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Bartz-Kurycki M, Dream S. Surgical Management of Secondary and Tertiary Hyperparathyroidism. Surg Clin North Am 2024; 104:825-835. [PMID: 38944502 DOI: 10.1016/j.suc.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Secondary hyperparathyroidism (SHPT) often arises from kidney disease and is characterized by elevated parathyroid hormone (PTH) levels. The reported optimal PTH level to balance the compensatory physiologic response in SHPT with the pathologic morbidity and mortality has changed over time with our evolving understanding. Parathyroidectomy for kidney-related hyperparathyroidism requires consideration of the patient's dialysis status, potential for kidney transplantation, and medical history. Extent of parathyroidectomy and intraoperative decision-making requires consideration to maximize cure with the risk of permanent hypoparathyroidism. Parathyroidectomy for kidney-related hyperparathyroidism can provide a reduction in morbidity, mortality, and improved kidney allograft function and survival.
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Affiliation(s)
- Marisa Bartz-Kurycki
- Surgical Services, James A. Haley Veterans Hospital, 13000 Bruce B. Downs Boulevard, Tampa, FL 33612, USA; Department of Surgery, University of South Florida, Tampa, FL, USA. https://twitter.com/MarisaBK6
| | - Sophie Dream
- Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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Chang LC, Liu SI, Liang TJ. Neck Reoperation for Recurrent or Persistent Renal Hyperparathyroidism. World J Surg 2023; 47:2784-2791. [PMID: 37714965 DOI: 10.1007/s00268-023-07172-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Patients with renal hyperparathyroidism undergoing parathyroidectomy may experience relapse. Reoperation for persistent or recurrent disease, particularly in the neck region, is challenging and has a high complication rate because of difficult exploration. We aimed to evaluate the effectiveness of neck reoperation in renal hyperparathyroidism. METHODS Patients with recurrent or persistent renal hyperparathyroidism who underwent neck reoperation between January 2015 and August 2022 were investigated, focusing on operative findings, perioperative biochemical changes, and significance of intraoperative parathyroid hormone (PTH) measurements. RESULTS During reoperation, 35 parathyroid glands were identified and removed from the 26 enrolled patients, with one, two, and three glands retrieved from 19 (73.2%), five (19.2%), and two (7.6%) patients, respectively. Most removed glands (68.6%) were located in the lower neck, followed by the mediastinum, carotid sheath, and upper neck. Successful resection, defined as a postoperative PTH level of <300 pg/mL, was achieved in 21 patients (80.8%). The remaining four (15.4%) and one (3.9%) patients were classified as having persistent and recurrent disease, respectively. The extent of PTH reduction was correlated with specimen weight, specimen volume, and preoperative alkaline phosphatase (ALP) level. The mean intraoperative PTH ratio (10 min after excision/pre-excision) was 0.23, and all patients with persistent or recurrent disease had a PTH ratio >0.3. Severe hypocalcemia (<7.5 mg/dL) occurred in 19 (73.0%) patients after reoperation. CONCLUSIONS Neck reoperation is an effective therapeutic option in patients with recurrent or persistent renal hyperparathyroidism. A decrease in PTH level by >70% during reoperation (PTH ratio <0.3) predicts successful resection.
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Affiliation(s)
- Lu-Chia Chang
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Zuoying District, No. 386, Dazhong 1st Rd., Kaohsiung, Taiwan, 813414
| | - Shiuh-Inn Liu
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Zuoying District, No. 386, Dazhong 1st Rd., Kaohsiung, Taiwan, 813414
- School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec. 2, Linong Street, Taipei, Taiwan, 112304
| | - Tsung-Jung Liang
- Division of General Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Zuoying District, No. 386, Dazhong 1st Rd., Kaohsiung, Taiwan, 813414.
- School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec. 2, Linong Street, Taipei, Taiwan, 112304.
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Nasiri S, Meshkati Yazd SM, Heshmati A, Mokhtari Ardekani A, Najafi M, Shahriarirad R. Investigating the effectiveness of intraoperative rapid parathyroid hormone assay in parathyroidectomy surgery in patients with secondary hyperparathyroidism. BMC Endocr Disord 2023; 23:120. [PMID: 37231458 DOI: 10.1186/s12902-023-01378-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/21/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION The use of Rapid Intraoperative parathyroid hormone (Io-PTH) assay during surgery in the management of parathyroid tissue in cases of primary hyperparathyroidism has been proven to be effective, while its utilization in secondary hyperparathyroidism (SHPT) has been rarely reported. In the present study, we aim to demonstrate the application of rapid Io-PTH assay in patients with SHPT following chronic kidney disease undergoing parathyroidectomy surgery. METHOD In this prospective study, five blood samples were taken from patients undergoing parathyroidectomy and upper thymectomy. Among the samples, two were pre-excision, including prior to the first incision, after exploration, and before parathyroids resection. Two additional samples were taken 10 and 20 min after the excision of the parathyroid glands. Another sample was collected twenty-four hours after the operation. Serum Calcium levels and PTH levels were evaluated and analyzed. RESULTS We successfully managed SHPT in all 36 patients in our study. The patients included 24 males (66.7%) with a mean age of 49.97 ± 14.92. The mean PTH decreased significantly at 10 min, 20 min, one day, and six months after surgery (P < 0.001). The highest reduction occurred 10 min after removal of the parathyroid glands so the mean PTH compared to time zero was reduced from 1737 to 439, and in 100% of cases, more than 50% reduction was seen in PTH. CONCLUSION A 60% or more reduction in PTH Rapid at 10 min after parathyroidectomy has an accuracy of 94.4% and a positive predictive value of 100%. Thus, if the PTH level does not decrease by more than 60% at 10 min or more than 80% at 20 min, tissue exploration is continued with the aim of finding the ectopic parathyroid gland.
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Affiliation(s)
- Shirzad Nasiri
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Alireza Heshmati
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Abnoos Mokhtari Ardekani
- Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Science, & Physiology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Masoud Najafi
- Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Shahriarirad
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran.
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Li L, He C, Cheng G, Cao J, Wang C, Tang Y, Zhang W. Recurrent renal secondary hyperparathyroidism caused by supernumerary mediastinal parathyroid gland and parathyromatosis: A case report. Front Surg 2023; 10:1135596. [PMID: 37021088 PMCID: PMC10067725 DOI: 10.3389/fsurg.2023.1135596] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 02/27/2023] [Indexed: 04/07/2023] Open
Abstract
Background Surgical parathyroidectomy (PTX) is necessary for patients with severe and progressive secondary hyperparathyroidism (SHPT) refractory to medical treatment. Recurrence of SHPT after PTX is a serious clinical problem. Both supernumerary mediastinal parathyroid gland and parathyromatosis are the rare causes of recurrent renal SHPT. We report a rare case of recurrent renal SHPT due to supernumerary mediastinal parathyroid gland and parathyromatosis. Case presentation A 53-year-old man underwent total parathyroidectomy with autotransplantation due to the drug-refractory SHPT 17 years ago. In the last 11 months, the patient experienced symptoms including bone pain and skin itch, and the serum intact parathyroid hormone (iPTH) level elevated to 1,587 pg/ml. Ultrasound detected two hypoechoic lesions located at the dorsal area of right lobe of the thyroid gland, and both lesions presented as characteristics of hyperparathyroidism in contrast-enhanced ultrasound. 99mTc-MIBI/SPECT detected a nodule in the mediastinum. A reoperation involved a cervicotomy for excising parathyromatosis lesions and the surrounding tissue and a thoracoscopic surgery for resecting a mediastinal parathyroid gland. According to a histological examination, two lesions behind the right thyroid lobe and one lesion in the central region had been defined as parathyromatosis. A nodule in the mediastinum was consistent with hyperplastic parathyroid. The patient remained well for 10 months with alleviated symptoms and stabilized iPTH levels in the range of 123-201 pg/ml. Conclusion Although rare, recurrent SHPT may be caused by a coexistence of both supernumerary parathyroid glands and parathyromatosis, which should receive more attention. The combination of imaging modalities is important for reoperative locations of parathyroid lesions. To successfully treat parathyromatosis, all the lesions and the surrounding tissue must be excised. Thoracoscopic surgery is a reliable and safe approach for the resection of ectopic mediastinal parathyroid glands.
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Affiliation(s)
- Longfei Li
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Chenchen He
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
- Department of Clinical Medicine and Surgery, China Medical University, Shenyang, China
| | - Guangming Cheng
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Junying Cao
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Chunhui Wang
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Yufu Tang
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
- Correspondence: Yufu Tang Wei Zhang
| | - Wei Zhang
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
- Correspondence: Yufu Tang Wei Zhang
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Liu J, Fan XF, Yang M, Huang LP, Zhang L. Effect of calcium supplementation on severe hypocalcemia in patients with secondary hyperparathyroidism after total parathyroidectomy. World J Clin Cases 2022; 10:4033-4041. [PMID: 35665128 PMCID: PMC9131232 DOI: 10.12998/wjcc.v10.i13.4033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/28/2021] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe hypocalcemia (SH) is a dreaded complication of total parathyroidectomy (TPTX) without auto-transplantation.
AIM To compare conventional and preventive calcium supplementation (CS) regimens in terms of SH occurrence after TPTX.
METHODS This retrospective study included patients who underwent TPTX between January 2015 and May 2018 at the China-Japan Friendship Hospital. From January 2015 to May 2016, conventional CS was performed in patients who underwent TPTX, with calcium amounts adjusted according to postoperative serum calcium levels. From October 2016 to May 2018, preventive CS was performed according to preoperative alkaline phosphatase (ALP) levels. The patients were defined as low-risk (ALP < 500 U/L) and high-risk (ALP > 500 U/L) for SH. All preoperative blood samples were collected in the fasting state on the day before surgery. Postoperative blood samples were obtained at 6-7 AM from the first postoperative day.
RESULTS A total of 271 patients were included. These patients were 47.7 ± 11.1 years old, and 57.6% were male. Their mean body mass index (BMI) was 22.9 ± 3.8 kg/m2. There were no significant differences in sex, age, BMI, preoperative ALP, serum calcium, serum phosphorus, calcium-phosphorus ratio, and intact parathyroid hormone (iPTH) between the two CS groups. Compared with conventional CS, preventive CS led to lower occurrence rates of hypocalcemia within 48 h (46.0% vs 74.5%, P < 0.001) and SH (31.7% vs 64.1%, P < 0.001). Multivariable analysis showed that preoperative iPTH levels [odds ratio (OR) = 1.001, 95% confidence interval (CI): 1.000-1.001, P = 0.009), preoperative ALP amounts (OR = 1.002, 95%CI: 1.001-1.003, P = 0.002), preoperative serum phosphorus levels (OR = 8.729, 95%CI: 1.518-50.216, P = 0.015) and preventive CS (OR = 0.132, 95%CI: 0.067-0.261, P < 0.001) were independently associated with SH. In patients with preoperative ALP ≥ 500 U/L, only preventive CS (OR = 0.147, 95%CI: 0.038-0.562. P = 0.005) was independently associated with SH.
