Parathyroid Hormone and Myocardial Performance in Dialysis Patients

Fellner, Susan K.; Lang, Roberto M.; Neumann, Alex; Bushinsky, David A.; Borow, Kenneth M.

doi:10.1016/s0272-6386(12)80090-4

Cited by 27 publications

(14 citation statements)

References 15 publications

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“…Secondary hyperparathyroidism is common in all stages of CKD [1], and elevations in PTH level have been associated with significantly higher mortality and morbidity in dialysis patients [2,3,4,5,6] and in patients with non-dialysis-dependent CKD [7], and with carotid intima-media thickness in kidney transplant recipients [25]. As the main physiologic role of PTH is the regulation of mineral homeostasis, its serum levels are widely used as a diagnostic marker of bone disease in patients with all stages of CKD, using the assumptions that abnormally elevated PTH levels reflect high turnover bone disease, abnormally low PTH levels represent low turnover or adynamic bone disease, and levels within the currently recommended target ranges reflect ideal bone turnover.…”

Section: Discussionmentioning

confidence: 99%

“…Secondary hyperparathyroidism is a common complication in chronic kidney disease (CKD) [1] and has been linked to higher cardiovascular morbidity [2,3] and mortality [4,5,6] in patients on maintenance hemodialysis and with higher mortality in patients with non-dialysis-dependent CKD [7]. Elevated parathyroid hormone (PTH) levels are utilized in clinical practice in the diagnosis of renal bone disease based on its association with histological bone abnormalities in CKD [8,9,10].…”

Section: Introductionmentioning

confidence: 99%

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Diagnostic Accuracy of Serum Parathyroid Hormone Levels in Kidney Transplant Recipients with Moderate-to-Advanced CKD

Kövesdy¹,

Molnar

Czira

et al. 2010

Nephron Clin Pract

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Background/Aims: Elevated parathyroid hormone (PTH) is used to diagnose high turnover bone disease in chronic kidney disease (CKD). The diagnostic accuracy of PTH in kidney transplant recipients with CKD is unknown. Methods: We examined kidney transplant recipients with CKD stages 3 (n = 498) and 4 (n = 141) to determine the sensitivity and specificity of the Kidney/Dialysis Outcome Quality Initiative (K/DOQI)-recommended PTH levels in detecting elevated serum β-CrossLaps (CTX) or osteocalcin (OC) levels. We performed receiver-operator curve analyses to determine CKD stage-specific PTH levels that provide optimal diagnostic accuracy. Results: PTH below the lower limits of the K/DOQI ranges (35 and 70 pg/ml in CKD stages 3 and 4, respectively) showed sensitivity of >90% in diagnosing increases in biochemical markers. The upper limits (70 and 110 pg/ml), however, showed poor specificity. A specificity of >90% for detecting increased biochemical markers was seen with PTH of >140 and >240 pg/ml in CKD stages 3 and 4, respectively. Conclusion: Currently applied cutoffs for PTH in kidney transplant recipients with CKD stages 3 and 4 do not appear to adequately detect increased biochemical markers of bone turnover. Diagnostic uncertainty exists in patients with CKD stage 3 and PTH between 35 and 140 pg/ml, and CKD stage 4 and PTH between 70 and 240 pg/ml.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Diagnostic Accuracy of Serum Parathyroid Hormone Levels in Kidney Transplant Recipients with Moderate-to-Advanced CKD

Kövesdy¹,

Molnar

Czira

et al. 2010

Nephron Clin Pract

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“…In a shortterm (15-wk) study, correction of SHPT with calcitriol was associated with a significant reduction in left ventricular mass and wall thickness (58). Several case reports highlight anecdotal improvements in left ventricular ejection fraction after subtotal parathyroidectomy in ESRD patients with severe SHPT (59), although other reports show no direct effect (60). We recently reported that PTH was directly related to the severity of aortic calcification by electron beam tomography (EBT) in 205 hemodialysis patients, although we failed to find a significant association between PTH and coronary artery calcification (61).…”

Section: Discussionmentioning

confidence: 99%

The Severity of Secondary Hyperparathyroidism in Chronic Renal Insufficiency is GFR-Dependent, Race-Dependent, and Associated with Cardiovascular Disease

