Incidence of intradialytic hypertension in hemodialysis patients in Beheira governorate and effect of high flux versus low flux dialysis on it

Background Intradialytic hypertension (IDH) is a common complication of hemodialysis (HD) that is under-recognized and its significance is underappreciated. No standard definition of IDH exists. As a unifying criteria for the diagnosis of IDH has not been proposed, the focus of this review will be on systolic blood pressure (SBP) rise = 10 mmHg at = 4 over six consecutive sessions. IDH is estimated at 5–15% of HD patients. IDH has been associated with poor clinical outcomes in HD patients including increased hospitalizations, higher ambulatory blood pressure (BP), cardiovascular morbidity, and mortality. Aim of the Work To detect the incidence of IDH in HD patients in Beheira governorate and to compare the effect of high flux versus low flux dialysis on it. Patients and Methods This study was conducted on 200 patients on maintenance HD from different HD units in Beheira governorate. The patients were divided into two groups: Group 1: 100 patients on HD with high flux dialyzers and Group 2: 100 patients on HD with low flux dialyzers. Results: Incidence of IDH in HD patients in Beheira governorate was 23.5% at the start, 21% after one month and 13% after three months duration. Results of our study demonstrated that there were no significant differences between both groups as regards effect of high-flux vs low-flux dialysis on IDH after one month and at the end of the study (P > 0.05), but there was a significant decrease in number of IDH patients after one month duration and after three months in both high-flux and low-flux dialysis patients. In our study, there was significant improvement in the form of reductions in all of pre-dialysis BUN, post-dialysis BUN, serum creatinine levels and serum IPTH levels at the end of the study in high flux group compared to low flux group. Finally, our results showed significant improvement in serum hemoglobin levels in high flux group by the end of the study in contrast to the low flux group. Conclusion No significant difference in the effect of high flux versus low flux dialysis on IDH, but there was significant improvement in all of pre-dialysis BUN, post-dialysis BUN, serum creatinine levels and serum IPTH levels by the end of the study in the high flux group compared to the low flux group.

Analyses of Predictive Factors Associated with Hypocalcemia and Elevated iPTH with Normocalcemia after Ultrasound-guided Radiofrequency Ablation for Primary Hyperparathyroidism

Purpose To assess the feasibility of ultrasound-guided (US-guided) radiofrequency ablation (RFA) for primary hyperparathyroidism (PHPT) and determine predictive factors for hypocalcemia and elevated serum intact parathyroid hormone(ePTH) with normocalcemia after ablation. Materials and Methods Between January 2015 and January 2021, data from 44 patients with PHPT who were treated with US-guided RFA were retrospectively evaluated. Serum intact parathyroid hormone(iPTH), total calcium (Ca), phosphorus, alkaline phosphatase (ALP), and 25-hydroxyvitamin D3 (25(OH)D3) levels and the volume of the abnormal enlarged parathyroid glands were recorded before RFA. Changes in iPTH and Ca levels at 1 and 3 days, and, 1, 3, and 6 months after ablation were recorded. Results Overall, thirteen patients developed hypocalcemia 1–3 days after RFA. ePTH with normocalcemia developed in 17 patients 1 month after RFA. Thirty-two patients were followed up for more than 6 months, and 27 of these patients had sustained normalized values for both serum iPTH and Ca levels more than 6 months after RFA. There were significantly more patients who developed hypocalcaemia, when the baseline ALP was greater than 261.5 U/L (sensitivity 61.5%, specificity 100.0%). The risk of ePTH decreased by 21.7% for every 1 ng/mL increase in 25 (OH) D3. The risk of ePTH was increased when a patient's serum iPTH was higher than 172.4 pg/mL (sensitivity 88.2%, specificity 76.2%). Conclusions US-guided RFA is feasible for clinical management of PHPT patients. Hypocalcaemia following RFA was associated with higher pre-RFA serum ALP levels. Elevated iPTH levels with normocalcemia at 1 month after RFA were associated with pre-RFA vitamin D deficiency and higher baseline iPTH levels. Patients with higher serum ALP and iPTH and lower 25 (OH) D3 levels before RFA need to be managed carefully and monitored closely after RFA of PHPT.