CONCLUSION This study suggests that preventive CS could reduce the occurrence of SH, indicating its critical value for hypocalcemia after TPTX.
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Affiliation(s)
- Jun Liu
- Department of General Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xue-Feng Fan
- Department of General Surgery, Shougang General Hospital, Shougang 553000, Guizhou Province, China
| | - Meng Yang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Lin-Ping Huang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Ling Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing 100029, China
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Lee CH, Chen JY, Kuo PC, Chen WT. Parathyroidectomy for dialysis patients in the era of calcimimetics: The surgeons' point of view. J Chin Med Assoc 2022; 85:279-285. [PMID: 35259131 DOI: 10.1097/jcma.0000000000000694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Calcimimetics is a new drug for lowering serum parathyroid hormone (PTH), calcium and phosphate in patients with hyperparathyroidism (HPT) on long-term dialysis. It became available on market in 2006. The impact of calcimimetics on the treatment by parathyroidectomy (PTx) was reviewed from the surgeons' point of view. Cure of renal HPT by calcimimetics is not feasible, but calcimimetics can improve preoperative cardiac ventricle ejection fractions by lowering serum PTH. Heart failure is not necessarily a contraindication for PTx. PTx should be done before irreversible organ damage occurs. Limb gangrenes is an ominous sign and should be prevented by frequent checkup for peripheral arterial circulation. The impact of renal osteodystrophy on the quality of life and as indirect cause of mortality deserves more attention in patients with renal HPT. Delayed referral to PTx leads to more complicated patients. A consensus between nephrologists and surgeons about propitious timing for PTx is necessary. Future prospect on the surgical treatment of renal HPT is proposed. Supplemental figure; http://links.lww.com/ASAIO/A782.
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Affiliation(s)
- Chen-Hsen Lee
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Divisions of General Surgery, Departments of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Jui-Yu Chen
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Divisions of General Surgery, Departments of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Po-Chung Kuo
- Divisions of General Surgery, Departments of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wei-Ting Chen
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- National Yang Ming Chiao Tung University Hospital, I-Lan, Taiwan, ROC
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龚 薇, 谢 宇, 林 雅, 孟 子, 王 玉. [Risk factors affecting graft survival after parathyroidectomy and parathyroid autotransplantation in patients on maintenance hemodialysis]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2021; 41:947-952. [PMID: 34238750 PMCID: PMC8267987 DOI: 10.12122/j.issn.1673-4254.2021.06.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Indexed: 12/08/2022]
Abstract
OBJECTIVE To investigate the risk factors affecting the survival of parathyroid autograft following total parathyroidectomy combined with autologous sternocleidomastoid muscle transplantation (TPTX + AT) in patients on maintenance hemodialysis (MHD) complicated with secondary hyperparathyroidism (SHPT). OBJECTIVE This retrospective study was conducted among the patients on maintenance hemodialysis with SHPT, who underwent successful parathyroidectomy and autotransplantation from January, 2010 to February, 2020 in our hospital. The clinical data and serum levels of calcium, phosphorus, intact parathyroid hormone, hemoglobin, and alkaline phosphatase (ALP) of the patients were collected. The enrolled patients were divided into survival group with bilateral forearm parathyroid hormone (iPTH) ratio > 1.5 and death group with a ratio < 1.5 at 2 weeks after surgery for comparison of the clinical data and perioperative indicators. The risk factors of postoperative parathyroid autograft survival were analyzed using logistic regression analysis. OBJECTIVE A total of 87 patients were included in the study, among whom the graft survival rate after parathyroid transplantation was 78.16%. In both groups, serum levels of calcium, phosphorus, iPTH and ALP decreased and hemoglobin level increased significantly at 1 week and 1, 2, 3, 6 and 12 months after surgery (P < 0.01). Logistic regression analysis showed that serum ALP level was an independent risk factor for graft survival following parathyroid autotransplantation [OR=1.003, 95% CI: 1.001-1.005, P=0.004]. OBJECTIVE TPTX+AT is a safe and effective treatment for SHPT, and parathyroid autografts are less likely to survive following parathyroid transplantation in patients with high preoperative level of ALP.
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Affiliation(s)
- 薇 龚
- 广东药科大学附属第一医院颌面外科,广东 广州 510080Department of Maxillofacial Surgery, First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou 510080, China
| | - 宇 谢
- 广东药科大学附属第一医院颌面外科,广东 广州 510080Department of Maxillofacial Surgery, First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou 510080, China
| | - 雅琪 林
- 广东药科大学附属第一医院颌面外科,广东 广州 510080Department of Maxillofacial Surgery, First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou 510080, China
| | - 子璐 孟
- 广东药科大学附属第一医院颌面外科,广东 广州 510080Department of Maxillofacial Surgery, First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou 510080, China
| | - 玉栋 王
- 广东药科大学附属第一医院口腔科,广东 广州 510080Department of Stomatology, First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou 510080, China
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Gong W, Lin Y, Xie Y, Meng Z, Wang Y. Predictors of early postoperative hypocalcemia in patients with secondary hyperparathyroidism undergoing total parathyroidectomy. J Int Med Res 2021; 49:3000605211015018. [PMID: 34038214 PMCID: PMC8161902 DOI: 10.1177/03000605211015018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/12/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To summarize the clinical features of secondary hyperparathyroidism (SHPT) in patients with chronic renal failure and to explore the predictive factors of postoperative hypocalcemia after total parathyroidectomy in these patients. METHODS The clinical data of 87 patients admitted to Guangdong Electric Power Hospital from May 2013 to February 2020 were reviewed. All patients underwent total parathyroid resection and sternocleidomastoid microtransplantation. Age, sex, and the serum calcium, phosphorus, alkaline phosphatase (ALP), and intact parathyroid hormone (iPTH) concentrations were analyzed as predictive factors of postoperative hypocalcemia. RESULTS Bone pain was the most common clinical manifestation in this study population, and all 87 patients experienced relief from their clinical symptoms after the surgical procedure. Age and the preoperative serum calcium, ALP, and iPTH concentrations were determined to be early predictive factors of postoperative hypocalcemia. CONCLUSIONS Age and the preoperative calcium, ALP, and iPTH concentrations are independent risk factors for postoperative hypocalcemia in patients with SHPT and renal disease who undergo total parathyroidectomy with sternocleidomastoid microtransplantation. These factors can help identify high-risk patients who can be managed by a multidisciplinary team to improve graft survival and quality of life.
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Affiliation(s)
| | | | | | | | - Yudong Wang
- Yudong Wang, Department of Stomatology, The First Affiliated Hospital of Guangdong Pharmaceutical University, No. 19 Nonglinxia Road, Yuexiu District, Guangzhou 510062, China.
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Suitability of denervated muscle flaps as recipient sites for pancreatic islet cell transplantation. Arch Plast Surg 2021; 48:133-143. [PMID: 33503758 PMCID: PMC7861985 DOI: 10.5999/aps.2020.01865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/18/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Extensive research has been conducted on islet transplantation as a possible cure for diabetes. Islet transplantation in the liver via the portal vein has shown remarkable results, but numerous other recipient sites are currently being investigated. We aimed to show the effectiveness of using a muscle flap as a recipient site for islet transplantation. METHODS Islet cells were harvested from 12 isogenic Lewis rats, and then diabetes was induced in another 12 isogenic Lewis rats by streptozotocin injection. In six rats, 3,000 islets were transplanted into gastrocnemius muscle flaps, and in the other six rats, the same number of islets were transplanted into the gastrocnemius muscle. The transplanted islet cell function between the two groups was compared by means of blood glucose tests, glucose tolerance tests, immunohistochemistry, and real-time reverse transcription polymerase chain reaction. RESULTS In the muscle flap group, blood glucose levels significantly decreased after islet transplantation. Blood glucose levels were significantly different between the two groups at 3 weeks after transplantation. The muscle flap group showed nearly normoglycemic results upon the glucose tolerance test, whereas the muscle group was hyperglycemic. Immunohistochemical evaluation showed positive results against insulin and glucagon in biopsies of both groups, and the islet cell density was higher in the muscle flap group. There were no statistically significant differences between the two groups in real-time reverse transcription polymerase chain reaction results. CONCLUSIONS Our results suggest that muscle flaps are promising candidates for islet cell transplantation.
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Liu J, Huang Q, Yang M, Huang L, Zhang L. Risk factors predicting severe hypocalcemia after total parathyroidectomy without autotransplantation in patients with secondary hyperparathyroidism. J Int Med Res 2020; 48:300060519897505. [PMID: 31948313 PMCID: PMC7113811 DOI: 10.1177/0300060519897505] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Objective This study was performed to investigate the risk factors for severe hypocalcemia (SH) after total parathyroidectomy without autotransplantation (TPTX) in patients with secondary hyperparathyroidism. Methods We retrospectively analyzed the records of 136 patients with secondary hyperparathyroidism treated by TPTX. The patients were categorized as having SH or non-SH based on their postoperative blood calcium concentration. The risk factors for SH were identified by comparing the clinical characteristics between the two groups and by performing multiple logistic regression analyses. Results After surgery, 46.0% of the patients had hypocalcemia and 31.7% had SH. Evidence of renal osteodystrophy on lumbar radiographs and the serum concentrations of intact parathyroid hormone (iPTH), calcium, and alkaline phosphatase (ALP) were different between the two groups. The SH group had higher preoperative iPTH and ALP concentrations than the non-SH group. In addition, more patients with SH showed renal osteodystrophy. Logistic regression analyses indicated that preoperative hypocalcemia and a high ALP concentration were independent predictors of SH. Conclusion Preoperative hypocalcemia and a high ALP concentration were identified as risk factors for SH following TPTX.
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Affiliation(s)
- Jun Liu
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Qinghua Huang
- Digital Plastic Center of Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Meng Yang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Linping Huang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Ling Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
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11
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Results of 150 Subtotal Parathyroidectomies for Secondary Hyperparathyroidism. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02119-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Reitz RJ, Dreimiller A, Khil A, Horwitz E, McHenry CR. Ectopic and supernumerary parathyroid glands in patients with refractory renal hyperparathyroidism. Surgery 2020; 169:513-518. [PMID: 32919783 DOI: 10.1016/j.surg.2020.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 07/23/2020] [Accepted: 08/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aims of this study were to determine the rate of ectopic and supernumerary parathyroid glands and the outcome of surgical therapy in patients with refractory renal hyperparathyroidism. MATERIALS AND METHODS A retrospective review of all patients who underwent parathyroidectomy for refractory renal hyperparathyroidism was completed. Operative and pathology reports were reviewed, and the number and location of resected parathyroid glands, patient outcomes, and follow-up were determined. RESULTS During the period 1993-2019, a total of 68 patients underwent subtotal or total parathyroidectomy for renal hyperparathyroidism. Of those, 59 patients (87%) were on dialysis for an average of 6.7 years. We determined that 18 patients (26%) had 24 ectopic parathyroid glands, including 9 (13%) patients with 11 supernumerary glands. A total of 2 patients had a supernumerary gland in a normal anatomic location. Of the 24 ectopic glands, 14 (58%) were in the thymus. After parathyroidectomy, 4 patients (5.9%) had persistent hyperparathyroidism, 6 patients (8.8%) developed recurrent hyperparathyroidism, and 2 patients (3%) had permanent hypoparathyroidism. CONCLUSION Ectopic and supernumerary parathyroid glands occurred in 26% and 16% of patients with renal hyperparathyroidism, respectively, and the thymus was the most common location. Thorough neck exploration and transcervical thymectomy are important to help reduce persistent and recurrent hyperparathyroidism after parathyroidectomy for renal hyperparathyroidism.
