Crisis hipercalcémica, presentación inusual de adenoma paratiroideo: reporte de 2 casos / Hypercalcemic crisis, unusual presentation of parathyroid adenoma

La crisis hipercalcémica (CH) es una emergencia endocrina inusual, definida por la presencia de calcemia > 14 mg/dl asociada a disfunción renal, alteraciones cardiovasculares, gastrointestinales y del sensorio; también podría considerarse en pacientes con síntomas graves y calcemia menor. El hiperparatiroidismo primario (HPTP) y las neoplasias malignas son las etiologías más comunes de la hipercalcemia (90% de los casos); sin embargo, rara vez el primero se presenta como CH. Debido a la alta mortalidad asociada a esta entidad, es de gran importancia establecer diagnóstico y tratamiento precoces. Presentamos dos pacientes con crisis hipercalcémica como primera manifestación del HPTP, el 1.° con bloqueo auriculoventricular (AV) completo y el 2.° con pancreatitis aguda. La anatomía patológica (AP) reveló adenoma oxifílico en ambos casos, que es una variante histológica poco frecuente y puede manifestarse clínicamente de forma grave. Conclusiones: los adenomas paratiroideos son causa poco frecuente de CH. Consideramos el tipo histológico observado (adenoma oxifílico) como probable factor condicionante. La pancreatitis y especialmente el bloqueo AV son manifestaciones poco frecuentes de la CH. Resaltamos la importancia de la determinación de los niveles de calcio dentro de la evaluación inicial de todo paciente con bloqueo AV. (AU)

Hypercalcemic crisis (HC) is an unusual endocrine emergency, defined as the presence of serum calcium > 14 mg/dl related to kidney dysfunction, cardiovascular, gastrointestinal and sensory disturbances. It could also be considered in patients with severe symptoms and lower serum calcium levels. Primary hyperparathyroidism (PHPT) and malignant neoplasms are the most common hypercalcemia etiologies (90% of cases), nevertheless, the former hardly ever occurs as HC. Due to the high mortality associated with HC, it is crucial to establish early diagnosis and treatment.We report two patients with HC as the first manifestation of PHPT; the former with atrioventricular (AV) block and the latter with acute pancreatitis. Pathology revealed oxyphilic adenoma in both cases, which is an infrequent histological variant that can have a severe clinical manifestation. Conclusions: parathyroid adenomas are a rare cause of HC. We consider the histological type observed (oxyphilic adenoma) as a probable conditioning factor. Pancreatitis and especially AV block are rare manifestations of HC. We emphasize the importance of determining calcium levels in the initial evaluation of all patients with AV block. (AU)

Estudio comparativo de la absorción neta de calcio de dos formulaciones distintas de carbonato de calcio en mujeres posmenopáusicas / Comparative study of net calcium absorption of two different pharma¬ceutical formulations of calcium carbonate in posmenopausal women

La suplementación con calcio reduciría, sola o asociada a otra medicación para osteoporosis, la pérdida de masa ósea y el riesgo de fracturas. Sin embargo, su tasa de adherencia es baja debido a la poca tolerancia. Objetivo: comparar la tasa de absorción neta de calcio entre dos formulaciones distintas de carbonato de calcio (500 mg): comprimidos vs. mousse. Material y métodos: 11 pruebas fueron realizadas en mujeres posmenopáusicas de 58,9±3 años. El diseño fue exploratorio abierto, aleatorizado, prospectivo cruzado de fase 4. Intervención: las participantes fueron aleatorizadas en dos grupos para recibir las dos formulaciones previa suplementación con vitamina D3. La tasa de absorción neta de calcio fue estudiada por la prueba de inhibición de hormona paratiroidea (PTH). Se obtuvieron muestras de sangre: basal y en la 1a, 2a y 3a hora posadministración del calcio asignado, y de orina de 2 horas basal y al final de la prueba. Determinaciones bioquímicas: calcio, fósforo, albúmina, 25-hidroxivitamina D y hormona paratiroidea intacta y calciuria. Análisis estadístico: método de los trapecios para calcular el área bajo la curva (AUC) de la concentración de calcio en el tiempo (R Development Core Team (2008). http://www.Rp-project.org) y Anova con dos términos de error para evaluar el efecto secuencia, período y formulación. Resultados: la mayor inhibición de PTH se observó a dos horas de la toma de ambas formulaciones (comprimidos -39,2% vs. mousse -38,0%; p=ns), con similar AUC0-3 h (comprimidos 3,35; IC 95%: 3,32; 3,37 vs. mousse 3,36; IC 95%: 3,33; 3,38). Cuando analizamos tolerancia y preferencias no se observaron diferencias estadísticamente significativas entre ambas formulaciones. Conclusión: el carbonato de calcio en mousse mostró similar tasa de absorción intestinal, preferencia y tolerancia gastrointestinal que en comprimido. (AU)

