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Oikonomou P, Nikolaou C, Romanidis K, Pitiakoudis M, Kesisoglou I, Sapalidis K. A comparison of surgical treatments for tertiary hyperparathyroidism. A systematic review. Folia Med (Plovdiv) 2024; 66:155-160. [PMID: 38690809 DOI: 10.3897/folmed.66.e116202] [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] [Received: 11/23/2023] [Accepted: 02/07/2024] [Indexed: 05/03/2024] Open
Abstract
INTRODUCTION Tertiary hyperparathyroidism develops in patients who have secondary hyperparathyroidism that persists despite successful kidney transplantation or in patients who are on chronic dialysis.
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Molinari P, Regalia A, Leoni A, Campise M, Cresseri D, Cicero E, Vettoretti S, Nardelli L, Brigati E, Favi E, Messa P, Castellano G, Alfieri CM. Impact of hyperparathyroidism and its different subtypes on long term graft outcome: a single Transplant Center cohort study. Front Med (Lausanne) 2023; 10:1221086. [PMID: 37636567 PMCID: PMC10449540 DOI: 10.3389/fmed.2023.1221086] [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] [Received: 05/11/2023] [Accepted: 07/20/2023] [Indexed: 08/29/2023] Open
Abstract
Purpose We studied the association between parathormone (PTH) levels and long-term graft loss in RTx patients (RTx-p). Methods We retrospectively evaluated 871 RTx-p, transplanted in our unit from Jan-2004 to Dec-2020 assessing renal function and mineral metabolism parameters at 1, 6, and 12 months after RTx. Graft loss and death with functioning graft during follow-up (FU, 8.3[5.4-11.4] years) were checked. Results At month-1, 79% had HPT, of which 63% with secondary HPT (SHPT) and 16% tertiary HPT (THPT); at month-6, HPT prevalence was 80% of which SHPT 64% and THPT 16%; at month-12 HPT prevalence was 77% of which SHPT 62% and THPT 15%. A strong significant correlation was found between HPT type, PTH levels and graft loss at every time point. Mean PTH exposure remained strongly and independently associated to long term graft loss (OR 3.1 [1.4-7.1], p = 0.008). THPT was independently associated with graft loss at month-1 when compared to HPT absence and at every time point when compared to SHPT. No correlation was found with RTx-p death. Discriminatory analyses identified the best mean PTH cut-off to predict long-term graft loss to be between 88.6 and 89.9 pg/mL (AUC = 0.658). Cox regression analyses highlighted that THPT was strongly associated with shorter long-term graft survival at every time-point considered. Conclusion High PTH levels during 1st year of RTx seem to be associated with long term graft loss.
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Affiliation(s)
- Paolo Molinari
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Post-Graduate School of Specialization in Nephrology, University of Milano, Milan, Italy
| | - Anna Regalia
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Alessandro Leoni
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Mariarosaria Campise
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Donata Cresseri
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Elisa Cicero
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Post-Graduate School of Specialization in Nephrology, University of Milano, Milan, Italy
| | - Simone Vettoretti
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Luca Nardelli
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Emilietta Brigati
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Evaldo Favi
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Department of Nephrology, Dialysis and Kidney Transplants, IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, Milan, Italy
| | - Giuseppe Castellano
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Carlo M. Alfieri
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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Single-Center Experience of Parathyroidectomy Using Intraoperative Parathyroid Hormone Monitoring. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58101464. [PMID: 36295623 PMCID: PMC9607390 DOI: 10.3390/medicina58101464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
Background and Objectives: Hyperparathyroidism (HPT) is a rare endocrine disease associated with the elevated metabolism of calcium, vitamin D, and phosphate by the hyperfunctioning of the parathyroid glands. Here, we report our experience of parathyroidectomy using intraoperative parathyroid hormone (IOPTH) monitoring in a single tertiary hospital. Materials and Methods: From October 2018 to January 2022, a total of 47 patients underwent parathyroidectomy for HPT. We classified the patients into two groups—primary HPT (PHPT, n = 37) and renal HPT (RHPT, n = 10)—and then reviewed the patients’ data, including their general characteristics, laboratory results, and perioperative complications. Results: Thirty-five of the thirty-seven patients in the PHPT group underwent focused parathyroidectomy, while all ten patients in the RHPT group underwent subtotal parathyroidectomy. IOPTH monitoring based on the Milan criteria was used in all cases. Preoperative and 2-week, 6-month, and 12-month postoperative parathyroid hormone (PTH) levels were within the normal range in the PHPT group, whereas they were higher than normal in the RHPT group. Transient hypocalcemia occurred only in the RHPT group, with calcium levels returning to normal levels 12 months after surgery. Conclusions: Parathyroidectomy with IOPTH monitoring in our hospital showed favorable clinical outcomes. However, owing to the small number of patients due to the low frequency of parathyroid disease, long-term, prospective studies are needed in the future.
