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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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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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Zhang JLH, Appelman-Dijkstra NM, Schepers A. Parathyroid Allotransplantation: A Systematic Review. Med Sci (Basel) 2022; 10:medsci10010019. [PMID: 35323218 PMCID: PMC8953572 DOI: 10.3390/medsci10010019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 11/24/2022] Open
Abstract
Background: To date, there is no satisfactory treatment for patients with calcium and vitamin D supplementation refractive hypoparathyroidism. Parathyroid allotransplantation by design is a one-time cure through its restoration of the parathyroid function and, therefore, could be the solution. A systematic literature review is conducted in the present paper, with the aim of outlining the possibilities of parathyroid allotransplantation and to calculate its efficacy. Additionally, various transplantation characteristics are linked to success. Methods: This review is carried out according to the PRISMA statement and checklist. Relevant articles were searched for in medical databases with the most recent literature search performed on 9 December 2021. Results: In total, 24 articles involving 22 unique patient cohorts were identified with 203 transplantations performed on 148 patients. Numerous types of (exploratory) interventions were carried out with virtually no protocols that were alike: there was the use of (non-) cryopreserved parathyroid tissue combined with direct transplantation or pretreatment using in vitro techniques, such as culturing cells and macro-/microencapsulation. The variability increased further when considering immunosuppression, graft histology, and donor–recipient compatibility, but this was found to be reported in its entirety by exception. As a result of the large heterogeneity among studies, we constructed our own criterium for transplantation success. With only the studies eligible for our assessment, the pooled success rate for parathyroid allotransplantation emerged to be 46% (13/28 transplantations) with a median follow-up duration of 12 months (Q1–Q3: 8–24 months). Conclusions: Manifold possibilities have been explored around parathyroid allotransplantation but are presented as a double-edged sword due to high clinical diverseness, low expertise in carrying out the procedure, and unsatisfactory study quality. Transplantations carried out with permanent immunosuppression seem to be the most promising, but, in its current state, little could be said about the treatment efficacy with a high quality of evidence. Of foremost importance in pursuing the answer whether parathyroid allotransplantation is a suitable treatment for hypoparathyroidism, a standardized definition of transplantation success must be established with a high-quality trial.
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Affiliation(s)
- Jaimie L. H. Zhang
- Department of Surgery, Leiden University Medical Center, 2333 Leiden, The Netherlands;
- Correspondence: ; Tel.: +31-624628572
| | - Natasha M. Appelman-Dijkstra
- Department of Internal Medicine, Division Endocrinology, Leiden University Medical Center, 2333 Leiden, The Netherlands;
| | - Abbey Schepers
- Department of Surgery, Leiden University Medical Center, 2333 Leiden, The Netherlands;
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Goncu B, Yucesan E, Ersoy YE, Aysan ME, Ozten Kandas N. HLA-DR, -DP, -DQ expression status of parathyroid tissue as a potential parathyroid donor selection criteria and review of literature. Hum Immunol 2022; 83:113-118. [PMID: 34955228 DOI: 10.1016/j.humimm.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/21/2021] [Accepted: 12/15/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Basic and clinical studies about parathyroid allotransplantation have to be utilized with more definitive criteria for longer graft survival. Several reports demonstrated different isolation and cultivation methods for parathyroid cells to minimize their immunogenicity. In this study, we aim to compare and evaluate the clinical characteristics and the status of HLA class II expression changes in parathyroid tissue. METHODS A total of 22 parathyroid hyperplasia tissue donors was included in this study. Clinical characteristics were evaluated and compared with the HLA-DR, -DP, -DQ mRNA, and protein expression levels which were determined by qRT-PCR and Western blot. RESULTS We have compared the clinical characteristics (age, dialysis duration, frequency, recurrency of hyperparathyroidism and, calcimimetic usage) and HLA class II expression. HLA class II mRNA and protein levels showed varied expression patterns between tissues. Only, the HLA-DP has high mRNA expression levels without affecting the protein level when compared with the ages of the tissue donors. In addition, the HLA-DR, HLA-DP, and HLA-DQα1 protein expression levels showed a permanent and varied expression rate between tissues. CONCLUSION Expression of HLA class II molecules in parathyroid cells appears to constitute a decisive factor. Despite the lack of clinical outcomes, present data proposes new insight with a detailed understanding of parathyroid immunogenicity. In the future, randomized controlled clinical trials are needed for the accurate assessment of the effect of the varied HLA class II expression profiles in parathyroid tissue.
