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Ahmad I, Alkomi S, Sharaha R, Manasrah S, Dukmak ON. Sagliker Syndrome in a Patient With Secondary Hyperparathyroidism and Chronic Kidney Disease: A Case Report From Palestine. Cureus 2024; 16:e51956. [PMID: 38333487 PMCID: PMC10852203 DOI: 10.7759/cureus.51956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 02/10/2024] Open
Abstract
Sagliker syndrome (SS) is a rare complication in patients with chronic kidney disease (CKD) on prolonged dialysis due to uncontrolled secondary hyperparathyroidism (SHPT). SS manifests with a constellation of clinical manifestations, including short stature, craniomaxillofacial abnormalities, hearing loss, and neuropsychiatric disorders. This article reports a 33-year-old male patient with CKD who complained of progressive disfiguring facial changes, multiple recurrent fractures, and shortened height. The condition affects his quality of life. On workup, his lab results showed highly elevated serum levels of parathyroid hormone, alkaline phosphatase (ALP), calcium, and phosphate. His comorbidities and poor health status limit his ability to do parathyroidectomy (Ptx). A reliable diagnostic approach must be considered, enabling physicians to make earlier interventions and get better outcomes.
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Affiliation(s)
- Ibtihal Ahmad
- Nephrology, Internal Medicine, School of Medicine, Palestine Polytechnic University, Hebron, PSE
| | - Saja Alkomi
- Nephrology, Internal Medicine, School of Medicine, Palestine Polytechnic University, Hebron, PSE
| | - Rula Sharaha
- Nephrology, Internal Medicine, School of Medicine, Palestine Polytechnic University, Hebron, PSE
| | - Shaheera Manasrah
- Nephrology, Internal Medicine, School of Medicine, Palestine Polytechnic University, Hebron, PSE
| | - Osama N Dukmak
- Nephrology, Internal Medicine, School of Medicine, Al-Quds University, Jerusalem, PSE
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Mi J, Fang Y, Xian J, Wang G, Guo Y, Hong H, Chi M, Li YF, He P, Gao J, Liao W. Comparative Effectiveness of MRI, 4D-CT and Ultrasonography in Patients with Secondary Hyperparathyroidism. Ther Clin Risk Manag 2023; 19:369-381. [PMID: 37159605 PMCID: PMC10163888 DOI: 10.2147/tcrm.s379814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 02/13/2023] [Indexed: 05/11/2023] Open
Abstract
Objective Accurate preoperative localization of abnormal parathyroid glands is crucial for successful surgical management of secondary hyperparathyroidism (SHPT). This study was conducted to compare the effectiveness of preoperative MRI, 4D-CT, and ultrasonography (US) in localizing parathyroid lesions in patients with SHPT. Methods We performed a retrospective review of prospectively collected data from a tertiary-care hospital and identified 52 patients who received preoperative MRI and/or 4D-CT and/or US and/or 99mTc-MIBI and subsequently underwent surgery for SHPT between May 2013 and March 2020. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of each imaging modality to accurately detect enlarged parathyroid glands were determined using histopathology as the criterion standard with confirmation using the postoperative biochemical response. Results A total of 198 lesions were identified intraoperatively among the 52 patients included in this investigation. MRI outperformed 4D-CT and US in terms of sensitivity (P < 0.01), specificity (P = 0.455), PPV (P = 0.753), and NPV (P = 0.185). The sensitivity and specificity for MRI, 4D-CT, and US were 90.91%, 88.95%, and 66.23% and 58.33%, 63.64%, and 50.00%, respectively. The PPV of combined MRI and 4D-CT (96.52%) was the highest among the combined 2 modalities. The smallest diameter of the parathyroid gland precisely localized by MRI was 8×3 mm, 5×5 mm by 4D-CT, and 5×3 mm by US. Conclusion MRI has superior diagnostic performance compared with other modalities as a first-line imaging study for patients undergoing renal hyperparathyroidism, especially for ectopic or small parathyroid lesions. We suggest performing US first for diagnosis and then MRI to make a precise localization, and MRI proved to be very helpful in achieving a high success rate in the surgical treatment of renal hyperparathyroidism in our own experience.
