Word Count：1634
Effect of parathyroidectomy on symptoms and quality of life in
patients with end-stage renal disease
Su-Chen Yang1 Wan-Ching Chao1 Chih-Kang Chiang4 Shih-Ping Hsu2 Yu-Sen Peng2
Kuan-Yu Hung4 Shih-Horng Huang3 Kai-Wei Wang5
Far Eastern Memorial Hospital, Department of Nursing 1Department of Nephrology 2
Department of Surgery3, National Taiwan University Hospital, Department of
Nephrology 4 Institute of Nursing National Yang-Ming University.5
Address correspondence to Kai-Wei Wang, Institute of Nursing National Yang-Ming
University.
Far Eastern Memorial Hospital, No.21, Sec.2 Nan-Ya South Road, Pan-Chiao, Taipei,
Taiwan.
E-mail: didoyangster@gmail.com , dido.yang@msa.hinet.net
Running title: parathyroidectomy and quality of life
1
Abstract
Background: Purpose was to measure quality of life (QOL) and symptom distress in
dialysis patients before and after parathyroidectomy.
Methods: We enrolled 37 dialysis patients who underwent parathyroidectomy at the
medical center. QOL was measured with the Health Survey (SF-36) and symptom
distress was evaluated by use of the Visual Analogue Scale (VAS).
Results: The results indicated that joint pain, muscle weakness, and itchy skin were
the most annoying symptoms. The QOL before surgery indicated a physical
component summary score of 31.7 ± 13.8 and a mental component summary score of
37.6 ± 14.4. A total of 32 patients (86.5%) reported experiencing adverse symptoms.
After surgery, there was a statistically significant reduction of symptoms. There was a
positive correlation between the calcium-phosphorus product and skin itching.
Symptom distress were significantly reduced after surgery.
Conclusion: Our results indicate that parathyroidectomy of dialysis patients with
hyperparathyroidism can relieve many symptoms and improve QOL.
Keywords: ESRD, Hyperparathyroidism, symptoms distress, quality of life
2
Introduction
Secondary hyperparathyroidism due to hypocalcemia is common in patients
with end-stage renal disease (ESRD) 〔18〕 The increased production of parathyroid
hormone (PTH) causes calcium to be re-absorbed from bone, so that more calcium is
taken up by the intestines and kidney If the parathyroid glands are unable to respond
to the increased levels of calcium, tertiary hyperparathyroidism and hypercalcemia
can result. This condition is associated with complications, such as psychological and
neurological disorders, ectopic ossification in the cardiovascular system, imbalanced
nutrition, and inflammation, that can severely compromise quality of life (QOL) and
increase the probability of mortality〔4,12〕.
According to Locatelli 〔5〕, the prevalence of parathyroidectomy among
dialysis patients is about 5.5%. In Taiwan, about 59,000 ESRD patients require
long-term dialysis (Taiwan Kidney Foundation, 2008). Taiwan has a very high
prevalence of ESRD, and our patient-centered healthcare system must consider
〔15,16〕hyperparathyroidism in order to improve patient QOL〔7,14〕. The daily life
of a dialysis patient is often stressed by physical symptoms 〔3,8〕, and
hyperparathyroidism can add to this burden by increasing bone disease, pain, pruritis,
and muscle weakness. 〔11〕
Internal medicine specialists can often use one or more medications to
successfully treat kidney disease patients with hyperparathyroidism. However, if the
level of PTH is greater than 500 pg/mL, the parathyroid gland is heavier than 500 mg,
or the patient has severe osteitis fibrosa, then parathyroidectomy is indicated to
alleviate the symptoms 〔9,,10,17〕In the present study, we examined the QOL of
ESRD patients before and after parathyroidectomy. The results serve as a basis for
clinical decision-making and education of healthcare workers.
Materials and Methods
(1) Subjects
This was a follow-up study that enrolled patients by convenience sampling. All
subjects were ESRD patients on peritoneal dialysis or hemodialysis for more than
three months and received subtotal parathyroidectomy at our hospital. All enrolled
patients were age 18 years or older, had clear consciousness and no mental disorder,
had the ability to speak clearly, had no active malignancy, and were not pregnant.
