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Cojuc-Konigsberg G, Tinajero-Sánchez D, Canaviri-Flores VA, Fueyo-Rodríguez O, Uribe-Uribe NO, Marino-Vazquez LA, Morales-Buenrostro LE, Ramirez-Sandoval JC. Impact of hyperparathyroidism on allograft histology and function after kidney transplantation: Rethinking its causal role in graft dysfunction. Clin Transplant 2024; 38:e15322. [PMID: 38678589 DOI: 10.1111/ctr.15322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/02/2024] [Accepted: 04/12/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION The causal relationship between hyperparathyroidism and kidney graft dysfunction remains inconclusive. Applying Bradford-Hill's temporality and consistency causation principles, we assessed the effect of parathyroid hormone (iPTH) on graft histology and eGFR trajectory on kidney transplant recipients (KTRs) with normal time-zero graft biopsies. METHODS Retrospective cohort study evaluating the effect of hyperparathyroidism on interstitial fibrosis and tubular atrophy (IF/TA) development in 1232 graft biopsies. Pre-transplant hyperparathyroidism was categorized by KDIGO or KDOQI criteria, and post-transplant hyperparathyroidism by iPTH >1× and >2× the URL 1 year after transplantation. RESULTS We included 325 KTRs (56% female, age 38 ± 13 years, follow-up 4.2 years [IQR: 2.7-5.8]). Based on pre-transplant iPTH levels, 26% and 66% exceeded the KDIGO and KDOQI targets, respectively. There were no significant differences in the development of >25% IF/TA between KTRs with pre-transplant iPTH levels above and within target range according to KDIGO (53% vs. 62%, P = .16, HR.94 [95% CI:.67-1.32]) and KDOQI (60% vs. 60%, P = 1.0, HR 1.19 [95% CI:.88-1.60]) criteria. Similarly, there were no differences when using 1 year post-transplant iPTH cut-offs > 88 pg/mL (58% vs. 64%, P = .33) and > 176 pg/mL (55% vs. 62%, P = .19). After adjusting for confounders, no significant differences were observed in eGFR trajectories among the iPTH strata. CONCLUSION In young KTRs who received a healthy graft, no association was found between increased pre- and post-transplant iPTH levels and graft dysfunction, as assessed histologically and through eGFR trajectory. The concept of hyperparathyroidism as a risk factor for graft dysfunction in recipients at low risk requires reevaluation.
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Affiliation(s)
- Gabriel Cojuc-Konigsberg
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Denisse Tinajero-Sánchez
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Vianca Anabel Canaviri-Flores
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Omar Fueyo-Rodríguez
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Norma O Uribe-Uribe
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Lluvia A Marino-Vazquez
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Luis Eduardo Morales-Buenrostro
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Juan C Ramirez-Sandoval
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
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Van Den Heede K, Claerhout T, Jansen S, Blontrock S, Brusselaers N, Van Slycke S. Morbidity and long-term outcome of surgery for renal hyperparathyroidism: results from a prospective cohort. Acta Chir Belg 2023; 123:525-534. [PMID: 35829630 DOI: 10.1080/00015458.2022.2101751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/11/2022] [Indexed: 11/01/2022]
Abstract
PURPOSES Surgery remains an important treatment option for renal hyperparathyroidism (rHPT). The number of long-term outcome studies of parathyroidectomy is limited. METHODS All consecutive patients with a parathyroidectomy for rHPT between 09/2009 and 04/2021 in a Belgian tertiary referral hospital were prospectively enrolled. The main outcomes were (long-term) cured proportion and postoperative morbidity (hypocalcemia, recurrent laryngeal nerve (RLN) palsy, re-intervention for bleeding, and wound morbidity). RESULTS Sixty patients with a median age of 57 years were analyzed, including 23 patients before kidney transplantation, 23 patients without kidney transplantation, and 14 patients after kidney transplantation. Median time to transplant was 15 (6-24) months after parathyroidectomy. Morbidity was low with only two non-urgent returns to theatre (wound infection and non-compressive hematoma), two temporary RLN paralyses, and no 30-day mortality. Length of hospital stay was longer in patients with parathyroidectomy before kidney transplant, due to a more severe and prolonged need for calcium supplementation. After a median follow-up of 63 months, 37 patients (62%) were still alive, and 11 patients (18%) developed a recurrence. CONCLUSIONS This single-surgeon, single-center cohort with long-term follow-up confirms the safety and excellent 'cure' proportions of surgery for rHPT but stretches the importance of long-term follow-up.