Boer

Gorodetskaya

Young

et al. 2002

Journal of the American Society of Nephrology

164

112

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Abstract. Secondary hyperparathyroidism (SHPT) is an important complication of end-stage renal disease. However, SHPT begins during earlier stages of chronic renal insufficiency (CRI), and little is known about risk factors for SHPT in this population. This study evaluated 218 patients in an ethnically diverse ambulatory nephrology practice at the University of California San Francisco during calendar years 1999 and 2000. Demographic data, comorbid diseases, medications, and laboratory parameters were collected, and independent correlates of intact parathyroid hormone (PTH) were identified by using multiple linear regression. The mean estimated GFR was 34 ml/min per 1.73 m 2 (10%-90% range, 13 to 61 ml/min per 1.73 m 2 ); PTH was inversely related to GFR (P Ͻ 0.0001). The adjusted mean PTH was higher among African Americans and lower among Asian/Pacific Islanders compared with white patients (233 versus 95 versus 139 pg/ml; P Ͻ 0.0001). Moreover, among the 196 patients with GFR Ͻ60 ml/min per 1.73 m 2 , the slope of GFR versus PTH was significantly steeper among African Americans than among white patients (10.6 versus 3.9 pg/ml per ml per min per 1.73 m 2 ; P ϭ 0.01). After adjusting for age and diabetes, PTH was associated with a history of myocardial infarction (OR, 1.6; 95% CI, 1.1 to 2.3 per unit natural log PTH) and congestive heart failure (OR, 2.0; 95% CI, 1.3 to 2.9 per unit natural log PTH) and not associated with other co-morbid conditions. These factors should be considered when screening and managing SHPT in CRI.Secondary hyperparathyroidism (SHPT) is a common, important, and treatable complication of chronic renal insufficiency (CRI) and end-stage renal disease (ESRD). Although its exact pathogenesis is unknown, hyperphosphatemia, (1,2), hypocalcemia (3), deficiency of 1,25-dihydroxyvitamin D 3 (4), decreased expression of calcium and vitamin D receptors (5,6), and parathyroid hormone (PTH) resistance (7) may each play a part. Longstanding SHPT results in osteitis fibrosa cystica (a high turnover bone lesion) and increases the risks for bone pain and fracture. Osteitis fibrosa cystica (OFC) may be present in 30 to 50% of CRI patients before the initiation of dialysis (8 -12).The prevalence and severity of SHPT have been shown to increase with declining renal function in CRI (13-17). Drug therapy with 1,25-dihydroxyvitamin D 3 and calcium salts have been reported to retard the progression of SHPT (18,19), improve BMD (20), and reverse abnormal bone histology (19,21,22).In the dialysis population, the degree of SHPT varies widely, although higher PTH has been associated with African American race, female gender, younger age, and lack of diabetes mellitus (23,24), along with higher serum phosphorus and lower serum calcium concentrations. We hypothesized that, in CRI, the degree of SHPT would be correlated inversely with GFR and the serum concentrations of calcium and bicarbonate and directly with the use of loop diuretics.

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“…Elevated PTH is also associated with cardiomyopathy, and parathyroidectomy lowers BP (37) and improves left ventricular function (38), albeit not in every study (39). In the Chronic Renal Insufficiency Cohort, PTH is a major risk factor for elevated pulse pressure; however, PTH was not associated with patient outcomes (40).…”

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confidence: 99%

The Case for Routine Parathyroid Hormone Monitoring

Sprague

Moe

2013

Clinical Journal of the American Society of Nephrology

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SummaryParathyroid hormone (PTH) is a uremic toxin with multiple systemic effects including bone disorders (renal osteodystrophy), myopathy, neurologic abnormalities, anemia, pruritus, and cardiomyopathy. Hyperparathyroidism is common in CKD and results in significant morbidity and mortality if left untreated. Clinical practice guidelines from the Kidney Disease Improving Global Outcomes initiative broadened the optimal PTH range to >2 and <9 times the upper limit of normal for the assay measured. Furthermore, the guidelines recommend following trends in PTH to determine the appropriate therapy. These guidelines overcome issues with the assay variability and help clinicians make judgments when treating individual patients. They also require frequent measurement in order to determine trends and implement appropriate treatments.

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Parathyroid Hormone and Myocardial Performance in Dialysis Patients

Cited by 27 publications

References 15 publications

Diagnostic Accuracy of Serum Parathyroid Hormone Levels in Kidney Transplant Recipients with Moderate-to-Advanced CKD

Diagnostic Accuracy of Serum Parathyroid Hormone Levels in Kidney Transplant Recipients with Moderate-to-Advanced CKD

The Severity of Secondary Hyperparathyroidism in Chronic Renal Insufficiency is GFR-Dependent, Race-Dependent, and Associated with Cardiovascular Disease

The Case for Routine Parathyroid Hormone Monitoring

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