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Prediction of Bone Mass Change after Parathyroidectomy in Patients with Primary Hyperparathyroidism¹

Third Division, Department of Medicine, Kobe University School of Medicine (D.N., T.S., T.K., T.Y., K.C.), Kobe 650-0017; and Kuma Hospital (A.K.), Kobe 650-0011, Japan

Address all correspondence and requests for reprints to: Toshitsugu Sugimoto, M.D., Third Division, Department of Medicine, Kobe University School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.

	Abstract

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A major challenge in the management of primary hyperparathyroidism (pHPT) is the decision regarding which patients should undergo parathyroidectomy (PTX), although the Consensus Development Conference of the NIH has proposed guidelines for the indication of surgery. In the present study, changes in bone mineral density (BMD) after PTX were compared between pHPT patients who did and did not meet the NIH criteria, and we further tried to predict the BMD change after PTX from preoperative parameters. The subjects were 44 pHPT patients (30 women and 14 men) who had had successful PTX. Lumbar and radial BMD were measured before and 1 yr after PTX by dual energy x-ray absorptiometry and single photon absorptiometry, respectively. Average annual percent increases in lumbar and radial BMD after PTX were 12.2 ± 1.4% and 11.6 ± 1.6% (mean ± SEM), respectively, and those net increases were 0.0803 ± 0.0008 and 0.0484 ± 0.0006 g/cm², respectively. There were no significant differences in percent or net changes in either radial or lumbar BMD after PTX between the groups divided according to each of the NIH criteria, such as age (50 and <50 yr), serum calcium level (12 and <12 mg/dL) or the existence of urinary stones (presence and absence). On the other hand, when the subjects were divided on the basis of radial BMD (above and below a z-score of -2), the annual percent and net increases in lumbar BMD and percent increase in radial BMD after PTX were significantly higher in the group with the lower z-score. Next, patients were divided into two groups with and without the indication of PTX based on NIH guidelines. Twenty-nine patients had the surgical indication by meeting one or more of these criteria and 15 patients had no indication without meeting any of the criteria. There were no significant differences between the two groups in annual percent or net changes in radial or lumbar BMD after PTX. A stepwise multiple regression analysis revealed that serum alkaline phosphatase level and the severity of cortical bone mass reduction were the best predictors of both percentage and net changes in lumbar BMD, with high determination coefficients (r² > 0.7). In conclusion, a considerable increase in BMD could be obtained after PTX even in patients without surgical indication from the NIH. Alkaline phosphatase and the severity of cortical bone mass reduction are clinically useful for predicting the changes in lumbar BMD after PTX. The present findings provide a useful clue for the indication of surgery in pHPT.

	Introduction

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PRIMARY HYPERPARATHYROIDISM (pHPT), a relatively common endocrine disorder, is now recognized as a disorder with few overt manifestations, presenting most often as asymptomatic hypercalcemia. Parathyroidectomy (PTX) is the only option available for the cure of pHPT. The Consensus Development Conference of the NIH proposed guidelines for the surgical indication of pHPT (1). These include 1) serum calcium (Ca) above 12 mg/dL, 2) marked hypercalciuria (>400 mg/g creatinine·day), 3) any overt manifestations of pHPT (nephrolithiasis, osteitis fibrosa cystica, or classical neuromuscular diseases), 4) markedly reduced cortical bone density (z-score, below -2), 5) reduced creatinine clearance in the absence of other causes, and 6) age less than 50 yr. In the United States, only about half of the patients meet one or more of these criteria for the surgical indication (2). PTX seems beneficial to pHPT patients, as there have been several reports documenting a postoperative increase in bone mineral density (BMD) (3, 4). In contrast, there is also substantial evidence that most cases of pHPT are not progressive and that conservative management of pHPT patients does not lead to progression of the disease (5). Therefore, the validity of PTX has been questioned, and it remains unclear which pHPT patients should be subjected to PTX. In this respect, it would be clinically useful if BMD changes after PTX could be predicted from preoperative parameters.

In the present study BMD changes after PTX were compared between pHPT patients who did and did not meet NIH criteria, and we further proposed a means for predicting the changes in BMD after PTX from various preoperative parameters.