Calcium supplementation, administered alone or in combination with a specific medication for osteoporosis, would reduce bone mass loss and fracture risk in postmenopausal women. However, the adherence rate to calcium supplements is low, mainly due to low tolerance. Objective: comparisson of net calcium absorption rate between two different pharmaceutical formulations of calcium carbonate (PFCa) in postmenopausal women. Materials and Methods: 11 tests were performed in postmenopausal women aged 58.9±3 yrs. Design: Comparative, randomized, prospective, open-label exploratory crossover study of calcium mousse versus calcium pills. Intervention: Participants were randomized in 2 groups to receive the 2 different PFCa (500mg): pills vs. mousse, with previous vitamin D3 supplementation. The parathyroid hormone (PTH) inhibition test and the area-under-thecurve (AUC) of calcium were analyzed. Blood samples were taken at baseline and 1, 2 and 3 hrs after intake of the assigned PFCa. Urine samples (2hs) were obtained at -baseline, after 2hs of PFCa intake and at the end of the test. Biochemical Determinations: Serum: calcium, phosphorus, albumin, 25-hydroxyvitamin D, and intact PTH. In urine: calcium. Statistical Analysis: The trapezoid rule was applied to assess AUC in time (R Development Core Team (2008). http://www.Rp-project.org). An ANOVA model with 2 error terms was used to assess the effect of sequence, period, and formulation. Results: The highest inhibition PTH rates were observed after 2 hrs of PFCa (pills -39.2% vs. mousse -38.0%; p=ns). The AUC0-3hrs for both PFCa was similar (pills 3.35; 95%CI: 3.32; 3.37 vs. mousse 3.36; 95%CI: 3.33; 3.38). No statistically significant differences were observed when we analyze tolerance and predilection. Conclusion: The calcium carbonate in mousse showed an adequate rate of intestinal absorption, similarly predilection and gastrointestinal tolerance than the pill presentation. (AU)

Salud ósea en pacientes sometidos a trasplante de precursores hematopoyéticos: un nuevo problema a considerar / Vitamin D and parathyroid hormone levels and bone mineral density in patients undergoing hematopoietic cell transplantation

Background: Patients undergoing hematopoietic cell transplantation (HCT) are at increased risk of developing osteoporosis. Aim: To determine the frequency and severity of Vitamin D deficiency, secondary hyperparathyroidism and low bone mass in patients undergoing HCT. Patients and Methods: Analysis of the database of patients undergoing HCT in our institution in the 2010-2015 period. We searched for patients with measurements of 25-OH vitamin D (25OHD), parathyroid hormone (PTH) and bone densitometry by double beam X ray absorptiometry (DXA) prior and up to one year after HCT. Results: Ninety patients were included, 53 were evaluated prior to HCT and 37 after HCT. They represent 73% of all patients undergoing HCT in the period. Median 25OHD was 12 ng/ml (range 4-41.4). Ninety seven percent of patients had levels considered insufficient and 85% compatible with deficiency. Median PTH was 60.5 pg/ml (range 21-186). Forty five percent of patients had secondary hyperparathyroidism. DXA was performed in 65 patients (prior to HCT in 54 and after HCT in 11). Of these, 11% had had a low bone mineral density. Conclusions: Patients undergoing HCT have a high risk of vitamin D deficiency, secondary hyperparathyroidism and low bone mineral density.

Association between atypical parathyroid adenoma and neurofibromatosis

Primary hyperparathyroidism is a disease characterized by excessive production of parathyroid hormone (PTH), which is due to a parathyroid adenoma in 85% of cases. An atypical parathyroid adenoma, with some histopathological features of parathyroid carcinoma, may be found in some of the cases, although it may not fulfill all the criteria for this diagnosis. Neurofibromatosis type 1 (NF1) is an autosomal dominant systemic disease that may be associated with hyperparathyroidism. We report here the rare combination of a patient with NF1 and clinical manifestations of hyperparathyroidism due to an atypical parathyroid adenoma.