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg 2022; 276:e141-e176. [PMID: 35848728 DOI: 10.1097/sla.0000000000005522] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.
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Frey S, Goronflot T, Blanchard C, Kerleau C, Gourraud PA, Wargny M, Caillard C, Hourmant M, Figueres L, Mirallié É. Impact of parathyroidectomy on kidney graft function in post-transplant tertiary hyperparathyroidism: a comparative study. Langenbecks Arch Surg 2022; 407:2489-2498. [PMID: 35596781 DOI: 10.1007/s00423-022-02555-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Parathyroidectomy to treat tertiary hyperparathyroidism (THPT) is now on a par with calcimimetic treatment. The effects of cinacalcet and parathyroidectomy on kidney transplant function remain controversial. The aim of this study was to evaluate kidney transplant function in THPT patients treated either by parathyroidectomy, cinacalcet, or not treated. METHODS Between 2009 and 2019, 231 patients with functional grafts presenting THPT, defined either by calcaemia superior to 2.5 mmol/L with elevated PTH level or hypercalcaemia with non-adapted PTH level 1 year after kidney transplantation, were included. Hyperparathyroid patients treated by cinacalcet and parathyroidectomy were matched for age, sex, graft rank, and baseline eGFR with cinacalcet-only and untreated patients. Conditional logistic regression models were used to compare eGFR variations 1 year after parathyroidectomy between operated patients and matched controls. Five-year survivals were compared with the Mantel-Cox test. RESULTS Eleven patients treated with parathyroidectomy and cinacalcet were matched with 16 patients treated by cinacalcet-only and 29 untreated patients. Demographic characteristics were comparable between groups. Estimated odds ratios for eGFR evolution in operated patients compared with cinacalcet-only and untreated patients were 0.92 [95%CI 0.83-1.02] and 0.99 [0.89-1.10] respectively, indicating no significant impairment of eGFR 1 year after surgery. Five-year allograft survival was not significantly impaired in operated patients. CONCLUSIONS Parathyroidectomy did not appear to substantially alter or improve graft function 1 year after surgery or 5-year allograft survival. It could be hypothesized that in addition to its known benefits, parathyroidectomy can be safely performed vis-à-vis graft function in tertiary hyperparathyroidism.
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Affiliation(s)
- Samuel Frey
- Chirurgie Cancérologique, Digestive Et Endocrinienne, Institut Des Maladies de L'Appareil Digestif, Place Alexis Ricordeau, CHU Nantes, Hôtel Dieu, 44093, Nantes, CEDEX 1, France.,Université de Nantes, quai de Tourville, 44000, Nantes, France.,L'institut du Thorax, Unité Inserm UMR 1087 / CNRS UMR 6291, IRS 8 Quai Moncousu, 44000, Nantes, France
| | - Thomas Goronflot
- CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11, Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des données, Nantes, France
| | - Claire Blanchard
- Chirurgie Cancérologique, Digestive Et Endocrinienne, Institut Des Maladies de L'Appareil Digestif, Place Alexis Ricordeau, CHU Nantes, Hôtel Dieu, 44093, Nantes, CEDEX 1, France.,Université de Nantes, quai de Tourville, 44000, Nantes, France.,L'institut du Thorax, Unité Inserm UMR 1087 / CNRS UMR 6291, IRS 8 Quai Moncousu, 44000, Nantes, France
| | - Clarisse Kerleau
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, 30, boulevard Jean-Monnet, 44093, Nantes cedex, France
| | - Pierre-Antoine Gourraud
- Université de Nantes, quai de Tourville, 44000, Nantes, France.,CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11, Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des données, Nantes, France
| | - Matthieu Wargny
- CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11, Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des données, Nantes, France
| | - Cécile Caillard
- Chirurgie Cancérologique, Digestive Et Endocrinienne, Institut Des Maladies de L'Appareil Digestif, Place Alexis Ricordeau, CHU Nantes, Hôtel Dieu, 44093, Nantes, CEDEX 1, France
| | - Maryvonne Hourmant
- Université de Nantes, quai de Tourville, 44000, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, 30, boulevard Jean-Monnet, 44093, Nantes cedex, France.,Service de Néphrologie-Immunologie Clinique, CHU de Nantes, 30, boulevard Jean-Monnet, 44093, Nantes cedex, France
| | - Lucile Figueres
- Université de Nantes, quai de Tourville, 44000, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, 30, boulevard Jean-Monnet, 44093, Nantes cedex, France.,Service de Néphrologie-Immunologie Clinique, CHU de Nantes, 30, boulevard Jean-Monnet, 44093, Nantes cedex, France
| | - Éric Mirallié
- Chirurgie Cancérologique, Digestive Et Endocrinienne, Institut Des Maladies de L'Appareil Digestif, Place Alexis Ricordeau, CHU Nantes, Hôtel Dieu, 44093, Nantes, CEDEX 1, France. .,Université de Nantes, quai de Tourville, 44000, Nantes, France.