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Affiliation(s)
- Robert J Reitz
- MetroHealth Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Alina Khil
- MetroHealth Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Edward Horwitz
- MetroHealth Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Christopher R McHenry
- MetroHealth Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH.
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Won HR, Koo BS. Recent Trends in the Surgical Treatment of Secondary Hyperparathyroidism. Clin Exp Otorhinolaryngol 2020; 13:91-92. [PMID: 32434308 PMCID: PMC7248605 DOI: 10.21053/ceo.2020.00493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
- Ho-Ryun Won
- Department of Otolaryngology-Head and Neck Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Bon Seok Koo
- Department of Otolaryngology-Head and Neck Surgery, Chungnam National University College of Medicine, Daejeon, Korea
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Addison P, Fatakhova K, Rodriguez Rilo HL. Considerations for an Alternative Site of Islet Cell Transplantation. J Diabetes Sci Technol 2020; 14:338-344. [PMID: 31394934 PMCID: PMC7196852 DOI: 10.1177/1932296819868495] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Islet cell transplantation has been limited most by poor graft survival. Optimizing the site of transplantation could improve clinical outcomes by minimizing required donor cells, increasing graft integration, and simplifying the transplantation and monitoring process. In this article, we review the history and significant human and animal data for clinically relevant sites, including the liver, spleen, and kidney subcapsule, and identify promising new sites for further research. While the liver was the first studied site and has been used the most in clinical practice, the majority of transplanted islets become necrotic. We review the potential causes for graft death, including the instant blood-mediated inflammatory reaction, exposure to immunosuppressive agents, and low oxygen tension. Significant research exists on alternative sites for islet cell transplantation, suggesting a promising future for patients undergoing pancreatectomy.
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Affiliation(s)
- Poppy Addison
- Donald and Barbara Zucker School of
Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Pancreas Disease Center, Northwell
Health System, Manhasset, NY, USA
| | - Karina Fatakhova
- Donald and Barbara Zucker School of
Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Pancreas Disease Center, Northwell
Health System, Manhasset, NY, USA
| | - Horacio L. Rodriguez Rilo
- Donald and Barbara Zucker School of
Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Pancreas Disease Center, Northwell
Health System, Manhasset, NY, USA
- Horacio L. Rodriguez Rilo, MD, Pancreas
Disease Center, 350 Lakeville Road, New Hyde Park, NY 11042, USA.
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Kim MS, Kim GH, Lee CH, Park JS, Lee JY, Tae K. Surgical Outcomes of Subtotal Parathyroidectomy for Renal Hyperparathyroidism. Clin Exp Otorhinolaryngol 2020; 13:173-178. [PMID: 32075361 PMCID: PMC7248609 DOI: 10.21053/ceo.2019.01340] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/28/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the effectiveness of subtotal parathyroidectomy for patients with renal hyperparathyroidism. METHODS We studied 25 patients with renal hyperparathyroidism who underwent subtotal parathyroidectomy from October 2002 to October 2017. We analyzed serum intact parathyroid hormone (iPTH), calcium, and inorganic phosphorus levels before and at multiple time points following surgery, and evaluated the surgical outcomes and complications. RESULTS Of the 25 patients, 13 (52%) were male and 12 (48%) were female, and the mean age was 53.4±9.3 years. The mean duration of dialysis before parathyroidectomy was 156.8±79.5 months. Mean preoperative serum iPTH and calcium levels were 1,199.0±571.3 pg/mL and 10.5±1.0 mg/dL, respectively. At 6 months postoperatively, the mean iPTH and calcium levels decreased to 49.2±47.6 pg/mL (P<0.01) and 8.0±1.0 mg/dL (P<0.01), respectively. Recurrent hyperparathyroidism occurred in two patients: one subsequently underwent kidney transplantation and the other continued hemodialysis and maintained normal calcium levels. One patient developed postoperative permanent hypoparathyroidism. CONCLUSION Subtotal parathyroidectomy is a safe and effective surgical treatment for renal hyperparathyroidism.
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Affiliation(s)
- Min Song Kim
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Gheun-Ho Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Chang Hwa Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Joon-Sung Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Ji Young Lee
- Department of Radiology, Hanyang University College of Medicine, Seoul, Korea
| | - Kyung Tae
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
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Kim WW, Rhee Y, Kim BS, Kim K, Lee CR, Kang SW, Lee J, Jeong JJ, Nam KH, Chung WY. Clinical outcomes of parathyroidectomy versus cinacalcet in the clinical management of secondary hyperparathyroidism. Endocr J 2019; 66:881-889. [PMID: 31189770 DOI: 10.1507/endocrj.ej19-0036] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Parathyroidectomy (PTX) is the standard treatment for secondary hyperparathyroidism (SHPT); however, the administration of cinacalcet has gained prominence as a noninvasive treatment. We aimed to determine whether PTX or cinacalcet is more effective in preventing morbidity and mortality through reviewing follow-up data concerning surgical management of SHPT. We retrospectively analyzed and divided 209 patients with SHPT into two treatment groups: PTX (n = 78) and cinacalcet (n = 131) groups. We compared clinical features, the over-the-target range rate during pre- and post-intervention periods, new cardiovascular events, and all-cause mortality between both groups. Almost all biochemical parameters were well controlled in the post-intervention period, and were within the recommended target range for the PTX group but not for the cinacalcet group. A significant difference was observed in the over-the-target range rate during the post-intervention period between the groups. PTX and cinacalcet interventions significantly lowered the over-the-target range rates for serum intact parathyroid hormone (iPTH) (>300 pg/mL), corrected calcium (>10.5 mg/mL), serum phosphorus (>5.5 mg/dL), and calcium-phosphorus product (>55) in both groups (p = 0.001). PTX reduced the risk of new cardiovascular events by 86% compared to cinacalcet (p = 0.001); however, all-cause mortality did not differ significantly (14.1% vs. 7.6%, p = 0.132). For patients with SHPT, PTX helps prevent cardiovascular events through normalizing biochemical variables, according to recommended guidelines. PTX should be considered before cinacalcet treatment to prevent new cardiovascular events. Early PTX for appropriate patients can help prevent immediate postoperative complications and mortality.
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Affiliation(s)
- Won Woong Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yumie Rhee
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Beom Seok Kim
- Division of Nephrology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kwangsoon Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Cho Rok Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sang-Wook Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jandee Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Ju Jeong
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kee-Hyun Nam
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Woong Youn Chung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Zhang J, Dong MJ, Yang J, Tian D. Unusual recurrent renal secondary hyperparathyroidism caused by hyperplastic autograft with supernumerary parathyroid adenoma: A case report. Medicine (Baltimore) 2019; 98:e16077. [PMID: 31192970 PMCID: PMC6587644 DOI: 10.1097/md.0000000000016077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
RATIONALE Secondary hyperparathyroidism (SHPT) is often complicated with chronic renal failure. Though the total parathyroidectomy (TPTX) with forearm autotransplantation (FAT) has been commonly used to treatment refractory renal SHPT, the recurrence of SHPT is not infrequent, resulting from hyperplastic autograft, remnant parathyroid tissues, and supernumerary parathyroid gland (SPG). PATIENT CONCERNS A 67-year-old man undergoing TPTX+FAT 4 years previously for renal SHPT, who received regular hemodialysis with active vitamin D supplements of Rocaltrol treatment postoperatively, was admitted to our hospital with progressively elevated serum intact parathyroid hormone (iPTH) from 176 to 1266 pg/mL for 8 months and bilateral ankle joints pain for 1 month. Tc-sestamibi dual-phase imaging with single positron emission tomography (SPECT)/computed tomography (CT) revealed a nodule in suprasternal fossa, besides a nodule in autografted site, accompanied with intense radioactivity. DIAGNOSIS Recurrent SHPT was easily diagnosed based on previous medical history, painful joints, increased serum iPTH level and positive findings of Tc-sestamibi imaging. Routine postoperative pathology showed that the nodules were consistent with an adenomatoid hyperplasic autograft and a supernumerary parathyroid adenoma in suprasternal fossa, respectively. INTERVENTIONS Reoperation for removing nodules in suprasternal fossa and autografted site was performed 1 month later. Then regular hemodialysis 3 times a week with Rocaltrol was continued. OUTCOMES During 12 months of follow-up, the joints pain improved obviously and the serum iPTH level ranged from 30.1 to 442 pg/mL. LESSONS Although rare, recurrent renal SHPT may be caused by a coexistence of both hyperfunctional autograft and SPG after TPTX+FAT. The Tc-sestamibi parathyroid imaging with SPECT/CT is helpful to locate the culprits of recurrent renal SHPT before reoperation. To prevent recurrence of renal SHPT, the present initial surgical procedures should be further optimized in patient on permanent hemodialysis.
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Parathyroidectomy versus cinacalcet for tertiary hyperparathyroidism; a retrospective analysis. Langenbecks Arch Surg 2019; 404:71-79. [PMID: 30729318 PMCID: PMC6394681 DOI: 10.1007/s00423-019-01755-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/17/2019] [Indexed: 01/12/2023]
Abstract
Introduction Tertiary hyperparathyroidism (tHPT), i.e., persistent HPT after kidney transplantation, affects 17–50% of transplant recipients. Treatment of tHPT is mandatory since persistently elevated PTH concentrations after KTx increase the risk of renal allograft dysfunction and osteoporosis. The introduction of cinacalcet in 2004 seemed to offer a medical treatment alternative to parathyroidectomy (PTx). However, the optimal management of tHPT remains unclear. Methods A retrospective analysis was performed on patients receiving a kidney transplantation (KT) in two academic centers in the Netherlands. Thirty patients undergoing PTx within 3 years of transplantation and 64 patients treated with cinacalcet 1 year after transplantation for tHPT were included. Primary outcomes were serum calcium and PTH concentrations 1 year after KT and after PTx. Results Serum calcium normalized in both the cinacalcet and the PTx patients. PTH concentrations remained above the upper limit of normal (median 22.0 pmol/L) 1 year after KT, but returned to within the normal range in the PTx group (median 3.7 pmol/L). Side effects of cinacalcet were difficult to assess; minor complications occurred in three patients. Re-exploration due to persistent tHPT was performed in three (10%) patients. Conclusion In patients with tHPT, cinacalcet normalizes serum calcium, but does not lead to a normalization of serum PTH concentrations. In contrast, PTx leads to a normalization of both serum calcium and PTH concentrations. These findings suggest that PTx is the treatment of choice for tHPT.