Medición de niveles de parathormona como predictor de hipocalcemia sintomática en el post-operatorio precoz de tiroidectomía total / Parathormone levels measurement as predictor of symptomatic hypocalcemia after total thyroidectomy

Introduction: The most frequent complication after total thyroidectomy is hypocalcemia. It is difficult to predict it. The objective of this paper is determinate if measurement of parathormone 6 hours after total thyroidectomy can predict symptomatic hypocalcemia, and determinate associated factors in the development of this complication. Material and Method: Prospective case series. Patients that underwent total thyroidectomy between 2006 and 2008 in our Hospital. We registered epidemiological data, related surgery factors and measurement of parathormone 6 hours after surgery. Hypocalcemia symptoms were registered. We used statistical analysis considering significant p < 0.05. Results: We included 82 patients. Median age was 53.2 years. 79.3 percent were female. The average of parathormone 6 hours after surgery was 28.7 pg/dL. Sensibility was 100 percent, specificity 79.4 percent, positive predictive value 59.4 percent, negative predictive value 100 percent and accuracy 84.1 percent to predict symptomatic hypocalcaemia. A statistical association among levels under the normal base line of parathormone and symptomatic hypocalcemia was detected (p < 0.0001). Relative risk was 4.84. Univariated analysis showed association between hypocalcemia and pre-operative thyroid cancer diagnosis (p = 0.01), cervical dissection (p = 0.03) and level of parathormone (p = 0.002). Multivariated analysis showed that only the level of parathormone associates with hypocalcemia (p = 0.002). Conclusion: The measurement of parathormone allows identifying which patients are at risk of presenting symptomatic hypocalcemia after total thyroidectomy.

Introducción: La complicación más frecuente de la tiroidectomía total es la hipocalcemia. Su predicción es difícil. El objetivo de este trabajo es determinar si la medición de parathormona a las 6 h posterior a una tiroidectomía total es un factor que pueda predecir la aparición de hipocalcemia sintomática y determinar los factores asociados al desarrollo de esta complicación. Material y Método: Serie de casos prospectiva. Pacientes intervenidos de tiroidectomía total entre 2006 y 2008 en el Hospital FACH. Se registraron datos epidemiológicos, factores relacionados a la cirugía y la medición de parathormona a las 6 h. Se registraron los síntomas de hipocalcemia. Se utilizó estadística analítica considerando significativo p < 0,05. Resultados: Se enrolaron 82 pacientes. La edad media fue 53,2 años. El 79,3 por ciento fue de sexo femenino. El promedio de parathormona a las 6 h fue 28,7 pg/dL. Se obtuvo sensibilidad 100 por ciento, especificidad 79,4 por ciento, valor predictivo positivo 59,4 por ciento, negativo 100 por ciento y precisión 84,1 por ciento para predecir hipocalcemia. Cuando los valores de PTH estaban bajo el margen normal, el riesgo relativo de hipocalcemia sintomática fue 4,84 (p < 0,0001). El análisis univariado mostró asociación entre hipocalcemia y el diagnóstico pre operatorio de cáncer (p = 0,01), la disección cervical (p = 0,03) y el nivel de parathormona a las 6 h (p = 0,002). El análisis multivariado demostró que sólo el nivel de parathormona se asocia con hipocalcemia (p = 0,002). Conclusión: La medición de parathormona es un elemento que permite estimar de manera adecuada qué pacientes están en riesgo de presentar hipocalcemia sintomática en el post-operatorio precoz de tiroidectomía total.

Hiperparatiroidismo primario: manejo quirúrgico / Primary hyperparathyroidism: surgical treatment

Background: Primary hyperparathyroidism (HPTP) is the most common cause of hypercalcaemia in the ambulatory setting. This condition affects between 0.1 -2 percent of the population. Surgery is the only curative treatment. Objective: The aim of the study is to present our 10-year surgical experience. Methods: Analytical-descriptive study. We included all patients diagnosed with HPTP treated with surgery in our hospital between June 2003 and June 2013. Results: 173 patients underwent surgery for HPTP. The mean age was 57.5 +/- 13.5 years. Asymptomatic in 98 cases (56.6 percent). Resection the abnormal parathyroid glands was performed in all cases with intraoperative PTH monitoring. In 167 patients (96.5 percent) intraoperative PTH declined ≥ 50 percent. The median follow-up was 61 months (1-117 months). Cure was achieved in 169 patients (97.7 percent). Four cases (2.3 percent) had recurrence. Conclusions: Surgery is effective and safe for the treatment of HPTP. A decline in intraoperative PTH > 50 percent predicts cure in 97.7 percent of cases.

