Renal osteodystrophy in dialysis patients: diagnosis and treatment

Aging and Bone Metabolism

Changes in bone architecture and metabolism with aging increase the likelihood of osteoporosis and fracture. Age-onset osteoporosis is multifactorial, with contributory extrinsic and intrinsic factors including certain medical problems, specific prescription drugs, estrogen loss, secondary hyperparathyroidism, microenvironmental and cellular alterations in bone tissue, and mechanical unloading or immobilization. At the histological level, there are changes in trabecular and cortical bone as well as marrow cellularity, lineage switching of mesenchymal stem cells to an adipogenic fate, inadequate transduction of signals during skeletal loading, and predisposition toward senescent cell accumulation with production of a senescence-associated secretory phenotype. Cumulatively, these changes result in bone remodeling abnormalities that over time cause net bone loss typically seen in older adults. Age-related osteoporosis is a geriatric syndrome due to the multiple etiologies that converge upon the skeleton to produce the ultimate phenotypic changes that manifest as bone fragility. Bone tissue is dynamic but with tendencies toward poor osteoblastic bone formation and relative osteoclastic bone resorption with aging. Interactions with other aging physiologic systems, such as muscle, may also confer detrimental effects on the aging skeleton. Conversely, individuals who maintain their BMD experience a lower risk of fractures, disability, and mortality, suggesting that this phenotype may be a marker of successful aging. © 2023 American Physiological Society. Compr Physiol 13:4355-4386, 2023.

Correction of Severe Knees Valgus Deformities in a Patient With Renal Osteodystrophy

Renal osteodystrophy (ROD) is a complex and rare entity that refers to a large spectrum of abnormalities of skeletal homeostasis in patients suffering from chronic kidney disease. The goal of this study was to present the outcome of the very rare case of an adult with severe deformity of painful bilateral valgus knees due to ROD, requiring multilevel osteotomies above and below the knee. A 42-year-old male patient was admitted to our department with painful severe bilateral valgus knees deformity due to ROD. The patient underwent bilateral lateral opening-wedge osteotomy of distal femur and medial tibial closing-wedge osteotomy. The osteotomies site healed in 8 weeks without complications. The surgical treatment of lower limb valgus knee deformities secondary to ROD is a challenging and demanding procedure. In our patient, the femoral opening-wedge osteotomy with blade-plate fixation, and tibial closing-wedge osteotomy with plate fixation, restored almost normal knee congruency to prevent lateral unicompartmental degenerative deterioration of the knee.

Recurrence of Hyperparathyroidism after Total Parathyroidectomy and Autotransplantation in Peritoneal Dialysis Patients

Objective

To evaluate the effectiveness of total parathyroidectomy (PTX) with autotransplantation in the treatment of secondary hyperparathyroidism (HPT), and to assess recurrence rate of HPT in this peritoneal dialysis (PD) population.

Design

A retrospective study in a single home PD unit.

Patients

Between 1994 and 1998, 19 of 574 patients on PD underwent PTX for treatment of secondary HPT.

Main Outcome Measures

Clinical and biochemical improvement, recurrence of HPT, improvement in anemia post-PTX.

Results

Nineteen (3.3%) patients required PTX between 1994 and 1998. These 5 men and 14 women ranged in age from 22 to 66 years; they had been on maintenance PD pre-PTX for 47.5 ± 38.1 months, and were followed for 26.1 ± 15.5 months post-PTX. Sixteen patients had temporary hypocalcemia that was managed by oral (n = 10) or intravenous (n = 6) calcium supplements and calcitriol, while 3 patients had severe “hungry bone” syndrome postoperatively. One patient had recurrent laryngeal nerve palsy post-PTX. Bone pain disappeared in all 12 patients. Pruritus improved in 12/13 patients; fatigue improved in 15/16 patients. Comparison showed significant differences between hemoglobin and hematocrit values 1 month pre-PTX and 12 months post-PTX ( p < 0.05). Parathyroid hormone (PTH) level in 15 (79%) patients returned to normal (≤€7.6 pmol/L) during the first month post-PTX. In 5/12 (42%) patients, PTH level was ≤ 7.6 pmol/L 2 years post-PTX, while in 2/12 (17%), PTH was > 22.8 pmol/L (three times normal) 2 years post-PTX, and 3/5 (60%) patients had a PTH > 22.8 pmol/L 3 years post-PTX.

Conclusions

Total PTX with autotransplantation is associated with a tendency for recurrence of HPT. Our findings suggest that total PTX with autotransplantation may be an ineffective procedure in controlling HPT over the long term.