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Affiliation(s)
- Beyza Goncu
- Bezmialem Vakif University, Vocational School of Health Services, Department of Medical Services and Techniques, Istanbul, Turkey; Bezmialem Vakif University, Experimental Research Center, Parathyroid Transplantation Unit, Istanbul, Turkey; Bezmialem Vakif University, Health Science Institute, Department of Biotechnology, Istanbul, Turkey.
| | - Emrah Yucesan
- Bezmialem Vakif University, Experimental Research Center, Parathyroid Transplantation Unit, Istanbul, Turkey; Bezmialem Vakif University, Faculty of Medicine, Department of Medical Biology, Istanbul, Turkey
| | - Yeliz Emine Ersoy
- Bezmialem Vakif University, Experimental Research Center, Parathyroid Transplantation Unit, Istanbul, Turkey; Bezmialem Vakif University, Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Mustafa Erhan Aysan
- Bezmialem Vakif University, Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Nur Ozten Kandas
- Bezmialem Vakif University, Faculty of Pharmacy, Department of Pharmaceutical Toxicology, Istanbul, Turkey
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Kim E, Ramonell KM, Mayfield N, Lindeman B. Parathyroid allotransplantation for the treatment of permanent hypoparathyroidism: A systematic review. Am J Surg 2021; 223:652-661. [PMID: 34304848 DOI: 10.1016/j.amjsurg.2021.07.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/22/2021] [Accepted: 07/18/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Hypoparathyroidism is the most common complication of bilateral operations in the central neck. No formal guidelines exist for the management of permanent hypoparathyroidism. Current treatment involving medical supplementation increases resource utilization and patient morbidity while decreasing quality of life. Parathyroid allotransplant (PA) offers a promising therapy; however, the optimal technique and role of immunosuppression (IS) in PA remain unclear. METHODS We performed a systematic search of the Embase, MEDLINE, and Cochrane Library databases to identify studies investigating PA for treatment of hypoparathyroidism. RESULTS A total of 24 studies including 186 individual allograft transplants in 146 patients were identified. Pooled graft survival for allotransplants in transplant-naïve vs prior transplant recipients was 29.9% and 80%, respectively. CONCLUSIONS PA using normocellular, fresh parathyroid donor tissue that is ABO-compatible, with induction and, at minimum, short-term maintenance IS presents a potentially safe and effective therapeutic option for permanent hypoparathyroidism in patients tolerating IS.
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Affiliation(s)
- Eric Kim
- University of Alabama at Birmingham, Department of Surgery, Division of Breast and Endocrine Surgery, Birmingham, AL, USA.
| | - Kimberly M Ramonell
- University of Alabama at Birmingham, Department of Surgery, Division of Breast and Endocrine Surgery, Birmingham, AL, USA.
| | - Nicolas Mayfield
- University of Alabama at Birmingham, Department of Surgery, Division of Breast and Endocrine Surgery, Birmingham, AL, USA.
| | - Brenessa Lindeman
- University of Alabama at Birmingham, Department of Surgery, Division of Breast and Endocrine Surgery, Birmingham, AL, USA.
