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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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Jung S, Kim H, Kwon H, Shin S, Kim YH, Kim WW, Sung TY, Lee YM, Chung KW, Park SK, Baek CH. Parathyroidectomy versus cinacalcet in the treatment of tertiary hyperparathyroidism after kidney transplantation: a retrospective study. Kidney Res Clin Pract 2022; 41:473-481. [PMID: 35286788 PMCID: PMC9346402 DOI: 10.23876/j.krcp.21.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/10/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Suyun Jung
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyosang Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyunwook Kwon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Woong Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae-Yon Sung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yu-Mi Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ki-Wook Chung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Su-Kil Park
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chung Hee Baek
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Frey S, Goronflot T, Kerleau C, Gourraud PA, Caillard C, Hourmant M, Mirallié É, Figueres L. Parathyroidectomy or cinacalcet: Do we still not know the best option for graft function in kidney-transplanted patients? A meta-analysis. Surgery 2021; 170:727-735. [PMID: 33810851 DOI: 10.1016/j.surg.2021.02.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 01/15/2021] [Accepted: 02/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Tertiary hyperparathyroidism occurs in 25% to 50% of kidney-transplanted patients. Indication of parathyroidectomy is now discussed, since the calcimimetic agent, cinacalcet, is an alternate option. The effects of either of these treatments on graft function remain controversial, studied only in small cohorts showing either decrease or absence of modification. We performed a meta-analysis to evaluate the evolution of graft function after surgical or medical treatment. METHODS Studies assessing graft function in tertiary hyperparathyroidism after parathyroidectomy or cinacalcet introduction were enrolled into quantitative analysis using Pubmed, Embase, and Cochrane databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelines. Among 68 screened studies, 18 had no missing data and were included for statistical analyses. We performed random effect meta-analysis to determine changes in serum creatinine and estimated glomerular filtration rate. RESULTS Seven studies assessing the evolution of graft function 6 and/or 12 months after parathyroidectomy and 13 after administration of cinacalcet were included. Meta-analysis found no significant variations after parathyroidectomy in serum creatinine (6 studies, 314 patients) and estimated glomerular filtration rate (2 studies, 105 patients). No significant variation was found after administration of cinacalcet in serum creatinine (10 studies, 404 patients) and estimated glomerular filtration rate (6 studies, 149 patients). A significant heterogeneity between the studies (P < .01, Cochran's Q) was found. CONCLUSION Meta-analysis shows that parathyroidectomy and cinacalcet do not significantly impair graft function in patients with tertiary hyperparathyroidism. However, the significant heterogeneity between selected studies, partially explained by the lack of consensual definition of tertiary hyperparathyroidism, limits the conclusions of all previously published series.
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Affiliation(s)
- Samuel Frey
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des maladies de l'Appareil Digestif, Hôtel Dieu, CHU Nantes, France; Université de Nantes, France
| | - Thomas Goronflot
- CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11: Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des Données, France
| | - Clarisse Kerleau
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, France
| | - Pierre-Antoine Gourraud
- Université de Nantes, France; CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11: Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des Données, France
| | - Cécile Caillard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des maladies de l'Appareil Digestif, Hôtel Dieu, CHU Nantes, France
| | - Maryvonne Hourmant
- Université de Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, France; Service de néphrologie-immunologie clinique, CHU de Nantes, France
| | - Éric Mirallié
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des maladies de l'Appareil Digestif, Hôtel Dieu, CHU Nantes, France; Université de Nantes, France
| | - Lucile Figueres
- Université de Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, France; Service de néphrologie-immunologie clinique, CHU de Nantes, France.
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Kirnap NG, Kirnap M, Sayin B, Akdur A, Bascil Tutuncu N, Haberal M. Risk Factors and Treatment Options for Persistent Hyperparathyroidism After Kidney Transplantation. Transplant Proc 2020; 52:157-161. [DOI: 10.1016/j.transproceed.2019.11.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/25/2019] [Accepted: 11/10/2019] [Indexed: 12/24/2022]
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Littbarski SA, Kaltenborn A, Gwiasda J, Beneke J, Arelin V, Schwager Y, Stupak JV, Marcheel IL, Emmanouilidis N, Jäger MD, Scheumann GFW, Klempnauer J, Schrem H. Timing of parathyroidectomy in kidney transplant candidates with secondary hyperparathryroidism: effect of pretransplant versus early or late post-transplant parathyroidectomy. Surgery 2017; 163:373-380. [PMID: 29284591 DOI: 10.1016/j.surg.2017.10.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 08/28/2017] [Accepted: 10/11/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The timing of parathyroidectomy in kidney transplant candidates suffering from secondary hyperparathyroidism before versus early or late after transplantation remains controversial. METHODS The short-term follow-up cohort comprised 66 patients with 1-year post-transplant follow-up, while the long-term follow-up cohort contained 123 patients. Risk-adjusted identification of independent risk factors for compromised renal graft function (KDIGO stage ≥ IV) was performed using multivariable regression analysis adjusted for propensity score logits for parathyroidectomy before versus after renal transplantation. Intra-individual matched-pairs analyses were used to identify significant effects of post-transplant parathyroidectomy on graft function as assessed by estimated glomerular filtration rate (eGFR) and paired t tests. RESULTS Donor kidney function KDIGO stage III (P = .030; OR = 5.191, 95% CI: 1.100-24.508), donor blood group 0 (P = .005; OR = 0.176, 95% CI: 0.048-0.642), and post-transplant parathyroidectomy (P = .032; OR = 17.849, 95% CI: 1.086-293.268) were revealed as independent significant risk factors for compromised renal graft function in the short-term follow-up cohort using propensity score risk adjustment while post-transplant parathyroidectomy had no independent influence in the long-term follow-up cohort (P = .651). Parathyroidectomy after renal transplantation compromised graft function early after parathyroidectomy and at last follow-up in all post-transplant parathyroidectomy cases (P ≤ .004). Parathyroidectomy within the first post-transplant year was associated with compromised renal graft function until last follow-up (P = .004), while parathyroidectomy late post-transplant was not. CONCLUSION Parathyroidectomy should be conducted before transplantation or, if this is not possible, preferably after the first post-transplant year.
