Parathyroidectomy Improves Restless Leg Syndrome in Patients on Hemodialysis.

BACKGROUND: Restless leg syndrome (RLS) is a sleep disorder with high prevalence among patients on hemodialysis. It has been postulated that high phosphate and high parathyroid hormone may be implicated in its pathogenesis. Standard international criteria and face-to-face interview are not always applied. METHODS: this was an interventional prospective study in which 19 patients (6 men, aged 48±11 years) with severe hyperparathyroidism were evaluated. RLS diagnosis and rating scale were accessed based on the International RLS Study Group pre- and post-parathyroidectomy. Patients also underwent standard polysomnography. RESULTS: At baseline, RLS was present in 10 patients (52.6%), and pain was the most reported symptom associated with the diagnosis. Patients with RLS had higher serum phosphate (p = 0.008) that remained independently associated with RLS in a logistic regression model, adjusted for hemoglobin, age and gender (HR = 7.28;CI = 1.14-46.3, p = 0.035). After parathyroidectomy, there was a reduction of serum parathyroid hormone, phosphate, calcium and alkaline phosphatase, and an increase of 25(OH)-vitamin D, and Fetuin-A. Parathyroidectomy alleviated RLS (from 52% to 21%; p = 0.04), which was accompanied by a decrease in severity scale, in association with relief of pain and pruritus. Polysomnography in these patients showed an improvement of sleep parameters as measured by sleep efficiency, sleep latency and percentage of REM sleep. CONCLUSION: RLS is associated with high levels of phosphate in patients with severe secondary hyperparathyroidism on hemodialysis. Pain is most reported complain in these patients. Parathyroidectomy provided an opportunity to relief RLS. Whether the reduction of serum phosphorus or parathyroid hormone contributed to this improvement merits further investigation.

Chronic Kidney Disease and Sleeping Disordered Breathing (SDB).

The outlines of the current manuscript are: 1. Re-establish the link between hypertension and SDB including prevalence, mechanism, and reversal of process (i.e. improvement in hypertension with improvement in SDB), why it is important-cardiovascular mortality with numbers. 2. Re-establish the link between hypertension and CKD including same points as above. Then ask if both CKD and SDB are combined, what happens to hypertension and cardiovascular mortality. 3. Lastly, talk about links between CKD and SDB on how each process feeds on the other and is a growing, common problem.

Síndrome das pernas inquietas em pacientes com hiperparatireoidismo secundário em hemodiálise pré e pós-paratireoidectomia / Restless leg syndrome in secondary hyperparathyroidism patients on hemodialysis pre and post parathyroidectomy

Síndrome das pernas inquietas (SPI) é um distúrbio do sono com alta prevalência entre pacientes em hemodiálise, nos quais o mecanismo é pouco conhecido. Tem sido postulado que alterações do metabolismo mineral e ósseo relacionadasà doença renal crônica, especialmente o hiperparatireoidismo secundário, possam estar relacionadas à patogênese da SPI. Este trabalho teve como objetivo principal avaliar a SPI antes e após paratireoidectomia (PTX). Além disso, avaliamos dados objetivos do sono por meio de polissonografia, com ênfase em apneia do sono. Estudamos prospectivamente 19 pacientes (6 homens, idade 48 ± 11 anos) com hiperparatireoidismo grave pré e pós-PTX. O diagnóstico e o escore de gravidade da SPI foram avaliados de acordo com o Grupo de Estudo Internacional de SPI. Polissonografia pré e pós-PTX forneceu dados de arquitetura do sono, movimentos periódicos de pernas e apneia do sono, medida por meio do índice de apneia-hipopneia/hora de sono (IAH). SPI foi encontrada em 10 pacientes (53%) e se associou com maiores níveis de fosfato (p=0,005) e maior gravidade da dor (p=0,003). Após a PTX, houve redução dos níveis séricos de paratormônio, fosfato e aumento dos níveis de 25-hidroxivitamina D, calicreína-6 e fetuína-A. A PTX reduziu a SPI para 21% (p=0,044), acompanhada por redução nos escores de gravidade e alívio da dor e do prurido. A análise de regressão logística mostrou que o fosfato pré-PTX permaneceu independentemente associado com SPI (OR=7,28; p=0,035), em modelo ajustado para hemoglobina, idade e sexo. Apneia do sono (IAH > 5) foi encontrada em 11 pacientes pré e 14 pós-PTX (63% vs. 74%, p=0,698). Observamos uma correlação entre o IAH e a relação água corporal extracelular/massa magra (r=0,535, p=0,018), assim como correlação com a circunferência do pescoço pré-PTX (r=0,471, p=0,042). Entretanto, não observamos correlação do IAH com o deslocamento de fluidos da perna direita durante o sono (p=0,09), que aumentou significativamente após PTX...

Restless legs syndrome (RLS) is a sleep disorder with high prevalence among patients on hemodialysis, which underlying mechanism is still unknown. It has been postulate that bone metabolism disorder, especially secondary hyperparathyroidism may be implicated in the pathogenesis. The present study aimed to evaluate RLS before and after parathyroidectomy (PTX). In addition, we evaluated objective data through polysomnography, focusing on sleep apnea. We prospectively evaluated 19 patients (6 men, aged 48 ± 11 years) with severe hyperparathyroidism pre and post-surgical treatment, parathyroidectomy (PTX). RLS diagnosis and rating scale were accessed based on the International RLS Study Group. Polysomnography pre and post PTX provided data on sleep architecture, periodic leg movements of sleep and apnea-hypopnea index (AHI). RLS was observed in 10 patients (53%), and was associated with higher levels of phosphate (p=0,005) and severe pain (p=0,003). After PTX, there was a reduction of serum parathyroid hormone, serum phosphate, and an increase of 25hydroxyvitamin D, kallicrein-6 and Fetuin-A. PTX improved RLS to 21% (p=0,04), accompanied by a decrease in rating scale, in association with alleviation of pain and pruritus. Logistic regression shows that serum phosphate pre PTX remained independently associated with RLS (HR=7,28; p=0,035), in a model adjusted for hemoglobin, age and gender. Sleep apnea (AHI > 5) was found in 11 patients pre and 14 patients post PTX (63% vs. 74%, p=0,698). There was a correlation between AHI and the relation extracellular water/ lean body mass (r=0,535; p=0,018) as well as a correlation between AHI and neck circumference (r=0,471; p=0,042). However, there was no correlation between AHI and spontaneous rostral fluid shift (p=0,09) that has increased after PTX (p=0,011). We concluded that PTX provided an opportunity to improve RLS. Whether RLS may be improved by reduction of serum phosphorus or parathyroid...