Evaluation of intraoperative parathormone measurement for predicting successful surgery in patients undergoing subtotal/total parathyroidectomy due to secondary hyperparathyroidism

Sex-Stratified Predictors of Prolonged Operative Time and Hospital Admission in Outpatient Parathyroidectomy

Our retrospective database study investigates sex-stratified predictors of prolonged operative time (POT) and hospital admission following parathyroidectomy for primary hyperparathyroidism (PHPT). The 2016 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for patients with PHPT undergoing parathyroidectomy. Cases analyzed were all outpatient status, arrived from home, coded as non-emergent, and elective. POT was defined by the 75th percentile. Hospital admission was defined as LOS ≥ 1 day. Univariate and multivariable binary logistic regressions were utilized. Of 7442 cases satisfying inclusion criteria, the majority were female (78.0%) and White (78.5%). Median OT (IQR) for females and males was 77 (58-108) and 81 (61-109) minutes, respectively (P = 0.003). 1965 (33.9%) females and 529 (32.3%) males required hospital admission. Independent predictors of POT included ASA class III/IV (aOR 1.342, 95% CI 1.007-1.788) and obesity (aOR 1.427, 95% CI 1.095-1.860) for males (P < 0.05). Independent predictors of hospital admission included age (aOR 1.008, 95% CI 1.002-1.014), ASA class III/IV (aOR 1.490, 95% CI 1.301-1.706), obesity (aOR 1.309, 95% CI 1.151-1.489), dyspnea (aOR 1.394, 95% CI 1.041-1.865), chronic steroid use (aOR 1.674, 95% CI 1.193-2.351), and COPD (aOR 1.534, 95% CI 1.048-2.245) for females (P < 0.05); and ASA class III/IV (aOR 1.931, 95% CI 1.483-2.516) and bleeding disorder (aOR 2.752, 95% CI 1.443-5.247) for males (P < 0.005). In conclusion, predictors of POT and hospital admission following parathyroidectomy for PHPT differed by patient sex. Identifying patients at risk for POT and hospital admission may optimize healthcare resource utilization. Level of Evidence: IV.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04444-3.

Predictive value of characteristics of resected parathyroid glands for persistent secondary hyperparathyroidism during parathyroidectomy

BACKGROUND

Parathyroidectomy (PTX), an effective treatment for refractory secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD) patients, still has a high persistent rate. This study aimed to analyze the predictive value of characteristics of resected parathyroid glands for postoperative persistent SHPT.

METHODS

The clinical data of patients with persistent SHPT and successful PTX controls who had or underwent total parathyroidectomy with forearm autotransplantation (TPTX + AT) was retrospectively collected. The characteristics including the number, minimum weight, maximum weight and total weight of resected parathyroid glands from each patient were recorded. Characteristics and cutoff value of resected parathyroid glands for the prediction of persistent SHPT were analyzed.

RESULTS

A total of 227 patients (62 persistent SHPT patients and 165 successful PTX controls) were enrolled in the study. Forty-one (66%) persistent SHPT cases related to supernumerary parathyroid and the remaining 21 (34%) cases related to residual undetected parathyroid. In addition, ectopic parathyroid was found in 8 patients (13%) before PTX. The average number of resected glands in the persistent SHPT group and successful PTX group was 3.53 ± 0.72 and 3.93 ± 0.25 respectively (p < 0.001). There was significance in the number of patients with different resected parathyroid glands between two groups (p < 0.001). When the resected gland number was 4, minimum weight of the parathyroid was noted to be heavier in the persistent SHPT group than that in the successful PTX group (0.52 ± 0.31 g vs. 0.38 ± 0.19 g, p < 0.001). For persistent SHPT prediction, cutoff value of minimum weight was 0.535 g, with sensitivity of 46% and specificity of 82% (AUC = 0.611; p = 0.029).