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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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Frey S, Goronflot T, Kerleau C, Gourraud PA, Caillard C, Hourmant M, Mirallié É, Figueres L. Parathyroidectomy or cinacalcet: Do we still not know the best option for graft function in kidney-transplanted patients? A meta-analysis. Surgery 2021; 170:727-735. [PMID: 33810851 DOI: 10.1016/j.surg.2021.02.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 01/15/2021] [Accepted: 02/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Tertiary hyperparathyroidism occurs in 25% to 50% of kidney-transplanted patients. Indication of parathyroidectomy is now discussed, since the calcimimetic agent, cinacalcet, is an alternate option. The effects of either of these treatments on graft function remain controversial, studied only in small cohorts showing either decrease or absence of modification. We performed a meta-analysis to evaluate the evolution of graft function after surgical or medical treatment. METHODS Studies assessing graft function in tertiary hyperparathyroidism after parathyroidectomy or cinacalcet introduction were enrolled into quantitative analysis using Pubmed, Embase, and Cochrane databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelines. Among 68 screened studies, 18 had no missing data and were included for statistical analyses. We performed random effect meta-analysis to determine changes in serum creatinine and estimated glomerular filtration rate. RESULTS Seven studies assessing the evolution of graft function 6 and/or 12 months after parathyroidectomy and 13 after administration of cinacalcet were included. Meta-analysis found no significant variations after parathyroidectomy in serum creatinine (6 studies, 314 patients) and estimated glomerular filtration rate (2 studies, 105 patients). No significant variation was found after administration of cinacalcet in serum creatinine (10 studies, 404 patients) and estimated glomerular filtration rate (6 studies, 149 patients). A significant heterogeneity between the studies (P < .01, Cochran's Q) was found. CONCLUSION Meta-analysis shows that parathyroidectomy and cinacalcet do not significantly impair graft function in patients with tertiary hyperparathyroidism. However, the significant heterogeneity between selected studies, partially explained by the lack of consensual definition of tertiary hyperparathyroidism, limits the conclusions of all previously published series.
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Affiliation(s)
- Samuel Frey
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des maladies de l'Appareil Digestif, Hôtel Dieu, CHU Nantes, France; Université de Nantes, France
| | - Thomas Goronflot
- CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11: Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des Données, France
| | - Clarisse Kerleau
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, France
| | - Pierre-Antoine Gourraud
- Université de Nantes, France; CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11: Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des Données, France
| | - Cécile Caillard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des maladies de l'Appareil Digestif, Hôtel Dieu, CHU Nantes, France
| | - Maryvonne Hourmant
- Université de Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, France; Service de néphrologie-immunologie clinique, CHU de Nantes, France
| | - Éric Mirallié
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des maladies de l'Appareil Digestif, Hôtel Dieu, CHU Nantes, France; Université de Nantes, France
| | - Lucile Figueres
- Université de Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, France; Service de néphrologie-immunologie clinique, CHU de Nantes, France.
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Parathyroidectomy for tertiary hyperparathyroidism after second kidney transplantation: a case report. CEN Case Rep 2020; 10:208-213. [PMID: 33079356 DOI: 10.1007/s13730-020-00545-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/04/2020] [Indexed: 10/23/2022] Open
Abstract
Successful kidney transplantation usually resolves secondary hyperparathyroidism (SHPT). However, some patients fail to normalize, and their condition is often referred to as tertiary hyperparathyroidism (THPT). Surgical consensus on the timing of post-transplant parathyroidectomy (PTX) for THPT has not been reached. Herein, we report a case of a 58-year-old post-transplant woman, considering the concrete timing of PTX for both SHPT and THPT. She initiated hemodialysis with end-stage renal disease at the age of 24, and underwent first kidney transplantation at the age of 28. When peritoneal dialysis (PD) was induced due to the worsening kidney function at the age of 50, the serum intact parathyroid hormone (iPTH) level remarkably increased (2332 pg/mL). Although cinacalcet was administered, the patient's iPTH levels were not sufficiently suppressed for seven years. Diagnostic images including ultrasound, computed tomography, and 99mTc-methoxyisobutylisonitrile scintigraphy indicated THPT as the reason for prolonged post-transplant hypercalcemia. Therefore, PTX was performed 14 months after the second transplantation. Histology showed nodular hyperplasia of all parathyroid glands, indicating autonomous secretion of parathyroid hormone. In general, patients with more severe THPT are recognized with more severe SHPT prior to transplantation during the dialysis period. We should consider a referral for surgery based on the individual risk factors. We recommend to perform parathyroidectomy earlier, before the kidney transplantation in the clinical suspicion of severe SHPT.
