Systems-Level Opportunities in the Management of Primary Hyperparathyroidism: An Informatics-Based Assessment

Abstract Context Primary hyperparathyroidism (PHPT), a leading cause of hypercalcemia and secondary osteoporosis, is underdiagnosed. Objective To establish a foundation for an electronic medical record-based intervention that would prompt serum parathyroid hormone (PTH) assessment in patients with persistent hypercalcemia and identify care gaps in their management. Design Retrospective cohort study. Setting Tertiary academic health system. Patients Outpatients with persistent hypercalcemia, who were then categorized as having classic or normohormonal PHPT. Main Outcome Measures The frequencies of serum parathyroid hormone (PTH) measurement in patients with persistent hypercalcemia, and their subsequent workup with bone mineral density (BMD) assessment, and ultimately, medical therapy or parathyroidectomy. Results Among 3151 patients with persistent hypercalcemia, 1526 (48%) had PTH measured, from whom 1377 (90%) were confirmed to have classic (49%) or normohormonal (41%) primary hyperparathyroidism (PHPT). PTH was measured in 65% of hypercalcemic patients with osteopenia or osteoporosis (p<0.001). Upon median two year follow-up, bone density was assessed in 275 (20%) patients with either variant of PHPT (p=0.003). Of women ≥ 50 years of age with classic PHPT, 95 (19%) underwent BMD assessment. Of patients with classic or normohormonal PHPT, 919 patients (67%) met consensus criteria for surgical intervention, though only 143 (15%) underwent parathyroidectomy. Conclusions Within a large academic health system, over half of patients with confirmed hypercalcemia were not assessed for PHPT, including many patients with preexisting bone disease. Care gaps in BMD assessment and medical or surgical therapy represent opportunities to avoid skeletal and other complications of PHPT.

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Low serum parathyroid hormone is a risk factor for peritonitis episodes in incident peritoneal dialysis patients: a retrospective study

BMC Nephrology ◽

10.1186/s12882-021-02241-0 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Yuqi Yang ◽

Jingjing Da ◽

Yi Jiang ◽

Jing Yuan ◽

Yan Zha

Keyword(s):

Risk Factor ◽

Peritoneal Dialysis ◽

Parathyroid Hormone ◽

Proportional Hazard ◽

Serum Parathyroid Hormone ◽

Cox Proportional Hazard ◽

Cox Proportional Hazard Regression ◽

Gram Negative Organisms ◽

Serum Pth

Abstract Background Serum parathyroid hormone (PTH) levels have been reported to be associated with infectious mortality in peritoneal dialysis (PD) patients. Peritonitis is the most common and fatal infectious complication, resulting in technique failure, hospital admission and mortality. Whether PTH is associated with peritonitis episodes remains unclear. Methods We examined the association of PTH levels and peritonitis incidence in a 7-year cohort of 270 incident PD patients who were maintained on dialysis between January 2012 and December 2018 using Cox proportional hazard regression analyses. Patients were categorized into three groups by serum PTH levels as follows: low-PTH group, PTH < 150 pg/mL; middle-PTH group, PTH 150-300 pg/mL; high-PTH group, PTH > 300 pg/mL. Results During a median follow-up of 29.5 (interquartile range 16–49) months, the incidence rate of peritonitis was 0.10 episodes per patient-year. Gram-positive organisms were the most common causative microorganisms (36.2%), and higher percentage of Gram-negative organisms was noted in patients with low PTH levels. Low PTH levels were associated with older age, higher eGFR, higher hemoglobin, calcium levels and lower phosphate, alkaline phosphatase levels. After multivariate adjustment, lower PTH levels were identified as an independent risk factor for peritonitis episodes [hazard ratio 1.643, 95% confidence interval 1.014–2.663, P = 0.044]. Conclusions Low PTH levels are independently associated with peritonitis in incident PD patients.