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Affiliation(s)
- Jiaoping Mi
- Department of Otolaryngology Head and Neck Surgery, The First Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
- Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Yijie Fang
- Department of Radiology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Jianzhong Xian
- Department of Ultrasound, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Guojie Wang
- Department of Radiology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Yuanqing Guo
- Department of Spinal Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Haiyu Hong
- Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Mengshi Chi
- Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Yong-Fang Li
- Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Peng He
- Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Jiebing Gao
- Department of Radiology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
- Jiebing Gao, Department of Radiology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China, Email
| | - Wei Liao
- Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
- Correspondence: Wei Liao, Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, 519020, People’s Republic of China, Email
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Zhou B, Zhu L, Xiang C, Cheng F, Zhu X, Zhou Y, Wang Y. Total parathyroidectomy with forearm autotransplantation in secondary hyperparathyroidism patients: analysis of muscle, subcutaneous and muscle + subcutaneous method. BMC Surg 2021; 21:226. [PMID: 33933053 PMCID: PMC8088620 DOI: 10.1186/s12893-021-01222-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 04/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background Forearm autotransplantation after parathyroidectomy has turned into the standard method for secondary hyperparathyroidism (SHPT) treatment in chronic kidney disease patients. Our study aimed to explore the effects of three methods including muscle, subcutaneous and muscle + subcutaneous transplant methods on SHPT. Methods Seventy five SHPT patients were enrolled and assigned into the muscle + subcutaneous (M + S) (n = 26), muscle (M) (n = 35), and subcutaneous (S) (n = 14) groups. The operation efficacy evaluation included preoperative and postoperative biological characteristics such as parathyroid hormone (PTH), serum phosphorus, serum calcium and alkaline phosphatase (ALP). The data were recorded from pre-operation time point to 1, 2, 3, 6, 12, 18, 24 month (mo) postoperation periods. After operation, short-form health survey (SF-36) scores was made for life quality identification at 1, 2, 3, 6, 12, 24 time points. Symptoms about SHPT including bone pain, fracture, pruritus, and coronary artery calcification were followed-up based on the scale. Results Compared with the preoperative record, all the M + S, M, and S groups showed postoperative decreased levels of PTH, serum phosphorus, serum calcium, calcium-phosphorus. In M + S group, the PTH and serum calcium level kept more steady compared with the M and S groups during a 24 mo duration observation. After this, a SF-36 score scale which represents the life quality show M + S group got more scores at 3, 6, 12, 18 and 24 mo points. At last, the incidence of SHPT associated symptoms including Bone pain, Fracture, Pruritus, and Coronary artery calcification in M + S group were decreased compared with M and S groups at 1, 3, 6, 12 and 24 mo post-operation time points. Conclusion M + S seems to be an efficient method for medical treatment of SHPT patients in the control of PTH and serum calcium. This mixed transplant strategy improves the biochemical characterizes compared with M and S groups in SHPT patients. Furthermore, the M + S method make beneficial on clinical outcomes and life quality of patients.
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Affiliation(s)
- Bin Zhou
- Department of Thyroid Surgery, The Second Affiliated Hospital of Zhejiang University College of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.,Department of Thyroid and Breast Surgery, Lishui Hospital of Zhejiang University, Lishui, 323000, Hangzhou, China
| | - Lei Zhu
- Department of Thyroid and Breast Surgery, Lishui Hospital of Zhejiang University, Lishui, 323000, Hangzhou, China
| | - Cheng Xiang
- Department of Thyroid Surgery, The Second Affiliated Hospital of Zhejiang University College of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
| | - Feng Cheng
- Department of Thyroid and Breast Surgery, Lishui Hospital of Zhejiang University, Lishui, 323000, Hangzhou, China
| | - Xi Zhu
- Department of Thyroid and Breast Surgery, Lishui Hospital of Zhejiang University, Lishui, 323000, Hangzhou, China
| | - Yi Zhou
- Department of Thyroid and Breast Surgery, Lishui Hospital of Zhejiang University, Lishui, 323000, Hangzhou, China
| | - Yong Wang
- Department of Thyroid Surgery, The Second Affiliated Hospital of Zhejiang University College of Medicine, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
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Yu Y, Zhu CF, Fu X, Xu H. Sagliker syndrome: A case report of a rare manifestation of uncontrolled secondary hyperparathyroidism in chronic renal failure. World J Clin Cases 2019; 7:3792-3799. [PMID: 31799306 PMCID: PMC6887613 DOI: 10.12998/wjcc.v7.i22.3792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/03/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Sagliker syndrome (SS) resulting from uncontrolled secondary hyperparathyroidism (SHPT) in chronic renal failure (CRF) is seldom reported.
