Timely Evaluation and Management of Primary Hyperparathyroidism in Patients With Kidney Stones (original) (raw)
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Biochemical characterization of primary hyperparathyroidism with and without kidney stones
Urological Research, 2007
The exact metabolic-physiological background for kidney stone formation in primary hyperparathyroidism (PHPT) is unclear. To obtain clariWcation, this retrospective data analysis was conducted in 131 patients with PHPT who had undergone a detailed ambulatory evaluation on a random diet since 1980. The baseline biochemical presentation of 78 patients with PHPT with stones was compared with that of 53 patients without stones. Compared to those without stones, the stone-forming patients had a more marked hypercalciuria (343 § 148 vs. 273 § 148 mg/day, P < 0.01). Urinary saturation of calcium oxalate and brushite was signiWcantly higher in stone-formers. Serum PTH and fasting urinary calcium were similar between the two groups, but serum phosphorus was signiWcantly lower in stone-formers. Serum calcitriol (available in some patients) showed a slightly higher mean value in stone-formers but the diVerence was not signiWcant. The increment in urinary calcium after oral load of 1-g calcium was twofold higher among stone-formers. Radial shaft and L2-L4 bone mineral densities resided within the normal ranges. Stone-formers with PHPT display exaggerated urinary calcium excretion due to intestinal hyperabsorption of calcium, contributing to a greater enhancement of the saturation of stone-forming calcium salts.
Evaluation for Primary Hyperparathyroidism in Patients Who Present With Nephrolithiasis
Journal of Surgical Research
Background: The incidence of primary hyperparathyroidism (PHP) is likely underestimated. Nephrolithiasis may indicate PHP with indication for parathyroidectomy. We sought to determine the proportion of patients with an index diagnosis of nephrolithiasis that have serum calcium levels measured, parathyroid hormone (PTH) levels measured if hypercalcemic, and time to referral for definitive management if PHP is diagnosed. Methods: A single-institution retrospective review was performed of adult patients presenting with nephrolithiasis between July 1, 2016 and December 31, 2018. Exclusion criteria included currently admitted patients, prior nephrolithiasis, congenital or acquired urinary tract anomalies, and patients on calciuretics. Records were assessed for serum calcium and PTH measurement, as well as referrals. Univariate statistical analysis was performed. Results: Of 1782 patients with nephrolithiasis screened, 968 met inclusion criteria. Patients were 49.8% female, 88.9% white. Mean age was 53 y. Within this cohort, 620 (64.0%) patients had a calcium measured, with a mean elapsed time from presentation of 27 d (interquartile range [IQR] 0-8). Twelve patients (1.58%) with calcium measured were hypercalcemic and eight (66.7%) had PTH measured with a mean elapsed time from presentation of 183 d (IQR 72-310), all had elevated or non-suppressed PTH. Five (62.5%) were referred to surgeons with mean elapsed referral time of 270 d (IQR 95-492). Conclusions: Many with index nephrolithiasis are not assessed for hypercalcemia or hyperparathyroidism. Patients with serum calcium and PTH values indicating PHP diagnosis may have significant delay to parathyroidectomy. Targeted interventions with electronic health record alerts or automated reflex testing may improve care in this domain.
Surgery, 2012
Background. Hyperparathyroidism is associated with hypercalciuria and nephrolithiasis. Urine calcium excretion decreases after parathyroidectomy, but whether there is a differential decrease between stone and nonstone formers remains controversial. We evaluated differences between stone formers and non-stone formers in serum and urinary parameters before and after parathyroidectomy. Methods. 90 patients, 40 with and 50 without a history of nephrolithiasis underwent parathyroidectomy for hyperparathyroidism; 24-hour urine samples were collected before and after parathyroidectomy. Overall, 92% of patients provided samples before parathyroidectomy and 63% after parathyroidectomy. Preoperative, postoperative and changes in urinary parameters were evaluated. Results. Preoperative hypercalciuria was present in ;65% in both groups (P = .68). Parathyroidectomy decreased serum levels of calcium, parathyroid hormone, and urinary calcium, but there were no differences between stone formers and nonstone formers. Stone formers were 12-fold (P = .001) more likely to resolve an increase in supersaturation of calcium oxalate (SSCaOx), and after adjustment for age, sex, and BMI were 46-fold (P = .002) more likely to resolve an increase in SSCaOx. After parathyroidectomy, the rate of stone recurrence was 23% and male sex (aOR 20, P = .032) and increasing BMI (aOR 1.23, P = .038) were the only independent predictors of stone recurrence after adjusting for age. No other factor evaluated preoperatively, postoperatively, or the change after parathyroidectomy differentiated stone and nonstone formers or predicted stone recurrence. Conclusion. Metabolic evaluation did not differentiate stone formers from nonstone formers reliably. Stone formers were more likely to resolve an increase in SSCaOx after parathyroidectomy. Male sex and increasing BMI were independently associated with stone recurrence after parathyroidectomy. (Surgery
BJU International, 2009
To compare the clinical presentation, laboratory features and outcome of treatment in stone formers (SF) with primary hyperparathyroidism (HPT) to those without systemic disease. We compared 105 (54 female) stone-formers (SF) with primary hyperparathyroidism (HPT) to 2416 (835 female) common SF with no systemic disease, and 260 normal subjects (NS, 106 female) using pre-treatment and treatment data from our kidney-stone programme. All were assessed before treatment, with three 24-h urine samples, for stone risk factors, each with a corresponding fasting blood sample. Records were reviewed for stone rates and urological stone-related procedures. The hypercalcaemia of HPT was modest, but hypercalciuria was far more marked than in SF because the fractional calcium excretion of HPT exceeded that of SF. Surgical cure of HPT did not completely eradicate either hypercalciuria or hypophosphataemia, suggesting that these patients have some additional mineral disorder. Serum calcium and phosphate, and fractional excretion of calcium, combined into a discriminant function provided the best separation between HPT and SF. However, we present 49 patients for whom the diagnosis (HPT vs SF) has never been resolved, despite years of observation and successful reduction of stone recurrence. Stones in HPT have slightly more phosphate than SF but the difference is not large enough to be of clinical interest. The stone frequency in HPT is about that for SF, and treatment reduces stones in HPT and SF by about the same amount, 10 times. No study to date has compared HPT with SF and NS, as done here. SF with even slight hypercalcaemia and brisk hypercalciuria probably have this curable disease, and after cure clinicians must be wary of residual hypercalciuria that requires medical treatment. Some patients will never be fully diagnosed and remain, like ours, an enigma, albeit responsive to usual medical treatments. Although stones are modestly enriched with phosphate, most are mainly calcium oxalate, so the stone analysis is not clinically a guide to diagnosis.
