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. 2010 May;55(5):897-906.
doi: 10.1053/j.ajkd.2009.12.041. Epub 2010 Mar 27.

Intact PTH combined with the PTH ratio for diagnosis of bone turnover in dialysis patients: a diagnostic test study

Johann Herberth  1 , Adam J Branscum, Hanna Mawad, Tom Cantor, Marie-Claude Monier-Faugere, Hartmut H Malluche
Affiliations

Intact PTH combined with the PTH ratio for diagnosis of bone turnover in dialysis patients: a diagnostic test study

Johann Herberth et al. Am J Kidney Dis. 2010 May.

Abstract

Background: Determination of parathyroid hormone (PTH) level is the most commonly used surrogate marker for bone turnover in patients with stage 5 chronic kidney disease on dialysis therapy (CKD-5D). The objective of this study is to evaluate the predictive value of various PTH measurements for identifying low or high bone turnover rate.

Study design: Diagnostic test study.

Settings & participants: 141 patients with CKD-5D from 15 US hemodialysis centers.

Index tests: Intact PTH, PTH 1-84, and PTH ratio (ratio of level of PTH 1-84 to level of large carboxy-terminal PTH fragments).

Reference test or outcome: Bone turnover determined using bone histomorphometry.

Other measurements: Demographic and treatment-related factors, serum calcium and phosphorus.

Results: Patients presented histologically with a broad range of bone turnover abnormalities. In white patients with CKD-5D (n = 70), PTH ratio <1.0 added to intact PTH level <420 pg/mL increased the positive predictive value for low bone turnover from 74% to 90%. In black patients (n = 71), adding PTH ratio <1.2 to intact PTH level <340 pg/mL increased the positive predictive value for low bone turnover from 48% to 90%. Adding PTH ratio >1.6 to intact PTH level of 340-790 pg/mL increased the positive predictive value for high bone turnover from 56% to 71%.

Limitations: Because the research protocol called for carefully controlled blood specimen handling, blood drawing and routine specimen handling might be less stringent in clinical practice. By limiting study participation to black and white patients with CKD-5D, we cannot comment on the roles of intact PTH, PTH 1-84, and PTH ratio in other racial/ethnic groups.

Conclusion: In black patients with CKD-5D, the addition of PTH ratio to intact PTH measurements is helpful for diagnosing low and high bone turnover. In white patients with CKD-5D, it aids in the diagnosis of low bone turnover.

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Figures

Figure 1
Figure 1
Figure 1 a and b: Classification and Regression Tree (CART) analysis using (a) intact PTH and (b) PTH 1–84 in combination with the PTH ratio for bone turnover assessment in White chronic kidney disease stage 5 patients. Abbreviations and definitions: l=low bone turnover; n=normal bone turnover; h=high bone turnover; PPV low = positive predictive value for low bone turnover; PPV high = positive predictive value for high bone turnover; iPTH = intact PTH; PTH ratio = ratio of level of PTH 1–84 to level of large carboxy-terminal PTH fragments.
Figure 1
Figure 1
Figure 1 a and b: Classification and Regression Tree (CART) analysis using (a) intact PTH and (b) PTH 1–84 in combination with the PTH ratio for bone turnover assessment in White chronic kidney disease stage 5 patients. Abbreviations and definitions: l=low bone turnover; n=normal bone turnover; h=high bone turnover; PPV low = positive predictive value for low bone turnover; PPV high = positive predictive value for high bone turnover; iPTH = intact PTH; PTH ratio = ratio of level of PTH 1–84 to level of large carboxy-terminal PTH fragments.
Figure 2
Figure 2
Figure 2 a and b: Classification and Regression Tree (CART) analysis using (a) intact PTH and (b) PTH 1–84 in combination with the PTH ratio for bone turnover assessment in Black chronic kidney disease stage 5 patients. Abbreviations and definitions: l=low bone turnover; n=normal bone turnover; h=high bone turnover; PPV low = positive predictive value for low bone turnover; PPV high = positive predictive value for high bone turnover; PPV non-low = positive predictive value for normal and high bone turnover; iPTH = intact PTH; PTH ratio = ratio of level of PTH 1–84 to level of large carboxy-terminal PTH fragments.
Figure 2
Figure 2
Figure 2 a and b: Classification and Regression Tree (CART) analysis using (a) intact PTH and (b) PTH 1–84 in combination with the PTH ratio for bone turnover assessment in Black chronic kidney disease stage 5 patients. Abbreviations and definitions: l=low bone turnover; n=normal bone turnover; h=high bone turnover; PPV low = positive predictive value for low bone turnover; PPV high = positive predictive value for high bone turnover; PPV non-low = positive predictive value for normal and high bone turnover; iPTH = intact PTH; PTH ratio = ratio of level of PTH 1–84 to level of large carboxy-terminal PTH fragments.
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References

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