CASE SUMMARY A 24-year-old woman presented with asymmetric facial deformity and stature shortening. She was diagnosed with SS, SHPT, CRF, and thyroid cancer. The patient underwent a total parathyroidectomy and thyroidectomy with central lymph node dissection. The patient’s condition was stable and was discharged from the hospital.
CONCLUSION Undergoing dialysis vintage, presenting high serum phosphate levels, and female gender may be risk factors for SS. Intramembranous ossification in the craniomaxillofacial region is possibly activated in this special pathophysiological condition. What’s more, the choice of surgery mainly depends on the treatment goal and the experience of the individual surgeon.
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Affiliation(s)
- Yu Yu
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Discipline Construction Research Center of China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai 200011, China
| | - Chen-Fang Zhu
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Discipline Construction Research Center of China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai 200011, China
| | - Xiao Fu
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Discipline Construction Research Center of China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai 200011, China
| | - Hua Xu
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Discipline Construction Research Center of China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai 200011, China
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Lin N, Fang YC, Song JC, Wang Y. Total parathyroidectomy plus multi-point subcutaneous transplantation in the forearm may be a reliable surgical approach for patients with end-stage renal disease: A case report. Medicine (Baltimore) 2019; 98:e17649. [PMID: 31764770 PMCID: PMC6882627 DOI: 10.1097/md.0000000000017649] [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: 11/26/2022] Open
Abstract
RATIONALE We studied the feasibility of total arathyroidectomy(tPTX)+multi-point transplantation in the forearm for treatment of secondary hyperparathyroidism. Considering the controversial nature of the appropriate timing for and location of this type of surgery, relevant research is relatively rare. Our experience may be a relatively successful one. PATIENT CONCERNS Our patient was a 28-year-old woman with end-stage renal disease (ESRD), who was on dialysis for 7 years, and a 2-year history of progressively aggravated bone pain. She also had hypercalcemia and hyperphosphatemia. DIAGNOSES Given the patient's history of long-term dialysis, bone pain, high levels of intact parathyroid hormone(i-PTH) and hypercalcemia, we performed ultrasonography which showed solid nodules in the bilateral parathyroid glands. She was accordingly diagnosed with SHPT. INTERVENTIONS The patient underwent tPTX+multi-point subcutaneous transplantation in the forearm. OUTCOMES Her i-PTH level dropped to < 300 pg/mL, and the symptoms of bone pain markedly reduced after surgery. LESSONS Total parathyroidectomy+multi-point subcutaneous transplantation in the forearm may be a reliable surgical approach for patients with ESRD.