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Affiliation(s)
- Simon A Littbarski
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Alexander Kaltenborn
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Jill Gwiasda
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Jan Beneke
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Viktor Arelin
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany; Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Ysabell Schwager
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Julia V Stupak
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Indra L Marcheel
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Nikos Emmanouilidis
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Mark D Jäger
- General, Visceral and Minimally Invasive Surgery, Municipal Hospital Wolfenbüttel, Hannover, Germany
| | | | - Jürgen Klempnauer
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany; General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany.
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6
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El-Husseini A, Wang K, Edon A, Saxon D, Lima F, Sloan D, Sawaya BP. Value of Intraoperative Parathyroid Hormone Assay during Parathyroidectomy in Dialysis and Renal Transplant Patients with Secondary and Tertiary Hyperparathyroidism. Nephron Clin Pract 2017; 138:119-128. [PMID: 29131092 DOI: 10.1159/000482016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/05/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In dialysis and renal transplant patients with secondary and tertiary hyperparathyroidism (HPT), the value of intraoperative parathyroid hormone (ioPTH) during parathyroidectomy (PTX) and its association with long-term PTH levels are unknown. The present study aims at evaluating the relationship of ioPTH with long-term PTH levels post-PTX in dialysis and renal transplant patients in a single-center study. METHODS The ioPTH was measured in 57 dialysis patients (33 females and 24 males) and 18 renal transplant recipients (12 males and 6 females) who underwent PTX from 2005 to 2015 for refractory HPT. Near-total PTX was performed in 56 patients and total PTX with autotransplantation in 20 patients. The PTH monitoring included 3 samples: pre-intubation, 10- and 20-min (pre-ioPTH, 10-ioPTH, and 20-ioPTH) post parathyroid gland excision. Patients were followed up for up to 5 years. RESULTS In the dialysis group, the median (25th-75th percentile) pre-, 10-, and 20-ioPTH levels were 1,447 pg/mL (938-2,176), 143 pg/mL (78-244) and 112 pg/mL (59-153) respectively. In the renal transplant group, pre-, 10-, and 20-ioPTH levels were 273 pg/mL (180-403), 42 pg/mL (25-72), and 34 pg/mL (23-45) respectively. All patients in the transplant group had a functional kidney transplant at the time of PTX with a median serum creatinine of 1.3 mg/dL (1.2-1.7) and estimated glomerular filtration rate of 55 mL/min (40-60). The median time between renal transplant and PTX surgeries was 22 months (7-81). The last median follow-up PTH level was 66 pg/mL (15-201) in the dialysis group and 54 pg/mL (17-72) in the transplant group (p = 0.438). The mean time for last PTH post-PTX was 2.3 ± 2.0 years. In both groups, there was no significant difference between 20-ioPTH and any-time post-PTX PTH levels (p = 0.6 and p = 0.9). Nineteen patients (25%) were readmitted within 90 days because of hypocalcemia. One patient in the dialysis group was readmitted for post-PTX hematoma evacuation. No patient required repeat PTX because of recurrent HPT that was refractory to medical therapy. Only one dialysis patient required repeat PTX because the first procedure failed. CONCLUSIONS The 20-ioPTH is a good indicator of long-term PTH levels in dialysis and renal transplant patients. Hypocalcemia is a common complication, particularly in dialysis patients, and it is the main reason for readmission after PTX. Hypoparathyroidism is a potential concern after PTX in dialysis patients.
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Affiliation(s)
- Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA.,Division of Nephrology, Mansoura University, Mansoura, Egypt
| | - Kevin Wang
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Annick Edon
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - David Saxon
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Florence Lima
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - David Sloan
- Section of Endocrine Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - B Peter Sawaya
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
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Dulfer RR, Franssen GJH, Hesselink DA, Hoorn EJ, van Eijck CHJ, van Ginhoven TM. Systematic review of surgical and medical treatment for tertiary hyperparathyroidism. Br J Surg 2017; 104:804-813. [PMID: 28518414 DOI: 10.1002/bjs.10554] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/23/2016] [Accepted: 03/01/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND A significant proportion of patients with chronic kidney disease and secondary hyperparathyroidism (HPT) remain hyperparathyroid after kidney transplantation, a state known as tertiary HPT. Without treatment, tertiary HPT can lead to diminished kidney allograft and patient survival. Parathyroidectomy was commonly performed to treat tertiary HPT until the introduction of the calcimimetic drug, cinacalcet. It is not known whether surgery or medical treatment is superior for tertiary HPT. METHODS A systematic review was performed and medical literature databases were searched for studies on the treatment of tertiary HPT that were published after the approval of cinacalcet. RESULTS A total of 1669 articles were identified, of which 47 were included in the review. Following subtotal and total parathyroidectomy, initial cure rates were 98·7 and 100 per cent respectively, but in 7·6 and 4 per cent of patients tertiary HPT recurred. After treatment with cinacalcet, 80·8 per cent of the patients achieved normocalcaemia. Owing to side-effects, 6·4 per cent of patients discontinued cinacalcet treatment. The literature regarding graft function and survival is limited; however, renal graft survival after surgical treatment appears comparable to that obtained with cinacalcet therapy. CONCLUSION Side-effects and complications of both treatment modalities were mild and occurred in a minority of patients. Surgical treatment for tertiary HPT has higher cure rates than medical therapy.