CONCLUSIONS

Major reason for the persistent SHPT is the existence of supernumerary parathyroid glands or resection of less than 4 glands. When 4 glands were resected, a minimum total parathyroid gland weight heavier than 0.535 g implied the potential presence of a missed supernumerary parathyroid gland, which also contributed to the persistent SHPT.

PTH Spikes During Surgical Treatment for Secondary and Tertiary Hyperparathyroidism: A Prospective Observational Study

BACKGROUND

The aim of the present study was to determine whether PTH spikes in renal hyperparathyroidism can interfere with the interpretation of intraoperative PTH monitoring and to determine its frequency and characteristics.

METHODS

This was a prospective observational study of consecutive patients who underwent surgical treatment in a single tertiary institution. Patients were divided into two groups: spike and no spike. Patients with secondary and tertiary hyperparathyroidism were analyzed separately. Intraoperative PTH monitoring by venous serial samples: two samples were taken before the excision of the parathyroid gland, and two others were taken after resection.

RESULTS

PTH spikes occurred in 23.5% (53 of 226), and their occurrence was similar between secondary and tertiary hyperparathyroidism patients (p = 0.074). The relative PTH spike intensity was higher in transplanted patients than in dialysis patients (55 vs. 20%, p = 0.029). A characteristic of the secondary hyperparathyroidism patients was the highest frequency of surgical failure (23 vs. 7.5%, p = 0.016) and the higher occurrence of supernumerary glands in the spike group (23 vs. 10.3%, p = 0.035). Supernumerary parathyroid was associated with surgical failure [19.1 (6.5-55.7) odds ratio [confidence interval], p < 0.001). In the studies evaluating the diagnostic test validity for patients on dialysis and experiencing spikes, the most significant impacts were in the sensitivity, accuracy, and negative predictive value of the method.

CONCLUSIONS

PTH spikes occurred in up to 23.5% of renal hyperparathyroidism surgical treatments and can negatively influence the intraoperative parathyroid hormone monitoring. Regarding the phenomenon of PTH spikes, it is prudent to think about the possibility of a hyperplastic supernumerary gland.

OUP accepted manuscript

Background

Several studies have reported on the use of intraoperative parathyroid hormone (ioPTH) measurements during parathyroidectomy (PTX) for renal hyperparathyroidism (rHPT), but there is no consensus on whether it is helpful and, if so, what protocol should be used. Therefore, the literature was systematically reviewed to assess a correlation between ioPTH and early postoperative parathyroid hormone (PTH) levels in patients undergoing PTX for rHPT, separately for those on dialysis and those with a functioning renal transplant.

Methods

A systematic literature search was performed in electronic databases. Quality assessment was performed using the Quality In Prognosis Studies tool. Mean ioPTH values were calculated at different time points and correlated to the postoperative PTH levels within 1 month. Fixed-effect and random-effects models were performed to assess the mean ioPTH levels at 10 or 20 min after resection (T10 and T20). Stratified analyses were performed for patients on dialysis and those with a functioning renal transplant.

Results

Of the 3087 records screened, 14 studies were included, including some 1177 patients; 1091 were on dialysis and 86 had a functioning kidney transplant. Risk of bias was moderate for most studies. For patients on dialysis, T10 and T20 mean ioPTH levels were 32.1 (95 per cent c.i. 24.3 to 39.9) pmol/l and 15.4 (95 per cent c.i. 7.8 to 22.9) pmol/l) in the random effects meta-analysis. Between individual studies, ioPTH ranged from 4.0–65.1 pmol/l at T10 and 8.6–25.7 pmol/l at T20. T10 and T20 ioPTH were 9.6 and 4.1 times the postoperative PTH—after T20 ioPTH stabilized in those on dialysis. In patients with a functioning renal transplant, ioPTH levels seemed to plateau after 10 min and measured 2.6 times the postoperative PTH.

Conclusion

There is a strong correlation between ioPTH and early postoperative PTH levels, indicating that ioPTH is potentially a useful instrument during PTX in patients with rHPT. For patients on dialysis, at T20 ioPTH levels have stabilized and are approximately four times the postoperative PTH. Therefore, it is recommended to use ioPTH 20 min after resection in patients on dialysis, which might be longer than necessary for those with a kidney transplant.