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Affiliation(s)
- K Van Den Heede
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst, Aalst, Belgium
- Department of Endocrine and Digestive Surgery, Hôpital Pitié-Salpêtrière, AP-HP, Sorbonne University, Paris, France
| | - T Claerhout
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst, Aalst, Belgium
- Faculty of Medicine, University of Leuven, Leuven, Belgium
| | - S Jansen
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst, Aalst, Belgium
- Faculty of Medicine, University of Leuven, Leuven, Belgium
| | - S Blontrock
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst, Aalst, Belgium
- Faculty of Medicine, University of Leuven, Leuven, Belgium
| | - N Brusselaers
- Center for Translational Microbiome Research Department of Microbiology, Tumor, and Cell Biology, Karolinska Institute, Karolinska Hospital, Stockholm, Sweden
- Global Health Institute, University of Antwerp, Wilrijk, Belgium
| | - S Van Slycke
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst, Aalst, Belgium
- Department of Head and Skin, University Hospital Ghent, Ghent, Belgium
- Department of General Surgery, AZ Damiaan, Ostend, Belgium
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Jørgensen HS, Evenepoel P. Persistent Hyperparathyroidism: A Reality Calling for Additional Evidence. Am J Kidney Dis 2023; 81:256-258. [PMID: 36424304 DOI: 10.1053/j.ajkd.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium; Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium; Department of Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium.
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Wang B, Li W, Wang Q, Zhang W. Timing of parathyroidectomy for kidney transplant patients with secondary hyperparathyroidism: A practical overview. Biosci Trends 2022; 16:426-433. [PMID: 36403958 DOI: 10.5582/bst.2022.01320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Kidney transplantation remains the best treatment for patients with end-stage kidney disease, and it could partially mitigate systemic disorders of mineral and bone metabolism caused by secondary hyperparathyroidism. However, persistent hyperparathyroidism is still observed in 30-60% of patients 1 year after kidney transplantation, leading to impairment of allograft function and a disturbance of mineral metabolism. The timing of parathyroidectomy varies among transplant centers because the possible negative effects of parathyroidectomy on allograft outcomes are still unclear. This review provides a comprehensive and detailed overview of the natural course of hyperparathyroidism following kidney transplantation and the effects of the timing and extent of parathyroidectomy on allograft function. It aims to provide useful information for surgeons to propose an appropriate intervention strategy to break the vicious cycle of post-kidney transplantation hyperparathyroidism and deterioration of allograft function.
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Affiliation(s)
- Bin Wang
- Department of Thyroid, Breast and Hernia Surgery, Changzheng Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Wei Li
- Department of Thyroid, Breast and Hernia Surgery, Changzheng Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Qiang Wang
- Department of Thyroid, Breast and Hernia Surgery, Changzheng Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Wei Zhang
- Department of Thyroid, Breast and Hernia Surgery, Changzheng Hospital Affiliated to Navy Medical University, Shanghai, China
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg 2022; 276:e141-e176. [PMID: 35848728 DOI: 10.1097/sla.0000000000005522] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.
