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Shenoy MT, Menon AS, Nazar PK, Moorthy S, Kumar H, Nair V, Pavithran PV, Bhavani N, Menon VU, Abraham N, Jayakumar RV. Radiofrequency Ablation Followed by Percutaneous Ethanol Ablation Leading to Long-Term Remission of Hyperparathyroidism. J Endocr Soc 2017; 1:676-680. [PMID: 29264521 PMCID: PMC5686659 DOI: 10.1210/js.2017-00094] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 04/13/2017] [Indexed: 11/19/2022] Open
Abstract
A 30-year-old male with cerebral palsy and motor impairment presented with right femur fracture. He had gradually worsening mobility and contractures of all extremities for the preceding 5 years. Evaluation showed multiple vertebral and femoral fractures, severe osteoporosis, a large parathyroid adenoma, and parathormone (PTH) exceeding 2500 pg/mL. Because of poor general health and high anesthetic risk, parathyroidectomy was deemed impractical. Ultrasound-guided radiofrequency ablation (RFA) helped achieve 50% size reduction and PTH levels with better control of hypercalcemia. Later, as calcium and PTH remained elevated, percutaneous ethanol ablation was performed with resultant normalization of PTH and substantial symptomatic improvement. Two years later, he still remains normocalcaemic with normal PTH levels. We propose that RFA and percutaneous ethanol ablation be considered as effective short-term options for surgically difficult cases, which could even help achieve long-term remission. Although not previously reported, our case illustrates that both RFA and percutaneous ethanol ablation could be safely performed successively achieving long-term remission.
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Affiliation(s)
- Mohan T Shenoy
- Department of Endocrinology, Sree Gokulam Medical College and Research Foundation, Venjaramoodu, Trivandrum, Kerala 695607
| | - Arun S Menon
- Department of Endocrinology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala 682041
| | - P K Nazar
- Department of Radiodiagnosis, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala 682041
| | - Srikanth Moorthy
- Department of Radiodiagnosis, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala 682041
| | - Harish Kumar
- Department of Endocrinology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala 682041
| | - Vasantha Nair
- Department of Endocrinology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala 682041
| | | | - Nisha Bhavani
- Department of Endocrinology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala 682041
| | - Vadayath Usha Menon
- Department of Endocrinology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala 682041
| | - Nithya Abraham
- Department of Endocrinology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala 682041
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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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Tomida K, Hamano T, Ichimaru N, Fujii N, Matsui I, Nonomura N, Tsubakihara Y, Rakugi H, Takahara S, Isaka Y. Dialysis vintage and parathyroid hormone level, not fibroblast growth factor-23, determines chronic-phase phosphate wasting after renal transplantation. Bone 2012; 51:729-36. [PMID: 22796419 DOI: 10.1016/j.bone.2012.06.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 06/07/2012] [Accepted: 06/27/2012] [Indexed: 12/11/2022]
Abstract
PURPOSE Fibroblast growth factor 23 (FGF23), rather than parathyroid hormone (PTH), has been shown to be the major factor behind hypophosphatemia in the early period after renal transplantation. However, it is not clear whether phosphate wasting persists in the chronic phase. Purpose of our study is to elucidate whether FGF23 can also explain phosphate wasting, if any, in the chronic phase. METHODS In this cross-sectional observational study, we enrolled 247 recipients who had received a graft more than 1 year prior to this study. We compared the phosphate metabolism of recipients and predialysis chronic kidney disease (CKD) patients who are matched on age and estimated glomerular filtration rate (eGFR). We also investigated the determinants of tubular reabsorption of phosphate normalized for glomerular filtration rate (TmP/GFR), as an index of renal threshold for phosphate. RESULTS Recipients had a median dialysis vintage of 27.0 months and eGFR 41.2 mL/min/1.73 m(2). Whereas hypophosphatemia (<2.4 mg/dL) was observed in 6.1% of the recipients, 55.2% had TmP/GFR lower than 2.4 mg/dL. Recipients showed significantly lower TmP/GFR in all CKD stages than their predialysis counterparts, indicating that phosphate wasting persists in the chronic phase. Compared to predialysis patients, the recipients in stages 2T and 3T showed lower phosphate and higher intact PTH levels, despite a higher percentage being active vitamin D users. However, in stage 4T, phosphate retention masked relative hypophosphatemia. FGF23 was higher in the recipients across all CKD stages, but adjustment for vitamin D prescription revealed that transplantation had no effect on FGF23. Multiple regression analysis in the recipients showed significant negative associations of intact PTH and dialysis vintage with TmP/GFR. CONCLUSIONS Renal phosphate wasting persists in the chronic-phase renal transplantation recipients even with normophosphatemia. Persistent hyperparathyroidism and longer dialysis vintage, not FGF23, was associated with renal phosphate wasting in the chronic phase. Such an impact on phosphate metabolism of the factors determined in dialysis period could be called as "uremic memory". This novel finding in the chronic phase is in sharp contrast to the previous finding in the early phase that FGF23 levels are determinants of phosphate wasting.
