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Epidemiology and Diagnosis of Hypoparathyroidism

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Epidemiology and Diagnosis of Hypoparathyroidism SPECIAL FEATURE Position Statement Epidemiology and Diagnosis of Hypoparathyroidism Bart L. Clarke, Edward M. Brown, Michael T. Collins, Harald Jüppner, Peter Lakatos, Michael A. Levine, Michael M. Mannstadt, John P. Bilezikian, Anatoly F. Romanischen, and Rajesh V. Thakker Mayo Clinic (B.L.C.), Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Rochester, Minnesota 55905; Harvard Medical School (E.M.B.), Division of Endocrinology, Diabetes and Hypertension, Boston, Massachusetts 02115; Skeletal Clinical Studies Unit (M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland 20892; Endocrine Unit and Pediatric Nephrology Unit (H.J.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114; First Department of Medicine (P.L.), Semmelweis University Medical School, Budapest 1085, Hungary; Division of Endocrinology and Diabetes (M.A.L.), Children’s Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104; Massachusetts General Hospital (M.M.M.), Boston, Massachusetts 02114; Columbia University College of Physicians & Surgeons (J.P.B.), New York, New York 10032; Department of Hospital Surgery and Oncology of St Petersburg State Pediatric Medical Academy (A.F.R.), St. Petersburg 194100, Russia; and Academic Endocrine Unit (R.V.T.), Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, OX3 7LJ, United Kingdom Context: Hypoparathyroidism is a disorder characterized by hypocalcemia due to insufficient secretion of PTH. Pseudohypoparathyroidism is a less common disorder due to target organ resistance to PTH. This report summarizes the results of the findings and recommendations of the Working Group on Epidemiology and Diagnosis of Hypoparathyroidism. Evidence Acquisition: Each contributing author reviewed the recent published literature regarding epidemi- ology and diagnosis of hypoparathyroidism using PubMed and other medical literature search engines. Evidence Synthesis: The prevalence of hypoparathyroidism is an estimated 37 per 100 000 person-years in the United States and 22 per 100 000 person-years in Denmark. The incidence in Denmark is approximately 0.8 per 100 000 person-years. Estimates of prevalence and incidence of hypoparathyroidism are currently lacking in most other countries. Hypoparathyroidism increases the risk of renal insufficiency, kidney stones, posterior subcapsular cataracts, and intracerebral calcifications, but it does not appear to increase overall mortality, cardiovascular disease, fractures, or malignancy. The diagnosis depends upon accurate mea- surement of PTH by second- and third-generation assays. The most common etiology is postsurgical hy- poparathyroidism, followed by autoimmune disorders and rarely genetic disorders. Even more rare are etiologies including parathyroid gland infiltration, external radiation treatment, and radioactive iodine therapy for thyroid disease. Differentiation between these different etiologies is aided by the clinical presentation, serum biochemistries, and in some cases, genetic testing. Conclusions: Hypoparathyroidism is often associated with complications and comorbidities. It is im- portant for endocrinologists and other physicians who care for these patients to be aware of recent advances in the epidemiology, diagnosis, and genetics of this disorder. (J Clin Endocrinol Metab 101: 2284–2299, 2016) ISSN Print 0021-972X ISSN Online 1945-7197 * Author affiliations are shown at the bottom of the next page. Printed in USA Abbreviations: ADH1, autosomal dominant hypocalcaemia type 1; AHO, Albright’s he- Copyright © 2016 by the Endocrine Society reditary osteodystrophy; CaSR, calcium-sensing receptor; CHARGE, coloboma-heart Received November 6, 2015. Accepted January 29, 2016. anomaly-choanal atresia-retardation-genital-ear; CHD7, chromodomain helicase DNA- First Published Online March 4, 2016 binding protein 7; CI, confidence interval; DGS, DiGeorge syndrome; DMR, differentially methylated region; GCM2, glial cells missing 2; HDR, hypoparathyroidism-deafness-renal For related articles see pages 2273, 2300, 2313 dysplasia; HR, hazard ratio; KSS, Kearns-Sayre syndrome; MELAS, mitochondrial enceph- alopathy, lactic acidosis, and stroke-like episodes; MTPDS, mitochondrial trifunctional pro- tein deficiency syndrome; NEBL, nebulette; 1,25(OH)2 vitamin D, 1,25-dihydroxyvitamin D; PDE4D, phosphodiesterase 4D; PHP, pseudohypoparathyroidism; PPHP, pseudopseudo- hypoparathyroidism; SEMA3E, sempahorin 3E; TBCE, tubulin-specific chaperone. 