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Endocrinology and Metabolism (Seoul,... Jun 2024Parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23) each play a central role in the pathogenesis of chronic kidney disease (CKD)-mineral and bone disorder.... (Review)
Review
Parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23) each play a central role in the pathogenesis of chronic kidney disease (CKD)-mineral and bone disorder. Levels of both hormones increase progressively in advanced CKD and can lead to damage in multiple organs. Secondary hyperparathyroidism (SHPT), characterized by parathyroid hyperplasia with increased PTH secretion, is associated with fractures and mortality. Emerging evidence suggests that these associations may be partially explained by PTH-induced browning of adipose tissue and increased energy expenditure. Observational studies suggest a survival benefit of PTHlowering therapy, and a recent study comparing parathyroidectomy and calcimimetics further suggests the importance of intensive PTH control. The mechanisms underlying the regulation of FGF23 secretion by osteocytes in response to phosphate load have been unclear, but recent experimental studies have identified glycerol-3-phosphate, a byproduct of glycolysis released by the kidney, as a key regulator of FGF23 production. Elevated FGF23 levels have been shown to be associated with mortality, and experimental data suggest off-target adverse effects of FGF23. However, the causal role of FGF23 in adverse outcomes in CKD patients remains to be established. Further studies are needed to determine whether intensive SHPT control improves clinical outcomes and whether treatment targeting FGF23 can improve patient outcomes.
Topics: Humans; Fibroblast Growth Factor-23; Fibroblast Growth Factors; Parathyroid Hormone; Renal Insufficiency, Chronic; Hyperparathyroidism, Secondary; Animals
PubMed: 38752265
DOI: 10.3803/EnM.2024.1978 -
Transplant International : Official... 2024Tertiary hyperparathyroidism (THPT) is characterized by elevated parathyroid hormone and serum calcium levels after kidney transplantation (KTx). To ascertain whether...
Pre-Transplant Calcimimetic Use and Dose Information Improves the Accuracy of Prediction of Tertiary Hyperparathyroidism after Kidney Transplantation: A Retrospective Cohort Study.
Tertiary hyperparathyroidism (THPT) is characterized by elevated parathyroid hormone and serum calcium levels after kidney transplantation (KTx). To ascertain whether pre-transplant calcimimetic use and dose information would improve THPT prediction accuracy, this retrospective cohort study evaluated patients who underwent KTx between 2010 and 2022. The primary outcome was the development of clinically relevant THPT. Logistic regression analysis was used to evaluate pre-transplant calcimimetic use as a determinant of THPT development. Participants were categorized into four groups according to calcimimetic dose, developing two THPT prediction models (with or without calcimimetic information). Continuous net reclassification improvement (CNRI) and integrated discrimination improvement (IDI) were calculated to assess ability to reclassify the degree of THPT risk by adding pre-transplant calcimimetic information. Of the 554 patients, 87 (15.7%) developed THPT, whereas 139 (25.1%) received pre-transplant calcimimetic treatment. Multivariate logistic regression analysis revealed that pre-transplant calcimimetic use was significantly associated with THPT development. Pre-transplant calcimimetic information significantly improved the predicted probability accuracy of THPT (CNRI and IDI were 0.91 [ < 0.001], and 0.09 [ < 0.001], respectively). The THPT prediction model including pre-transplant calcimimetic information as a predictive factor can contribute to the prevention and early treatment of THPT in the era of calcimimetics.
Topics: Humans; Kidney Transplantation; Retrospective Studies; Male; Female; Middle Aged; Calcimimetic Agents; Adult; Calcium; Hyperparathyroidism; Parathyroid Hormone; Logistic Models
PubMed: 38751772
DOI: 10.3389/ti.2024.12704 -
EJNMMI Reports May 2024To determine the use of four-dimensional CT as first-line imaging compared to the traditional combination of ultrasound and [Tc]Tc-Sestamibi SPECT.
Four-dimensional computed tomography as first-line imaging in primary hyperparathyroidism, a retrospective comparison to conventional imaging in a predominantly single adenoma population.
BACKGROUND
To determine the use of four-dimensional CT as first-line imaging compared to the traditional combination of ultrasound and [Tc]Tc-Sestamibi SPECT.
MATERIALS AND METHODS
Retrospective review of preoperative imaging in patients with primary hyperparathyroidism, who underwent parathyroidectomy between 2012 and 2021. In one group, the combination ultrasound and [Tc]Tc-Sestamibi SPECT was used as first-line imaging (n = 54), in the other group four-dimensional CT was the first-line imaging modality (n = 51). Sensitivity and positive predictive value were calculated on patient, lateralisation and localisation level. The need for additional imaging was also assessed for both groups.