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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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Qi J, Zhang R, Cai C, Wang H, Zhou M, Shen W, Tang Y, Pan T, Wu D, Han Y. HLA-DQB1 mismatch increase risk of severe bleeding independently in recipients of allogeneic stem cell transplant. Ann Hematol 2021; 100:2351-2361. [PMID: 33846855 DOI: 10.1007/s00277-021-04520-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 04/07/2021] [Indexed: 12/19/2022]
Abstract
Severe bleeding is a major cause of death in acute leukemia (AL) patients with graft-versus-host disease (GVHD) after allogene hematopoietic stem-cell transplantation (allo-HSCT). However, the prognostic value and prediction of HSCT-associated severe bleeding in GVHD patients have not been reported in cohort studies. We did a retrospective analysis of 200 AL patients with GVHD after allo-HSCT from Feb 1, 2014, to Dec 1, 2015. Multivariate analysis showed that the severe bleeding class was associated with the risk of death (HR 2.26, 95% CI 1.31-3.92, p<0.001***). In order to predict severe bleeding and figure out the solution to bleeding events, we established a multiple logistic regression model. HLA-DQB1 unmatching, megakaryocyte reconsititution failure, and III or IV GVHD were the independent risk factors for severe bleeding. Among all the variations above, OR of HLA-DQB1 was the highest (OR: 16.02, 95% CI: 11.54-48.68). Adding HLA-DQB1 to other factors improved the reclassification for predicting severe bleeding (NRI=0.195, z=2.634, p=0.008**; IDI=0.289, z=3.249, p<0.001***). Lasso regression was used to select variants. A nomogram of the logistic model was generated and displayed. Calibration curve demonstrated excellent accuracy in estimating severe bleeding (C index of 0.935). HLA-DQB1 showed excellent efficacy of predicting severe bleeding in HSCT patients.
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Affiliation(s)
- Jiaqian Qi
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, 215000, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Rui Zhang
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, 215000, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Chengsen Cai
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, 215000, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Hong Wang
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, 215000, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Meng Zhou
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, 215000, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Wenhong Shen
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, 215000, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Yaqiong Tang
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, 215000, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Tingting Pan
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, 215000, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Depei Wu
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, 215000, China.
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.
- Institute of Blood and Marrow Transplantation, Suzhou, China.
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.
- National Clinical Research Center for Hematologic Diseases, Suzhou, China.
- State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.
| | - Yue Han
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, No.188 Shizi Street, Suzhou, 215000, China.
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.
- Institute of Blood and Marrow Transplantation, Suzhou, China.
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.
- National Clinical Research Center for Hematologic Diseases, Suzhou, China.
- State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.
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Goncu B, Salepcioglu Kaya H, Yucesan E, Ersoy YE, Akcakaya A. Graft survival effect of HLA-A allele matching parathyroid allotransplantation. J Investig Med 2020; 69:785-788. [PMID: 33443056 DOI: 10.1136/jim-2020-001648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 11/04/2022]
Abstract
Permanent hypoparathyroidism is an endocrine disease that is mostly associated with the disruption of the parathyroid glands during surgery. Allotransplantation is the most promising approach for treatment particularly for its cost-effective and exact curative potential. Herein our aim was to evaluate human leukocyte antigen (HLA)-A allele matching effect on clinical improvement and graft survival after parathyroid transplantation. We performed parathyroid transplantation between ABO/Rh compatible recipient and an unrelated donor who has chronic kidney disease. Preoperative immunological tests include panel reactive antibody, T-flow cytometry crossmatch, B-flow cytometry crossmatch, autoflow cytometry crossmatch, and complement-dependent cytotoxicity crossmatch tests were performed. After histopathological evaluation, half of the resected parathyroid gland cells were isolated and transplanted to the omentum surface by laparoscopy. The transplantation outcome was followed up throughout 382 days. The recipient discharged 2 days after transplantation without any complication. During follow-up, calcium and vitamin D supplementation reduced to a one-third dose; even the intact PTH levels remained low. However, clinical improvement was observed by serum calcium levels. The recipient still continues with low-dose supplementation after 382 days of post-transplantation. Parathyroid cell transplantation to the omental tissue is the most promising option even with only one allele matching for patients with using lifelong high-dose supplementation. Clinical improvements and long-term effect of HLA-A allele matching should be evaluated with more studies and in larger cohorts as well.
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Affiliation(s)
- Beyza Goncu
- Experimental Research Center, Bezmialem Vakif University, Istanbul, Turkey .,Parathyroid Transplantation Laboratory, Bezmialem Vakif University, Istanbul, Turkey
| | - Harika Salepcioglu Kaya
- Faculty of Medicine, Department of General Surgery, Bezmialem Vakif University, Istanbul, Turkey
| | - Emrah Yucesan
- 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.,Parathyroid Transplantation Laboratory, Bezmialem Vakif University, Istanbul, Turkey
| | - Adem Akcakaya
- Faculty of Medicine, Department of General Surgery, Bezmialem Vakif University, Istanbul, Turkey.,Organ Transplantation Unit, Bezmialem Vakif University, Istanbul, Turkey
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