The effects of parathyroidectomy on nutritional and biochemical status of hemodialysis patients with severe secondary hyperparathyroidism

RESUMO Objetivo: avaliar o benefício de paratireoidectomia em pacientes submetidos à hemodiálise, em relação ao estado nutricional e bioquímico, composição corporal e a qualidade de vida. Métodos: estudo longitudinal envolvendo 28 adultos em programa de hemodiálise, com hiperparatireoidismo secundário grave, avaliados antes e um ano após a cirurgia. Critérios de inclusão: níveis de paratormônio dez vezes superior ao valor de referencia e doença renal crônica em programa de hemodiálise. O índice de massa corporal foi utilizado para classificação do estado nutricional. A bioimpedância elétrica para avaliação da composição corporal. A análise bioquímica incluiu dosagem de lipídios e marcadores do metabolismo ósseo. A qualidade de vida foi avaliada pelo questionário SF36 (Short Form Health Survey). Todos os pacientes foram submetidos à paratireoidectomia total com implante em antebraço. Resultados: houve ganho significativo de peso corporal (61,7 vs 66,0 kg; p<0,001), da massa celular corporal (22,0 vs 24,5 kg/m2; p=0,05) e da qualidade de vida (p=0,001) após a cirurgia. Com relação ao metabolismo ósseo, PTH intacto, cálcio, fósforo e fosfatase alcalina, se estabilizaram e houve melhora em parâmetros bioquímicos, tais como albumina e hemoglobina. Conclusão: a paratireoidectomia melhora a sobrevida em pacientes de hemodiálise e está associada a aumento de peso, ganho de massa óssea e melhoria na qualidade de vida.

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“…The data are in accordance with a recent study showing the importance of parathyroid resection in CKD patients with advanced disease 17 .…”

Section: Discussionsupporting

confidence: 93%

Paratireoidectomia na doença renal crônica: efeitos no ganho de peso e na melhora da qualidade de vida

Valente-Da-Silva

Maya

Moreira

2017

Rev. Col. Bras. Cir.

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“…The first one, a retrospective study, observed a weight gain of more than 5% in 53% of the hemodialysis patients during the first year after total parathyroidectomy. No changes in albumin or protein equivalent of nitrogen appearance had been found (9). The second study was a prospective one in which 34 patients were followed for 12 mo after parathyroidectomy.…”

Section: Discussionmentioning

confidence: 99%

“…Increased protein catabolism, therefore, might increase energy expenditure and adversely affect the nutritional status of patients with secondary HPT. Actually, improvement in one or more nutritional markers has been observed in patients with severe secondary HPT after parathyroidectomy (8,9). The resting energy expenditure (REE) of patients with CKD has been demonstrated to be lower (10,11), similar to (12,13), or greater than (14) that of healthy individuals.…”

mentioning

confidence: 99%

Increased Resting Energy Expenditure in Hemodialysis Patients with Severe Hyperparathyroidism

