Risk factors for secondary hyperparathyroidism in a nursing home population

Stein, Mark S.; Scherer, Samuel; Walton, Sarah L.; Gilbert, Richard E.; Ebeling, Peter R.; Flicker, Leon; Wark, John D.

doi:10.1046/j.1365-2265.1996.701521.x

Cited by 88 publications

(52 citation statements)

References 32 publications

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“…This observation suggested that excessive urinary calcium losses in CKD patients, who are prone to tenuous calcium balance because of relative calcitriol deficiency, may promote intermittent reductions in serum calcium with resulting spikes in PTH, which eventually manifest clinically as secondary hyperparathyroidism. This hypothesis is supported by studies in the general population and CKD that showed that excessive calciuria driven by loop diuretics was associated with elevated PTH (7)(8)(9)(10)(11).…”

Section: Introductionsupporting

confidence: 67%

Daily Variability in Mineral Metabolites in CKD and Effects of Dietary Calcium and Calcitriol

Isakova

Xie

Barchi-Chung

et al. 2012

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Primary prevention of disordered mineral metabolism in CKD necessitates knowledge of its early pathophysiology. This study evaluated daily fluctuations in mineral metabolites in patients with CKD stages 3 and 4 before and after short-term calcitriol treatment and tested the effects of dietary calcium and calcitriol supplementation on these parameters in the dynamic postprandial setting.Design, setting, participants, & measurements Twelve CKD patients received calcitriol (0.25 mg daily for 1 week) with hourly assessments of mineral metabolites made throughout the day and in the context of standardized meals before and after treatment. Calcium content (250 versus 500 mg) in the breakfasts constituted the dietary calcium intervention. Twelve healthy volunteers were used as controls.Results At baseline, compared with controls, fasting CKD subjects had higher parathyroid hormone and fibroblast growth factor 23 levels and greater fractional excretion of phosphate. After breakfast, urinary calcium excretion increased and parathyroid hormone levels dipped transiently in both groups, but they rose soon thereafter, reaching higher peaks in CKD. Calcitriol decreased fasting parathyroid hormone levels, and when combined with dietary calcium load, it normalized the postprandial parathyroid and calcemic responses. Daily variability in mineral metabolites was preserved in CKD before and after calcitriol. Fibroblast growth factor 23 levels increased after calcitriol, although the response was heterogeneous.Conclusions Short-term treatment with calcitriol and dietary calcium supplementation normalizes the parathyroid and calcemic postprandial responses in patients with CKD, in whom the diurnal rhythms of mineral metabolites are preserved. Future studies should investigate the variable fibroblast growth factor 23 response to calcitriol in CKD.

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Section: Introductionsupporting

confidence: 67%

Daily Variability in Mineral Metabolites in CKD and Effects of Dietary Calcium and Calcitriol

Isakova

Xie

Barchi-Chung

et al. 2012

Clinical Journal of the American Society of Nephrology

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“…Following MV supplementation, serum 25(OH)D concentrations increased by a mean of 27 nmol l À1 (77%), and reduced the rate of serum 25(OH)D deficiencies (p50 nmol l À1 ) from 77 to 23%, with no subjects having an insufficient level (p25 nmol l À1 ). In Australia, the number of aged care residents with low 25(OH)D levels is high, with estimates ranging between 22 and 74% (Stein et al, 1996;Flicker et al, 2003;. Only one previous study in community dwelling elderly assessed 25(OH)D concentrations following 8 weeks of MV supplementation, which found an increase in serum 25(OH)D of 30%, reducing the rates of serum 25(OH)D levels o37.5 nmol l À1 from 7 to 0% (McKay et al, 2000b).…”

Section: Discussionmentioning

confidence: 99%

Multivitamin supplementation improves nutritional status and bone quality in aged care residents

et al. 2007

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Objectives: To assess the effectiveness of a multivitamin (MV) tablet on nutritional status, quantitative heel ultrasound (QUS), mobility, muscle strength and falls. The design comprised two groups matched on mobility levels, randomized to receive a daily MV or placebo (P) tablet for 6 months. The setting was an Australian residential care facility. Subjects: A total of 92 aged care residents. Serum micronutrients, body weight, QUS, rate of falls, hand grip strength, and the timed up and go test were assessed at baseline and 6 months. Results: A total of 49 participants consumed a MV and 43, a matched P for 6 months. There was a greater increase in the MV vs P group for serum 25(OH)D (mean difference ± standard error, 33.4 ± 2.6 nmol l À1 ), folate (13.4 ± 2.8 nmol l À1 ), and vitamin B12 (178.0±40.3 pmol l À1 ) (all Po0.001). Adequate 25(OH)D concentrations (X50 nmol l À1 ) were found among 77% of participants in the MV group vs 10% taking P (Po0.001). Adjusting for baseline levels, the increase in QUS was greater in the MV vs P group (3.0±2.0 dB MHz À1 vs À2.9±2.1 dB MHz À1 , respectively, P ¼ 0.041). There was a trend towards a 63% lower mean number of falls in the MV vs P group (0.3 ± 0.1 falls vs 0.8 ± 0.3 falls, P ¼ 0.078). Conclusions: MV supplementation raised serum vitamin B12 and folate concentrations and increased serum 25(OH)D, which was accompanied by an apparent positive effect on bone density. We also found a trend towards a reduction in falls and this could contribute to a reduction in fractures.

