Clinical course after parathyroidectomy in adults with end-stage renal disease on maintenance dialysis

A New Calculation Model for Calcium Requirements After Parathyroidectomy in Patients With Secondary Hyperparathyroidism

OBJECTIVES

We aimed to develop a new calculation model for calcium requirements in dialysis patients following parathyroidectomy.

METHODS

A total of 98 patients with secondary hyperparathyroidism receiving parathyroidectomy from January 2014 to January 2022 were enrolled in this study. Among these patients, 78 were randomly selected for construction of the calcium requirement calculation model, and the remaining 20 patients were selected for model validation. The calcium requirement model estimated the total calcium supplementation for 1 week after surgery using variables with significant relationships in the derivation group by stepwise multiple linear regression analysis. Bias, precision, and accuracy were measured in the validation group to determine the performance of the model.

RESULTS

The model was as follows: calcium requirement for 1 week after surgery=33.798-8.929×immediate postoperative calcium+0.190×C-reactive protein-0.125×age+0.002×preoperative intact parathyroid hormone+0.003×preoperative alkaline phosphatase (R2=0.8). The model was successfully validated.

CONCLUSION

We generated a novel model to guide calcium supplementation. This model can assist in stabilizing the serum calcium levels of patients during the early postoperative period. Furthermore, it contributes to the individualized and precise treatment of hypocalcemia in patients following parathyroidectomy.

A retrospective observational study of patients on maintenance hemodialysis receiving parathyroidectomy by ultrasonic scalpel

Background

Secondary hyperparathyroidism (SHPT) remains a common complication in many patients on maintenance hemodialysis. Kidney Disease Improve Global Outcomes (KDIGO) 2017 guidelines suggest that parathyroidectomy (PTX) should be performed in severe SHPT patients with chronic kidney disease stage 3a-stage 5D. In the present study, we observed the efficacy of ultrasonic scalpel for PTX in SHPT patients on maintenance hemodialysis.

Methods

A total of 74 patients on maintenance hemodialysis who underwent PTX (34 with traditional electrocautery and 40 with an ultrasonic scalpel) were observed between August 2020 and August 2021 at Xiangyang Central Hospital (Hubei University of Arts and Science). Baseline demographic and clinic characteristics were collected pre- and post-PTX. Moreover, the postoperative complications and operation time were assessed between the two groups.

Results

The univariate analysis showed that there was no statistical significance in weight, dialysis duration, serum potassium, serum calcium, serum magnesium, alkaline phosphate, triglyceride, and intact parathyroid hormone (iPTH) before and after PTX between the two groups (P > 0.05). The operation time in the ultrasonic scalpel group was significantly decreased compared with the traditional electrocautery group (P < 0.05). Compared with the traditional electrocautery group, the drainage amount was significantly reduced in the ultrasonic scalpel group, and the number of days with drain and postoperative hospital stay were also remarkably decreased (P < 0.05).

Conclusions

The use of ultrasonic scalpel significantly reduced the operation time and postoperative hospital stay in patients on maintenance hemodialysis undergoing PTX.

Pain in Hemodialysis Patients: Prevalence, Intensity, Location, and Functional Interference in Daily Activities

Although pain is a frequent complaint of patients with chronic kidney disease who undergo hemodialysis, few studies have assessed the functional interference of pain in activities of daily living (ADLs). Hence, the aim of this study was to evaluate the prevalence, location, intensity, and functional interference of pain in ADLs of chronic kidney disease patients undergoing hemodialysis and to estimate the association of specific pain sites with severe functional interference by pain in ADLs. This cross-sectional study included patients with chronic kidney disease undergoing hemodialysis. The prevalence, intensity, and functional interference of pain in ADLs were assessed using the brief pain inventory. Poisson regression was used to calculate the prevalence ratio. A total of 65 patients participated in the study. The overall prevalence of pain was 89.23%; the prevalence of headache was 18.46% and that of pain in the trunk was 55.38%, upper limbs was 35.38%, and lower limbs was 60.00%. The prevalence of moderate and severe pain at the time of hemodialysis was 13.85% and 21.54%, respectively. A high prevalence of severe functional interference of pain in general activity (61.54%), mobility (56.92%), and disposition (55.38%) was observed. Pain is a frequent complaint in patients undergoing hemodialysis, mainly musculoskeletal and intradialytic, and it interferes with ADLs and incapacitates the patient. Pain was highly prevalent in the upper and lower limbs and the trunk. Furthermore, a higher prevalence of severe pain at the time of hemodialysis and functional interference of pain, mainly in general activity, mobility, and disposition, were observed.