RESULTS
Four-dimensional CT had a significantly higher sensitivity compared to the combination of ultrasound/[Tc]Tc-Sestamibi SPECT on patient and localisation level (70.6% vs. 51.9%, p = 0.049 and 60.8% vs. 35.2%, p = 0.009 respectively). Sensitivity for lateralisation also appeared higher, but did not reach significance (62.7% vs. 44.4%, p = 0.060). Positive predictive value was not significantly higher for four-dimensional CT compared to ultrasound and [Tc]Tc-Sestamibi SPECT (88.9% vs. 85.7% for lateralisation and 86.1% vs. 67.9% for localisation respectively). Additional imaging was required in 14 patients with four-dimensional CT as first-line imaging (27.4%) consisting of 2 ultrasound/[Tc]Tc-Sestamibi SPECT and 13 [F]fluorocholine PET/CT, compared to 24 patients with ultrasound/[Tc]Tc-Sestamibi SPECT as first-line imaging (44.4%), requiring 22 four-dimensional CT and 9 [F]fluorocholine PET/CT.
CONCLUSIONS
Four-dimensional CT as the sole first-line parathyroid imaging modality had higher sensitivity than the combination of ultrasound and [Tc]Tc-Sestamibi SPECT, therefore requiring fewer additional procedures. Although the most costly, [F]fluorocholine PET/CT was the most effective technique to localise parathyroid adenoma in case all other imaging was negative.
PubMed: 38748330
DOI: 10.1186/s41824-024-00198-5 -
BJS Open May 2024Multicentre studies have previously reported on national outcomes of surgery for primary hyperparathyroidism, but not investigated whether management and outcome are... (Observational Study)
Observational Study
BACKGROUND
Multicentre studies have previously reported on national outcomes of surgery for primary hyperparathyroidism, but not investigated whether management and outcome are uniform among countries. This study investigated whether there are differences among European countries in operative management and outcome of surgery for primary hyperparathyroidism.
METHODS
Using data from Eurocrine®, a pan-European registry for endocrine surgeries, a retrospective observational cross-sectional multicentre study with 99 participating centres in 14 European countries was performed. Data on age, sex, calcium levels, operative strategy, conversion rate and rate of failed exploration were analysed for patients who underwent initial surgery for sporadic primary hyperparathyroidism. Primary outcome measures were intention to perform limited parathyroidectomy and the rate of hypercalcaemia at first follow-up.
RESULTS
A total of 9548 patients were registered between 2015 and 2020. There were 7642 (80%, range 74.5-93.2%) females. There was intention to perform limited parathyroidectomy in 7320 of 9548 (76.7%) operations, ranging from 498 of 1007 (49.5%) to 40 of 41 (97.6%) among countries. Hypercalcaemia at first follow-up (median time to follow-up 15 days) was found in 416 of 9548 (4.4%) operations, ranging from 0 of 119 (0%) to 3 of 38 (7.9%) among countries.
CONCLUSION
This study demonstrated large differences in the intention to perform limited parathyroidectomy for primary hyperparathyroidism among European countries, as well as differences in the rate of postoperative hypercalcaemia. Future studies are needed to evaluate the impact of these different healthcare practices on patient outcomes.
Topics: Humans; Hyperparathyroidism, Primary; Female; Male; Parathyroidectomy; Europe; Retrospective Studies; Middle Aged; Cross-Sectional Studies; Hypercalcemia; Aged; Adult; Treatment Outcome; Registries
PubMed: 38747104
DOI: 10.1093/bjsopen/zrae037 -
Cureus Apr 2024Secondary hyperparathyroidism is a prevalent complication of end-stage renal disease (ESRD), arising from chronic renal insufficiency leading to disturbed calcium...
Secondary hyperparathyroidism is a prevalent complication of end-stage renal disease (ESRD), arising from chronic renal insufficiency leading to disturbed calcium metabolism. This disruption triggers hypersecretion of the parathyroid gland, characterizing the condition. Osteitis fibrosa cystica (OFC), a rare complication of untreated secondary hyperparathyroidism, results in benign resorptive bone lesions and the formation of cystic cavities within bones. Our case report describes a 46-year-old incarcerated Hispanic male with a 17-year history of end-stage renal disease and secondary hyperparathyroidism. The patient initially presented with a traumatic right elbow injury. Further diagnostic evaluation revealed an 8 cm destructive process involving the distal humerus, initially suspected as malignancy but confirmed as OFC through bone biopsy. Management involved orthopedic surgery performing an open reduction and internal fixation (ORIF) of the affected limb, with subsequent consideration for inpatient parathyroidectomy. Imaging studies, including magnetic resonance imaging (MRI) and computed tomography (CT) scans, elucidated a 6 × 5.5 cm soft tissue mass, further confirmed as a brown tumor. The case underscores the complexities of diagnosing OFC, often misinterpreted in radiologic studies, and highlights the multidisciplinary approach involving orthopedics, otolaryngology, and nephrology in managing this intricate scenario. The objective is to explore clinical manifestations and treatment challenges of OFC and secondary hyperparathyroidism triggered by trauma in end-stage renal disease, emphasizing the need for continued awareness and precise diagnostic strategies in resource-rich areas.
PubMed: 38741796
DOI: 10.7759/cureus.58208 -
Hormone and Metabolic Research =... May 2024Kidney transplantation (KT) is the best option for patients with end-stage renal disease, but recipients still have legacy bone mineral disease from the pretransplant...
Kidney transplantation (KT) is the best option for patients with end-stage renal disease, but recipients still have legacy bone mineral disease from the pretransplant period, especially patients with severe secondary hyperparathyroidism (sHPT). Patients who had severe sHPT and underwent KT were analyzed retrospectively. Two groups were identified (patients with severe sHPT who had parathyroidectomy or calcimimetic before KT). Bone mineral density (BMD) was measured in the first year and last follow-up at the femoral neck, total hip, and lumbar spine using the dual-energy X-ray absorptiometry (DXA). Persistent hyperparathyroidism (perHPT) incidence was significantly higher in the calcimimetic group (75% vs. 40%, p=0.007). In patients with parathyroidectomy, BMDs were higher at femoral neck (0.818±0.114 vs. 0.744±0.134, p=0.04) and lumbar spine (1.005±0.170 vs. 0.897±0.151, p=0.01) at the first assessment. The BMD comparison between patients treated with parathyroidectomy and calcimimetic found a significant difference only in the femoral neck at second evaluation (0.835±0.118 vs. 0.758±0.129; p=0.03). In multivariate, linear regression revealed a positive association between the last BMD of the femoral neck with body mass index (CC: 0.297, 95% CI, 0.002-0.017) and parathyroidectomy (CC: 0.319, 95% CI, 0.021-0.156). Parathyroidectomy is associated with a significantly better femoral neck BMD and a lower incidence of perHPT in patients with severe sHPT.
PubMed: 38740062
DOI: 10.1055/a-2309-2240 -
The Journal of Clinical Endocrinology... May 2024Parathyroidectomy is recommended for curing primary hyperparathyroidism (PHPT), although uncertainty remains regarding the extent of fracture risk reduction following...
CONTEXT
Parathyroidectomy is recommended for curing primary hyperparathyroidism (PHPT), although uncertainty remains regarding the extent of fracture risk reduction following surgery.
OBJECTIVE
To compare fracture risk and bone mineral density (BMD) changes in patients with PHPT undergoing parathyroidectomy (PTX) versus observation (OBS).
DATA SOURCES
We systematically searched PubMed, Embase, and the Cochrane Library until September 2022, including randomized controlled trials (RCTs) and cohort studies, and reviewed citations from previous reviews.
STUDY SELECTION
Among 1,260 initial records, 48 eligible articles from 35 studies (5 RCTs; 30 cohorts) included PHPT patients receiving PTX or OBS interventions with reported fracture events at any site, including the hip, spine, or forearm, and/or BMD changes at each location.
DATA EXTRACTION
Following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines by two independent reviewers.
DATA SYNTHESIS
In 238,188 PHPT patients (PTX: 73,778 vs. OBS: 164,410), parathyroidectomy significantly reduced fractures at any site (RR, 0.80; 95%CI, 0.74-0.86) compared to observation. In 237,217 patients (PTX: 73,458 vs. OBS: 163,759), the risk of hip fractures decreased (RR, 0.63; 95%CI, 0.52-0.76). No reduction in forearm and vertebral fractures was observed in 3,574 and 3,795 patients, respectively. The annual percentage BMD changes from baseline were higher in the PTX group: femoral neck, 1.91% (95%CI, 1.14-2.68); hip, 1.75% (95%CI, 0.58-2.92); radius, 1.75% (95%CI, 0.31-3.18); spine, 2.13% (95%CI, 1.16-3.10).
CONCLUSIONS
Parathyroidectomy significantly reduced overall and hip fracture risks in PHPT patients. Despite minimal BMD increase, the substantial decrease in fracture risk suggests additional benefits of PTX beyond mineral content enhancement.
PubMed: 38739762
DOI: 10.1210/clinem/dgae326 -
Radiology Case Reports Aug 2024An 18-year-old male with multiple endocrine neoplasm type 1 (MEN1) syndrome presented with hyperparathyroidism. Parathyroidectomy was performed. Patient complained of...
An 18-year-old male with multiple endocrine neoplasm type 1 (MEN1) syndrome presented with hyperparathyroidism. Parathyroidectomy was performed. Patient complained of bone pain afterwards, multiple imaging modalities revealed features of osteitis fibrosa cystica and biochemical profile showed features of hungry bone syndrome. Incidental suspicious pancreatic lesion was initially revealed by F-FDG PET/CT scan while MRI further characterized the possibility of insulinoma. Ultimately, the patient was diagnosed of MEN1 syndrome by genetic test. This case report demonstrates the utilization of various imaging modalities such as ultrasound, Tc-sestamibi parathyroid scintigraphy, bone scintigraphy, CT, PET/CT and MRI, which leads to ultimately the diagnosis of MEN1 syndrome.
PubMed: 38737174
DOI: 10.1016/j.radcr.2024.04.024 -
International Journal of Surgery Case... Jun 2024Maxillomandibular involvement with brown tumours is rare, especially in the paediatric population. We present a rare case of a young girl with brown tumour (BT)...
INTRODUCTION AND IMPORTANCE
Maxillomandibular involvement with brown tumours is rare, especially in the paediatric population. We present a rare case of a young girl with brown tumour (BT) occurring in the mandible as the first manifestation of hyperparathyroidism.
CASE PRESENTATION
A 7-year-old black female, presented with a 6-month history of a swelling on the left mandible. Patient had a history of intractable gastrointestinal symptoms such as nausea, vomiting and abdominal cramps. Biopsy confirmed the lesion as a giant cell lesion. Elevated parathyroid hormone (PTH) levels confirmed the diagnosis of a BT of hyperparathyroidism. The patient underwent surgical intervention involving parathyroidectomy. This was followed by segmental resection of the mandibular tumour two years later.
CLINICAL DISCUSSION
Brown Tumour is a rare, non-neoplastic lesion resulting from abnormal bone metabolism secondary to hyperparathyroidism. BT predominantly arise in long bones and the axial skeleton. Maxillomandibular involvement is very rare. In the present case, after parathyroidectomy, normal PTH and calcium levels were restored, and there was relief of gastrointestinal tract hypercalcaemic symptoms. However, there was no spontaneous regression of the mandibular tumour over a 2-year observation period. Hemimandibulectomy followed by reconstruction with a plate and costochondral graft was then performed.
CONCLUSION
It is difficult to differentiate BT from other giant cell lesions without blood chemistry revealing hyperparathyroidism. The distinction is imperative to avoid mutilating and aggressive treatment for BTs. Although BTs are amenable for conservative treatment, the present case illustrates that for bigger tumours, in the absence of spontaneous regression, aggressive surgical treatment may be required.
PubMed: 38735218
DOI: 10.1016/j.ijscr.2024.109735 -
American Journal of Surgery Apr 2024This is the first study of Canadian thyroid and parathyroid surgery legal decisions, and the first study of surgical malpractice using the Canadian Legal Information...
BACKGROUND
This is the first study of Canadian thyroid and parathyroid surgery legal decisions, and the first study of surgical malpractice using the Canadian Legal Information Institute (CanLII) database. The objective was to identify quality improvement opportunities in surgical practice, to increase patient safety and satisfaction.
METHODS
Legal decisions relating to thyroid and parathyroid surgery in the CanLII database were screened. Cases were included if a surgeon was listed as applicant or respondent; they related to pre-, intra-, or post-operative management of thyroid or parathyroid disease; and malpractice was alleged. Cases were excluded if surgery was mentioned incidentally or for non-surgical focus.
RESULTS
Of the 347 unique legal decisions screened, 14 met inclusion and exclusion criteria. Surgeries occurred between 1976 and 2012, with 13 thyroid surgeries, 1 parathyroidectomy, and 4 mortalities.
CONCLUSIONS
Quality improvement lessons include communication, pre-operative patient education and documentation of risks discussed, and in-person assessment of complications.
PubMed: 38734539
DOI: 10.1016/j.amjsurg.2024.04.018