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The serum 24,25-dihydroxyvitamin D concentration, a marker of vitamin D catabolism, is reduced in chronic kidney disease.
Bosworth CR, Levin G, Robinson-Cohen C, Hoofnagle AN, Ruzinski J, Young B, Schwartz SM, Himmelfarb J, Kestenbaum B, de Boer IH
(2012) Kidney Int 82: 693-700
MeSH Terms: African Americans, Aged, Biomarkers, Comorbidity, Cross-Sectional Studies, Down-Regulation, Female, Glomerular Filtration Rate, Humans, Hyperparathyroidism, Secondary, Kaplan-Meier Estimate, Kidney, Linear Models, Male, Mass Spectrometry, Middle Aged, Multivariate Analysis, Parathyroid Hormone, Prognosis, Proportional Hazards Models, Renal Insufficiency, Chronic, Risk Assessment, Risk Factors, Steroid Hydroxylases, Vitamin D, Vitamin D3 24-Hydroxylase, Washington
Show Abstract · Added September 19, 2017
Chronic kidney disease is characterized, in part, as a state of decreased production of 1,25-dihydroxyvitamin D (1,25(OH)(2)D); however, this paradigm overlooks the role of vitamin D catabolism. We developed a mass spectrometric assay to quantify serum concentration of 24,25-dihydroxyvitamin D (24,25(OH)(2)D), the first metabolic product of 25-hydroxyvitamin D (25(OH)D) by CYP24A1, and determined its clinical correlates and associated outcomes among 278 participants with chronic kidney disease in the Seattle Kidney Study. For eGFRs of 60 or more, 45-59, 30-44, 15-29, and under 15 ml/min per 1.73 m(2), the mean serum 24,25(OH)(2)D concentrations significantly trended lower from 3.6, 3.2, 2.6, 2.6, to 1.7 ng/ml, respectively. Non-Hispanic black race, diabetes, albuminuria, and lower serum bicarbonate were also independently and significantly associated with lower 24,25(OH)(2)D concentrations. The 24,25(OH)(2)D concentration was more strongly correlated with that of parathyroid hormone than was 25(OH)D or 1,25(OH)(2)D. A 24,25(OH)(2)D concentration below the median was associated with increased risk of mortality in unadjusted analysis, but this was attenuated with adjustment for potential confounding variables. Thus, chronic kidney disease is a state of stagnant vitamin D metabolism characterized by decreases in both 1,25(OH)(2)D production and vitamin D catabolism.
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27 MeSH Terms
Two teenage males with hypocalcemia and elevated parathyroid hormone levels.
Shoemaker AH, Bremer AA
(2012) Pediatr Ann 41: e1-5
MeSH Terms: Adolescent, Humans, Hyperparathyroidism, Hypocalcemia, Male, Parathyroid Hormone
Show Abstract · Added January 20, 2015
Vitamin D deficiency is not a rare disorder, particularly in minority groups. The Institute of Medicine recommends serum 25-hydroxyvitamin (OH)D levels >20 ng/mL and The Endocrine Society recommends levels >30 ng/mL for good health. In contrast, the 2003-2006 National Health and Nutrition Examination Survey reported average total 25-(OH)D concentrations of 25.6 ± 0.4 ng/mL in whites, 19.5 ± 0.5 ng/mL in Mexican Americans, and 14.8 ± 0.4 ng/mL in blacks. Pediatric patients with vitamin D deficiency may be asymptomatic or may present either with rickets, hypocalcemia, or seizures. Pseudohypoparathyroidism (PHP) is a rare disorder characterized by parathyroid hormone (PTH) resistance with (type 1a) or without (type 1b) the Albright Hereditary Os-teodystrophy (AHO) phenotype of short stature, brachydactyly, and mental retardation. Patients with PHP have elevated PTH levels and may have hyperphosphatemia and hypocalcemia. However, the same laboratory values can be seen in children with vitamin D deficiency, and diagnostic confusion is common. We report two cases of vitamin D deficiency with presentations suggestive of PHP.