	Subjects and Methods

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Subjects

Sixty-nine patients had been hospitalized in Kobe University Hospital from 1989 to 1997. Thirty-seven patients (54%) were asymptomatic. PTX was recommended to all pHPT patients whose abnormal parathyroid glands were successfully identified by image techniques and who had no serious complications regardless of whether patients met the surgical indications of the NIH. Several patients either refused operation or were unable to undergo surgery because of serious complication such as cardiac dysfunction. Of those operated, we retrospectively and consecutively evaluated 44 patients who had been followed with biochemical and BMD measurements at least 1 yr after PTX. The 44 patients (age, 56 ± 3 yr; mean ± SEM) included 14 men (mean age, 54 yr) and 30 women (mean age, 58 yr). Twenty-two patients (50%) were postmenopausal women not receiving any therapy for osteoporosis, including estrogen replacement or bisphosphonate. Twenty-six patients (59%) had asymptomatic pHPT. Sixteen patients (36%) had a history of urinary stones. Twenty-nine patients (66%) fulfilled 1 or more of the following accepted surgical criteria from NIH: age 50 yr or younger (n = 10; 23%), serum Ca level above 12 mg/dL (n = 8; 18%), history of nephrolithiasis (n = 16; 36%); z-score at the radius of -2 or lower (n = 14; 32%), and classic neuromuscular signs of pHPT (n = 0; 0%). Baseline indexes are shown in Table 1. All data were compatible with the existence of pHPT. All subjects were successfully operated upon, with removal of their abnormal parathyroid glands, and biochemical values such as serum concentrations of Ca, phosphorus (P), alkaline phosphatase (ALP), midregion PTH, and intact PTH returned to normal levels 1 yr after PTX as previously reported (6, 7) (Table 1). Surgical pathology showed adenoma in 37 (84%) and hyperplasia in 7 patients (16%). None of them had hepatic or renal dysfunction or other metabolic diseases that might cause changes in bone metabolism. No subjects were taking drugs known to influence bone or Ca metabolism, such as supplemental calcium, vitamin D, estrogen, or bisphosphonate, before operation and during 1 yr postoperative period, except for 2 patients who received short-term supplementation of calcium because of severe hungry bone syndrome. The clinical and biochemical data were obtained by reviewing the chart records at admission, by questionnaires, or by interviews. Some missing information was requested by letters sent to some patients. This study was approved by the ethical review board of Kobe University Hospital. The subjects agreed to participate in this study and gave informed consent for monitoring biochemical markers and BMD after PTX.

Serum concentrations of Ca, P, and ALP were measured by automated techniques at the central laboratory of Kobe University Hospital (normal range: Ca, 8.5–9.9 mg/dL; P, 2.4–4.5 mg/dL; ALP, 100–303 IU/L). Intact PTH and midregion PTH were measured by immunoradiometric assay (Allegro Intact PTH RIA kit, Nichols Institute Diagnostics, San Juan Capistrano, CA; normal range, 10–65 pg/mL) (8, 9) and RIA (Yamasa hypersensitive PTH-RIA kit, YAMASA Shoyu Co. Ltd., Tokyo, Japan; normal range, 160–520 pg/mL) (10), respectively. The intact PTH RIA kit only reacts with human (h) PTH-(1–84), whereas hPTH-(1–34), hPTH-(39–84), and hPTH-(39–68) are nonreactive (11). The Yamasa PTH-RIA kit consists of chicken PTH antiserum raised by Hruska et al., ¹²⁵I-labeled [Tyr⁴³]hPTH-(44–68) as a radioligand, and synthetic hPTH-(1–84) as a standard (12). This assay recognizes the fragments containing at least the amino acid sequence of 44–68 in the PTH molecule and intact PTH as well.

BMD measurements

BMD measurements were performed before and 1 yr after PTX. Lumbar spine BMD was measured by dual energy x-ray absorptiometry (QDR-1000, Hologic, Inc., Waltham, MA). BMD of the lumbar spine at L2–L4 was measured separately and expressed as the mean. As vertebral fractures may cause aberrations in BMD, data from fractured vertebrae were excluded. Bone mineral content, bone width, and BMD (defined as bone mineral content/bone width) were measured at the distal one third of the radius using single photon absorptiometry (Bone Mineral Analyzer Type 278 O, Norland Corp., Fort Atkinson, WI). The coefficients of variation (precision) in BMD measurements of the lumbar spine and radius by our methods were 0.9% and 1.9%, respectively. The z-score is the number of SDs a given measurement differs from the mean for a sex- and age-matched reference population. The t-score is the number of SDs a given measurement differs from the mean for a normal young adult reference population.

