伍希元1 許舜能2 陳金順2 林石化2 朱柏齡2 俞志誠1 詹德全1施銘朗1 三軍總醫院外科部一般外科1 內科部腎臟內科2 Consideration for Renal Hyperparathyroidism Patients Receiving Parathyroidectomy: Peritoneal dialysis versus Hemodialysis 腎性副甲狀腺亢進病人於副甲狀腺全切術後照顧：腹膜透析與血液透析之考量 伍希元1 許舜能2 陳金順2 林石化2 朱柏齡2 俞志誠1 詹德全1施銘朗1 三軍總醫院外科部一般外科1 內科部腎臟內科2 2017/03/19 內分泌外科伍希元01

Introduction Parathyroidectomy improve symptoms and bone disease in patients with renal hyperparathyroidism Survival benefit when compared to calcium mimetics Hypocalcemia after parathyroidectomy Hypo-para Hunger bone syndrome (HBS) 2017/03/19 內分泌外科伍希元01

Hungry bone syndrome (HBS) Profound (< 8.5 mg/dL), prolonged hypocalcemia after operation Mechanism: High bone turnover rate before operation  sudden withdraw of PTH decrease osteoclastic resorption  imbalance, net influx of Ca, P, Mg in bone High turn-over bone disease are at risk High PTH with high Alk-P Ostetis fibrosa cystica 2017/03/19

Radiological bone disease Skeletal abnormalities Risk factor of HBS Findings Reference Age 10 yrs older < 45 yrs Brasier 1988 (1 HPT) Goldfaro 2012 (2 HPT) Lab High Ca, PTH High Alk-P Low Mg, Albumin Low Ca Spiegel 1981 Health 1979 (1 HPT) Lee 2006 (1 HPT) Latus 2013 (2HPT) Radiological bone disease Skeletal abnormalities Osteitis fibrosa cystica Most literature support Volume and weight of resected glands 4±1 vs. 2±0.2g Single adenoma > 2g More than half of HBS pts had at least 1 adenoma Zamboni 1986 Goldfarb 2012 (2HPT) 2017/03/19 內分泌外科伍希元01

Bone disease in renal hyperparathyroidism The turnover rate of bone cannot be assessed accurately PTH and Alk-P Bone image studies is not routinely checked, and bone biopsy is occasionally made Possible different prevalence among hemodialysis (HD) and peritoneal dialysis (PD)  Severity of HBS could be different 2017/03/19 內分泌外科伍希元01

Material and methods From 2010 to 2016, patients with secondary hyperparathyroidism underwent total parathyroidectomy at Tri-Service General Hospital 214 patients, only 130 patients with complete data were included A retrospective cohort design, to compare outcome between HD and PD Define HBS: Day 3 tCa < 8.5 mg/dl Pre-OP: demographics, history of cinacalcet, bone disease diagnosis, serum test (total Ca, iPTH, P ,Alk-P) Post-OP: Day 3 serum test (total Ca, PTH, P, Alk-P), Day 1-3 Calcium requirement, hospital day　 2017/03/19

Results_1 Preoperative baseline patient data HD (n= 107) CAPD (n= 23) P value Age 60.7±4.5 52.0±2.5 0.377 Gender (M/F) 41/66 (38.3%/61.7%) 6/17 (26.1%/73.9%) 0.342 Cinacalcet 8 (7.5%) 1 (6.7%) 1.000 iPTH 1278.1±74.5 1303.6±85.9 0.876 tCa 10.5±0.9 10.2±0.2 0.102 P 5.7±0.2 7.3±0.4 (H) <0.001 Alk-P 204.9±21.1 185.1±23.7 0.618 2017/03/19 內分泌外科伍希元01

Results_2 Incidence of HBS HD (n= 107) CAPD (n= 23) HBS 69 (64.5%) 18 P value HBS 69 (64.5%) 18 (78.3%) 0.232 D3 tCa >7, <8.5 mg/dl 41 (39.4%) 15 (68.2%) 0.018 D3 tCa ≦7 mg/dl 28 (26.9%) 3 (13.6%) 0.277 2017/03/19 內分泌外科伍希元01

Results Preoperative data of HBS subgroups HD (n= 69) CAPD (n= 18) Age P value Age 62.1±6.9 50.4±2.8 0.395 Gender (M/F) iPTH 1468.9±88.5 1307.0±107.6 0.376 tCa 10.3±0.1 10.1±0.2 0.374 P 6.12±0.2 7.1±0.5 0.031 Alk-P 241.3±27.3 173.7±23.0 0.168 2017/03/19 內分泌外科伍希元01

Results Postoperative data of HBS subgroups HD (n= 69) CAPD (n= 18) P value PTH 107.7±27.3 17.1±7.9 0.055 ▽PTH 1462.2±119.7 1289.8±120.2 0.423 D3 tCa 7.3±0.1 7.7±0.2 0.039 P 4.6±0.2 4.9±0.3 0.680 AlkP 235.6±42.4 242.5±56.9 0.932 △Alk-P -34.3±35.5 56.7±46.2 0.191 D1 Ca intake 1042.6±127.7 877.5±271.6 0.568 D2 Ca intake 1233.0±148.6 1009.0±214.2 0.474 D3 Ca intake 1412.4±147.1 1097.9±328.6 0.334 Hospital day 4.1±0.3 4.1±0.5 0.943 2017/03/19 內分泌外科伍希元01

Discussion The prevalence of HBS is similar, but hypoCa in PD group is generally Mild to Moderate Most PD pt with HBS have D3 tCa 7-8.5 mg/dl Average Less Severe hypocalcemia on D3 7.3±0.1 (HD) vs. 7.7±0.2 (PD), p=0.039 Tend to require Less Ca intake postoperatively 2017/03/19 內分泌外科伍希元01

Schrier‘s diseases of the kidney 9th edition 2017/03/19 內分泌外科伍希元01

Incidence of adynamic bone disease is up to 58% in PD patients Higher prevalence of osteitis fibrosa in HD patients, whereas adynamic bone disease is more prevalent in PD patients ~ by KDIGO Incidence of adynamic bone disease is up to 58% in PD patients Kidney Int Suppl. 2009 Aug;(113):S1-130 J Bone Miner Res, 26: 1368–1376 HD PD P value PreOP AlkP 241.3±27.3 173.7±23.0 0.168 PostOP AlkP 235.6±42.4 242.5±56.9 0.932 △Alk-P -34.3±35.5 56.7±46.2 0.191 2017/03/19 內分泌外科伍希元01

Conclusion PD patients undergoing parathyroidectomy for renal hyperparathyroidism have similar incidence of HBS as compared to HD patients, but the hypocalcemia is less severe and easier to handle. 2017/03/19 內分泌外科伍希元01