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19
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Safety and efficacy of subtotal or total parathyroidectomy for patients with secondary or tertiary hyperparathyroidism in four academic centers in the Netherlands. Langenbecks Arch Surg 2018; 403:999-1005. [PMID: 30415287 PMCID: PMC6328516 DOI: 10.1007/s00423-018-1726-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/31/2018] [Indexed: 12/14/2022]
Abstract
Purpose Hyperparathyroidism (HPT) is a common abnormality in patients with end-stage renal disease (ESRD). Since the introduction of cinacalcet in 2004, a shift from surgery toward predominantly medical treatment has occurred. Surgery is thought to be associated with more complications than oral medication. The aim of this retrospective study was to evaluate 30-day outcomes and effectiveness of parathyroidectomy (PTx) in ESRD patients in the Netherlands. Methods A national database containing data from four academic medical centers in the Netherlands of patients with ESRD-related HPT, who had undergone PTx and kidney transplantation between 1994 and 2015, was established. Primary endpoints were 30-day mortality and complication rate. Secondary endpoints were biochemical measurements. Results We identified 187 HPT patients undergoing PTx, with a median age of 46 years. Median preoperative PTH level was 866 pg/mL (interquartile range [IQR] 407–1547 pg/mL). At 3 months, the median PTH drop from baseline was 93% (IQR, 71–98%) to a median of 61 pg/mL (IQR, 23–148 pg/mL, p < 0.001). Over the 25-year inclusion period, 13 patients (7.0%) required re-exploration for persistent or recurrent disease. Thirty-day mortality and complication rate were 0.0% and 7.9% respectively. Median serum calcium levels improved significantly postoperatively from 2.6 (2.4–2.8) mmol/L to 2.3 (2.1–2.5) mmol/L (p < 0.001). Conclusions PTx is a safe and effective procedure in the frail ESRD population. These data show that there should be no reluctance for surgical intervention and when indicated, nephrologists can safely refer these patients for PTx.
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Li C, Lv L, Wang H, Wang X, Yu B, Xu Y, Zhou X, Zhou Y. Total parathyroidectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism: systematic review and meta-analysis. Ren Fail 2018; 39:678-687. [PMID: 28853301 PMCID: PMC6446159 DOI: 10.1080/0886022x.2017.1363779] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Total parathyroidectomy (tPTX) and total parathyroidectomy with autotransplantation (tPTX + AT) are effective and inexpensive treatments for secondary hyperparathyroidism (sHPT), but we do not know which one is the optimal approach. Therefore, we undertook a meta-analysis to compare the safety and efficacy of these two surgical procedures. Methodology: Studies published in English on PubMed, Embase and the Cochrane Library from inception to 27 September 2016 were searched systematically. Eligible studies comparing tPTX with tPTX + AT for sHPT were included and Review Manager v5.3 was used. Results: Eleven studies were included in this meta-analysis. Ten cohort studies and one randomized controlled trial (RCT) involving 1108 patients with sHPT were identified. There was no significant difference in the prevalence of surgical complications (relative risk [RR], 1.71; 95% confidence interval [CI], 0.77–3.79; p = .19), all-cause mortality (RR, 0.68; 95% CI, 0.33–1.39; p = .29), sHPT persistence (RR, 3.81; 95% CI, 0.56–25.95; p = .17) or symptomatic improvement (RR, 1.02; 95% CI, 0.91–1.13; p = .79). tPTX could reduce the risk of sHPT recurrence (RR, 0.19; 95% CI, 0.09–0.41; p < .0001) and reoperation because of recurrence or persistence of sHPT (RR, 0.46; 95% CI 0.24–0.86; p = .01) compared with tPTX + AT. Simultaneously, tPTX increased the risk of hypoparathyroidism (RR, 2.63; 95% CI, 1.06–6.51; p = .04). Conclusions: We found tPTX and tPTX + AT to be useful methods for sHPT treatment. tPTX was superior for reducing the risk of sHPT recurrence and reoperation than tPTX + AT but, due to a lack of high statistical-power RCTs, comparative studies will be needed in the future.
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Affiliation(s)
- Changjia Li
- a Department of General Surgery , Affiliated Hospital of Qingdao University , Qingdao , China
| | - Liang Lv
- a Department of General Surgery , Affiliated Hospital of Qingdao University , Qingdao , China
| | - Hongqiao Wang
- b Department of Ultrasound , Affiliated Hospital of Qingdao University , Qingdao , China
| | - Xufu Wang
- c Department of Nuclear Medicine , Affiliated Hospital of Qingdao University , Qingdao , China
| | - Bangxu Yu
- d Department of Intensive Care Unit , Affiliated Hospital of Qingdao University , Qingdao , China
| | - Yan Xu
- e Department of Nephrology , Affiliated Hospital of Qingdao University , Qingdao , China
| | - Xiaobin Zhou
- f Department of Epidemiology and Health Statistics , Qingdao University Medical College , Qingdao , China
| | - Yanbing Zhou
- a Department of General Surgery , Affiliated Hospital of Qingdao University , Qingdao , China
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21
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Neves MCD, Rocha LAD, Cervantes O, Santos RO. Initial surgical results of 500 Parathyroidectomies for Hyperparathyroidism related to chronic kidney disease - mineral and bone disorder. ACTA ACUST UNITED AC 2018; 40:319-325. [PMID: 29944161 PMCID: PMC6534011 DOI: 10.1590/2175-8239-jbn-3924] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 11/14/2017] [Indexed: 12/17/2022]
Abstract
Introduction: Surgical treatment of hyperparathyroidism related to chronic kidney disease
is a challenging procedure even for experienced parathyroid surgeons. Over
the years, adjuvant techniques have been developed to assist the medical
team to improve surgical outcomes. However, medical staff in poor countries
have less access to these techniques and the effectiveness of surgery in
this context is unclear. Objective: verify the effectiveness of surgery for treatment of hyperparathyroidism
related to chronic kidney disease without adjuvant techniques. Methods: Over a 5-years period, patients with hyperparathyroidism that had clinical
therapeutic failure were evaluated for surgical treatment. Total
parathyroidectomy with autograft or subtotal resection were the selected
procedures. Surgeries were performed in a tertiary hospital in Brazil
without the assistance of some of the adjuvant techniques that are usually
applied, such as frozen section, nerve monitoring, and gamma probe.
Intraoperative PTH and localization pre-operative exams were applied, but
with huge restrictions. Results: A total of 518 patients with hyperparathyroidism (128 secondary and 390
tertiary) were surgically treated. Total parathyroidectomy were performed in
81.5%, subtotal in 12.4%, and 61% of patients had a surgical failure. Of all
failures, only 1.4% needed a second surgery totaling 98.6% of successful
initial surgical treatment. Neck hematoma and unilateral focal fold
paralysis occurred in 1.9% and 1.5%, respectively. Conclusion: parathyroidectomy is a safe and reproducible surgical procedure even in the
absence of adjuvant techniques.
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22
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Abstract
PURPOSE OF REVIEW Parathyroidectomy (PTx) is the definitive therapy for refractory secondary hyperparathyroidism (SHPT). The drastic effects of PTx on biochemical parameters of SHPT increases the possibility that this intervention will lead to a reduction in the adverse outcomes related to uncontrolled SHPT. RECENT FINDINGS The effect of PTx on mortality and cardiovascular outcomes among dialysis patients with severe SHPT have been evaluated in many observational studies from different regions of the world, including Asia, Europe, North America, and South America. In all but one small study, there was a significant association of PTx with lower all-cause mortality. In addition, in all studies, there was a trend in favor of PTx for cardiovascular morbidity and mortality. The effect of PTx on fractures has been evaluated in only one epidemiological study from the United States, which demonstrated a significant association of PTx and lower hip and combined fractures. SUMMARY Although randomized evidence is lacking, these highly consistent results may suggest a strong beneficial effect of PTx on long-term clinical outcomes and eliminate the potential concern of low parathyroid hormone after PTx.
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Sakr M, El-Kerm Y, Abo-Elwafa W, Mahmoud A, Fathi I. Heterotopic thyroid autotransplantation: A preliminary clinical study. Head Neck 2018; 40:34-45. [PMID: 29076198 DOI: 10.1002/hed.24904] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 05/06/2017] [Accepted: 06/28/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Thyroid autotransplantation offers an attractive alternative to subtotal thyroidectomy and replacement therapy. However, it has not been sufficiently clinically investigated. METHODS Total thyroidectomy was performed for 20 patients with benign thyroid disorders, and at least 10 g of thyroid tissue were implanted intramuscularly. Graft monitoring was achieved through 99m Tc scan at 2 months, free triiodothyronine (FT3), FT4, and thyroid-stimulating hormone (TSH) measurements at 1, 2, 4, 6, 8, 10, and 12 months postoperatively, and clinical examination. RESULTS Grafts survived and gradually functioned in all patients to a variable extent after a latent period (mean 99m Tc uptake = 1.28 ± 0.37%). Mean values for FT3, FT4, TSH at 12 months were 1.75 ± 0.48 pg/mL, 1.06 ± 0.26 ng/dL, and 28.08 ± 34.01 μIU/mL respectively. CONCLUSION Thyroid autotransplantation restored euthyroid status in 33.3% of patients after 12 months. A role of age, operative time, and 99m Tc-uptake in determining the final graft outcome is possible.
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Affiliation(s)
- Mahmoud Sakr
- Department of Surgery, Head, Neck, and Endocrine Surgery Unit, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Yasser El-Kerm
- Department of Cancer Management and Research, Medical Research Institute, University of Alexandria, Alexandria, Egypt
| | - Waleed Abo-Elwafa
- Department of Surgery, Head, Neck, and Endocrine Surgery Unit, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Ahmed Mahmoud
- Department of Surgery, Head, Neck, and Endocrine Surgery Unit, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Ibrahim Fathi
- Department of Surgery, Head, Neck, and Endocrine Surgery Unit, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
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Koratala A, Leghrouz M, Kazory A. Bone-eating kidney disease. SAGE Open Med Case Rep 2017; 5:2050313X17744983. [PMID: 29238578 PMCID: PMC5721960 DOI: 10.1177/2050313x17744983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 11/06/2017] [Indexed: 12/04/2022] Open
Abstract
In the current era of early detection of chronic kidney disease and efficient therapeutic options for management of its complications, skeletal manifestations of renal hyperparathyroidism are increasingly rare. A 31-year-old female patient presented for evaluation of severe pain in the left forearm, right hand, right knee, right hip, and lower back following a fall sustained 3 days prior to presentation. She had a history of end-stage renal disease and received maintenance hemodialysis. Review of the medical records revealed that she had poor compliance with her diet, medications, and dialysis treatments. Laboratory values were significant for marked elevation in serum parathyroid hormone level (1735 pg/mL), as well as hyperphosphatemia and normal serum calcium levels. Interestingly, X-ray images showed generalized severe demineralization of the extremities with the pelvic computed tomography scan revealing presence of diffuse brown tumors. In addition, she had insufficiency fractures of the extremities that left her incapacitated and had to be managed conservatively due to her poor functional status and ongoing severe hyperparathyroidism. Unfortunately, the patient refused surgical removal of the parathyroid glands and was hence treated with a high-dose phosphate binder and a calcimimetic agent together with reinforcement of compliance. This case highlights the importance of metabolic assessment of patients presenting with unexpected bone complications and can be used to raise awareness of the physicians on the extreme cases of mineral bone complications secondary to renal disease that are observed rarely.