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Affiliation(s)
- Nan Lin
- Department of General Surgery, Dongfang Hospital, Xiamen University
- Department of General Surgery, Fuzhou General Hospital, Fuzhou, Fujian, China
| | - Yong Chao Fang
- Department of General Surgery, Dongfang Hospital, Xiamen University
| | - Jun Chuan Song
- Department of General Surgery, Dongfang Hospital, Xiamen University
| | - Yu Wang
- Department of General Surgery, Dongfang Hospital, Xiamen University
- Department of General Surgery, Fuzhou General Hospital, Fuzhou, Fujian, China
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Zhu M, Zhang Z, Lin F, Miao J, Wang P, Zhang C, Yu H, Deng H, Liu Z, Liu L, Wan B, Yang H, Song M, Zhao Y, Jiang N, Zhang Z, Zhang Z, Pan L. Therapeutic experience of severe and recurrent secondary hyperparathyroidism in a patient on hemodialysis for 18 years: A case report. Medicine (Baltimore) 2018; 97:e10816. [PMID: 29768384 PMCID: PMC5976323 DOI: 10.1097/md.0000000000010816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION For patients with refractory secondary hyperparathyroidism (SHPT), parathyroidectomy (PTX) has received increasing attention. However, evidence-based medicine shows that there is still controversy regarding surgical methods, efficacy, and safety. We retrospectively analyzed the process of diagnosis and treatment in one patient with severe SHPT and long-term chronic renal failure (CRF), so as to further improve the therapeutic effect. CASE PRESENTATION A 61-year-old female with SHPT and CRF manifested as no urine for 18 years, underwent PTX 4 times since September 2010, with satisfactory final recovery. The first operation involved resection of 3 parathyroid glands in the normal position; the second operation involved removal of an ectopic parathyroid gland, combined with parathyroid gland autotransplantation; the third operation was performed to resect suspected recurrent parathyroid gland; the fourth operation involved partial excision of the autotransplanted parathyroid glands. CONCLUSION Accurate preoperative localized diagnosis and optimal surgical approach play key roles in the prevention and treatment of SHPT; postoperative recurrence of SHPT caused by ectopic or autotransplanted parathyroid gland should receive more attention.
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Affiliation(s)
| | | | | | | | - Pei Wang
- Department of Nuclear Medicine, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University
| | | | | | | | | | | | | | | | | | | | - Nan Jiang
- Department of General Surgery, The First Affiliated Hospital, School of Medicine, Tsinghua University, Beijing, China
| | - Zichao Zhang
- Department of General Surgery, The First Affiliated Hospital, School of Medicine, Tsinghua University, Beijing, China
| | - Zhenya Zhang
- Department of General Surgery, The First Affiliated Hospital, School of Medicine, Tsinghua University, Beijing, China
| | - Lijie Pan
- Department of General Surgery, The First Affiliated Hospital, School of Medicine, Tsinghua University, Beijing, China
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Li JG, Xiao ZS, Hu XJ, Li Y, Zhang X, Zhang SZ, Shan AQ. Total parathyroidectomy with forearm auto-transplantation improves the quality of life and reduces the recurrence of secondary hyperparathyroidism in chronic kidney disease patients. Medicine (Baltimore) 2017; 96:e9050. [PMID: 29245308 PMCID: PMC5728923 DOI: 10.1097/md.0000000000009050] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Our study aims to explore the effect of total parathyroidectomy (PTX) with forearm autotransplantation (FAT) on the quality of life and recurrence of secondary hyperparathyroidism (SHPT) in chronic kidney disease patients. METHODS A total of 104 chronic kidney disease patients with SHPT were enrolled and divided into the PTX (n = 62) and PTX + FAT (n = 42) groups. The operation efficacy was evaluated by analyzing preoperative and postoperative values, including levels of intact parathyroid hormone (iPTH), serum phosphorus, serum calcium, alkaline phosphatase (ALP), calcium-phosphorus product, signs and symptoms, and MOS 36-item short-form health survey (SF-36) scores. Moreover, complications and recurrences were followed up for 12 months after the operation. Binary logistic regression was to present the risk factors for the recurrence of chronic kidney disease patients with SHPT. RESULTS Compared with the preoperative values, the PTX and PTX + FAT groups showed decrease postoperative levels of iPTH, serum phosphorus, serum calcium, calcium-phosphorus product, bone pain, and skin pruritus at all time periods. The PTX and PTX + FAT groups demonstrated decreased ALP, fracture or deformity, and coronary artery calcification at 1 month, decreased short stature at 3 months after the operation but increased SF-36 score after operation. Compared with the PTX group, the level of iPTH decreased and the levels of serum calcium, calcium-phosphorus product increased at 3, 6, and 12 months after the operation in the PTX + FAT group. The levels of ALP, fracture or deformity, short stature, and SF-36 decreased separately at 1 week and 6 and 12 months after the operation, along with the decrease of coronary artery calcification and the recurrence rate, respectively, at 6 and 12 months after the operation in the PTX + FAT group when compared with those in the PTX group. Logistic regression analysis evidenced that the preoperative iPTH level, SF-36 score, and operation type were the risk factors for the recurrence of chronic kidney disease with SHPT. CONCLUSION Total PTX combined with FAT is more effective in improving the quality of life and reducing the recurrence of chronic kidney disease with SHPT than PTX alone.