The relationship between bone mineral indices and survival in patients on peritoneal dialysis

Introduction: Disorders of minerals metabolism are common metabolic problems in patients undergoing peritoneal dialysis (PD) which causes increase in mortality and morbidity in these patients. Objectives: In this study, the relationship between bone metabolic indices and mortality rate in patients on PD was assessed. Patients and Methods: Data were collected from Iranian peritoneal dialysis registry database, covering the period 2009–2015 and comprised 2000 adult patients. Patients with less than three months follow-up and incomplete data were excluded. Demographic and some laboratory data (including age, gender, body mass index, serum albumin, dialysis vintage and comorbidities) of patients recorded. Additionally, the unadjusted and adjusted, hazard ratios (HRs) of serum phosphorus (P), calcium (Ca) and parathyroid hormone (PTH) levels, to find their association with mortality were calculated, using the Cox proportional-hazards model. Results: In total, 1197 out of 2000 patients had the inclusion criteria and were included in the study. We found that serum iPTH (intact parathyroid hormone) over 600 pg/mL significantly increased the mortality rate by 2.7 times compared to iPTH levels between 200 to 600 pg/ mL (HR: 2.7, P=0.002). Additionally, the serum phosphorus level less than 4 mg/dL was significantly (P=0.0001) related to higher mortality rate (HR: 1.6). There was no significant association of serum calcium and alkaline phosphatase (ALP) levels with mortality (P > 0.05). Conclusion: Although high serum iPTH and low-serum phosphorus levels could determine the mortality risk in PD patients, Ca and ALP levels were not risk factors for mortality.

Hyperplastic thyroid nodule masquerading as parathyroid adenoma in a patient with tubercular lymphadenitis induced hypercalcaemia

Serum intact parathyroid hormone (iPTH) levels are high or high normal in patients with parathyroid adenoma. Rarely these patients can have normal or low serum iPTH values. With sandwich immunometric assays, an exceptionally high serum iPTH level can lead to falsely low measurement due to the ‘hook effect’. Here, we describe the case of a 66-year-old female patient with PTH-independent hypercalcaemia which mimicked parathyroid adenoma. A multidisciplinary team approach helped in the diagnosis and management leading to complete recovery.

The optimal level of serum vitamin D in apparently healthy Bangladeshi adult volunteer

Introduction: Vitamin D level has profound clinical implications but there is a dilemma of optimal vitamin D cut off level among the Bangladeshi population as well in many parts of the world. This study aimed to determine the optimal level of vitamin D in relation to intact parathyroid hormone (iPTH) and serum calcium in apparently healthy adult volunteer. Methods: This observational cross-sectional study was carried out in 130 apparently healthy adult participants of BSMMU. All the subjects were taken their demographic profile and investigated for vitamin D level, iPTH, corrected calcium and phosphate. Serum 25(OH)D was measured by high-performance liquid chromatography (HPLC) whereas iPTH, corrected serum calcium and serum phosphate were measured by chemiluminescent method. Results: The mean 25(OH)D level was found to be 16.78(SD8.47) ng/ml and extensively distinct by age distribution and adequacy of sun exposure. There was substantially inverse correlation between serum iPTH and serum 25(OH)D (r = - 0.22, p = 0.01). Serum 25(OH)D levels < 27.5ng/ml were associated with a steep increase in serum iPTH levels. Serum iPTH was stabilized at level 54.5pg/ml by using the quadratic fit with plateau model. Conclusions: From this study the optimal level of 25(OH)D for the apparently healthy adult in Bangladesh is 27.5 ng/ml.

P1427ROLE OF ETECALCETIDE IN THE MANAGEMENT OF SECUNDARY HYPERPARATHYROIDISM

Background and Aims Secondary Hyperparathyroidism (SHPT) is a complication of chronic kidney disease (CKD). Etelcalcetide is the first intravenous calcimimetic authorized for the treatment of SHPT in haemodialysis (HD). It has proven to be effective in lowering parathyroid hormone (PTH), with an acceptable and comparable safety profile. The aim of this descriptive study was to evaluate the results of using etelcalcetide in patients on HD with SHPT. Method Thirty patients on HD received etelcalcetide were enrolled (figure 1). The minimum observation period was 6 months. Fifteen (50%) were previously with cinacalcet (group 1) and 15 (50%) received etelcalcetide at onset (group 2). We analyzed change of serum iPTH, calcium (Ca) and phosphorus (P) in both cohorts; as well as the dosage of calcium carbonate, non-calcium (phosphate binders) and / or vitamin D analogs. The presence of adverse effects were also recorded. Results Thirty patients on HD received etelcalcetide were enrolled (figure 1). The minimum observation period was 6 months. Fifteen (50%) were previously with cinacalcet (group 1) and 15 (50%) received etelcalcetide at onset (group 2). We analyzed change of serum iPTH, calcium (Ca) and phosphorus (P) in both cohorts; as well as the dosage of calcium carbonate, non-calcium (phosphate binders) and / or vitamin D analogs. The presence of adverse effects were also recorded. In global, serum iPTH levels were significantly decreased during therapy compared to baseline levels. When comparing both groups, we found a significant decrease of Ca, P and iPTH in group 2. However, we only found significant decrease of Ca in group 1 (figure 2). When we analyzed the reducton of PTH &gt;30% in both groups, we observed that 46.6% of patients treated with etecalcetide compared to 33.3% of patients treated with cinacalcet, achieved this reduction in PTH. The dosage of calcium binders (33.3% pretreatment vs 56.7% at the end of follow-up, p 0.054), non-calcium binders (40% pretreatment vs 63.3% at the end of follow-up, p 0.02) and vitamin D analogues (56,7% pretreatment vs 66,7% at the end of follow-up, p 0,3) were increased when etelcalcetide treatment was started. No changes were made in dialysate calcium concentration. Six patients, presented hypocalcemia (Ca &lt; 7.5 mEq/l). Conclusion In our cohort, etelcalcetide has shown to be effective in reducing serum iPTH. In addition, etecalcetide was noninferior to cinacalcet reducing PTH&gt;30%. An increase in the use of vitamin D analogues, calcium binders and non-calcium binders has been observed, probably due to the hypocalcemia.