After hospital admission, we explained the research goals to patients and families, and
obtained informed consent for participation in the survey. Participation was voluntary.
In order to understand each patient’s symptoms of stress and QOL, questionnaires
3
were distributed before parathyroidectomy, one month after parathyroidectomy, and
three months after parathyroidectomy,
(2) Research tools and measurements
The Visual Analogue Scale (VAS) and the Health Survey (SF-36) were used to
assess subjective feelings of patients. The VAS is a psychometric measure of a
patient's perception of joint pain, muscle weakness, and skin itches, with lower scores
indicating better QOL. The SF-36 assesses a patient's health-related QOL and assesses
a subject's physical and mental health status in eight categories with a total of 36
questions: physical function (PF), ten questions; role limitation due to physical
problems (RP), four questions; bodily pain (BP), two questions; general health (GH),
five questions; vitality (VT), four questions; social function (SF), two questions; role
limitation due to emotional problems (RE), three questions; mental health (MH), five
questions; one question on reported health transition for the past year. SF-36 scores
were expressed as individual scores in each of the eight categories, with scores
ranging from zero to one hundred. Finally, the scores were also summarized a
physical component summary score (PCS) and a mental component summary score
(MCS). Higher scores indicate better QOL 〔1〕.
Additional background information was also collected, including age, gender,
education, occupation, marital status, religion, primary disease that led to ESRD,
dialysis modality (hemodialysis or peritoneal dialysis), dialysis frequency, total
months of dialysis, presence of other chronic diseases, and routine blood biochemistry
and blood cell counts.
All statistical analysis was conducted with SPSS 12.0 software (SAS, Chicago,
IL). Demographic characteristics, dialysis-related information, and VAS scores were
analyzed with descriptive statistics, including average, median, standard deviation,
and 25th and 75th percentiles. Pre- and post-surgical laboratory tests and SF-36 scores
were reported as average, median, and percentile. The difference between these
variables was examined with a nonparametric test. The presence of correlation
between variables and the strength of the correlation was measured with the Wilcoxon
signed-rank test.
Results
Thirty-seven questionnaires were distributed before and one month after
surgery, and 36 were distributed at the three-month follow-up (CAD due to the death
of one patient). The response rate was 100%.
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(1) Patient Demographics
Table 1 shows basic patient demographics. The average patient age was 54.6 ±
11.72 years, 21 of 37 (56.8%) patients were female, and 25 (67.6%) patients were
married. A total of 91.9% of patients had a high school education or less, 21% had
stable employment, 43.2% were homemakers, and 2.7% were able to work but
remained unemployed. The major religion was Taoism (51.4%).
The average PCS and MCS of females were 29.56 ± 14.62 and 36.83 ± 16.60,
respectively. The average PCS and MCS of males were 34.53 ± 12.50 and 38.57 ±
11.45, respectively. There were no significant gender difference in PCS (p = 0.283) or
MCS (p = 0.721).
(2) Dialysis characteristics
Table 2 shows the dialysis modality and comorbidities of all patients. Overall,
36 (97.3%) patients were on hemodialysis, and 34 (91.9%) of these patients had three
dialysis sessions per week. One patient was on peritoneal dialysis. The average
duration of dialysis was 106.0 ± 61.6 months (range: 17∼268 months). Two subjects
had renal transplants. Thirteen subjects (35.1%) had hypertension, seven (18.9%) had
diabetes, two (5.4%) had heart disease, and one (2.7%) had stroke.
(3) Laboratory data before and after surgery
Table 3 shows laboratory data of patients before and after surgery.
Ultrasonography of the 37 parathyroid glands before surgery indicated that nodule
volume ranged from 0.5×0.5 ×0.3 cm3 to 2.5×2×1.6 cm3. Twenty-four patients
developed two or more nodules.
(4) Symptoms before and after surgery
Table 4 summarizes symptom severity (joint pain, itching, and muscle
weakness) before and after surgery. Joint pain was noted in multiple joints, including
the shoulders, elbows, knees, hips, and fingers. There were 42 anatomical sites with
joint pain before surgery, and 33 sites with joint pain after surgery .After surgery,
there were significant reductions in joint pain, muscle weakness, and itching. At the
three-month post-surgery follow-up, four patients with joint pain, eight patients with
muscle weakness, and ten patients with pruritis reported no abatement of symptoms.