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Influence of Parathyroidectomy on Kidney Graft Function in Secondary and Tertiary Hyperparathyroidism. Transplant Proc 2020; 52:3134-3143. [PMID: 32402458 DOI: 10.1016/j.transproceed.2020.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/20/2020] [Accepted: 03/12/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Timing of parathyroidectomy (PTX) remains controversial in candidates for kidney transplant with concomitant renal hyperparathyroidism (HPT). The aim of this retrospective study was to identify the influence of early vs late posttransplant PTX compared to pretransplant PTX on renal graft function and morbidity. METHODS This single-center cohort study includes 57 patients with renal HPT and kidney transplantation treated between 2007 and 2017. Ninety-six patients had surgery for renal HPT between 2007 and 2017 as a consecutive sample. Group 1 (n = 30; tertiary HPT), group 2 (n = 66; secondary HPT). Of group 1, 4 patients were excluded for PTX before and after kidney transplantation. In group 2, 20 patients were excluded since they had not undergone kidney transplantation during follow-up. Twelve patients were excluded because of short follow-up (kidney transplantation in 2018), and 3 patients were excluded because of transplant failure within 90 days. Twenty-six patients underwent posttransplant PTX (10 patients within 12 months after transplant), and 31 patients had undergone PTX prior to kidney transplantation. Graft function, serum calcium concentrations, parathyroid hormone (PTH) levels, postoperative morbidity, and 90-day mortality were recorded. RESULTS Median age was 53.1 years in group 1 and 49.1 years in group 2. Most patients were male (53.8% in group 1; 54.8% in group 2). Median preoperative PTH levels were significantly different with 331.6 pg/mL in group 1 and 667.5 pg/mL in group 2 (P = .003). Creatinine levels changed little from 1.4 mg/dL (range, 0.8-2.5) to 1.7 mg/dL (range, 0.7-7.3) in group 1, and no difference was seen between early or late PTX after transplantation. In group 2, creatinine levels were 8.5 mg/dL (range, 4.6-11.7) before PTX and 8.7 mg/dL (range, 5.1-11.9) after PTX. We saw no correlation between postoperative PTH and kidney function. Thirty-five patients with postoperative PTH < 15 pg/mL displayed a mean postoperative creatinine of 5.5 mg/dL (range, 4.3-6.8), similar to other patients. Both the 30-day and 90-day mortality rates were zero. CONCLUSIONS PTX had no negative effect on graft function, whether performed before or after (early or late) kidney transplantation. Surgical cure of renal HPT should be performed as soon as possible to prevent secondary complications and can also be safely carried out early after transplantation.