Use of 99mTc-sestamibi SPECT/CT imaging in predicting the degree of pathological hyperplasia of the parathyroid gland: semi-quantitative analysis

Background

Previous studies have demonstrated that ^99mTc-sestamibi (^99mTc-MIBI) Single-Photon Emission Computed Tomography/ Computed Tomography (SPECT/CT) imaging is an effective isotopic technique for locating the parathyroid in secondary hyperparathyroidism (SHPT). This study aimed to explore further the correlation between ^99mTc-MIBI SPECT/CT imaging and SHPT to demonstrate the value of ^99mTc-MIBI SPECT/CT in evaluating the degree of pathological hyperplasia of the parathyroid gland (PG).

Methods

The demographics, surgical records, and follow-up information of 91 patients were recorded and analyzed. A total of 216 paraffin-embedded PGs of 54 patients were obtained and analyzed.

Results

Patients with ^99mTc-MIBI negative PG(s) had significantly lower preoperative serum phosphorus and higher serum calcium levels at 6 months postoperatively compared to those with ^99mTc-MIBI positive PG(s) (P<0.05). We also found a higher total uptake ratio of the region of interest (URRI) and higher URRI max in the hypocalcemia group than in the non-hypocalcemia group. Both URRI total (P=0.003) and URRI max (P=0.028) were independent risk factors for hypocalcemia 6 months postoperatively. The URRI values of the PGs were significantly positively correlated with glandular weight (R²=0.343, P<0.001), glandular volume (R²=0.240, P<0.001), and degree of pathological hyperplasia (P<0.001). However, the URRI value of the PGs exhibited a notably weak correlation with proliferating cell nuclear antigen (PCNA) (R²=0.035, P=0.006). The area under the receiver operating characteristic curve showed a URRI evaluative value of 0.771 for diffuse and nodular types in 216 PGs (P<0.001). We further evaluated 167 nodular-type PGs, distinguishing between nodular hyperplasia and a single nodule; the URRI evaluative value reached 0.819, which was higher than the volume or weight (P<0.001).

Conclusions

The ^99mTc-MIBI SPECT/CT scintigraphy results were related to serum calcium levels at 6 months after total parathyroidectomy with autotransplantation (TPTX+AT), suggesting the occurrence of hypocalcemia (6 months after TPTX+AT). More importantly, this technique effectively evaluated the pathological hyperplasia of PGs preoperatively, and therefore, could assist surgeons in selecting the PGs with the lowest degree of hyperplasia intraoperatively.

Diagnostic Values of Intraoperative (1-84) Parathyroid Hormone Levels are Superior to Intact Parathyroid Hormone for Successful Parathyroidectomy in Patients With Chronic Kidney Disease

OBJECTIVE

Persistent secondary hyperparathyroidism (SHPT) may occur because of residual cervicothoracic parathyroids in parathyroidectomy (PTX) patients with chronic kidney disease. We prospectively compared the predictive values of intraoperative plasma (1-84) parathyroid hormone (PTH) and intact PTH (iPTH) levels to improve the safety and efficacy of PTX.

METHODS

We included 100 healthy controls, 162 stage 5 chronic kidney disease patients without SHPT, and 214 patients who underwent PTX because of SHPT. Plasma iPTH and (1-84) PTH levels were measured before incision (io-iPTH0 and io-[1-84]PTH0, respectively) and 10 minutes (io-iPTH10 and io-[1-84]PTH10, respectively) and 20 minutes (io-iPTH20 and io-[1-84]PTH20, respectively) after removing all parathyroids. The percentage reduction of iPTH and (1-84) PTH at 10 minutes (io-iPTH10% and io-[1-84]PTH10%, respectively) and 20 minutes (io-iPTH20%, and io-[1-84]PTH20%, respectively) was calculated. iPTH and (1-84) PTH were measured using second- and third-generation PTH assays, respectively.

