Characteristics of patients surgically treated for primary hyperparathyroidism with and without urolithiasis

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Characteristics of patients surgically treated for primary hyperparathyroidism with and without

urolithiasis

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INTRODUCTION

• Urolithiasis is a common disease in the general population.

• Lifetime risk is approximately 3–5% in women and 10–15% in males, with an increased

incidence during the past two to three decades

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INTRODUCTION

• The etiology of urolithiasis is multifactorial, but hypercalcemia and hypercalciuria are known to be the primary risk factors for stones

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• Patients with primary hyperparathyroidism(PHPT) tend to have elevation of serum calcium level

and urine calcium level

• Primary hyperparathyroidism is a known risk

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• 2010, Wu et al: Prevalence assessed using imaging

techniques (Patients number:

3388)

=> Prevalence rate: 8%

PREVALENCE RATE

Adopt from “Nephrolithiasis and renal calcifications in Primary Hyperparathyroidism”

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PREVALENCE RATE – TEMPORAL TREND

y = -0.7657x + 1560.5 R² = 0.0668

10 20 30 40 50 60 70 80

Percentage(%)

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PURPOSE

• We hope to characterize the biochemical and

pathological features of patients with primary

hyperparathyroidism(PHPT) with and without

urolithiasis.

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MATERIAL AND METHOD

• Patients:

- 49 patients with hyperparathyroidism who underwent parathyroidectmomy were collected from 2002-2010.

- 14 patients were ESRD. (Secondary hyperparathyroidism) - 35 patients were included(PHPT patient)

• Subgroups:

I: Patients with urolithiasis and without urolithiasis before

parathyroidectomy

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• Demographics: Age, Body weight, Gender, Plasma Calcium, Plasma Phosphate, PTH, Plasma Creatinine and Pathology result.

• Operation: Routine bilateral cervical exploration performed. Pre-operative biopsy is not routine.

• Duration of follow-up: 1 year

• Stone recurrence: Patients who underwent

parathyroidectomy got urolithiasis within one year.

(KUB, Computed tomograpgy, Renal echo)

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RESULT

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RESULT

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RESULT

• There are no significant differences between

parahyperthyroism patients with urolithiasis and without urolithiasis before operation in Age,

Gender, Body weight, Renal function,

Plasma calcium, Plasma phosphatate,

PTH and Pathological type.

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RESULT

• The overall stone recurrence rate: 36 %

• Patients with stone recurrence after parathroidectomy have higher plasma calcium level than without stone recurrence (3.55 vs 2.94, p<0.05)

• No significant difference on pre-operative and post-operative group:

- Age

- Body weight - Plasma PTH, P

- Creatinine and estimated GFR - Pathological type

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-Studies on potential predictors for stone formation in patients with PHPT -Studies on potential predictors for stone recurrence after parathyroidectomy

DISCUSSION AND LITERATURE REVIEW

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AGE

• Wu et al. 2010: 3388 patients with PHPT, retrospective study (J Clin Endocrin Metab)

- Increase risk of nephrolithiasis: younger age - Hyperparathyroidism: younger age

predominant

• Odvina et al. 2007: 131 patients with PHPT, retrospective study (Uro Res)

- Increase risk of nephrolithiasis: younger age

Stone-former vs. Non-stone former(y/o): 49.8 vs. 53.8(p < 0.05)

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AGE

• Mollerup et al. 1999: 297 patients, prospective (World J Surgery)

- Increased risk of nephrolithiasis: younger age (50 y/o vs. 61 y/o, p< 0.00001)

• Soreide et al. 1996: 1038 patients undergoing initial cervical exploration for primary hyperparathyroidism (PHPT),

retrospective (Surgery)

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AGE

• No effect of age on risk of nephrolithiasis: - 2009 Berger et al: (J Urol.)

patient number: 60 patients with primary hyperparathyroidism - 2002 Frokjaer: patient number: 91 patients (World J Surgery) - NTUH: 35 patients with primary hyperparathyroidism

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GENDER

• Cooperberg et al. 2007: 339 patients undergoing surgery for PHPT(Int J Urol) - Nephrolithiasis was more common among men than women

(40% vs 15%, P < 0.001)

• Odvina et al. 2007: 131 patients with PHPT, retrospective study (Uro Res) - Nephrolithiasis was more common among men than women

(38% vs 23.2%, P < 0.05)

• Seroide et al. 1996: 1038 patients undergoing initial cervical exploration for primary hyperparathyroidism (pHPT), retrospective (Surgery)

- Nephrolithiasis was more common among men than women

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GENDER

• No effect of age on risk of nephrolithiasis:

- 2009 Berger: patient number: 60 patients with primary hyperparathyroidism (J Urol.)