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Affiliation(s)
- Kodo Tomida
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandai-higashi, Osaka, 558-8558, Japan
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Douthat WG, Chiurchiu CR, Massari PU. New options for the management of hyperparathyroidism after renal transplantation. World J Transplant 2012; 2:41-5. [PMID: 24175195 PMCID: PMC3782233 DOI: 10.5500/wjt.v2.i3.41] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 04/08/2012] [Accepted: 06/01/2012] [Indexed: 02/05/2023] Open
Abstract
The persistence and severity of hyperparathyroidism (HPT) post-renal transplantation is relatively frequent and primarily associated with the timing and its magnitude in the pre-transplant period and with the presence of parathyroid adenomas. HPT after renal transplantation is clinically manifested with hypercalcemia, hypophosphatemia, bone pain, fractures, and in more serious cases with cardiovascular calcifications that affect the survival. The primary clinical objective for patients with secondary HPT after renal transplantation is to obtain a level of parathyroid hormone (PTH) adequate to the renal transplanted function and to normalize levels of calcium, phosphorus and vitamin D. In many cases during this period, the development of hypercalcemia and/or hypophosphatemia makes it necessary to take different therapeutic measures. The use of vitamin D or its analogues has been extrapolated from the management of pre-transplant HPT obtaining variable outcomes, although its use is limited by its capacity to produce hypercalcemia. Calcimimetics are drugs that have proven be effective in reducing PTH levels in patients with HPT on dialysis and has been effective in reducing up to 50% PTH levels in moderate to severe HPT in post-renal transplantation.When HPT persists after renal transplantation and does not respond to medical treatment, invasive management by percutaneous ethanol injection therapy of parathyroid glands or parathyroidectomy should be considered. The emergence of new methods for the management of HPT expands the availability of therapeutic tools for transplant patients.
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Affiliation(s)
- Walter Guillermo Douthat
- Walter Guillermo Douthat, Carlos Raul Chiurchiu, Pablo Ulises Massari, Bone and Mineral Metabolism Section, Renal Service, Hospital Privado, Centro Médico de Córdoba, 5016 Córdoba, Argentina
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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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Douthat WG, Cardozo G, Garay G, Orozco S, Chiurchiu C, de la Fuente J, de Arteaga J, Massari PU. Use of percutaneous ethanol injection therapy for recurrent secondary hyperparathyroidism after subtotal parathyroidectomy. Int J Nephrol 2011; 2011:246734. [PMID: 21716690 PMCID: PMC3118542 DOI: 10.4061/2011/246734] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 03/31/2011] [Accepted: 04/04/2011] [Indexed: 01/19/2023] Open
Abstract
We evaluated the efficacy of percutaneous ethanol injection therapy (PEIT) as a therapeutic option for recurrence of secondary hyperparathyroidism after subtotal parathyroidectomy in ESRD patients. Six patients underwent PEIT. A mean of 1.3 ± 0.8 ethanol injections was performed. Nodular volume was 1.5 ± 1.7 cm3, and 2.8 ± 2.8 cm3 of ethanol was injected per patient. After ethanol injection PTH decreased significantly (1897 ± 754 to 549 ± 863 pg/mL (P < .01)). There was also a reduction in serum calcium, phosphorus and calcium-phosphorus product. A positive and significant correlation was found between nodular volume with ethanol injected and time from parathyroidectomy. Only one patient required hospitalization due to severe hypocalcaemia. In other two cases, local discomfort and temporary mild dysphonia were registered. PEIT is an effective treatment to control recurrences of secondary hyperparathyroidism postsubtotal parathyroidectomy.
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Affiliation(s)
- Walter G Douthat
- Bone and Mineral Metabolism Section, Renal Service, Hospital Privado-Centro Médico de Córdoba, Postgraduate School of Nephrology, Catholic University of Córdoba, Naciones Unidas 346, 5016 Córdoba, Argentina
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Park NY, Jung YS, Rim H. Post-renal transplant calciphylaxis: treatment of hyperparathyroidism by percutaneous ethanol injection therapy and parathyroidectomy. NDT Plus 2010; 3:93-4. [PMID: 25949415 PMCID: PMC4421552 DOI: 10.1093/ndtplus/sfp139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Accepted: 08/31/2009] [Indexed: 11/19/2022] Open
Affiliation(s)
- Nam Young Park
- Department of Internal Medicine , Kosin University College of Medicine, Gospel Hospital , Busan , Korea
| | - Yeon Soon Jung
- Department of Internal Medicine , Kosin University College of Medicine, Gospel Hospital , Busan , Korea
| | - Hark Rim
- Department of Internal Medicine , Kosin University College of Medicine, Gospel Hospital , Busan , Korea
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Riancho JA, Lastra P, Amado JA. Alcoholización: una opción para el tratamiento del hiperparatiroidismo. Med Clin (Barc) 2009; 132:682-3. [DOI: 10.1016/j.medcli.2008.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Accepted: 04/15/2008] [Indexed: 10/20/2022]
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Cappelli C, Pelizzari G, Pirola I, Gandossi E, De Martino E, Delbarba A, Agosti B, Agabiti Rosei E, Castellano M. Modified percutaneous ethanol injection of parathyroid adenoma in primary hyperparathyroidism. QJM 2008; 101:657-62. [PMID: 18499732 DOI: 10.1093/qjmed/hcn062] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Surgery is the treatment of choice for symptomatic primary hyperparathyroidism; unlikely few patients do not meet established surgical criteria or have comorbid conditions that prohibit surgery. In these subjects, medical therapy alone offers little hope for a sustained long normocalcemic period. However percutaneous ethanol injection (PEI) may represent an alternative therapeutic procedure. It is currently in use for the treatment of secondary or tertiary hyperparathyroidism, however, few studies or case reports suggest it for the treatment of primary hyperparathyroidism. Moreover, little information is available about the long-term follow-up, where incomplete necrosis or the spreading of ethanol in the surrounding tissues is often reported. We believe that many of the side effects could be correlated to procedure itself. Taking these experiences into account, we have reasoned that in order to limit these side effects, we had to modify the standard PEI procedure. We reported this preliminary experience describing our modified PEI procedure.
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Affiliation(s)
- C Cappelli
- Department of Medical and Surgical Sciences, Internal Medicine and Endocrinology Unit, University of Brescia, 1, 25100 Brescia, Italy.
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