Abstract
The present report describes a case of a 64-year-old pre-dialysis woman with chronic kidney disease (CKD) stage 5, who developed severe hyperparathyroidism. This patient had been on a very low protein diet (VLPD) to delay the progression of CKD and the need for renal replacement therapy (RRT). Her serum calcium levels were high-normal to slightly high during this time. However, her serum intact parathyroid hormone (PTH) levels increased from 400 to 1160 pg/ml rapidly over a period of 3 months. Serum 1,25-(OH)2D levels were low, and ultrasound of the neck showed three markedly enlarged parathyroid glands exceeding 2 cm. Parathyroidectomy was performed, and all glands showed nodular hyperplasia, which indicated severe secondary hyperparathyroidism leading to tertiary. Severe secondary hyperparathyroidism requiring surgical intervention is usually observed in patients with long-term RRT and is relatively rare in the pre-dialysis patient. In this case, extension of the pre-dialysis period by VLPD may have predisposed this patient to develop severe secondary hyperparathyroidism. Thus, careful monitoring of calcium, phosphorus, and PTH may be necessary in patients treated with VLPD even before renal replacement therapy. Furthermore, initiation of dialysis should not be excessively delayed by strict protein restriction dietary therapy.
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References
Martin KJ, Gonzalez EA (2011) Prevention and control of phosphate retention/hyperphosphatemia in CKD-MBD: what is normal, when to start, and how to treat? Clin J Am Soc Nephrol 6:440–446
Takasaki I, Shionoiri H, Yabana M, Takagi N, Kamijo S, Nakatani Y, Umemura S (1999) Severe hyperparathyroidism with hypercalcemia associated with chronic renal failure at pre-dialysis stage. Endocrinol J 46:167–171
Mizumoto D, Watanabe Y, Fukuzawa Y, Aoi N, Yamazaki C (1994) Clinical profile and outcome of primary hyperparathyroidism accompanied by chronic renal failure. Clin Nephrol 42:315–321
Smith DH, Johnson ES, Thorp ML, Yang X, Neil N (2009) Hyperparathyroidism in chronic kidney disease: a retrospective cohort study of costs and outcomes. J Bone Miner Metab 27:287–294
Breslau NA (1988) Normal and abnormal regulation of 1,25-(OH)2D synthesis. Am J Med Sci 296:417–425
Kusano K, Segawa H, Ohnishi R, Fukushima N, Miyamoto K (2008) Role of low protein and low phosphorus diet in the progression of chronic kidney disease in uremic rats. J Nutr Sci Vitaminol 54:237–243
Silverberg SJ, Vitamin D (2007) Deficiency and primary hyperparathyroidism. J Bone Miner Res 2(22 Suppl):V100–V104
Silverberg SJ, Shane E, Dempster DW, Bilezikian JP (1999) The effects of vitamin D insufficiency in patients with primary hyperparathyroidism. Am J Med 107:561–567
Fraser WD (2009) Hyperparathyroidism. Lancet 374:145–158
Carlson D (2010) Parathyroid pathology: hyperparathyroidism and parathyroid tumors. Arch Pathol Lab Med 134:1639–1644
Hakim RM, Lazarus JM (1995) Initiation of dialysis. J Am Soc Nephrol 6:1319–1328
Churchill DN (1997) An evidence-based approach to earlier initiation of dialysis. Am J Kidney Dis 30:899–906
Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Johnson DW, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA (2010) A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med 363:609–619
Evans M, Tettamanti G, Nyren O, Bellocco R, Fored CM, Elinder CG (2011) No survival benefit from early-start dialysis in a population-based, inception cohort study of Swedish patients with chronic kidney disease. J Intern Med 269:289–298
Rosansky SJ, Eggers P, Jackson K, Glassock R, Clark WF (2011) Early start of hemodialysis may be harmful. Arch Intern Med 171:396–403
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Ohta, E., Akazawa, M., Noda, Y. et al. Severe hyperparathyroidism in a pre-dialysis chronic kidney disease patient treated with a very low protein diet. J Bone Miner Metab 30, 238–242 (2012). https://doi.org/10.1007/s00774-011-0320-6
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DOI: https://doi.org/10.1007/s00774-011-0320-6