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      Full normalization of severe hypertension after parathryoidectomy – a case report and systematic review

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          Abstract

          Background

          Although the relationship between hyperparathyroidism and hypertension has been described for decades, the role of hyperparathyroidism in hypertension in dialysis is still unclear. Following the case of a severely hypertensive dialysis patient, in which parathyroidectomy (PTX) corrected the metabolic imbalance and normalized blood pressure (BP), we tried to contextualize our observation with a systematic review of the recent literature on the effect of PTX on BP.

          Case presentation

          A dialysis patient, aged 19 years at the time of this report, with chronic kidney disease (CKD) from childhood; he was an early-preterm baby with very low birth weight (910 g), and is affected by a so-far unidentified familial nephropathy. He started dialysis in emergency at the age of 17. Except for low-dose Bisoprolol, he refused all chronic medication; hypertension (165–200/90–130 mmHg) did not respond to attainment of dry weight (Kt/V > 1.7; BNP 70–200 pg/ml pre-dialysis). He underwent subtotal PTX 1 year after dialysis start; after PTX, his blood pressure stabilized in the 100–140/50–80 range, and is normal without treatment 5 months later.

          Conclusion

          Our patient has some peculiar features: he is young, has a non-immunologic disease, poor compliance to drug therapy, excellent dialysis efficiency. His lack of compliance allows observing the effect of PTX on BP without pharmacologic interference.

          The prompt, complete and long-lasting BP normalization led us to systematic review the current literature (Pubmed, Embase, Cochrane Collaboration 2000–2016) retrieving 8 case series (194 cases), and one case report (3 patients).

          The meta-analysis showed a significant, albeit moderate, improvement in BP after PTX (difference: systolic BP -8.49 (CI 2.21–14.58) mmHg; diastolic BP -4.14 (CI 1.45–6.84) mmHg); analysis is not fully conclusive due to lack of information on anti-hypertensive agents. The 3 cases reported displayed a sharp reduction in BP after PTX.

          In summary, PTX may have a positive influence on BP control, and may result in complete correction or even hypotension in some patients. The potential clinical relevance of this relationship warrants prospective large-scale studies.

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          Most cited references 28

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          Hyperparathyroidism

          The Lancet, 374(9684), 145-158
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            Mechanisms of vascular calcification in chronic kidney disease.

             X. Chen,  Sharon Moe (2008)
            Vascular calcification is common in chronic kidney disease and associated with increased morbidity and mortality. Its mechanism is multifactorial and incompletely understood. Patients with chronic kidney disease are at risk for vascular calcification because of multiple risk factors that induce vascular smooth muscle cells to change into a chondrocyte or osteoblast-like cell; high total body burden of calcium and phosphorus due to abnormal bone metabolism; low levels of circulating and locally produced inhibitors; impaired renal excretion; and current therapies. Together these factors increase risk and complicate the management of vascular calcification.
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              Serum iPTH, calcium and phosphate, and the risk of mortality in a European haemodialysis population

              Background. A number of US observational studies reported an increased mortality risk with higher intact parathyroid hormone (iPTH), calcium and/or phosphate. The existence of such a link in a European haemodialysis population was explored as part of the Analysing Data, Recognising Excellence and Optimising Outcomes (ARO) Chronic Kidney Disease (CKD) Research Initiative. Methods. The association between the markers of mineral and bone disease and clinical outcomes was examined in 7970 patients treated in European Fresenius Medical Care facilities over a median of 21 months. Baseline and time-dependent (TD) Cox regression were performed using Kidney Disease Outcomes Quality Initiative (KDOQI) target ranges as reference categories, adjusting for demographics, medical history, dialysis parameters, inflammation, medications and laboratory parameters. Fractional polynomial (FP) models were also used. Results. Hazard ratio (HR) estimates from baseline analysis for iPTH were U-shaped [>600 pg/mL, HR = 2.10, 95% confidence interval (CI) 1.62–2.73; 2.75 mmol/L increased risk of death (HR = 1.70, 95% CI 1.19–2.42). TD analysis showed that both low (HR = 1.19, 95% CI 1.04–1.37) and high calcium (HR = 1.74, 95% CI 1.30–2.34) increased risk of death. Baseline analysis for phosphate showed a U-shaped pattern ( 1.78 mmol/L, HR = 1.32, 95% CI 1.13–1.55). TD analysis confirmed the results for phosphate <1.13 mmol/L. HR estimates were higher in patients with diabetes versus those without diabetes for baseline analysis only (P-value = 0.014). FP analysis confirmed the results of baseline and TD analyses. Conclusion . Patients with iPTH, calcium and phosphate levels within the KDOQI target ranges have the lowest risk of mortality compared with those outside the target ranges.
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                Author and article information

                Contributors
                andreea.sofronie@gmail.com
                isabelle.kooij@hotmail.com
                cboursot@ch-lemans.fr
                giulia.santagati@hotmail.it
                jpcoindre@ch-lemans.fr
                0033.669733371 , gbpiccoli@yahoo.it
                Journal
                BMC Nephrol
                BMC Nephrol
                BMC Nephrology
                BioMed Central (London )
                1471-2369
                11 May 2018
                11 May 2018
                2018
                : 19
                Affiliations
                [1 ]ISNI 0000 0004 1771 4456, GRID grid.418061.a, Nephrology Centre Hospitalier Le Mans, ; Le Mans, France
                [2 ]ISNI 0000 0001 2336 6580, GRID grid.7605.4, Dipartimento di Scienze Cliniche e Biologiche, , Università di Torino, ; Turin, Italy
                [3 ]ISNI 0000 0004 1771 4456, GRID grid.418061.a, Nuclear Medicine, Centre Hospitalier Le Mans, ; Le Mans, France
                [4 ]ISNI 0000 0004 1771 4456, GRID grid.418061.a, Nephrology Centre Hospitalier Le Mans, ; 194 Avenue Rubillard 72000, Le Mans, France
                Article
                900
                10.1186/s12882-018-0900-y
                5948802
                29751781
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Categories
                Case Report
                Custom metadata
                © The Author(s) 2018

                Nephrology

                parathyroidectomy, dialysis, hypertension, case report, systematic review

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