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“…Before the diagnosis of normocalcemic PHPT can be established, it will be highly important to rule out carefully any other potential causes of high PTH as outlined (9). This includes any chronic disease associated with malabsorption such as cystic fibrosis (13) or celiac disease (14), both conditions often being associated with vitamin D deficiency endocrinopathies such as hypothyroidism (15), renal hypercalciuria (16), chronic renal failure (the definition of which must be more clearly defined in terms of GFR), very low daily calcium intake, use of drugs having an influence on calcium metabolism such as anticonvulsants (17), furosemide (18), lithium (19), or bisphosphonates (20), and vitamin D insufficiency. Concerning this last condition, it is now consensual that serum 25OHD is the correct functional indicator of vitamin D status (21).…”

Section: Discussionmentioning

confidence: 99%

The Use in Clinical Practice of Parathyroid Hormone Normative Values Established in Vitamin D-Sufficient Subjects

Souberbielle¹,

Lawson-Body²,

Hammadi³

et al. 2003

The Journal of Clinical Endocrinology & Metabolism

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We have found recently that excluding subjects with low serum 25OHD has a significant impact on the PTH reference range (10 -46 ng/liter instead of 10 -65 ng/liter with the same assay). However, before being used routinely, this new range had to be clinically validated. We thus reviewed the chart of 708 consecutive osteopenic patients who were referred to our unit for a biological exploration in search of secondary causes for their low bone mass. They were classified into two groups. Group 1 (n ‫؍‬ 360) included the patients for whom no reasons for high PTH were found after examination of their chart. Group 2 (n ‫؍‬ 348) included patients with one of the following potential reasons for an increased PTH concentration: hyperor hypocalcemia, normocalcemic primary hyperparathyroidism (PHPT), renal hypercalciuria, vitamin D insufficiency, chronic renal failure, use of bisphosphonates, and any chronic disease known to potentially alter calcium metabolism. Among the 360 group 1 patients, 15 (4.2%) had a serum PTH level more than 46 ng/liter, which is not different from the theoretical rate of 3% of normal subjects whose serum PTH may be above the 97th centile of the reference ( 2 ‫؍‬ 2.8; NS). Forty-two group 2 patients had a surgically proven PHPT. Among these, serum PTH was <65 ng/liter in 17 (40.5%) and tion that still remains undetected in many patients. It induces mild secondary hyperparathyroidism with a subsequent increase in bone turnover and, at least in the elderly, an enhanced risk of osteoporotic fracture, mainly at cortical sites (1). It could be defined by the serum concentration of 25OHD below which serum PTH starts to increase in a population (2). We recently proposed to include only normal subjects without low serum 25OHD concentration to establish a reference range for serum PTH (3). By doing this in healthy subjects aged 60 -79 yr, we found with a widely used PTH assay that the highest normal concentration at P Ͻ 0.05 (46 ng/liter) was consistently lower than what is generally accepted with the same assay (65 ng/liter) (4). However, before being used routinely, this new reference range had to be clinically validated. This is the goal we aimed to achieve in the present study by showing that our proposed PTH reference range induced a decrease in the number of false negative values [i.e. less normal serum PTH levels in surgically proven primary hyperparathyroidism (PHPT)] without an increase in the rate of false positive values (i.e. no more than 3% of high values in normocalcemic patients without any potential reason to have an increased serum PTH concentration). Patients and Methods PatientsWe reviewed the medical chart of 708 consecutive osteopenic/porotic patients (74 premenopausal women, 552 menopausal women and 82 men) aged 59.2 Ϯ 13.4 yr. They were referred to our bone/calcium metabolism unit over a 1-yr period (from July 17, 2000, to July 16, 2001 by their primary care physician in search of secondary causes for their low bone mass. The patients came on a single morning to our unit after an over...

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Risk factors for secondary hyperparathyroidism in a nursing home population

Abstract: Vitamin D deficiency is a common risk factor for secondary hyperparathyroidism in nursing home residents despite a climate in which vitamin D nutrition is thought to be ample. However, the daily frusemide dose is a more important predictor of PTH in this population.

Cited by 88 publications

References 32 publications

Daily Variability in Mineral Metabolites in CKD and Effects of Dietary Calcium and Calcitriol

Daily Variability in Mineral Metabolites in CKD and Effects of Dietary Calcium and Calcitriol

Multivitamin supplementation improves nutritional status and bone quality in aged care residents

The Use in Clinical Practice of Parathyroid Hormone Normative Values Established in Vitamin D-Sufficient Subjects

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