Serum Markers of Low-Turnover Bone Disease in Mexican Children with Chronic Kidney Disease Undergoing Dialysis

Background

The frequency of low-turnover bone disease (LTBD) in patients with chronic kidney disease (CKD) has increased in past years. This change is important because LTBD is associated with bone pain, growth delay, and higher risk for bone fractures and extraosseous calcifications. LTBD is a histological diagnosis. However, serum markers such as parathyroid hormone (PTH) and calcium levels offer a noninvasive alternative for diagnosing these patients.

Objective

To describe the prevalence of LTBD in pediatric patients with renal failure undergoing some form of renal replacement therapy, using serum calcium and intact PTH levels as serum markers.

Methods

In this cross-sectional study, 41 children with CKD undergoing dialysis treatment (31 on continuous ambulatory peritoneal dialysis and 10 on hemodialysis) were included. There were no inclusion restrictions with respect to gender, cause of CKD, or dialysis modality. The children were studied as outpatients. The demographic data, CKD course, time on dialysis, phosphate-binding agents, and calcitriol prescription were registered, as well as weight, height, Z-score for height, linear growth rate, and Z-score for body mass index. Serum calcium, phosphorus, aluminum, PTH, alkaline phosphatase, osteocalcin, glucose, creatinine, urea, cholesterol, and triglycerides were measured.

Results

There were 20 (48.8%) children with both PTH <150 pg/mL and corrected total calcium >10 mg/dL who were classified as having LTBD[(+)]; the remaining 21 (51.2%) children were classified as having no LTBD[(–)]. The LTBD(+) patients were younger (11.2 ± 2.7 vs 13.2 ± 2.4 years, p < 0.01) but they had no differences regarding Z-scores for height. Linear growth in 6 months was less than expected in both groups (-0.15 ± 0.23 cm/month), but the difference between expected and observed growth was higher in the LTBD(+) group (-0.24 ± 0.14 vs –0.07 ± 0.28 cm/mo, p < 0.03). LTBD(+) patients also had lower serum creatinine (8.69± 2.75 vs 11.19 ± 3.17 mg/dL, p < 0.01), higher serum aluminum levels [median (range) 38.4 (9 – 106) vs 28.1 (9 – 62) μg/L, p < 0.05], and lower systolic blood pressure (112.0 ± 10.3 vs 125.0 ±12.9 mmHg, p < 0.015) and diastolic blood pressure (76.0 ± 9.7 vs 84.5 ± 8.2 mmHg, p < 0.017). A significant correlation was found between PTH and alkaline phosphatase ( r = 0.68, p < 0.001), but not between PTH and aluminum.

Conclusion

The LTBD(+) biochemical profile was found in 48.8% of the children and was associated with impaired linear growth. Aluminum contamination, evidenced by higher serum aluminum levels, may have had a pathogenic role in these disorders. Higher systolic and diastolic blood pressure levels may be related to higher serum PTH levels.

Assessment of Renal Osteodystrophy via Computational Analysis of Label-free Raman Detection of Multiple Biomarkers

Accurate clinical evaluation of renal osteodystrophy (ROD) is currently accomplished using invasive in vivo transiliac bone biopsy, followed by in vitro histomorphometry. In this study, we demonstrate that an alternative method for ROD assessment is through a fast, label-free Raman recording of multiple biomarkers combined with computational analysis for predicting the minimally required number of spectra for sample classification at defined accuracies. Four clinically relevant biomarkers: the mineral-to-matrix ratio, the carbonate-to-matrix ratio, phenylalanine, and calcium contents were experimentally determined and simultaneously considered as input to a linear discriminant analysis (LDA). Additionally, sample evaluation was performed with a linear support vector machine (LSVM) algorithm, with a 300 variable input. The computed probabilities based on a single spectrum were only marginally different (~80% from LDA and ~87% from LSVM), both providing an unacceptable classification power for a correct sample assignment. However, the Type I and Type II assignment errors confirm that a relatively small number of independent spectra (7 spectra for Type I and 5 spectra for Type II) is necessary for a p < 0.05 error probability. This low number of spectra supports the practicality of future in vivo Raman translation for a fast and accurate ROD detection in clinical settings.

Live Donor Renal Transplant With Simultaneous Bilateral Nephrectomy for Autosomal Dominant Polycystic Kidney Disease Is Feasible and Satisfactory at Long-term Follow-up

BACKGROUND

Timing of bilateral nephrectomy (BN) is controversial in patients with refractory symptoms of autosomal dominant polycystic kidney disease (APKD) in need of a renal transplant.

