[Parathyroid allotransplantation as permanent treatment in a renal transplant patient]

Living-donor parathyroid allotransplantation for therapy-refractory postsurgical persistent hypoparathyroidism in a nontransplant recipient - three year results: a case report

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.

[Allogeneic parathyroid: 2-year follow-up]

BACKGROUND

Hypoparathyroidism is one of the most frequent complications of neck surgery. The treatment is currently medical; however this involves several complications secondary to high doses of calcium and vitamin D, thus making parathyroid allotransplantation a good management option.

MATERIAL AND METHODS

Patients with hypoparathyroidism were selected in the April-December period of 2011 in the general surgical clinic. They were between 16 and 65 years, and ingested high doses of calcium. The donors were patients with primary and secondary hyperparathyroidism, and the transplants were performed in relation to blood group and human leucocyte antigen.

RESULTS

Five parathyroid allografts were performed. All the patients had iatrogenic hypoparathyroidism, all women with a mean age of 49.8 years. The graft was implanted under local anaesthesia in the non-dominant forearm. Four of the patients are so far considered functional due to the increase in paratohormone, and demonstrating its function by scintigraphy with sestamibi. One of the patients showed no increase in paratohormone or imaging studies that demonstrate its functionality. After a two year follow up the graft remains functional but with with oral calcium intake at a lower dose than before transplantation. None of the patients had immunosuppression side effects.

CONCLUSIONS

In this study, allogeneic unrelated living parathyroid transplant with an immunosuppressive regimen of six months has proven to be a safe alternative treatment to improve quality of life by decreasing the excessive calcium intake and improving physical activity with adequate graft survival at 24 months follow up.