Copyright 2012, SLACK Incorporated.
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6 MeSH Terms
Factors determining insulin resistance in chronic hemodialysis patients.
Hung AM, Ikizler TA
(2011) Contrib Nephrol 171: 127-134
MeSH Terms: Adipokines, Chronic Disease, Glucose, Humans, Hyperparathyroidism, Secondary, Inflammation, Insulin Resistance, Kidney Failure, Chronic, Renal Dialysis, Vitamin D Deficiency
Show Abstract · Added February 24, 2014
Insulin resistance (IR) is common in chronic hemodialysis (CHD) patients and is associated with excess mortality. The gold standard for assessment of insulin sensitivity is hyperinsulinemic euglycemic clamp studies which provide the precision and accuracy necessary, especially for mechanistic studies. However, clamp studies are labor-intensive and complicated for more practical use. Accordingly, additional indices such as homeostatic model assessment of insulin resistance (HOMA), quantitative insulin sensitivity check index, and adipokine-based measurements represent appropriate alternatives for large epidemiological and interventional studies. The etiology of IR in the CHD population is complex and multifactorial. The predominant pathophysiological mechanism of 'uremic insulin resistance' is a post-receptor defect in the skeletal muscle; however, other glucose metabolism abnormalities are also present. Some of the proposed determinants of IR in CHD patients include chronic inflammation, excess visceral fat, adipokine deregulation and accumulation, metabolic acidosis, oxidative stress, vitamin D deficiency, anemia, decreased physical activity, and accumulation of uremic toxins. The relative importance of each of these abnormalities is not well-defined, although excess visceral fat and inflammation seem to be the most important correlates of IR in this patient population. There are only few interventional studies targeted at improving insulin resistance in CHD patients. Insulin sensitizers such as metformin and PPAR-γ agonists are either contraindicated or sparingly used due to their potential side effects, even in CHD patients with overt diabetes mellitus. More novel approaches to improving IR in this patient population might lead to potential strategies for preventing excess mortality.
Copyright © 2011 S. Karger AG, Basel.
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10 MeSH Terms
Surgical management of primary hyperparathyroidism: state of the art.
Lew JI, Solorzano CC
(2009) Surg Clin North Am 89: 1205-25
MeSH Terms: Diagnostic Imaging, Humans, Hyperparathyroidism, Primary, Minimally Invasive Surgical Procedures, Monitoring, Intraoperative, Parathyroid Glands, Parathyroidectomy
Show Abstract · Added March 5, 2014
This article reviews the current state of the art regarding therapy for primary hyperparathyroidism. Clinical evaluation and indications for parathyroidectomy are described, followed by a review of surgical techniques currently being practiced and possible outcomes involved. Focused parathyroidectomy has become a successful alternative to conventional bilateral cervical exploration.
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7 MeSH Terms
Surgeon-performed ultrasound: a single institution experience in parathyroid localization.
Jabiev AA, Lew JI, Solorzano CC
(2009) Surgery 146: 569-75; discussion 575-7
MeSH Terms: Adolescent, Adult, Aged, Aged, 80 and over, False Positive Reactions, Female, Humans, Hyperparathyroidism, Primary, Male, Middle Aged, Parathyroid Glands, Physician's Role, Ultrasonography
Show Abstract · Added March 5, 2014
BACKGROUND - Ultrasound has been used successfully to localize parathyroid glands. This study evaluates surgeon-performed ultrasound (SUS) for pre-operative parathyroid localization prior to parathyroidectomy.
METHODS - In all, 442 patients with primary hyperparathyroidism (HPT) underwent SUS at a single institution. Patients were divided into 2 groups: group 1 (n = 338) had correct localization, and group 2 (n = 104) had incorrect localization. The true-positive (TP) rate and peri-operative findings were compared. TP was defined as localization of all abnormal parathyroids resulting in operative success. A P value >.05 was considered significant.