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Affiliation(s)
| | | | | | - Yun Li
- Department of Thyroid Breast Surgery
| | | | | | - Ai-Qin Shan
- Department of Nephrology, Yinzhou Hospital of Ningbo University Medical College, Ningbo, China
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Khalil D, Kerr PD. PTH monitoring after total parathyroidectomy with forearm auto-transplantation: potential for spuriously high levels from grafted forearm. J Otolaryngol Head Neck Surg 2017. [PMID: 28645310 PMCID: PMC5481912 DOI: 10.1186/s40463-017-0226-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background We have identified a cause of falsely elevated parathyroid hormone (PTH) levels after total parathyroidectomy with forearm auto-transplantation (TPT-ATx). Our cases highlight the need to draw PTH samples remotely, away from forearm graft sites, to ensure accurate levels. Case presentations We report on four patients who were referred to our surgical team at an academic tertiary care center for what was perceived to be recurrent hyperparathyroidism 2–5 years following total parathyroidectomy with auto-transplantation. Further evaluation revealed highly discrepant results in these patients depending on where the blood was drawn, with spuriously high levels in blood drawn from the grafted arm (Range 337–3885 ng/l), and much lower levels when blood was drawn remotely away from the graft site (Range 9–242 ng/l). The difference in PTH level between the grafted forearm and remote site for these patients ranged between 328 and 3643 ng/l. Over the period these cases were accrued (2008–2012), 89 patients underwent TPT-ATx in our institution. Therefore, our case report series suggests that this phenomenon will be evident to a clinically important extent in at least 4% of patients. Conclusions One can acquire spuriously high PTH levels from grafted forearms, leading to the false diagnosis of recurrent hyperparathyroidism. We recommend PTH levels be drawn remotely from graft sites to ensure accurate systemic levels are reflected.
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Affiliation(s)
- Diana Khalil
- Department of Otolaryngology, Health Sciences Center, University of Manitoba, GB421 - 820 Sherbrook Street, Winnipeg, Manitoba, R3A1R9, Canada
| | - Paul D Kerr
- Department of Otolaryngology, Health Sciences Center, University of Manitoba, GB421 - 820 Sherbrook Street, Winnipeg, Manitoba, R3A1R9, Canada.
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Wetmore JB, Liu J, Do TP, Lowe KA, Ishani A, Bradbury BD, Block GA, Collins AJ. Changes in secondary hyperparathyroidism-related biochemical parameters and medication use following parathyroidectomy. Nephrol Dial Transplant 2015; 31:103-11. [PMID: 26292694 DOI: 10.1093/ndt/gfv291] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 07/03/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Little is known about changes in parathyroid hormone (PTH), calcium and phosphorous levels after parathyroidectomy in hemodialysis patients. We studied the effects of parathyroidectomy on these biochemical values in a large cohort of patients receiving maintenance hemodialysis. METHODS This retrospective cohort study included patients identified in both the United States Renal Data System and the database of a large dialysis organization who underwent parathyroidectomy in 2007-09, were aged ≥ 18 years, had Medicare Parts A and B as primary payer and had received hemodialysis for ≥ 1 year pre-parathyroidectomy. Descriptive statistics were calculated for continuous variables; categorical variables were used to characterize the population and evaluate monthly laboratory and medication use; median values were calculated for laboratory measures. RESULTS Among 1402 parathyroidectomy patients, mean age was 48.9 years, 52.4% were males, 58.8% were African American and mean dialysis duration was 7.5 years. Median PTH levels increased over the year before parathyroidectomy from 1039 to 1661 pg/mL and decreased afterward to 98 pg/mL at 1 month; levels remained ≥ 897 pg/mL for 10% of patients. Median calcium levels fell from 9.6 mg/dL before to 7.9 mg/dL 1 month after parathyroidectomy; levels were ≤ 7.1 mg/dL for 25% and remained ≤ 7.2 mg/dL for the lowest 25% at 3 months. Median phosphorous level was 6.8 mg/dL immediately before parathyroidectomy, decreased to 3.8 mg/dL immediately after and reached 5.8 mg/dL at 1 year. CONCLUSIONS While PTH levels dropped after parathyroidectomy for most patients, surgery was sometimes ineffective in reducing levels and sometimes led to over-suppression. Hypocalcemia could be profound and long lasting, suggesting the need for prolonged vigilance.