Cuppari

Carvalho²,

Avesani³

et al. 2004

Journal of the American Society of Nephrology

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Abstract. Several metabolic derangements, including enhanced protein catabolism, have been suggested to be associated with increased circulating parathyroid hormone (PTH) in patients with secondary hyperparathyroidism (HPT). Such conditions, therefore, might lead to an increase in energy expenditure. The present study examined by indirect calorimetry the resting energy expenditure (REE) of 15 hemodialysis patients who have severe HPT (PTH ϭ 1457 Ϯ 676 pg/ml) and were pair-matched for age and gender to 15 hemodialysis patients with mild to moderate HPT (PTH ϭ 247 Ϯ 196 pg/ml). Both groups were also pair-matched for age and gender to a group of 15 healthy adult subjects (control). In six patients from the severe HPT group submitted to total parathyroidectomy, REE was determined 6 mo after the surgery. The groups were not different regarding lean body mass (LBM) measured by bioelectric impedance, serum C-reactive protein, and bicarbonate. Thyroid-stimulating hormone was within the normal range in all groups. Nonadjusted REE was significantly higher in the severe HPT group (1674 Ϯ 337 kcal/d) compared with patients with mild to moderate HPT (1388 Ϯ 229 kcal/d; P Ͻ 0.05). Both groups did not differ from the control group (1468 Ϯ 323 kcal/d). When adjustment of REE for LBM was performed using the multiple regression analysis, patients with mild to moderate HPT and control subjects had significantly lower REE (Ϫ231 and Ϫ262 kcal, respectively) than that of the severe HPT group. Considering all patients together, nonadjusted REE correlated directly with LBM (r ϭ 0.61; P Ͻ 0.01). PTH correlated strongly with LBM in the severe HPT group (r ϭ Ϫ0.82; P Ͻ 0.01). In the multiple linear regression analysis, only LBM and PTH were independent determinants of REE (n ϭ 30; R 2 ϭ 0.47). REE decreased significantly in the six patients who were evaluated 6 mo after parathyroidectomy (from 1617 Ϯ 339 to 1226 Ϯ 253; P ϭ 0.02). These results demonstrate that hemodialysis patients with severe HPT have increased REE that might be reduced after parathyroidectomy.Reasonable evidence exists to support the notion that parathyroid hormone (PTH) is a uremic toxin (1). Indeed, in excess, the hormone can contribute to many of the cellular and metabolic abnormalities frequently observed in patients with chronic kidney disease (CKD) (2). Increased circulating PTH may cause wasting, weight loss, weakness, muscle atrophy, and negative nitrogen balance in patients with primary and secondary hyperparathyroidism (HPT) (3-5). These observations suggest that PTH may exert its effect by affecting protein metabolism and/or bioenergetics of skeletal muscle. In fact, a study has shown that PTH impairs energy production, transfer, and utilization of skeletal muscle (6). In addition, Garber (7) demonstrated in vitro that PTH enhances muscle proteolysis and increases the release of alanine and glutamine. Increased protein catabolism, therefore, might increase energy expenditure and adversely affect the nutritional status of patients with secondary HPT. Actually,...

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“…23 Nutrition parameters subsequently improved after PTX. 24 This raises the possibility of increased REE in the presence of HPT, which could have contributed to our patient's malnutrition.…”

Section: Protein/energy Requirementsmentioning

confidence: 87%

The Use of Parenteral Nutrition in a Severely Malnourished Hemodialysis Patient With Hypercalcemia

2005

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There is a high prevalence of protein-energy malnutrition (PEM) in chronic dialysis patients. Causes of PEM include the catabolic effects of hemodialysis treatments, acidemia associated with end-stage renal disease, common comorbid conditions, and uremia-induced anorexia. Morbidity and mortality increase with PEM. Before considering parenteral nutrition (PN) as a nutrition intervention in a maintenance dialysis patient, all other efforts to promote optimal nutrition need to be exhausted. The first step is careful evaluation of protein-energy status, followed by intensive nutrition counseling. If necessary, this is followed by oral nutrition supplementation, appetite stimulation, enteral tube feedings, and finally PN. Short-term parenteral nutrition (PN) became a crucial component of the management of a 38-year-old hemodialysis (HD) patient who endured serious complications after kidney transplant rejection. A profound and prolonged malnourished state followed her treatment for necrotizing pancreatitis. She had developed persistent hypercalcemia believed secondary to tertiary hyperparathyroidism (HPT) and immobilization. Later, she developed hungry bone syndrome (HBS) after parathyroidectomy (PTX). She also developed refeeding syndrome after initiation of PN. The patient's persistent, poorly understood hypercalcemia did not resolve even after PTX and removal of all other sources of vitamin D and calcium from her feedings, medications, and dialysis bath. The close communication of the inpatient and outpatient dialysis multidisciplinary teams became a key component to the successful outcome in this complex patient.

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The effects of parathyroidectomy on nutritional and biochemical status of hemodialysis patients with severe secondary hyperparathyroidism

Cited by 16 publications

References 18 publications

Paratireoidectomia na doença renal crônica: efeitos no ganho de peso e na melhora da qualidade de vida

Paratireoidectomia na doença renal crônica: efeitos no ganho de peso e na melhora da qualidade de vida

Increased Resting Energy Expenditure in Hemodialysis Patients with Severe Hyperparathyroidism

The Use of Parenteral Nutrition in a Severely Malnourished Hemodialysis Patient With Hypercalcemia

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