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P114 Effect of vitamin D on parathyroid hormone, serum calcium and bone mineral density in patients with primary hyperparathyroidism being managed conservatively

Rheumatology ◽

10.1093/rheumatology/keab247.110 ◽

2021 ◽

Vol 60 (Supplement_1) ◽

Author(s):

Mahrukh Khalid ◽

Vismay Deshani ◽

Khalid Jadoon

Keyword(s):

Bone Mineral Density ◽

Vitamin D ◽

Parathyroid Hormone ◽

Primary Hyperparathyroidism ◽

Bone Mineral ◽

Serum Calcium ◽

Mineral Density ◽

Neck Of Femur ◽

Vitamin D Levels ◽

Significant Difference

Abstract Background/Aims Vitamin D deficiency is associated with more severe presentation of primary hyperparathyroidism (PTHP) with high parathyroid hormone (PTH) levels and reduced bone mineral density (BMD). We analyzed data to determine if vitamin D levels had any impact on PTH, serum calcium and BMD at diagnosis and 3 years, in patients being managed conservatively. Methods Retrospective analysis of patients presenting with PHPT. Based on vitamin D level at diagnosis, patients were divided into two groups; vitamin D sufficient (≥ 50 nmol/L) and vitamin D insufficient (≤ 50 nmol/L). The two groups were compared for age, serum calcium and PTH levels at diagnosis and after mean follow up of 3 years. BMD at forearm and neck of femur (NOF) was only analyzed in the two groups at diagnosis, due to lack of 3 year’s data. Results There were a total of 93 patients, 17 males, mean age 70; range 38-90. Mean vitamin D level was 73.39 nmol/L in sufficient group (n = 42) and 34.48 nmol/L in insufficient group (n = 40), (difference between means -38.91, 95% confidence interval -45.49 to -32.33, p < 0.0001). There was no significant difference in age, serum calcium and PTH at the time of diagnosis. After three years, there was no significant difference in vitamin D levels between the two groups (mean vitamin D 72.17 nmol/L in sufficient group and 61.48 nmol/L in insufficient group). Despite rise in vitamin D level in insufficient group, no significant change was observed in this group in PTH and serum calcium levels. BMD was lower at both sites in vitamin D sufficient group and difference was statistically significant at NOF. Data were analyzed using unpaired t test and presented as mean ± SEM. Conclusion 50% of patients presenting with PHPT were vitamin D insufficient at diagnosis. Vitamin D was adequately replaced so that at 3 years there was no significant difference in vitamin D status in the two groups. Serum calcium and PTH were no different in the two groups at diagnosis and at three years, despite rise in vitamin D levels in the insufficient group. Interestingly, BMD was lower at forearm and neck of femur in those with sufficient vitamin D levels and the difference was statistically significant at neck of femur. Our data show that vitamin D insufficiency does not have any significant impact on PTH and calcium levels and that vitamin D replacement is safe in PHPT and does not impact serum calcium and PTH levels in the short term. Lower BMD in those with adequate vitamin D levels is difficult to explain and needs further research. Disclosure M. Khalid: None. V. Deshani: None. K. Jadoon: None.

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Bone histomorphometry, bone mineral density at multiple skeletal sites, and biochemical markers in a three year follow-up study of surgical treated patients with primary hyperparathyroidism.

Bone ◽

10.1016/8756-3282(96)89387-2 ◽

1996 ◽

Vol 19 (3) ◽

pp. 162S

Author(s):

T STEINICHE

Keyword(s):

Bone Mineral Density ◽

Primary Hyperparathyroidism ◽

Bone Mineral ◽

Biochemical Markers ◽

Bone Histomorphometry ◽

Mineral Density ◽

Follow Up Study

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Low Calcium Dialysate and Hyperparathyroidism

Peritoneal Dialysis International ◽

10.1177/089686089601601s101 ◽

1996 ◽

Vol 16 (1_suppl) ◽

pp. 499-503 ◽

Cited By ~ 5

Author(s):

Rachel Duncan ◽

Tracey Cochrane ◽

Carol Bhalla ◽

Jonathan Michael ◽

Nicholas Talbot Richards ◽

...

