Increased Resting Energy Expenditure in Hemodialysis Patients with Severe Hyperparathyroidism

Abstract

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,...

A Patient with CKD and Poor Nutritional Status

“…Appropriate management of these disturbances, along with an emphasis on oral health, especially in the elderly, is critical to maintain optimal oral nutrient intake. Uncontrolled hyperparathyroidism and cardiac cachexia are associated with systemic inflammation and increased energy expenditure, so their appropriate management is also necessary to prevent PEW (43,44). Depressive symptoms, which are common in patients with CKD and ESRD and were quite evident in the illustrated case, are linked to fatigue, lack of appetite (45), and weight loss.…”

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

“…Reduced renal function leads to several adaptive changes involving serum levels of calcium, phosphorus, and regulatory hormones, such as parathyroid hormone (PTH) and 1,25-hydroxy-vitamin D 1 . Metabolic changes due to renal failure result not only in bone mineral disease with its effects on the skeleton generating pain, deformities and incapacity due to changes in remodeling and errors in bone mineralization, but they are associated with high mortality mainly due to cardiovascular disease [5][6][7] . Regarding bone mineral disease, secondary hyperparathyroidism (HPT) is characterized by elevated levels of PTH, usually greater than 800 pg/mL, associated with bone lesions, increased resting energy expenditure (REE) and worsening of quality of life 2,7 .…”

Estimativa das necessidades energéticas em pacientes com doença renal crônica

“…Ao compilar trabalhos que avaliaram o papel de comorbidades (diabetes Mellitus, hiperparatireoidismo secundário e condição inflamatória crônica) sobre o GER, observou-se que ele, nessas condições, encontrava-se aumentado em cerca de 12% a 23% 5,16,[21][22][23] . Vale mencionar ainda que o próprio procedimento de HD também é capaz de aumentar o gasto energético.…”

“…Monteon et al 13 Schneeweiss et al 14 Ikizler et al 15 Avesani et al 16 O´Sullivan et al 17 Ikizler et al 24 Cuppari et al 21 Wang et al 23 Avesani et al 18 Utaka et al 22 Kamimura et al 20 Kamimura et al 5 12 …”