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Kirnap NG, Kirnap M, Sayin B, Akdur A, Bascil Tutuncu N, Haberal M. Risk Factors and Treatment Options for Persistent Hyperparathyroidism After Kidney Transplantation. Transplant Proc 2020; 52:157-161. [DOI: 10.1016/j.transproceed.2019.11.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/25/2019] [Accepted: 11/10/2019] [Indexed: 12/24/2022]
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Ermer JP, Kelz RR, Fraker DL, Wachtel H. Intraoperative Parathyroid Hormone Monitoring in Parathyroidectomy for Tertiary Hyperparathyroidism. J Surg Res 2019; 244:77-83. [PMID: 31279997 DOI: 10.1016/j.jss.2019.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/25/2019] [Accepted: 06/06/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Tertiary hyperparathyroidism (THPT) is characterized by hypercalcemia and hyperparathyroidism after renal allograft. Limited data exist regarding the use of intraoperative parathyroid hormone (IOPTH) for THPT. We examined our series of parathyroidectomies performed for THPT to determine clinical outcomes with respect to IOPTH. MATERIALS AND METHODS Patients who underwent parathyroidectomy for THPT (1999-2017) were identified for inclusion. Retrospective chart review was performed. Cure was defined as eucalcemia ≥6 mo after surgery. Statistical analysis was performed. RESULTS Of 41 patients included in the study, 41% (n = 17) were female. The median duration of dialysis before renal allograft was 34 mo (interquartile interval [IQI]:6-60). Preoperatively, the median calcium level was 10.4 mg/dL (IQI:10.0-11.2), median parathyroid hormone was 172 pg/mL (IQI:104-293), and renal function was minimally abnormal with median glomerular filtration rate 58 mL/min/1.73 m2 (IQI:49-71). At surgery, the median final IOPTH was 40 pg/mL (IQI:29-73), and median decrease in IOPTH was 78% (IQI:72-87), with 88% (n = 36) of patients demonstrating >50% decrease. Median calcium level ≥6 mo after surgery was 9.4 mg/dL (IQI:8.8-9.7), and only one patient had recurrent hypercalcemia. Failure to achieve >50% decrease in IOPTH was not significantly associated with recurrent hypercalcemia (P = 1.000). With a median follow-up time of 41 mo (IQI:25-70), only three patients had graft failure. The positive predictive value of IOPTH for cure was 89% (95% confidence interval: 0.752-0.971), with 0% negative predictive value and 87% accuracy (95% confidence interval: 0.726-0.957). CONCLUSIONS Subtotal parathyroidectomy is a successful operation with durable cure of THPT. IOPTH fails to predict long-term cure in THPT despite minimally abnormal renal function.
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Affiliation(s)
- Jae P Ermer
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas L Fraker
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Heather Wachtel
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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Veyrat M, Fessi H, Haymann JP, Ronco P, Lacau St Guily J, Périé S. Conservative three-quarter versus subtotal seven-eighths parathyroidectomy in secondary hyperparathyroidism. Eur Ann Otorhinolaryngol Head Neck Dis 2018; 136:63-68. [PMID: 30327179 DOI: 10.1016/j.anorl.2018.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE There is at present no consensus concerning surgical techniques for secondary hyperparathyroidism (SHPT) in end-stage renal disease (ESRD). Although both subtotal and total parathyroidectomy provide low rates of recurrence, they may induce hypoparathyroidism, damaging the bone and cardiovascular systems. The aim of our study was to compare 3/4 and 7/8 parathyroidectomy in this population and to discuss the potential benefit of more conservative treatment. STUDY DESIGN Prospective observational study in a university teaching hospital between 2010 and 2014. METHODS The study included 34 consecutive ESRD patients with SHPT: 19 underwent 3/4 parathyroidectomy (group A*3/4) and 15 underwent 7/8 parathyroidectomy (group B*7/8). Serum intact 1-84 PTH levels (before and 6 months after surgery) and hospital stay were compared between the two groups. RESULTS Before surgery, PTH levels were similar between the two groups. At month 6 following surgery, median PTH levels were significantly higher in group A*3/4 than in group B*7/8 (109 versus 24pg/mL, respectively; P<0.0006). Hospital stay was shorter in group A*3/4 (4.79 versus 6.80 days, respectively; P=0.008). Postoperative hypoparathyroidism requiring long-term calcium and 1alpha(OH) D3 treatment was reported in 5% of patients in group A*3/4 and 26% of patients in group B*7/8 (P=0.04). CONCLUSIONS In this preliminary study, 3/4 conservative parathyroidectomy seemed effective and safe, with less reported morbidity than 7/8 parathyroidectomy, as assessed by lower rates of irreversible hypoparathyroidism and shorter hospital stay. LEVEL OF EVIDENCE 3b, individual case-control study.
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Affiliation(s)
- M Veyrat
- Department of Otolaryngology Head and Neck Surgery, Tenon Hospital, Faculty of Medicine Sorbonne University, Assistance publique-Hôpitaux de Paris, AP-HP, 4, Rue de la Chine, 75020 Paris, France
| | - H Fessi
- Department of Nephrology-Dialysis, Tenon Hospital, Faculty of Medicine Sorbonne University, Assistance publique-Hôpitaux de Paris, AP-HP, 4, Rue de la Chine, 75020 Paris, France
| | - J-P Haymann
- Department of Functional Renal Explorations, Tenon Hospital, Faculty of Medicine Sorbonne University, Assistance publique-Hôpitaux de Paris, AP-HP, 4, Rue de la Chine, 75020 Paris, France
| | - P Ronco
- Department of Nephrology-Dialysis, Tenon Hospital, Faculty of Medicine Sorbonne University, Assistance publique-Hôpitaux de Paris, AP-HP, 4, Rue de la Chine, 75020 Paris, France
| | - J Lacau St Guily
- Department of Otolaryngology Head and Neck Surgery, Tenon Hospital, Faculty of Medicine Sorbonne University, Assistance publique-Hôpitaux de Paris, AP-HP, 4, Rue de la Chine, 75020 Paris, France
| | - S Périé
- Department of Otolaryngology Head and Neck Surgery, Tenon Hospital, Faculty of Medicine Sorbonne University, Assistance publique-Hôpitaux de Paris, AP-HP, 4, Rue de la Chine, 75020 Paris, France.
