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      Secondary Hyperparathyroidism Is Associated with Higher Cost of Care among Chronic Kidney Disease Patients with Cardiovascular Comorbidities

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          Background: Chronic kidney disease (CKD) is associated with high morbidity and mortality, and incurs a substantial cost. Secondary hyperparathyroidism (SHPT) is a major complication associated with CKD and has been linked with cardiovascular disease, leading to poor outcomes. Methods: We analyzed retrospective studies for the prevalence of congestive heart failure (CHF) and acute myocardial infarction/ischemic heart disease (AMI/IHD) in pre-dialysis CKD patients to estimate the additional hospitalization cost incurred secondary to high parathyroid hormone (PTH) levels. Two models were developed to estimate the contribution of elevated PTH levels towards hospitalization costs in CKD patients with CHF and AMI/IHD. Results: Cost contributions were estimated for the time intervals relative to initiation of dialysis, with the largest contributions estimated for the 3- to 1-month period prior to initiation of dialysis, USD 205.24 per patient-month at risk for CHF and USD 69.44–111.75 per patient-month at risk for AMI/IHD, without and with major complications, respectively. Conclusion: Higher PTH levels are associated with a high prevalence of CHF and AMI/IHD. Our cost analyses show that elevated PTH levels contribute significantly toward the overall cost of care among CKD patients with CHF and AMI/IHD. The contribution of elevated PTH levels toward hospitalization cost is highest during the months directly leading up to initiation of dialysis. Further studies are required to evaluate the relationship between hyperparathyroidism and cardiovascular disease, and its impact on economic outcomes.

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          Most cited references 11

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          Predictors and consequences of altered mineral metabolism: the Dialysis Outcomes and Practice Patterns Study.

          Altered mineral metabolism contributes to bone disease, cardiovascular disease, and other clinical problems in patients with end-stage renal disease. This study describes the recent status, significant predictors, and potential consequences of abnormal mineral metabolism in representative groups of hemodialysis facilities (N= 307) and patients (N= 17,236) participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS) in the United States, Europe, and Japan from 1996 to 2001. Many patients fell out of the recommended guideline range for serum concentrations of phosphorus (8% of patients below lower target range, 52% of patients above upper target range), albumin-corrected calcium (9% below, 50% above), calcium-phosphorus product (44% above), and intact PTH (51% below, 27% above). All-cause mortality was significantly and independently associated with serum concentrations of phosphorus (RR 1.04 per 1 mg/dL, P= 0.0003), calcium (RR 1.10 per 1 mg/dL, P < 0.0001), calcium-phosphorus product (RR 1.02 per 5 mg(2)/dL(2), P= 0.0001), PTH (1.01 per 100 pg/dL, P= 0.04), and dialysate calcium (RR 1.13 per 1 mEq/L, P= 0.01). Cardiovascular mortality was significantly associated with the serum concentrations of phosphorus (RR 1.09, P < 0.0001), calcium (RR 1.14, P < 0.0001), calcium-phosphorus product (RR 1.05, P < 0.0001), and PTH (RR 1.02, P= 0.03). The adjusted rate of parathyroidectomy varied 4-fold across the DOPPS countries, and was significantly associated with baseline concentrations of phosphorus (RR 1.17, P < 0.0001), calcium (RR 1.58, P < 0.0001), calcium-phosphorus product (RR 1.11, P < 0.0001), PTH (RR 1.07, P < 0.0001), and dialysate calcium concentration (RR 0.57, P= 0.03). Overall, 52% of patients received some form of vitamin D therapy, with parenteral forms almost exclusively restricted to the United States. Vitamin D was potentially underused in up to 34% of patients with high PTH, and overused in up to 46% of patients with low PTH. Phosphorus binders (mostly calcium salts during the study period) were used by 81% of patients, with potential overuse in up to 77% patients with low serum phosphorus concentration, and potential underuse in up to 18% of patients with a high serum phosphorus concentration. This study expands our understanding of the relationship between altered mineral metabolism and outcomes and identifies several potential opportunities for improved practice in this area.
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            Parathyroid hormone, vitamin D, and cardiovascular disease in chronic renal failure.

            Parathyroid hormone and vitamin D have been shown to influence cardiac and vascular growth and function experimentally in human subjects with normal renal function. Because of the increased prevalence of hyperparathyroidism and altered vitamin D status in chronic renal failure, these alterations have been considered to contribute to the increased prevalence of cardiovascular disease and hypertension seen in this patient population. Methods and Results. In this article, we review experimental and clinical literature on the cardiovascular effects of parathyroid hormone and vitamin D and relate them to the development of cardiac and vascular dysfunction in uremia, such as: cardiomyopathy, myocardial hypertrophy, and fibrosis, as well as to myocardial ischemia; uremic glucose intolerance, dyslipidemia, and atherosclerosis; hypertension; and vascular and cardiac calcifications. The hyperparathyroid state and altered vitamin D status found in uremia contribute to the cardiovascular pathology seen clinically in uremia and also to the excess mortality from cardiovascular causes found in this patient group. The therapeutic implications of these observations are also discussed.
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              Parathyroid hormone and left ventricular hypertrophy.

              A relation between left ventricular hypertrophy and parathyroid hormone (PTH) has been described in patients with end stage renal disease and secondary hyperparathyroidism. In vitro studies indicate a hypertrophic effect of PTH on cardiomyocytes. The purpose of this study was to examine the relation between PTH and left ventricular hypertrophy in a general population. The fourth Tromsø study (1994-1995) included 27159 subjects. 2700 had serum PTH measurement and left ventricular mass by height (LVMH) estimated with M-mode echocardiography. Among these, 980 males and 1060 females were without known cardiovascular disease or valvular heart disease and did not use blood pressure medication. In this group, using a multiple linear regression model, body mass index (BMI), followed by systolic blood pressure, were found to be the strongest predictors of LVMH. In males older than 59 years and females younger than 60 years, PTH was a significant and positive predictor of LVMH (P<0.05). The relation between PTH and LVMH was not linear. There was a sharp increase in LVMH (both unadjusted and adjusted for age, BMI, and systolic blood pressure) in the upper PTH percentiles with the breaking point being the 95 percentile for men and the 98 percentile for women. Subjects in these upper PTH ranges had 12-17% higher adjusted LVMH than those in the lower 10% of the PTH range. This effect was not related to serum calcium level. If examining separately those with PTH levels within +/-2SD from the mean, no relation between PTH and LVMH was found. PTH is an independent predictor of LVMH in males older than 59 years and females younger than 60 years. This effect is only seen when PTH is substantially elevated and may then be involved in cardiac pathophysiology.

                Author and article information

                Nephron Clin Pract
                Nephron Clinical Practice
                S. Karger AG
                March 2007
                25 January 2007
                : 105
                : 4
                : c159-c164
                Tufts University School of Medicine, Boston, Mass., USA
                99006 Nephron Clin Pract 2007;105:c159–c164
                © 2007 S. Karger AG, Basel

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                Page count
                Tables: 7, References: 21, Pages: 1
                Self URI (application/pdf): https://www.karger.com/Article/Pdf/99006
                Original Paper


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