RESULTS - Of 442 patients, 338 (76.5%) had TP results. Group 1 patients were younger (57 vs 63 years; P < .0001) with larger gland size: 2.1 versus 1.8 cm (P = .08). In group 2, 45/104 (43%) patients had false-positive SUS, and 59/104 (57%) had negative studies or missed multiglandular disease (MGD). Group 1 patients had shorter operative times (60 vs 80 min, P = .002), fewer bilateral neck explorations (BNEs) (8% vs 39%; P < .0001), and lower MGD rates (2% vs 19%; P < .0001). Operative failure was 0.3% in group 1 and 9.6% in group 2 (P < .0001).
CONCLUSION - Younger patients have a greater rate of correct localization. When SUS correlates with operative findings, MGD is significantly lower and fewer BNEs are performed. Additionally, operations are shorter with a higher success rate.
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13 MeSH Terms
Sporadic primary hyperparathyroidism in young individuals: different disease and treatment?
Sneider MS, Solorzano CC, Montano RE, Anello C, Irvin GL, Lew JI
(2009) J Surg Res 155: 100-3
MeSH Terms: Adolescent, Adult, Age Factors, Aged, Aged, 80 and over, Child, Contraindications, Female, Humans, Hyperparathyroidism, Primary, Male, Middle Aged, Parathyroidectomy, Retrospective Studies, United States, Young Adult
Show Abstract · Added March 5, 2014
BACKGROUND - Younger individuals with hyperparathyroidism may experience severe disease with a higher incidence of multigland disease (MGD) and operative failure, thereby requiring subtotal parathyroidectomy. This study examines the characteristics and surgical outcome of younger compared with older patients with sporadic primary hyperparathyroidism (SPHPT).
METHODS - Prospectively collected data of 1101 patients with SPHPT who underwent parathyroidectomy at a single institution were retrospectively reviewed. Patients with multiple endocrine neoplasia (MEN), familial, secondary, or tertiary hyperparathyroidism, parathyroid carcinoma, rickets, or lithium induced disease were excluded. Patients were subdivided into two groups: (1) younger individuals < or = 40 y of age (n = 110) and (2) older individuals > 40 y of age (n = 991). Both age groups were compared for gender, clinical manifestations, pre- and postoperative laboratory values, MGD, operative success, and recurrent disease.
RESULTS - There was greater male predominance in younger compared with older patients treated for SPHPT (41% versus 25%, P = 0.0004). Of the clinical manifestations of SPHPT, kidney stones were more common in younger compared with older individuals (45% versus 29%, P = 0.0006). Conversely, bone pain was more common in older compared with younger patients (32% versus 14%, P = 0.0002). There was no statistical difference in biochemical values, MGD, and outcome between both groups.
CONCLUSIONS - Despite male predominance and few differences in symptoms, SPHPT is a similar disease entity in both younger and older individuals. Patients from both age groups can be similarly treated for SPHPT with a high rate of operative success. Routine BNE and subtotal parathyroidectomy is not necessary in younger individuals.
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16 MeSH Terms
Long-term outcome of patients with intraoperative parathyroid level remaining above the normal range during parathyroidectomy.
Carneiro-Pla DM, Solorzano CC, Lew JI, Irvin GL
(2008) Surgery 144: 989-93; discussion 993-4
MeSH Terms: Calcium, Humans, Hyperparathyroidism, Intraoperative Care, Parathyroid Hormone, Parathyroidectomy, Recurrence, Retrospective Studies, Treatment Outcome
Show Abstract · Added March 5, 2014
BACKGROUND - Criterion requiring intraoperative parathyroid hormone (IOPTH) drops >50% from the highest, preincision or preexcision level, 10 minutes after the abnormal gland's excision predicts operative success with 98% accuracy. The purpose of this study is to correlate IOPTH dynamics with recurrent hyperparathyroidism (RecHPT) and eucalcemia with high PTH (HPTH).
