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Goncu B, Yucesan E, Salepcioglu Kaya H, Kazancioglu R, Ersoy YE, Akcakaya A. The Challenge of Preoperative Panel Reactive Antibody Positivity in Parathyroid Transplantation. EXP CLIN TRANSPLANT 2024; 22:233-242. [PMID: 38385404 DOI: 10.6002/ect.mesot2023.p59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVES Identifying suitable recipient criteria and matching recipients with appropriate donors are required to increase survival for parathyroid transplant. This study was undertaken to evaluate transplant survival rates while comparing preoperative panel reactive antibody positivity. MATERIALS AND METHODS The study included 14 hypoparathyroidism patients who presented to our clinic for parathyroid transplant. Preoperative ABO compatibility and negative cross-match tests were prioritized for recipient-donor matching, and panel reactive antibody screening tests were performed. During the 24-month follow-up, we evaluated medication use and serum calcium, phosphorus, and parathormone levels of patients. RESULTS Preoperative panel reactive antibody positivity was assessed in 3 groups. The HLA class I-positive group (mean fluorescence intensity range, 179-1770) showed decreased medication use and stability in serum calcium levels. The HLA class IIpositive (mean fluorescence intensity range, 85-3959) showed decreased medication use by 25% to 50% and returned to their former prescription doses after 12 months. An opposite pattern was observed in 2 patients with panel reactive antibody positivity for both HLA classes (mean fluorescence intensity range, 462-2289), with 1 patient requiring medication for continuing symptoms and the other patient occasionally taking additional magnesium supplementation, despite decreased medication doses after 12 months. Serum calcium levels remained normal, and parathormone and phosphorus levels were elevated. CONCLUSIONS Improving patient symptoms and having no requirement for intravenous calcium replacement are priorities, and monitoring serum levels is the next important step. Varied panel reactive antibody positivities and survival rates indicate a requirement, and each HLA class could require a proper limitation for the mean fluorescence intensity. Preoperative mean fluorescence intensity cut-off value should be <900. Higher mean fluorescence intensity values in panel reactive antibody screenings could increase risk of short-term graft survival after parathyroid transplant. Further studies should include immunological risk assessments by individualizing the outcome with donor-specific antibodies.
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Affiliation(s)
- Beyza Goncu
- From the Department of Medical Services and Techniques, Vocational School of Health Services, Bezmialem Vakif University; and the Parathyroid Transplantation Unit, Organ Transplantation Center, Bezmialem Vakif University Hospital, Istanbul, Türkiye
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Onder CE, Kuskonmaz SM, Koc G, Firat SN, Omma T, Culha C. Evaluation of management of patients with postoperative permanent hypoparathyroidism. How close are we to the targets? Minerva Endocrinol (Torino) 2023; 48:12-18. [PMID: 33269571 DOI: 10.23736/s2724-6507.20.03291-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Postoperative hypoparathyroidism (PO-HypoPT) is a complication usually seen after thyroid surgery. PO-HypoPT, which lasts longer than 6 months is defined permanently. The aim of this study was to evaluate how close permanent PO-HypoPT patients can approach target values. METHODS One hundred seven patients who were followed-up with permanent diagnosis of PO-HypoPT between 2016-2020 were included in the study. The study protocol includes serum albumin corrected total calcium (Alb-sCa), phosphate (P), Ca-P product, and 24 h urine calcium measurements. Laboratory measurements of the patients include the values recorded in 4-year visits and in the last visit. In addition, radiological reports of renal/abdominal ultrasound and cranial tomography examinations performed in our hospital for any reason during this period were also reviewed. RESULTS When looking at the total measurements in the 4-year period, the Alb-sCa level was below the target in most of the measurements (68.1%). P level was higher than normal in 296 (46.2%) measurements. Twenty-four h urine ca excretion was measured 185 times in total visits, and 81 (43.7%) of these measurements showed hypercalciuric values. The patient's latest visit measurements were evaluated on 4 targets (Alb-sCa, P, Ca-P product and 24 h urine Ca excretion). The number of patients meeting all four targets was only 21 (19.6%). Six (7.5%) patients had kidney stones or nephrocalcinosis. Three (0.09%) patients with imaging had calcification in the basal ganglia. CONCLUSIONS Our study shows that the management of the patients with PO-HypoPT is suboptimal with active vitamin D and cholecalciferol treatment.
