RENAL DATA FROM THE ASIA - AFRICA
Year : 2008 | Volume
: 19 | Issue : 1 | Page : 116--119
Evaluation of Secondary Hyperparathyroidism in Patients undergoing Hemodialysis
Mohammad Rahimian, Ramin Sami, Fariba Behzad
Department of Medicine, Division of Nephrology, Shahid Rahnemoon Hospital, Yazd Medical University, Iran
Nephrology Ward, Yazd Medical University
Renal osteodystrophy is a complication of chronic kidney disease (CKD) that present in low and high turnover patterns. This disorder has a key role in the disability of CKD patients in whom early diagnosis and treatment can result in better outcome. We studied hyperparathyroidism prevalence and its relationship with renal osteodystrophy in our advanced CKD population. We included 80 patients (of whom 44 (55%) were diabetic) during 6 months period. The patients answered a questionnaire about symptoms related to bone disease and blood levels of parathormone (PTH), calcium, phosphorus, and alkaline phosphatase were obtained, in addition to hand and skull radiographs in all the study patients. Prevalence of clinically evident hyperparathyroidism in our patients was 45%. Hyperparathyroidism had significant relationship with alkaline phosphatase and radiological findings, but did not have a significant relationship with dialysis duration, age, sex, familial history, diabetes mellitus, or hypertension. We conclude that secondary hyperparathyroidism is prevalent in our dialysis population and has high correlation with serum alkaline phosphatase levels and radiological changes.
|How to cite this article:|
Rahimian M, Sami R, Behzad F. Evaluation of Secondary Hyperparathyroidism in Patients undergoing Hemodialysis.Saudi J Kidney Dis Transpl 2008;19:116-119
|How to cite this URL:|
Rahimian M, Sami R, Behzad F. Evaluation of Secondary Hyperparathyroidism in Patients undergoing Hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 Feb 17 ];19:116-119
Available from: http://www.sjkdt.org/text.asp?2008/19/1/116/37450
Renal osteodystrophy is one of the metabolic disorders that occur in chronic kidney disease (CKD) patients. Patients with mild to moderate CKD rarely have clinical evident bone disease, however, recent studies have revealed that histological changes may develop several years before presentation as clinically symptomatic disease.  Bone histopathological changes may include high or low turnover depending on over stimulated or over suppressed parathormone (PTH), respectively. Many CKD patients usually have a mixture of both patterns of the bone disease. 
In the 1980s, elevated PTH in CKD patients was introduced as the main the factor in osteodystrophy,  in addition to acidosis, calciteriol resistance and decreased synthesis of 1,25 dihydroxy Vitamin D 3 , and increased phosphorus blood levels.  New therapeutic methods were designed for prevention or controlling these causes.
Confirmation of diagnosis of renal osteodystrophy in CKD patients requires histological, histomorphological and histodynamic studies. Although bone biopsy is the gold standard for the diagnosis of osteodystrophy, some clinical and biochemical markers such as the PTH level, phosphorus and calcium levels, and alkaline phosphatase (ALP) may be considered in lieu of bone biopsy.
The aim of our study is to evaluate the prevalence of hyperparathyroidism and its correlation with the other laboratory parameters in our CKD patients undergoing hemodialysis.
Methods and Patients
This cross-sectional study included 80 CKD patients who were undergoing chronic hemodialysis (HD). One of patients was died and 4 patients weren't agreeing to include the study. We included in the study the demographic data of the patients, HD duration, and HD frequency.
Blood samples for evaluation of PTH (immunoassay method) Calcium, phosphorous, alkaline phosphatase (ALP) levels were obtained. Radiological studies of the hands and skull were evaluated by our radiologist for detection of osteodystrophy.
Data were analyzed with the aide of SPSS statistical software and appropriate statistical methods. P values ,,, tartarat resistance acid phosphatase, c-terminal telopeptide, collagen type I, and pyridinolin as bone reabsorption markers, in addition to alkaline phosphatase as marker osteoblasts' activity.
Correlation between PTH and ALP the levels to distinguish the patterns of renal osteodystrophy produced variable results. ,, Elevated PTH levels are prevalent in CKD patients. , They were prevalent in our study patient. Moreover, there were significant correlations between ALP blood levels and the radiological findings with the elevated PTH. In similar study from England, the patients with elevated PTH blood levels and ALP had histological changes in their bones biopsy characteristic of high turn over pattern.  The radiological changes were also observed in an Italian study in patients with elevated levels of ALP and PTH. 
In our study, we did not observe a significant correlation between HD frequency, diabetes mellitus, age and gender of patients, bone pain, or muscle weakness with hyperparathyroidism.
PTH resistance, high levels of phosphorus, low levels calcium, and deficiency of 1, 25 dihydroxi vitamin D 3 can cause high levels of PTH in CKD patients.  Three to 5 times higher than normal level is a reliable marker for high turnover bone pattern.  PTH level higher than 450 pg/ml correlates with 100% sensitivity and 95.5% specificity for patients with high turnover bone disease, while levels from 450 - - 650 pg/ml in HD patients (especially younger than 45 years old) correlated with 67.3%-87.1% positive predictive value.  However, several studies revealed variable results due to differences in the methodology of PTH measurements. , Some of differences in PTH measurements maybe due to secretion of two hormones from parathyroid gland; One of them stimulates bone turnover, while the other suppresses it. 
Finally, some dialysis related factors have been implicated in the pathology of bone and mineral disease in CKD patients. The type of dialyzer has a role in osteodystrophy; HD Patients dialyzed with cellulose membranes demonstrated more prevalence of hyperparathyroidism than those dialyzed with polyacrynitrile membranes.  In addition, low dialysate calcium level could decrease the prevalence of bone metabolism and soft tissue calcifications. 
We conclude that secondary hyperparathyroidism is prevalent in our dialysis population and has high correlation with serum alkaline phosphatase levels and radiological changes
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