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13
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Low THH, Yoo J. Subtotal Parathyroidectomy and Relocation of the Parathyroid Remnant for Renal Hyperparathyroidism: modification of a traditional operation. J Otolaryngol Head Neck Surg 2017; 46:60. [PMID: 29061193 PMCID: PMC5654001 DOI: 10.1186/s40463-017-0238-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/09/2017] [Indexed: 11/22/2022] Open
Abstract
Background We describe a modification of the conventional subtotal parathyroidectomy operation where the parathyroid gland(s) remnant is repositioned with intact vascular supply to a plane superficial to the infrahyoid strap muscles and immediately under the skin incision. This technique called Subtotal Parathyroidectomy and Remnant Relocation (SPARE) retains all the metabolic advantages of the conventional operation with the added advantage of easier identification of a recurrent hyperplastic remnant if re-exploration becomes necessary. Methods In the SPARE technique, four parathyroid glands were identified and the quality of each gland and the length of each vascular pedicle to the parathyroid glands were assessed. The optimal parathyroid gland was relocated to a plane superficial to the strap muscles. The remainder of the glands were removed. Results In total, 30 patients with hyperparathyroidism secondary to renal failure (HSRF) underwent parathyroidectomy with the SPARE technique. The mean age was 53.1±12.5 years and median follow-up was 17.1 months (range 1-78.9 months). There were no recurrent laryngeal nerve (RLN) injuries or hematomas. The pre- and post-operative value for corrected calcium and PTH were 158.4±109.4 pmol/L and 11.4±12.1 pmol/L, respectively (p < 0.05). Three recurrences were noted (10.0%), with a mean time to recurrence of 15.3±6.6 months. One patient had excision of the remnant parathyroid glands performed under local anaesthetic (29 min); one had re-exploration performed under general anaesthetic (81 min), and one was managed medically. Conclusion We described a novel parathyroidectomy technique for patients with HSRF, which provides the advantages of conventional subtotal parathyroidectomy while mitigating the challenges of thyroid bed re-exploration when recurrences arise.
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Affiliation(s)
- Tsu-Hui Hubert Low
- Head and Neck Department, Chris O'Brien Lifehouse, Missenden Road, Camperdown, NSW, Australia
| | - John Yoo
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine& Dentistry, Western University, 800 Commissioners Road East, Suite B3-433A, London, ON, N6A 5W9, Canada.
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Tang JA, Friedman J, Hwang MS, Salapatas AM, Bonzelaar LB, Friedman M. Parathyroidectomy for tertiary hyperparathyroidism: A systematic review. Am J Otolaryngol 2017; 38:630-635. [PMID: 28735762 DOI: 10.1016/j.amjoto.2017.06.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/14/2017] [Accepted: 06/19/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Analyze the efficacy and indications for parathyroidectomy as an intervention for tertiary hyperparathyroidism. DATA SOURCES PubMed, MEDLINE, and Cochrane Library databases. REVIEW METHODS A systematic literature search was performed using the. Original research articles in English were retrieved using the search terms ("tertiary hyperparathyroidism" OR "3HPT") AND "parathyroidectomy". Articles were analyzed in regards to their surgical indications, operative endpoints, comparison between different surgical interventions, characterization of disease recurrence rates, and evaluation of alternative medical management. RESULTS Thirty studies met the criteria for inclusion. Among the studies that report indications for parathyroidectomy, persistent hypercalcemia as well as clinical manifestations of hypercalcemia despite medical therapy predicted which patients would eventually need surgical intervention. The majority of studies comparing the extent of parathyroidectomy recommended a more focused approach to parathyroidectomy when warranted. All studies found that parathyroidectomy was an effective treatment for 3HPT. Three studies discussed alternative conservative approaches. CONCLUSION Interestingly, hyperparathyroidism alone is not an indication for surgery without other findings; rather, symptomatic hypercalcemia appears to be the main indication. Most studies recommend limited or subtotal parathyroidectomy for 3HPT. The operative endpoint of surgery is not necessarily a return of PTH to normal, but a >50% drop in PTH level even if PTH remains above normal. Additionally, "success" or "cure" is defined as normal calcium levels regardless of whether or not PTH is elevated. It appears the goal of surgery for 3HPT is not a normal PTH value, but a normal calcium level at least six months postoperatively.
