The optimal surgical procedure for severe renal secondary hyperparathyroidism (sHPT) is still a point of controversy. Total parathyroidectomy (PTX) without auto-transplantation was abandoned for fear of an adynamic bone condition; however, in the case of autotransplantation recurrent sHPT is frequent and promotes atherosclerosis. We studied 11 hemodialysis patients (age 59±12 years) on dialysis for 18 (12–30) years in whom total PTX was performed due to severe sHPT (group I; intact PTH: 1,240±230 pg/ml), and 5 patients (age 55±10 years) without renal insufficiency who inadvertently received total PTX during thyroid surgery (group II). After total PTX (group I, 26±18 [9–59] months; group II, 252±188 [22^480] months) both groups showed no measurable intact PTH levels. Calcium homeostasis was maintained by oral substitution with calcium (group I, calcium dialysate of 2.0 mmol/l), vitamin D and calcitriol (serum parameters in groups I and II: calcium 2.4 and 2.2 mmol/l; phosphate 1.8 and 1.1 mmol/l; 25(OH)-vitamin D3 21 and 34 ng/ml; 1,25(OH)2-vitamin D3 32 and 41 pg/ml, respectively). In group I, after total PTX there was a rapid and sustained improvement in bone pain with markedly enhanced physical activity and endurance. High turnover osteopathy markedly improved as indicated by declining levels of native osteocalcin (90±17 vs. 26±18 ng/ml), bone alkaline phosphatase (74±12 vs. 12±6 ng/ml), and carboxyterminal cross-linked telopeptide of type-I collagen (65±16 vs. 40±21 ng/ml) but increasing levels of carboxyterminal propeptide of type-I procollagen (120±36 vs. 148±41 ng/ml). Recalcification of bone was excellent as demonstrated by X-ray and confirmed by bone histology. Itching extravascular calcific deposits and calcifications of blood vessel and cardiac valves immediately stopped after total PTX. Moreover, 6 sHPT patients suffered from severe atherosclerotic lesions such as thoracic aortic aneurysm (n = 3) or abdominal aortic aneurysm (n = 3) which showed size progression before but not after total PTX when annually controlled by ultrasonography. In group II, even long after total PTX, there was no clinical, radiological, histological or biochemical evidence for low turnover osteopathy. In conclusion, our data indicate that substitution with vitamin D3 metabolites and calcium can prevent deleterious bone effects of hypoparathyroidism in hemodialysis patients and in patients with normal kidney function and may compensate for the missing PTH action. Over this, a better survival rate is expected as a consequence of the beneficial effect of total PTX on the progression of atherosclerotic lesions. We suggest reconsideration of total PTX without autotransplantation in dialysis patients with severe sHPT who are not eligible for renal transplantation.
The therapeutical effect of keto acids on bone histology was investigated in a prospective randomized controlled study of 40 patients. A marked improvement in osteofibrotic as well as in osteomalacic changes was found in bone biopsies after 12 months of treatment with keto acids.
Twenty-six patients with advanced renal failure (glomerular filtration rate less than 6 ml/min) were treated with a mixed quality low protein diet and ketoacid analogues. An improvement in nitrogen balance, serum transferrin and phosphate, and base excess was observed after 2 weeks of treatment. In a longer term study, the result of 20 patients treated with ketoacids for up to 14 months were compared to a group 40 patients who received a low-protein diet with essential amino acids. Patients responded similarly to the two diets; however, the group receiving ketoacids had a significantly lower glomerular filtration rate. There was improvement in calcium and phosphate metabolism with ketoacid treatment. The patients were able to tolerate treatment with both the ketoacids and vitamin D.
In the present study the influence of a mixture of keto analogues/amino acids (KA) on PTH levels in 18 RDT patients was examined. Ten of them were treated with KA over a period of 3 months, while the other 8 patients served as control group. The KA-treated patients showed a significant fall in PTH and plasma phosphate levels, while no changes of plasma 25-OH-D or plasma calcitonin were observed. Consequently, KA administration may also be beneficial with respect to control of secondary hyperparathyroidism.
A case is reported of a successful pregnancy of a woman with advanced renal failure treated nutritionally. The importance of an intensive interdisciplinary medical coworking is stressed, and the individual adaptation of the dietary treatment to the special nutritional requirements in pregnancy is discussed.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.