Prediction model of recurrence after parathyroidectomy in secondary hyperparathyroidism / 临床耳鼻咽喉头颈外科杂志

Objective:To quantitatively evaluate the risk of recurrence in patients with secondary hyperparathyroidism after parathyroidectomy. Methods:The clinical data of 168 patients who underwent parathyroidectomy（PTX） from June 2017 to May 2019 were collected. The prediction model was constructed by using Akaike information criterion（AIC） to screen factors. A total of 158 patients treated with PTX from June 2019 to September 2021 were included in the validation set to conduct external validation of the model in three aspects of differentiation, consistency and clinical utility. Results:The prediction model we constructed includes different dialysis methods, ectopic parathyroid gland, the iPTH level at one day and one month after surgery, the number of excisional parathyroid and postoperative blood phosphorus. The C index of external validation of this model is 0.992 and the P value of the Calibration curve is 0.886[KG0.5mm]1. The decision curve analysis also shows that the evaluation effect of this model is perfect. Conclusion:The prediction model constructed in this study is useful for individualized prediction of recurrence after PTX in patients with secondary hyperparathyroidism.

Distúrbio mineral e ósseo: prevalência subestimada nos estágios iniciais da doença renal crônica / Mineral and bone disorder: underestimated prevalence in the early stages of chronic kidney disease / Trastorno mineral y óseo: prevalencia subestimada en las primeras fases de la enfermedad renal crónica

Introdução: o objetivo foi avaliar a prevalência do distúrbio mineral e ósseo em pacientes com doença renal crônica e a associação entre Taxa de Filtração Glomerular estimada (TFGe) e os indicadores do distúrbio mineral e ósseo (DMO) (cálcio, fósforo e PTH) em pacientes renais crônicos não dialíticos. Materiais e Métodos: estudo seccional da linha de base de uma coorte de dois anos, com adultos e idosos renais crônicos em tratamento conservador. Para identificação do DMO utilizamos os seguintes valores séricos: PTH (> 150 pg/mL) e/ou hipocalcemia (Ca < 8,8mg/dl) e/ou hiperfosfatemia (P > 4,6 mg/dl). Na análise estatística utilizou-se: regressão de Poisson; T de Student, Mann Whitney e correlações de Pearson e Spearman. Nível de significância foi de 5%. Resultados: prevalência de DMO de 54,6% (n=41) (IC 95%: 43,45 - 65,43). A maior prevalência de DMO foi em pessoas do sexo feminino, alfabetizadas, idosas, não etilistas, não tabagistas, sedentárias e de cor de pele branca, porém, sem diferença estatística entre os grupos com e sem DMO. As correlações entre P e PTH com TFGe foram significativas, inversas, de força moderada (p= <0,005 e p = 0,003; coeficientes de correlação = - 0,312 e - 0,379 respectivamente). Discussão:os achados desse estudo mostraram que existe uma lacuna no acompanhamento do DMO-DRC pela atenção primária e a prática clínica deve ser revista. Conclusão:identificou-se prevalência robusta de DMO nos estágios precoces da DRC, além de correlações significativas entre o aumento dos níveis de fósforo e PTH e piora das funções renais.

Introduction: mineral and bone disorder (BMD) is a serious complication of chronic kidney disease (CKD) that increases risks for death from cardiovascular causes and impairs quality of life of affected patients. Objetive: to evaluate the prevalence of BMD in patients with CKD and the association between estimated Glomerular Filtration Rate (eGFR) and BMD indicators (calcium, phosphorus and PTH) in non-dialysis patients. Materials and Methods:sectional study of a two-year cohort of chronic renal adults and elderly patients on conservative treatment. BMD was identified by serum values of: PTH (> 150 pg/mL) and/or hypocalcemia (Ca < 8.8mg/dl) and/or hyperphosphatemia (P > 4.6 mg/dl). The statistical analysis used: Poisson regression; Student's T, Mann Whitney and Pearson and Spearman correlations with 5% significance level. Results:BMD prevalence was 54.6% (n=41) (95% CI: 43.45 - 65.43), more frequent in women, literate, elderly, non-drinkers, non-smokers, sedentary and white skin color. Correlations between P and PTH with GFRe were significant, inverse, moderate strength (p= <0.005 and p = 0.003; correlation coefficients = - 0.312 and - 0.379 respectively). Discussion: the findings of this study highlighted gaps in the monitoring of BMD-DRC by primary care, requiring a review of clinical practices. Conclusion: robust prevalence of BMD in the early stages of CKD was identified, in addition to correlations between increased phosphorus and PTH levels and worsening kidney function.

Introducciòn: el trastorno mineral y óseo (TMO) es una complicación grave de la enfermedad renal crónica (ERC) que aumenta el riesgo de muerte por causas cardiovasculares y deteriora la calidad de vida de los pacientes afectados. Objetivo: evaluar la prevalencia de la DMO en pacientes con RDC y la asociación entre la tasa de filtración glomerular estimada (TFGe) y los indicadores de DMO (calcio, fósforo y PTH) en pacientes no dialíticos. Materiales y Métodos: estudio seccional de una cohorte de dos años de pacientes renales crónicos adultos y ancianos en tratamiento conservador. La DMO se identificó por los valores séricos de: PTH (> 150 pg/mL) y/o hipocalcemia (Ca < 8,8mg/dl) y/o hiperfosfatemia (P > 4,6 mg/dl). El análisis estadístico utilizado: regresión de Poisson; T de Student, Mann Whitney y correlaciones de Pearson y Spearman con un nivel de significación del 5%. Resultados: la prevalencia de DMO fue del 54,6% (n=41) (IC 95%: 43,45 - 65,43), más frecuente en mujeres, alfabetizadas, de edad avanzada, no bebedoras, no fumadoras, sedentarias y de color de piel blanca. Las correlaciones entre el P y la PTH con el GFRe fueron significativas, inversas, de fuerza moderada (p= <0,005 y p = 0,003; coeficientes de correlación = - 0,312 y - 0,379 respectivamente). Discusión: los resultados de este estudio evidencian lagunas en el seguimiento de la DMO-DRC por parte de la atención primaria, lo que requiere una revisión de las prácticas clínicas. Conclusión: se identificó una fuerte prevalencia de la DMO en las primeras fases de la ERC, además de correlaciones entre el aumento de los niveles de fósforo y PTH y el empeoramiento de la función renal.

