Impact of 25-Hydroxyvitamin D Deficiency on Perioperative Parathyroid Hormone Kinetics and Results in Patients with Primary Hyperparathyroidism

Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
Surgery (Impact Factor: 3.38). 12/2007; 142(6):1022-6. DOI: 10.1016/j.surg.2007.09.026
Source: PubMed


Successful parathyroidectomy for sporadic primary hyperparathyroidism (pHPT) is predicted by a 50% drop in PTH intra-operatively. Vitamin D is a known inhibitor of PTH secretion and is associated with secondary HPT following adenoma resection. This study examined the impact of 25-hydroxyvitamin D (25OHD) deficiency on perioperative PTH kinetics and outcomes following parathyroidectomy.
Patients undergoing adenoma resection for pHPT (n=93) had PTH levels recorded at six perioperative time points. Preoperative 25OHD levels were examined retrospectively. Patients were considered 25OHD deficient if the level was <25 ng/mL (n=47) and adequate if the level was >or=25 ng/mL (n=46).
Patients with 25OHD-deficiency had significantly higher preoperative calcium, alkaline phosphatase, and PTH levels. PTH levels were significantly higher in 25OHD-deficient patients at incision, at 1 week postop and 1-3 months postop. Average drop in PTH level five minutes post resection was 79+/-14% in the deficient group and 72+/-22% in the non-deficient group (P=.03). 25OHD levels inversely correlated with adenoma weight (P=.03) and postoperative PTH measurements (P=.008).
Sporadic pHPT patients with 25OHD deficiency have higher baseline and postoperative PTH levels compared to non-deficient patients but do not have altered intraoperative PTH kinetics. Vitamin D deficiency is associated with postoperative elevation of PTH.