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Affiliation(s)
- James B Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - Thy P Do
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - Kimberly A Lowe
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - Areef Ishani
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA Section of Renal Diseases and Hypertension, Minneapolis Veterans Administration Health Care System, Minneapolis, MN, USA Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Brian D Bradbury
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | | | - Allan J Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Fang L, Tang B, Hou D, Meng M, Xiong M, Yang J. Relationship between parathyroid mass and parathyroid hormone level in hemodialysis patients with secondary hyperparathyroidism. BMC Nephrol 2015; 16:82. [PMID: 26058796 PMCID: PMC4461925 DOI: 10.1186/s12882-015-0077-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 05/21/2015] [Indexed: 01/07/2023] Open
Abstract
Background To evaluate the influence of parathyroid mass on the regulation of parathyroid hormone (PTH) secretion, we investigated the relationship between the resected parathyroid gland in total parathyroidectomy and the parathyroid hormone level in hemodialysis patients with secondary hyperparathyroidism. Methods From January 2009 to July 2014, 223 patients undergoing total parathyroidectomy were included. The size and the weight of parathyroid gland were measured during the operation. Results 874 parathyroid glands were removed. A positive correlation was identified between the size and the weight of resected parathyroid glands. We found that both the preoperative PTH and the reduction of PTH were significantly correlated with the size and the weight of parathyroid glands in a positive manner. However, in the subgroup of patients with PTH < 1000 pg/ml, no significant correlation was found. Conclusions Larger parathyroid gland secretes more PTH and high level of serum PTH usually indicated that surgical removal might be required. However, since PTH levels could be influenced by the pharmaceutical drug, the large size of parathyroid gland might be used as a much more appropriate guide that indicates the requirement of surgery treatment even when the parathyroid hormone was less than 1000 pg/ml.
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Affiliation(s)
- Li Fang
- Center for Kidney Disease, 2nd Affiliated Hospital, Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China.
| | - Bing Tang
- Center for Kidney Disease, 2nd Affiliated Hospital, Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China.
| | - Dawei Hou
- Department of General Surgery, 2nd Affiliated Hospital, Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China.
| | - Meijuan Meng
- Center for Kidney Disease, 2nd Affiliated Hospital, Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China.
| | - Mingxia Xiong
- Center for Kidney Disease, 2nd Affiliated Hospital, Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China.
| | - Junwei Yang
- Center for Kidney Disease, 2nd Affiliated Hospital, Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China.
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Zhang LN, Yang G, Cheng C, Shen C, Cui YY, Zhang J, Zhang JJ, Shen ZX, Zeng M, Ge YF, Sun B, Yu XB, Ouyang C, Zhang B, Mao HJ, Liu J, Xing CY, Zha XM, Wang NN. Plasma FGF23 levels and heart rate variability in patients with stage 5 CKD. Osteoporos Int 2015; 26:395-405. [PMID: 25224292 DOI: 10.1007/s00198-014-2862-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 08/14/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED Fibroblast growth factor 23(FGF23) is a bone-derived hormone which regulates mineral homeostasis but may also have a role in cardiovascular disease. Here, we found that higher plasma FGF23 was independently associated with decreased heart rate variability in stage 5 CKD patients and parathyroidectomy may reverse these abnormal indicators. INTRODUCTION Lower heart rate variability (HRV) in patients with chronic kidney disease (CKD) compared with healthy controls is associated with increased risk of cardiovascular disease (CVD). Higher levels of plasma FGF23 also predict higher risk of CVD. Here, we aimed to evaluate the relationship between plasma FGF23 levels and HRV in patients with stage 5 CKD and to investigate longitudinal changes of them together with the correlation between their changes in two severe secondary hyperparathyroidism (SHPT) subgroups with successful parathyroidectomy (PTX) and persistent SHPT. METHODS This cross-sectional study included 100 stage 5 CKD patients, 78 controls, and a prospective study in two PTX subgroups classified as successful PTX (n = 24) and persistent SHPT (n = 4) follow-up. Blood examination and 24-h Holter monitoring for HRV were measured. RESULTS Most HRV indices were lower in stage 5 CKD patients than in healthy controls, and plasma FGF23 levels were higher. In multivariate stepwise regression models, levels of plasma FGF23 and serum parathyroid hormone (PTH) were correlated with HRV. The successful PTX subgroup had significant improvements over baseline in HRV indices. Persistent SHPT subgroup had numerically similar changes in HRV indices. However, plasma FGF23 levels decreased in both subgroups. CONCLUSIONS Plasma FGF23 levels were higher in CKD patients than in controls, much higher in patients with severe SHPT. FGF23 was independently associated with decreased HRV in stage 5 CKD. Successful PTX may reverse these abnormal indicators and contribute to decreases in the risk of cardiovascular disease.