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Frey S, Goronflot T, Blanchard C, Kerleau C, Gourraud PA, Wargny M, Caillard C, Hourmant M, Figueres L, Mirallié É. Impact of parathyroidectomy on kidney graft function in post-transplant tertiary hyperparathyroidism: a comparative study. Langenbecks Arch Surg 2022; 407:2489-2498. [PMID: 35596781 DOI: 10.1007/s00423-022-02555-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Parathyroidectomy to treat tertiary hyperparathyroidism (THPT) is now on a par with calcimimetic treatment. The effects of cinacalcet and parathyroidectomy on kidney transplant function remain controversial. The aim of this study was to evaluate kidney transplant function in THPT patients treated either by parathyroidectomy, cinacalcet, or not treated. METHODS Between 2009 and 2019, 231 patients with functional grafts presenting THPT, defined either by calcaemia superior to 2.5 mmol/L with elevated PTH level or hypercalcaemia with non-adapted PTH level 1 year after kidney transplantation, were included. Hyperparathyroid patients treated by cinacalcet and parathyroidectomy were matched for age, sex, graft rank, and baseline eGFR with cinacalcet-only and untreated patients. Conditional logistic regression models were used to compare eGFR variations 1 year after parathyroidectomy between operated patients and matched controls. Five-year survivals were compared with the Mantel-Cox test. RESULTS Eleven patients treated with parathyroidectomy and cinacalcet were matched with 16 patients treated by cinacalcet-only and 29 untreated patients. Demographic characteristics were comparable between groups. Estimated odds ratios for eGFR evolution in operated patients compared with cinacalcet-only and untreated patients were 0.92 [95%CI 0.83-1.02] and 0.99 [0.89-1.10] respectively, indicating no significant impairment of eGFR 1 year after surgery. Five-year allograft survival was not significantly impaired in operated patients. CONCLUSIONS Parathyroidectomy did not appear to substantially alter or improve graft function 1 year after surgery or 5-year allograft survival. It could be hypothesized that in addition to its known benefits, parathyroidectomy can be safely performed vis-à-vis graft function in tertiary hyperparathyroidism.
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Affiliation(s)
- Samuel Frey
- Chirurgie Cancérologique, Digestive Et Endocrinienne, Institut Des Maladies de L'Appareil Digestif, Place Alexis Ricordeau, CHU Nantes, Hôtel Dieu, 44093, Nantes, CEDEX 1, France.,Université de Nantes, quai de Tourville, 44000, Nantes, France.,L'institut du Thorax, Unité Inserm UMR 1087 / CNRS UMR 6291, IRS 8 Quai Moncousu, 44000, Nantes, France
| | - Thomas Goronflot
- CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11, Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des données, Nantes, France
| | - Claire Blanchard
- Chirurgie Cancérologique, Digestive Et Endocrinienne, Institut Des Maladies de L'Appareil Digestif, Place Alexis Ricordeau, CHU Nantes, Hôtel Dieu, 44093, Nantes, CEDEX 1, France.,Université de Nantes, quai de Tourville, 44000, Nantes, France.,L'institut du Thorax, Unité Inserm UMR 1087 / CNRS UMR 6291, IRS 8 Quai Moncousu, 44000, Nantes, France
| | - Clarisse Kerleau
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, 30, boulevard Jean-Monnet, 44093, Nantes cedex, France
| | - Pierre-Antoine Gourraud
- Université de Nantes, quai de Tourville, 44000, Nantes, France.,CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11, Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des données, Nantes, France
| | - Matthieu Wargny
- CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11, Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des données, Nantes, France
| | - Cécile Caillard
- Chirurgie Cancérologique, Digestive Et Endocrinienne, Institut Des Maladies de L'Appareil Digestif, Place Alexis Ricordeau, CHU Nantes, Hôtel Dieu, 44093, Nantes, CEDEX 1, France
| | - Maryvonne Hourmant
- Université de Nantes, quai de Tourville, 44000, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, 30, boulevard Jean-Monnet, 44093, Nantes cedex, France.,Service de Néphrologie-Immunologie Clinique, CHU de Nantes, 30, boulevard Jean-Monnet, 44093, Nantes cedex, France
| | - Lucile Figueres
- Université de Nantes, quai de Tourville, 44000, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, 30, boulevard Jean-Monnet, 44093, Nantes cedex, France.,Service de Néphrologie-Immunologie Clinique, CHU de Nantes, 30, boulevard Jean-Monnet, 44093, Nantes cedex, France
| | - Éric Mirallié
- Chirurgie Cancérologique, Digestive Et Endocrinienne, Institut Des Maladies de L'Appareil Digestif, Place Alexis Ricordeau, CHU Nantes, Hôtel Dieu, 44093, Nantes, CEDEX 1, France. .,Université de Nantes, quai de Tourville, 44000, Nantes, France.
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