RESULTS

Compared with the controls and non-PTX patients, the PTX group had more obvious mineral metabolism disorders. There were 187 successful PTXs, 19 patients with persistent SHPT, and 8 patients lost to follow-up. The receiver operating characteristic curves revealed that io-(1-84)PTH10% >86.6% and io-(1-84)PTH20% >87.5% suggested successful PTX. The sensitivity of io-iPTH20% and io-(1-84)PTH20% were higher than those at the timepoint of 10 minutes. Moreover, the specificity and sensitivity of the (1-84) PTH reduction percentage were superior to that of iPTH.

CONCLUSION

Intraoperative reduction percentages of plasma (1-84) PTH levels are superior to iPTH for accurately predicting successful PTX, especially at 20 minutes after all cervicothoracic parathyroids had been resected.

Critical analysis of the intraoperative parathyroid hormone decrease during parathyroidectomy for secondary and tertiary hyperparathyroidism

BACKGROUND

This study aims to determine whether intraoperative parathyroid hormone monitoring helps to predict early surgical outcomes in patients with renal hyperparathyroidism and evaluate the impact on decision making during surgery.

METHODS

A prospective study was conducted. Serial samples of the intraoperative parathyroid hormone were collected; 2 of these were taken before the excision, and 2 were taken after the planned parathyroid resection (10 minutes and 15 minutes). We tested the criterion of an intraoperative parathyroid hormone percentage decay ≥80% of the highest value of the basal samples as a predictor of success.

RESULTS

Of the 228 patients, parathyroidectomy achieved success in 92.1%. In patients with secondary hyperparathyroidism, the failure group showed a tendency to stabilize or even increase the intraoperative parathyroid hormone values from the 10-minute measure (577 pg/mL) to the 15-minute measure (535 pg/mL) (P = .903). Conversely, intraoperative parathyroid hormone continued to drop in those with a successful outcome: 245 pg/mL (10 minutes) and 206 pg/mL (15 minutes) (P < .001). The failure group had a significantly lower percentage decay (P < .001) from baseline when compared with the success group. The intraoperative parathyroid hormone influenced the surgical management in up to 7% of the cases. The intraoperative parathyroid hormone dosage method showed an accuracy of 86%, a sensitivity of 88%, and specificity of 67%.

CONCLUSION

In patients with renal hyperparathyroidism undergoing parathyroidectomy, the use of intraoperative parathyroid hormone may help to predict an early therapeutic outcome with high sensitivity and accuracy by indicating the operation's success when there is an 80% reduction of baseline intraoperative parathyroid hormone 15 minutes after removal of the enlarged glands, an associated continuous decrease in serum intraoperative parathyroid hormone levels between 10 and 15 minutes, and achievement of plasma target values <500 pg/mL.

Diagnostic performance of ultrasonography, dual-phase 99mTc-MIBI scintigraphy, early and delayed 99mTc-MIBI SPECT/CT in preoperative parathyroid gland localization in secondary hyperparathyroidism

BACKGROUND

Secondary hyperparathyroidism (SHPT) usually requires parathyroidectomy when drug regimens fail. However, obtaining an exact preoperative map of the locations of the parathyroid glands is a challenge. The purpose of this study was to compare the diagnostic performance of US, dual-phase ^99mTc-MIBI scintigraphy, early and delayed ^99mTc-MIBI SPECT/CT in patients with SHPT.

METHODS

Sixty patients with SHPT who were undergoing dialysis were evaluated preoperatively by US, dual-phase ^99mTc-MIBI scintigraphy, early and delayed ^99mTc-MIBI SPECT/CT. Postoperative pathology served as the gold standard. The sensitivity, specificity, and accuracy were determined for each method. Spearman correlation analysis was used to analyse the correlation of hyperplastic parathyroid calcification with serum alkaline phosphatase (ALP) and parathyroid hormone (PTH).