Cambios en el metabolismo óseo y mineral en pacientes con Enfermedad Renal Crónica sometidos a trasplante renal en el Hospital General Plaza de la Salud durante el período comprendido entre enero 2010­agosto 2018 / Changes in bone and mineral metabolism in patients with chronic kidney disease undergoing kidney transplantation at Plaza de la Salud General Hospital during the period between January 2010­August 2018

Introducción: las alteraciones del metabolismo óseo-mineral, son una causa importante de morbilidad en los pacientes con trasplante renal, por lo que el manejo de las complicaciones del paciente trasplantado, a largo plazo, deben de ser seguidas. El estudio intenta demostrar cambios en el metabolismo óseo y mineral en pacientes con enfermedad renal crónica sometidos a trasplante renal en el Hospital General Plaza de la Salud durante el período comprendido entre enero 2010 ­ agosto 2018, Santo Domingo, República Dominicana. Método: estudio observacional, descriptivo, retrospectivo y transversal de 131 trasplantes realizados en el Hospital General Plaza de la Salud, evaluando cambios de calcio (Ca), fósforo (P) y hormona paratiroidea (PTH) antes y tres meses post-trasplante. Resultados: la edad media de los pacientes incluidos fue 43.1 ±13.1 años, 72.51 % pertenecía al sexo masculino, con un tiempo medio en hemodiálisis en meses de 27.0 ± 33.6, 60 % de los trasplantes realizados fueron de donante vivo y un 63 % de los pacientes tenía HTA como comorbilidad. El nivel medio de PTH disminuyó en los primeros 3 meses posteriores al trasplante comparado con el pre-trasplante (779.6 ± 1004.0 vs. 167.9 ± 138.2 pg/ml). El fosfato disminuyó significativamente (4.9 ± 1.6 vs. 3.5 ± 0.8) y el calcio aumentó (9.0 ± 1.2 mg/dl vs. a 9.7± 0.8 mg/dl). Discusión: los cambios generales en los niveles séricos de Ca, P, PTH, BUN y creatinina desde el momento del TR a los 3 meses post TR, fueron todos significativos

Introduction: Alterations of bone-mineral metabolism are an important cause of morbidity in patients with kidney transplantation, so the management of long-term transplant patient complications should be followed. The study tries to demonstrate changes in bone and mineral metabolism in patients with chronic renal disease undergoing kidney transplant in the Hospital General Plaza de la Salud during the period January 2010 to August 2018, Santo Domingo, Dominican Republic. Method: Observational, Descriptive, Retrospective and Cross-sectional Study of 131 transplants performed at Hospital General Plaza de la Salud, evaluating changes of calcium (Ca), phosphorus (P) and parathyroid hormone (PTH) before and 3 months post-transplant. Results: The mean age of the patients included was 43.1 ± 13.1 years, 72.51% belonged to the male sex, with a mean time on hemodialysis in months of 27.0 ± 33.6, 60% of the transplants performed were from live donors and 63% from the patients had hypertension as comorbidity. The mean PTH level decreased in the first 3 months after transplantation compared to the pre-transplant (779.6 ± 1004.0 vs 167.9 ± 138.2 pg/ml). Phosphate decreased significantly (4.9 ± 1.6 vs 3.5 ± 0.8) and calcium increased (9.0 ± 1.2 mg / dl vs. 9.7 ± 0.8 mg / dl). Discussion: The general changes in serum levels of Ca, P, PTH, BUN and Creatinine from the time of TR to 3 months post TR were all significant

Identification of microRNAs targeting vitamin D receptor and their effect on parathyroid hormone secretion in secondary hyperparathyroidism / 南方医科大学学报

OBJECTIVE@#To identify the miRNAs targeting vitamin D receptor (VDR) gene and their effect on parathyroid hormone (PTH) secretion in secondary hyperparathyroidism.@*METHODS@#Primary parathyroid cells with secondary hyperparathyroidism were isolated by collagenase digestion and cultured. The miRNAs targeting VDR were screened by bioinformatics methods and full transcriptome sequencing, and dual-luciferase reporter assay was used to verify the targeting relationship between VDR and the screened miRNA. The effects of overexpression or inhibition of the candidate miRNA on VDR mRNA and protein expressions and PTH secretion were evaluated using qRT-PCR and Western blotting. The expression levels of the candidate miRNAs and VDR mRNA in clinical specimens of parathyroid tissues were verified by qRT-PCR, and the expression of VDR protein was detected by immunohistochemistry.@*RESULTS@#We successfully isolated primary parathyroid cells. Dual-luciferase reporter assay verified the targeting relationship of hsa-miR-149-5p, hsa-miR-221-5p, hsa-miR-222-3p, hsa-miR-29a-5p, hsa-miR-301a-5p, hsa-miR-873-5p, hsa-miR-93-3p with VDR, and among them, the overexpression of hsa-miR-149-5p and hsa-miR-301a-5p significantly increased PTH secretion in the parathyroid cells. In patients with secondary hyperparathyroidism, hsa-miR-149-5p was highly expressed in the parathyroid tissues (P=0.046), where the expressions of VDR mRNA (P=0.0267) and protein were both decreased.@*CONCLUSION@#The two miRNAs, hsa-miR-149-5p and hsa-miR-301a-5p, may promote the secretion of PTH in patients with secondary hyperparathyroidism by down-regulating the expression of VDR gene.

Cultivation and characterization of primary human parathyroid cells from patients with severe secondary hyperparathyroidism / 南方医科大学学报

OBJECTIVE@#To establish an cell model of hyperparathyroidism by isolation, in vitro culture, and identification of parathyroid cells from patients with secondary hyperparathyroidism (SHPT).@*METHODS@#The parathyroid gland tissues obtained from 10 patients with SHPT were dissociated by collagenase digestion for primary culture of the parathyroid cells. Morphological changes and growth characteristics of the cells were assessed by microscopic imaging and cell counting. The mRNA and protein expression levels of parathyroid hormone (PTH), calcium-sensing receptor (CaSR), and glial cells missing 2 (GCM2) in the primary and passaged cells were determined by immunofluorescence, qRT-PCR, and Western blotting.@*RESULTS@#Primary cultures of parathyroid cells were successfully obtained. The cells exhibited a high expression of PTH shown by immunofluorescence assay and had a population doubling time of approximately 71.61 h. PTH secretion in the second-passage (P2) cells was significantly lower than that in the primary (P0) and first-passage (P1) cells (P < 0.001). Despite a significant downregulation of CaSR mRNA (P=0.017) and protein (P=0.006) in P1 cells as compared with P0 cells, no significant differences were found in mRNA and protein expressions of PTH or GCM2 between the two cell generations.@*CONCLUSION@#Primary cultures of parathyroid cells isolated from SHPT patients by collagenase digestion show similar biological properties to the cells in vivo.

High ankle-brachial index predicts cardiovascular events and mortality in hemodialysis patients with severe secondary hyperparathyroidism / Índice tornozelo-braquial elevado prediz eventos e mortalidade cardiovasculares nos pacientes em hemodiálise com hiperparatireoidismo secundário grave

Abstract Introduction: Vascular calcification related to severe secondary hyperparathyroidism (SHPT) is an important cause of cardiovascular and bone complications, leading to high morbidity and mortality in patients with chronic kidney disease (CKD) undergoing hemodialysis (HD). The present study aimed to analyze whether ankle-brachial index (ABI), a non-invasive diagnostic tool, is able to predict cardiovascular outcomes in this population. Methods: We selected 88 adult patients on HD for at least 6 months, with serum iPTH>1,000pg/mL. We collected clinical data, biochemical and hormonal parameters, and ABI (sonar-Doppler). Calcification was assessed by lateral radiography of the abdomen and by simple vascular calcification score (SVCS). This cohort was monitored prospectively between 2012 and 2019 for cardiovascular outcomes (death, myocardial infarction (MI), stroke, and calciphylaxis) to estimate the accuracy of ABI in this setting. Results: The baseline values were: iPTH: 1770±689pg/mL, P: 5.8±1.2 mg/dL, corrected Ca: 9.7±0.8mg/dL, 25(OH)vit D: 25.1±10.9ng/mL. Sixty-five percent of patients had ABI>1.3 (ranging from 0.6 to 3.2); 66% had SVCS≥3, and 45% aortic calcification (Kauppila≥8). The prospective evaluation (51.6±24.0 months), provided the following cardiovascular outcomes: 11% of deaths, 17% of nonfatal MI, one stroke, and 3% of calciphylaxis. After adjustments, patients with ABI≥1.6 had 8.9-fold higher risk of cardiovascular events (p=0.035), and ABI≥1.8 had 12.2-fold higher risk of cardiovascular mortality (p=0.019). Conclusion: The presence of vascular calcifications and arterial stiffness was highly prevalent in our population. We suggest that ABI, a simple and cost-effective diagnostic tool, could be used at an outpatient basis to predict cardiovascular events in patients with severe SHPT undergoing HD.

Resumo Introdução: A calcificação vascular relacionada ao hiperparatireoidismo secundário (HPTS) grave é uma causa importante de complicações cardiovasculares e ósseas, levando a alta morbidade e mortalidade em pacientes com doença renal crônica (DRC) em hemodiálise (HD). O presente estudo objetivou analisar se o índice tornozelo-braquial (ITB), uma ferramenta diagnóstica não invasiva, pode predizer desfechos cardiovasculares nesta população. Métodos: Selecionamos 88 adultos em HD há pelo menos 6 meses, com PTHi sérico>1.000pg/mL. Coletamos dados clínicos, parâmetros bioquímicos e hormonais, e ITB (sonar-Doppler). A calcificação foi avaliada por radiografia lateral do abdome e por escore de calcificação vascular simples (ECVS). Esta coorte foi monitorada prospectivamente entre 2012 e 2019 para desfechos cardiovasculares (óbito, infarto do miocárdio (IM), acidente vascular cerebral e calcifilaxia) para estimar a precisão do ITB neste cenário. Resultados: Os valores basais foram: PTHi: 1770±689pg/mL, P: 5,8±1,2 mg/dL, Ca corrigido: 9,7±0,8mg/dL, 25(OH)vit D: 25,1±10,9ng/Ml; 65% dos pacientes apresentaram ITB>1,3 (variando de 0,6 a 3,2); 66% tiveram ECVS≥3, e 45% calcificação da aorta (Kauppila≥8). A avaliação prospectiva (51,6±24,0 meses) forneceu os seguintes desfechos cardiovasculares: 11% de óbitos, 17% de IM não fatal, um AVC, 3% de calcifilaxia. Após ajustes, pacientes com ITB≥1,6 tiveram risco 8,9 vezes maior de eventos cardiovasculares (p=0,035), e ITB≥1,8 apresentaram risco 12,2 vezes maior de mortalidade cardiovascular (p=0,019). Conclusão: A presença de calcificações vasculares e rigidez arterial foi altamente prevalente em nossa população. Sugerimos o ITB, uma ferramenta diagnóstica simples e econômica, para ser usada em ambulatório para prever eventos cardiovasculares em pacientes com HPTS grave em HD.

Maior frequência de neuropatia periférica diabética associada ao hiperparatireoidismo secundário / Higher prevalence of diabetic peripheral neuropathy associated with secondary hyperparathyroidism

INTRODUÇÃO: A neuropatia periférica diabética (ND) é comum na nefropatia diabética (NFD) e não há informações se o hiperparatireoidismo secundário (HPS) aumenta seus sintomas. O objetivo foi determinar ND por sinais em pacientes com HPS. MATERIAL E MÉTODOS: É um estudo caso-controle. O Grupo Controle (GC) é composto por doentes com NFD e valores de paratormônio (PTH)<60pg / ml. O Grupo de Hiperparatireoidismo (GH) engloba pacientes com NFD e PTH≥60pg/ml e critérios bioquímicos de HPS. As variáveis foram, entre outras, a presença de sinais de ND e foram comparados com o teste t de Student e o qui-quadrado. RESULTADOS: Foram 60 participantes em cada grupo, sendo 35 (58,3%) homens no GC vs 33 (55,0%) em GH (p = 0,713). A idade do GC foi de 67±11,0 anos, vs 72±11 anos GH (p=0,009). A taxa de filtração glomerular (TFG) no GC foi 53,82±25,13 vs GH 35,34±18,43ml/min/1,73m2 (p <0,001). O PTH no GC foi de 38,02±15,32 pg/ml, em GH 119,07±84,33 pg/ml (p <0,001). A ND, devido aos sintomas no GC, foi de 28,3% e 36,6% no GH (p=0,330). A neuropatia por sinais no GC foi de 38,3% e no GH 83,3% (p<0,001). O odds ratio de GH para neuropatia presente devido a sinais foi de 8,044 (IC 95% 3,42­8,92). CONCLUSÃO: Constatou-se uma maior presença de sinais de NPD em pacientes com HPS em nosso centro.

BACKGROUND: Diabetic peripheral neuropathy (DN) is common in diabetic nephropathy (DNP), and there is no information if secondary hyperparathyroidism (SHP) increases its symptoms. The purpose was to determine DN by signs in patients with SHP. METHODS: It is a case-control study. Control patients (CG) with DN and parathyroid hormone (PTH) values<60pg/ml. The Hyperparathyroidism group (HG), patients with DNP and PTH≥60pg/ml and HPS biochemical criteria. The variables were, among others, the presence of DN signs, and were compared with Student's t and chi-square. RESULTS: There were 60 participants in each group, 35(58.3%) men in CG vs.33(55.0%) in GH (p=0.713). The age of the CG was 67±11.0 years, vs 72±11years HG (p=0.009). The glomerular filtration rate (GFR) in the CG was 53.82±25.13 vs in HG 35.34±18.43ml/min/1.73m2(p<0.001). The PTH in the CG were 38.02±15.32pg/ml and in GH 119.07±84.33pg/ml(p<0.001). The DN due to symptoms in CG was 28.3% and in GH 36.6%(p=0.330). Neuropathy due to signs in the CG was 38.3% and in GH 83.3% (p<0.001). The HG odds ratio to present neuropathy due to signs was 8.044 (95% CI 3.42­18.92). CONCLUSION: There was a statistical association between HPS and signs of DN in patients with DNP in our canter.

The disparity of measuring bone mineral content using bioimpedance and dual-energy absorptiometry in the context of hyperparathyroidism / A disparidade nos valores do conteúdo mineral ósseo medido usando bioimpedância e absorciometria de dupla energia no contexto do hiperparatireoidismo

Abstract Introduction: Body composition is critical for the evaluation of patients with Chronic Kidney Disease (CKD) and can be obtained from either multifrequency bioelectrical impedance analysis (BIA) or dual-energy absorptiometry (DXA). Although the discrepancy between the results obtained from both methods has already been described, reasons are unknown, and might be related to secondary hyperparathyroidism, which is associated with bone loss. Methods: We have evaluated 49 patients (25 males and 24 females): 20 with CKD not on dialysis and 29 on maintenance hemodialysis [18 with severe hyperparathyroidism (HD-SHPT) and 11 submitted to parathyroidectomy (HD-PTX)]. All patients underwent DXA and BIA. Results: The median age and body mass index (BMI) were 49 years and 25.6 kg/m2, respectively. Patients exhibited low bone mineral content (BMC) measured by DXA, particularly those from the HD-SHPT group. The largest BMC measurement disagreement between DXA and BIA was found in the HD-SHPT group (p=0.004). Factors independently associated with this discrepancy in BMC measurement were serum phosphate (p=0.003) and patient group (p=0.027), even after adjustments for age, BMI, and gender (adjusted r2=0.186). PTX attenuated this difference. Discussion: BIA should be interpreted with caution in patients with SHPT due to a loss of accuracy, which can compromise the interpretation of body composition.

Resumo Introdução: A composição corporal é fundamental para a avaliação de pacientes com Doença Renal Crônica (DRC), e pode ser obtida por análise de impedância bioelétrica por multifrequência (BIA) ou absorciometria de dupla energia (DXA). Embora a discrepância entre os resultados obtidos pelos dois métodos já tenha sido descrita, os motivos são desconhecidos e podem estar relacionados ao hiperparatireoidismo secundário, devido à perda óssea. Métodos: Avaliamos 49 pacientes (25 homens e 24 mulheres): 20 com DRC não em diálise e 29 em hemodiálise de manutenção [18 com hiperparatireoidismo grave (HD-SHPT) e 11 submetidos à paratireoidectomia (HD-PTX)]. Todos os pacientes foram submetidos à DXA e BIA. Resultados: A mediana da idade e do índice de massa corporal (IMC) foram de 49 anos e 25,6 kg/m2, respectivamente. Os pacientes exibiram baixo conteúdo mineral ósseo (CMO) medido pelo DXA, particularmente aqueles do grupo HD-SHPT. A maior discordância da medida do CMO entre DXA e BIA foi encontrada no grupo HD-SHPT (p = 0,004). Os fatores independentemente associados a essa discrepância na medida do CMO foram fosfato sérico (p = 0,003) e grupo de pacientes (p = 0,027), mesmo após ajustes para idade, IMC e sexo (r2 ajustado = 0,186). PTX atenuou essa diferença. Discussão: A BIA deve ser interpretada com cautela em pacientes com HPTS devido a uma perda de precisão, o que pode comprometer a interpretação da composição corporal.

Parathyroid hormone levels after parathyroidectomy for secondary hyperparathyroidism

SUMMARY OBJECTIVE: The parathormone level after parathyroidectomy in dialysis patients are of interest. Low levels may require cryopreserved tissue implantation; however, the resection is necessary in case of recurrence. We analyzed post parathyroidectomy parathormone levels in renal hyperparathyroidism. METHODS: Prospective observation of postoperative parathormone levels over defined periods in a cohort of dialysis patients that underwent total parathyroidectomy and immediate forearm autograft from 2008 to 2010, at a single tertiary care hospital. RESULTS: Of 33 patients, parathormone levels until 36 months could be divided into four patterns. Patients with stable function (Pattern 1) show relatively constant levels after two months (67% of the cases). Early function and later failure (Pattern 2) were an initial function with marked parathormone reduction before one year (18%). Graft recurrence (Pattern 3) showed a progressive increase of parathormone in four cases (12%). Complete graft failure (Pattern 4) was a nonfunctioning implant at any period, which was observed in one patient (3%). Parathormone levels of Pattern 3 became statistically different of Pattern 1 at 36 months. CONCLUSIONS: Patients that underwent the total parathyroidectomy and autograft present four different graft function patterns with a possible varied therapeutic management.

Comparison between different sources of minerals in horses with nutritional secondary hyperparathyroidism / [Comparação entre diferentes fontes de minerais em cavalos com hiperparatireoidismo secundário nutricional]

Minerals perform several functions in the body, such as coagulation actions, muscle contraction, enzymatic and hormonal production, among others. This study aims to evaluate the effect of a 150 days chelated and not chelated mineral supplementation with and without potassium oxalate on serological parameters and bone mineral density of horses. Twenty-four crossbred yearlings (12 females and 12 males) with an average age of 21±3 months and body weight of 330.8±37.9kg were divided into four groups containing six equines in each (three females and three males) in a completely randomized design with repeated measurements in a 2x2 factorial arrangement. Treatments were: 1 - chelated minerals compound; 2 - chelated minerals compound and potassium oxalate; 3 - not chelated minerals compound; and 4 - not chelated minerals compound and potassium oxalate. Clinical signs of nutritional secondary hyperparathyroidism (NSH) were observed only in treatment 4. Results showed no treatment effect in bone biopsy for calcium, phosphorus and bone density. There were significant reductions of parathyroid hormone (PTH) means concentrations in treatments 2 and 4 during supplementation. Animals supplemented with chelated minerals compounds avoided mineral imbalances and NSH even when in dietary potassium oxalate challenged.(AU)

Os minerais desempenham diversas funções no organismo, como ações de coagulação, contração muscular, produção enzimática e hormonal, entre outras. O objetivo deste estudo foi avaliar o efeito da suplementação de minerais quelatados e não quelatados, por 150 dias, com e sem oxalato de potássio, sobre parâmetros sorológicos e densidade mineral óssea em equinos. Vinte e quatro filhotes mestiços (12 fêmeas e 12 machos), com idade média de 21±3 meses e peso corporal de 330,8±37,9kg, foram divididos em quatro grupos contendo seis equinos cada (três fêmeas e três machos), em delineamento inteiramente ao acaso, com repetição medida em arranjo fatorial 2x2. Os tratamentos foram: 1 - composto mineral quelatado; 2 - composto mineral quelatado e oxalato de potássio; 3 - composto mineral não quelatado; e 4 - composto mineral não quelatado e oxalato de potássio. Os sinais clínicos do hiperparatireoidismo secundário nutricional (NSH) foram observados apenas no tratamento 4. Os resultados não mostraram efeito de tratamento na biópsia óssea para cálcio, fósforo e densidade óssea. Houve redução significativa do hormônio da paratireoide (PTH) em concentrações médias nos tratamentos 2 e 4 durante a suplementação. Os animais suplementados com compostos minerais quelatados evitaram desequilíbrios minerais e NSH, mesmo quando desafiados no oxalato de potássio na dieta.(AU)

Prediction of perioperative hyperkalemia in dialysis patients with secondary hyperparathyroidism / 中华耳鼻咽喉头颈外科杂志

Objective: To explore the influencing factors for serum potassium >4.4 mmol/L in the morning of parathyroidectomy in hemodialysis patients with secondary hyperparathyroidism (SHPT). Methods: The clinical data of 72 patients with SHPT who received regular hemodialysis and underwent parathyroidectomy in Guangdong Provincial People's Hospital from January 2012 to December 2018 were analyzed retrospectively. There were 37 males and 35 females, aged from 25 to 69 years, and the dialysis timespan was from 0.5 to 11 years. The levels of parathyroid hormone, serum potassium and serum calcium before hemodialysis were examined one day before operation, and hemodialysis time and dewatering volume after hemodialysis without heparin were recorded, and also the level of serum potassium in the morning of parathyroidectomy was detected. The occurrences of hyperkalemia during and after operation were studied. The factors related to hyperkalemia in the morning of parathyroidectomy were evaluated by Pearson or Spearman correlation analysis, and the cut-off values of risk factors were calculated by receiver operating characteristic (ROC) curve. Results: Serum potassium >4.4 mmol/L in the morning of parathyroidectomy existed in 23 of 72 patients. Correlation analysis showed that serum potassium one day before operation ((4.93±0.56)mmol/L, r=0.656, P<0.001) and dehydration volume ((2.37±0.75)L, r=0.261, P=0.027) were positively correlated with serum potassium in the morning of parathyroidectomy((4.16±0.54)mmol/L). Serum potassium before hemodialysis one day before operation was a main predictor for serum potassium in the morning of parathyroidectomy (AUC=0.791, P<0.001). The cut-off value of serum potassium before hemodialysis one day before operation was 5.0 mmol/L. Conclusion: Serum potassium before hemodialysis one day before operation in patients with SHPT can predict serum potassium in the morning of parathyroidectomy, offering imformation for the safety of operation.

Parathyroid hormone assay with eluent of aspirated tissues in parathyroidectomy / 中华耳鼻咽喉头颈外科杂志

Objective: To explore the values of intraoperative fine-needle aspiration (IFNA) and parathyroid hormone (PTH) detection in the eluate of aspirated tissue during parathyroidectomy. Methods: Fifty-four patients with secondary hyperparathyroidism (SHPT) including 24 males and 30 females, aged 20-83 years, admitted to Zhongnan Hospital of Wuhan University from January 2019 to October 2019, were included. All patients received subtotal parathyroidectomy with autologous transplantation, during surgery, IFNA and PTH detection in the eluate of aspirated tissue were performed, and also routine postoperative pathological examination was performed. The results of PTH detection in the eluate of aspirated tissue and postoperative pathological examinations were compared and analyzed by SPSS and R software for evaluating of the sensitivity, specificity, positive predictive value, negative predictive value, misdiagnosis rate, missed diagnosis and accuracy. Results: Surgery was completed successfully in all patients. After surgery, the symptoms were improved in the patients except two who were asymptomatic. None had any serious postoperative complications such as hypocalcaemia or hoarseness. A total of 231 aspirated tissue samples were tested, of which 216 were identified as parathyroid and 15 non-parathyroid based on intraoperative PTH detection in tissue eluate; while 217 were confirmed as parathyroid tissues and 14 non-parathyroid tissues with postoperative pathological examinations. The specificity and sensitivity of intraoperative IFNA and PTH detection in tissue eluate for identifying parathyroid tissues were 99.5% and 100.0%, respectively. Conclusion: The IFNA and PTH detection in tissue eluate is a rapid, simple, and accurate procedure, which helps the surgeon to identify parathyroid tissue and to ensure the endocrine activity of preserved or autografted parathyroid tissue during parathyroidectomy.

Arteriolopatía urémica calcificante: presentación de caso clínico con manejo médico conservador / Calcific uremic arteriolopathy: presentation of a clinical case with conservative medical management

Antecedentes: La arteriolopatia calcificante urémica o calcifilaxis es un síndrome raro, potencialmente mortal, que afec-ta casi en exclusiva a pacientes con insuficiencia renal y diálisis, caracterizado por calcificación vascular de arterias de pequeño y mediano calibre, con posterior proliferación, fibrosis y trombosis que conducen finalmente a necrosis y úlceras cutáneas. Se asocia con la enfermedad renal crónica terminal y trasplante renal, con preva-lencia de 1-4% de los pacientes con insuficiencia renal crónica. El tratamiento es especializado a base de cámara hiperbárica y para-tiroidectomía para inducir curación. Descripción del caso clínico: Femenina de 42 años, captada en la consulta externa de nefrología en el Instituto Hondureño de Seguridad Social en el año 2017, con antecedente de hipertensión arterial y nefropatía crónica, sometida a trasplante renal en 1998 el cual fue fallido, posteriormente en pro-grama de hemodiálisis y manejo conservador desde el año 2005. La paciente desarrolló lesiones equimóticas en tronco y úlceras en sitios de nódulos subcutáneos que se sobreinfectaron, desarrollan-do signos de respuesta inflamatoria sistémica. Los exámenes de laboratorio mostraron hiperfosfatemia, paratohormona 3518 pg/ml, producto calcio-fósforo 73.5. Ante la falta de manejo quirúrgico (pa-ratiroidectomía) y cámara hiperbárica en la institución, en el 2017 se estableció tratamiento conservador a base de antibióticos, analgési-cos, y hemodiálisis diarias, con lo que presentó mejoría del cuadro clínico; sin embargo, sin resolución de su cuadro de base de la calci-filaxis. Conclusión: El manejo conservador en el caso de pacientes con calcifilaxis es una opción de tratamiento disponible con buena respuesta en pacientes con seguimiento estrecho...(AU)

Therapy for persistent hypercalcemic hyperparathyroidism post-renal transplant: cinacalcet versus parathyroidectomy / Tratamento do hiperparatireoidismo hipercalcêmico persistente pós-transplante renal: cinacalcete versus paratireoidectomia

ABSTRACT Background: Persistent hyperparathyroidism post-transplant is associated with increases in the incidence of cardiovascular events, fractures, and deaths. The aim of this study was to compare both therapeutic options available: parathyroidectomy (PTX) and the calcimimetic agent cinacalcet. Methods: A single center retrospective study including adult renal transplant recipients who developed hypercalcemia due to persistent hyperparathyroidism. Inclusion criteria: PTH > 65 pg/mL with serum calcium > 11.5 mg/dL at any time after transplant or serum calcium persistently higher than 10.2 mg/dL one year after transplant. Patients treated with cinacalcet (n=46) were compared to patients treated with parathyroidectomy (n=30). Follow-up period was one year. Clinical and laboratory data were analyzed to compare efficacy and safety of both therapeutic modalities. Results: PTX controlled calcemia faster (month 1 x month 6) and reached significantly lower levels at month 12 (9.1±1.2 vs 9.7±0.8 mg/dL, p < 0.05); PTX patients showed significantly higher levels of serum phosphate (3.8±1.0 vs 2.9±0.5 mg/dL, p < 0.05) and returned PTH to normal levels (45±51 pg/mL). Cinacalcet, despite controlling calcium and phosphate in the long term, decreased but did not correct PTH (197±97 pg/mL). The proportion of patients that remained with PTH above normal range was 95% in the cinacalcet group and 22% in the PTX group. Patients treated with cinacalcet had better renal function (creatinine 1.2±0.3 vs 1.7±0.7 mg/dL, p < 0.05). Conclusions: Surgical treatment was superior to cinacalcet to correct the metabolic disorders of hyperparathyroidism despite being associated with worse renal function in the long term. Cinacalcet proved to be a safe and well tolerated drug.

RESUMO Introdução: O hiperparatireoidismo persistente pós-transplante está associado a aumento na incidência de eventos cardiovasculares, fraturas e óbitos. O objetivo deste estudo foi comparar as opções terapêuticas disponíveis: paratireoidectomia (PTX) e o agente calcimimético cinacalcete. Métodos: Estudo retrospectivo de um único centro incluiu pacientes transplantados renais adultos que desenvolveram hipercalcemia devido a hiperparatireoidismo persistente. Critérios de inclusão: PTH > 65 pg/mL com cálcio sérico > 11,5 mg/dL a qualquer momento após o transplante, ou cálcio sérico persistentemente superior a 10,2 mg/dL um ano após o transplante. Os pacientes tratados com cinacalcete (n = 46) foram comparados aos pacientes tratados com paratireoidectomia (n = 30). O período de acompanhamento foi de um ano. Dados clínicos e laboratoriais foram analisados para comparar a eficácia e a segurança de ambas as modalidades terapêuticas. Resultados: a PTX controlou a calcemia mais rapidamente (mês 1 x mês 6) e atingiu níveis significativamente mais baixos no mês 12 (9,1 ± 1,2 v.s. 9,7 ± 0,8 mg/dL, p < 0,05); pacientes submetidos à PTX apresentaram níveis significativamente mais altos de fósforo sérico (3,8 ± 1,0 v.s. 2,9 ± 0,5 mg/dL, p < 0,05) e retornaram aos níveis normais de PTH (45 ± 51 pg/mL). O cinacalcete, apesar de controlar o cálcio e o fósforo no longo prazo, diminuiu, mas não corrigiu o PTH (197 ± 97 pg/mL). A proporção de pacientes que permaneceram com PTH acima da faixa normal foi de 95% no grupo cinacalcete e 22% no grupo PTX. Os pacientes tratados com cinacalcete apresentaram melhor função renal (creatinina 1,2 ± 0,3 v.s. 1,7 ± 0,7 mg/dL, p < 0,05). Conclusões: O tratamento cirúrgico foi superior ao cinacalcete para corrigir os distúrbios metabólicos do hiperparatireoidismo, apesar de estar associado a pior função renal no longo prazo. Cinacalcete provou ser um medicamento seguro e bem tolerado.

Vía aérea difícil en paciente con Síndrome de Sagliker / CEPHALIC DUODENOPANCREATIC RESECTION - Pathology, complications, follow-up (Part II)

Introducción: El síndrome de Sagliker es una enfermedad rara que requiere manejo de la vía aérea por personal experimentado, fue descrito en 2004 por Sagliker. Presentación del caso: Mujer de 30 años de edad, hipertensa con enfermedad renal crónica de 10 años de evolución, trasplante renal derecho con rechazo al año y manejada con hemodiálisis. Se le realizó paratiroidectomía bilateral, el manejo de la vía aérea fue con la paciente despierta y uso de fibroscopio. La evolución transoperatoria fue buena, se extubó sin incidentes y después de 3 días fue egresada a su domicilio. Conclusiones: El manejo de la vía aérea en pacientes con Síndrome de Sagliker requiere de experiencia ya que un manejo inadecuado compromete la vida de los pacientes.

Sagliker syndrome is a rare disease that requires airway management by experienced personnel, it was described in 2004 by Sagliker. Case presentation: 30-year-old woman, hypertensive with chronic kidney disease of 10 years of evolution, right kidney transplant with one-year rejection and managed with hemodialysis. A bilateral parotidectomy was performed, the airway was managed with the patient awake and using a fibroscope. The intraoperative evolution was good, she was extubated without incident and after 3 days she was discharged to her home. Conclusions: The management of the airway in patients with Sagliker Syndrome requires experience, since inadequate management compromises the lives of patients.

