OBJECTIVE

To review minimally invasive parathyroidectomy (MIP) in patients undergoing initial surgical management of primary hyperparathyroidism (HPT) with preoperative, localizing sestamibi scanning (MIBI), and concordant ultrasonography (US) to determine if intraoperative parathyroid hormone (iPTH) is necessary in these cases. Minimally invasive parathyroidectomy has become an acceptable therapeutic option in treating primary HPT. Preoperative MIBI scanning, high-resolution US with color Doppler flow, and iPTH monitoring have refined this technique.

METHODS

Retrospective review.

METHODS

The medical records of 738 consecutive patients who had undergone surgery for HPT. After excluding revision surgical procedures, secondary and tertiary HPT, unavailable intraoperative parathyroid (PTH) data, concomitant thyroid disease requiring thyroidectomy, and patients without preoperative MIBI or US, 428 patients (58%) were included in the study.

RESULTS

The mean decrease in PTH level was 85%. Of the 428 patients with primary HPT included in the study, 209 patients (49%) had localizing, concordant preoperative MIBI and US. A decline of more than 50% in iPTH levels was observed in 202 patients (97%) after removal of parathyroid tissue localized by MIBI and US. The procedures for 4 patients were converted to bilateral neck explorations after the postexcision PTH level failed to drop less than 50%.

CONCLUSIONS

Our results show that iPTH monitoring may be eliminated in MIP surgery in a carefully selected group of patients who have preoperative, localizing MIBI with concordant US. This potentially allows an increase in operating room efficiency and a decrease in costs while performing MIP.

Severe hypercalcemia occurred in a child with metastatic disease from a rhabdoid tumor of the kidney. Because there was no evidence of skeletal involvement by tumor, an investigation of the cause for hypercalcemia was undertaken. A greatly elevated serum concentration of immunoreactive parathyroid hormone (iPTH) was documented. This together with the observation of histologically normal parathyroid glands and the immunohistologic demonstration of parathyroid hormone within tumor cells supports the hypothesis of ectopic iPTH production by the tumor. The concurrence of an unusual metabolic complication with an infrequently encountered tumor variant is notable.

The aim of this study was to assess the late outcome of patients with primary hyperparathyroidism and multiple gland enlargement (MGE) treated by conservative surgery. MGE in primary hyperparathyroidism is the presence of two or more enlarged glands weighing more than 50 mg. Conservative surgery consists in resecting the grossly enlarged glands without biopsying the normal glands. Some authors have suggested that this approach overlooks minute hyperplasia, leading to late recurrences of hyperparathyroidism; conversely, it may result in the unnecessary resection of grossly enlarged, but not hyperfunctioning, glands. Altogether 1231 patients were operated on for primary hyperparathyroidism between 1966 and 1995. Of these patients, 304 (24.9%) had MGE, including 42 cases of multiple endocrine neoplasia (MEN), 12 familial cases, and 250 seemingly sporadic cases. Two, three, or four glands (or more) were involved in 61.8%, 21.4%, and 16.4% of cases, respectively. During the early postoperative period one patient died and ten were reoperated for persistent hypercalcemia. The pathologic diagnoses were double adenomas (13.5%), hyperplasia (35.8%), association of the two (39.8%), and a normal second gland (10.8%) on light microscopy findings. None of the 30 deaths that occurred during follow-up was related to hyperparathyroidism. Altogether 190 patients (79%) were available for follow-up (average 89.3 months): 90% were normocalcemic, 4.7% hypocalcemic, and 5.2% hypercalcemic. A late iPTH assay was done in 147. PTH was appropriate to the serum calcium level in 84.3% and appropriate to normal calcemia in 91.6% of 132 cases. Conservative surgery is thus an acceptable treatment for MGE in patients with hyperparathyroidism. Few late recurrences occur, for which there are no individual predictive criteria.

The use of calcium (Ca) supplements by postmenopausal women is growing rapidly. A commercial preparation of tricalcium phosphate (TCP) is available in the USA. Depending on the relative absorption of Ca versus phosphate, a rise in serum phosphorus (P) could stimulate parathyroid hormone (iPTH) secretion. We therefore compared Ca absorption and the metabolic responses following TCP to that of Ca carbonate (CC) on separate occasions in each of 10 women, aged 22-40 years. The subjects were fasted overnight for 12 hours while good hydration was maintained. Following a 2-hour baseline-urine collection, 1200 mg calcium (as CC or TCP) was ingested and two 2-hour postload urine collections were made. Blood was drawn at 1, 2, and 4 hours after the Ca load. Serum (S) and urine (U) Ca, P, and creatinine, and U cyclic AMP (cAMP) were determined. iPTH levels following TCP were also measured. Ca absorption was determined by the postload rise in Uca above baseline. Uca excretion increased significantly and was accompanied by significant rises in Sca after both preparations. Following TCP, S and U phosphorus increased. Urinary cAMP did not change after either preparation, and iPTH levels fell after oral TCP. We conclude that Ca taken as TCP is absorbed adequately and, thus, despite a rise in the S phosphorus level does not stimulate parathyroid activity.

This study evaluated the effect of somatostatin on immunoreactive parathyroid hormone (iPTH) and calcitonin (iCT) secretion in vivo in rats and monkeys and on iPTH secretion in vitro by normal bovine parathyroid tissue and by a human parathyroid adenoma. Somatostatin infusion promptly (within 0.5 h) suppressed both iPTH and iCT in both species studied in vivo, the suppression being progressive during the infusion period. In in vitro studies, somatostatin caused significant dose-related decreases in basal, low Ca-stimulated, and high Ca-suppressed PTH secretion from normal bovine parathyroid tissue and from basal and low Ca-stimulated PTH secretion from a human parathyroid adenoma. Therefore, somatostatin 1) suppresses both PTH and CT secretion in vivo; 2) acts directly on the parathyroid cell and presumably directly on the C-cell also; 3) acts upon normal and adenomatous parathyroid tissue; 4) suppresses basal, low Ca-stimulated and high Ca-suppressed PTH secretion; and 5) has a dose-related effect. The possible role of somatostatin in the physiological control of PTH and CT secretion (and therefore in Ca homeostasis), and in the pathogenesis of abnormalities of Ca homeostasis, requires further evaluation.

OBJECTIVE

To describe a patient with severe hypercalcemia and elevated intact parathyroid hormone (iPTH) levels associated with a hepatocellular carcinoma.

METHODS

We present a case report, detailing the laboratory, surgical, and sestamibi scanning findings. Moreover, the literature relating to paraneoplastic ectopic production of iPTH is reviewed.

RESULTS

A 72-year-old man had the following laboratory results at the time of initial assessment: serum calcium of 14.5 mg/dL, ionized calcium of 6.8 mg/dL, serum iPTH of 92 pg/mL, and a PTH-related peptide of <0.7 pg/mL. Findings on preoperative sestamibi scanning were suggestive of a parathyroid adenoma, with additional uptake in the dome of the liver. He was diagnosed as having primary hyperparathyroidism, and a neck exploration was undertaken. The right superior, right inferior, and left superior parathyroid glands were mildly enlarged and were excised. The left inferior parathyroid gland could not be identified, despite an extensive neck exploration. Bilateral internal jugular vein sampling demonstrated elevated iPTH levels, an indication of a systemic origin of the hormone. Postoperatively, a repeated sestamibi scan confirmed hyperactivity in the liver, and a subsequent computed tomographic scan revealed masses in segments IV, VII, and VIII of the liver in conjunction with portal vein involvement. Tissue biopsy confirmed the presence of hepatocellular carcinoma, and the fluid obtained with the biopsy specimen was strongly positive for iPTH. The patient was treated with transarterial chemoembolization but subsequently died.

CONCLUSIONS

This case demonstrates the rare occurrence of hepatocellular carcinoma producing iPTH as the cause of life-threatening hypercalcemia. Sestamibi scans were accurate in detecting focal hyperactivity that correlated with the malignant involvement.

BACKGROUND

Primary hyperparathyroidism (PHPT) and metabolic syndrome (MS) have been independently related to cardiovascular morbidities, however this association is still controversial. Mexican population has a high prevalence of metabolic syndrome, however its frequency seems to be even higher than expected in patients with PHPT.

METHODS

We retrospectively reviewed the charts of patients that underwent parathyroidectomy for PHPT in a referral center and used the criteria from the National Cholesterol Educational Program (NCEP)/Adult Treatment Panel III (ATP III) to define MS before surgery. We compared the characteristics between the patients with and without MS.

RESULTS

60 patients were analyzed, 77% were female and 72% had a single parathyroid adenoma. MS was present in 59% of the patients, this group was significantly older (57 vs. 48 years, p = 0.01) and they had lower iPTH (115 vs. 161 ng/ml, p = 0.017). Other parameters did not show differences.

CONCLUSIONS

MS is frequent in our population diagnosed with primary hyperparathyroidism, adverse cardiovascular parameters are common and significant differences in calcium metabolism compared to the non-MS group are present.

BACKGROUND

Cinacalcet is an effective treatment for hypercalcemia due to persistent hyperparathyroidism (HPT) in patients who have undergone kidney transplantation (KT). Few data are available about their long-term follow-up.

OBJECTIVE

We aimed to evaluate the long-term efficacy of cinacalcet in functioning stable KT subjects with hypercalcemia secondary to persistent HPT.

METHODS

Twenty-three patients (6 men) with a stable KT showed persistent hypercalcemia (>12 months) secondary to HPT (parathyroid hormone by radioimmunoassay [iPTH]>> 150 pg/mL). The mean age was 54 ± 13 years. Time after KT to beginning cinacalcet treatment was 36.5 ± 37.9 (range 12 to 172) months. Initial cinacalcet doses were 30 mg/d. Median follow-up was 53 ± 7.4 months (range 42 to 60 months). We determined serum calcium, phosphorus, alkaline phosphatase, iPTH, creatinine, and immunosuppressant concentrations at baseline as well as 3, 6, and 12 months and after every 6 months thereafter.

RESULTS

Initial serum calcium was 11 ± 0.65 mg/dL and mean calcium during treatment, 10.25 ± 0.81 mg/dL (P < .001). Initial serum phosphorus was 2.8 ± 0.58 mg/dL and mean value serum phosphorus during the treatment period, 3.13 ± 0.6 mg/dL (P = 0.015). Initial iPTH was 260 ± 132 pg/mL and during the treatment period; 237 ± 131 pg/mL (P = ns). There was no change in renal function nor in immunosuppressant blood levels. Doses of cinacalcet at the end of the follow-up were 40.4 ± 18.9 mg/d.

CONCLUSIONS

Cinacalcet was effective for long-term control of hypercalcemia related to persistent HPT for patients with stable KT.

OBJECTIVE

The aim of this study is to investigate the predictive value of intraoperative parathormone measurement addressing successful surgical resection in patients with secondary hyperparathyroidism.

METHODS

The study included 42 consecutive patients operated on between May 2006 and July 2008. Patients were grouped according to successful surgery (Group 1, n = 36) and persistent postoperative hyperparathyroidism (Group 2, n = 6). Serum phosphorus (P), total calcium (tCa), ionized calcium (iCa), intact parathormone (iPTH), and alkaline phosphatase (ALP) were drawn preoperatively and intraoperatively upon 15 minutes after completion of resection (iPTH(15)). The rate of decrease of pith detected by iPTH(15) compared to preoperative values was calculated (iPTH(%)).

RESULTS

Preoperative P, tCa, iCa, iPTH, and ALP were comparable. Subtotal parathyroidectomy (sPx) (n = 27) and total parathyroidectomy with autotransplantation (tPx) (n = 15) were performed. Mean iPTH(15) value, iPTH(%) rates were 145.9 +/- 12.3 pg/mL, % 91.6 +/- 0.7, and 522.5 +/- 85.4 pg/mL, % 75.1 +/- 2.0 (P = ,001) in Groups 1 and 2, respectively. Mean serum tCa and iCa at POD#1 in Group 1 were 7.6 +/- 0.1 mg/dL, 0.910 +/- 0.4 mmol/L, and Group 2 were 8.3 +/- 0.3 mg/dL, 1.050 +/- 0.4 mmol/L (P < .05), respectively. ALP levels were similar.

CONCLUSIONS

iPTH(15) value and iPTH(%) rate accurately predicts the completeness of resection in secondary hyperparathyroidism. The rate of decrease in serum iPTH detected intraoperatively compared to preoperative baseline levels exceeding 90% in sPx, 95% in tPx, accurately predicts the success of surgery. Postoperative normocalcemia without calcium replacement would raise a suspicion about completeness of surgical resection.

BACKGROUND

An inverse relationship between major depressive disorder (MDD) and bone mineral density (BMD) has been suggested, but prospective evaluation in premenopausal women is lacking.

METHODS

Participants of this prospective study were 21 to 45 year-old premenopausal women with MDD (n = 92) and healthy controls (n = 44). We measured BMD at the anteroposterior lumbar spine, femoral neck, total hip, mid-distal radius, trochanter, and Ward's triangle, as well as serum intact parathyroid hormone (iPTH), ionized calcium, plasma adrenocorticotropic hormone (ACTH), serum cortisol, and 24-hour urinary-free cortisol levels at 0, 6, 12, 24, and 36 months. 25-hydroxyvitamin D was measured at baseline.

RESULTS

At baseline, BMD tended to be lower in women with MDD compared to controls and BMD remained stable over time in both groups. At baseline, 6, 12, and 24 months intact PTH levels were significantly higher in women with MDD vs. controls. At baseline, ionized calcium and 25-hydroxyvitamin D levels were significantly lower in women with MDD compared to controls. At baseline and 12 months, bone-specific alkaline phosphatase, a marker of bone formation, was significantly higher in women with MDD vs. controls. Plasma ACTH was also higher in women with MDD at baseline and 6 months. Serum osteocalcin, urinary N-telopeptide, serum cortisol, and urinary free cortisol levels were not different between the two groups throughout the study.

CONCLUSIONS

Women with MDD tended to have lower BMD than controls over time. Larger and longer studies are necessary to extend these observations with the possibility of prophylactic therapy for osteoporosis.

BACKGROUND

ClinicalTrials.gov NCT 00006180.

During the course of chronic renal failure (CRF) in man, renal osteodystrophy (osteitis fibrosa and/or osteomalacia) gradually develops. The present study aimed to establish a similar type of CRF leading to renal osteodystrophy in rats. During progressive CRF development over 225 days after 5/6 nephrectomy, the following serum variables were measured: creatinine, immunoreactive parathyroid hormone (iPTH), 1,25-dihydroxyvitamin D3 (1,25(OH)2D3), a25-hydroxyvitamin D3, (25(OH)D3), alkaline phosphatase, albumin, phosphate, urea nitrogen, total calcium, and other blood electrolytes. Subsequent to sacrifice, mechanical properties of the rat femur, bone histomorphometry (osteoid and eroded surfaces) and bone contents of calcium, phosphate and hydroxyproline were also examined. Serum creatinine in rats with CRF gradually escalated by some 70%, while circulating 1,25(OH)2D3 was reduced beneath detection level. Total plasma calcium and phosphate concentrations were, however, almost unchanged indicating that PTH-induced bone remodeling due to moderate hyperparathyroidism sustained calcium homeostasis. Alkaline phosphatase levels were reduced by some 50%, which reflects chronically impeded bone formation. Bone histomorphometry assessment revealed substantial elevation of resorption with moderate accompanying fibrosis in about 70% of afflicted animals. Bone calcium, phosphate and hydroxypyrroline contents remained unaltered. However, hydroxyproline/calcium ratio was marginally reduced. These results, together with altered mechanical bending stress characteristics and diminished diaphysis cross section area, confirm development of mixed bone lesions in the uremic animals. Our results are compatible with the early development of CRF in man. The established rat model is therefore useful in elucidating the precipitation and early treatment of renal osteodystrophy in humans.

The aim of this study was to follow the changes in bone mineral density (BMD) and biochemical markers of bone turnover in 10 children (7.5-17.5 years of age) with severe juvenile idiopathic arthritis (JIA), during a 3-year therapy with salmon calcitonin (100 IU/day 2 months on and 2 off for a year and 200 IU/day for 2 years) and calcium (500 mg/day). All patients were functional classes III and IV and were measured at yearly intervals with a dual photon absorptiometer at the lumbar spine. The changes observed were 7.2-9.5% per year for BMD and 2.0-6.0% for volumetric bone mineral density (BMDvol). The bone resorption markers showed significant decreases after a year's treatment (Pyr/Cr from 175+/-15 to 108+/-15 nm/mm, P < 0.001, Pyr-D/Cr from 24.3+/-3.5 to 13.3+/-1.9 nm/mm, P < 0.05, and OHPr/Cr from 57.4+/-11 to 35.1+/-8.4 microg/mg) and smaller changes thereafter. No significant changes were observed in the bone formation markers of osteocalcin and alkaline phosphatase. Serum iPTH, the vitamin D metabolites, and calcium concentrations fluctuated within normal, while calcium excretion increased from 0.3+/-0.1 to 1.9+/-0.4 mg/kg/24 hours, P < 0.001. In conclusion, the present study, despite its limitations of not being placebo controlled, shows possible beneficial effects of intranasal calcitonin on bone resorption and pain relief in JIA patients.

A group of 16 infants, 2 weeks to 11 months old, with malignant osteopetrosis were investigated to examine their vitamin D metabolism and parathyroid function. Bone biopsies from 6 children were studied by light microscopic histomorphometry and by electron microscopy. Considerable heterogeneity existed among the patients with respect to the parameters reflecting mineral metabolism and with respect to the histological manifestations of the disease. The most constant findings were as follows. Immunoreactive parathyroid hormone (iPTH) was elevated in all children, except in 1 patient who had tubular acidosis, and plasma calcium was low or normal, suggesting skeletal resistance to PTH. Plasma 1,25-dihydroxyvitamin D [1,25-(OH)2D] was not constantly elevated and appeared to depend on plasma phosphorus, as both parameters were negatively correlated (r = 0.704, p less than 0.01). Osteoblast activity, as evaluated by circulating alkaline phosphatase and osteocalcin and osteoblast number, measured for 6 children by bone histology, were not increased, despite hyperparathyroidism, suggesting PTH resistance or defective osteoblasts. Osteoclasts could be detected in 5 of the 6 children who had a biopsy. Osteoclast number (5.7-13.3% of bone surface) was normal or mildly increased, and marrow spaces were relatively well developed in 4 patients, whereas 1 child had markedly increased osteoclast number (28.3% of bone surface) and reduced marrow cavities. These 5 children received transplants, and engraftment occurred in all, except in the "hyperosteoclastic" patient. Further studies are necessary to establish the prognostic significance of this histologic feature.

We aimed to evaluate the diagnostic and preoperative localization capacity of 99mTc methoxyisobutylnitrile (MIBI) parathyroid scintigraphy and ultrasonography (USG) in enlarged parathyroid glands in the primary hyperparathyroidism (pHPT) as well as the relationship between the success rate of these techniques and biochemical values. In this study, we retrospectively evaluated 39 patients with clinical and biological evidence of pHPT who referred to the university hospital for MIBI parathyroid scintigraphy. Patients were examined with USG and double-phase MIBI parathyroid scintigraphy for the detection of enlarged parathyroid glands. Preoperative serum intact parathyroid hormone (iPTH) levels, calcium (Ca), phosphate and alkaline phosphatase measurements were obtained. A total of 45 parathyroid lesions in 39 patients were reviewed. Thirty-four patients had a single adenoma and 5 patients with multi-gland disease had 11 abnormal parathyroid glands including three adenomas, whereas the remaining 8 glands showed hyperplasia. The overall sensitivities of MIBI parathyroid scintigraphy, USG and combined techniques were 85.3%, 72.5% and 90.4%, respectively; the positive predictive values (PPV) were 89.7%, 85.2% and 92.6%, respectively. The most successful approach for detection of enlarged parathyroid glands in hyperparathyroidism is the concurrent application of USG and MIBI parathyroid scintigraphy modalities. The concomitancy of thyroid diseases decreases the sensitivity of both MIBI parathyroid scintigraphy and USG in enlarged parathyroid glands.

The effect of mild, non-insulin-dependent diabetes (NIDDM) on bone calcification and calcium (Ca) homeostasis was studied in growing rats (males and females). The diabetic state was characterized by mild insulin deficiency, plasma levels being 73% of controls, and mild hyperglycemia, with nonfasting plasma glucose levels of 1.5 times normal. There was no difference in plasma levels of Ca, phosphate (Pi), magnesium (Mg), alkaline phosphatase, immunoreactive parathyroid hormone (iPTH), calcitonin, 25-(OH)vitamin D (25[OH]D), 1,25-dihydroxyvitamin D (1,25[OH]2D), and 24,25-dihydroxyvitamin D (24,25[OH]2D) between the NIDDM rats and their controls of either sex. Metabolic Ca and Pi balance studies revealed that the experimental animals of both sexes were in positive Ca and Pi balance similar to that of their controls. Histologic studies of the kidney and intestinal slices from the experimental group were normal. Ca and Pi bone content calculated per gram bone ash of the femur, mandible, and second and fourth caudal vertebrae, and the organic content in the bones of the NIDDM animals showed no difference from their controls. Femur bone density and tibial epiphyseal growth plate width and morphology were similar histologically in the experimental and control rats. No decreased osteoid content in the tibial bone was found in the diabetic rats compared with controls. Physiologic sex differences, consisting of lower plasma Pi, higher plasma calcitonin levels, increased ratio of femur dry bone weight to total body weight, and increased percentage of mineralized and total bone volume at the tibial metaphysis seen in female compared with male control rats were also seen in the diabetic animals.(ABSTRACT TRUNCATED AT 250 WORDS)

