31.7.5 Frequency of Abnormal Parathyroid Hormone in Patients of Renal Failure Planned to Undergo Hemodialysis

Original Article

 

Abnormal Parathyroid Hormone in Patients of Renal Failure Undergo Hemodialysis

Frequency of Abnormal Parathyroid Hormone in Patients of Renal Failure Planned to Undergo Hemodialysis

Abdul Kareem Zarkoon, Habib Ullah Rind, Fazal Muhammad, Syed Mohkamuddin, Nadia Ifthekhar and Hamid Ali

ABSTRACT

Objective: To define the frequency distribution of abnormal parathyroid hormone in patients of renal failure planned to undergo hemodialysis, at a tertiary care center at Karachi

Study Design: Single center, cross sectional study

Place and Duration of Study: This study was conducted at the Department of Nephrology, Balochistan Institute of Nephro-Urology Quetta from April 2018 to March 2019.

Materials and Methods: There were 90 patients with diagnosis of CRF planned to undergo hemodialysis included. Before dialysis blood sample was obtained and sent to the laboratory of the hospital for assessment of PTH level. Then patients underwent haemodialysis. Dialysis was done as per hospital protocol. All the data was collected using the proforma.

Results: Patients` mean age was computed to be 53.79±6.51 years. Frequency of abnormal parathyroid was observed in 71.11% (64/90), in which hypoparathyroidism was 44.44% (40/90) and 26.67% (24/90) had hyperparathyroidism.

Conclusion: We found high frequency of abnormal parathyroid hormone in patients of renal failure planned to undergo hemodialysis.  Derangement of Parathyroid hormone is progressive and it prevalence is found in the patients with chronic kidney disease (CKD) and with serious outcomes for the health of patients. If it is poorly overcome, this imbalance can result in the bone disease, calcification of soft tissue and vascular calcification, all of these are found to be influential on mortality and morbidity.

Key Words: Chronic Kidney Disease, Hemodialysis, Hypoparathyroidism, Hyperparathyroidism.

Citation of article: Zarkoon AK, Rind HU, Muhammad F, Mohkamuddin S, Ifthekhar N, Ali H. Frequency of Abnormal Parathyroid Hormone in Patients of Renal Failure Planned to Undergo Hemodialysis. Med Forum 2020;31(7):20-24.

 

 

INTRODUCTION

Chronic Kidney Disease (CKD) is a commonly found its prevalence is more in population of elder patients (1). CKDis observed to an increasing extent and has been the global public issue. Although, lack of information is there on the side of its determinants, prevalence, and management from the countries having middle and low income(2).

Anstudy which is population based revealed that the rate of End Stage Renal Disease (ESRD) was counted to be 152 per population of million in South Asia (3).

 

 

Department of Nephrology, Balochistan Institute of Nephro-Urology Quetta.

 

 

Correspondence: Dr. Habib Ullah Rind, Assistant Professor of Nephrology, Balochistan Institute of Nephro-Urology Quetta/

Contact No: 0333-0282967

Email: habeebaloch@gmail.com

 

 

Received:    January, 2020

Accepted:    March, 2020

Printed:        July, 2020

 

 

 

 

 

 

 

 

In a cross-sectional investigation on 2873 members led in Karachi found that the general commonness (95% CI) of Chronic Kidney disease (CKD) was found to be 12.5% (11.4 – 13.8%) (2).

Hyperparathyroidism is one of the pathologic appearances of CKD which may prompt expanded danger of cardiovascular disease (CVD)(1). Hyperparathyroidism with hoisted serum parathyroid hormone (PTH) is related with expanded CV mortality in end Stage Renal Disease and this association is indistinct in moderate Chronic Kidney Disease
(CKD) (4).

Hyperparathyroidism, which is related with the hazardous complications, which can be developed in patients who are dependent on dialysis and having chronic Kdney Disease CKD(5). Early determination of auxiliary hyperparathyroidism is vital in the administration of patients with CKD(6).

It is known that renal failure has some negative impact on life of the patient and may cause some other problems in body. Through literature, it has come to know that due to CKD, parathyroid hormone level may derange which may lead to CVD, bone diseases, Chronic Resistant Anemia and in addition to that dialysis may exaggerate this disturbance. So we want to conduct this study to find the frequency of disturbed parathyroid hormone level in local population of CKD. So that abnormal PTH level can be detected on early stages and patients can be prevented from developing CVD diseases as well as bone destruction due to loss of calcium and vitamin D which is also manifested due to abnormal PTH level. This study will help in planning better management protocols for such delicate cases and can give them better quality of life.