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Affiliation(s)
- R R Dulfer
- Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - G J H Franssen
- Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - D A Hesselink
- Department of Nephrology and Kidney Transplantation, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - E J Hoorn
- Department of Nephrology and Kidney Transplantation, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - T M van Ginhoven
- Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Caravaca F, Caravaca-Fontán F, Azevedo L, Luna E. Changes in renal function after discontinuation of vitamin D analogues in advanced chronic kidney disease. Nefrologia 2017; 38:179-189. [PMID: 28676189 DOI: 10.1016/j.nefro.2017.05.012] [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: 02/10/2017] [Revised: 04/25/2017] [Accepted: 05/22/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In routine clinical practice, the prescription of vitamin D analogues (VDA) in patients with chronic kidney disease (CKD) is often associated with a decline of the estimated renal function. The reason for this is not fully understood. AIMS To analyse the effects of VDA discontinuation in advanced CKD and to determine the factors associated with changes in renal function. MATERIAL AND METHODS Retrospective cohort study of adult patients with advanced CKD. The case subgroup was treated with VDA and this medication was discontinued at baseline (the first visit). The control subgroup was not treated with VDA and they were selected according to comparability principles for CKD progression by propensity score matching. The primary outcome measure was a change to both the estimated glomerular filtration rate (MDRD-GFR) and the measured glomerular filtration rate (mGFR by combined creatinine and urea clearances). Baseline parameters related to mineral metabolism and creatinine generation were analysed as potential determinants of renal function changes. RESULTS The study sample consisted of 67 cases and 67 controls. Renal function improved in 67% of cases and worsened in 72% of controls (p<0.0001). Changes in MDRD-GFR for the case subgroup and the control subgroup were +0.455±0.997 vs. -0.436±1.103ml/min/1.73 m2/month (p<0.0001), respectively. Total creatinine excretion was slightly higher in cases than in controls but the difference was not significant. According to multivariate logistic and linear regression analyses, baseline total serum calcium was one of the best determinants of both renal function recovery (Odds ratio=3.49; p=0.001), and of the extent of renal function recovery (beta=0.276; p=0.001). CONCLUSIONS Discontinuation of VDA treatment in CKD patients is associated with significant recovery of estimated renal function. The extent of these changes is mainly associated with baseline total serum calcium.
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Affiliation(s)
| | | | - Lilia Azevedo
- Servicio de Nefrología, Hospital Infanta Cristina, Badajoz, España
| | - Enrique Luna
- Servicio de Nefrología, Hospital Infanta Cristina, Badajoz, España
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9
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Chudzinski W, Wyrzykowska M, Nazarewski S, Durlik M, Galazka Z. Does the Parathyroidectomy Endanger the Transplanted Kidney? Transplant Proc 2017; 48:1633-6. [PMID: 27496461 DOI: 10.1016/j.transproceed.2016.01.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/21/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Some investigators maintain that a parathyroidectomy (PTX) performed for tertiary hyperparathyroidism may potentially cause graft malfunction or even loss of the transplanted kidney after the operation. The goal of this study was to determine if parathyroidectomy affects transplanted kidney function. METHODS The study group consisted of 48 renal graft recipients who underwent operation due to tertiary hyperparathyroidism. Thirty-nine subtotal parathyroidectomies and 9 more selective, less than subtotal parathyroidectomies were performed. The estimated glomerular filtration rate (eGFR) was calculated retrospectively on days 2 to 3 and 4 to 5 and at 1, 3, 6, 12, 24, and 36 months after PTX; these findings were compared with preoperative values. The cumulative graft survival rate in the postoperative period was assessed. RESULTS In the follow-up period, 4 of 48 patients returned to hemodialysis (after 1, 7, 22, and 57 months after PTX). In the first case, the patient had stopped taking the immunosuppressive drugs 1 month after PTX. Cumulative graft survival rate after PTX was 98.0% after 6 months, 96% after 12 months, and 93% after 2 and 3 years. The mean preoperative eGFR was 52 ± 17.15 mL/min/1.73 m(2), and the median was 48.28 mL/min/1.73 m(2). Overall and in the subtotal parathyroidectomy group, eGFR was significantly lower (P < .001) only on days 2 to 3. There were no differences between preoperative and postoperative eGFR values in the other follow-up periods. In the more selective, less than subtotal parathyroidectomy group, the decrease in eGFR values was nonsignificant compared with preoperative findings in the early postoperative period as well as in all follow-up periods. CONCLUSIONS In this study, PTX did not significantly impair transplanted kidney function, but in the early postoperative period, transient reductions in graft function did occur.