Introducción: El hiperparatiroidismo primario (HPTP), es una entidad frecuente que afecta entre el 0,1 y 2 por ciento de la población. La cirugía es el único tratamiento curativo. Objetivo: Evaluar la eficacia y riesgos del tratamiento quirúrgico del HPTP. Material y Métodos: Estudio analítico-descriptivo. Se incluyó a todos los pacientes con diagnóstico de HPTP referidos para cirugía al Hospital Clínico de la Pontificia Universidad Católica de Chile entre junio de 2003 y junio de 2013. Resultados: 173 pacientes fueron operados en nuestra institución por HPTP. El promedio de edad de los pacientes fue de 57,5 +/- 13,5 años. La forma de presentación fue asintomática en 98 casos (56,6 por ciento) y sintomática en 75 casos (43,4 por ciento). Todos los pacientes fueron tratados con resección de la o las glándulas hiperfuncionantes con medición de PTH intraoperatoria. En 167 pacientes (96,5 por ciento) se logró caída de PTH intraoperatoria > 50 por ciento. Catorce pacientes (8,1 por ciento) presentaron complicaciones post operatorias. La mediana de hospitalización fue de 2 días (1 a 23 días). La mediana de seguimiento fue de 61 meses (6 a 117 meses). Se logró curación en 169 pacientes (97,7 por ciento). Cuatro casos (2,3 por ciento) presentaron recidiva. Conclusiones: La cirugía es eficaz y segura para el tratamiento del hiperparatiroidismo primario. Una caída de PTH intraoperatoria > 50 por ciento del valor basal predice curación en 97,7 por ciento de los casos.

Surgical approach in patients with hyperparathyroidism in multiple endocrine neoplasia type 1: total versus partial parathyroidectomy

Usually, primary hyperparathyroidism is the first endocrinopathy to be diagnosed in patients with multiple endocrine neoplasia type 1, and is also the most common one. The timing of the surgery and strategy in multiple endocrine neoplasia type 1/hyperparathyroidism are still under debate. The aims of surgery are to: 1) correct hypercalcemia, thus preventing persistent or recurrent hyperparathyroidism; 2) avoid persistent hypoparathyroidism; and 3) facilitate the surgical treatment of possible recurrences. Currently, two types of surgical approach are indicated: 1) subtotal parathyroidectomy with removal of at least 3-3 K glands; and 2) total parathyroidectomy with grafting of autologous parathyroid tissue. Transcervical thymectomy must be performed with both of these procedures. Unsuccessful surgical treatment of hyperparathyroidism is more frequently observed in multiple endocrine neoplasia type 1 than in sporadic hyperparathyroidism. The recurrence rate is strongly influenced by: 1) the lack of a pre-operative multiple endocrine neoplasia type 1 diagnosis; 2) the surgeon's experience; 3) the timing of surgery; 4) the possibility of performing intra-operative confirmation (histologic examination, rapid parathyroid hormone assay) of the curative potential of the surgical procedure; and, 5) the surgical strategy. Persistent hyperparathyroidism seems to be more frequent after subtotal parathyroidectomy than after total parathyroidectomy with autologous graft of parathyroid tissue. Conversely, recurrent hyperparathyroidism has a similar frequency in the two surgical strategies. To plan further operations, it is very helpful to know all the available data about previous surgery and to undertake accurate identification of the site of recurrence.

Evaluation of osteopathy in thalassemia by bone mineral densitometry and biochemical indices.

Objective To evaluate osteopathy in thalassemia by bone mineral densitometry (BMD) and biochemical indices. Methods Prospective review analysis with no follow up from 2006 to 2007 of 42 regularly transfused thalassemics aged 10–25 years (27 boys, 15 girls) was done. Anthropometry, pubertal stage and symptomatology were noted. Urinary C–terminal cross–linked telopeptide of type–1 collagen (Crosslaps) by ELISA; serum 25–OH vitamin D and osteocalcin by RIA; parathyroid hormone (PTH) and ferritin by chemiluminescence and IGF–1 by Enzyme immunoassay were evaluated. Dual Energy X-ray Absorptiometry (DEXA) of lumbar spine and femur was done on Lunar prodigy system. Data was entered and analyzed using the SPSS for Windows software. Mean comparisons were done by ANOVA 1 and data was compared using Chi–square test and p value<0.05 was taken as significant. Results Of 42 patients, 81% had osteoporosis by Z–score of DEXA. Urinary crosslaps was high in 55%; 36% had increased osteocalcin; 62% had low vitamin D levels; 38% had high parathyroid levels and IGF–1 was low in 52%. Mean serum ferritin level was 5344±2855 ng/dl. There was statistical significance (p=0.046) between chronological age and BMD. All 42 cases were divided into two groups: Group–1 (Normal DEXA), Group–2 (Abnormal DEXA) and analysis of biochemical indices between two groups showed no significant difference in any of the biochemical parameters. Conclusion This study revealed majority of thalassemics with inadequate chelation have bone resorption with advancing chronological age and BMD should be evaluated regularly for early diagnosis to prevent morbidity.