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    • "Although age and 25OHD3 would seem interrelated as the latter tends to decrease with age, our data seemed to support the hypothesis that preexisting vitamin D deficiency is a possible cause of postoperative ePTH. This is consistent with previous studies.7,13,19,20 The implication is that perhaps patients with advanced age or with low preoperative 25OHD3 may benefit from a course of vitamin D supplementation after surgery. "
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    ABSTRACT: Patients with eucalcemic parathyroid hormone elevation (ePTH) after parathyroidectomy for primary hyperparathyroidism (HPT) may be at risk of recurrence. We aimed to examine risk factors, trend of PTH level, and outcome of patients with ePTH 6 months after parathyroidectomy. A total of 161 primary HPT were analyzed. The 6-month postoperative calcium and PTH levels were obtained. ePTH was defined as an elevated PTH level in the presence of normocalcemia. At 6 months, 98 had eucalcemic normal PTH and 63 (39.1%) had ePTH. Perioperative variables, PTH trend, and outcome were compared between 2 groups. Multivariable analyses were performed to identify independent preoperative and operative/postoperative risk factors for ePTH. Among preoperative factors, advanced age (odds ratio [OR] = 1.042, P = .027) and low 25-hydroxyvitamin D(3) (25OHD(3)) (OR = 1.043, P = .009) were independently associated with ePTH, whereas among operative/postoperative factors, high 10-min intraoperative PTH level (OR = 1.015, P = .040) and high postoperative 3-month PTH (OR = 1.048, P < .001) were independently associated with ePTH. After a mean follow-up of 38.7 months, recurrence rate was similar between the 2 groups (P = 1.00). In the first 2 postoperative years, 75 (46.6%) had ePTH on at least 1 occasion and 8 (5.0%) had persistently ePTH on every occasion. Advanced age, low 25OHD(3), high 10-min intraoperative PTH, and high postoperative 3-month PTH were independently associated with ePTH at 6-month. Although 39.1% of patients had ePTH at 6 months, more than 50% had at least 1 ePTH within the first 2 years of follow-up. Recurrence appeared similar between those with or without ePTH at 6 months.
    Full-text · Article · Jul 2011 · Annals of Surgical Oncology
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    • "Location and Year N Mean Vitamin D Low Vitamin D Group Results of Low Preoperative Vitamin D 1999 Silverberg SJ [46] New York, US 124 52 nmol/l (21 ng/ml) < 40 nmol/l, N=41 (33%) PTH, AP P 2000 Rao DS [55] Detroit, US 1992-1997 148 47 nmol/l (18.8 ng/ml) < 37.5 nmol/l, N=51 (33%) PTH, Ca, AP and adenoma weight P 2002 Yamashita H [54] Japan 1998-2000 72 36.5 nmol/l (14.6 ng/ml) < 25 nmol/l, N=23 (32%) Age but no other differences 2005 Moosgaard B [11] Aarhus, Denmark 1994-2003 289 33 nmol/l (13 ng/ml) < 50 nmol/l, N=234 (81%) PTH, Ca and AP BMD of the femoral neck and forearm 2005 Stewart ZA [53] Baltimore, US 1998-2004 191 60 nmol/l (23.9 ng/ml) < 62.5 nmol/l, N=74 (65%) PTH and adenoma weight 2006 Boubou P [16] Paris, France 72 22.5 nmol/l (9.0 ng/ml) < 50 nmol/l, N=67 (93%) PTH and Ca 2006 Özbey N [52] Istanbul, Turkey 2000-2004 80 57 nmol/l (23 ng/ml) < 37.5 nmol/l, N=44 (55%) PTH, post-op PTH, AP, adenoma weight and U-Ca 2007 Beyer TD [51] Chicago, US 2003-2006 110 56 nmol/l (22.4 ng/ml) < 50 nmol/l, N=55 (50%) PTH, Ca, AP, adenoma size and weight 2007 Untch BR [50] Durham, US 2005-2007 93 Data not available < 62.5 nmol/l, N=47 (50%) PTH, post-op PTH, Ca, AP, and adenoma weight (p=0.08) 2008 Kandil E [48] Baltimore, US 2002-2006 421 52 nmol/l (21 ng/ml) < 62.5 nmol/l, N=233 (61%) PTH, adenoma weight, AP, Ca and more SestaMIBI findings 2008 Priya G [49] New Delhi, India 2004-2006 36 25.5 nmol/l (10.2 ng/ml) < 25 nmol/l, N=20 (56%) post-op PTH and BMI post-op Ca 2010 Lang BH [47] Hong Kong 2006-2008 80 48 nmol/l (19 ng/ml) < 50 nmol/l, N=45 (56%) PTH post-op Ca (24 hours) VITAMIN D TREATMENT IN PHPT "
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    ABSTRACT: Primary hyperparathyroidism (PHPT) and vitamin D insufficiency are two very frequent conditions. In cases where the combination of both vitamin D insufficiency and PHPT is diagnosed, vitamin D repletion is an option. However, only limited evidence exists for this treatment. The aim of this review is to describe different aspects of concomitant vitamin D insufficiency and PHPT and in this setting to evaluate existing evidence on safety and possible outcome of vitamin D treatment. Background literature was found based on a search in and Multiple association studies support the hypothesis that the clinical presentation of PHPT is more severe in patients with vitamin D insufficiency. Treatment with vitamin D in PHPT may decrease PTH levels and bone turnover and potentially increase bone mass in various compartments. However, some patients experience increasing plasma or urine levels of calcium, triggering either vitamin D withdrawal or surgery. Measurement of vitamin D in PHPT is important to fully assess the disorder. The causality of the frequent coexistence of vitamin D insufficiency and PHPT is not fully understood. Vitamin D treatment is recommended and may decrease PTH levels in PHPT. However, there is no randomized controlled trial to prove any beneficial effect. For safety reasons, it is recommended to monitor plasma and urinary calcium during treatment. Furthermore, the effect of vitamin D repletion on other outcomes like quality of life, muscle function and CNS symptoms should be assessed.
    Full-text · Article · Apr 2011

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