Where are we now? Emerging opportunities and challenges in the management of secondary hyperparathyroidism in patients with non-dialysis chronic kidney disease

Rising levels of parathyroid hormone (PTH) are common in patients with chronic kidney disease (CKD) not on dialysis and are associated with an elevated risk of morbidity (including progression to dialysis) and mortality. However, there are several challenges for the clinical management of secondary hyperparathyroidism (SHPT) in this population. While no recognised target level for PTH currently exists, it is accepted that patients with non-dialysis CKD should receive early and regular monitoring of PTH from CKD stage G3a. However, studies indicate that adherence to monitoring recommendations in non-dialysis CKD may be suboptimal. SHPT is linked to vitamin D [25(OH)D] insufficiency in non-dialysis CKD, and correction of low 25(OH)D levels is a recognised management approach. A second challenge is that target 25(OH)D levels are unclear in this population, with recent evidence suggesting that the level of 25(OH)D above which suppression of PTH progressively diminishes may be considerably higher than that recommended for the general population. Few therapeutic agents are licensed for use in non-dialysis CKD patients with SHPT and optimal management remains controversial. Novel approaches include the development of calcifediol in an extended-release formulation, which has been shown to increase 25(OH)D gradually and provide a physiologically-regulated increase in 1,25(OH)2D that can reliably lower PTH in CKD stage G3-G4 without clinically meaningful increases in serum calcium and phosphate levels. Additional studies would be beneficial to assess the comparative effects of available treatments, and to more clearly elucidate the overall benefits of lowering PTH in non-dialysis CKD, particularly in terms of hard clinical outcomes.

Outcomes following parathyroidectomy for secondary hyperparathyroidism in patients with chronic kidney disease - a single-centre study

BACKGROUND

Surgical parathyroidectomy may be required for severe and refractory secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD). Parathyroidectomy is associated with long-term survival benefit despite an increase in short-term morbidity and mortality. Global variation in practice exists, with limited Australian data on outcomes following parathyroidectomy.

METHODS

We conducted a retrospective study of patients who underwent parathyroidectomy for SHPT between January 2010 and December 2019 at a single tertiary referral centre in Melbourne, Australia. Biochemical markers and medications were assessed 12 months pre- and post-surgery. Clinical outcomes, including hospital readmission, cardiovascular events and mortality were assessed following surgery.

RESULTS

During the 10-year study period, 129 patients underwent parathyroidectomy for SHPT (mean age 50.7 ± 15 years, 109 (85%) on dialysis). Significant immediate post-operative complications were seen in eight patients (6%), requiring admission to the intensive care unit (n = 6) or return to theatre (n = 2). Within the first 6 months, 24 patients (19%) required hospital readmission. Within 12 months post-parathyroidectomy, 100 (78%) and 103 patients (80%) experienced at least one episode of hypercalcaemia (corrected calcium >2.6 mmol/L) or hypocalcaemia (corrected calcium <2.1 mmol/L) respectively. Over a 12-month period there were six deaths (5%), and eight patients (6%) experienced a major cardiovascular event.

CONCLUSION

Significant fluctuations in serum calcium levels are common post-parathyroidectomy, however long-term morbidity and mortality in our cohort were lower than previously reported, highlighting that parathyroidectomy in a carefully selected cohort is safe for severe SHPT refractory to medical treatment. This article is protected by copyright. All rights reserved.

Pain in Patients With Chronic Kidney Disease Undergoing Hemodialysis: A Systematic Review

AIMS

To assess the presence of pain, its location, intensity, and effects on the daily activities of patients with chronic kidney disease (CKD) undergoing hemodialysis (HD).

PARTICIPANTS/SUBJECTS

Patients with chronic kidney disease (CKD) undergoing hemodialysis (HD).

DESIGN

A systematic review.

METHODS

We carried out search for articles published until December 2020, including publications in Portuguese, English, and Spanish during the past 15 years (2005-2020), using the Embase, SciELO, PubMed, and Web of Science databases. The following information was collected: type of pain, pain treatment, pain assessment instrument, prevalence of pain, location, and influence of pain on quality of life.

RESULTS

Twenty-five studies were selected for a systematic review. These studies involved a total of 98,162 adult and elderly patients with CKD who were undergoing HD. There was a high prevalence of pain in patients with CKD on HD. The most frequent sites of pain were the head, back, bones, chest, and the upper and lower limbs. The presence of acute, chronic, neuropathic pain, and myalgia was also reported in the studies. In addition, there was a higher frequency of moderate and severe pain, which influenced daily activities, the ability to walk, mood, relationships with other people, sleep, and work in patients on dialysis.

CONCLUSIONS

The analyzed studies suggest that acute and chronic pain is a prevalent complaint in adults and elderly patients undergoing HD. There was a higher frequency of moderate and severe pain in different parts of the body, and pain interfered with everyday activities.

Predictors of early postoperative hypocalcemia in patients with secondary hyperparathyroidism undergoing total parathyroidectomy

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.