Statistical analysis

All data were expressed as the mean ± SEM for each index. A regression analysis was performed using the statistical computer program Abacus Concepts StatView (Abacus Concepts, Inc., Berkeley, CA). A simple regression analysis was used to assess the linear relationship between various parameters, and then Pearson’s correlation coefficients were calculated. To determine which variables in the preoperative state were independently and significantly associated with BMD changes in the radius and lumbar spine after PTX, a stepwise multiple regression analysis was performed. P < 0.05 was considered significant.

	Results

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Clinical characteristics in preoperative and postoperative states

As shown in Table 1, all patients had elevated serum levels of Ca and PTH. Elevated serum ALP levels indicated that bone turnover was accelerated. Baseline z- and t-scores of lumbar spine BMD were significantly higher than those of radial BMD. Biochemical values, such as serum Ca, P, ALP, midregion PTH, and intact PTH, returned to normal levels 1 yr after PTX. On the other hand, radial and lumbar BMD values remained lower than normal 1 yr after PTX, judging from their z-scores.

Comparison of changes in BMD after PTX between groups who did and did not meet criteria of NIH guidelines

The annual percent increases in lumbar and radial BMD after PTX were 12.2 ± 1.4% and 11.6 ± 1.6% (mean ± SEM), respectively, and their net increases were 0.0803 ± 0.0008 and 0.0484 ± 0.0006 g/cm², respectively. We divided pHPT patients into two groups according to each of the NIH criterion and compared the annual percent changes in radial and lumbar BMD after PTX. There were no significant differences in percent or net changes in either radial or lumbar BMD after PTX between two groups based on age (50 and <50 yr), serum Ca level (12 and <12 mg/dL), or the existence of urinary stones (presence and absence; data not shown). On the other hand, as shown in Fig. 1, annual percent and net increases in lumbar BMD and annual percent increases in radial BMD after PTX were significantly higher in groups with a z-score of radial BMD below -2 than in groups with the z-score of -2 or more.

View larger version (34K): [in this window] [in a new window]   Figure 1. Comparison of annual percent and net changes in BMD after PTX between two groups divided according to a NIH criterion for cortical bone density (z-score at the radius, below -2). Annual percent and net increases in lumbar BMD and annual percent increases in radial BMD after PTX were significantly higher in the group with a z-score of radial BMD below -2, than in a group with a z-score of -2 or more.

View larger version (42K): [in this window] [in a new window]   Figure 2. Comparison of annual percent and net changes in BMD after PTX between groups with and without the indication of PTX based on the NIH guidelines. Met, The group of patients who met one or more NIH guidelines. Not Met, The group of patients who did not meet any of the NIH guidelines. There were no significant differences between the two groups in annual percent or net changes in either radial or lumbar BMD after PTX.

Prediction of BMD changes after PTX

Figure 3 shows the relationships between various indexes and annual percent changes in radial as well as lumbar BMD after PTX. The annual percent change in lumbar BMD was positively and significantly correlated with intact PTH, midregion PTH, and ALP and was negatively and significantly correlated with the z-score of radial BMD, but not with the z-score of lumbar BMD. In contrast, the annual percent change in radial BMD was significantly and negatively correlated only with the z-score of radial BMD. The similar correlations were also observed between each parameter and annual net changes in lumbar or radial BMD. The annual net change in lumbar BMD was positively and significantly correlated with intact PTH (r = 0.664; P < 0.0001), midregion PTH (r = 0.554; P < 0.0001), and ALP (r = 0.702; P < 0.0001) and was negatively and significantly correlated with the z-score of radial BMD (r = -0.606; P = 0.0001), but not with the z-score of lumbar BMD. In contrast, the annual net change in radial BMD was significantly and negatively correlated only with the z-score of radial BMD (r = -0.310; P < 0.05; graphical data not shown). Next, we tried to predict the annual percent and net changes in radial and lumbar BMD after PTX from various indexes in the preoperative state, such as age; serum levels of Ca, P, ALP, intact PTH, and midregion PTH; as well as the z-scores of radial and lumbar BMD. Table 3 shows stepwise multiple regression equations describing the annual percent and net changes in radial and lumbar BMD after PTX. As for BMD at the radius, the midregion PTH and radial z-score were selected for the percent change, and the radial z-score and age were selected for the net change, with relatively lower determination coefficients based on the analysis (r² = 0.356 and 0.338, respectively). As for BMD at the lumbar spine, ALP and the radial z-score were selected for the percent change, and ALP, radial z-score, and age were selected for the net change, with higher determination coefficients (r² = 0.725 and 0.789, respectively).