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Affiliation(s)
- Cagatay E Onder
- Department of Endocrinology and Metabolism, Ankara Training and Research Hospital, Ankara, Türkiye -
| | - Serife M Kuskonmaz
- Department of Endocrinology and Metabolism, Ankara Training and Research Hospital, Ankara, Türkiye
| | - Gonul Koc
- Department of Endocrinology and Metabolism, Ankara Training and Research Hospital, Ankara, Türkiye
| | - Sevde N Firat
- Department of Endocrinology and Metabolism, Ankara Training and Research Hospital, Ankara, Türkiye
| | - Tulay Omma
- Department of Endocrinology and Metabolism, Ankara Training and Research Hospital, Ankara, Türkiye
| | - Cavit Culha
- Department of Endocrinology and Metabolism, Ankara Training and Research Hospital, Ankara, Türkiye
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Gadelha DD, Filho WA, Brandão MAJ, Montenegro RM. Is parathyroid allotransplantation a viable option in the treatment of permanent hypoparathyroidism? A review of the literature. Endocrine 2022; 80:253-265. [PMID: 36583826 DOI: 10.1007/s12020-022-03292-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The standard clinical treatment for hypoparathyroidism, replacement of calcium and vitamin metabolites (calcitriol), has been used for decades; however, evidence points to its inefficiency in acting on the pathophysiology of the disease, which may precipitate or aggravate conditions already related to hypoparathyroidism. Therapies based on recombinant human parathyroid hormone have emerged in recent years but still have low availability due to their high cost. Parathyroid allotransplantation (Pt-a) has been reported as a strategy for treating more severe cases. METHODS This narrative review highlights relevant aspects of conventional permanent hypoparathyroidism treatment and provides a comprehensive and critical review of the reports of applications of Pt-a, especially those carried out in recent years. Particular focus is placed on the following key points: parathyroid immunogenicity, immunosuppression regimens (short-term or chronic), techniques to reduce the expression of immunogenic molecules, follow-up time, and reductions in calcium and vitamin D supplementation. CONCLUSION Pt-a has been considered a safe and relatively low-cost therapy and is believed to have the potential to cure the disease, in addition to treating symptoms. However, there is considerable heterogeneity in treatment protocols; therefore, more studies are required to improve the standardization of the procedure and thus improve the consistency of outcomes.
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Mihai R, Thakker RV. MANAGEMENT OF ENDOCRINE DISEASE: Postsurgical hypoparathyroidism: current treatments and future prospects for parathyroid allotransplantation. Eur J Endocrinol 2021; 184:R165-R175. [PMID: 33599211 PMCID: PMC8052514 DOI: 10.1530/eje-20-1367] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/17/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Permanent postsurgical hypoparathyroidism (POSH) is a major complication of anterior neck surgery in general and of thyroid surgery in particular. Depending on diagnostic criteria, up to 10% of patients undergoing bilateral thyroid surgery develop POSH. This leads to a multitude of symptoms that decrease the quality of life and burden the healthcare provision through complex needs for medication and treatment of specific complications, such as seizures and laryngospasm. METHODS Narrative review of current medical treatments for POSH and of the experience accumulated with parathyroid allotransplantation. RESULTS In most patients, POSH is controlled with regular use of calcium supplements and active vitamin D analogues but a significant proportion of patients continue to experience severe symptoms requiring repeated emergency admissions. Replacement therapy with synthetic PTH compounds (PTH1-34, Natpara® and PTH1-84, teriparatide, Forsteo®) has been assessed in multicentre trials, but the use of this medication is restricted by costs and concerns related to the risk of development of osteosarcoma. Based on recent case reports of successful allotransplantation of parathyroid tissue between siblings, there is renewed interest in this technique. Data on selection of donors, parathyroid cell preparation before allotransplantation, site and timing of transplantation, need for immunosuppression and long-term outcomes are reviewed. CONCLUSION A prospective trial to assess the efficacy of parathyroid allotransplantation in patients with severely symptomatic protracted post-surgical hypoparathyroidism is warranted.