METHODS

Adults who underwent live donor renal transplant (LRT) + simultaneous BN (SBN) from August 2003 to 2013 at a single transplant center (n = 66) were retrospectively compared to a matched group of APKD patients who underwent LRT alone (n = 52). All patients received general health and polycystic kidney symptom surveys.

RESULTS

Simultaneous BN increased operative duration, estimated blood loss, transfusions, intravenous fluid, and hospital length of stay. Most common indications for BN were pain, loss of abdominal domain, and early satiety. There were more intraoperative complications for LRT + SBN (6 vs 0, P = 0.03; 2 vascular, 2 splenic, and 1 liver injury; 1 reexploration to adjust graft positioning). There were no differences in Clavien-Dindo grade I or II (39% vs 25%, P = 0.12) or grade III or IV (7.5% vs 5.7%, P = 1.0) complications during the hospital course. There were no surgery-related mortalities. There were no differences in readmission rates (68% vs 48%, P = 0.19) or readmissions requiring procedures (25% vs. 20%, P = 0.51) over 12 months. One hundred percent of LRT + SBN allografts functioned at longer than 1 year for those available for follow-up. Survey response rate was 40% for LRT-alone and 56% for LRT + SBN. One hundred percent of LRT + SBN survey responders were satisfied with their choice of having BN done simultaneously.

CONCLUSIONS

Excellent outcomes for graft survival, satisfaction, and morbidity suggest that the combined operative approach be preferred for patients with symptomatic APKD to avoid multiple procedures, dialysis, and costs of staged operations.

Risk factors leading to reduced bone mineral density in hemodialysis patients with metabolic syndrome

Although metabolic syndrome (MS) is associated with low bone mineral density (BMD) in the general population, it is unknown whether similar associations exist in patients with chronic kidney disease. We investigated risk factors that can lead to low BMD values in hemodialysis patients with MS according to the diagnostic criteria set by International Diabetes Federation (IDF) in this study. A total of 64 patients with MS undergoing hemodialysis and 60 hemodialysis patients who were matched in terms of age, gender, and hemodialysis duration without MS were enrolled in the study. BMD was measured at lumbar vertebra (LV) and femur neck (FN) by performing dual-energy X-ray absorptiometry (DEXA). LV and/or FN-BMD results revealed that, of the hemodialysis patients with MS, 45% had osteoporosis and 48% had osteopenia. On the other hand, of the hemodialysis patients without MS, 42% had osteoporosis and 52% had osteopenia. Low BMD values were observed to be correlated negatively with age, hemodialysis period, and parathormone (PTH) both in the group with MS and in the group without MS. Height, weight, BMI, calcium, phosphorus, alkaline phosphatase, heparin, and vitamin D therapy and urea reduction ratio were not established to be correlated with BMD.

Evaluation and management of osteoporosis and fragility fractures in the elderly

Osteoporosis is characterized by low bone mass and microarchitectural deterioration that leads to increased bone fragility and fracture. The medical, psychosocial and economic burden that fragility fractures have on individuals and society is staggering. As the geriatric segment of the population continues to expand, so to will the magnitude of this epidemic. There are multiple mechanisms influencing bone quality and bone loss with age. Fragility fracture is a composite of multiple intrinsic and extrinsic factors related to the individual and their environment. Fall prevention remains the cornerstone of management in this problem. The FRAX® fracture risk assessment program, which estimates the 10-year probability of a major osteoporotic fracture, is an exciting new tool in assessing risk. Novel therapeutics, including zoledronic acid, strontium and teriparatide, are now available to complement proven osteoporosis treatments and more effectively decrease fracture risk in vulnerable individuals. Agents in Phase III trials, including denosumab and lasofoxifene, will probably increase the armamentarium of tools clinicians can use to combat the growing problem of osteoporosis and its complications.

Osteomalacia in a hemodialysis patient receiving an active vitamin D sterol

BACKGROUND

A 17-year-old Filipino male hemodialysis patient presented for renal transplant evaluation. He had significant skeletal abnormalities characterized by bone pain, an inability to walk, and secondary hyperparathyroidism despite therapy with an active vitamin D sterol (paricalcitol).

INVESTIGATIONS

The patient underwent a physical examination, and his serum levels of calcium, phosphorus, alkaline phosphatase, parathyroid hormone, aluminum and 25-hydroxycholecalciferol (25OH-vitamin D) were determined. X-rays of hips and lower extremities, MRI, and bone histomorphometry after double tetracycline labeling were performed.