Prevalence and Predictors of Primary Hyperparathyroidism Amongpatients with Urolithiasis
Endocrine Practice, 2017
Urolithiasis may be the only presenting manifestation of primary hyperparathyroidism (PHPT), and early detection of PHPT in such patients may prevent future urolithiasis and other PHPT complications. This study was performed to study the prevalence and predictors of PHPT in patients presenting with urolithiasis. Consecutive patients presenting with urolithiasis were evaluated for clinical and biochemical manifestations of PHPT with serum and urine calcium (Ca), serum intact parathyroid hormone and 25 (OH) vitamin D. We then compared the clinical and biochemical characteristics of PHPT patients presenting with urolithiasis (group A) and without (group B). During the 3-year study period, 381 patients with urolithiasis were seen with a mean age of 38.5 ± 13.9 years. Nineteen of the 381 (5%) patients had histologically proven PHPT (group A). Four patients in group A (21%) and 8 in group B (2%) had nephrocalcinosis (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.0001), multiple stones (≥3), calcific pancreatitis, and neuropsychiatric manifestations were more common in group A (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.0001). Presence of multiple or bilateral stones, and recurrent stone episodes predicted PHPT (odds ratio [OR]: 3.06, confidence interval [CI]: 0.87, 0.7). One out of every 20 patients with urolithiasis had PHPT, which is higher than the prevalence of PHPT in general population. The presence of nephrocalcinosis and multiple, bilateral, and recurrent stone disease increased the risk of PHPT among stone formers. Ca = calcium; CI = confidence interval; iPTH = intact parathyroid hormone; nPHPT = normocalcemic PHPT; OR = odds ratio; PHPT = primary hyperparathyroidism.
Primary hyperparathyroidism (PHPT) is a disease involving a broad range of alterations of calcium homeostasis, sustained by parathyroid hormone (PTH) levels that are clearly abnormal. The anomalies directly associated with hyperparathyroidism are nephrolithiasis and fibrocystic bone disease. Since PHPT resolves when abnormal parathyroid tissue is removed, surgery is clearly the only definitive approach to this type of hyperparathyroidism. However there are large subgroups of patients for whom medical therapy should be considered instead of surgery. Pharmacological therapy consists largely of biphosphonates, or calciomimetics such as cinacalcet. Recent preliminary data suggests however that cinacalcet could also be effective in the specific group of patients with primary hyperparathyroidism associated with nephrolithiasis. Finally, since cinacalcet reduces calcemia in most PHPT patients without improving bone mass, whereas biphosphonates and especially alendronate improve bone mass, it could make sense to combine the two drugs in PHPT patients with concomitant bone loss and possibly nephrolithiasis who cannot or do not wish to undergo surgery.
The Journal of Clinical Endocrinology & Metabolism
Context Primary hyperparathyroidism (PHPT) is associated with an increased risk of kidney stones. Few studies account for PHPT severity or stone risk when comparing stone events after parathyroidectomy vs nonoperative management. Objective Compare the incidence of kidney stone events in PHPT patients treated with parathyroidectomy vs nonoperative management. Design Longitudinal cohort study with propensity score inverse probability weighting and multivariable Cox proportional hazards regression. Setting Veterans Health Administration integrated health care system. Patients A total of 44 978 patients with > 2 years follow-up after PHPT diagnosis (2000-2018); 5244 patients (11.7%) were treated with parathyroidectomy. Main outcomes measure Clinically significant kidney stone event. Results The cohort had a mean age of 66.0 years, was 87.8% male, and 66.4% White. Patients treated with parathyroidectomy had higher mean serum calcium (11.2 vs 10.8mg/dL) and were more likely to have a h...
Giornale italiano di nefrologia : organo ufficiale della Societa italiana di nefrologia
Primary hyperparathyroidism (PHPT) is a disease involving a broad range of alterations of calcium homeostasis, sustained by parathyroid hormone (PTH) levels that are clearly abnormal. The anomalies directly associated with hyperparathyroidism are nephrolithiasis and fibrocystic bone disease. Since PHPT resolves when abnormal parathyroid tissue is removed, surgery is clearly the only definitive approach to this type of hyperparathyroidism. However there are large subgroups of patients for whom medical therapy should be considered instead of surgery. Pharmacological therapy consists largely of bisphosphonates, or calcimimetics such as cinacalcet. However, recent preliminary data suggests that cinacalcet could also be effective in the specific group of patients with primary hyperparathyroidism associated with nephrolithiasis. Finally, since cinacalcet reduces calcemia in most PHPT patients without improving bone mass, whereas bisphosphonates and especially alendronate improve bone mass...