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Affiliation(s)
- Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
- Correspondence should be addressed to R Mihai;
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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Yucesan E, Basoglu H, Goncu B, Akbas F, Ersoy YE, Aysan E. Microencapsulated parathyroid allotransplantation in the omental tissue. Artif Organs 2019; 43:1022-1027. [DOI: 10.1111/aor.13475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/28/2019] [Accepted: 04/18/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Emrah Yucesan
- Institute of Life Sciences and Biotechnology Bezmialem Vakif University Istanbul Turkey
| | - Harun Basoglu
- Faculty of Medicine, Department of Biophysic Bezmialem Vakif University Istanbul Turkey
| | - Beyza Goncu
- Experimental Research Center Bezmialem Vakif University Istanbul Turkey
| | - Fahri Akbas
- Faculty of Medicine, Department of Medical Biology Bezmialem Vakif University Istanbul Turkey
| | - Yeliz Emine Ersoy
- Faculty of Medicine, Department of General Surgery Bezmialem Vakif University Istanbul Turkey
| | - Erhan Aysan
- Faculty of Medicine, Department of General Surgery Bezmialem Vakif University Istanbul Turkey
- Faculty of Medicine, Department of General Surgery Yeditepe University Istanbul Turkey
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Yucesan E, Goncu B, Basoglu H, Ozten Kandas N, Ersoy YE, Akbas F, Aysan E. Fresh tissue parathyroid allotransplantation with short-term immunosuppression: 1-year follow-up. Clin Transplant 2017; 31. [PMID: 29044732 DOI: 10.1111/ctr.13086] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Permanent hypoparathyroidism is a serious problem and requires medications indefinitely. Parathyroid allotransplantation (PA) with short-term immunosuppression is definitive choice but long-term results are not clear. METHOD We performed PA from two donors to two recipients. Both recipients were 39-year-old females. Donors were a 32-year-old female and a 36-year-old male, who both have chronic kidney disease. Routine tests, viral markers, and cross-matches were analyzed individually. The parathyroid glands were resected from the living donors, fragmented quickly in the operation room and injected into the left deltoid muscles of the two recipients. RESULTS Methylprednisolone was administered on post-PA day one and two. Recipients were discharged from the hospital without complications. Calcium and PTH levels were observed throughout 1 year. We did not observe any complications during the follow-up period. Medications ceased in post-transplantation week 1 for Case 1 and after 1 month for Case 2. CONCLUSION Fresh tissue PA with short-term immunosuppression appears to be a promising technique that is easy to perform, is cost-effective, has low risk of side effects and minimal complications with compatibility for HLA conditions. A longer follow-up period and more case studies are needed to determine the risks and benefits of this procedure for future cases.
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Affiliation(s)
- Emrah Yucesan
- Institute of Life Sciences and Biotechnology, Bezmialem Vakif University, Istanbul, Turkey
| | - Beyza Goncu
- Experimental Research Center, Bezmialem Vakif University, Istanbul, Turkey
| | - Harun Basoglu
- Department of Biophysics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Nur Ozten Kandas
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Bezmialem Vakif University, Istanbul, Turkey
| | - Yeliz Emine Ersoy
- Department of General Surgery, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Fahri Akbas
- Department of Medical Biology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Erhan Aysan
- Department of General Surgery, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
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Agha A, Scherer MN, Moser C, Karrasch T, Girlich C, Eder F, Jung EM, Schlitt HJ, Schaeffler A. Living-donor parathyroid allotransplantation for therapy-refractory postsurgical persistent hypoparathyroidism in a nontransplant recipient - three year results: a case report. BMC Surg 2016; 16:51. [PMID: 27488573 PMCID: PMC4972976 DOI: 10.1186/s12893-016-0165-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 07/22/2016] [Indexed: 11/30/2022] Open
Abstract
Background Therapy-refractory persistent hypoparathyroidism after extensive neck surgery is a rare but severe complication. Parathyroid allotransplantation may represent a definitive treatment option. Case presentation A 32-year old female was referred to our hospital with intractable persistent hypocalcemia after neck surgery for papillary thyroid cancer. Despite optimal medical treatment including calcium and vitamin D supplementation and even hormonal replacement therapy hypocalcemic symptoms failed to improve. The quality of life was considered very low. In light of the unsuccessful medical therapy and the young age of the patient parathyroid allotransplantation seemed an attractive treatment option to restore normal calcium homeostasis despite of the need for immunosuppressive therapy after the procedure. Therefore, we performed living-donor allotransplantation of two healthy parathyroid glands to the recipient’s left forearm. The surgical intervention was successful. Neither the donor nor the recipient showed any complications. In the postoperative course clinical symptoms of hypocalcemia significantly improved whereas serum calcium and parathyroid hormone (PTH) levels progressively increased into the normal range. Former intense replacement therapy could be discontinued completely in a stepwise fashion. To date, nearly three years after transplantation, the patient remains asymptomatic with normal serum levels of calcium and PTH. Conclusion Successful living-donor parathyroid allotransplantation for postsurgical hypoparathyroidism represents an innovative therapeutic strategy that could provide the definitive treatment in those patients in which the disease is therapy-refractory. The procedure can be justified even in nontransplant recipients. Retrieval of parathyroid glands from healthy donors is feasible and safe.
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Affiliation(s)
- Ayman Agha
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany.
| | - Marcus Nils Scherer
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Christian Moser
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Thomas Karrasch
- Medical Clinic and Policlinic III, University Hospital Giessen, D-35392, Giessen, Germany
| | - Christiane Girlich
- Department of Internal Medicine I, University Hospital Regensburg, D-93053, Regensburg, Germany
| | - Fabian Eder
- Department of Pathology, University Hospital Regensburg, D-93053, Regensburg, Germany
| | - Ernst-Michael Jung
- Department of Radiology, University Hospital Regensburg, D-93053, Regensburg, Germany
| | - Hans Juergen Schlitt
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Andreas Schaeffler
- Medical Clinic and Policlinic III, University Hospital Giessen, D-35392, Giessen, Germany
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