Low-calcium peritoneal dialysis solution is effective in bringing PTH levels to the range recommended by current guidelines in patients with PTH levels < 150 pg/dL / Alteração do teor de cálcio no banho de DP para 2, 5 mEq/L é eficaz no reestabelecimento dos valores preconizados por diretrizes atuais em pacientes com PTH < 150 pg/dL

INTRODUÇÃO/OBJETIVO: A doença óssea adinâmica (DOA) é um achado comum em diálise peritoneal (PD) e é considerada fator de risco para desenvolvimento de fraturas e doença cardiovascular. Dados do BRAZPD apontam as soluções de cálcio a 3,5 mEq/L presentes na maioria das prescrições no país, que possui quase 9.000 pacientes em PD. É comum o balanço positivo de cálcio com concentrações a 3,5 mEq/L contribuindo para o desenvolvimento de DOA. Diretrizes atuais recomendam um PTHi na DRC V em diálise entre 2 e 9 vezes (150-500 pg/mL) o valor máximo da normalidade. O objetivo deste estudo foi avaliar a resposta em 6 meses do PTH-i após a conversão para solução de cálcio a 2,5 mEq/L de pacientes que usavam soluções com cálcio a 3,5 mEq/L e com PTH-i basal < 150 pg/mL. MÉTODOS: Coorte prospectiva, observacional, na qual todos pacientes prevalentes em PD entre janeiro de 2008 e janeiro de 2009 de um único centro foram incluídos. Critérios de inclusão foram:(1) estar em uso de solução de DP com cálcio a 3,5 mEq/L; (2)PTH sérico < 150 pg/mL. A critério médico, os pacientes poderiam ser convertidos ou não para soluções cálcio a 2,5 mEq/L. RESULTADOS: 35 pacientes (idade média 62 ± 17 anos) foram incluídos. Desses, 22 foram convertidos para solução de cálcio 2,5 mEq/L. Nefropatia diabética foi a principal doença de base (36 por cento) seguido por HAS (25 por cento) e GNC (14 por cento). Os grupos apresentavam valores basais semelhantes de PTH, cálcio, fósforo e fosfatase alcalina. No grupo-intervenção, houve aumento significativamente maior de PTH em 6 meses comparado com o grupo-controle (Δ194 pg/dL versus Δ 92/dL; p < 0,05).

INTRODUCTION/OBJECTIVE: Adinamic bone disease (ABD) is a common finding in peritoneal dialysis (PD) and is associated with higher risk of developing cardiovascular and bone disease. Data from BRAZPD indicates that 3.5 mEq/L calcium PD solutions represents the majority of PD prescriptions in the country. A positive calcium balance can contribute to ABD development. Currently guidelines suggest that PTH-i levels in end stage renal disease should be kept from 150-300 pg/mL. The purpose of this study is to evaluate 6 month PTH-i response after conversion to 2.5 mEq/L calcium PD solution in patients with baseline PTH-i levels < 150 pg/mL. METHODS: Prospective, observational study of all prevalent patients (at least 90 days on therapy) on PD of a single Brazilian center from January 2008 to May 2009. Inclusion criteria (1) be in use of a PD solution with 3.5mEq/L of calcium; (2) baseline PTH leves < 150 pg/ mL. According to clinical practice patients could be switched to PD solutions with 2.5 mEq/L of calcium. RESULTS: 35 patients (age 62 ± 17 years) were included. Of these 22 were converted to 2.5 mEq/L calcium solutions. Diabetic nephropathy (36 percent) was the main cause of renal disease followed by nephrosclerosis (25 percent) and glomerulonephritis (14 percent). Converted group presented a greater increase in PTH levels when compared with the control group (Δ194 pg/dL versus Δ 92/dL; p < 0,05). Among patients switched to low calcium solution, 41 percent reached the target values (PTH 150300 pg/mL) compared to 14 percent whose remain with normal calcium solutions (p < 0.05). There were no differences between groups regarding calcium, phosphorus and alkaline phosphatase. CONCLUSION: In patients with PTH < 150 pg/mL conversion to low calcium solutions (2.5 mEq/L) appears to be a simple and effective strategy to bring PTH levels to the range determined by current guidelines when compared with 3.5mEq/L calcium PD solutions.

