male presented with chest pain and dyspnea. He was anephric following nephrectomy for focal segmental glomerulosclerosis, had a subsequent failed transplant, and had been dialysis dependent for 3 years. Workup revealed hyperparathyroidism and an abnormal chest X-ray and computed tomography scan, significant for massive extra-skeletal pulmonary calcification. A markedly abnormal Technitium99 methylene diphosphonate (Tc99m-MDP) bone scan confirmed the clinical suspicion of metastatic pulmonary calcification. Metastatic pulmonary calcification (MPC) is common, occurring in 60% to 80% of dialysis patients on autopsy and bone scan series. It may lead to impaired oxygenation and restrictive lung disease. Typically, the calcium crystal is whitlockite rather than hydroxyapatite, which occurs in vascular calcification. Four major predisposing factors may contribute to MPC in dialysis patients. First, chronic acidosis leaches calcium from bone. Second, intermittent alkalosis favors deposition of calcium salts. Third, hyperparathyroidism tends to cause bone resorption and intracellular hypercalcemia. Finally, low glomerular filtration rate can cause hyperphosphatemia and an elevated calcium-phosphorus product. There may be other factors. Some authors suggest that the incidence of MPC in recent years may be lower due to improved dialysis techniques. The diagnosis is confirmed by biopsy, but can be suspected by typical findings on a Tc99m-MDP bone scan. Therapy is limited to ensuring adequate dialysis, correcting calcium-phosphorus product, and hyperparathyroidism; discontinuing vitamin D analogues may help. Conflicting reports show that transplantation may either improve or worsen the situation. MPC should be considered in dialysis patients who have characteristic abnormal chest radiography and/or pulmonary symptoms. [source] | |||||||||||||||||||||||||||||||||||||