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Affiliation(s)
- Abhilash Koratala
- Division of Nephrology, Hypertension & Renal Transplantation, University of Florida, Gainesville, FL, USA
| | - Muhannad Leghrouz
- Division of Nephrology, Hypertension & Renal Transplantation, University of Florida, Gainesville, FL, USA
| | - Amir Kazory
- Division of Nephrology, Hypertension & Renal Transplantation, University of Florida, Gainesville, FL, USA
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Espes D, Lau J, Carlsson PO. MECHANISMS IN ENDOCRINOLOGY: Towards the clinical translation of stem cell therapy for type 1 diabetes. Eur J Endocrinol 2017; 177:R159-R168. [PMID: 28487297 DOI: 10.1530/eje-17-0080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/24/2017] [Accepted: 05/08/2017] [Indexed: 01/21/2023]
Abstract
Insulin-producing cells derived from human embryonic stem cells (hESCs) or induced pluripotent stem cells (iPSCs) have for long been a promising, but elusive treatment far from clinical translation into type 1 diabetes therapy. However, the field is now on the verge of moving such insulin-producing cells into clinical trials. Although stem cell therapies provide great opportunities, there are also potential risks such as teratoma formation associated with the treatment. Many considerations are needed on how to proceed with clinical translation, including whether to use hESCs or iPSCs, and whether encapsulation of tissue will be needed. This review aims to give an overview of the current knowledge of stem cell therapy outcomes in animal models of type 1 diabetes and a proposed road map towards the clinical setting with special focus on the potential risks and hurdles which needs to be considered. From a clinical point of view, transplantation of insulin-producing cells derived from stem cells must be performed without immune suppression in order to be an attractive treatment option. Although costly and highly labour intensive, patient-derived iPSCs would be the only solution, if not clinically successful encapsulation or tolerance induction protocols are introduced.
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Affiliation(s)
- Daniel Espes
- Departments of Medical Cell Biology
- Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Joey Lau
- Departments of Medical Cell Biology
| | - Per-Ola Carlsson
- Departments of Medical Cell Biology
- Medical Sciences, Uppsala University, Uppsala, Sweden
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26
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Polistena A, Sanguinetti A, Lucchini R, Galasse S, Avenia S, Monacelli M, Johnson LB, Jeppsson B, Avenia N. Surgical treatment of secondary hyperparathyroidism in elderly patients: an institutional experience. Aging Clin Exp Res 2017; 29:23-28. [PMID: 27830521 DOI: 10.1007/s40520-016-0669-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/01/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Secondary hyperparathyroidism in elderly fragile patients presents clinical difficulties due to severity of symptoms and related comorbidity. The optimal surgical approach for this group of patients is still debated. AIM The aim of the study was to define the optimal technique of parathyroidectomy in elderly patients with secondary hyperparathyroidism. METHODS Retrospective analysis in a series of 253 patients including 35 elderly individuals at a single institution was carried out. Postoperative parathyroid hormone decrease, surgical complications and symptoms control were analyzed for all patients in relation to the types of parathyroidectomy performed. RESULTS In elderly patients, total parathyroidectomy was the most used approach. Subtotal parathyroidectomy was mostly reserved for younger patients suitable for kidney transplantation. No elderly patients treated with total parathyroidectomy were autotransplanted. No significant difference in surgical complications was observed between younger and elderly patients and considering the different procedures. Adequate symptom control after surgery was achieved in almost 90% of patients. A limited rate of recurrence requiring repeat surgery was observed only after subtotal parathyroidectomy. DISCUSSION Considering the features of all types of parathyroidectomy, very low recurrence rate, contained postoperative hypocalcemia and limited complications following total parathyroidectomy, might represent specific advantages for elderly patients. CONCLUSIONS Total parathyroidectomy without parathyroid transplantation is safe for elderly patients with secondary hyperparathyroidism and a good alternative to the well-established total parathyroidectomy with autografting.
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Affiliation(s)
- Andrea Polistena
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy.
| | - Alessandro Sanguinetti
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Roberta Lucchini
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Segio Galasse
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Stefano Avenia
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Massimo Monacelli
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Louis Banka Johnson
- Surgical Department, Skåne University Hospital, University of Lund, Malmö, Sweden
| | - Bengt Jeppsson
- Surgical Department, Skåne University Hospital, University of Lund, Malmö, Sweden
| | - Nicola Avenia
- UOC Chirurgia Generale e Specialità Chirurgiche, Endocrine Surgery Unit, Medical School, S. Maria University Hospital, University of Perugia, via Tristano di Joannuccio 1, 05100, Terni, Italy
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Koratala A, Bhatti V. Skeletal findings in secondary hyperparathyroidism. Oxf Med Case Reports 2017; 2017:omw097. [PMID: 28116110 PMCID: PMC5241711 DOI: 10.1093/omcr/omw097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/12/2016] [Accepted: 12/23/2016] [Indexed: 11/15/2022] Open
Affiliation(s)
- Abhilash Koratala
- Division of Nephrology , Hypertension and Renal Transplantation , University of Florida , Gainesville , FL, USA
| | - Vikrampal Bhatti
- Division of Nephrology , Hypertension and Renal Transplantation , University of Florida , Gainesville , FL, USA
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van der Plas WY, Engelsman AF, Özyilmaz A, van der Horst-Schrivers AN, Meijer K, van Dam GM, Pol RA, de Borst MH, Kruijff S. Impact of the Introduction of Calcimimetics on Timing of Parathyroidectomy in Secondary and Tertiary Hyperparathyroidism. Ann Surg Oncol 2017; 24:15-22. [PMID: 27459979 PMCID: PMC5179588 DOI: 10.1245/s10434-016-5450-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hyperparathyroidism (HPT), both secondary and tertiary, is common in patients with end-stage renal disease, and is associated with severe bone disorders, cardiovascular complications, and increased mortality. Since the introduction of calcimimetics in 2004, treatment of HPT has shifted from surgery to predominantly medical therapy. OBJECTIVE The aim of this study was to evaluate the impact of this change of management on the HPT patient population before undergoing (sub-)total parathyroidectomy (PTx). METHODS Overall, 119 patients with secondary or tertiary HPT undergoing PTx were included in a retrospective, single-center cohort. Group A, who underwent PTx before January 2005, was compared with group B, who underwent PTx after January 2005. Patient characteristics, time interval between HPT diagnosis and PTx, and postoperative complications were compared. RESULTS Group A comprised 70 (58.8 %) patients and group B comprised 49 (41.2 %) patients. The median interval between HPT diagnosis and PTx was 27 (interquartile range [IQR] 12.5-48.0) and 49 (IQR 21.0-75.0) months for group A and B, respectively (p = 0.007). Baseline characteristics were similar among both groups. The median preoperative serum parathyroid hormone (PTH) level was 936 pg/mL (IQR 600-1273) for group A versus 1091 pg/mL (IQR 482-1373) for group B (p = 0.38). PTx resulted in a dramatic PTH reduction (less than twofold the upper limit: A, 80.0 %; B, 85.4 %), and postoperative complication rates were low in both groups (A: 7.8 %; B: 10.2 %) [p = 0.66]. CONCLUSIONS The introduction of calcimimetics in 2004 is associated with a significant 2-year delay of surgery with continuously elevated preoperative PTH levels, while parathyroid surgery, even in a fragile population, is considered a safe and effective procedure.
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Affiliation(s)
- Willemijn Y van der Plas
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anton F Engelsman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Akin Özyilmaz
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Dialysis Center Groningen, Groningen, The Netherlands
| | | | - Kornelis Meijer
- Department of Clinical Chemistry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gooitzen M van Dam
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Nuclear Medicine and Molecular Imaging and Intensive Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin H de Borst
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Schelto Kruijff
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Schlosser K, Zielke A, Rothmund M. Medical and Surgical Treatment for Secondary and Tertiary Hyperparathyroidism. Scand J Surg 2016; 93:288-97. [PMID: 15658670 DOI: 10.1177/145749690409300407] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Prevention and treatment of secondary hyperparathyroidism (SHPT) in patients on chronic maintenance hemodialysis and of tertiary hyperparathyroidism (THPT) in patients after kidney transplantation is a challenge for the nephrologist and for the surgeon. Indication and results of medical and surgical therapy for SHPT and THPT have remained under discussion during the last decades. This review resumes the current medical and surgical strategies for patients with SHPT and THPT.
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Affiliation(s)
- K Schlosser
- Department of Visceral, Thoracic and Vascular Surgery, Philipps-University, Marburg, Germany.
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Vulpio C, Bossola M, Di Stasio E, Pepe G, Nure E, Magalini S, Agnes S. Intra-operative parathyroid hormone monitoring through central laboratory is accurate in renal secondary hyperparathyroidism. Clin Biochem 2016; 49:538-43. [PMID: 26800781 DOI: 10.1016/j.clinbiochem.2016.01.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/08/2016] [Accepted: 01/12/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The usefulness, the methods and the criteria of intra-operative monitoring of the parathyroid hormone (ioPTH) during parathyroidectomy (PTX) for renal secondary hyperparathyroidism (rSHPT) in patients on chronic hemodialysis remain still matter of debate. The present study aimed to evaluate the ability of a low cost central-laboratory second generation PTH assay to predict an incomplete resection of parathyroid glands (PTG). METHODS The ioPTH decay was determined In 42 consecutive patients undergoing PTX (15 subtotal and 27 total without auto-transplant of PTG) for rSHPT. The ioPTH monitoring included five samples: pre-intubation, post-manipulation of PTG and at 10, 20 and 30min post-PTG excision. The patients with PTH exceeding the normal value (65pg/ml) at the first postoperative week, 6 and 12months were classified as persistent rSHPT. RESULTS The concentrations of ioPTH declined significantly over time in patients who received total or subtotal PTX; however, no difference was found between the two types of PTX. Irrespective of the type of PTX and the number of PTG removed, combining the absolute and percentage of ioPTH decay at 30min after PTG excision, we found high sensitivity (100%), specificity (92%), negative predictive value (100%) and accuracy (93%) in predicting the persistence of rSHPT. CONCLUSIONS The monitoring of the ioPTH decline by a low cost central-laboratory second generation assay is extremely accurate in predicting the persistence of disease in patients on maintenance hemodialysis undergoing surgery for rSHPT.