Surgical Management of Secondary Hyperparathyroidism

Secondary hyperparathyroidism (SHPT) affects a majority of patients with chronic kidney disease (CKD) of stage 3 or worse. Despite the development of calcimimetics and their effectiveness in treating SHPT, many patients continue to fail medical management and should be referred to a parathyroid surgeon. In this narrative review, we summarize the indications for surgical referral, preoperative planning, intraoperative strategies to guide resection, and postoperative management. In the absence of universal guidelines, it can be difficult to determine when it is appropriate to make this referral. The majority of studies evaluating parathyroidectomy (PTX) for SHPT use the criteria of parathyroid hormone level (PTH) >800 pg/ml with hypercalcemia and/or hyperphosphatemia, which may be accompanied by symptoms such as bone pain and pruritis that can improve after surgery. Although the reported utility of the various imaging modalities (i.e., 99m-technetium-sestamibi scintigraphy with computed tomography [SPECT/CT], CT, or ultrasound) is highly variable in SHPT, SPECT/CT appears to be the most sensitive. Intraoperatively, PTH monitoring is effective in predicting long-term cure of SHPT but not in predicting hypoparathyroidism. Ectopic and supernumerary parathyroid glands are common in these patients and are often implicated in persistent or recurrent disease. Postoperatively, patients are at risk of severe hypocalcemia and hungry bone syndrome requiring close monitoring and replenishment.

Surgical Outcomes of Subtotal Parathyroidectomy for Renal Hyperparathyroidism

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.

Evaluation of laboratory parameters and symptoms after parathyroidectomy in dialysis patients with secondary hyperparathyroidism

Objectives: The aim of the study was to evaluate the laboratory parameters and symptoms after parathyroidectomy (PTX) in dialysis patients with secondary hyperparathyroidism (SHPT), and to briefly analyze the different therapeutic effects of the three surgical methods.

Methods: A total of 182 dialysis patients who underwent PTX between February 2012 and January 2018 at the Second Affiliated Hospital of Soochow University were included in this study and followed for 12 months. Laboratory parameters such as calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), and intact parathyroid hormone (iPTH) were measured before and after operation. According to the follow-up time and type of operation, we calculated the percentage of laboratory indicators reaching the recommended range of the KDIGO guidelines after surgery. We also analyzed the improvement of bone pain and pruritus, as well as surgical complications.

Results: After the operation, the levels of iPTH, Ca, and P decreased significantly at each time point. ALP increased at the first postoperative week and gradually decreased to normal range after 3 months. Symptoms, such as bone pain and pruritus, were significantly relieved. According to the follow-up time and three surgical methods (subtotal parathyroidectomy, total parathyroidectomy, total parathyroidectomy plus autologous transplantation), we found that the ratio of each laboratory parameter reaching the recommended range of KDIGO guidelines was significantly different.

Conclusion: PTX is a safe and effective therapy for treating SHPT that is refractory to medical therapies and accompanied by related signs and symptoms in dialysis patients. All three operative techniques were effective in controlling SHPT.

Acute pancreatitis in end-stage renal disease patients in the USA: a nationwide, propensity score-matched analysis

BACKGROUND

Limited data exist regarding the effects of end-stage renal disease (ESRD) on acute pancreatitis (AP). This study aimed to evaluate the association between ESRD and outcomes and resource utilization of AP.

MATERIALS AND METHODS

The 2014 National Inpatient Sample database was used to identify all hospitalized patients with a principal diagnosis of AP. Propensity score matching was performed to create a matched cohort of ESRD and non-ESRD patients. The in-hospital mortality, morbidity, resource utilization and expenditures of AP in ESRD patients were compared to non-ESRD patients. Multivariate analysis was performed for further adjustment for potential confounders.

RESULTS

Of 382 595 AP patients, 7380 ESRD patients and 8050 non-ESRD patients were created after propensity score matching. ESRD patients had more tendency to have hypercalcemia-related or AP-related to other/unspecified causes, whereas non-ESRD patients had more tendency to have alcohol-related, gallstone-related, and hypertriglyceridemia-related AP. In multivariate analysis, ESRD was associated with increased in-hospital mortality, increased length of hospital stay, and increased hospitalization costs and charges. No differences were observed in inpatient morbidity, imaging study use, and procedures performed during hospitalization.

CONCLUSION

In this large nationwide study using inpatient USA database, we demonstrate higher AP-related mortality, and resource utilization among ESRD patients when compared with non-ESRD patients.

Parathyroidectomy in dialysis patients: Indications, methods, and consequences

Secondary hyperparathyroidism, characterized by increased PTH synthesis and secretion, is often seen in advanced stages of chronic kidney disease. Excessive proliferation of parathyroid cells leads to the development of diffuse hyperplasia that subsequently progresses to nodular histology. Refractory hyperparathyroidism occurs when parathyroid glands fail to respond to medical therapy. Parathyroidectomy (PTX), surgical resection of parathyroid glands, is usually performed in cases of persistent serum levels of PTH above 1000 pg/mL associated with hypercalcemia or when hyperparathyroidism is refractory to conservative therapy. Parathyroidectomy can be carried out using different procedures: subtotal PTX or total PTX with or without parathyroid autotransplantation. Parathyroid surgery may have undesirable consequences due to PTH oversuppression, such as the development of adynamic bone disease; hungry bone syndrome is quite common after this surgery. However, PTX improves survival and parameters of mineral metabolism. Parathyroidectomy needs to be considered in those patients with severe hyperparathyroidism with a poor response to pharmacological treatment and with distinct undesirable effects of PTH on bone and mineral metabolism parameters.