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Affiliation(s)
- W Chudzinski
- Department of General and Endocrine Surgery, Medical University of Warsaw, Warsaw, Poland.
| | - M Wyrzykowska
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - S Nazarewski
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - M Durlik
- Department of Immunology, Transplantology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Z Galazka
- Department of General and Endocrine Surgery, Medical University of Warsaw, Warsaw, Poland
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10
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Meng C, Martins P, Frazão J, Pestana M. Parathyroidectomy in Persistent Post-transplantation Hyperparathyroidism — Single-center Experience. Transplant Proc 2017; 49:795-798. [DOI: 10.1016/j.transproceed.2017.01.067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Wong J, Tan MZW, Chandran M. Fifty shades of gray: Bone disease in renal transplantation. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815611808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Kidney transplantation is the renal replacement therapy of choice for patients with end stage renal disease. Advances in technology, surgical techniques and pharmacotherapy have improved renal allograft survival. Increasingly, we are seeing long term side effects related to renal transplantation, bone disease being a major one amongst them. Renal transplant patients have a higher risk of fragility fractures even when compared to those who remain on dialysis. This is likely to be related to pre-existing underlying bone disease and the emergence of new metabolic bone problems post-transplant. Conditions such as persistent hyperparathyroidism and the use of certain immunosuppressive agents have a deleterious effect on the post renal transplant bone. Remarkable advances in the field of metabolic bone research have been made in the last decade and newer imaging techniques, biomarkers and therapeutic options are now available for osteoporosis in the general population. Interest is being focused on attempting to extrapolate these new discoveries to the management of bone disease post renal transplant. This review will briefly describe the metabolic bone changes that occur after transplantation and will provide an update on the currently available investigative options and therapeutic strategies for the management of post renal transplant bone disease.
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Affiliation(s)
- Jiunn Wong
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Manju Chandran
- Department of Endocrinology, Singapore General Hospital, Singapore
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Chonchol M, Wüthrich RP. Potential future uses of calcimimetics in patients with chronic kidney disease. NDT Plus 2015; 1:i36-i41. [PMID: 25983955 PMCID: PMC4421155 DOI: 10.1093/ndtplus/sfm043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Accepted: 09/10/2007] [Indexed: 11/23/2022] Open
Abstract
Cinacalcet has proven effective in the treatment of secondary hyperparathyroidism (SHPT) in dialysis patients, and it may also have benefits in stage 3 and 4 chronic kidney disease (CKD). The efficacy of cinacalcet in the treatment of SHPT was investigated in a study of 54 patients with stage 3 and 4 CKD not receiving dialysis. A significant number of these patients achieved at least a 30% reduction in parathyroid hormone (PTH) from baseline with cinacalcet therapy compared with placebo (56% versus 19%; P = 0.006). Another potential use of cinacalcet is in the treatment of persistent hyperparathyroidism (HPT) after kidney transplantation. The pathophysiologic considerations for persistent HPT in patients who have undergone renal transplantation are different from those in stage 3 and 4 CKD. Post-transplant patients with normal graft function often present with hypercalcaemia, low serum phosphorus and persistently elevated levels of PTH. In eight small open-label studies including a total of 83 patients with persistent HPT after successful kidney transplantation, cinacalcet treatment effectively corrected hypercalcaemia and significantly reduced elevated PTH levels. These studies suggest that cinacalcet therapy is an effective therapy in controlling hyperparathyroidism in patients with stage 3 and 4 CKD and in post-transplant patients with persistent hyperparathyroidism.
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Affiliation(s)
- Michel Chonchol
- University of Colorado Health Sciences Center , Denver, CO , USA
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Parikh S, Nagaraja H, Agarwal A, Samavedi S, Von Visger J, Nori U, Andreoni K, Pesavento T, Singh N. Impact of post-kidney transplant parathyroidectomy on allograft function. Clin Transplant 2013; 27:397-402. [PMID: 23448282 DOI: 10.1111/ctr.12099] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND The impact of parathyroidectomy on allograft function in kidney transplant patients is unclear. METHODS We conducted a retrospective, observational study of all kidney transplant recipients from 1988 to 2008 who underwent parathyroidectomy for uncontrolled hyperparathyroidism (n = 32). Post-parathyroidectomy, changes in estimated glomerular filtration rate (eGFR) and graft loss were recorded. Cross-sectional associations at baseline between eGFR and serum calcium, phosphate, and parathyroid hormone (PTH), and associations between their changes within subjects during the first two months post-parathyroidectomy were assessed. RESULTS Post-parathyroidectomy, the mean eGFR declined from 51.19 mL/min/1.73 m(2) at parathyroidectomy to 44.78 mL/min/1.73 m(2) at two months (p < 0.0001). Subsequently, graft function improved, and by 12 months, mean eGFR recovered to 49.76 mL/min/1.73 m(2) (p = 0.035). Decrease in serum PTH was accompanied by a decrease in eGFR (p = 0.0127) in the first two months post-parathyroidectomy. Patients whose eGFR declined by ≥20% (group 1) in the first two months post-parathyroidectomy were distinguished from the patients whose eGFR declined by <20% (group 2). The two groups were similar except that group 1 had a higher baseline mean serum PTH compared with group 2, although not significant (1046.7 ± 1034.2 vs. 476.6 ± 444.9, p = 0.14). In group 1, eGFR declined at an average rate of 32% (p < 0.0001) during the first month post-parathyroidectomy compared with 7% (p = 0.1399) in group 2, and the difference between these two groups was significant (p = 0.0003). The graft function recovered in both groups by one yr. During median follow-up of 66.00 ± 49.45 months, 6 (18%) patients lost their graft with a mean time to graft loss from parathyroidectomy of 37.2 ± 21.6 months. The causes of graft loss were rejection (n = 2), pyelonephritis (n = 1) and chronic allograft nephropathy (n = 3). No graft loss occurred during the first-year post-surgery. CONCLUSION Parathyroidectomy may lead to transient kidney allograft dysfunction with eventual recovery of graft function by 12 months post-parathyroidectomy. Higher level of serum PTH pre-parathyoidectomy is associated with a more profound decrease in eGFR post-parathyroidectomy.
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Affiliation(s)
- Samir Parikh
- Division of Nephrology, Department of Internal Medicine, The Wexner Medical Center, The Ohio State University, Columbus, OH, USA
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Jeon HJ, Kim YJ, Kwon HY, Koo TY, Baek SH, Kim HJ, Huh WS, Huh KH, Kim MS, Kim YS, Park SK, Ahn C, Yang J. Impact of parathyroidectomy on allograft outcomes in kidney transplantation. Transpl Int 2012; 25:1248-56. [PMID: 23020185 DOI: 10.1111/j.1432-2277.2012.01564.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We performed retrospective, multi-center study of the impacts of parathyroidectomy (PTX) after or before kidney transplantation on allograft outcomes. A total of 63 patients who underwent PTX after kidney transplantation were identified. Deterioration in eGFR by more than 25% at 1 month after PTX occurred in 20% of the patients. The baseline eGFR was significantly lower in impairment group than nonimpairment group [adjusted odds ratio (OR) 0.87, 95% confidence interval (CI) 0.77-0.99, P = 0.033]. Low iPTH concentration after PTX was also a significant risk factor for the renal impairment (OR 0.96, CI 0.94-0.99, P = 0.009). A total of 37 patients who underwent PTX before transplantation were identified. Thirty-six percent of the patients had persistent hyperparathyroidism by 1 year after transplantation. A high iPTH level before PTX was a significant risk factor for persistent post-transplant hyperparathyroidism (adjusted OR 1.002, CI 1.000-1.005, P = 0.039). Finally, eGFR values during the first 5 years after transplantation were significantly lower in the patients who underwent PTX at less than 1 year after transplantation, than the pretransplant PTX patients (P = 0.032). As PTX after kidney transplantation has a risk of deterioration of allograft function, pretransplant PTX should be considered for patients with severe hyperparathyroidism, who could undergo post-transplant PTX.
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Affiliation(s)
- Hee Jung Jeon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Hsieh TM, Sun CK, Chen YT, Chou FF. Total Parathyroidectomy versus Subtotal Parathyroidectomy in the Treatment of Tertiary Hyperparathyroidism. Am Surg 2012. [DOI: 10.1177/000313481207800544] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purposes of this study are to evaluate the merits of surgical treatment, including subtotal parathyroidectomy (SP) and total parathyroidectomy (TP), in patients with tertiary hyperparathyroidism (THPT) and compare the outcome of the two surgical options. Medical records of patients undergoing parathyroidectomy for THPT were retrospectively reviewed and long-term outcomes between the two groups were compared. Fourteen out of 488 renal transplantation recipients required parathyroidectomy for THPT during a 24-year follow-up period with a median follow-up of 35.5 [interquartile range (IQR), 19.3–133.3] months. All patients had hypercalcemia, whereas 13 had varying symptoms and one was asymptomatic. Median serum calcium level decreased from 12.4 (IQR, 11.9–12.6) mg/dL preoperatively to 8.9 (IQR, 8.1–9.4) mg/dL postoperatively ( P = 0.001), whereas median intact parathyroid hormone (iPTH) dropped from a preoperative level of 340.5 (IQR, 247–540) pg/mL to 55.1 (IQR, 24.4–66.4) pg/mL after surgery ( P = 0.018). Comparison between patients receiving TP and SP revealed no difference in incidence of recurrence or permanent complications, whereas the former had significantly lower calcium levels ( P = 0.048) and higher phosphorus levels ( P = 0.017) compared with the latter. Moreover, a significant reduction in calcium level was noted in TP group on long-term follow-up compared with their immediately postoperative level (8.1 vs 9.0 mg/dL, respectively, P < 0.05), whereas there was no significant decrease in SP group. We concluded that parathyroidectomy is efficient and safe in treating THPT. Because TP would increase the risk of hypocalcemia, a less radical procedure (SP) is preferred.