DIAGNOSIS

Osteomalacia associated with low 25OH-vitamin D levels.

MANAGEMENT

Monthly therapy with ergocalciferol (vitamin D2) and discontinuation of paricalcitol.

Oral Feeding Acutely Down-Regulates Serum PTH in Hemodialysis Patients

BACKGROUND

Changes in serum parathyroid hormone (PTH) within minutes are known only to be mediated by changes in ionized calcium. Recent animal studies show ingestion of a low phosphorus meal can lower serum PTH within 15 min, before changes in serum ionized calcium or phosphorus occur, suggesting a rapid gastrointestinal signal may regulate PTH.

METHODS

Eight hemodialysis patients with secondary hyperparathyroidism were admitted twice to a metabolic unit and ate a high and low phosphorus meal after an overnight fast. Serum PTH, total and ionized calcium, phosphorus, pH, and glucose were measured at 0, 15, 30, 60, 120 and 240 min. In the second protocol, we examined the possible role of volume or glucose changes in rapid PTH suppression by administering intravenous saline and glucose after an overnight fast to 6 patients, with similar testing.

RESULTS

Intact PTH decreased 24% from 419 +/- 331 at baseline to 312 +/- 221 pg/ml (p = 0.002) 15 min after a meal. Total and ionized calcium and pH did not change, glucose rose by 15 min, and phosphorus changed only after 60-90 min. During the second protocol, saline and glucose infusions failed to change PTH.

CONCLUSIONS

In dialysis patients, a glucose-containing meal, with or without phosphorus, rapidly suppresses serum PTH approximately 25% within 15 min. This effect is not mediated by changes in ionized calcium, phosphorus, pH, glucose, or insulin. These data suggest there may be an as yet unknown enteral signal that rapidly suppresses PTH.

Imaging of renal osteodystrophy

Chronic renal insufficiency, hemodialysis, peritoneal dialysis, renal transplantation and administration of different medications provoke complex biochemical disturbances of the calcium-phosphate metabolism with wide spectrum of bone and soft tissue abnormalities termed renal osteodystrophy. Clinically most important manifestation of renal bone disease includes secondary hyperparathyroidism, osteomalacia/rickets, osteoporosis, adynamic bone disease and soft tissue calcification. As a complication of long-term hemodialysis and renal transplantation amyloid deposition, destructive spondyloarthropathy, osteonecrosis, and musculoskeletal infections may occur. Due to more sophisticated diagnostic methods and more efficient treatment classical radiographic features of secondary hyperparathyroidism and osteomalacia/rickets are now less frequently seen. Radiological investigations play an important role in early diagnosis and follow-up of the renal bone disease. Although numerous new imaging modalities have been introduced in clinical practice (scintigraphy, CT, MRI, quantitative imaging), plain film radiography, especially fine quality hand radiograph, still represents most widely used examination.

Update on vitamin D and its newer analogues: actions and rationale for treatment in chronic renal failure

Vitamin D is an important hormone for mineral homeostasis and the proper formation and maintenance of bone. In addition, vitamin D has broader functions in the body that expand its traditionally known role in mineral balance. In chronic renal failure, calcitriol deficiency contributes to the development and progression of secondary hyperparathyroidism, bone disorders, and altered mineral metabolism. Recent revelations of the broader role of vitamin D also suggest calcitriol deficiency may contribute to decreased cardiac and immune function in chronic renal failure patients. Research on vitamin D has led to a more complete understanding of the actions of vitamin D at the transcriptional level and with respect to the clinical use of vitamin D and its analogs to control parathyroid hormone overactivity and to replace the other D hormone-dependent actions in patients with renal failure. Limitations of vitamin D and its metabolites include hypercalcemia, hyperphosphatemia and suppression of bone turnover with the risk of adynamic bone disease. Vitamin D analogs may offer greater selectivity and potentially greater safety as compared to calcitriol because of their altered relative potency on calcium and phosphorus metabolism. This review focuses on the current understanding of the biological actions of vitamin D and its analogs and the rationale for treating patients with chronic renal failure.

