Clinical experience with percutaneous ethanol injection therapy in hemodialysis patients with renal hyperparathyroidism

Consensus document for ultrasound training in the specialty of Nephrology

Ultrasound is an essential tool in the management of the nephrological patient allowing the diagnosis, monitoring and performance of kidney intervention. However, the usefulness of ultrasound in the hands of the nephrologist is not limited exclusively to the ultrasound study of the kidney. By ultrasound, the nephrologist can also optimize the management of arteriovenous fistula for hemodialysis, measure cardiovascular risk (mean intimate thickness), implant central catheters for ultrasound-guided HD, as well as the patient's volemia using basic cardiac ultrasound, ultrasound of the cava inferior vein and lungs. From the Working Group on Interventional Nephrology (GNDI) of the Spanish Society of Nephrology (SEN) we have prepared this consensus document that summarizes the main applications of ultrasound to Nephrology, including the necessary basic technical requirements, the framework normative and the level of training of nephrologists in this area. The objective of this work is to promote the inclusion of ultrasound, both diagnostic and interventional, in the usual clinical practice of the nephrologist and in the Nephrology Services portfolio with the final objective of offering diligent, efficient and comprehensive management to the nephrological patient.

Hyperparathyroidism caused by distant pulmonary lesions and parathyromatosis after ethanol injection/parathyroidectomy for secondary hyperparathyroidism

Secondary hyperparathyroidism (SHPT) treatment includes parathyroidectomy and percutaneous ethanol injection therapy (PEIT), which are invasive procedures. The condition in which benign hyperfunctioning parathyroid tissue is distributed throughout the neck and mediastinum is termed parathyromatosis. Here, we present the case of a 51-year-old woman who began hemodialysis in 1986 due to chronic kidney disease of unknown etiology and developed SHPT in 1999. She underwent 6 rounds of PEIT followed by total a parathyroidectomy with partial forearm autotransplantation. Between 2011 and 2013, surgeons removed several nodules from her pulmonary and cervical regions and the transplanted masses from her forearm; all showed hyperplasia but exhibited no histological evidence of malignancy. Damage to the parathyroid capsule after repeated PEITs may cause local cervical recurrence and pulmonary lesions, although distant lesions are extremely rare in SHPT. This case is of interest due to the possible association between PEIT and parathyromatosis and distal lesions.

Safety and efficiency of microwave ablation for recurrent and persistent secondary hyperparathyroidism after parathyroidectomy: A retrospective pilot study

BACKGROUND

Recurrent and persistent secondary hyperparathyroidism (SHPT) nodules have an incidence of 10-70% after surgery. The treatment of recurrent and persistent SHPT nodules is a challenge, and surgical resection of difficult-to-reach or post-operative adhesions often fails.

PURPOSE

The aim of this research was to study the safety and effectiveness of microwave ablation (MWA) for recurrent and persistent SHPT.

MATERIALS AND METHODS

This was a retrospective study of 11 patients enrolled with a total of 16 nodules, and MWA was employed to manage SHPT. The laboratory test results, including the intact parathyroid hormone (iPTH), serum calcium, phosphorus and alkaline phosphatase (ALP) levels, improvement of SHPT-related symptoms after ablation, and complications during and after MWA were recorded and analysed.

RESULTS

After ablation the value of iPTH was markedly decreased from 1570 ± 1765 pg/mL to 287 ± 239 pg/mL 1 day after MWA (p < 0.05). The levels of serum calcium and phosphorus decreased from 2.51 ± 0.23 mmol/L to 2.06 ± 0.27 mmol/L (p < 0.001) and 1.80 ± 0.43 mmol/L to 1.48 ± 0.32 mmol/L (p < 0.05), respectively, 1 day after MWA. There was no significant difference in the ALP value before and after MWA (p > 0.05). The clinical symptoms, including ostalgia, pruritus, disability, and restless legs, improved after MWA. Minor complications and side effects encountered during or after MWA include haematoma (1/11, 9%), transient hoarseness (2/11, 18.2%), hypocalcemia (6/11, 54.5%). No major complication occurred.

CONCLUSION

MWA may be safe and effective to manage recurrent and persistent SHPT nodules; a definite conclusion needs to expand the sample size with a longer follow-up time.