1,25-Dihydroxyvitamin D(3) (calcitriol) therapy has been extensively used for posttransplant osteoporosis. Beside its effect on bone metabolism, calcitriol has an important immunomodulatory effect. We evaluated the effects of oral calcitriol therapy on allograft function and parathyroid hormone levels after renal transplantation. The patients were retrospectively selected from a renal transplant patient population who received calcitriol (group 1, n = 59, 36 male/23 female, follow-up: 52.8 +/- 12.2 months) compared with group (group 2, n = 52, 42 male/9 female, follow-up: 62.0 +/- 24.4 months) without calcitriol therapy after renal transplantation. Calcitriol therapy was started 24.0 +/- 19.1 months posttransplantation. All patients were under three-drug immunosuppression. The pretransplant and posttransplant data were studied retrospectively. Additionally, creatinine levels before and after the initiation of calcitriol therapy were recorded at 6 months intervals for 3 successive years. Our results were analyzed according to the first and third year on therapy data. According to the first year data, there were no differences in patient groups in terms of creatinine and iPTH levels. In the third year, the patients in group 1 showed significantly lower creatinine (P = .01) and iPTH (P < .04) levels and needed lower pulse steroid doses (P < .04). According to a Friedman repeated measures variance test, the creatinine level was significantly lower among group I (P < .04) at 3-year follow-up. In conclusion, even a delayed start of calcitriol therapy after renal transplantation exerts a protective effect on renal allograft function and prevents the development of hyperparathyroidism.

The effect of combined administration of 24R,25-dihydroxyvitamin D3 (24,25-(OH)2D3) and 1 alpha-hydroxyvitamin D3 (1 alpha-(OH)D3) was studied in 24 non-dialyzed patients with chronic renal insufficiency (CRI), matched pairwise as to age, sex, and creatinine clearance (Cr.cl). Low Ca intake had been supplemented beforehand. Then, 1 alpha-(OH)D3 (mean dose 0.55 micrograms daily) was given orally to all patients for 3 months (T0 to T3). Subsequently, patients were assigned randomly to 6 months further treatment either with 1 alpha-(OH)D3 alone (Group A) or with 1 alpha-(OH)D3 plus a high dosage of 24,25-(OH)2D3 (50 micrograms orally, twice weekly) (Group B). Histomorphometry was performed at T0, T3, and T9. In both groups iPTH was equally suppressed, into the lower normal range. Whereas in Group A, serum Ca rose steadily and Cr.cl declined, in Group B both parameters levelled off between T6 and T9. At T9, in Group A the elevated resorption and osteoid indices had normalized markedly, but osteoblasts (Ob.Pm) and mineralizing boundaries (M.Bd) were depressed considerably between T3 and T9. In contrast, in Group B, preservation of Ob.Pm and improved mineralizing activity were observed (M.Bd at T9>> T3>> T0). Resorption indices hardly changed. In the patients with high Ob.Pm at T0, cancellous bone area increased significantly. This was not observed in Group A. Thus, in Group B, osteoblast recruitment appeared maintained and M.Bd appeared normalized. Decline of remodeling toward an adynamic state with an increased risk of hypercalcemia appeared prevented.

BACKGROUND

Transient hypocalcemia is one of the postoperative complications of thyroidectomy for Graves' disease, and perioperative parathyroid hormone (PTH) assays are used to predict postoperative hypocalcemia. We evaluated long-term changes in parathyroid function after surgery for Graves' disease.

METHODS

Serum PTH values were measured in Graves' patients with postoperative hypocalcemia, and those patients were followed postoperatively.