Analysis of renal bone disease treatment in dialysis patients

End-Stage Renal Disease Network 11 initiated a renal osteodystrophy quality improvement activity in 1999. One component was the collection and assessment of dialysis facility renal osteodystrophy protocols, whereas another component was the analysis of bone disease-related medication use. Two hundred eighty-eight facilities were invited to submit protocols. A model bone disease and mineral metabolism protocol was developed as the standard for comparison. From the model protocol, an instrument was created to evaluate eight key areas (baseline screening of key laboratory data, dietary intervention, phosphate-binder use, vitamin D use, monitoring of key laboratory indicators, management of hypercalcemia, oversuppression of parathyroid hormone [PTH], and guidelines for both hemodialysis and peritoneal dialysis patients). A bone disease-related prescription survey was completed for 749 randomly selected patients. Survey information included vitamin D and phosphate-binder use and related laboratory values (calcium, phosphorus, intact PTH [iPTH], and calcium x phosphorus product). Although 45% of facilities had six or more points on the evaluation tool, protocols were still incomplete compared with the model. Mean facility-specific scores among the five states in the Network ranged from 1.0 to 5.9 (possible scores, 0 to 8). Most patients were prescribed a phosphate binder; however, 31.8% had average phosphorus levels greater than 6.0 mg/dL during the 3-month period. Only 58% of patients with average iPTH concentrations greater than 260 pg/mL were prescribed vitamin D. Of patients treated with vitamin D, 39% had iPTH concentrations less than 130 pg/mL. There is opportunity to improve renal osteodystrophy protocols in Network 11 and reinforce potential hazards of sustained hyperphosphatemia and hyperparathyroidism.

Stimulated salivary flow rate in chronic hemodialysis patients

BACKGROUND

Reduced salivary flow has been reported in patients undergoing hemodialysis (HD) treatment. Our aim was to investigate the most important factors associated with stimulated salivary flow rate (ssfr) in chronic HD patients.

METHODS

Fifty HD patients (27 F, 23 M, mean age 46. 7 +/- 13.2 years) were divided into two groups according to the duration of HD treatment as those receiving HD therapy less than or equal to (group I) or those more than (group II) 24 months. Fasting blood samples were obtained to determine hepatitis B and C serology, and biochemical and hematological parameters before a HD session. After prestimulation with a standard weight paraffin wax, stimulated saliva was collected in the HD patients and control group (23 F, 25 M, mean age 45.7 +/- 19.1 years) and the flow rate was expressed as ml/min.

RESULTS

Both HD groups consisted of 25 patients. There was no significant difference between the two HD groups other than serum alkaline phosphatase (ALP) levels and presence of HCV. The ssfr was decreased than controls in both groups (0.8 +/- 0.6 and 0.7 +/- 0.4, respectively, vs. 1.5 +/- 0.5 ml/min) and it did not correlate with any parameter. Smoking had a positive effect on ssfr in all groups.

CONCLUSION

Although the salivary flow rate decreased significantly in chronic HD patients, the duration of therapy displayed no effect on the salivary changes in HD patients, but smoking increased ssfr.

Percutaneous bone biopsy in the diagnosis of renal osteodystrophy

Renal failure is associated with many complex bone and mineral complications. The spectrum of diseases is wide, encompassing defects in bone turnover, remodeling, and mineralization. Disease is currently defined in terms of whether a high or low turnover lesion is present. Measurement of serum parathyroid hormone levels (PTH) remains an important aspect in the management of renal bone disease, however, is limited by its lack of sensitivity in many clinical settings. Multiple biochemical markers are also available both commercially and experimentally to assist in assessing the degree of bone formation or resorption. However, when definitive diagnosis is important, when the clinical setting is confusing or complex, or when parathyroidectomy is being considered, the use of percutaneous bone biopsy is an essential tool in the understanding of underlying bone pathology and in directing therapy intervention.

Parathyroidectomy in chronic renal failure: short- and long-term results on parathyroid function, blood pressure and anemia

To evaluate the long-term results of parathyroidectomy (PTX) on parathyroid function, blood pressure and anemia, data of 45 patients with secondary Hyperparathyroidism in dialysis who had undergone PTX were collected retrospectively from 8 different dialysis units. The patients, 25 M and 20 F, mean age 56 +/- 11 years, who were followed up for an average period of 3.3 +/- 2.3 years, were divided into four groups according to the surgical procedure: 19 patients had had a subtotal PTX; 10 patients had undergone total PTX with autotransplantation (AT); 10 patients had had total PTX without AT, and 6 patients had undergone partial PTX. Taking a reduction in intact PTH > 50% as sign of successful PTX, only 5 patients did not attain this result. Considering values of PTH between 20 and 200 pg/ml at the mid-term observation (1-2 years) as the optimal result, values under 20 pg/ml as an expression of permanent hypoparathyroidism, and those above 200 pg/ml as indicating persistent/recurrent hyperparathyroidism, 65.5% of patients operated with subtotal PTX and total PTX + AT had a therapeutic success, versus 31.2% of patients in the other two groups, due to excess permanent hypoparathyroidism and persistent/recurrent hyperparathyroidism; 20 of 45 patients with preoperative hypertension experienced a statistically and clinically significant decrease in blood pressure levels. An increase in serum hemoglobin was also observed, despite a reduction of administered erythropoietin. In conclusion, the results of PTX obtained from this multicenter study are comparable to those reported by single leading centers. Recommended surgical procedures are subtotal PTX and total PTX with AT. The fall in blood pressure in hypertensive patients is clinically significant, and improvement in anemia is also observed with a reduction in erythropoietin dosage.