Autosomal Dominant Hypocalcemia Caused by an Activating Mutation of the Calcium-Sensing Receptor Gene: The First Case Report in Korea

Hypoparathyroidism is an abnormality of calcium metabolism characterized by low serum levels of parathyroid hormone in spite of hypocalcemia. The causes of hypoparathyroidism are numerous. Activating mutations in the calcium-sensing receptor (CaSR) gene are well-known causes of familial isolated hypoparathyroidism, also known as autosomal dominant hypocalcemia (ADH). Here we describe members of a Korean family with a heterozygous Pro221Leu mutation causing ADH. This case is the first report in Korea.

Prevalencia de hipercalcemia en pacientes con transplante [sic] renal: factores predictores / Prevalence of hypercalcemia in patients with renal transplant: predictive factors

El transplante renal (TxR) mejora el hiperparatiroidismo urémico. Sin embargo algunos pacientes pueden presentar hipercalcemia en el post TxR que altera la función del injerto y requiere en muchos casos cirugía de la paratiroides. El objetivo del trabajo fue establecer la prevalencia de hipercalcemia en pacientes con TxR y los factores que la predicen. Se incluyeron 60 adultos con insuficiencia renal crónica que recibieron un transplante renal. Se consignaron los valores de Calcemia, Fosfatemia, Fosfatasa alcalina y PTH intacta, previo al transplante y durante el seguimiento posterior. Se subdividió a la población en tres grupos según la calcemia post transplante y su duración en el período de un año: pacientes con 1. Calcemia normal (NC); 2. Hipercalcemia transitoria (HT) (se normaliza antes del año del transplante); 3. Hipercalcemia persistente (HP) (hipercalcemia sostenida más de 12 meses y que se adscribe a disfunción paratiroidea). Se verificó hipercalcemia post-transplante en el 33,4% de los pacientes (16,7% con HP y 16,7% con HT). Los factores asociados a hipercalcemia persistente fueron: 1) Mayor tiempo de hemodiálisis (NC: 30,5±4,8 meses; HT: 45,4±11,7 meses y HP: 64,7±14,0 meses; ANOVA: p=0,02); 2) Calcemias elevadas (NC: 9,4±0,1 mg/dl, HT: 10,2±0,3mg/dl y HP: 10,3±0,4 mg/dl; ANOVA: p=0,002) y PTH pre TxR (NC: 202 (78-485) pg/ml; HT: 146 (115-508) pg/ml y HP: 759 (368-1126) pg/ml; mediana 1er-3er cuartilo, test de Kruskall-Wallis: p=0,02). Se comprobaron correlaciones positivas entre tiempo de hemodiálisis y PTH post TxR (r=0,65; p<0,05) y Ca post TxR (r=0,32; p=0,02); la PTH pre y post TxR correlacionaron en forma directa (r=0,55; p<0,05). El grupo de pacientes con hipercalcemia transitoria presentó calcemias superiores a las óptimas con niveles de PTH adecuados. Los niveles de calcio y PTH elevados en pacientes en diálisis se asocian al desarrollo de hipercalcemia persistente en el período posterior al TxR.

Concentração sérica de paratormônio intacto em cães com insuficiência renal crônica / Serum concentration of intact parathormone in dogs with chronic renal failure

Estudou-se a ocorrência de hiperparatireoidismo secundário renal e determinaram-se as concentrações séricas de paratormônio intacto (PTHi-c), cálcio total e fósforo em 30 cães com insuficiência renal crônica (IRC) e em 40 cães sadios. Para a determinação do PTHi-c, foi utilizado o método imunofluorométrico, com o emprego de anticorpos anti-aminoterminal (extraídos de gema de ovo da galinha) e de anticorpos monoclonais anti-carboxiterminal (H5P10), marcados com Europium. As concentrações séricas de PTHi-c (717,23±469,13pg/ml no grupo IRC e 36,76±34,40pg/ml no grupo-controle; P=0,0001), cálcio total (11,46±2,03mg/dl no grupo IRC e 10,11±0,91mg/dl no grupo-controle; P=0,003) e fósforo (12,01±8,06mg/dl no grupo IRC e 4,33±0,74mg/dl no grupo-controle; P=0,0001) foram mais altas nos cães com IRC. Observou-se estreita correlação entre PTHi-c e fósforo (r=0,56; P=0,0006), o que não ocorreu entre PTHi-c e cálcio. Hipercalcemia em cães com alta concentração de PTHi-c demonstrou a possível ocorrência de hiperparatireoidismo terciário em 11 animais. A hiperfosfatemia pode indicar, de forma indireta, a ocorrência de hiperparatireoidismo secundário nos cães com IRC.