Keyword(s):

Parathyroid Hormone ◽

High Serum ◽

Phosphate Binders ◽

Serum Parathyroid Hormone ◽

Aluminum Salts ◽

Low Calcium ◽

Increased Risk ◽

Intact Molecule ◽

Alkaline Phosphate

A low calcium dialysate reduces hypercalcemia from calcium-containing phosphate binders and makes phosphate control possible without the use of aluminum salts. We asked whether this might, however, lead to hyperparathyroidism. We prospectively studied serum concentrations of parathyroid hormone levels (by an immunoreactive intact molecule assay) in 173 patients on continuous ambulatory peritoneal dialysis (CAPD) who were started on a low calcium dialysate (Ca2+ 1.25 or 1.00 mmol/L) because of hypercalcemia. Median follow-up was 13.2 months (range 1 -28). Initial serum parathyroid hormone was [median (range)]: 70 (5 -1043) ng/L pre low calcium dialysate, and this rose to 130(5 -914) ng/LatO 6 months; 130 (5 -1030) ng/Lat 6 -12 months; 170 (170 1400) ng/L at 12 -18 months; and 130 (5 -1200) ng/L at 18 24 months (p = 0.0006). Twenty-two patients required a parathyroidectomy because of a sustained rise in parathyroid hormone that was not responsive to alfacalcidol and hypercalcemia. Initial serum parathyroid hormone was significantly higher in these patients at 359 (5 1073) ng/L as compared to a level of 69.5 (6 1147) ng/L in patients who did not have a parathyroidectomy (p = 0.0009). There was a significant sustained fall in mean serum corrected calcium from 2.77 (2.37 3.51) mmol/L to 2.53 (1.39 3.20) mmol/L at three months (p = 0.0006), a nonsignificant rise in mean serum alkaline phosphate from 179 (47 -1858) mmol/L to 191 (55 -1821) mmol/L (p = 0.15), and a fall in mean serum phosphate levels from 1.87 (0.59–3.18) mmol/L to 1.68 (0.45–3.6) mmol/L (p = 0.76). Our data suggest that the benefits of a low calcium dialysate in CAPD patients are balanced by an increased risk of hyperparathyroidism, and that this risk is higher in patients with an initially high serum parathyroid hormone level.

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Primary Hyperparathyroidism with a Low-Normal, Atypical Serum Parathyroid Hormone as Shown by Discordant Immunoassay Curves

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2006-0273 ◽

2006 ◽

Vol 91 (10) ◽

pp. 3826-3829 ◽

Cited By ~ 15

Author(s):

Fred W. Lafferty ◽

Clive R. Hamlin ◽

Kristin R. Corrado ◽

Andrew Arnold ◽

Jerry M. Shuck

Keyword(s):

Parathyroid Hormone ◽

Primary Hyperparathyroidism ◽

Serum Parathyroid Hormone

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Three-year follow-up of serum 25-hydroxyvitamin D, parathyroid hormone, and bone mineral density in nursing home residents who had received 12 months of daily bread fortification with 125 μg of vitamin D3

Nutrition Journal ◽

10.1186/1475-2891-12-137 ◽

2013 ◽

Vol 12 (1) ◽

Cited By ~ 11

Author(s):

Veronica Mocanu ◽

Reinhold Vieth

Keyword(s):

Bone Mineral Density ◽

Nursing Home ◽

Parathyroid Hormone ◽

Bone Mineral ◽

Vitamin D3 ◽

Nursing Home Residents ◽

Mineral Density ◽

Hydroxyvitamin D ◽

25 Hydroxyvitamin D

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Preliminary approaches to early detect the primary hyperparathyroidism from patients with normocalcemia and elevated serum parathyroid hormone levels

Bone ◽

10.1016/j.bone.2008.07.207 ◽

2008 ◽

Vol 43 ◽

pp. S101-S102

Author(s):

Lin Zhao ◽

Jianmin Liu ◽

Minjia Zhang ◽

Guang Ning

Keyword(s):

