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Master's Dissertation
DOI
10.11606/D.5.2015.tde-13052015-111006
Document
Author
Full name
Roxana de Fátima Camelo de Albuquerque
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2014
Supervisor
Committee
Oliveira, Rodrigo Bueno de (President)
Carvalho, Aluizio Barbosa de
Elias, Rosilene Motta
Title in Portuguese
Tratamento cirúrgico do hiperparatireoidismo secundário: fatores que influenciam o funcionamento do autoimplante
Keywords in Portuguese
Calcificação vascular
Hiperparatireoidismo secundário
Hormônio paratireóideo
Insuficiência renal crônica
Paratireoidectomia
Proteína Klotho
Vitamina D
Abstract in Portuguese
O hiperparatireoidismo secundário à doença renal crônica (HPS) acomete inúmeros pacientes. Não existe consenso sobre qual tipo de paratireoidectomia (PTx) se associa com melhores resultados. Na PTx total com autoimplante (PTx-AI) especula-se se o número de fragmentos implantados melhora desfechos clínicos. Trinta e seis (36) pacientes com HPS foram randomizados para PTx-AI com 45 ou 90 fragmentos de paratireoide. Prospectivamente, avaliamos os fatores clínicos, bioquímicos e anatomopatológicos que influenciaram a função do AI. No início do estudo (t0), o Grupo-45 (N = 28) e Grupo-90 (N = 8) eram semelhantes, com exceção dos níveis séricos de fosfato. Após 12 meses (t12), os níveis séricos de PTH do enxerto e sistêmico correlacionaram-se com o cálcio iônico (Cai)-t0 (r2 = 0,442, p = 0,016; r2= 0,450, p = 0,008, respectivamente). A duração da fome óssea correlacionou-se com fosfatase alcalina (FA)-t0 (r2 = 0,593, p = 0,001). Nas células paratireoideanas, a expressão de PCNA correlacionou-se com o tempo em hemodiálise (r2 = 0,437, p = 0,016); a expressão do receptor-1 do fator de crescimento de fibroblastos (FGFR1) com FA-t0 (r2 = -0,758; p = 0,0001); o receptor de vitamina-D (VDR) com Cai-t0 (r2 = -0,464, p = 0,007) e carga cumulativa de Ca elemento (r2 = - 0,359, p = 0,04); o receptor sensível ao Ca (CaSR) com menor uso de calcitriol (r2 = -0,445, p = 0,049); e o Klotho com a dose de vitamina D pré- PTx (r2 = 0,811, p = 0,027) e com fosfato-t0 (r2= -0,528, p = 0,017). Houve progressão do escore de calcificação vascular [0,53 (0 - 4) vs. 1,1 (0 - 8); p = 0,04], que se correlacionou com a carga cumulativa de Ca elemento (r2 = 0,605, p = 0,006) e com o fosfato-t0 (r2 = 0,503; p = 0,028). Em conclusão, a PTx independentemente do número de AI controlou o HPS; porém parece piorar a calcificação vascular. Os níveis séricos de PTH pós-PTx ou evolução para hipo- ou normoparatireoidismo não foram influenciados pelo número de AI, nem por outros parâmetros bioquímicos e tão pouco pela densidade de expressão de PCNA, CaSR, VDR, FGFR1 ou Klotho nas células paratireoideanas
Title in English
Surgical treatment of secondary hyperparathyroidism: factors influencing the functioning of auto transplant
Keywords in English
Hyperparathyroidism secondary
Klotho protein
Parathyroid hormone
Parathyroidectomy
Renal insufficiency chronic
Vascular calcification
Vitamin D
Abstract in English
Hyperparathyroidism secondary to chronic kidney disease (SHP) affects many patients. There is no consensus about what kind of parathyroidectomy (PTx) is associated with better results. In total PTx with auto transplant (PTx- AT) it is speculated that the number of implanted fragments improves clinical outcomes. Third six (36) patients with refractory SHP were randomized to PTx-AT with 45 or 90 parathyroid fragments. We prospectively evaluated the clinical, biochemical and pathological factors influencing AT function. At baseline (t0) Group-45 (N = 28) and Group-90 (N = 8) were similar, except for serum phosphate levels. After 12 months (t12), PTH levels of graft and systemic correlated with ionic calcium (Cai) t0 (r2 = 0.442, p = 0.016; r2 = 0.450, p = 0.008, respectively). The duration of hungry bone syndrome correlated with alkaline phosphatase (AP) -t0 (r2 = 0.593, p = 0.001). In parathyroid cells, PCNA expression correlated with time on hemodialysis (r2 = 0.437, p = 0.016), expression of receptor-1 of fibroblast growth factor (FGFR1) with AP-t0 (r2 = -0.758; p = 0.0001), vitamin D receptor (VDR) with Cai t0 (r2 = -0.464, p = 0.007) and cumulative elemental Ca load (r2 = -0.359, p = 0.04), Ca sensing receptor (CaSR) with less use of calcitriol (r2 = -0.445, p = 0.049), and Klotho with the dose of vitamin D pre-PTx (r2 = 0.811, p = 0.027) and phophate-t0 (r2 = -0.528, p = 0.017). There was progression of vascular calcification score [0.53 (0 to 4) vs. 1.1 (0 to 8); p = 0.04] which correlated with cumulative elemental Ca load (r2 = 0.605, p = 0.006) and with phosphate-t0 (r2 = 0.503; p = 0.028). In conclusion, PTx controlled refractory SHP regardless of the number of AT; however, it seems to worsening vascular calcification. Serum levels of PTH or post-PTx evolution of hypo- or normoparathyroidism were not influenced by the number of AT or other biochemical parameters, nor by the density of PCNA expression, CaSR, VDR, FGFR1 or Klotho in parathyroid cells
 
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Publishing Date
2015-05-13
 
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