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Affiliation(s)
- Carlo Vulpio
- Division of General Surgery and Organ Transplantation, Catholic University of the Sacred Heart, Roma, Italy.
| | - Maurizio Bossola
- Division of General Surgery and Organ Transplantation, Catholic University of the Sacred Heart, Roma, Italy
| | - Enrico Di Stasio
- Institute of Biochemistry, Catholic University of the Sacred Heart, Roma, Italy
| | - Gilda Pepe
- Division of General Surgery and Organ Transplantation, Catholic University of the Sacred Heart, Roma, Italy
| | - Eda Nure
- Division of General Surgery and Organ Transplantation, Catholic University of the Sacred Heart, Roma, Italy
| | - Sabina Magalini
- Division of General Surgery and Organ Transplantation, Catholic University of the Sacred Heart, Roma, Italy
| | - Salvatore Agnes
- Division of General Surgery and Organ Transplantation, Catholic University of the Sacred Heart, Roma, Italy
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Kang BH, Hwang SY, Kim JY, Hong YA, Jung MY, Lee EA, Lee JE, Lee JB, Ko GJ, Pyo HJ, Kwon YJ. Predicting postoperative total calcium requirements after parathyroidectomy in secondary hyperparathyroidism. Korean J Intern Med 2015; 30:856-64. [PMID: 26552461 PMCID: PMC4642015 DOI: 10.3904/kjim.2015.30.6.856] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 08/27/2013] [Accepted: 05/11/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND/AIMS To prevent hypocalcemia after parathyroidectomy (PTX), parenteral calcium is required in addition to oral calcitriol and calcium. After switching to oral calcium, patients can be discharged from the hospital. The aim of this study was to analyze the clinical characteristics and outcomes of PTX performed at a single Korean center and to investigate the associated laboratory factors used to analyze the total amount of postoperative calcium required. METHODS We enrolled 91 hemodialysis patients undergoing PTX from November 2003 to December 2011. We collected clinical and laboratory data preoperatively, 12 and 48 hours postoperatively, at discharge, and 3 and 6 months postoperatively. RESULTS In total, 59 patients underwent PTX with autotransplantation (AT), 6 underwent total PTX without AT, 11 underwent subtotal PTX, and 15 underwent limited PTX. Total PTX without AT showed the lowest recurrence rate. At all postoperative time points, the mean levels of serum calcium, phosphorus, and intact parathyroid hormone (iPTH) decreased significantly, compared with preoperative levels; however, alkaline phosphatase (ALP) increased significantly from 48 hours postoperatively to discharge (p < 0.001). On multiple linear regression analysis, the total amount of injected calcium during hospitalization showed a significant correlation with preoperative ALP (p < 0.001), preoperative iPTH (p = 0.037), and Δphosphorus at 48 hours (p < 0.001). We developed an equation for estimating the total calcium requirement after PTX. CONCLUSIONS Preoperative ALP, preoperative iPTH, and Δphosphorus at 48 hours may be significant factors in estimating the postoperative calcium requirement. The formula for postoperative calcium requirement after PTX may help to predict the duration of postoperative hospitalization.
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Affiliation(s)
- Byung Heon Kang
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Soon Young Hwang
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Jeong Yeop Kim
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Yu Ah Hong
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Mi Yeon Jung
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Eun Ah Lee
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ji Eun Lee
- Division of Nephrology, Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Jae Bok Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Gang Jee Ko
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Heui Jung Pyo
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Young Joo Kwon
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Correspondence to Young Joo Kwon, M.D. Department of Internal Medicine, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea Tel: +82-2-2626-3036 Fax: +82-2-2626-2024 E-mail:
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Lorenz K, Bartsch DK, Sancho JJ, Guigard S, Triponez F. Surgical management of secondary hyperparathyroidism in chronic kidney disease--a consensus report of the European Society of Endocrine Surgeons. Langenbecks Arch Surg 2015; 400:907-27. [PMID: 26429790 DOI: 10.1007/s00423-015-1344-5] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 09/18/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite advances in the medical management of secondary hyperparathyroidism due to chronic renal failure and dialysis (renal hyperparathyroidism), parathyroid surgery remains an important treatment option in the spectrum of the disease. Patients with severe and complicated renal hyperparathyroidism (HPT), refractory or intolerant to medical therapy and patients with specific requirements in prospect of or excluded from renal transplantation may require parathyroidectomy for renal hyperparathyroidism. METHODS Present standard and actual controversial issues regarding surgical treatment of patients with hyperparathyroidism due to chronic renal failure were identified, and pertinent literature was searched and reviewed. Whenever applicable, evaluation of the level of evidence concerning diagnosis and management of renal hyperparathyroidism according to standard criteria and recommendation grading were employed. Results were discussed at the 6th Workshop of the European Society of Endocrine Surgeons entitled Hyperparathyroidism due to multiple gland disease: An evidence-based perspective. RESULTS Presently, literature reveals scant data, especially, no prospective randomized studies to provide sufficient levels of evidence to substantiate recommendations for surgery in renal hyperparathyroidism. Appropriate surgical management of renal hyperparathyroidism involves standard bilateral exploration with bilateral cervical thymectomy and a spectrum of four standardized types of parathyroid resection that reveal comparable outcome results with regard to levels of evidence and recommendation. Specific patient requirements may favour one over the other procedure according to individualized demands. CONCLUSIONS Surgery for patients with renal hyperparathyroidism in the era of calcimimetics continues to play an important role in selected patients and achieves efficient control of hyperparathyroidism. The overall success rate and long-term control of renal hyperparathyroidism and optimal handling of postoperative metabolic effects also depend on the timely indication, individually suitable type of parathyroid resection and specialized endocrine surgery.
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Affiliation(s)
- Kerstin Lorenz
- Department of General-, Visceral-, and Vascular Surgery, Martin-Luther University of Halle-Wittenberg, Ernst-Grube-Str. 40, Halle (Saale), 06120, Germany.
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstraße 1, Marburg, 35043, Germany.
| | - Juan J Sancho
- Department of General Surgery, Endocrine Surgery Unit, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, Barcelona, 08003, Spain.
| | - Sebastien Guigard
- Department of Thoracic and Endocrine Surgery, University Hospitals of Geneva, Switzerland, Rue Gabrielle Perret-Gentil 4, 14, Geneva, 1211, Switzerland.
| | - Frederic Triponez
- Chirurgie thoracique et endocrinienne, Hôpitaux Universitaires de Genève, Rue Gabrielle Perret-Gentil 4, 14, Geneva, 1211, Switzerland.
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Goto S, Komaba H, Fukagawa M. Pathophysiology of parathyroid hyperplasia in chronic kidney disease: preclinical and clinical basis for parathyroid intervention. NDT Plus 2015; 1:iii2-iii8. [PMID: 25983967 PMCID: PMC4421132 DOI: 10.1093/ndtplus/sfn079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Accepted: 03/14/2008] [Indexed: 01/15/2023] Open
Abstract
Secondary hyperparathyroidism is characterised by excessive secretion of parathyroid hormone and parathyroid hyperplasia, resulting in both skeletal and extraskeletal consequences. Recent basic and clinical studies have brought considerable advances in our understanding of the pathophysiology of parathyroid hyperplasia and have also provided practical therapeutic approaches, especially with regard to indications for parathyroid intervention. In this context, it is quite important to recognize the development of nodular hyperplasia, because the cells in nodular hyperplasia are usually resistant to calcitriol treatment. Patients with nodular hyperplasia should undergo parathyroid intervention including percutaneous ethanol injection therapy (PEIT). Selective PEIT of the parathyroid gland is an effective approach in which the enlarged parathyroid gland with nodular hyperplasia is 'selectively' destroyed by ethanol injection, and other glands with diffuse hyperplasia are then managed by medical therapy. With a more focused attention to applying parathyroid intervention, we can expect significant improvement in the management of secondary hyperparathyroidism in dialysis patients.
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Affiliation(s)
- Shunsuke Goto
- Division of Nephrology and Kidney Center , Kobe University School of Medicine , Kobe 650-0017 , Japan
| | - Hirotaka Komaba
- Division of Nephrology and Kidney Center , Kobe University School of Medicine , Kobe 650-0017 , Japan
| | - Masafumi Fukagawa
- Division of Nephrology and Kidney Center , Kobe University School of Medicine , Kobe 650-0017 , Japan
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Tanaka M, Fukagawa M. Medical management after parathyroid intervention. NDT Plus 2015; 1:iii18-iii20. [PMID: 25983966 PMCID: PMC4421127 DOI: 10.1093/ndtplus/sfn091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Accepted: 03/21/2008] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Motoko Tanaka
- Department of Nephrology, Akebono Clinic, Kumamoto, Kumamoto
| | - Masafumi Fukagawa
- Division of Nephrology and Kidney Center , Kobe University School of Medicine , Kobe, Hyogo , Japan
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Jia X, Wang R, Zhang C, Cui M, Xu D. Long-Term Outcomes of Total Parathyroidectomy With or Without Autoimplantation for Hyperparathyroidism in Chronic Kidney Disease: A Meta-Analysis. Ther Apher Dial 2015; 19:477-85. [PMID: 25950238 DOI: 10.1111/1744-9987.12310] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of the present study was to compare total parathyroidectomy without autotransplantation (TPTX) versus total parathyroidectomy with autotransplantation (TPTX + AT) for renal hyperparathyroidism (RHPT) with respect to long-term outcomes. A literature search was undertaken using Medline and EMBASE from inception to December 2013. Data were analyzed using Review Manager version 5.0. A total of seven cohort studies comprising 931 patients were identified. Compared with TPTX + AT, patients in the TPTX group have lower "recurrence" (odds ratio (OR) 0.08, confidence interval (CI) 0.03 to 0.21; P < 0.00001), lower "recurrence or persistence"(OR 0.11, 95% CI 0.05 to 0.25; P < 0.00001), lower "requiring reoperation because of recurrence or persistence" (OR 0.17, CI 0.06 to 0.54; P = 0.002), and higher "hypoparathyroidism" (OR 2.97, CI 1.09 to 8.08; P = 0.03). None of the patients in these seven studies were recorded as having severe hypocalcemia or adynamic bone disease. Compared with TPTX + AT, TPTX is associated with lower "requiring reoperation because of recurrence or persistence" and without severe hypocalcemia or adynamic bone disease.