Parathyroid Hormone ◽

Primary Hyperparathyroidism ◽

Elevated Serum ◽

Serum Parathyroid Hormone ◽

Hormone Levels

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Primary Hyperparathyroidism: Modern Conception and Clinical Observation

The Russian Archives of Internal Medicine ◽

10.20514/2226-6704-2020-10-2-94-101 ◽

2020 ◽

Vol 10 (2) ◽

pp. 94-101

Author(s):

L. M. Farkhutdinova

Keyword(s):

Parathyroid Hormone ◽

Primary Hyperparathyroidism ◽

Parathyroid Adenoma ◽

Clinical Manifestations ◽

Premature Death ◽

Developed Countries ◽

Severe Form ◽

Mineral Density ◽

Target Organs ◽

Increased Risk

The article is devoted to one of the actual medical and social problems — primary hyperparathyroidism, the late diagnosis of which leads to the development of severe complications and an increased risk of premature death. Unlike developed countries, where 80% of cases are represented by mild forms of the disease, in the Russian Federation this indicator does not exceed 30%, while 70% are manifest forms. Widespread awareness of doctors of various specialties in the diagnosis of parathyroid adenoma is necessary for the timely detection of the disease. The article reflects the main stages of the study of the disease, the pathogenesis of the clinical manifestations of primary hyperparathyroidism, the classic symptoms of which are changes in the target organs of the parathyroid hormone — bone tissue, urinary system and gastrointestinal tract, is considered. Bone disorders are the most common manifestation of hyperparathyroidism and are characterized by increased bone metabolism with a progressive decrease in bone mineral density. Typical changes in the kidneys include nephrolithiasis and nephrocalcinosis, causing the formation of renal failure. Gastrointestinal signs of hyperparathyroidism are erosion and ulcers of the stomach and duodenum, prone to bleeding, recurrent pancreatitis. Diagnosis of the disease is based on laboratory results, characterized by elevated levels of calcium and parathyroid hormone in the blood. Visualization of the paradenomas in most cases is provided by ultrasound and scintigraphy. Removal of parathyroid adenoma is the most effective treatment. A clinical case of a severe form of the disease is presented, indicating an urgent need to take measures to solve the problem of primary hyperparathyroidism.

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Low Serum Parathyroid Hormone is a Risk Factor for Peritonitis Episodes in Incident Peritoneal Dialysis Patients: A Retrospective Study

10.21203/rs.3.rs-55536/v1 ◽

2020 ◽

Author(s):

Yuqi Yang ◽

Jingjing Da ◽

Yi Jiang ◽

Jing Yuan ◽

Yan Zha

Keyword(s):

Risk Factor ◽

Peritoneal Dialysis ◽

Parathyroid Hormone ◽

Proportional Hazard ◽

Serum Parathyroid Hormone ◽

Cox Proportional Hazard ◽

Cox Proportional Hazard Regression ◽

Serum Pth ◽

Technique Failure

Abstract Backgroud: Serum parathyroid hormone (PTH) levels have been reported to be associated with infectious mortality in peritoneal dialysis (PD) patients. Peritonitis is the most common and fatal infectious complication, resulting in technique failure, hospital admission and mortality. Whether PTH is associated with peritonitis episodes remains unclear.Methods: We examined the association of PTH levels and peritonitis incidence in a 7-year cohort of 270 incident PD patients who were maintained on dialysis between January 2012 and December 2018 using Cox proportional hazard regression analyses. Patients were categorized into three groups by serum PTH levels as follows: low-PTH group, PTH<150pg/mL; middle-PTH group, PTH=150-300pg/mL; high-PTH group, PTH>300pg/mL .Results: During a median follow-up of 29.5 (interquartile range 16-49) months, 73 (27.0%) peritonitis episodes occurred. Low PTH levels were associated with older age, higher calcium levels and lower alkaline phosphatase levels. After multivariate adjustment, lower PTH levels were identified as an independent risk factor for peritonitis episodes [hazard ratio 1.643, 95% confidence interval 1.014-2.663, P=0.044].Conclusions: Low PTH levels are independently associated with peritonitis in incident PD patients.

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