View larger version (26K): [in this window] [in a new window]   Figure 3. Relationships between annual percent changes in BMD after PTX and various indices. The annual percent change in lumbar BMD was positively and significantly correlated with intact PTH, midregion PTH, and ALP and was negatively and significantly correlated with the z-score of radial BMD, but not with the z-score of lumbar BMD. In contrast, the annual percent change in radial BMD was significantly and negatively correlated only with the z-score of radial BMD.

	Discussion

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Cortical bone is predominant in the distal one third of the radius, whereas cancellous bone is rich in the lumbar spine. In the present study the reduction of radial BMD was more prominent than that of lumbar BMD, indicating the preferential reduction of cortical bone mass in the patients. The present data are compatible with previous findings that most pHPT patients had reduced cortical BMD in the face of relatively preserved cancellous BMD (17, 18, 19, 20, 21, 22). This phenomenon is thought to be partly explained by the anabolic action of PTH on cancellous bone (23, 24, 25). In addition, this study showed that the increase in lumbar BMD, but not the increase in radial BMD, was positively correlated with preoperative serum levels of ALP and PTH, suggesting that abrupt reduction in a circulating PTH level also affects cortical and cancellous bones in different manners. Alternatively, as serum ALP is a marker for the bone turnover rate, this finding suggests that higher preoperative bone turnover rate augments the recovery of cancellous bone mass after PTX.

In the present study the extent of the increases in both lumbar and radial BMD after PTX was negatively correlated with the preoperative z-score of radial BMD, namely the extent of the increases in BMD at each site after PTX was higher in patients with the greatest reduction in preoperative radial BMD, as previously shown by Silverberg et al. (4). In contrast, such a relationship was not found between the extent of the increases in BMD at each site after PTX and the preoperative z-score of lumbar BMD, implying that a similar degree of BMD increase was obtained regardless of the severity of preoperative reduction in lumbar bone mass. The present study also revealed that there was no difference in the overall percent increase in BMD between the radius and the lumbar spine after PTX. These findings were somewhat different from those of Silverberg et al., who reported that the patients most severely affected at the lumbar spine had the greatest response to PTX (26), and that the percent increase in lumbar BMD after PTX was greater than that in radial BMD (4). This discrepancy might be partly explained by more severe states of hyperparathyroidism and radial BMD reduction in our subjects, judging by higher serum levels of PTH and ALP as well as a higher population with z-score at the radius of -2 or lower compared with those documented in their study (4). Alternatively, some racial differences might exist in the reversibility of cortical bone after PTX, because the data obtained from Caucasian patients with classical pHPT showed no or only modest improvements at the cortical site (13, 14, 15, 16).

Biochemical and bone densitometric indexes have shown that conservative management of pHPT patients is not associated with progression of the disease (5). We also found long term stable biochemical parameters and BMD values in conservatively managed patients. Thus, it is possible that the hyperparathyroid state provides some ongoing protection from the expected bone loss. Nonetheless, this study shows that PTX brings about increases in radial and lumbar BMD values as much as approximately 10% in virtually all pHPT patients, including postmenopausal women. This is in sharp contrast with the well known fact that bone loss caused by postmenopausal osteoporosis is difficult to satisfactorily restore. As pHPT predominantly affects women and occurs frequently during the postmenopausal period (27), it may be beneficial to recommend PTX, particularly in postmenopausal women who could not otherwise obtain such a large increase in bone mass.

This study has some limitations. First, the sample size was not large enough to make definite conclusions. Second, in Japan, the percentage of pHPT patients who are asymptomatic is not as high as in the United States (28). However, subjects admitted to Kobe University Hospital, a tertiary care center, might have a relatively severe pathological state of pHPT. It is therefore possible that patients enrolled in this study were not representative of Japanese pHPT patients. Third, we presented only preoperative and 1 yr postoperative data. Therefore, the time course of changes in BMD and biochemical data could not be determined from these limited results.

In conclusion, the serum ALP level and the severity of cortical bone mass reduction are clinically useful indices for predicting the extent of increase in lumbar BMD after PTX. A considerable increase in BMD was obtained after PTX even in patents without severe reduction of bone mass as well as in patients who did not meet any criteria for the surgical indication from NIH.

	Footnotes

 
¹ This work was supported in part by Smoking Research Foundation and the Research Society for Metabolic Bone Disease (to T.S.) and by Research Society for Metabolic Bone Disease and Health Sciences Research grants.

Received May 5, 1999.

Revised January 12, 2000.

Accepted February 7, 2000.

	References

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