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Affiliation(s)
- L-N Zhang
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, People's Republic of China
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12
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Ishani A, Liu J, Wetmore JB, Lowe KA, Do T, Bradbury BD, Block GA, Collins AJ. Clinical outcomes after parathyroidectomy in a nationwide cohort of patients on hemodialysis. Clin J Am Soc Nephrol 2014; 10:90-7. [PMID: 25516915 DOI: 10.2215/cjn.03520414] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients receiving dialysis undergo parathyroidectomy to improve laboratory parameters in resistant hyperparathyroidism with the assumption that clinical outcomes will also improve. However, no randomized clinical trial data demonstrate the benefits of parathyroidectomy. This study aimed to evaluate clinical outcomes up to 1 year after parathyroidectomy in a nationwide sample of patients receiving hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using data from the US Renal Data System, this study identified prevalent hemodialysis patients aged ≥18 years with Medicare as primary payers who underwent parathyroidectomy from 2007 to 2009. Baseline characteristics and comorbid conditions were assessed in the year preceding parathyroidectomy; clinical events were identified in the year preceding and the year after parathyroidectomy. After parathyroidectomy, patients were censored at death, loss of Medicare coverage, kidney transplant, change in dialysis modality, or 365 days. This study estimated cause-specific event rates for both periods and rate ratios comparing event rates in the postparathyroidectomy versus preparathyroidectomy periods. RESULTS Of 4435 patients who underwent parathyroidectomy, 2.0% died during the parathyroidectomy hospitalization and the 30 days after discharge. During the 30 days after discharge, 23.8% of patients were rehospitalized; 29.3% of these patients required intensive care. In the year after parathyroidectomy, hospitalizations were higher by 39%, hospital days by 58%, intensive care unit admissions by 69%, and emergency room/observation visits requiring hypocalcemia treatment by 20-fold compared with the preceding year. Cause-specific hospitalizations were higher for acute myocardial infarction (rate ratio, 1.98; 95% confidence interval, 1.60 to 2.46) and dysrhythmia (rate ratio 1.4; 95% confidence interval1.16 to 1.78); fracture rates did not differ (rate ratio 0.82; 95% confidence interval 0.6 to 1.1). CONCLUSIONS Parathyroidectomy is associated with significant morbidity in the 30 days after hospital discharge and in the year after the procedure. Awareness of clinical events will assist in developing evidence-based risk/benefit determinations for the indication for parathyroidectomy.