RESULTS

Subtotal thyroidectomy was performed in 275 patients with Graves' disease. Their serum calcium levels were measured on postoperative day (POD) 1, and patients with transient postoperative hypocalcemia were treated with calcium and vitamin D supplementation and followed up. The amount of calcium and vitamin D supplementation was adjusted to keep the patient's serum calcium level within the normal range. Measurement of their serum intact PTH value on POD 1 revealed normal value in 18 patients, a below normal level in 22, and an above normal level in the other 2. During the follow-up period, the serum iPTH values remained normal in 12 patients, recovered to the normal level in 21 patients, and rose above the normal range in 9 patients. The serum iPTH values of all patients eventually reached the normal range during the follow-up period. A marked difference in preoperative serum alkaline phosphatase concentration was observed between the high-iPTH patients and the normocalcemic patients.

CONCLUSIONS

The phenomenon of an elevated serum PTH level after surgery for Graves' disease was observed in 21% of the patients with postoperative hypocalcemia despite the achievement of normal serum calcium levels by calcium and vitamin D supplementation.

1. Calcium and immunoreactive parathyroid hormone (iPTH) levels were measured in sera of 1334 normal subjects ranging from newborn to over 80 years of age. Albumin was measured in samples from the population of adults, which was 80% white, 15% black and 5% oriental. 2. Serum calcium and iPTH levels in children tended to be higher in the first three years of age; no sex differences were noted. Values for serum calcium and iPTH were higher in children than in adults. 3. Serum calcium, iPTH and albumin showed more variation in groups of white, black and oriental women than in similar groups of men. In white females the mean serum calcium remained fairly constant until age 60, whereas in black women it rose steadily from age 20-29 until age 50-59. Serum iPTH levels were lower in black women than in white women and usually were not measurable in oriental women. 4. In men (white, black and oriental) there was a steady decrease in mean serum calcium with age, and iPTH levels were not different from those observed in white women. 5. Although the number of samples from oriental women was small, the serum calcium was consistently lower and serum albumin was constantly higher than in white or black women, and iPTH levels usually were unmeasurable.

This study was designed to compare calcium bioavailability and serum parathyroid hormone acute changes after oral intake of 500 mg of elemental calcium from liquid milk, yogurt, calcium-citrate-enriched powdered milk or a calcium carbonate pill; or after intake of soybean imitation-milk. After a 12-h fast, blood samples were drawn both at baseline and 1, 2, 3 and 4 h after an oral intake of the above-mentioned products, which were ingested together with a light neutral breakfast. The administration order of the study products was randomly assigned to each of 19 healthy young volunteers (11 females, 8 males). The baseline serum concentrations of ionized calcium, phosphorus and intact parathyroid hormone (iPTH) were normal. Calcium-citrate-enriched powdered milk induced a significant increase in serum ionized calcium (p<0.001) and a significant and continuous decrease in serum iPTH concentration (p<0. 001). Yogurt and the calcium carbonate pill induced a similar but less significant effect, increasing serum ionized calcium (p<0.05) and decreasing serum iPTH (p<0.01). Liquid milk only induced a significant change in serum ionized calcium and iPTH concentration during the first 2 h; this effect was lost during the following 2 h. In conclusion, our study suggests the possibility that the addition of calcium citrate to powered milk may improve calcium bioavailability and enhance the inhibitory effect on serum iPTH in the assayed conditions.

This study examines the interrelationship between serum levels of substances important in mineral metabolism including the 3 vitamin D metabolites 25OHD, 24.25(OH)2D and 1.25(OH)2D and static and dynamic histomorphometric measurements of bone remodelling in iliac crest biopsies in 17 patients with chronic renal failure. No correlation was found between the serum values of any of the vitamin D metabolites and the histomorphometric values. However, significant inverse correlations were found between serum calcium and both the osteoid surface extent (P less than 0.05) and osteoid volume (P less than 0.05) in trabecular bone. Serum immunoreactive parathyroid hormone (iPTH) was positively related to trabecular osteoclastic bone resorption. The serum level of 1.25(OH)2D was inversely related to endogenous creatinine clearance (P less than 0.01). These results support the hypothesis that the serum calcium concentration is more important than the serum concentration of vitamin D metabolites for bone remodelling in chronic renal failure.

OBJECTIVE

The development of rapid, sensitive assays for measuring the intact parathyroid hormone (iPTH) molecule has the potential to allow the surgeon to determine the success of parathyroid surgery intraoperatively. The purpose of the study was to review our results in the context of currently held beliefs regarding the ability of the intraoperative iPTH to predict resolution of hyperparathyroidism.

METHODS

Retrospective review.