MATERIALS AND METHODS

This single center, cross sectional study was carried out in Department of Nephrology,Balochistan Institute of Nephro-Urology Quettafrom April 2018 to March 2019.90patients fulfilling the inclusion criteria were incorporated in the study from OPD, admitted in ward of Department of Nephrology,Balochistan Institute of Nephro-Urology Quetta. Data was collected with the consensus of the patients which taken before the data collection by keeping in view the ethical consideration. Demographic information (name, age, gender, duration of CKD and dialysis) were also recorded. Then patients were undergone dialysis. Before dialysis blood sample was obtained and sent to the laboratory of the hospital for assessment of PTH level. Reports was assessed and abnormal PTH level was labeled (as per operational definition). Then patients undergo haemodialysis. Dialysis was done as per hospital protocol. All the data was collected using the proforma (attached).

Statistical analysis: Data analysis was conducted in statistical package for social sciences (SPSS) version 20.0.Mean and standard deviation of quantitative variables i.e. age and duration of CKD were calculated. Frequency distribution of qualitative variables i.e. gender and abnormal PTH level (hypothyroidism or hyperparathyroidism) was presented. Data was stratified for age, gender and duration of CRF. Chi square test was applied for post-stratification, with confidence interval of 95%.

RESULTS

There were 90 patients with diagnosis of CKD planned to undergo hemodialysis included.  Age distribution of the patients is shown in Graph-I.  The average age of the patients was 53.79±6.51 years similarly mean duration of CKD is also shown in table 8. Out of 90 cases, 52(57.78%) were male and 38(42.22%) female as shown in Table-I.

Frequency of abnormal parathyroid hormone in patients of renal failure planned to undergo hemodialysis was observed in 71.11% (64/90) cases as shown in Graph-2. It was also found that hypoparathyroidism was observed in 44.44% (40/90) cases and 26.67% (24/90) had hyperparathyroidism in patients of CKD undergoing hemodialysis as shown Table-2.

Stratification analysis was performed and observed that hypoparathyroidism was significantly high in above 50 years of age patients (p=0.005) while hyperpara-thyroidism was not statistical significant among different age groups as shown in Table-3. Rate of hypoparathyroidism was high in female as compare to male (p=0.028) while rate of hyperparathyroidism was significantly high in male than female (p=0.046) as shown in Table-4.

Graph No.1: Frequency distribution of Age (Years)

 

Graph No.2: Frequency of abnormal parathyroid hormone in patients of renal failure planned to undergo hemodialysis  n=90

Table No.1: Descriptive statistics of study patients n=90

Statistics

Age

(Years)

Duration of

CKD

(months)

PTH

 (pg/ml)

Mean

53.79

11.71

279.93

Std. Deviation

6.51

3.82

167.90

95% Confidence Interval for Mean

Lower Bound

52.42

10.91

244.77

Upper Bound

55.15

12.51

315.10

Median

53.00

12.00

246.00

Inter quartile Range

9

3

358

 

 

Table No.2: Frequency distribution of gender &Abnormal parathyroid hormone)(n=90)

 

Gender

Frequency

n=(100)

Percentage (%)

Male

52

57.78%

Female

38

42.22%

Total

90

100%

Abnormal parathyroid hormone

 

 

 

Yes

Hyperpara-thyroidism

24

%

Hypoparathy-roidism

40

%

No

26

28.89%

Total

90

100%

Table No.3: Abnormal parathyroid hormone (Hypoparathyroidism and Hyperparathyroidism) with  respect to age groups & gender

Abnormal PTH

Age Group (Years)

P-Value

41 to 50 Years

51 to 60 Years

61 to 70 Years

Hypopara-thyroidism

4(17.4%)

29(58%)

7(41.2%)

0.005

Hyperpara-thyroidism

6(26.1%)

12(24%)

6(35.3%)

0.65

Table No.4: Abnormal parathyroid hormone (Hypoparathyroidism and Hyperparathyroidism) with respect to gender

Abnormal PTH

Male

n=52

Female

n=38

P-Value

Hypopara-thyroidism

18(34.6%)

22(57.9%)

0.028

Hyperpara-thyroidism

18(34.6%)

6(15.8%)

0.046

DISCUSSION

Chronic kidney infection (CKD) is expanding being perceived as a noteworthy general medical issue internationally  7 . The antagonistic results related with CKD incorporating kidney failure, quickened cardiovascular ailment (CVD), and untimely mortality have more prominent societal and prudent effect in countries of low-and medium income 8 . South Asian nations are experiencing an epidemiological change with an expansion in hazard elements of CKD, and therefore representing a weight on health systems of wellbeing9. Besides, CKD is likewise known to advance quick in Asians contrasted with Western partners underscoring the requirement for anticipation through early recognition and risk factors` administration 10 . Unsettling influences in mineral digestion that are optional to chronic kidney disease (CKD, for example, hypocalcaemia, hyperphosphatemia and weakened union of 1,25-dihydroxyvitamin D3 (calcitriol), result in abundantsecretion of parathyroid hormone (PTH) which is a feature of secondary hyperparathyroidism (sHPT)  11,12 .As opposed to low levels of parathyroid organ multiplication and development in typical grown-ups, hyperparathyroidism optional to CKD is described by strangely expanded parathyroid cell expansion  13 . Expanded parathyroid cell multiplication has additionally been seen in patients with essential hyperparathyroidism with noticeable parathyroid hyperplasia  14  

Those patients who were having renal disease of last stage and chronic hemodialysis, Adequate consideration of PTH serum levels are somewhere in the range of 150 and 300 pg/ml. Four to eightfold rises of PTH are prescient for high-turnover bone disease and levels over this have strong association with Osteitisfibrosacystica (OFC)  15,16 .