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Affiliation(s)
- Ting-Min Hsieh
- Divisions of General Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheuk-Kwan Sun
- Urology, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yen-Ta Chen
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Fong-Fu Chou
- Divisions of General Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Madorin C, Owen RP, Fraser WD, Pellitteri PK, Radbill B, Rinaldo A, Seethala RR, Shaha AR, Silver CE, Suh MY, Weinstein B, Ferlito A. The surgical management of renal hyperparathyroidism. Eur Arch Otorhinolaryngol 2011; 269:1565-76. [PMID: 22101574 DOI: 10.1007/s00405-011-1833-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 10/30/2011] [Indexed: 01/22/2023]
Abstract
Secondary and tertiary hyperparathyroidism (HPT) develop in patients with renal failure due to a variety of mechanisms including increased phosphorus and fibroblast growth factor 23 (FGF23), and decreased calcium and 1,25-dihydroxy vitamin D levels. Patients present with various bone disorders, cardiovascular disease, and typical laboratory abnormalities. Medical treatment consists of controlling hyperphosphatemia, vitamin D/analog and calcium administration, and calcimimetic agents. Improved medical therapies have led to a decrease in the use of parathyroidectomy (PTX). The surgical indications include parathyroid hormone (PTH) levels >800 pg/ml associated with hypercalcemia and/or hyperphosphatemia despite medical therapy. Other indications include calciphylaxis, fractures, bone pain or pruritis. Transplant recipients often show decreased PTH, calcium and phosphorus levels, but some will have persistent HPT. Evidence suggests that PTX may cause deterioration in renal graft function in the short-term calling into the question the indications for PTX in these patients. Pre-operative imaging is only occasionally helpful except in re-operative PTX. Operative approaches include subtotal PTX, total PTX with or without autotransplantation, and possible thymectomy. Each approach has its proponents, advantages and disadvantages which are discussed. Intraoperative PTH monitoring has a high positive predictive value of cure but a poor negative predictive value and therefore is of limited utility. Hypocalcemia is the most common complication requiring aggressive calcium administration. Benefits of surgery may include improved survival, bone mineral density and alleviation of symptoms.
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Affiliation(s)
- Catherine Madorin
- Department of Surgery, Division of Metabolic, Endocrine and Minimally Invasive Surgery, Mount Sinai School of Medicine, New York, NY, USA
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The effect of cinacalcet on bone remodeling and renal function in transplant patients with persistent hyperparathyroidism. Transplantation 2011; 91:560-5. [PMID: 21192318 DOI: 10.1097/tp.0b013e3182079431] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Parathyroidectomy is associated with renal functional losses in transplant patients; cinacalcet offers an attractive alternative. METHODS We performed a prospective observational study in 58 patients with persisting hyperparathyroidism after renal transplantation (Ca≥2.6 mmol/L) and impaired renal transplant function (estimated glomerular filtration rate [eGFR] <50 mL/min). The patients received 30 to 90 mg cinacalcet for 12 months with the target to normalize serum Ca. We measured parathyroid hormone (PTH), serum Ca, serum phosphorus, alkaline phosphatase, bone-specific alkaline phosphatase, osteocalcin, and telopeptide at 0, 1, 2, 3, 6, 9, and 12 months of cinacalcet treatment. Fractional excretion of calcium and phosphorus (n=24) were monitored at 0 and 1 month. RESULTS At inclusion, creatinine was 181±70 μmol/L, eGFR 43±19 mL/min, PTH 371±279 pg/mL, and Ca 2.73±0.22 mmol/L. We observed nephrocalcinosis in 58% of biopsied patients at enrollment. After cinacalcet, Ca decreased significantly and normalized at nearly any measurement. Phosphorus increased significantly at months 1, 9, and 12. PTH decreased significantly, but only at months 9 and 12 and did not normalize. Bone-specific alkaline phosphatase increased significantly (>normal) by month 12. eGFR decreased and serum creatinine increased at all time points. The Δ(creatinine) % increase correlated significantly with the Δ(PTH) % decrease at month 1 and 12. Telopeptide and alkaline phosphatase correlated with PTH and telopeptide also correlated with serum creatinine. CONCLUSION Calcium-phosphorus homeostasis in hypercalcemic renal transplant patients normalizes under cinacalcet and PTH decreases, albeit not to normal. The renal functional decline could be PTH mediated, analogous to the effects observed after parathyroidectomy.
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Park JH, Kang SW, Jeong JJ, Nam KH, Chang HS, Chung WY, Park CS. Surgical treatment of tertiary hyperparathyroidism after renal transplantation: a 31-year experience in a single institution. Endocr J 2011; 58:827-33. [PMID: 21804261 DOI: 10.1507/endocrj.ej11-0053] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Tertiary hyperparathyroidism (tHPT) most commonly refers to a persistent secondary hyperparathyroidism even after successful renal transplantation. Parathyroidectomy (PTX) is an efficient method for treatment of tHPT. In this study, we examined our 31-year experience with patients who underwent PTX for tHPT after KTX and assessed the effects of PTX on graft function according to the type of surgery. Among 2,981 recipients who underwent renal allograft between April 1979 and Dec. 2010, 15 patients (0.5%) were identified as having tHPT and underwent PTX. Levels of intact parathyroid hormone (iPTH) and serum calcium were measured before and after PTX for evaluation of the therapeutic effect, and glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease (MDRD) equation for investigation of any effect on graft function. One patient showed persistent hyperparathyroidism and hypercalcemia after limited PTX. We experienced 14 successful PTXs, including 3 total PTX with autotransplantations, 8 subtotal PTXs, and 3 limited PTXs. Level of iPTH and serum calcium were at normal range after PTX. Estimated GFR decreased after PTX. Total PTX with autotransplantation showed a tendency of more decrease in the values of iPTH, and GFR after PTX than Subtotal PTX. PTX can cure tHPT-specific symptoms and signs by recovery of hypercalcemia, but may carry the risk of deterioration of kidney graft function. We suspect that subtotal PTX, rather than total PTX with AT, prevent any risk of kidney graft deterioration in surgical treatment of tHPT, and, in selective tHPT patients, limited PTX might be recommended.