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Affiliation(s)
- Xiaoyan Jia
- Department of Nephrology, Qianfoshan Hospital, Shandong University, Jinan, China
| | - Rong Wang
- Provincial Hospital Shandong University, Jinan, China
| | - Chengyin Zhang
- Yidu Central Hospital Affiliated to Weifang Medical College, Weifang, China
| | - Meiyu Cui
- Department of Nephrology, Qianfoshan Hospital, Shandong University, Jinan, China
| | - Dongmei Xu
- Department of Nephrology, Qianfoshan Hospital, Shandong University, Jinan, China
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Komaba H, Taniguchi M, Wada A, Iseki K, Tsubakihara Y, Fukagawa M. Parathyroidectomy and survival among Japanese hemodialysis patients with secondary hyperparathyroidism. Kidney Int 2015; 88:350-9. [PMID: 25786097 DOI: 10.1038/ki.2015.72] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 01/10/2015] [Accepted: 01/29/2015] [Indexed: 02/07/2023]
Abstract
Parathyroidectomy (PTx) drastically improves biochemical parameters and clinical symptoms related to severe secondary hyperparathyroidism (SHPT) but the effect of PTx on survival has not been adequately investigated. Here we analyzed data on 114,064 maintenance hemodialysis patients from a nationwide registry of the Japanese Society for Dialysis Therapy to evaluate the associations of severity of SHPT and history of PTx with 1-year all-cause and cardiovascular mortality. We then compared the mortality rate between 4428 patients who had undergone PTx and 4428 propensity score-matched patients who had not despite severe SHPT. During a 1-year follow-up, 7926 patients of the entire study population died, of whom 3607 died from cardiovascular disease. Among patients without a history of PTx, severe SHPT was associated with an increased risk for all-cause and cardiovascular mortality. However, such an increased risk of mortality was not observed among patients with a history of PTx. In the propensity score-matched analysis, patients who had undergone PTx had a 34% and 41% lower risk for all-cause and cardiovascular mortality, respectively, compared to the matched controls. The survival benefit associated with PTx was robust in several sensitivity analyses and consistent across subgroups, except for those who had persistent postoperative SHPT. Thus, successful PTx may reduce the risk for all-cause and cardiovascular mortality in hemodialysis patients with severe, uncontrolled SHPT.
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Affiliation(s)
- Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Masatomo Taniguchi
- Committee of Renal Data Registry of the Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Atsushi Wada
- Committee of Renal Data Registry of the Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Kunitoshi Iseki
- Committee of Renal Data Registry of the Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Yoshiharu Tsubakihara
- Committee of Renal Data Registry of the Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
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Ohe MN, Santos RO, Neves MCD, Carvalho AB, Kunii IS, Abrahão M, Cervantes O, Lazaretti-Castro M, Vieira JGH. Autotransplant tissue selection criteria with or without stereomicroscopy in parathyroidectomy for treatment of renal hyperparathyroidism. Braz J Otorhinolaryngol 2014; 80:318-24. [PMID: 25183182 PMCID: PMC9444608 DOI: 10.1016/j.bjorl.2014.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 01/24/2014] [Indexed: 11/28/2022] Open
Abstract
Introduction Several methods have been proposed to improve operative success in renal hyperparathyroidism. Objective To evaluate stereomicroscopy in parathyroid tissue selection for total parathyroidectomy with autotransplantation in secondary (SHPT)/tertiary (THPT) hyperparathyroidism. Methods 118 renal patients underwent surgery from April of 2000 to October 2009. They were divided into two groups: G1, 66 patients operated from April of 2000 to May of 2005, with tissue selection based on macroscopic observation; G2, 52 patients operated from March of 2008 to October 2009 with stereomicroscopy for tissue selection searching for the presence of adipose cells. All surgeries were performed by the same surgeon. Patients presented SHPT (dialysis treatment) or THPT (renal-grafted). Follow-up was 12–36 months. Intra-operative parathyroid hormone (PTH) was measured in 100/118 (84.7%) patients. Results Data are presented as means. G1 included 66 patients (38 SHPT, 24 females/14 males; 40.0 years of age; 28 THPT, 14 females/14 males; 44 years of age). G2 included 52 patients (29 SHPT, 11 females/18 males; 50.7 years of age; 23 THPT, 13 females/10 males, 44.4 years of age). SHPT patients from G2 presented preoperative serum calcium higher than those of SHPT patients in G1 (p < 0.05), suggesting a more severe disease. Definitive hypoparathyroidism was found in seven of 118 patients (5.9%). Graft-dependent recurrence occurred in four patients, two in each group. All occurred in dialysis patients. Conclusion Stereomicroscopy in SHPT/THPT surgical treatment may be a useful tool to standardize parathyroid tissue selection.
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Affiliation(s)
- Monique Nakayama Ohe
- Department of Endocrinology and Metabology, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil.
| | - Rodrigo Oliveira Santos
- Department of Otorhinolaryngology, Head and Neck, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Murilo Catafesta das Neves
- Department of Otorhinolaryngology, Head and Neck, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Aluizio Barbosa Carvalho
- Department of Nephrology, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Ilda Sizue Kunii
- Department of Endocrinology and Metabology, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Márcio Abrahão
- Department of Otorhinolaryngology, Head and Neck, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Onivaldo Cervantes
- Department of Otorhinolaryngology, Head and Neck, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Marise Lazaretti-Castro
- Department of Endocrinology and Metabology, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - José Gilberto Henriques Vieira
- Department of Endocrinology and Metabology, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
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Lin HC, Chen CL, Lin HS, Chou KJ, Fang HC, Liu SI, Hsu CY, Huang WC, Huang CW, Huang CK, Chang TY, Chang YT, Lee PT. Parathyroidectomy improves cardiovascular outcome in nondiabetic dialysis patients with secondary hyperparathyroidism. Clin Endocrinol (Oxf) 2014; 80:508-15. [PMID: 24102421 DOI: 10.1111/cen.12333] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 09/05/2013] [Accepted: 09/12/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Secondary hyperparathyroidism and its associated abnormalities in mineral metabolism and haemodynamic changes increase the cardiovascular risk in patients with end-stage renal disease (ESRD). Our objective was to determine the association of parathyroidectomy (PTX) with major cardiovascular events in nondiabetic dialysis patients with severe secondary hyperparathyroidism (SHPTH). DESIGN AND PATIENTS We performed a cohort study with fifty-three nondiabetic ESRD patients who were treated with maintenance haemodialysis and who had intact parathyroid hormone (PTH) levels > 800 pg/ml. Participants received either only medical therapy or medical therapy and total PTX with autotransplantation for SHPTH. MEASUREMENTS We evaluated the associations between PTX and major cardiovascular events including death, cerebrovascular accident and myocardial infarction. The biochemical and haemodynamic changes associated with PTX were measured. RESULTS During the mean follow-up of 72 months, twenty-three patients received only medical treatment (medical group) while thirty patients underwent PTX in addition to medical treatment (PTX group). The two groups were comparable in respect of baseline characteristics. PTX group was found to be associated with a reduced incidence of major cardiovascular events (P = 0·021). A multiple Cox regression analysis showed that the variable significantly associated with major cardiovascular events was treatment modality (medical therapy vs medical therapy and parathyroidectomy, hazard ratio = 26·12, 95% CI = 1·30-526·27, P = 0·033). Blood pressure, haemoglobin, alkaline phosphatase, calcium, phosphate and calcium × phosphate product significantly improved after PTX. CONCLUSIONS PTX was associated with better cardiovascular outcome in nondiabetic dialysis patients with severe SHPTH.
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Affiliation(s)
- Ho-Cheng Lin
- Division of Nephrology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Nephrology, Department of Internal Medicine, Kaohsiung Armed Force General Hospital, Kaohsiung, Taiwan
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Sakman G, Parsak CK, Balal M, Seydaoglu G, Eray IC, Sarıtaş G, Demircan O. Outcomes of Total Parathyroidectomy with Autotransplantation versus Subtotal Parathyroidectomy with Routine Addition of Thymectomy to both Groups: Single Center Experience of Secondary Hyperparathyroidism. Balkan Med J 2014; 31:77-82. [PMID: 25207173 DOI: 10.5152/balkanmedj.2014.9544] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Accepted: 11/13/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Secondary hyperparathyroidism is a common acquired disorder seen in chronic renal failure. It may result in potentially serious complications including metabolic bone diseases, severe atherosclerosis and undesirable cardiovascular events. Parathyroidectomy is required in about 20% of patients after 3-10 years of dialysis and in up to 40% after 20 years. AIMS The aim of the current study was to evaluate the short-term and long-term outcomes of patients with secondary hyperparathyroidism who had undergone total parathyroidectomy with autotransplantation and thymectomy or subtotal parathyroidectomy with thymectomy by the same surgical team during the study period. STUDY DESIGN Retrospective comparative study. METHODS Clinical data of 50 patients who underwent parathyroid surgery for secondary hyperparathyroidism between 2003 and 2011 were reviewed retrospectively. Patients were divided into two subgroups of total parathyroidectomy with autotransplantation or subtotal parathyroidectomy. Thymectomy was routinely performed for both groups. Short term outcome parameters included intact parathyroid hormone, ionized calcium and alkaline phosphatase levels. Bone pain, bone fractures, persistent or recurrent disease were included in long term outcome parameters. RESULTS The mean duration of dialysis was eight years. The mean ionized calcium levels dropped significantly in the total parathyroidectomy with autotransplantation group (p=0.016). No serious postoperative complications were observed. Postoperative intravenous calcium supplementation was required in four patients in the total parathyroidectomy with autotransplantation group (total PTX+AT) and in three patients in the subtotal parathyroidectomy group (subtotal PTX). Postoperatively, all patients received oral calcium carbonate and calcitriol. The length of average hospital stay was 5 (3-10) days. Including nine patients who underwent successful renal transplantation pre-operative bone symptoms, hypercalcemia, hyperphosphatemia, and an increased alkaline phosphatase levels were improved or resolved in all patients. After a mean follow-up of 65 months, three patients (6%) had persistent and one (2%) had recurrent disease. CONCLUSION Total parathroidectomy with autotransplantation is a beneficial and safe surgical procedure for patients on chronic dialysis with otherwise uncontrollable secondary hyperparathroidism and even in patients who have undergone renal transplantation after parathyroidectomy. Careful cervical exploration and routine thymectomy should be considered as a routine part of the surgical approach regardless of the preferred technique.
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Affiliation(s)
- Gürhan Sakman
- Department of General Surgery, Çukuruva University Faculty of Medicine, Adana, Turkey
| | - Cem Kaan Parsak
- Department of General Surgery, Çukuruva University Faculty of Medicine, Adana, Turkey
| | - Mustafa Balal
- Department of Nephrology, Çukuruva University Faculty of Medicine, Adana, Turkey
| | - Gülşah Seydaoglu
- Department of Biostatistics, Çukuruva University Faculty of Medicine, Adana, Turkey
| | - Ismail Cem Eray
- Department of General Surgery, Çukuruva University Faculty of Medicine, Adana, Turkey
| | - Gökhan Sarıtaş
- Department of General Surgery, Çukuruva University Faculty of Medicine, Adana, Turkey
| | - Orhan Demircan
- Department of General Surgery, Acıbadem Hospital, Adana, Turkey
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Sakata N, Aoki T, Yoshimatsu G, Tsuchiya H, Hata T, Katayose Y, Egawa S, Unno M. Strategy for clinical setting in intramuscular and subcutaneous islet transplantation. Diabetes Metab Res Rev 2014; 30:1-10. [PMID: 24000195 DOI: 10.1002/dmrr.2463] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 07/09/2013] [Accepted: 08/27/2013] [Indexed: 01/08/2023]
Abstract
Intraportal islet transplantation has a long history as a procedure for clinical islet transplantation. However, many recent studies revealed that the intraportal procedure has some disadvantages in transplant efficiency and safety. Many candidates as an optimal transplant site for islets have been assessed, but further studies and clinical trials are still necessary. Intramuscular and subcutaneous spaces are important candidates, because the transplant and biopsy procedures are simple approaches with minimal invasion and few complications. Although they are sites with hypovascularity and hypoxia, which contribute to the poor transplant efficiency, many experimental trials for improving the outcome in intramuscular and subcutaneous islet transplantations have been performed, focusing on early angiogenesis and scaffolds for engrafting transplanted islets. We review current progress in intramuscular and subcutaneous islet transplantations and discuss ways to develop them as optimal transplant sites for islets.
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Affiliation(s)
- Naoaki Sakata
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Fukagawa M, Yokoyama K, Koiwa F, Taniguchi M, Shoji T, Kazama JJ, Komaba H, Ando R, Kakuta T, Fujii H, Nakayama M, Shibagaki Y, Fukumoto S, Fujii N, Hattori M, Ashida A, Iseki K, Shigematsu T, Tsukamoto Y, Tsubakihara Y, Tomo T, Hirakata H, Akizawa T. Clinical Practice Guideline for the Management of Chronic Kidney Disease-Mineral and Bone Disorder. Ther Apher Dial 2013; 17:247-88. [DOI: 10.1111/1744-9987.12058] [Citation(s) in RCA: 251] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Relevance of Bilateral Cervical Thymectomy in Patients with Renal Hyperparathyroidism: Analysis of 161 Patients Undergoing Reoperative Parathyroidectomy. World J Surg 2013; 37:2155-61. [DOI: 10.1007/s00268-013-2091-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
BACKGROUND The aim of the present study was to evaluate the outcome of different surgical procedures for patients on permanent dialysis who underwent initial parathyroidectomy for renal hyperparathyroidism (rHPT). METHODS Out of a prospective database of patients who underwent parathyroid surgery for rHPT between 1976 and 2009, patients on permanent dialysis who underwent initial parathyroidectomy were further analyzed regarding perioperative biochemical changes and postoperative outcome. RESULTS A total of 606 patients were analyzed. Total parathyroidectomy with autotransplantation (group A) was performed in 504 patients, total parathyroidectomy without autotransplantation in 32 (group B), subtotal parathyroidectomy in 21 (group C), and incomplete parathyroidectomy in 49 (group D). After surgery, mean calcium levels dropped from 2.76 to 1.91 mmol/l in group A, from 2.67 to 2.11 mmol/l in group B, from 2.70 to 2.09 mmol/l in group C, and from 2.65 to 1.94 mmol/l in group D. The parathyroid hormone level dropped from 1,371.4 pg/ml to 28.8 pg/ml in group A, from 1,078.4 pg/ml to 27.0 pg/ml in group B, from 2,377.9 pg/ml to 61.4 pg/ml in group C, and from 1,010.2 pg/ml to 99.5 pg/ml in group D. Persistent rHPT occurred in 2/504 patients from group A (0.4%), 0/32 patients from group B (0%), 1/21 patients from group C (4.8%), and 2/49 patients from group D (4.1%). After a mean follow-up of 57.6 months, recurrent rHPT occurred in 27/504 patients from group A (5.4%), in 0/32 patients from group B (0%), in 2/21 patients from group C (9.5%), and in 3/49 patients from group D (6.1%). CONCLUSIONS Total parathyroidectomy with or without autotransplantation is a feasible and safe surgical procedure for patients on permanent dialysis with otherwise uncontrollable rHPT.
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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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[Increased bone mineral density in patients with tertiary hyperparathyroidism after total parathyroidectomy and autotransplantation of the parathyroid gland]. Cir Esp 2012; 90:382-7. [PMID: 22445112 DOI: 10.1016/j.ciresp.2012.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 01/08/2012] [Accepted: 01/12/2012] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Changes in bone metabolism and bone mineral density are observed in renal transplant patients with tertiary hyperparathyroidism. The objective of this work was to analyse the increase in bone mineral density, as well the laboratory results, after total parathyroidectomy and autotransplantation in renal transplant patients with tertiary hyperparathyroidism. MATERIAL AND METHODS A retrospective study was conducted in which the bone mineral density values at femoral and lumbar level were analysed, together with the serum levels of calcium, phosphorous, parathyroid hormone (PTH), and alkaline phosphatase in 13 renal transplant patients with tertiary hyperparathyroidism before and after total parathyroidectomy and autotransplantation of the parathyroid glands. RESULTS Parathyroidectomy is associated with an increase in bone mineral density at femoral and lumbar level, with an increase of 8.6 ± 6.7% at lumbar level, and 4 ± 16.1% at femoral level. The decrease in calcium after the parathyroidectomy was 2.8 mg/dL (95% CI; 1.9-4). The decrease in PTH was 172 pg/mL (95% CI; 98-354) and the decrease in alkaline phosphatase was 229 U/L (95% CI; 70-371). CONCLUSIONS Total parathyroidectomy and autotransplantation of the parathyroid glands in renal transplant patients with tertiary hyperparathyroidism increases the bone mineral density. Furthermore, the calcium, PTH and alkaline phosphatase returned to normal in the long-term.
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Komaba H, Moriwaki K, Goto S, Yamada S, Taniguchi M, Kakuta T, Kamae I, Fukagawa M. Cost-effectiveness of cinacalcet hydrochloride for hemodialysis patients with severe secondary hyperparathyroidism in Japan. Am J Kidney Dis 2012; 60:262-71. [PMID: 22445709 DOI: 10.1053/j.ajkd.2011.12.034] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 12/30/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cinacalcet effectively reduces elevated levels of parathyroid hormone (PTH) in patients with secondary hyperparathyroidism (SHPT), even those with severe disease for whom parathyroidectomy can be the treatment of choice. The objective of this study was to estimate the cost-effectiveness of cinacalcet treatment in hemodialysis patients with severe SHPT in Japan. STUDY DESIGN Cost-effectiveness analysis. SETTING & POPULATION Patients with severe SHPT (intact PTH >500 pg/mL) who were receiving hemodialysis in Japan. MODEL, PERSPECTIVE, & TIMEFRAME A Markov model was constructed from the health care system perspective in Japan. Patients were followed up over their lifetime. Dialysis costs were not included in the base case. INTERVENTION Cinacalcet as an addition to conventional treatment compared to conventional treatment alone. In both arms, patients underwent parathyroidectomy if intact PTH level was >500 pg/mL for 6 months and they were eligible for surgery. OUTCOMES Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS ICERs for cinacalcet for those who were eligible for surgery and those who were not were $352,631/QALY gained and $21,613/QALY gained, respectively. Sensitivity and scenario analyses showed that results were fairly robust to variations in model parameters and assumptions. In the probabilistic sensitivity analysis, cinacalcet was cost-effective in only 0.9% of simulations for those eligible for surgery, but in more than 99.9% of simulations for those ineligible for surgery, if society would be willing to pay $50,000 per additional QALY. LIMITATIONS Data for the long-term effect of cinacalcet on patient-level outcomes are limited. The model predicted rates for clinical events using data for the surrogate biochemical end points. CONCLUSIONS The use of cinacalcet to treat severe SHPT is likely to be cost-effective for only those who cannot undergo parathyroid surgery for medical or personal reasons.
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Affiliation(s)
- Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
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The Japanese Society for Dialysis Therapy. Clinical Practice Guideline for CKD-MBD. ACTA ACUST UNITED AC 2012. [DOI: 10.4009/jsdt.45.301] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Striated muscle as implantation site for transplanted pancreatic islets. J Transplant 2011; 2011:352043. [PMID: 22174984 PMCID: PMC3235886 DOI: 10.1155/2011/352043] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Accepted: 09/20/2011] [Indexed: 01/27/2023] Open
Abstract
Islet transplantation is an attractive treatment for selected patients with brittle type 1 diabetes. In the clinical setting, intraportal transplantation predominates. However, due to extensive early islet cell death, the quantity of islets needed to restore glucose homeostasis requires in general a minimum of two donors. Moreover, the deterioration of islet function over time results in few insulin-independent patients after five-year followup. Specific obstacles to the success of islet transplantation include site-specific concerns for the liver such as the instant blood mediated inflammatory reaction, islet lipotoxicity, low oxygen tension, and poor revascularization, impediments that have led to the developing interest for alternative implantation sites over recent years. Within preclinical settings, several alternative sites have now been investigated and proven favorable in various aspects. Muscle is considered a very promising site and has physiologically properties and technical advantages that could make it optimal for islet transplantation.
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Caliseo CT, Santos SRCL, Nascimento CPD, Arap SS, Brandão LG, Montenegro FLDM. [Functional results of parathyroid autotransplantation in one single pocket for treatment of secondary hyperparathyroidism]. Rev Col Bras Cir 2011; 38:85-9. [PMID: 21710044 DOI: 10.1590/s0100-69912011000200003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 04/05/2010] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the operation and surgical time of autotransplanted parathyroid in a single site comparing it to the implant performed in five and twenty locations. METHODS Patients who underwent total parotidectomy with auto implant (Ptx-AI) for secondary and tertiary hyperparathyroidism were evaluated in groups of 20 implant sites (A), 5 sites (B) and single site (C), compared as for Functional Status (FE) of the implant and the surgical time of the procedure. Four functional states were determined according to the systemic level of PTH: 1-below normal, 2-normal, 3-high, no more than three times and 4 - more than three times higher. RESULTS There were 349 patients subjected to Ptx-AI for renal hyperparathyroidism from 1994 to 2009. For the functional study, 101 patients were eligible for the following observations: group A (n = 30) - 16.6% EF1, 50% EF2, 23.3% EF3 and 10%EF4; group B (n = 41) - 14.6% EF1, 58.5% EF2, 22% EF3 and 4.9% EF4; Group C (n = 30) - 17% EF1, 57% EF2, 20%EF3 and 6% EF4 (p = 0.9, x²). But in group C the mean operative time of implant was statistically lower (7.9 minutes) compared to the average of 5 site (18.6 minutes) and 20-site (44 minutes) implants in 66 evaluated patients (p<0,0001, ANOVA). CONCLUSION The self-implantation in a single site decreases the operative time without changing its functionality.
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Affiliation(s)
- Caio Tosato Caliseo
- Laboratório de Investigação Médica 28, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, BR.
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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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