Unique classification of parathyroid dysfunction in patients with transfusion dependent thalassemia major using Nomogram-A cross sectional study

Introduction: Hypoparathyroidism is a rare complication of iron overload in patients with transfusion dependent beta thalassemia major (beta-TM). We aim to determine the prevalence of parathyroid dysfunction in patients with beta-TM. Methods: Diagnosed cases of transfusion dependent beta-TM between 5 and 17 years of age were recruited from outpatient clinics of a non-profit organization in Karachi, Pakistan. Blood and urine samples were collected in fasting to determine Ca, P, Alb, Mg, Cr 25OHD and iPTH. Patients were grouped on the basis of upper and lower levels of Ca, 25OHD and iPTH for assessing parathyroid dysfunction into primary hypoparathyroidism [low calcium (Ca) & intact parathyroid hormone (iPTH)], sub-clinical hypoparathyroidism [low iPTH and 25 hydroxy vitamin D (25OHD), low/normal Ca], normal functioning parathyroid gland [Normal Ca, iPTH and 25OHD] and secondary hyperparathyroidism [high iPTH, low/normal Ca and/or 25OHD]. Using PTH nomogram subject specific expected PTH (maxPTH) was calculated. Difference between maxPTH and measured iPTH was determined to assess the utility of nomogram in identifying parathyroid gland dysfunction. The statistical analysis was performed using the Statistical Package of Social Sciences (SPSS) version 20. Results: Median age of patients was 11 years (13-7) with males being 54.2% (n= 205). Based on Ca, 25OHD and iPTH, primary hypoparathyroidism was identified in 3.4% (n= 13) [median iPTH 11.3 pg/ml (12.6-7)], 52.3% (n= 192) had subclinical hypoparathyroidism [iPTH 40.4 pg/ml (52.7-28.7)], and 34% (n= 125) were identified as secondary hyperparathyroidism [iPTH 88.6 pg/ml (116-74.7)]. Normal response to Ca & 25OHD was seen in 10.6% (n= 39) [iPTH 44.2 pg/ml (53.8-33.4)] patients. High phosphorous was present in all groups. Difference between maxPTH & iPTH was highest in primary hypoparathyroidism, followed by subclinical and secondary hyperparathyroidism. Conclusion: Nomogram by Harvey et al. identify low secretion capacity of parathyroid gland that correlated with biochemical classification of patients. It requires clinical validation before using in clinical practice for assessing parathyroid dysfunction.