METHODS - We followed 383 consecutive patients with parathyroidectomy guided by IOPTH monitoring using the above criterion for >6 months. Calcium and PTH levels were measured for 50 months (range, 6-173). Patients were divided in 2 groups: group 1 comprised 302 participants with IOPTH levels that decrease to the normal range (NR), and group 2, with 81 participants who had >50% IOPTH decrease but remained above the normal range. The incidence of RecHPT and eucalcemia with HPTH was evaluated.
RESULTS - RecHPT was found in 2% (8/383) of patients and eucalcemia with HPTH was present in 19% (74/383). In group 1, 17% (52/302) had eucalcemia with HPTH, whereas in group 2, this incidence was 27% (22/81; P = .04). However, only 2% of those (6/302) in group 1 and 2.5% (2/81) in group 2 developed RecHPT (P = .76). Conversely, 70.5% of those (57/81) in group 2 were eucalcemic with normal PTH.
CONCLUSION - Although postoperative eucalcemia with HPTH was significantly higher among patients with IOPTH above the normal range than in patients in group 1, the incidence of RecHPT was not increased. The majority of patients in whom IOPTH did not drop to the normal range continue to be biochemically normal after the operation.
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9 MeSH Terms
A prospective evaluation of the effect of sample collection site on intraoperative parathormone monitoring during parathyroidectomy.
Beyer TD, Chen E, Ata A, DeCresce R, Prinz RA, Solorzano CC
(2008) Surgery 144: 504-9; discussion 509-10
MeSH Terms: Adult, Aged, Blood Specimen Collection, Evaluation Studies as Topic, Female, Follow-Up Studies, Humans, Hyperparathyroidism, Primary, Male, Middle Aged, Minimally Invasive Surgical Procedures, Monitoring, Intraoperative, Parathyroid Hormone, Parathyroidectomy, Probability, Prospective Studies, Sensitivity and Specificity, Treatment Outcome
Show Abstract · Added March 5, 2014
BACKGROUND - Sample collection site may affect the dynamics of intraoperative parathyroid hormone monitoring (IPM) and influence surgical decisions.
METHODS - We prospectively studied 45 patients undergoing parathyroidectomy for primary hyperparathyroidism. The IPM cure criterion was a decrease in peripheral vein (PV) parathyroid hormone (PTH) of >50% at 10 minutes after gland excision. PTH samples were collected simultaneously from PV and central vein (CV) and compared for PTH decay, the incidence of >50% PTH decay, and the incidence of normal PTH values after gland excision.
RESULTS - Mean PTH levels were significantly higher from the CV before and after gland excision. Mean PTH decay 10 minutes after gland excision was 89% PV versus 88% CV, resulting in mean PTH levels of 27 +/- 23 and 39 +/- 35 pg/mL, respectively (P < .0001). At 5 minutes, >50% decay in PTH was present in 98% PV versus 88% CV samples. By 10 minutes, the incidence of >50% PTH decay was equivalent (98%). This yielded normal range PTH levels from the PV versus CV in 90% versus 76% of patients at 5 minutes, 96% versus 89% at 10 minutes, and 95% versus 81% at 20 minutes. Of 45 patients, 44 (98%) are normocalcemic at a mean follow-up of 6.3 months. IPM predicted the single operative failure.
CONCLUSIONS - CV sampling produces significantly higher PTH levels. Surgeons sampling from a PV may observe a >50% decrease in PTH and normal range PTH values starting 5 minutes after gland excision. Surgeons who sample from the CV and require normalization of PTH levels may have to wait longer and/or continue potentially unnecessary neck exploration.
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18 MeSH Terms
Role of intraoperative parathormone monitoring during parathyroidectomy in patients with discordant localization studies.
