Parathyroidectomy Improves Restless Leg Syndrome in Patients on Hemodialysis

Abstract

BackgroundRestless 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.Methodsthis 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.ResultsAt 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.ConclusionRLS 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.

The interfaces between vitamin D, sleep and pain

“…The risk factors for the decrease of vitamin D status in this study were ethnicity, obesity and age. In patients with hyperparathyroidism supplemented with vitamin D after parathyroidectomy, a decrease in RLS symptoms (from 56.2% to 21.0%) and pain relief were observed (Santos et al 2016). Although it resulted in an increase in serum 25OHD levels, there was no significant correlation between 25OHD levels and RLS severity.…”

Restless Leg Syndrome in the Setting of Patients With End-Stage Renal Disease on Hemodialysis: A Literature Review

“…Araujo, on the other hand, found that RLS patients had lower hemoglobin, albumin, and alkaline phosphatase levels [ 11 ]. Santos et al says that secondary hyperparathyroidism is associated with RLS exhibiting high phosphate and PTH [ 17 ]. Studies show that BMI is directly proportional to the association of uremic RLS due to the reduced number of dopamine receptors in obese patients' brains [ 15 ].…”

“…Most antidepressants worsen RLS symptoms, but studies show that bupropion does not exacerbate RLS symptoms and is the drug of choice to treat depression in uremic RLS [ 39 ]. Studies are yet to prove the beneficiary effect of parathyroidectomy in treating secondary hyperparathyroidism and high serum phosphate levels associated with uremic RLS [ 17 ].…”

Exploring sleep disorders in patients with chronic kidney disease

“…In addition, the patient also develops anemia due to various reasons including blood loss directly from the dialysis, frequent blood tests, and a decrease in the levels of erythropoietin. 99 – 102 Because iron is bound to hemoglobin, a decrease in the count of red blood cells leads to a decrease in hemoglobin levels thereby causing a decrease in the levels of iron. 100 Low levels of iron have been implicated as the primary cause of RLS and is directly linked to CKD and dialysis.…”

“… 94 , 95 One study suggests that parathyroidectomy as the treatment of hypercalcemia in primary hyperparathyroidism could be a feasible technique to effectively manage and resolve RLS. 102 Mortazavi et al provided data promoting aerobic exercise to manage RLS in patients with CKD on dialysis. 103 …”