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Affiliation(s)
- Jae Hyun Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
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Exploring the effect of parathyroidectomy for tertiary hyperparathyroidism after kidney transplantation. Am J Med Sci 2010; 339:420-4. [PMID: 20234299 DOI: 10.1097/maj.0b013e3181d8b6ff] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Tertiary hyperparathyroidism (tHPT) usually regresses after renal transplantation. Persistent tHPT after successful renal transplantation may require parathyroidectomy (PTX). PTX has been reported to be associated with deterioration of renal function and graft survival. We retrospectively analyzed 794 kidney transplants performed at our center with at least 3 years of follow-up to examine the effect of PTX on the renal function and graft survival. Forty-nine of the 794 renal transplant recipients were diagnosed with hyperparathyroidism (HPT) before transplant. Nineteen of 49 patients had persistent tHPT and underwent PTX after kidney transplants. Patients with HPT and non-HPT had similar 3-year graft survival (88% versus 84%, P = 0.51). PTX was associated with a decreased glomerular filtration rate at 3 years (44.7 +/- 20.0 versus 57.7 +/- 23.7 mL/min, P = 0.04); however, there was no statistical difference in the 3-year graft survival (71% versus 88%, P = 0.06). PTX in renal transplant recipients seems to be a safe and effective therapy for persistent tHPT. PTX may be associated with worsening glomerular filtration rate, but it may not be associated with significantly decreased long-term graft survival.
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Morales E, Gutierrez E, Andres A. Treatment with calcimimetics in kidney transplantation. Transplant Rev (Orlando) 2010; 24:79-88. [DOI: 10.1016/j.trre.2010.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Accepted: 01/18/2010] [Indexed: 11/26/2022]
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Schaefer B, Schlosser K, Wuhl E, Schall P, Klaus G, Schaefer F, Schmitt CP. Long-term control of parathyroid hormone and calcium-phosphate metabolism after parathyroidectomy in children with chronic kidney disease. Nephrol Dial Transplant 2010; 25:2590-5. [DOI: 10.1093/ndt/gfq074] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Sprague SM, Belozeroff V, Danese MD, Martin LP, Olgaard K. Abnormal bone and mineral metabolism in kidney transplant patients--a review. Am J Nephrol 2007; 28:246-53. [PMID: 17989497 DOI: 10.1159/000110875] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Accepted: 09/10/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Abnormal bone and mineral metabolism is common in patients with kidney failure and often persists after successful kidney transplant. METHODS To better understand the natural history of this disease in transplant patients, we reviewed the literature by searching MEDLINE for English language articles published between January 1990 and October 2006 that contained Medical Subject Headings and key words related to secondary or persistent hyperparathyroidism and kidney transplant. RESULTS Parathyroid hormone levels decreased significantly during the first 3 months after transplant but typically stabilized at elevated values after 1 year. Calcium tended to increase after transplant and then stabilize at the higher end of the normal range within 2 months. Phosphorus decreased rapidly to within or below normal levels after surgery and hypophosphatemia, if present, resolved within 2 months. Low levels of 1,25(OH)2 vitamin D typically did not reach normal values until almost 18 months after transplant. CONCLUSION This review provides evidence demonstrating that abnormal bone and mineral metabolism exists in patients after kidney transplant and suggests the need for treatment of this condition. However, better observational and interventional research is needed before advocating such a treatment guideline.
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Affiliation(s)
- Stuart M Sprague
- Evanston Northwestern Healthcare, Northwestern University Feinberg School of Medicine, Evanston, Ill. 60201, USA.
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Schlosser K, Endres N, Celik I, Fendrich V, Rothmund M, Fernández ED. Surgical Treatment of Tertiary Hyperparathyroidism: The Choice of Procedure Matters! World J Surg 2007; 31:1947-53. [PMID: 17665243 DOI: 10.1007/s00268-007-9187-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Parathyroid surgery (PTX) in patients with tertiary hyperparathyroidism (tHPT) may endanger the long-term survival of transplanted renal grafts. The mechanism by which graft function deteriorates is unknown. We reviewed our experience in regard to the operative procedures and postoperative outcome. METHODS Sixty-nine patients were operated on for tHPT between 1987 and 2006 at our institution. Serum (s) calcium, s-creatinine, and levels of intact parathyroid hormone (PTH) were measured before and after PTX. The Modification of Diet in Renal Disease (MDRD) equation was used to estimate glomerular filtration rate (GFR). RESULTS The entire patient group developed a deterioration of kidney graft function after PTX. Nineteen of 69 patients developed a decrease in GFR of more than 20% during the hospital stay, persisting for more than one year after PTX. Ten of them had to restart dialysis during the first year after PTX. Mean preoperative s-creatinine was 4.4 +/- 0.6 mg/dl in these patients. When divided according to the surgical procedure performed, only the subgroup who underwent total parathyroidectomy showed a significant worsening of graft function when compared to subtotal or reoperative PTX. CONCLUSIONS PTX is an efficient way to treat tHPT but represents a risk for impairing graft function, especially for patients that already demonstrate poor kidney function at the time of surgery. In the aim to prevent transient hypoparathyroidism, which may provoke reduced graft perfusion, as one possible cause of kidney graft deterioration associated with PTX, one should consider subtotal instead of total parathyroidectomy.