Indication and efficacy of PEIT in the management of secondary hyperparathyroidism

Control of secondary hyperparathyroidism (SHPT) using active vitamin D analogues becomes difficult in advanced SHPT, because the enlarged parathyroid glands (PTGs) are resistant to medical therapy. Percutaneous ethanol injection therapy (PEIT) has been widely used in Japan since the 1990s as a surgical intervention for advanced SHPT, by selectively destroying only the enlarged glands with nodular hyperplasia (i.e. >0.5 cm(3), measured by ultrasonography). If there is only one PTG with nodular hyperplasia, PEIT will be successful with a small number of injections, and it then becomes possible to maintain target levels of parathyroid hormone by treatment with active vitamin D analogues. Recent studies have demonstrated that in the advanced phase of SHPT, it is desirable to perform PEIT when it is restricted to patients with not more than one PTG larger than 0.5 cm(3) in terms of superior prognosis can be obtained including efficacy, low recurrence, and long-term remission period.

Long-term prognosis of parathyroid function in chronic dialysis patients after PEIT-a single-centre trial

Background. Secondary hyperparathyroidism (SHPT) is a common complication observed in long-term dialysis patients. Percutaneous ethanol injection therapy (PEIT) of parathyroid glands (PTGs) is now established in Japan as a treatment option for SHPT. In this study, to elucidate the factors influencing efficacy in 1 year and relapse following PEIT, we analysed the long-term prognosis of parathyroid function that is known to have the greatest effect on therapeutic results.

Methods. The study design was a retrospective cohort study. We studied 104 patients with SHPT, who underwent PEIT at Tokai University Hospital between January 1993 and December 2002, and we followed them up until January 2008. The effective group reached intact parathyroid hormone of 200 pg/ml or less, corrected calcium (Ca) of 10.5 mg/dl or less and phosphate (P) of 6.0 mg/dl or less. The ineffective group failed to achieve these criteria.

Results. Among the 104 patients, 66 patients (63%) fulfilled the criteria for the effective group within the first year of PEIT. Using the multivariate logistic regression analysis, the number of PTGs before PEIT was a significant risk factor to deviate from the criteria. At the end of the surveillance period, 31 patients (30%) fulfilled the criteria, and their SHPT was controlled with PEIT. Using the multivariate logistic regression analysis, more than three PTGs at the beginning, and the increase in PTGs during the observation period were significant risk factors to deviate from the criteria. In conclusion, superior results with PEIT are obtained in terms of efficacy, remission period and risk of relapse, regardless of the size of the gland.

Effects of percutaneous ethanol injection therapy on subsequent surgical parathyroidectomy

Background. Renal hyperparathyroidism (RHPT) is a serious complication of long-term dialysis treatment. Two intervention methods can be administered to treat RHPT, namely percutaneous ethanol injection therapy (PEIT) and a parathyroidectomy (PTx). PEIT is associated with a significant adverse event, adhesion formation. This study was performed to investigate the effect of PEIT on subsequent PTx.

Methods. A total of 80 subjects were included in the study. The patients had a diagnosis of RHPT for which surgery was indicated. They were divided according to whether they underwent PEIT (PEIT group) or not (non-PEIT group). The outcomes of PTx following PEIT were evaluated.

Results. There were 19 patients in the PEIT group and 61 in the non-PEIT group. The operation time was significantly longer in the PEIT group but no significant differences in the amount of bleeding or frequency of recurrent nerve paralysis were observed. The intact PTH levels immediately following surgery were slightly higher in the PEIT group. The postoperative intact PTH levels were found to be significantly higher in those who received two or more courses of PEIT. The number of patients with an intact PTH level >60 pg/ml on postoperative Day 1 was significantly higher in the PEIT group.

Conclusions. These findings suggested that PEIT prior to PTx can affect the subsequent surgical outcome due to associated adhesions and dissemination. For patients with a possibility of either a decreased efficacy or a lack of efficacy for PEIT, it is therefore important to consider PTx from the very beginning of the treatment.

New clinical guidelines for selective direct injection therapy of the parathyroid glands in chronic dialysis patients

In 2000, the Japanese Society for Parathyroid Intervention issued the 'Guidelines for percutaneous ethanol injection therapy of the parathyroid glands in chronic dialysis patients'. Since then, the concept of 'selective PEIT' has been well accepted and the number of patients treated by this method in Japan has increased. Recently, it has been reported that the effect of PEIT differs depending on the degree of nodular hyperplasia. Several new drugs have become available since 2000, and active vitamin D and its analogue have also been used for direct injection into the parathyroids. We present the new 'Guidelines for selective direct injection therapy of the parathyroid glands in chronic dialysis patients', a revised version of the 2000 Guidelines. We believe that these new guidelines are useful for selecting direct injection therapy in patients with advanced secondary hyperparathyroidism.