- 2002 Frokjaer: patient number: 91 patients (World J Surgery) - 1999 Mollerup: 297 patients, prospective(World J Surgery) - NTUH: 35 patients with primary hyperparathyroidism

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PLASMA CALCIUM LEVEL

• Lower in stone former group:

• Mollerup et al. 1999: 297 patients, prospective

- Stone former vs non-stone former (2.90 vs 3.04, p< 0.001)

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PLASMA CALCIUM LEVEL

• No difference between stone former and non-stone former group:

- 2007 Odvina: 131 patients with PHPT, retrospective study (Uro Res)

- 2002 Frokjaer: patient number: 91 patients (World J Surgery) - 1996 Seroide: 1038 patients, retrospective(Surgery)

- 1990 Silverberg: 62 patients, retrospective(Am J Med) - NTUH: 35 patients with primary hyperparathyroidism

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PLASMA PHOSPHATE LEVEL

• Lower in stone former group:

- Seroide et al. 1996: 1038 patients, retrospective(Surgery) => plasma phosphate was lower in stone former group

Stone former vs. Non-stone former: 2.7 vs. 2.8 (p < 0.05)

- Odvina et al. 2007: 131 patients with PHPT, retrospective study (Uro Res) => plasma phosphate was lower in stone former group

Stone former vs. Non-stone former: 2.55 vs. 2.74 (p < 0.05)

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PLASMA PHOSPHATE LEVEL

- 2002 Frokjaer: patient number: 91 patients (World J Surgery) - 1999 Mollerup: 297 patients, prospective (World J Surgery) - 1990 Silverberg: 62 patients, retrospective(Am J Med)

- NTUH: 35 patients with primary hyperparathyroidism

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PLASMA PTH LEVEL

- 2007 Odvina: 131 patients with PHPT, retrospective study (Uro Res)

- 2002 Frokjaer: patient number: 91 patients (World J Surgery) - 1999 Mollerup: 297 patients, prospective (World J Surgery) - 1996 Seroide: 1038 patients, retrospective (Surgery)

- 1990 Silverberg: 62 patients, retrospective (Am J Med)

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SUMMARY: POTENTIAL PREDICTORS

Potential predictors Studies reporting increased risk Studies reporting no effects Age (Increased potential in

younger age)

(1) Wu et al. 2010 (2) Odvina et al. 2007 (3) Mollerup et al. 1999 (4) Soreide et al. 1996

(1) Berger et al. 2009 (2) Frokjaer et al. 2002 (3) NTUH

Gender(Male predominant) (1) Cooperberg et al. 2007 (2) Odvina et al. 2007 (3) Seroide et al. 1996

(1) Berger et al. 2009 (2) Frokjaer et al. 2002 (3) Mollerup et al. 1999 (4) NTUH

Plasma calcium level

(Lower in stone former group)

(1) Mollerup et al. 1999 (1) Berger et al. 2009 (2) Odvina et al. 2007 (3) Frokjaer et al. 2002 (4) Seroide et al. 1996 (5) Silverberg et al 1990 (6) NTUH

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Potential predictors Studies reporting increased risk Studies reporting no effects Plasma phosphate(Lower in

stone former group)

(1) Seroide et al. 1996 (2) Odvina et al. 2007

(1) Berger et al. 2009 (2) Frokjaer et al. 2002 (3) Mollerup et al. 1999 (4) Silverberg et al. 1990 (5) NTUH

Plasma PTH level None (1) Berger et al. 2009

(2) Odvina et al. 2007 (3) Frokjaer et al. 2002 (4) Mollerup et al. 1999 (5) Seroide et al. 1996

SUMMARY: POTENTIAL PREDICTORS

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The potential predictor of stone recurrence after parathyroidectomy

- 1999 Word Journal of Surgery: Charlotte L. Mollerup et al.

Renal stone and primary hyperparathyroidism:

Natural history of renal disease after successful parathyroidectomy.

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• 107 patients:

Urolithiasis and parathyroidectomy

• Prospective follow up

• 5 years follow up

• Overall stone

recurrence rate: 29.9%

1999 MOLLERUP ET AL

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• Patients with stone recurrence after

parathroidectomy have higher plasma calcium level than without

stone recurrence(3.55 vs 2.94, p<0.05)

NTUH

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PATIENT STATUS POST PTX WITH STONE RECURRENCE

• Clinical studies have indicated that surgical cure does not completely eradicate hypercalciuria and hypophosphatemia, suggesting that these patients have some additional mineral disorder ( 2009 Park.et al (BJU Int. 103: 670-678)

• Associations between BMI and risk of renal stones after PTX: It has been suggested that the increased incidence of

nephrolithiasis in the general population during the last two to three decades. This maybe due to an increased excretion of urinary oxalate, uric acid, sodium, and phosphate in obese

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LIMITATIONS

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• Problem 1: Small population(n=35)

• Problem 2: Retrospective study

- Variable follow-up interval after parathyroidectomy: 12 months ~ 10+ years - Some missing data: KUB image, Lab data

• Problem 3: More important stone predictors are not available - 24hr Urine calcium level

- Urine calcium concentration - Plasma Vitamin D3

- Weight of parathyroid gland

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CONCLUSION

• There are no significant differences between PHT patients with urolithiasis and without urolithiasis in age, gender, body weight, renal function, plasma calcium, plasma phosphatate, PTH and pathological type.

• The overall stone recurrence rate: 36 %

• Patients with stone recurrence after parathroidectomy have

higher plasma calcium level than without stone recurrence(3.55 vs 2.94, p<0.05)

• In clinical practice, post-parathyroidectomy patients who receive calcium supplement should closely monitor plasma calcium level because of the association of stone recurrence

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THANKS FOR YOUR ATTENTION

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REFERENCES

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REFERENCES

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REFERENCES

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