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Okada M, Futamura K, Hiramitsu T, Tsujita M, Goto N, Narumi S, Watarai Y, Ichimori T, Tominaga Y. Hypercalcemia resistant to cinacalcet caused by a mediastinal hyperplastic parathyroid gland in a renal transplant patient. Eur Surg 2017. [DOI: 10.1007/s10353-017-0484-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Subtotal parathyroidectomy for secondary renal hyperparathyroidism: a 20-year surgical outcome study. Langenbecks Arch Surg 2016; 401:965-974. [PMID: 27233241 PMCID: PMC5086343 DOI: 10.1007/s00423-016-1447-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 05/10/2016] [Indexed: 11/04/2022]
Abstract
Aim The aim of this study was to evaluate the outcomes of surgery for patients with secondary renal hyperparathyroidism (rHPT). Methods This is a retrospective cohort study. Our institutional database was searched for eligible patients treated in 1995–2014. The inclusion criterion was initial parathyroidectomy for rHPT. Clinical and follow-up data were analyzed to estimate the cure rate (primary outcome), and morbidity (secondary outcome). Results The study group comprised 297 patients (154 females, age 44.5 ± 13.7 years, follow-up 24.6 ± 10.5 months), including 268 (90.2 %) patients who had underwent subtotal parathyroidectomy, and 29 (9.8 %) who had had incomplete parathyroidectomy. Intraoperative iPTH assay was utilized in 207 (69.7 %) explorations. Persistent rHPT occurred in 12/268 (4.5 %) patients after subtotal parathyroidectomy and 5/29 (17.2 %) subjects after incomplete parathyroidectomy (p = 0.005). The patients operated on with intraoperative iPTH assay had a higher cure rate than non-monitored individuals, 201/207 (97.1 %) vs. 79/90 (87.8 %), respectively (p = 0.001). In-hospital mortality occurred in 1/297 (0.3 %) patient. The hungry bone syndrome occurred in 84/268 (31.3 %) patients after subtotal parathyroidectomy and 2/29 (6.9 %) subjects after incomplete parathyroidectomy (p = 0.006). Transient recurrent laryngeal nerve paresis occurred in 14/594 (2.4 %) and permanent in 5/594 (0.8 %) nerves at risk. Conclusions Subtotal parathyroidectomy is a safe and efficacious treatment for patients with rHPT. Utilization of intraoperative iPTH assay can guide surgical exploration and improve the cure rate.
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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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McIntyre CJ, Allen JLY, Constantinides VA, Jackson JE, Tolley NS, Palazzo FF. Patterns of disease in patients at a tertiary referral centre requiring reoperative parathyroidectomy. Ann R Coll Surg Engl 2015; 97:598-602. [PMID: 26444799 PMCID: PMC5096614 DOI: 10.1308/rcsann.2015.0039] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2015] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Reoperative parathyroidectomy is required when there is persistent or recurrent hyperparathyroidism following the initial surgery (at least 5% of parathyroidectomies nationally). By convention, 'persistent disease' is defined as the situation where the patient has not been cured by the first operation. The term 'recurrent hyperparathyroidism' is used when the patient was confirmed to be biochemically cured for six months from the first operation but has hyperparathyroidism after this date. Reoperative surgery is associated with higher rates of postoperative complications as well as a greater rate of failure to cure. The aim of our study was to review our departmental experience of reoperative parathyroidectomy, with a view to identify patterns of disease persistence and recurrence. METHODS Using a departmental database, patients were identified who had undergone reoperative parathyroidectomy between 2006 and 2014. All the pre, intra and postoperative information was documented including the operative note so as to record the location of the abnormal parathyroid gland found at reoperation. RESULTS Almost two-thirds (63%) of patients had negative, equivocal or discordant conventional imaging so secondary investigative tools were required frequently. The majority of abnormal glands were found in eutopic locations. The most common locations for ectopic glands were intrathyroidal, mediastinal and intrathymic. A third (33%) of the patients had multigland disease and over a quarter (28%) had coexisting thyroid disease. CONCLUSIONS Persistent hyperparathyroidism represents a challenging patient subgroup for which access to all radiological modalities and intraoperative parathyroid hormone monitoring are required. Patient selection for reintervention is a key determinant in the reoperation cure rate.