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Affiliation(s)
- Katja Schlosser
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstrasse, 35033, Marburg, Germany.
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El-Amm JM, Doshi MD, Singh A, Migdal S, Morawski K, Sternbauer D, Cincotta E, West MS, Losanoff JE, Gruber SA. Preliminary experience with cinacalcet use in persistent secondary hyperparathyroidism after kidney transplantation. Transplantation 2007; 83:546-9. [PMID: 17353771 DOI: 10.1097/01.tp.0000253429.33198.2f] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is limited experience with the use of cinacalcet in the treatment of persistent secondary hyperparathyroidism after kidney transplantation. METHODS We retrospectively analyzed our experience in 18 renal allograft recipients who initiated cinacalcet therapy from 1 month to 23 years (median 3 years) posttransplantation and were maintained on the drug for 6 months. The daily dose was titrated from 30 mg up to a maximum of 180 mg to achieve a reduction in serum intact parathyroid hormone (PTH) levels. RESULTS Sustainable, significant decreases in mean calcium and alkaline phosphatase were noted at 1 month and intact PTH by 3 months, with 50% of patients achieving at least a 30% drop in PTH levels at 6 months. Serum phosphorous increased at 6 months, whereas urine N-telopeptides decreased. There were no significant changes in serum osteocalcin, albumin, and hemoglobin levels. We did not observe a tachyphylaxis phenomenon. Two patients reported occasional nausea, but did not require medication discontinuation. Estimated glomerular filtration rate did decrease progressively over the 6-month period. CONCLUSION Cinacalcet appears to be an effective drug for the treatment of posttransplant hypercalcemia due to persistent secondary hyperparathyroidism. Further studies with more patients and longer follow-up will be needed to better elucidate the efficacy/safety profile for this agent, particularly with regard to long-term bone histology and renal outcomes.
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Affiliation(s)
- Jose-Marie El-Amm
- Division of Nephrology, Department of Medicine, Wayne State University School of Medicine, Harper Professional Building, Detroit, MI 48201, USA.
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Szwarc I, Argilés A, Garrigue V, Delmas S, Chong G, Deleuze S, Mourad G. Cinacalcet chloride is efficient and safe in renal transplant recipients with posttransplant hyperparathyroidism. Transplantation 2006; 82:675-80. [PMID: 16969292 DOI: 10.1097/01.tp.0000232452.80018.ad] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Persistent hyperparathyroidism (HPT) is observed in approximately 50% of kidney transplant recipients one year after transplantation. It may result in hypercalcemia, hypophosphatemia, bone demineralization, vascular calcification, lithiasis, and participate in chronic allograft nephropathy. We evaluated the use of the calcimimetic cinacalcet chloride to correct chronic hypercalcemia in posttransplant HPT, in a prospective single-center study. METHODS Nine patients with persistent hypercalcemia (>2.6 mmol/L) and stable graft function were treated with cinacalcet (30 mg/day, thereafter adapted to obtain normal serum Ca levels) for six months. Their immunosuppressive schedule included mycophenolate mofetil (MMF), steroids, and cyclosporine A (4), tacrolimus (4), or sirolimus (2). RESULTS Serum Ca levels significantly decreased from 2.75+/-0.15 to 2.59+/-0.10, 2.42+/-0.29 and 2.44+/-0.25 mmol/L by one, two, and six months, respectively (P<0.02, Wilcoxon test for paired data, for all the data points). Parathyroid hormone (PTH) serum levels decreased from 171+/-102 to 134+/-63 pg/ml by two months (P<0.05) and stabilized thereafter (148+/-99 pg/ml at six months; NS). No changes in glomerular filtration rate (49.8+/-18.6 and 51.3+/-19 ml/min at initiation and six months, respectively) and no variation in serum concentration of the immunosuppressive drugs were observed. Three patients withdrew the treatment because gastrointestinal intolerance. CONCLUSION Cinacalcet allows the correction of hypercalcemia with no interference in immunosuppressive treatment or renal function. However, whether the increased intolerance observed was due to the association of cinacalcet chloride with other drugs required in renal transplantation (e.g., MMF) needs to be assessed.
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Affiliation(s)
- Ilan Szwarc
- Service de Néphrologie, Transplantation et Dialyse Péritonéale, CHU Lapeyronie, Montpellier, France
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Evaluation and management of bone disease following renal transplantation. Curr Opin Organ Transplant 2006. [DOI: 10.1097/01.mot.0000236705.60457.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lewin E, Olgaard K. Parathyroidectomy vs calcimimetics for treatment of persistent hyperparathyroidism after kidney transplantation. Nephrol Dial Transplant 2006; 21:1766-9. [PMID: 16762962 DOI: 10.1093/ndt/gfl283] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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