Paper Information

Title: 

RENAL STONE DISEASE IN IRANIAN HYPERPARATHYROID PATIENTS

Type: PAPER
Author(s): BAHRAMI A.*
 
 *
 
Name of Seminar: CONGREH ANJOMAN UROLOGY IRAN
Type of Seminar:  CONGRESS
Sponsor:  ANJOMAN OROLOGY
Date:  2005Volume 8
 
 
Abstract: 

THE ORIGINAL STUDIES OF ALBRIGHT AND REIFENSTEIN CHARACTERIZED PRIMARY HYPERPARATHYROIDISM AS A DISEASE OF "BONES AND STONES". IN SOME PATIENTS, THE DISEASE WAS COMPLICATED BY RENAL INVOLVEMENT. IN OTHERS, A DISTINCTIVE BONE DISEASE PREDOMINATED. BONE PAIN, FRACTURES AND SKELETAL DEFORMITIES WERE NOT UNCOMMON. IN WESTERN COUNTRIES, PRIMARY HYPERPARATHYROIDISM IS NOT LONGER COMMONLY SEEN WITH COMPLICATING FEATURES. THE DISEASE AT PRESENT IS RECOGNIZED MOST FREQUENTLY AS A TOTALLY ASYMPTOMATIC CONDITION, DETECTION BEING BASED ON THE FINDING OF HYPERCALCEMIA IN THE ROUTINE SCREEING OF SERUM CALCIUM LAVALS. RECENT STUDIES HAVE SHOWN THAT THE INCIDANCE OF RENAL DISEASE HAS BEEN REDUCED FROM 30 TO 50% COMMON IN THE PAST TO 10–15% OF PATIENTS CURRENTLY. THERE IS CLEARLY ALSO A CHANGING OF SKLELETAL MANIFESTATIONS OF HYPERPARATHYROIDISM. OSTEITIS FIBROSA CYSTICA. THE CLASSIC FROM OF SKELETAL DISEASE IN HYPERPARATHYROIDISM IS DECLINING SHARPLY IN RELATIVE FREQUENCY. IN AN ANALYSIS 138 CASES, IT WAS NOTAD THAT. DURING THE DECADES BETWEEN 1930 AND 1949, 53 PERCENTS OF PATIENTS HAD SYMPTOMATIC OSTETIS FIBROSA CYSTICA, BUT NO SKELETAL SYMPTOMS AT ALL WERE DETECTION IN THE 58 PATIENTS WITH PRIMARY HYPERPARATHYROIDISM SEEN FROM 1980–1983.
PREVIOUS STUDIES, INCLUDING MY OWN REPORT ON 48 PATIENTS FROM NORTH–WESTERN PART OF THE COUNTRY SHOWED THAT ADVANCED BONE DISEASE WAS THE MOST COMMON CLINICAL PRESENTATION OF PRIMARY HYPERPARATHYROIDISM IN IRANIANS. THE PURPOSE OF THE PRESENT STUDY WAS TO DETERMINE THE INCIDENCE AND PATERN OF KIDNEY INVOLVEMENT IN IRANIAN HYPERPARATHYROID POPULATION.
FROM 1985 THROURH 2001 FIFTY–SIX PATIENTS WITH PRIMARY HYPERPARATHYROIDISM WERE STUDIES PROSPECTIVELY FROM NORTH–WESTERN PART OF IRAN. IN ADDITION TO ROUTINE STUDIES, THE FOLLOWING EVALUATIONS WERE MADE IN ALL PATIENTS: 1) SERIAL MEASUREMENTS OF CALCIUM, PHOSPHOROUS, ALKALINE PHOSPHATASE, CREATININE, ELECTROLYTES AND 24–H URINARY CALCIUM; 2) X–RAYS OF SKULL, HANDS, CLAVICLES, PELVIS, VERTEBRAL BONES, ABDOMEN, LONG BONES, AND DENTAL FILM OF LAMINA DURA. TO EVALUATE RENAL INVOLVMENT, IVP AND/OR ULTRASONOGRAPHY FROM KIDNEY WERE DONE. UNEXPLAINED RENAL DYSFUNCTION AND PRESENCE OF NEPHROLITHIASIS OR NEPHROCALCINOSIS WERE CHOOSEN AS MARKERS OF PARATHYROID RELATED RENAL DISEASE.
RESULTS–THERE WERE 48 FEMALES AND 8 MALES WITH A FEMALE TO MALE RATIO OF 6:1 PATIENTS WERE AGED FROM 13 TO 71 YEARS WITH A MEAN AGE OF 44.2 YEARS. 87.5% OF PATIENTS HAD PERSISTENT HYPERCALCEMIA 5.3% HAD INTERMITTENT HYPERCALCEMIA AND 7.1% WERE NORMOCALCEMIC. MEAN SERUM CALCIUM LEVEL WAS 11 MG/DL. IN FORTY-FIVE PATIENTS (80.3%) SERUM PHOSPHOROUS CONCENTRATIONS WERE ABNORMALLY LOW. SERUM PTH WAS MEASURED IN 23 PATIENTS AND WAS HIGHER THAN UPPER LIMITED OF NORMAL IN ALL CASES. THE MEAN 24-H URINARY CALCIUM WHICH WAS DETERMINED IN 31 PATIENTS WAS 96 MG/24H. ONLY IN 2 PATIENTS IT WAS HIGHER THAN 200 MG/24H. THE VAST MAJORITY OF PATIENTS IN THIS SERIES PRESENTED WITH SYMPTOMS REFERRABLE TO SKELETAL INVOLVEMENT. FIFTY–THREE PATIENTS (94.6%) SUFFERED FROM BONE DISEASE. RENAL COLIC WAS A LESS FREQUENT COMPLAINT, ONLY IN 3 (5.3%) PATIENTS CLINICAL RENAL DISEASE LED TO THE DIAGNOSIS OF HYPERPARATHYROIDISM. RENAL DISEASE WAS PRESENT IN 5 (8.9%) PATIENTS. THE PATTERNS OF KIDNEY INVOLVEMENT WERE NEPHROLITHIASIS IN 4 CASES AND NEPHROCALCINOSIS IN ONE PATIENT. IN IS CONCLUDED THAT RENAL DISEASE IS LESS FREQUENT IN IRANIAN HYPERPARATHYROID POPULATION. THIS CAN BE EXPLAINED BY RARE OCCURANCE OF HYPERCALCIURIA IN THESE PATIENTS. LOW MEAN SERUM CALCIUM LEVEL, DESPITE ADVANCED BONE DISEASE, MOST PROBABLY DUE TO LOW DIETARY CALCIUM AND VITAMIN-D MAY BE RESPONSIBLE.
TABLE –1. RESULTS OF THIS STUDY IN COMPARISON WITH REPORTED RESULTS FROM WESTERN COUNTRIES

PARAMETER

PRESENT STUDY

WESTERN COUNTRIES

BEFORE 1970S

AFTER 1970S

FEMALE TO MALE RATIO

6 : 1

2 : 1

3 – 4 : 1

MEAN AGE OF PATIENTS (Y)

44.2

52.4

53.7

MOST COMMON PATTERN OF PRESENTATION

BONE DISEASE

RENAL DISEASE

ASYMPTOMATIC HYPERCALCEMIA

BONE DISEASE (%)

94.6%

15 – 20 %

RATE

RENAL DISEASE (%)

8.9%

50 – 70 %

7 – 10 %

ASYMPTOMATIC HYPERCALCEMIA (%)

-

3 – 5 %

50 – 60 %

 
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