Recidiva del hiperparatiroidismo secundario a enfermedad renal crónica en diálisis luego de la paratiroidectomía / Recurrence of secondary hyper¬parathyroidism in dialysis patients after parathyroidectomy

La paratiroidectomía (PTX) es la terapia de elección en el hiperparatiroidismo secundario a enfermedad renal crónica (HPT-ERC) resistente al tratamiento médico. El objetivo del presente estudio fue evaluar el resultado de la PTX a largo plazo y sus factores predictores. Métodos: estudio unicéntrico retrospectivo observacional. Se incluyeron 92 pacientes con HPT-ERC en diálisis, en quienes se realizó la primera PTX en el Hospital Italiano de Buenos Aires entre 2006 y 2015 con seguimiento ≥ 6 meses. Se consideró persistencia del HPTERC con PTH > 300 pg/ml en el semestre posoperatorio, y recidiva con PTH > 500 pg/ml luego. Resultados: edad: 43,6±12,8 años, 50% mujeres, mediana 4,6 años de diálisis, PTH preoperatoria mediana 1639 pg/ml. A 39 se les realizó PTX subtotal (PTXS) y a 53 total con autoimplante (PTXT+AI). Se observó persistencia en 16 pacientes (17,4%). Presentaron recidiva 30 de 76 pacientes con adecuada respuesta inicial (39,5%; IC 95 28,5-50,5). La mediana de tiempo hasta la recidiva fue de 4,7 años (RIC 2,3-7,5). Los pacientes con recidiva presentaron mayor calcemia preoperatoria (mediana 9,9 vs. 9,3 mg/dl, p=0,035; OR ajustado 2,79) y menor elevación de fosfatasa alcalina en el posoperatorio (333 vs. 436 UI/l, p=0,031; OR ajustado 0,99). La recidiva se presentó más frecuentemente luego de la PTXT+AI (48,9%; OR ajustado 4,66), que en la PTXS (25,8%). Conclusiones: el tiempo en diálisis con inadecuado control metabólico constituye el principal factor para la recurrencia del HPT. Se postula que la mayor calcemia preoperatoria está relacionada con un HPT más severo y se asocia a recurrencia. Llamativamente, hallamos menores elevaciones de la fosfatasa alcalina durante el posoperatorio en pacientes con recurrencia. Hipotetizamos que esto pueda asociarse con menor mineralización en el posoperatorio e hiperfosfatemia sostenida, con consecuente estímulo paratiroideo. La menor recurrencia del HPT luego de la PTXS se vincula al sesgo generado en la selección del tipo de cirugía. (AU)

Parathyroidectomy is an effective therapy for refractory secondary hyperparathyroidism (sHPT). Continued dialysis represents risk for recurrent sHPT. The aim of this study was to estimate the proportion of recurrence and determine its predictors. Methods: We conducted a retrospective observational study of 92 adults in chronic dialysis, who underwent their first parathyroidectomy in this center between 2006 and 2015. We considered persistence of sHPT if PTH was > 300 pg/ml during the first postoperative semester, and recurrence if it was > 500 pg/ml afterwards. Results: Age 43.6+-12 y/o, 50% female, 4.6 years on dialysis, median preoperative PTH 1636 pg/ml (IQR 1226-2098). Subtotal parathyroidectomy (sPTX) was performed in 39, Total with autotransplantation (TA-PTX) in 53 patients. Persistence of sHPT occurred in 16 patients; relapse in 30 out of 76 with adequate initially response (39.5%; 95CI 28,5-50,5). Median time to recurrence: 4.7 y. Recurring patients had higher preoperative calcemia (9.9 vs 9.3 mg/dl; adj OR 2.79) and lower postoperative elevation of ALP (333 vs 436 UI/ml; adj OR 0.99). Recurrence presented more frequently in TA-PTX (48.9%; adj OR 4.66) than sPTX (25.8%). Conclusions: Time on dialysis with inadequate metabolic control remains the most important risk factor for sHPT recurrence. Higher preoperative levels of calcemia, related to sHPT severity, are associated with recurrence. Lower elevations of ALP during postoperative period in recurring patients are an interesting finding. We hypothesize that patients with less significant postoperative mineralization may have chronically higher levels of phosphatemia, stimulating parathyroid glands. Fewer recurrence in sPTX is associated to a bias in the procedure selection. (AU)

La parathyroïdectomie dans le traitement de l'hyperparathyroïdie secondaire chez les dialysés chroniques

Introduction: L'hyperparathyroïdie secondaire est une complication grave de l'insuffisance rénale chronique, ayant un impact négatif sur la morbi-mortalité. La parathyroïdectomie trouve toute son indication en cas d'échec du traitement médical. Le but de cette étude était de partager notre expérience dans la prise en charge de l'hyperparathyroïdie secondaire et de présenter les caractéristiques démographiques, biochimiques, cliniques et thérapeutiques des patients opérés dans notre service. Matériels et Méthodes : Etude d'une série de cas consécutifs opérés entre janvier 2002 et décembre 2013. Etaient inclus tous les patients ayant présenté une hyperparathyroïdie secondaire prouvée biologiquement et remplissant les critères d'opérabilité. Résultats : La série était composée de 69 patients (35 femmes, 34 hommes). La moyenne d'âge était de 37,7 ±13 ans. Le tableau clinique était dominé par les signes osseux et cutanés. En préopératoire, la valeur moyenne de la PTH était de 1727 ± 1380,10 pg/mL et celle de la calcémie de 2,39 ± 0,28 mmol/L. Sur le plan chirurgical, la parathyroïdectomie était subtotale chez 60 patients (87%) et totale chez 9 patients (13%) dont 7 avec auto transplantation et 2 sans autotransplantation. En post opératoire, la valeur de la PTH avait baissé significativement par rapport à la valeur préopératoire (p<0,01). Conclusion : Les résultats de cette étude suggèrent que la parathyroïdectomie entre les mains d'experts est un moyen efficace pour réduire la sécrétion de PTH avec une faible morbi-mortalité dans le cadre de l'hyperparathyroïdie secondaire réfractaire au traitement médical