RESULTS

A total of 229 lesions in 60 patients were pathologically confirmed to be parathyroid hyperplasia, with 209 lesions in typical sites, 15 lesions in the upper mediastinum and 5 lesions in the thyroid. A total of 88.33% (53/60) of patients had four lesions. US, early and delayed ^99mTc-MIBI SPECT/CT had significantly higher sensitivity and accuracy than dual-phase ^99mTc-MIBI scintigraphy (P < 0.001). Furthermore, early ^99mTc-MIBI SPECT/CT had significantly higher sensitivity (P < 0.001) and accuracy (P = 0.001 and P < 0.001) than US and delayed ^99mTc-MIBI SPECT/CT. In patients with ectopic hyperplastic parathyroid glands, the sensitivity of early ^99mTc-MIBI SPECT/CT (90%) was significantly higher than that of US (55%) and dual-phase ^99mTc-MIBI scintigraphy (50%) (P < 0.05). The Spearman correlation results showed a significant albeit weak association between calcification and both serum PTH and ALP (P = 0.002).

CONCLUSION

The ability of early ^99mTc-MIBI SPECT/CT to detect hyperplastic parathyroid glands in patients with SHPT is superior to that of US, dual-phase ^99mTc-MIBI scintigraphy and delayed ^99mTc-MIBI SPECT/CT; furthermore, dual-phase ^99mTc-MIBI SPECT/CT is not essential.

99mTc-MIBI SPECT/CT imaging had high sensitivity in accurate localization of parathyroids before parathyroidectomy for patients with secondary hyperparathyroidism

Purpose: Accurate preoperative parathyroid localization is important for successful parathyroidectomy (PTX). The aim of our study was to investigate whether SPECT/CT has enhanced effect in preoperative localization of parathyroids. Methods: In our retrospective cohort study, we evaluated the effects of technetium-99m methoxyisobutylisonitrile-single-photon emission computed tomography/computed tomography (^99mTc-MIBI SPECT/CT) on preoperative parathyroid localization for 645 secondary hyperparathyroidism (SHPT) patients. Among them, 569 successful PTX patients were divided into group A (received ^99mTc-MIBI scintigraphy, n = 175) and group B (received ^99mTc-MIBI scintigraphy and SPECT/CT imaging, n = 394). Sensitivity, specificity, and consistency of two imaging methods in preoperative localization of parathyroids were compared. Results: Overall sensitivity and consistency were higher in group B, while there was no difference in specificity between the two groups. In group A, the sensitivity of ^99mTc-MIBI was 50.00%, 77.11%, 61.76%, and 76.54% in the right upper gland (RU), right lower gland (RL), left upper gland (LU), and left lower gland (LL) subgroups, while the consistency was 52.00%, 76.57%, 61.71%, and 75.43%, respectively. In group B, the sensitivity of ^99mTc-MIBI with SPECT/CT was 69.39%, 90.03%, 78.07%, and 84.27%, and the consistency was 69.54%, 88.32%, 78.43%, and 84.26%, respectively. The sensitivity and consistency in lower glands were higher than in upper glands in both groups. Sensitivity for eutopic parathyroid was higher in group B, while there was no difference for ectopic parathyroid. Conclusions: ^99mTc-MIBI SPECT/CT can increase the sensitivity and consistency of preoperative localization of eutopic parathyroid glands, and it can accurately locate ectopic parathyroid without sensitivity improvement.

Effects of parathyroidectomy on tumoral calcinosis in uremic patients with secondary hyperparathyroidism

BACKGROUND

Tumoral calcinosis (TC) is a rare disease derived from uremic secondary hyperparathyroidism (SHPT). However, parathyroidectomy (PTX) seems to be ineffective at relieving TC in some patients. In this study, we investigated the relationship between PTX and TC shrinkage.

METHODS

We retrospectively followed up nine TC patients who underwent PTX, dividing them into two groups: those with TC size reduced by > 80% were in the "effective group" (group A), and the rest in the "ineffective group" (group B).

RESULTS

We enrolled nine patients (7 men; mean age 38.6 ± 10.9 years) with SHPT-related TC. One patient with calciphylaxis was excluded due to sudden death. The efficiency of PTX in causing TC regression was 62.5% (5 patients in group A). Group A had a shorter overall duration of TC (6 [5.5, 6.0] vs. 9 [8.0, 10.0] months; P = 0.02) and higher serum levels of alkaline phosphatase (ALP; 408.0 [217.9, 1101.7] vs. 90.8 [71.0, 102.1] pg/ml; P = 0.03) and high-sensitivity C-reactive protein (hs-CRP; 82.7 [55.0, 112.4] vs. 3.1 [3.1, 4.5] mg/l; P = 0.02). Average calcium supplementation within 1 week of surgery was significantly greater in group A than in group B (96.8 [64.1, 105.3] vs. 20.1 [13.1, 32.7] g; P = 0.04). Patients in both the groups demonstrated similar serum phosphate levels before PTX, but these levels were higher in group B than in group A at follow-up times (3 months, P = 0.03; 6 months, P = 0.03).

CONCLUSIONS

The shorter duration of pre-existing TC and higher ALP levels before PTX, as well as lower serum phosphate levels after PTX, were correlated with effective SHPT-TC shrinkage.

Parathyroid Hormone Fragments: New Targets for the Diagnosis and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder

As a common disorder, chronic kidney disease (CKD) poses a great threat to human health. Chronic kidney disease-mineral and bone disorder (CKD-MBD) is a complication of CKD characterized by disturbances in the levels of calcium, phosphorus, parathyroid hormone (PTH), and vitamin D; abnormal bone formation affecting the mineralization and linear growth of bone; and vascular and soft tissue calcification. PTH reflects the function of the parathyroid gland and also takes part in the metabolism of minerals. The accurate measurement of PTH plays a vital role in the clinical diagnosis, treatment, and prognosis of patients with secondary hyperparathyroidism (SHPT). Previous studies have shown that there are different fragments of PTH in the body's circulation, causing antagonistic effects on bone and the kidney. Here we review the metabolism of PTH fragments; the progress being made in PTH measurement assays; the effects of PTH fragments on bone, kidney, and the cardiovascular system in CKD; and the predictive value of PTH measurement in assessing the effectiveness of parathyroidectomy (PTX). We hope that this review will help to clarify the value of accurate PTH measurements in CKD-MBD and promote the further development of multidisciplinary diagnosis and treatment.

Sixty-Two-Year-Old Male Suffering From Uremic Leontiasis Ossea Caused by Severe Secondary Hyperparathyroidism

Secondary hyperparathyroidism (SHPT) is a long‐term complication of chronic kidney disease–mineral and bone disorder (CKD‐MBD). SHPT is characterized by hyperplasia of the parathyroid glands and abnormal secretion of parathyroid hormones (PTH), calcium and phosphorous metabolic disorders, renal osteodystrophy, vascular and soft tissue calcification, malnutrition, and other multiple system complications, which can seriously affect the quality of life of the patient and increase the risk of cardiovascular disease and mortality rate. Uremic leontiasis ossea (ULO) is a medical condition only rarely encountered clinically. SHPT causes craniofacial bone deformity accompanied by lesions of the nerve, cardiovascular, respiratory, bone, or other systems within the body. The case discussed here is related to severe SHPT. A 62‐year‐old male patient was suffering from leontiasis ossea, pectus excavatum, vascular calcification, spontaneous bone fractures, and lower limb deformities. He was undergoing hemodialysis and given total parathyroidectomy (TPTX) with autotransplantation (AT). We further analyzed the multivariate therapeutic effects of TPTX on this patient in order to provide clinical data for standardized treatment of individuals with CKD‐MBD. © 2018 The Authors JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Diagnostic Accuracy Study of Intraoperative and Perioperative Serum Intact PTH Level for Successful Parathyroidectomy in 501 Secondary Hyperparathyroidism Patients