However, most patients experienced reduction of symptoms one month after surgery.
Among patients who experienced no symptom improvement, there were equal
numbers of males and females. Comorbidities such as diabetes, hypertension, or heart
disease, were reported, but did not show any trend of concentration with a particular
disease.
5
(5) Quality of Life(SF-36 )before and after surgery
Table 5 summarizes the Quality of life improvement following surgery.and
Correlation between PCS and MCS at the one-month and three-month post-surgery
follow-up
(6) Correlation between symptom distress and PCS and MCS before and after
surgery
Figure 1-6 shows Relationship of physical component summary score
(PCS),mental component summary score (MCS) and symptom distress score.
Discussion
In this study, we examined the association of the severity of hyperparathyroidism
and QOL in 37 ESRD patients before and after parathyroidectomy. We also examined
the extent of symptom relief following surgery. The results showed that symptom
distress, serum calcium, phosphate, and the calcium-phosphate product were all
related to patient QOL.
In addition, we found that patients who had more severe symptoms had worse
QOL. However, we found no significant correlation between the level of iPTH and
QOL. According to Tanaka 〔13〕, patients with higher levels of serum calcium,
phosphate, and calcium- phosphate product have lower SF-36 scores and experience
greater impact on QOL.
We believe that our results can guide nurses in the evaluation of
symptom-induced stress and the needs of ESRD patients before parathyroidectomy, so
that they can provide personalized and appropriate care and help to improve patients'
QOL 〔3〕. Previous studies, in Taiwan and elsewhere, have shown that the symptoms
of ESRD patients have a moderate to severe effect on QOL 〔2,6〕(Huang, 2005;). We
suggest that better knowledge of potential symptoms and of patients’ subjective
perceptions of such symptoms is needed for better management in clinical nursing.
Our study has certain limitations. First, all subjects were recruited from the same
medical center, but they were treated at different dialysis centers throughout northern
Taiwan. Second, considering patients’ privacy rights and the survey-based nature of
this study, some laboratory data were not available. Third, the total number of
enrolled patients was slightly less than expected (there was an average of 45
parathyroidectomy patients per year in the two years prior to this study). Despite
6
these limitations, we believe that our study will aide in the management of ESRD
patients with hyperparathyroidism.
Acknowledgments
This study was supported by the Far Eastern Memorial Hospital.
Reference
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8
Appendix
Table 1. Demographic characteristics of patients (N = 37).
Variables
Number of
Sex (male/female)
patients
Percentage (%)
16/21
43.2/56.8
34
91.9
3
8.1
Employed
10
27.0
Unemployed
1
2.7
Full-time homemaker
16
43.2
Others or not reported
10
27.0
Single
8
21.6
Married
25
67.6
Divorced
1
2.7
Widowed
3
8.1
Buddhism
7
18.9
Taoism
19
51.4
Others/unknown
11
29.7
Educational level
Not a high school graduate
College or above
Employment
Marital status
Religion
Table 2. Dialysis modalities and comorbidities of patients (N = 37).
Variables
Number of patients
Percentage(%)
Dialysis modalities
Hemodialysis three times per week
34
91.9
Hemodialysis two times per week
2
5.4
Peritoneal dialysis
1
2.7
Diabetes
7
18.9
Hypertension
13
35.1
Cardiac disease
2
5.4
CVA
1
2.7
Others
6
16.2
None
8
21.6
Post renal transplant
2
5.4
Comorbidities
9
Table 3. Laboratory data of patients before and after surgery (N = 37, mean ±SD).
Variable
Pre-OP
Post-op 1 month
Post-op 3 months
calcium (mg/dL)
10.4±0.9
8.1±1.4
8.9±1.3
phosphorus (mg/dL)
5.2±1.3
4.1±1.3
4.3±1.3
Ca × P (mg2/dL2)
53.4±14.9
34.3±14.6
38.3±13.9
iPTH (pg/mL)
2086.3±1452.2
219.0±262.1
286.6±311.8
Albumin (g/dL)
4.0±0.4
4.0±0.3
4.1±0.3
Table 4. Symptom distress (VAS score)before and after surgery (mean ± SD).
Variables
Pre-OP
Post-op 1 month
Joint pain
4.98±3.37
3.21±2.32**
2.61±2.19 *
Itching
4.31±3.33
3.52±2.74 **
3.00±2.19**
Muscle weakness
4.63±2.90
3.59±2.28 **
3.30±2.19
*
P<0.05 as compared with baseline
#
P < 0.05 as compared with Post-OP Month 1
Post-op 3 months
**
P< 0.001 as compared with baseline
Table 5. SF-36 scores before and after surgery (N=37).
Pre-OP
Characteristic
th
Post-op 1 month
th
th
50 (25 , 75 )
*
50 (25 , 75 )
Post-op 3 months
50 (25th, 75th)
PF
55(30,85)
60(40,80)
75(45,90)
RP
0(0,62.5)
25(0,62.5)
50(0,100)**,#
RE
33.3(0,100)
33.3(0,100)
100(8.3,100)*,#
VT
50(32.5,65)
45(37.5,65)
55(32.5,60)
MH
60(48,74)
56(46,72)
64(49,76)
SF
62.5(37.5,87.5)
75(37.5,75)
50(75,87.5)**,#
BP
47.5(22.5,70)
57.5(32.5,77.5)**
67.5(45,79.4)**,#
GH
40(20,57.5)
40(22.5,57.5)
40(30,68.8)**,#
PCS
31.3(20,45.1)
32.3(22.5,44.3)
42.9(27.7,48.7)**, #
MCS
39.5(25.1,48.6)
36.2(26.7,47.4)
42.4(29.8,49.2)*,#
P<0.05 as compared with baseline
#
th
**
P< 0.001 as compared with baseline
P < 0.05 as compared with Post-oP Month 1
10
symptom
distress
10.0
8.0
Pre-op joint pain,PCS& MCS
Pre-op itching, PCS& MCS
6.0
→Pre-op muscle weakness, PCS& MCS
4.0
2.0
0.0
PCS score 0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
Figure 1. Relationship of PCS score and pre-operative symptom distress
due to joint pain, itching, and muscle weakness.
10.0
symptom
distress
8.0
6.0
4.0
2.0
0.0
MCS score 10.0
20.0
30.0
40.0
50.0
60.0
70.0
Figur e 2. Relationship of MCS scor e and pr e-oper ative symptom distr ess due to joint pain,
itching, and muscle weakness.
11
10.0
symptom
distress
8.0
6.0
Post-op joint pain,PCS_1& MCS_1
4.0
Post-op itching, PCS_1& MCS_1
Post-op mscle weakness, PCS_1&
2.0
MCS_1
0.0
PCS score
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
Figur e 3. Relationship of PCS scor e and sym ptom distr ess due to joint pain,
itching, and m uscle weakness at one m onth after sur ger y.
symptom
distress
10.0
8.0
6.0
4.0
2.0
0.0
MCS score
10.0
20.0
30.0
40.0
50.0
60.0
70.0
Figur e 4. R elationship of M C S scor e and sym ptom distr ess due to joint pain, itching, and
m uscle weakness at one m onth after sur ger y.
12
10.0
symptom
distress
8.0
Post-op joint pain,PCS_3& MCS_3
6.0
Post-op itching, PCS_3& MCS_3
4.0
Post-op mscle weakness, PCS_3&
2.0
MCS_3
0.0
PCS score 10.0
20.0
30.0
40.0
50.0
60.0
70.0
Figur e 5. Relationship of PCS scor e and sym ptom distr ess due to joint pain,
itching, and m uscle weakness at thr ee m onths after sur ger y.
10.0
symptom
distress 8.0
6.0
4.0
2.0
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
MCS score
Figur e 6. R elationship of M C S scor e and sym ptom distr ess due to joint
pain, itching, and m uscle weakness at thr ee m onths after sur ger y.
13