Anemia and Iron Deficiency in Children with Chronic Kidney Disease (CKD): Data from the Know-Ped CKD Study

Children with chronic kidney disease (CKD) are at high risk of anemia, an important risk factor for cardiovascular disease and poor quality of life. The present study used baseline data from the Korean cohort study for Outcome in patients With Pediatric Chronic Kidney Disease (KNOW-PedCKD). A Total of 437 patients was included in the analyses excluding missing data. The characteristics of patients with and without anemia and those of patients with and without iron deficiency were compared. Logistic regression analysis and Pearson correlation were conducted to evaluate associated risk factors and correlations in children with CKD. Anemia in children with CKD was associated with older age, low body weight and body mass index (BMI) z-score, birth age, preceding glomerulonephritis, decreased estimated glomerular filtration rate (eGFR), low levels of serum albumin and calcium, high levels of serum intact parathyroid hormone (iPTH), and serum phosphorus. Anemia was correlated positively with changes in the BMI z-score, body weight, and serum albumin and cholesterol levels, but correlated negatively with serum calcium, iPTH, ferritin levels, and transferrin saturation. Iron deficiency in children with CKD was associated with young age, low hemoglobin and serum ferritin levels, high BMI z-scores, and low levels of serum iPTH. This is the first nationwide cohort study of anemia in Korean children with CKD and the first prospective pediatric CKD cohort study in Asia. The study results demonstrated that anemia and iron deficiency are affected by various factors, including age, BMI, and levels of serum iPTH. To improve the retrospective outcome of affected children, it is important to understand the effect of each of these factors and to attempt an early intervention to prevent anemia and iron deficiency by regular measurement of these parameters in children at risk.

Vitamin D and bone mineral density status among postmenopausal Bangladeshi women

Background and objectives: Low vitamin D is a global problem in all age groups as is osteoporosis in postmenopausal women. The present study was carried out in an urban hospital to assess serum 25-hydroxyvitamin D [25(OH)D] level and bone mineral density (BMD) in postmenopausal women (PMW) and to evaluate correlation between serum 25(OH)D levels and BMD. Methods: A single center cross-sectional study was conducted among 133 apparently healthy PMW aged 45 years and above with the history of complete cessation of menstruation over a period of more than 1 year. Serum 25(OH)D, BMD and serum intact parathyroid hormone (iPTH) were determined. Patients having both vitamin D and BMD values were analyzed for correlations. Similarly, correlation of vitamin D, iPTH and BMD were determined. Results: Among the study population, 63 (47.4%) had deficient (<20 ng/ml), 46 (34.6%) had insufficient (20-30ng/ml) and 24(18%) had sufficient (30-100ng/ml) levels of serum 25(OH)D. Among the 121 patients whose BMD was done, 52 (43.0%) and 60 (49.6%) had osteoporosis and osteopenia respectively. Serum iPTH levels were normal in 34 (89.5%) patients. The proportion of osteopenia and osteoporosis in vitamin D deficient group were 44.1% and 50.8% and in insufficient group 47.5 and 45.0%, respectively. Age had significant negative correlation with BMD value (r=-0.246, p=.005) and significant positive correlation with serum iPTH (r=0.358, p=.024). There was no statistically significant influence of serum 25(OH)D or iPTH on occurrence of osteoporosis (P=0.322 and P=0.592 respectively). Conclusion: A large proportion of postmenopausal women had low vitamin D levels and as well as osteopenia and osteoporosis. Low vitamin D level coexisted with low BMD. However, there was no correlation between serum 25(OH)D levels and BMD status. IMC J Med Sci 2018; 12(2): 44-49