Parathyroidectomy (PTX) is an effective treatment for severe secondary hyperparathyroidism (SHPT); however, persistent SHPT may occur because of supernumerary and ectopic parathyroids. Here a diagnostic accuracy study of intraoperative and perioperative serum intact parathyroid hormone (iPTH) was performed to predict successful surgery in 501 patients, who received total PTX + autotransplantation without thymectomy. Serum iPTH values before incision (io-iPTH0), 10 and 20 min after removing the last parathyroid (io-iPTH10, io-iPTH20), and the first and fourth day after PTX (D1-iPTH, D4-iPTH) were recoded. Patients whose serum iPTH was >50 pg/mL at the first postoperative week were followed up within six months. Successful PTX was defined if iPTH was <300 pg/mL, on the contrary, persistent SHPT was regarded. There were 86.4% patients underwent successful PTX, 9.8% remained as persistent SHPT and 3.8% were undetermined. Intraoperative serum iPTH demonstrated no significant differences in two subgroups with or without chronic hepatitis. Receiver operating characteristic (ROC) curves showed that >88.9% of io-iPTH20% could predict successful PTX (area under the curve [AUC] 0.909, sensitivity 78.6%, specificity 88.5%), thereby avoiding unnecessary exploration to reduce operative complications. D4-iPTH >147.4 pg/mL could predict persistent SHPT (AUC 0.998, sensitivity 100%, specificity 99.5%), so that medical intervention or reoperation start timely.

Kidney Disease Improving Global Outcomes guidelines and parathyroidectomy for renal hyperparathyroidism

BACKGROUND

Patients with end-stage renal disease develop hypocalcemia, resulting in secondary hyperparathyroidism (SHPT). No clear criterions exist to aid in surgical decision making for SHPT. The 2009 Kidney Disease Improving Global Outcomes (KDIGO) guidelines provide target ranges for serum calcium, phosphate, and parathyroid hormone (PTH) levels in patients with end-stage renal disease. Parathyroidectomy can help achieve these targets. The study purpose was to examine how parathyroidectomy for SHPT impacts KDIGO targets during immediate and long-term follow-up and to evaluate KDIGO categorization with receipt of additional surgical intervention.

METHODS

A retrospective review of a prospective parathyroidectomy database was performed. Included patients had SHPT, were on dialysis, and underwent parathyroidectomy. Calcium, phosphate, and PTH values were classified as below, within, or above KDIGO targets.

RESULTS

Between 2000 and 2013, 36 patients with SHPT met criteria. Subtotal parathyroidectomy was performed in 89%, total parathyroidectomy in 11%. Follow-up time was 54 ± 7 mo. Eight patients (22%) required additional surgery. Twenty-eight patients (76%) were alive at the last follow-up. At the last-follow up, patients had phosphate (46%), and PTH (17%) above KDIGO ranges. Factors associated with reoperation were assessed. Patient PTH within or above target immediately postoperative had a higher rate of reoperation (P < 0.01). At the last follow-up, higher phosphate (P = 0.054) and PTH (P < 0.001) were associated with higher reoperation rates, but calcium (P = 0.33) was not.

CONCLUSIONS

PTH and phosphate levels above KDIGO indices were associated with additional surgical intervention. Many patients had laboratory indices above range at the last follow up, suggesting more patients had persistent or recurrent disease than those who underwent reoperation. Patients may benefit from more aggressive medical and/or surgical management.

Plasma FGF23 levels and heart rate variability in patients with stage 5 CKD

Fibroblast growth factor 23(FGF23) is a bone-derived hormone which regulates mineral homeostasis but may also have a role in cardiovascular disease. Here, we found that higher plasma FGF23 was independently associated with decreased heart rate variability in stage 5 CKD patients and parathyroidectomy may reverse these abnormal indicators.