Lew JI, Solorzano CC, Montano RE, Carneiro-Pla DM, Irvin GL
(2008) Surgery 144: 299-306
MeSH Terms: Adolescent, Adult, Aged, Aged, 80 and over, Female, Humans, Hyperparathyroidism, Primary, Male, Middle Aged, Monitoring, Intraoperative, Parathyroid Glands, Parathyroid Hormone, Parathyroidectomy, Radionuclide Imaging, Radiopharmaceuticals, Technetium Tc 99m Sestamibi, Ultrasonography
Show Abstract · Added March 5, 2014
BACKGROUND - Many patients with sporadic primary hyperparathyroidism (SPHPT) have discordant preoperative Tc-99m-sestamibi (MIBI) and ultrasonography studies prior to focused parathyroidectomy (PTX). This study examines the usefulness of intraoperative parathormone monitoring (IPM) during PTX in patients with discordant preoperative localization studies.
METHODS - A retrospective series of 225 consecutive SPHPT patients with MIBI scans and surgeon performed ultrasonography (SUS) prior to focused parathyroidectomy were studied. All patient operations were reviewed, and how IPM changed operative management was determined. Correct gland localization, presence of multigland disease (MGD), and operative outcome were also examined.
RESULTS - In 225 patients, overall operative success was 97%, and IPM changed operative management in 29% of patients. In 85 patients (38%) with discordant studies, operative success was 93%; IPM changed operative management in 74% of these patients. IPM allowed for 66% (56/85) of these operations to be performed as unilateral neck exploration and confirmed removal of abnormal glands in 7 patients with MGD. In 140 patients (62%) with concordant localization, in which operative success was 99%, IPM changed operative management in only 2% (3/140) of these patients with MGD.
CONCLUSION - Although of marginal benefit in patients with concordant imaging studies, IPM remains essential for performing successful PTX with discordant or incorrect concordant localization.
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17 MeSH Terms
Long-term outcome of patients with elevated parathyroid hormone levels after successful parathyroidectomy for sporadic primary hyperparathyroidism.
Solorzano CC, Mendez W, Lew JI, Rodgers SE, Montano R, Carneiro-Pla DM, Irvin GL
(2008) Arch Surg 143: 659-63; discussion 663
MeSH Terms: Adolescent, Adult, Aged, Aged, 80 and over, Calcium, Female, Humans, Hyperparathyroidism, Male, Middle Aged, Parathyroid Hormone, Parathyroidectomy, Postoperative Period, Recurrence, Retrospective Studies
Show Abstract · Added March 5, 2014
HYPOTHESIS - Untreated long-term elevated parathyroid hormone (PTH) levels after successful parathyroidectomy may predict recurrent hyperparathyroidism (HPT). Although elevated PTH levels have been reported in eucalcemic patients after parathyroidectomy for sporadic primary HPT, the long-term clinical significance of this finding remains unclear.
DESIGN - Retrospective case series.
SETTING - Tertiary referral center.
PATIENTS - Five hundred seventy-six consecutive patients with HPT.
INTERVENTION - Parathyroidectomy guided by intraoperative monitoring of PTH levels.
MAIN OUTCOME MEASURES - Overall incidence of elevated PTH levels (measurements of >or= 70 pg/mL at any time during follow-up) and recurrent HPT (hypercalcemia and elevated PTH levels more than 6 months after parathyroidectomy).
RESULTS - Of the 505 patients who underwent successful parathyroidectomy in this series and were followed up for more than 6 months, 337 (66.7%) consistently had PTH levels within the reference range, and 168 (33.3%) had elevated PTH levels. Of the 168 patients with elevated PTH levels, only 8 (4.8%) developed recurrent disease. The earliest recurrence occurred 2 years postoperatively. Factors associated with elevated PTH levels included advanced age, higher preoperative PTH levels, and mild postoperative renal insufficiency.
CONCLUSION - Although one-third of the patients had elevated PTH levels after successful parathyroidectomy, most of these patients with elevated PTH levels (95%) will achieve long-term eucalcemia.
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15 MeSH Terms