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Affiliation(s)
- C J McIntyre
- Hammersmith Hospital, Imperial College Healthcare NHS Trust , UK
| | | | | | - J E Jackson
- Hammersmith Hospital, Imperial College Healthcare NHS Trust , UK
| | - N S Tolley
- Hammersmith Hospital, Imperial College Healthcare NHS Trust , UK
| | - F F Palazzo
- Hammersmith Hospital, Imperial College Healthcare NHS Trust , UK
- Imperial College London , UK
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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: 72] [Impact Index Per Article: 8.0] [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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Magnabosco FF, Tavares MR, Montenegro FLDM. [Surgical treatment of secondary hyperparathyroidism: a systematic review of the literature]. ACTA ACUST UNITED AC 2015; 58:562-71. [PMID: 25166048 DOI: 10.1590/0004-2730000003372] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 05/12/2014] [Indexed: 11/22/2022]
Abstract
Secondary hyperparathyroidism (HPT) has a high prevalence in renal patients. Secondary HPT results from disturbances in mineral homeostasis, particularly calcium, which stimulates the parathyroid glands, increasing the secretion of parathyroid hormone (PTH). Prolonged stimulation can lead to autonomy in parathyroid function. Initial treatment is clinical, but parathyroidectomy (PTx) may be required. PTx can be subtotal or total followed or not followed by parathyroid tissue autograft. We compared the indications and results of these strategies as shown in the literature through a systematic literature review on surgical treatment of secondary HPT presented in MedLine and LILACS from January 2008 to March 2014. The search terms were: hyperparathyroidism; secondary hyperparathyroidism; parathyroidectomy and parathyroid glands, restricted to research only in humans, articles available in electronic media, published in Portuguese, Spanish, English or French. We selected 49 articles. Subtotal and total PTx followed by parathyroid tissue autograft were the most used techniques, without consensus on the most effective surgical procedure, although there was a preference for the latter. The choice depends on surgeon's experience. There was consensus on the need to identify all parathyroid glands and cryopreservation of parathyroid tissue whenever possible to graft if hypoparathyroidism arise. Imaging studies may be useful, especially in recurrences. Alternative treatments of secondary HPT, both interventional and conservative, require further study.
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Affiliation(s)
| | - Marcos Roberto Tavares
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
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21
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Jäger MD, Emmanouilidis N, Jackobs S, Kespohl H, Hett J, Musatkin D, Tränkenschuh W, Schrem H, Klempnauer J, Scheumann GFW. Presence of small parathyroid glands in renal transplant patients supports less-than-total parathyroidectomy to treat hypercalcemic hyperparathyroidism. Surgery 2013; 155:22-32. [PMID: 24621404 DOI: 10.1016/j.surg.2013.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 06/20/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Parathyroid glands (PG) are rarely analyzed in renal transplant (RTX) patients. This study analyzes comparatively PG of RTX and end-stage renal disease (ESRD) patients. The clinical part of the study evaluates if total parathyroidectomy with autotransplantation (TPT+AT) treats appropriately hypercalcemic hyperparathyroidism in RTX patients. METHODS TPT+AT was performed in 15 of 23 RTX and 21 of 27 ESRD patients. Remaining patients underwent less-than-total PT. Volume and stage of hyperplasia were determined from 86 PG of RTX and 109 PG of ESRD patients. Patients were categorized according to the presence of small PG (volume < 100 mm(3)). Calcium homeostasis and hyperparathyroidism were evaluated 2 years after PT in RTX patients. RESULTS PG of RTX patients were significantly smaller, but similar hyperplastic in comparison to PG of ESRD patients. Small PG were more frequent in RTX than in ESRD patients (19% vs 6%) and mainly graded normal or diffuse hyperplastic (94%). Forty-seven percent of RTX, but only 14% of ESRD, patients receiving a total PT possessed ≥1 small PG (P < .05). Overall, PT treated successfully hypercalcemic hyperparathyroidism. However, TPT+AT caused permanent hypocalcemia in 50% of RTX patients without small PG and even in 83% of RTX patients with small PG. All RTX patients receiving less-than-total PT were normocalcemic at 2-year follow-up. Logistic regression revealed a 10.7 times greater risk of permanent hypocalcemia in RTX patients with small PG receiving TPT+AT compared with RTX patients without small PG receiving TPT+AT or RTX patients undergoing less-than-total PT. CONCLUSION Surgeons performing PT should be aware of the high frequency of small and less diseased PG in RTX patients. In this context, TPT+AT might overtreat hypercalcemic hyperparathyroidism in RTX patients, especially when small PG are present.
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Affiliation(s)
- