This study aims to determine the effect of a trained dedicated dietitian on clinical outcomes among Lebanese hemodialysis (HD) patients: and thus demonstrate a viable developing country model. This paper describes the study protocol and baseline data. The study was a multicenter randomized controlled trial with parallel-group design involving 12 HD units: assigned to cluster A (n = 6) or B (n = 6). A total of 570 patients met the inclusion criteria. Patients in cluster A were randomly assigned as per dialysis shift to the following: Dedicated Dietitian (DD) (n = 133) and Existing Practice (EP) (n = 138) protocols. Cluster B patients (n = 299) received Trained Hospital Dietitian (THD) protocol. Dietitians of the DD and THD groups were trained by the research team on Kidney Disease Outcomes Quality Initiative nutrition guidelines. DD protocol included: individualized nutrition education for 2 hours/month/HD patient for 6 months focusing on renal osteodystrophy and using the Trans-theoretical theory for behavioral change. EP protocol included nutrition education given to patients by hospital dietitians who were blinded to the study. The THD protocol included nutrition education to patients given by hospital dietitian as per the training received but within hospital responsibilities, with no set educational protocol or tools. Baseline data revealed that 40% of patients were hyperphosphatemics (> 5.5 mg/dl) with low dietary adherence and knowledge of dietary P restriction in addition to inadequate daily protein intake (58.86%+/- 33.87% of needs) yet adequate dietary P intake (795.52 +/- 366.94 mg/day). Quality of life (QOL) ranged from 48-75% of full health. Baseline differences between the 3 groups revealed significant differences in serum P, malnutrition status, adherence to diet and P chelators and in 2 factors of the QOL: physical and social functioning. The data show room for improvement in the nutritional status of the patients. The NEMO trial may be able to demonstrate a better nutritional management of HD patients.
Chelating Agents ; Developing Countries ; Dialysis ; Diet ; Education* ; Humans ; Kidney Diseases ; Lebanon* ; Malnutrition ; Nutrition Policy ; Nutritional Status ; Nutritionists ; Quality of Life ; Renal Dialysis ; Renal Osteodystrophy

The role of surgery in parathyroid disease has shown a recent decrease with development of calcinomimetics such as cinacalcet. During thyroid surgery, every endocrine surgeon makes every effort to preserve the parathyroid gland. However, postoperative hypoparathyroidism cannot be completely prevented. Knowledge of the precise anatomy of the parathyroid, including embryological movement of parathyroid glands, is needed. Surgical indications of parathyroidectomy include primary hyperparathyroidism, secondary hyperparathyroidism, tertiary hyperparathyroidism and parathyroid carcinoma. Parathyroidectomy for primary hyperparathyroidism has shown a significant change due to introduction of the sestamibi scan, intraoperative PTH assay, and focused parathyroidectomy. Minimally invasive surgery has now become standard operation for primary hyperparathyroidism. However, focused unilateral parathyroid operation should be done very cautiously because you can lose the chance of cure. Recurrence rate after parathyroidectomy is approximately 5% and experience of a surgeon can only reduce this rate. Surgery for secondary hyperparathyroidismis performed in only 1~2% of CKD patients. Surgical methods include subtotal parathyroidectomy, total parathyroidectomy, and total parathyroidectomy with autotransplantation and the results of the operation are not different. With the introduction of cinacalcet, comparison between surgery and medication showed an effective drop down of serum PTH level and increase of BMD only in surgery. Cincalcet did not show improvement of mortality, vascular calcification, and nephrplithiasis. According to oneJapanese report, PTH more than 500 pg/ml, size larger than 1 cm, and more than two enlarged parathyroid favor parathyroidectomy in renal osteodystrophy. During parathyroid surgery, high suspicion for carcinoma gives the only chance for cure because en bloc resection is important. Parathyroid disease has evolved since introduction of Cinacalcet and endocrine surgeons should join with physicians as a team for development of a treatment plan.
Autografts ; Cinacalcet Hydrochloride ; Humans ; Hyperparathyroidism ; Hyperparathyroidism, Primary ; Hyperparathyroidism, Secondary ; Hypoparathyroidism ; Minimally Invasive Surgical Procedures ; Mortality ; Parathyroid Diseases ; Parathyroid Glands ; Parathyroid Neoplasms ; Parathyroidectomy ; Recurrence ; Renal Osteodystrophy ; Surgeons ; Thyroid Gland ; Transplantation, Autologous ; Vascular Calcification

Maxillary enlargement is a rare complication of secondary hyperparathyroidism (SHPT). A 35-year-old Korean man undergoing chronic hemodialysis presented with a painless enlargement involving the maxilla and mandible. Plain radiography and CT scan showed bony expansion at the maxilla and mandible with multiple radiolucency. Serum intact parathyroid hormone (iPTH) was >1,600 pg/mL. Tc-99m sestamibi (MIBI) parathyroid scan and neck sonogram were compatible with SHPT. He underwent limited parathyroidectomy and commenced a course of paricalcitol. Fifteen months after surgery, maxillary enlargement and bony resorptions involving both hands markedly improved. Thirty-six months after the surgery, the serum iPTH level was 109.3 pg/mL. This is the first report in Korea documenting a patient with maxillary enlargement in SHPT who was successfully treated with limited parathyroidectomy and paricalcitol.
Adult ; Ergocalciferols ; Hand ; Humans ; Hyperparathyroidism ; Hyperparathyroidism, Secondary ; Korea ; Mandible ; Maxilla ; Neck ; Parathyroid Hormone ; Parathyroidectomy ; Renal Dialysis ; Renal Osteodystrophy

BACKGROUND/AIMS: Whereas higher dialysate calcium (Ca) levels may pose a risk of hypercalcemia, lower levels may induce a negative Ca balance. We evaluated the effect of lowering dialysate Ca levels from 1.75 to 1.5 mmol/L and explored the appropriate use of calcitriol to regulate bone metabolism in hemodialysis patients. METHODS: The dialysate Ca levels of 36 patients were reduced from 1.75 to 1.5 mmol/L. They were divided into three groups according to basal intact parathyroid hormone (iPTH) level (group 1, iPTH < 150 pg/mL, n = 21; group 2, iPTH 150-300 pg/mL, n = 7; group 3, iPTH > 300 pg/mL, n = 8). Data were collected at 3-month intervals for 1 year. RESULTS: Throughout the study period, no significant difference in phosphate binders, serum Ca, phosphorus (P), or Ca x P products was observed among groups. However, iPTH, alkaline phosphatase (AP), and calcitriol dosage patterns differed among groups. In group 1, iPTH and AP increased significantly over 12 months (p = 0.01). In group 2, iPTH and AP showed no significant changes. In group 3, iPTH and AP declined significantly over 12 months (p = 0.02). Calcitriol dosage did not change in groups 1 and 2, but increased significantly in group 3 (p = 0.001). CONCLUSIONS: After converting hemodialysate Ca levels from 1.75 to 1.5 mmol/L, the initially different iPTH concentrations converged to a modestly elevated level. The use of 1.5 mmol/L hemodialysate Ca may thus be appropriate for both high- and low-turnover bone disease if phosphate binders and calcitriol are combined appropriately.
Alkaline Phosphatase ; Bone Diseases ; Calcitriol ; Calcium ; Humans ; Hypercalcemia ; Parathyroid Hormone ; Phosphorus ; Renal Dialysis ; Renal Osteodystrophy

BACKGROUND/AIMS: Whereas higher dialysate calcium (Ca) levels may pose a risk of hypercalcemia, lower levels may induce a negative Ca balance. We evaluated the effect of lowering dialysate Ca levels from 1.75 to 1.5 mmol/L and explored the appropriate use of calcitriol to regulate bone metabolism in hemodialysis patients. METHODS: The dialysate Ca levels of 36 patients were reduced from 1.75 to 1.5 mmol/L. They were divided into three groups according to basal intact parathyroid hormone (iPTH) level (group 1, iPTH < 150 pg/mL, n = 21; group 2, iPTH 150-300 pg/mL, n = 7; group 3, iPTH > 300 pg/mL, n = 8). Data were collected at 3-month intervals for 1 year. RESULTS: Throughout the study period, no significant difference in phosphate binders, serum Ca, phosphorus (P), or Ca x P products was observed among groups. However, iPTH, alkaline phosphatase (AP), and calcitriol dosage patterns differed among groups. In group 1, iPTH and AP increased significantly over 12 months (p = 0.01). In group 2, iPTH and AP showed no significant changes. In group 3, iPTH and AP declined significantly over 12 months (p = 0.02). Calcitriol dosage did not change in groups 1 and 2, but increased significantly in group 3 (p = 0.001). CONCLUSIONS: After converting hemodialysate Ca levels from 1.75 to 1.5 mmol/L, the initially different iPTH concentrations converged to a modestly elevated level. The use of 1.5 mmol/L hemodialysate Ca may thus be appropriate for both high- and low-turnover bone disease if phosphate binders and calcitriol are combined appropriately.
Alkaline Phosphatase ; Bone Diseases ; Calcitriol ; Calcium ; Humans ; Hypercalcemia ; Parathyroid Hormone ; Phosphorus ; Renal Dialysis ; Renal Osteodystrophy

PURPOSE: Hyperphosphatemia and renal osteodystrophy increase the mortality and morbidity in chronic kidney disease. We compared the effects of lanthanum carbonate (LC) and calcium carbonate (CC) on phosphate homeostasis and bone bio-markers in hemodialysis patients. METHODS: The Korean dialysis patients with serum phosphorus more than 5.6 mg/dL were randomized to LC (n=12) or CC (n=11). Serum calcium, phosphorus, intact PTH, bone alkaline phosphatase, and osteocalcin were checked at regular intervals for 6 months. RESULTS: The reduction of serum phosphorus and calcium x phosphorus product at 24-week (wk) from baseline values was similar in LC and CC groups (Phosphorus: baseline, 7.28+/-1.04 mg/dL vs 7.41+/- 1.39 mg/dL, p=NS; at 24-wk, 5.39+/-1.85 mg/dL vs 5.67+/-1.43 mg/dL, p=NS) (Calcium x phosphorus product: baseline, 64.5+/-11.1 mg2/dL2 vs 61.3+/-11.9 mg2/dL2, p=NS; at 24-wk, 47.9+/-14.5 mg2/dL2 vs 51.8+/-14.0 mg2/dL2, p=NS). Despite higher baseline serum calcium levels in LC group, the changes of serum calcium from the baseline at 24-wk were significantly higher in CC group (LC vs CC; 0.23+/-0.38 mg/dL vs 0.94+/-0.87 mg/dL, p<0.05). Bone bio-markers, including iPTH, bone ALP, and osteocalcin, were comparable in 2 groups. However, significant gastrointestinal side effects leading to discontinuing the study were predominantly observed in LC (LC vs CC; n=5/12 vs n=0/11). CONCLUSION: Compared to calcium carbonate, lanthanum carbonate has similar efficacy to reduce serum phosphorus level, but less tendency to increase serum calcium level. However, the high incidence of gastrointestinal side effects in lanthanum carbonate needs further investigation in its correlation to Korean.
Alkaline Phosphatase ; Calcium ; Calcium Carbonate ; Carbon ; Dialysis ; Homeostasis ; Humans ; Hyperphosphatemia ; Incidence ; Lanthanum ; Osteocalcin ; Phosphorus ; Renal Dialysis ; Renal Insufficiency, Chronic ; Renal Osteodystrophy

Renal osteodystrophy (ROD) is an early complication in chronic kidney disease (CKD). Irreversible skeletal complications and deformities in children are already present before CKD progresses to end stage renal disease; therefore, the early detection of coexisting ROD is important in children with CKD. In the present work, we present a case of ROD in a 14-year-old female patient with chronic renal failure. The patient had already suffered bilateral femoral neck fractures before starting extracorporeal dialysis. On the 21st day after dialysis, external fixations of the femoral neck were performed.
Adolescent ; Child ; Congenital Abnormalities ; Dialysis ; Female ; Femoral Neck Fractures ; Femur Neck ; Humans ; Kidney Failure, Chronic ; Renal Dialysis ; Renal Insufficiency, Chronic ; Renal Osteodystrophy ; Renal Replacement Therapy

Slipped capital femoral epiphysis is a rare hip disorder that mainly occurs in pubertal children. Although the exact cause of this disorder is unknown, it is known to be associated with obesity, trauma, delayed sexual development, delayed bone maturation, chronic renal failure, genetic diseases, endocrine disorders (growth hormone deficiency, hypothyroidism, hypogonadism), growth hormone therapy, and gonadotropin releasing hormone agonist (GnRH agonist) therapy. We report 2 cases of slipped capital femoral epiphysis in adolescent females who were receiving growth hormone therapy. The first case is of a 16 year-old-girl with chronic renal failure and renal osteodystrophy. The second case is of an 11 year-old-girl with idiopathic precocious puberty who had received GnRH agonist and growth hormone therapy. Unilateral or bilateral slipped capital femoral epiphysis developed at 1 year 3 months after treatment in both the cases. The chief complaints were pain in the hip joint and lower extremities. Growth hormone and/or GnRH agonist therapy was stopped, and in situ screw fixations of the involved hip epiphyses were performed.
Adolescent ; Child ; Endocrine System Diseases ; Epiphyses ; Female ; Gonadotropin-Releasing Hormone ; Growth Hormone ; Hip ; Hip Joint ; Humans ; Hypothyroidism ; Kidney Failure, Chronic ; Lower Extremity ; Obesity ; Puberty, Precocious ; Renal Osteodystrophy ; Sexual Development ; Slipped Capital Femoral Epiphyses

BACKGROUND/AIMS: Checking bone mineral density (BMD) is not sufficient for determining the progression of renal osteodystrophy. Measuring pyridinoline or deoxypyridinoline in urine does not give an accurate bone status, due to insufficient urine in patients with renal failure. However, another biochemical marker, beta-CTX (the carboxy-terminal telopeptide of type 1 collagen), in serum is believed to be a good indicator of the status of renal osteodystrophy. METHODS: Fifty-nine patients undergoing hemodialysis agreed to have their blood and BMD checked. Beta-CTX was measured using an electro-chemiluminescence sandwich immunoassay and BMD was counted at the lumbar spine, femoral neck, and distal humerus using a Discovery-Wi (Hologic). RESULTS: Bone-alkaline phosphatase (49.8+/-36.7 U/L), parathormone (PTH) (192.8+/-263.3 U/L), osteocalcin (33.4+/-18.2 ng/mL), and beta-CTX (2.1+/-1.2 ng/mL) were all increased, while the average BMD of the lumbar spine (0.86+/-0.17), femoral neck, (0.67+/-0.14) and distal humerus (0.67 +/- 0.17) were all decreased. The BMD of the femoral neck in females was significantly lower than in males (p=0.044). The serum phosphate and PTH concentrations in non-diabetics were significantly higher than in diabetics (p=0.001, p=0.04, respectively). The measured serum osteocalcin and beta-CTX concentrations in patients older than 40 years were much lower than in patients younger than 40 (p=0.009, p=0.01, respectively). Beta-CTX was strongly correlated with bone-alkaline phosphatase (r=0.625, p=0.00), osteocalcin (r=0.698, p=0.00), and PTH (r=0.648, p=0.00). CONCLUSIONS: Beta-CTX is another convenient, significant marker for evaluating renal osteodystrophy.
Amino Acids ; Biomarkers ; Bone Density ; Bone Resorption ; Collagen Type I ; Female ; Femur Neck ; Humans ; Humerus ; Immunoassay ; Male ; Osteocalcin ; Parathyroid Hormone ; Peptides ; Renal Dialysis ; Renal Insufficiency ; Renal Osteodystrophy ; Spine

PURPOSE: The cause of renal hyperparathyroidism is unclear and the role of hyperphosphatamia is the only well established cause of renal osteodystrophy. The long life span of the parathyroid cells and the absence of a definite tissue marker for nodular parathyroid gland prohibit the timing of surgical intervention. The discrepancy between proliferation and apoptosis has been proposed as one possible cause of nodular development of the parathyroid gland in patients suffering with renal osteodystrophy. In the present study, we investigated the apoptotic labeling index of the parathyroid tissue in patients with renal hyperparathyroidism. METHODS: The parathyroid tissues of 76 patients with renal hyperparathyroidism and those of 33 normal glands were used for determining the level of apoptosis by performing a Tdt-mediated dUTP nick end labeling (TUNEL) assay. The patients' information was collected by a review of the clinical charts. Statistical comparison was done via two tailed t-tests. RESULTS: The averages of the TUNEL indices were 0.19 in the normal parathyroid glands and 1.84 in the hyperplastic parathyroid glands (P=0.00). The TUNEL index was higher in the oxyphil type of cells than in the chief cells and the water clear cell types (P=0.01). There was statistically significant correlation of the TUNEL index with the duration of the dialysis and less than 10 years dialysis showed a 2.23 index, which was higher than that of the longer term dialysis patients (P=0.00). The preoperative PTH level, recurrence, the Ki-67 labeling index and the pathologic type didn't show any statistical correlation with the TUNEL index (P>0.05). CONCLUSION: Our findings showed that the TUNEL index is useful for separating the cases of advanced renal hyperparathyroidism from the early ones and the TUNEL index is well correlated with hyperplastic types of cells. A decrease of apoptosis could be a probable cause of the progression of parathyroid hyperplasia in renal patients who are on dialysis support.
Apoptosis ; Dialysis ; Humans ; Hyperparathyroidism ; Hyperparathyroidism, Secondary* ; Hyperplasia ; In Situ Nick-End Labeling ; Kidney Failure, Chronic* ; Parathyroid Glands ; Recurrence ; Renal Osteodystrophy ; Tail ; Water