Medical management after parathyroid intervention

Vitamin D or vitamin D analogues pulse therapy is seldom effective in patients with at least one parathyroid gland with nodular hyperplasia, and surgical parathyroidectomy or parathyroid intervention is indicated. In parathyroid interventions, especially in selective percutaneous ethanol injection therapy (PEIT), the enlarged parathyroid gland(s) with nodular hyperplasia is selectively destroyed by ethanol injection, while other glands with diffuse hyperplasia are managed by medical therapy. Thus, medical management, e.g., use of appropriate dose of vitamin D or vitamin D analogues after the PEIT procedure, is as important as the destruction of the hyperplastic tissue itself. Recent studies showed that the combination of PEIT and intravenous vitamin D pulse therapy lead to reduce serum PTH level and calcium-phosphorus products in haemodialysis patients. In this article, we focus on the importance of medical therapy after PEIT, and review the efficacy of the combination of PEIT and intravenous vitamin D pulse therapy for haemodialysis patients with secondary hyperparathyroidism.

Midterm outcome of ultrasound-guided alcohol gel sclerotherapy for symptomatic leiomyoma

OBJECTIVE

The purpose of this study was to describe the outcome of ultrasound-guided ethanol gel sclerotherapy of myomatous nodules 1 to 18 months after treatment.

METHODS

A total of 118 consecutive patients with a diagnosis of symptomatic leiomyomas referred for ethanol gel sclerotherapy were studied between November 2005 and July 2007. Clinical (self-administered symptom questionnaire) and ultrasound follow-ups were done 1 to 2, 6 to 8, and 12 to 18 months after the procedure.

RESULTS

The mean baseline volumes +/- SD were 223.3 +/- 158.3 cm(3) for the uterus and 68.4 +/- 110.5 cm(3) for the dominant fibroid. The most common adverse reaction in the immediate postoperative period was pelvic pain in 27.1% of the patients, but 58.4% had no reactions. After 12 months, a 29.5% reduction in uterine volume was observed in 64.7% of the patients. A 55.5% reduction in dominant fibroid volume was observed in 82.8% of the patients. Pelvic pain improved in 29.8% of the sample, dysmenorrhea in 51.7%, and menstrual flow in 39%. Most patients (77%) reported being satisfied or very satisfied with the treatment.

CONCLUSIONS

The results suggest that ethanol gel sclerotherapy is a safe, conservative alternative for treating symptomatic uterine leiomyomas. Further randomized studies are necessary to determine the suitability and indications of this procedure in comparison to other minimally invasive techniques.

Role of the parathyroid gland vascularization index in predicting percutaneous ethanol injection efficacy in refractory uremic hyperparathyroidism

AIMS

To evaluate the role of the quantitative vascularization index (VI) as a measure of the completeness of percutaneous ethanol injection therapy (PEIT).

METHODS

A total of 37 dialysis patients with secondary hyperparathyroidism refractory to medical therapy received PEIT. We analyzed the role of a quantitative marker of parathyroid adenoma activity, i.e. VI, flow index and vascular flow index as measured by 3-dimensional Doppler ultrasound with a 3-dimensional histogram software, for all patients before treatment and at 1 month and 6 months after PEIT.

RESULTS

Serum intact parathyroid hormone (i-PTH) level showed a strong positive correlation with the VI both before (p < 0.001) and after (p < 0.001) PEIT. There was no correlation between i-PTH level and the volume of the gland either before (p = 0.697) or after (p = 0.564) PEIT. One month after PEIT, 20 patients (group 1) reached the target of i-PTH ≤ 300 pg/ml and 17 patients (group 2) did not. Group 2 patients had significantly greater VI and i-PTH prior to PEIT than group 1 patients (42.23 ± 8.38 vs. 14.95 ± 8.07, p <0.001 and 1,447 ± 243 vs. 859 ± 231, p < 0.001 respectively).

CONCLUSION

A higher VI indicates a higher i-PTH, and the VI may be a reliable predictor of the completeness of PEIT.

Percutaneous ethanol injection therapy: a surgery-sparing treatment for primary hyperparathyroidism

OBJECTIVE

To describe our 3-year experience in the long-term efficacy and safety of percutaneous ethanol injection therapy (PEIT), as an alternative to surgery for the management of patients with primary hyperparathyroidism (p-HPT).

DESIGN

Prospective study with a mean follow-up of 19.6 +/- 10.6 months.

PATIENTS

Our study population included 19 consecutive high risk patients with p-HPT, who met the criteria for surgery.