In our study criteria. It was labeled as hypoparathyroidism if PTH levels < 100 pg/ml and hyperparathyroidism if PTH > 400 pg/ml. In our study out of 90 cases, 57.78% were males and 42.22% were females. This male predominance was also observed in a prospective, multicenter epidemiologic study conducted in the Ile-de-France district,  A total of 2775 adult patients were recorded, including 64% males and 36% females. 17

In NHANES, the conveyance of evaluated GFRs for the phases of CKD was found to be similar in both genders. In the United States Renal Data System (USRDS) 2011 Annual Data Report, nonetheless, the occurrence rate of ESRD cases at the commencement of hemodialysis year 2009 was found to be greaterinmale patients, with 415.1 for every million populationin comparison with 256.6 for female patients  18 . Patients having age from 40 to 70years of belonging to either gender with the analysis of CRF were incorporated, the mean age of the patients came out to be 53.79±6.51 years in our investigation. Chronic kidney disease (CKD) is basic in the patients who are elderly  19,20  driving some expert associations to suggest routine age-based examination for CKD in the essential care setting 21 ; Most past investigations of CKD and current proposals for its administration have not recognized patients of various ages, and endeavors to distinguish hazard factors for movement of CKD have for the most part centered around patient attributes other than age  22,23 .

Patients in the beginning periods of CKD don't generally demonstrate any difference in their serum calcium and phosphate levels, and their PTH levels might be just marginally higher than reference esteems. Recent literature have demonstratedan increased levels of FGF-23 in these patients, which may control serum levels of phosphate and calcium24 . Numerous patients who are having mild to moderate chronic kidney disease CKD additionally have diminished serum 1,25(OH)2 vitamin D and greater PTH levels25 and their bone biopsies indicate the proof of PTH abundance and excessive turnover of bone26.

In patients with end stage renal disease measurement of PTH is helpful in assessing parathyroid function, estimating bone turn over and improving management27. In our study, frequency of abnormal parathyroid hormone in patients of renal failure planned to undergo hemodialysis was observed in 71.11%. Hypo parathyroidism was observed in 44.44% cases and 26.67% had hyperparathyroidism. Previously it was reported elevation of PTH levels are common among patients with moderate CKD28. Our results are in contrast to Gallieni et al 29  study, hypoparathyroidism was observed in 43% cases and 25.4% had hyperparathyroidism in patients of CKD undergoing hemodialysis.7 One more study has also showed that there were 47% cases of CKD undergoing dialysis had hypoparathyroidism. 30

Hypoparathyroidism is occasionally seen in the dialysis population, of which the most common cause is parathyroidectomy for advanced SHPT. Diabetes mellitus is another potential cause of  hypoparathyroidism. High concentrations of glucose suppress PTH secretion in parathyroid cells in vitro  31 , and observational studies also show an association between poor glycemic control and lower intact PTH levels  32

Excessive synthesis and secretion of PTH leads inadequate hindrance of PTH interpretation, therefore, broadening of hyperplasia and parathyroid gland add to raised serum PTH  28 .

Hypoparathyroidism is sometimes found in the population of dialysis, of which the most widely recognized reason is parathyroidectomy for advanced SHPT. Diabetes mellitus is another strong reason for hypoparathyroidism. High convergences of glucose stifle PTH emission in parathyroid cells in vitro 31, and observational examinations additionally demonstrate a relationship between poor glycemic control and lower flawless PTH levels.32

CONCLUSION

Parathyroid hormone level usually deranged in patients of CKD, and dialysis may exaggerate this disturbance. We found high frequency of abnormal parathyroid hormone in patients of renal failure planned to undergo hemodialysis.  Derangement of Parathyroid hormone is progressive and it prevalence is found in the patients with chronic kidney disease (CKD) and with serious outcomes for the health of patients. If it is poorly overcome, this imbalance can result in the bone disease, calcification of soft tissue and vascular calcification, all of these are found to be influential on mortality and morbidity.

Author’s Contribution:

Concept & Design of Study:

Abdul Kareem Zarkoon

Drafting:

Habib Ullah Rind, Fazal Muhammad

Data Analysis:

Syed Mohkamuddin, Nadia Ifthekhar, Hamid Ali

Revisiting Critically:

Abdul Kareem Zarkoon, Habib Ullah Rind

Final Approval of version:

Abdul Kareem Zarkoon

Conflict of Interest: The study has no conflict of interest to declare by any author.

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