Cost-effectiveness of sevelamer versus calcium carbonate plus atorvastatin to reduce LDL in patients with chronic renal insufficiency with dyslipidemia and hyperphosphatemia

We conducted a cost-effectiveness analysis to compare costs and clinical outcomes of sevelamer versus calcium carbonate plus atorvastatin for treatment of dyslipidemia in patients with chronic renal insufficiency. The model was from the third-party payer perspective. Efficacy and adverse event rates for each regimen were obtained from published clinical trials. Drug costs were based on average wholesale prices; monitoring costs were based on Medicare reimbursement rates. Our model suggests that the combination of calcium carbonate plus atorvastatin is substantially more cost-effective than sevelamer in reducing low-density lipoprotein (LDL) in these patients. One-way sensitivity analyses were performed to assess if 25% and 50% price reductions in sevelamer affected overall cost-effectiveness results. A 50% sevelamer price reduction was less expensive than combination therapy but remained less cost-effective. A two-way sensitivity analysis on the probability that a patient achieves the goal of a 35% LDL reduction resulted in calcium carbonate plus atorvastatin remaining more cost-effective. Further cost-effectiveness studies are necessary to corroborate our data.

Osteodystrophy in the millennium

Despite three decades of intensive research on the derangements of calcium phosphate metabolism of renal failure, several unresolved issues are still with us at the turn of the millennium: poor control of hyperphosphatemia, relative inefficacy of active vitamin D to prevent progressive parathyroid hyperplasia, and persistence of bone disease despite lowering of parathyroid hormone (PTH) and administration of active vitamin D. Although predictions are problematic, it is not unreasonable to hope that, barring unforeseen side effects, calcimimetics will prove to be valuable for suppressing or even preventing hyperparathyroidism, thus potentially replacing, at least in part, active vitamin D. There is also reason to hope that more effective phosphate binders with fewer side effects will become available and that controlled studies will provide a rationale for the administration of estrogens to dialyzed women. As regards understanding the pathological mechanisms, one can anticipate that the disturbances leading to autonomous growth of parathyroid cells will be elucidated and the signals involved in osteoclast/osteoblast differentiation pathways and osteoclast/osteoblast coupling will be clarified, with obvious impact on patient management.

Subcutaneous forearm transplantation of autologous parathyroid tissue in patients with renal hyperparathyroidism

BACKGROUND

Parathyroidectomy is required in up to 5% of patients with chronic renal failure. Intramuscular transplantation of autologous parathyroid tissue in the forearm has been the traditional method of transplantation at the time of total parathyroidectomy. The removal of an intramuscular transplantation can be technically difficult should graft-dependent hyperparathyroidism (GRH) occur. This problem resulted in our initiating a study of subcutaneous transplantation with total parathyroidectomy in patients with renal failure.

METHODS

Twenty-six patients who were receiving dialysis therapy underwent total parathyroidectomy and subcutaneous transplantation. Parathyroid tissue was diced into 1- to 2-mm pieces, and 6 pieces were grafted into 6 subcutaneous pockets of the forearm. Intact parathyroid hormone was measured within 48 hours of operation and in the bilateral antecubital veins 1 to 24 months after the operation to assess completeness of resection and graft function, respectively.

RESULTS

No major surgical complications occurred. Symptoms improved in 24 patients (85%). Graft failure rate was 4.3%. No GRH was observed. Follow-up was 4 to 55 months (mean, 27 months).

CONCLUSIONS

This study indicates that the subcutaneous transplantation function is comparable to intramuscular transplantation and suggests a decreased incidence of GRH. Subcutaneous transplantation is technically easier than intramuscular transplantation and has the additional advantage of easy removal should GRH occur.