MEASUREMENTS

Under ultrasonic guidance, ethanol (95%) was injected into parathyroid glands with a volume of >or= 0.15 cm(3). With the aim of normalizing intact parathormone (iPTH) values, repeated ethanol injections were carried out, in an interval of 2 weeks, until normalization of iPTH was reached or until no residual blood supply was detected by ultrasound in the gland. Biochemical parameters were monitored throughout the study.

RESULTS

At 6-month follow-up, normalization of iPTH levels (10-65 ng/l) was achieved in 11 (58%) patients (responders). Of the eight remaining patients (nonresponders), six patients had reduced (but not normalized) iPTH levels and two patients required parathyroid surgery. Seventeen (11 responders and 6 nonresponders) of the 19 patients (89.5%) became normocalcaemic (serum Ca <or= 2.57 mmol/l) and remained so for a mean follow-up of 21 months (8-39 months). The odds ratio (P < 0.05) of response vs. no response to PEIT was 16.7-fold for pretreatment iPTH < 200 vs. > 200 ng/l. The only complication was a transient dysphonia noticed in three patients.

CONCLUSIONS

PEIT is a safe and effective nonsurgical treatment for patients with p-HPT, who are unsuitable for surgical intervention.

The kidney and bone metabolism: Nephrologists' point of view

The kidney plays an important role in the regulatory system for bone and mineral metabolism. In chronic kidney disease (CKD), various abnormalities, recently named CKD-mineral and bone disorder (CKD-MBD), may develop in this system. The optimal management of CKD-MBD should be achieved without increasing the risk of metastatic calcification, including that of blood vessels. Thus, it is quite important to identify severe cases of hyperparathyroidism refractory to medical therapy. The size of the parathyroid glands, serum levels of fibroblast growth factor (FGF)23, and, possibly, the overproduction of a novel form of parathyroid hormone (PTH), serve as useful markers for this purpose. Adynamic bone disease with low buffering capacity for calcium is another major cause of hypercalcemia in dialysis patients. Our recent studies suggest that indoxyl sulfate accumulated in uremic serum is responsible for the suppression of osteoblastic function. In order to maintain the bone quality in patients with CKD, bone changes due to aging, menopause, and malnutrition need to be considered by nephrolgists and non-nephrologists in collaboration.

Combination therapy of intravenous maxacalcitol and percutaneous ethanol injection therapy lowers serum parathyroid hormone level and calcium x phosphorus product in secondary hyperparathyroidism

BACKGROUND

Percutaneous ethanol injection therapy (PEIT) is an alternative treatment for secondary hyperparathyroidism (SHPT). Although maxacalcitol has been recently developed as a new vitamin D3 and its efficacy is anticipated in SHPT, there are only few reports on the usefulness of combination therapy of intravenous maxacalcitol and selective PEIT.

METHODS

The study population comprised 10 hemodialysis patients (6 males and 4 females, mean age; 51.5 +/- 13.5 years, mean HD period 13.7 +/- 3.5 years), with high intact-PTH level (>400 pg/ml) and 1 or 2 enlarged parathyroid glands detected by power Doppler ultrasonography. Intravenous maxacalcitol therapy commenced one week after PEIT at 15 microg/week. The effect of combination therapy was monitored by measuring intact-PTH, serum Ca and P, bone metabolic markers, parathyroid gland volume and bone mineral density, prior to and at 6 and 12 months after PEIT.

RESULTS

Successful control of intact-PTH, bone metabolic markers and parathyroid gland volume was achieved using the combination therapy. Serum P and CaxP product were significantly decreased 12 months after PEIT. The mean values of serum intact-PTH, P and CaxP product fulfilled all of the K/DOQI guidelines at 12 months after PEIT. None of the patients developed complications related to PEIT-maxacalcitol therapy during 12 months following PEIT.

CONCLUSION

Combination therapy of intravenous maxacalcitol therapy and selective PEIT is safe and effective for the treatment of refractory SHPT. This combination therapy results in suppression of PTH secretion, regression of parathyroid hyperplasia and the control of CaxP product, which may prevent calcific uremic arteriolopathy in dialysis patients.

