By Peter Laird, MD
Smoking is a grave health risk for all people, but in those already at risk of cardiovascular disease such as the ESRD population, adding the risks of smoking carries significant risks of complications. After nearly twenty years of clinical practice, I still advise people I meet that they should consider smoke cessation. Old habits are hard to break, that is my commenting on cigarette smoking. Stopping smoking is not that hard if and when the patient makes up their mind to do so. We can now add one more malady to the extensive list of adverse diseases associated with tobacco abuse, that of increased PTH levels in dialysis patients:
We investigated the relationship between smoking and hyperparathyroidism in a well-characterized group of 161 nondiabetic dialysis patients. Results: Sixty-four patients (40%) were smokers. Heavy smokers had higher intact PTH (median: 280 pg/mL) and PTH1-84 (188 pg/mL) than light smokers (180 pg/mL and 95 pg/mL) and nonsmokers (169 pg/mL and 95 pg/mL). In a multiple regression analysis, smoking was independently associated with intact PTH (ß=0.29, p=0.002) and PTH1-84 (ß=0.29, p=0.002). Fifty-six of 161 patients (35%) were classified as having hyperparathyroidism. In a multiple logistic regression model the odds of hyperparathyroidism were about 4 times higher in heavy smokers (odds ratio 3.88, 95% CI 1.16-12.92, p=0.027) than in nonsmokers. Conclusion: In dialysis patients heavy smoking is independently associated with high levels of intact PTH and PTH1-84. Further observational, mechanistic and interventional studies are needed to assess the nature (causal or noncausal) of these links in ESRD.
Patients who smoked more than one pack per day were at the highest risk of elevated PTH, although those smoking less than a pack a day had a significantly higher measured PTH compared to controls. Secondary hyperparathyroidism in dialysis patients is further associated with mineral bone disease, poor phosphorus control and increased risk of cardiac anomalies. The take home message for all smokers and especially those on dialysis is to explore smoke cessation with your health care team. With the calls by many to reduce Medicare spending on both sides of the congressional aisles, it is the responsibility of each individual to not only consider their own health consequences, but that of all patients on dialysis. Being your own best friend when it comes to taking care of yourself on dialysis is also one way to be your brother's keeper at the same time.