The occurrence of renal secondary hyperparathyroidism was studied and serum intact parathormone (PTHi-c), total calcium and phosphorus were measured in thirty dogs with chronic renal failure (CRF) and in forty healthy dogs. The imunnofluorometric method was used for the PTHi-c assay, using anti-aminoterminal antibodies (obtained from chicken yolk) and anti-carboxiterminal monoclonal antibodies (H5P10), marked with Europium. Mean value ± SD of serum concentration of PTHi-c was 717.23±469.13pg/ml in CRF group and 36.76±34.40pg/ml in control group (P=0.0001); for total calcium it was 11.46±2.03mg/dl in CRF group and 10.11±0.91mg/dl in control group (P=0.003); and for phosphorus it was 12.01±8.06mg/dl in CRF group and 4.33±0.74mg/dl in control group (P=0.0001). The highest values were observed in CRF dogs. A positive correlation between PHTi-c and phosphorus was observed (r=0.56; p=0.0006), and no correlation was detected between PTHi-c and total calcium. In dogs with CRF, hypercalcemia in presence of high level of serum PTHi-c showed a possible indication of tertiary hyperparathyroidism in 11 animals. In conclusion, hyperphosphatemia could indirectly demonstrate the occurrence of secondary hyperparathyroidism in CRF dogs.

La osteodistrofia renal y la paratohormona supresora de la remodelación ósea / Renal osteodystrophy and supressor paratohormone in bone remodeling

El Hiperparatiroidismo juega un rol central en la Osteodistrofia Renal (ODR) en pacientes con Insuficiencia Renal Crónica (IRC). Las primeras determinaciones de paratohormona (PTH) sérica aplicadas a la clínica en los años 1960, se basaban en métodos de radioinmunoanálisis (RIA) que usaban un solo anticuerpo contra la región carboxiterminal o la región media de la hormona. En 1987 se introdujo un método inmunométrico (IMA) basado en 2 anticuerpos, denominada en sandwich o PTH intacta, rutinariamente usado hasta hoy en la Investigación y Guías de manejo de la Osteodistrofia. A fines de la década del 90, autores detectaron 2 picks inmunoreactivos al usar el método tradicional, uno de ellos comigraba con la PTH intacta 1-84, en tanto que el 2º pick comigraba con la fracción 7-84, sugiriendo que un importante fragmento inactivo era incluido en las mediciones IMA, sobreestimando el real valor de la PTH, y exponiendo al paciente a tratamientos con altas dosis de vitamina D activa. Este método permitió separar la fracción biológicamente activa, denominada CAP-PTH, de una fracción supresora del metabolismo óseo, la CIP-PTH, y ha sido asociado a la falta de correlación entre la histomorfometría ósea y la PTH intacta 1-84. El importante aumento de la forma adinámica de ODR y las calcificaciones vasculares en los adultos urémicos, se han relacionado a elevadas dosis de vitamina D, calcio y fósforo, terapias que hasta hoy eran orientadas por los niveles de PTH plasmática. El actual manejo de la ODR debe ser reevaluado a la luz del conocimiento actual, y de futuras investigaciones que permitirán un mejor control de esta complicación de la Insuficiencia Renal Crónica.

Osteodistrofia renal en pacientes con isuficiencia renal crónica atendidos en el Hospital Escuela, Tegucigalpa / Renal osteodystrophy in patients with chronic renal failure attended at Hospital Escuela, Tegucigalpa

OBJETIVO: Estudiar la frecuencia de los diferentes tipos de osteodistrofia renal en una muestra de pacientes atendidos en el Hospital Escuela. MEDOTOLOGIA. Estudio realizado en los meses de agosto y septiembre del año 2004. A través de un instrumento se recolectó la información clínica y los resultados de los exámenes de gabinete de una muestra de 39 pacientes con insuficiencia renal crónica (IRC) a quienes se les efectuó pruebas de función renal medición de Paratohormona y biopsia de hueso. RESULTADOS. De los 39 pacientes estudiados, la biopsia de hueso demostró enfermedad ósea renal en 28.3%(11), mieloma múltiple en 2.6%(1) y sin alteración ósea en 36.0% (14). En los 13 casos restantes (33.1%), el resultado fue indeterminado debido a biopsia no evaluable. De los 26 pacientes con el resultado histopatológico, la frecuencia de ostrodistrofia renal fue de 42.3% (11). entre estos 11 pacientes, la enfermedad ósea adinámica fue la mas frecuente (46%), seguida de osteítis fibrosa (36%) y osteomalacia (18%). Se detectó niveles de paratohormona (PTH) mayores de 400 pg/ml en los 4 pacientes con osteítis fibrosa (enfermedad ósea de alto remodelado) y niveles menores de 125pg/ml en 5 de los 7 pacientes con enfermedad ósea de bajo remodelado (enfermedad ósea adinámica y osteomalacia).De los 14 pacientes sin osteodistrofia renal, uno demostró valores mayores de 400 pg/ml,5 demostraron valores entre 126 y 400 pg/ml, y 8 demostraron valores menores de 125 pg/ml.CONCLUSIONES:La frecuencia de ostiodistrofia renal fue de 44%, es decir que aproximadamente por cada 2 pacientes con enfermedad renal crónica atendido en el Hospital Escuela durante el período que duró el estudio, uno tenía osteodistrofia renal. La paratohormona podría ser utilizada como marcador bioquímico para detectar enfermedad ósea de alto remodelado en los pacientes con insuficiencia renal...