METHODS

The study series is a retrospective review of 107 consecutive parathyroidectomies performed by a single surgeon. Patients with primary, secondary, and tertiary hyperparathyroidism were included.

RESULTS

The intraoperative assay allowed an overall success rate of 93.4% across all patient categories. The success rate in patients with primary hyperparathyroidism was 95.7%. Measuring the iPTH level at 10 versus 15 minutes after the removal of tissue did not significantly affect the predictive value of the test. A decrease of 50% in the iPTH level after the resection of hyperfunctioning tissue was prognostic of successful treatment of the hyperparathyroid state. By contrast, a postexcision iPTH level that was within the normal range was not always predictive of cure.

CONCLUSIONS

The intraoperative iPTH assay is particularly useful in the treatment of primary hyperparathyroidism. The assay eliminates the need for intraoperative frozen-section analysis in most cases and allows the surgeon to perform limited resections with confidence. This is especially true in complicated parathyroid surgeries, such as revision surgeries or those requiring concomitant thyroid surgery. The assay is also useful in secondary hyperparathyroidism, although it appears that the inability to identify small nonfunctional or hypofunctional supernumerary parathyroid glands means that long-term normocalcemia may not be assured.

BACKGROUND

Our aim was to investigate the quality of life (QoL) in 103 patients undergoing chronic hemodialysis (HD) in an integrated assessment of clinical, personological, and adaptation parameters, also in a non-urban context.

OBJECTIVE

We collected data from all chronic HD patients attending four HD units. Clinical status was assessed by Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines and by Age-adjusted Charlson Comorbidity Index (ACCI). Patients completed the following questionnaires: Kidney Disease Quality of Life Short Form (KDQOL-SF), Pittsburgh Sleep Quality Index (PSQI). Personality profile and coping style were assessed by Temperament and Character Inventory (TCI) revised and Coping Inventory for Stressful Situation (CISS). Data were analyzed by conventional descriptive statistics. Multiple forward stepwise linear regression analyses were performed.

RESULTS

Variables significantly associated with physical and mental components of KDQOL-SF were: intact parathyroid hormone (iPTH) (p = .004; p = .0015), typology of cohabitant (family member or not) (p = .022; p = .007), years of dialysis (p = .022; p = .048). Variables associated with mental component of KDQOL-SF were: PSQI (p = .000), task-coping (p = .000), avoidance-coping (p = .003), work status (p = .021). Principle conclusions: Our results suggest the importance of an integrated and multidirectional management of patients chronically undergoing HD and living in a non-urban context.

OBJECTIVE

To evaluate the influence of sevelamer hydrochloride and calcium acetate on biomarkers of bone turnover in patients with hyperphosphatemia receiving hemodialysis.

METHODS

In this prospective, open-label, randomized, active-controlled study, 70 patients (38 men and 32 women) with hyperphosphatemia (serum phosphorus level >6.0 mg/dL) underwent a two-week washout period and were randomly selected to receive sevelamer hydrochloride (n = 37) or calcium acetate (n = 33) for eight weeks. Changes in serum levels of intact parathyroid hormone (iPTH), alkaline phosphatase (Alk-P), phosphorus, and calcium were measured and compared.

RESULTS

After eight weeks of treatment, calcium acetate lowered iPTH levels significantly more than sevelamer hydrochloride did (-178.0 vs. -69.0 pg/mL, p = 0.0019). Levels of Alk-P were significantly elevated in patients given sevelamer hydrochloride compared with levels in those given calcium acetate treatment (24.09 vs. 7.45 U/L, p = 0.0014). Changes in serum phosphorus levels did not differ between sevelamer hydrochloride (-1.93 mg/dL) and calcium acetate (-2.5 mg/dL) at the end of the study (p = 0.0514). Changes in the calcium and phosphorous product did not significantly differ between the sevelamer-hydrochloride group (-18.06 mg2/dL2) and the calcium-acetate group (-19.05 mg2/dL2, p = 0.6764). Fifteen patients (45.5%) treated with calcium acetate had hypercalcemia (serum-adjusted calcium level >10.5 mg/dL); the rate was significantly higher than that of patients treated with sevelamer (five [13.5%] of 37, p = 0.0039).

CONCLUSIONS

Treatment with sevelamer hydrochloride had the advantage of maintaining stable iPTH levels and elevating Alk-P levels while lowering serum phosphorus levels and calcium-phosphorous product.