INTRODUCTION

Lower heart rate variability (HRV) in patients with chronic kidney disease (CKD) compared with healthy controls is associated with increased risk of cardiovascular disease (CVD). Higher levels of plasma FGF23 also predict higher risk of CVD. Here, we aimed to evaluate the relationship between plasma FGF23 levels and HRV in patients with stage 5 CKD and to investigate longitudinal changes of them together with the correlation between their changes in two severe secondary hyperparathyroidism (SHPT) subgroups with successful parathyroidectomy (PTX) and persistent SHPT.

METHODS

This cross-sectional study included 100 stage 5 CKD patients, 78 controls, and a prospective study in two PTX subgroups classified as successful PTX (n = 24) and persistent SHPT (n = 4) follow-up. Blood examination and 24-h Holter monitoring for HRV were measured.

RESULTS

Most HRV indices were lower in stage 5 CKD patients than in healthy controls, and plasma FGF23 levels were higher. In multivariate stepwise regression models, levels of plasma FGF23 and serum parathyroid hormone (PTH) were correlated with HRV. The successful PTX subgroup had significant improvements over baseline in HRV indices. Persistent SHPT subgroup had numerically similar changes in HRV indices. However, plasma FGF23 levels decreased in both subgroups.

CONCLUSIONS

Plasma FGF23 levels were higher in CKD patients than in controls, much higher in patients with severe SHPT. FGF23 was independently associated with decreased HRV in stage 5 CKD. Successful PTX may reverse these abnormal indicators and contribute to decreases in the risk of cardiovascular disease.

Secondary parathyromatosis in a patient with normal kidney function: review of diagnostic modalities and approaches to management

OBJECTIVE

To present a patient with secondary parathyromatosis, a rare complication of parathyroidectomy, and to discuss issues currently pertinent to its diagnosis and management.

METHODS

Data were derived from clinical and pathologic observations obtained during patient care.

RESULTS

The index patient developed intractable hyperparathyroidism and hypercalcemia that has persisted after 4 surgical procedures and has remained largely resistant to medication, albeit with partial amelioration with combined bisphosphonate and cinacalcet.

CONCLUSION

Despite the rarity of this difficult complication of parathyroidectomy, its iatrogenic basis emphasizes a need for heightened awareness and caution among surgeons and endocrinologists. Herein we report an instance of intractable secondary parathyromatosis in a patient with normal kidney function, and we review current approaches to diagnosis and management.

Surgical parathyroidectomy versus cinacalcet therapy: in the management of secondary hyperparathyroidism

OBJECTIVES

The aim of this study was to compare the clinical effectiveness of surgery with calcimimetics as treatment strategies for managing the biochemical abnormalities that characterize secondary hyperparathyroidism (2HPTH), resistant to optimal conventional therapy in patients with end-stage renal failure (ESRF).

STUDY DESIGN

A historical cohort study.

SETTING

Maxillofacial Department, Morriston Hospital, Swansea, United Kingdom.

SUBJECTS AND METHODS

Fifty-four patients with 2HPTH resistant to optimal conventional medical management were studied. One cohort of 20 patients was treated with surgical parathyroidectomy, the other cohort of 34 patients with cinacalcet. Serum parathyroid hormone (PTH) and bone profile were measured before and at monthly intervals after intervention.

RESULTS

Both cohorts were comparable in their demographic profile, pretreatment comorbidities, baseline PTH, and bone profile. In all 20 surgical patients, the 1-week postoperative PTH had decreased by 97% (P < .001); in the medical cohort after 4 months of daily cinacalcet, the PTH decreased by 48% (P < .001) from baseline. This reduction was maintained at 18 months. In all but 1 surgical patient, alkaline phosphatase (ALP) decreased to normal levels, whereas on cinacalcet, there was no statistically significant reduction. Patients who underwent parathyroidectomy had a more significant decrease in PTH (P < .001) and ALP (P < .0014) than did patients on cinacalcet therapy. All patients managed surgically who complained of preoperative symptoms of pruritis and bone pain expressed complete resolution or significant improvement after parathyroidectomy (P < .001, P < .003, respectively).

CONCLUSION

Surgery was superior to "medical" parathyroidectomy in controlling PTH and ALP.