Treatment of uremic hyperparathyroidism with percutaneous ethanol injection

The percutaneous ethanol injection (PEI) with ultrasound guidance has been suggested for the treatment of patients with hyperparathyroidism who are on dialysis, with the aim of selectively treating the parathyroid glands with nodular hyperplasia. We present our experience in 25 patients with chronic renal failure followed during 13.4 +/- 10.6 months. A decrease in the levels of parathormone (PTH) (1,236.32 +/- 129.8 vs. 721.66 +/- 142.24 pg/ml), phosphatemia (6.16 +/- 0.35 vs. 4.93 +/- 0.36 mg/dl) and calcium-phosphorous product (60.82 +/- 3.81 vs. 46.47 +/- 3.46 mg2/dl2) was verified. In 56% of patients, PTH levels decreased (>50% of the baseline value) and 36% had final values <300 pg/ml. Patients in whom ultrasound showed a single gland responded better than those with more than one gland (83.3 vs. 30.8% of responders in each group). The procedures performed had a 4.9% complication rate: hematoma, symptomatic hypocalcemia, temporary paresis of the vocal cords. In summary, treatment with PEI is useful for the management of patients with hyperparathyroidism who are on dialysis, and the results achieved are better in patients who have a single gland identified by ultrasonography.

Near-total parathyroidectomy is beneficial for patients with secondary and tertiary hyperparathyroidism

BACKGROUND

Despite several options for the extent of parathyroidectomy in secondary and tertiary hyperparathyroidism, <5% of patients are referred for surgical procedures. The purpose of this study was to identify beneficial outcomes of near-total parathyroidectomy (NTPTX) in this population.

METHODS

NTPTX (a vascularized parathyroid remnant is left in situ, and cryopreservation is performed) was completed in 142 patients with secondary (n = 93 patients) and tertiary (n = 49 patients) hyperparathyroidism, and was guided by intraoperative intact PTH (IOPTH).

RESULTS

One hundred thirty-six of 142 patients (96%) remain cured at a mean follow-up time of 23 +/- 26 months. Six patients had missed mediastinal (n = 4 patients) or cervical (n = 2 patients) parathyroid glands. No patient required re-resection of a cervical parathyroid remnant. One patient had hypoparathyroidism and underwent autografting with cryopreserved tissue. NTPTX reduced parathyroid mass (4526 +/- 4515 mg to 77 +/- 56 mg) and IOPTH (1171 +/- 1252 pg/mL to 101 +/- 127 pg/mL). Fatigue and musculoskeletal pain resolved promptly after operation. Patients with tertiary hyperparathyroidism experienced an improvement in bone density of 3.6% per year. NTPTX achieved full healing of extremity ulcers without amputations or perioperative death in 22 patients with calciphylaxis.

CONCLUSIONS

NTPTX effectively treats secondary and tertiary hyperparathyroidism in >95% patients. IOPTH monitoring and cryopreservation are valuable procedural adjuncts. Limb salvage in calciphylaxis, symptomatic relief, and improved bone density are substantial benefits to recommend this procedure to patients with renal hyperparathyroidism.

Percutaneous ethanol injection treatment of severe hyperparathyroidism in maintenance dialysis: risks and benefits

Renal hyperparathyroidism is one of the main and serious complications that occur in chronic kidney disease and particularly during long-term maintenance dialysis. Several recent trials indicate that a high calcium phosphorus product is correlated with high cardiovascular morbidity and mortality and poor outcome. Thus, it is important to improve the control of hyperparathyroidism in chronic renal failure patients. Several methods have been reported for treating severe hyperparathyroidism resistant to medical therapy. Total parathyroidectomy and transplantation or excision of tumor is considered as the treatment of choice. More recently, interventional methods with percutaneous ethanol or calcitriol injection have been developed. These latter techniques have been reported as an alternative to surgical treatment for patients with high perioperative risk. We report the occurrence of laryngeal recurrent nerve palsy, vocal fold paralysis, and hemiplegia after a successful injection of ethanol in a left parathyroid adenoma in a maintenance hemodialysis patient and discuss the restrictions of the procedure and alternative treatments in view of the available studies.

The coronary effects of parathyroid hormone

OBJECTIVE

The aim of the present study was to characterize the role of the ATP-sensitive potassium channels (K(+)(ATP)) in the coronary dilator action of parathyroid hormone (PTH).

METHODS

Dose-response curves of intracoronary administrated PTH (0.15-1.33 nmol) were obtained in control phases and during continuous intracoronary administration of the K(+)(ATP) channel-selective antagonist glibenclamide (0.1-1.0 micromol/min) in dogs (n = 13).

RESULTS

Increments of integrated coronary conductance (excess coronary conductance) at PTH doses of 0.15 and 1.33 nmol were 1.17 versus 0.03 ml/mm Hg (p < 0.05) and 4.03 versus 0.94 ml/mm Hg (p < 0.05) in the control versus during maximal blockade, respectively.

CONCLUSION

The results indicate that the activation of K(+)(ATP) channels significantly contributes to the PTH-induced coronary vasodilation.