2284 press.endocrine.org/journal/jcem J Clin Endocrinol Metab, June 2016, 101(6):2284–2299 doi: 10.1210/jc.2015-3908 The Endocrine Society. Downloaded from press.endocrine.org by [${individualUser.displayName}] on 05 July 2016. at 09:04 For personal use only. No other uses without permission. All rights reserved. doi: 10.1210/jc.2015-3908 press.endocrine.org/journal/jcem 2285 ypoparathyroidism is an uncommon disorder char- database over the interval studied. A surgical incidence H acterized by low serum calcium, increased serum estimate was based on calculation of the proportion of phosphorus, and deficient production of PTH (1, 2). The total neck operations resulting in transient (Ͻ6 months) or epidemiology of hypoparathyroidism has become better chronic (Ͼ6 months) hypoparathyroidism. A physician understood, with a number of recent studies quantitating primary market research study was conducted to assess aspects of the disease not previously appreciated. Pseudo- disease severity and to determine the percentage of new hypoparathyroidism (PHP), a disorder of PTH resistance, nonsurgical patients with hypoparathyroidism. Surgical is an even less common disease characterized by similarly incidence data were entered into an epidemiological model abnormal mineral biochemical abnormalities, but with in- to derive a second prevalence estimate. The surgical-based creased circulating levels of PTH (1). incidence approach gave an estimate of 117 342 relevant Operationally, hypoparathyroidism can be divided neck surgeries, resulting in 8901 cases of hypoparathy- into primary hypoparathyroidism due to intrinsic defects roidism over 12 months. Approximately 7.6% of surgeries within the parathyroid glands primarily due to genetic resulted in hypoparathyroidism, with 75% of these cases causes, and the much more common secondary or ac- being transient and 25% being chronic. The prevalence of quired forms due to etiologies that ablate, impair, or de- insured patients with chronic hypoparathyroidism in the stroy parathyroid gland function. Secondary causes of hy- surgical database was 58 625, similar to that obtained in poparathyroidism are by far the most common etiologies the diagnostic estimate. Assuming that 15.4% of the U.S. (2). Although the diagnosis of hypoparathyroidism is usu- population was uninsured at the time this study was done, ally straightforward once serum calcium, phosphorus, these findings were used to project an estimate of 77 000 and PTH levels are known, determining the cause of non- total insured and uninsured individuals in the United surgical hypoparathyroidism may be challenging. States that had hypoparathyroidism. Another estimate of the prevalence of hypoparathy- roidism comes from the longitudinal population-based Epidemiology of Hypoparathyroidism Rochester Epidemiology Project (Table 1) in which med- ical records linkage resources were used to identify all Anterior neck surgery is the most common cause of ac- persons residing in Olmsted County, Minnesota, in 2009 quired hypoparathyroidism and is responsible for about with any diagnosis of hypoparathyroidism assigned by a 75% of cases (1). The next most common acquired cause health care provider since 1945 (5). Detailed medical re- in adults is thought to be autoimmune disease, affecting cords were reviewed to confirm the diagnosis of hypo- either the parathyroid glands alone or multiple other en- parathyroidism and to assign an etiology. Subjects were docrine glands (2). Remaining cases of acquired hypo- assigned two age- and sex-matched controls per confirmed parathyroidism are secondary due to a variety of rare in- case. Fifty-four cases were confirmed, of mean age 58 Ϯ 20 filtrative disorders in which the parathyroid glands are years, with 71% female, giving a prevalence estimate of 37 affected by metastatic disease or iron or copper overload per 100 000 person-years. This prevalence estimate was or by ionizing radiation exposure. These latter causes of projected to approximately 115 000 patients in the United hypoparathyroidism are covered in more detail in the ac- States having hypoparathyroidism of any cause. Hypo- companying paper on presentation of hypoparathyroid- parathyroidism was caused by neck surgery in 78% of ism, including what little is known regarding the epide- cases, other secondary causes in 9%, familial disorders in miology of these disorders (3). Rare genetic disorders may 7%, and without an identified cause in 6%. also cause hypoparathyroidism. Only a few data exist on the epidemiology of hypo- parathyroidism in Europe. In a recent nationwide Danish Prevalence historic cohort study, the prevalence of hypoparathyroid- The best prevalence estimate of hypoparathyroidism in ism was estimated using data from the Danish National the United States is
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