Primary Hyperparathyroidism: A Tale of Two Cities Revisited — New York and Shanghai

Abstract

In the 1970s, with the advent of biochemical multichannel screening in the United States and other western countries, the clinical presentation of primary hyperparathyroidism (PHPT) changed from a symptomatic to an asymptomatic disorder. However, in Asian countries, like China, PHPT did not show this evolution, but rather continued to be a symptomatic disease with target organ involvement. In this paper, we revisit the clinical features of PHPT in New York and Shanghai, representative United States and Chinese cites, over the past decade. The questions we address are whether the disease evolved in China to a more asymptomatic one and, whether in the United States further changes are evident. The results indicate that while PHPT continues to present primarily as an asymptomatic disease in the United States, a new phenotype characterized by normal serum calcium and high parathyroid hormone levels, normocalcemic PHPT, has emerged. Data from Shanghai demonstrates a trend for PHPT to present more commonly as an asymptomatic disorder in China. However, most patients with PHPT in China still manifest classical symptoms, i.e. nephrolithiasis and fractures. A comparison of the two cohorts shows that Chinese patients with PHPT are younger, with higher serum calcium and PTH levels, and lower 25-hydroxyvitamin D levels than patients in New York. Normocalcemic PHPT has not yet been recognized in Shanghai. In summary, although the phenotypes of PHPT in both cities are evolving towards less evident disease, sharp clinical and biochemical differences are still apparent in PHPT as expressed in China and the United States. Keywords: normocalcemic primay hyperparathyroidism; asymptomatic; symptomatic Bone Research (2013) 2: 162-169. doi: 10.4248/BR201302005 IntroductionIn countries that began to utilize the multichannel biochemical screening test in the 1970s, the presentation of primary hyperparathyroidism (PHPT) changed from a disease that was classically symptomatic with "stones, bones, moans and groans" to a contemporary asymptomatic disorder ( 1). While this clinical evolution was apparent in the United States and other Western countries, in Asian countries, such as India and China, In this paper, we review the more recent experience in two cities, Shanghai and New York, with the central question: has the clinical expression of PHPT changed in these countries over the past 10 years? MethodsThe cohort from Shanghai has recently been reported (4). These subjects form the basis for the description of the more recent experience in China. In the United States, an ongoing new cohort of subjects since 2010 form the basis of the New York experience, along with a published experience of subjects who present with normocalcemic PHPT (5-6). As opposed to asymptomatic cases, symptomatic PHPT refers to symptoms related with hypercalcemia, such as skeletal and renal diseases, neuromuscular, gastrointestinal, articular, hematologic, cardiovascular and central nervous system manifestations. Statistical analysesAll statistical analyses were pe...

Primary hyperparathyroidism

“…In the 35-year period between 1958 and 1993, 97% of PHPT in China was characterized by kidney stones, classic skeletal lesions (for example, osteitis fibrosa cystica, generalized skeletal demineralization and pathological fractures) and other features of symptomatic PHPT 16 . Recently, the clinical profile of 249 patients with PHPT who were diagnosed and treated from 2000 to 2010 in one clinical centre in China was compared to American patients 17,18 . Chinese patients were younger (51.3 years of age) than American patients (66.4 years of age) at diagnosis and were less likely to be women (female/male ratio of 2.07/1) than patients in New York City, USA (female/male ratio of 4.5/1).…”

Primary Hyperparathyroidism: A Single-Center Experience

“…19 In some regions of the world where PHPT is mostly symptomatic, reported rates of nephrolithiasis were as high as 55%. 20,21 The prevalence of osteoporosis in PHPT has varied in different studies between 39- 62.9%. 11,21,22 The prevalence of osteoporosis, nephrolithiasis, and hypercalciuria in our study was 45.3%, 21.7%, and 59.0%, respectively.…”

Clinical Presentation of Primary Hyperparathyroidism

“…15,16 Most cases occur in women (74%), but the incidence is similar in men and women younger than 45 years of age. 17 Recently II.…”

“…In a series of 70 patients with PHPT (33 normocalcemic and 37 with mild hypercalcemia), we found no statistically significant difference in the frequency of nephrolithiasis [ 29 In this decade, a total of 249 consecutive PHPT patients coming from 17 out of 31 provinces in China were recognized and treated in a single clinical center in Shanghai. As compared to patients from Western countries, 15,16 Chinese patients were younger 15 and less likely to be women (F:M 2.07:1 vs. approximately 3:1 in Western countries). Their serum calcium (11.7 ± 1.4 mmol/L), PTH 402 pg/mL [(range 103-2700), normal range 15-65 pg/mL], and creatinine levels were all significantly higher, while serum albumin and mean 25-hydroxyvitamin D (25OHD) concentrations (13 ng/mL; range 5.2-29.9) were much lower.…”