Paratireoidectomia total com ou sem autotransplante no tratamento do hiperparatireoidismo secundário / Total parathyroidectomy with or without autotransplantation in the treatment of secondary hyperparathyroidism

A progressão do hiperparatireoidismo secundário no doente com insuficiência renal crônica é acompanhada de complicações. Após tentativa de tratamento clínico, pode ser necessária paratireoidectomia. O tipo de operação é assunto controverso. A paratireoidectomia total sem autotransplante poderia representar uma opção com menor risco de recidiva.

effect of extracorporeal shock wave lithotripsy [ESWL] on angiotensin I, N-acetyl-B-glucosaminidase, urinary marker proteins, parathyroid hormone, pancreatic amylase and muscle injury enzyme markers

To detect the source of relevant acute intrarenal side effects after extracorporeal shock wave lithotripsy [ESWL], urinary excretion of highly specific marker proteins [alpha 1 and beta 2 microglobulin], as well as tubular enzyme N-acetyl-beta-D glucosaminidase [NAG] were analyzed before and after ESWL. A highly significant increase in urinary marker proteins [alpha 1 M and beta 2 M] and urinary enzyme NAG were recognized immediately following ESWL. Alpha 1 M and NAG returned to their pre-ESWL levels but beta 2 M remained high till day 30. Plasma renin activity-PRA [angiotensin I] was highly significantly elevated immediately after ESWL and remained high after 1 month. The parathyroid hormone [PTH], CK-MB were highly significant elevated. Gamma glutamyl transferase [GGT], alanine aminotransferase [ALT], aspartate aminotransferase[AST], alkaline phosphatase[ALP] and pancreatic amylase were significantly higher than normal immediately after ESWL but all to their pre-ESWL values after 1 month

Funçäo da glândula paratiróide em mulheres osteopênicas após a menopausa / Function of the parathyroid gland in osteopenic women after menopause

Níveis de hormônio paratiroidiano já foram descritos mais baixos, inalterados e até mais elevados em mulheres com osteoporose pós-menopausa. Alguns autores, ao infundirem EDTA e medirem o cálcio ionizado em mulheres menopausadas, observaram uma reatividade menor das glândulas paratiróides nessas mulheres. A resposta da glândula paratiróide ao estímulo com fosfato oral, em mulheres osteopênicas, nos primeiros anos da menopausa (1-6 anos) foi investigado. Doze mulheres osteopênicas (densidade óssea na coluna entre 0,900 e 0,970g/cm2), menopausadas, com idade entre 50 e 55 anos, e 11 mulheres saudáveis, controles (densidade óssea na coluna maior que 1.100g/cm2) receberam 1,5 gramas de fosfato oral, durante 15 dias. O cálcio, fósforo, fosfatase alcalina e creatinina séricas, bem como o Ca/Cr e hidroxiprolina/Cr urinários foram semelhantes nos dois grupos no início do estudo. Entretanto, o PTH aminoterminal foi estatisticamente inferior nas mulheres osteopênicas. Após ingestäo de fosfato oral, o Ca/Cr urinário nos dois grupos apresentou queda ao redor de 42-46%. O PTH aminoterminal subiu significantemente no grupo controle normal após administraçäo do fosfato, porém 75% das osteopênicas näo apresentaram qualquer alteraçäo. A resposta negativa nas mulheres ostopênicas pode ser devida a sensibilidade alterada ao PTH nessas pacientes. Os autores propöem novos estudos com sobrecarga de fosfato em todas as mulheres, nos primeiros anos da menopausa, para verificar se as "näo respondedoras" perdem mais massa óssea que as "respondedoras"