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Affiliation(s)
- Areef Ishani
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota;
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - James B Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Kimberly A Lowe
- Center for Observational Research, Amgen Inc, Thousand Oaks, California; and
| | - Thy Do
- Center for Observational Research, Amgen Inc, Thousand Oaks, California; and
| | - Brian D Bradbury
- Center for Observational Research, Amgen Inc, Thousand Oaks, California; and
| | | | - Allan J Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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Hebert LA, Parikh S. Is fluid overload as measured by bioimpedance spectroscopy harmful in CKD-if so, why? Clin J Am Soc Nephrol 2014; 10:1-3. [PMID: 25512645 DOI: 10.2215/cjn.11311114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Lee A Hebert
- Internal Medicine/Nephrology, The Ohio State University Medical Center, Columbus, Ohio
| | - Samir Parikh
- Internal Medicine/Nephrology, The Ohio State University Medical Center, Columbus, Ohio
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14
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He Q, Zhuang D, Zheng L, Fan Z, Zhou P, Zhu J, Duan S, Li Y, Ge Y, Lv Z, Cao L. Total parathyroidectomy with trace amounts of parathyroid tissue autotransplantation as the treatment of choice for secondary hyperparathyroidism: a single-center experience. BMC Surg 2014; 14:26. [PMID: 24886230 PMCID: PMC4021022 DOI: 10.1186/1471-2482-14-26] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 04/25/2014] [Indexed: 12/31/2022] Open
Abstract
Background The aim of the study was to evaluate total parathyroidectomy with trace amounts of parathyroid tissue (30 mg) as a surgical option in secondary hyperparathyroidism (sHPT) treatment. Methods From January 2008 to March 2012, 47 patients underwent parathyroidectomy. Comparisons of demographic data, symptoms, and preoperative or postoperative biochemistry were made between total parathyroidectomy with trace amounts of parathyroid tissue autotransplantation group and total parathyroidectomy group. Results Out of 47 cases, 45 had successful operation. 187 parathyroid glands identified at the initial operation were reported in 47 patients. 43 patients had been diagnosed with parathyroid hyperplasia, and 4 patients had a benign adenoma. After operation, pruritus, bone pain and muscle weakness disappeared, also serum PTH and serum phosphate were declined markedly as well. After discharge, two patients (in total parathyroidectomy group) were readmitted because of postoperative hypoparathyroidism. Graft-dependent recurrence was not observed in an average follow-up of 42 months. Conclusions Total parathyroidectomy with sternocleidomastoid muscle trace amounts of parathyroid tissue autotransplantation is considered to be a feasible, safe and effective surgical option for the patients with sHPT.
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Affiliation(s)
- Qingqing He
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, No,25 Shifan Road, Jinan 250031, People's Republic of China.
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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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Zhang J, Yu X, Sun B, Bai J, Wei Y, Zha X, Cui Y, Zeng M, Zhang J, Liu J, Mao H, Zhang B, Ren H, Ge Y, Xu X, Shen Z, Xing C, Cao K, Wang N. Parathyroidectomy and heart rate variability in patients with stage 5 CKD. Clin J Am Soc Nephrol 2013; 8:1378-87. [PMID: 23660181 DOI: 10.2215/cjn.10381012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Lower heart rate variability implies increased risk of cardiovascular disease. This study aimed to evaluate the relationship between mineral metabolism and heart rate variability and longitudinal changes of heart rate variability after parathyroidectomy in stage 5 CKD patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This cross-sectional study included 118 stage 5 CKD patients, 87 controls, and a prospective study in two subgroups classified as successful (n=17) and unsuccessful (n=4) parathyroidectomy follow-up enrolled from March of 2011 to December of 2012. Blood examination and 24-hour Holter for heart rate variability were measured. RESULTS Most heart rate variability indices were lower in stage 5 CKD patients. In multivariate stepwise regression models, serum intact parathyroid hormone was correlated with mean normal-to-normal R-R intervals, mean heart rate, and very low frequency, serum calcium was correlated with SD of 5-minute average of normal R-R intervals, and serum phosphorus was correlated with very low frequency and low frequency/high frequency. Compared with baseline, the successful parathyroidectomy subgroup had significant improvements in mean normal-to-normal R-R intervals, mean heart rate, SD of normal-to-normal R-R intervals, SD of 5-minute average of normal R-R intervals, very low frequency, high frequency, and low frequency/high frequency. There was no significant change of heart rate variability in patients after unsuccessful parathyroidectomy. CONCLUSIONS Disorders of mineral metabolism are associated with decreased heart rate variability in stage 5 CKD. Successful parathyroidectomy may contribute to reverse this cardiovascular disease risk in severe secondary hyperparathyroidism patients.
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Affiliation(s)
- Jing Zhang
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
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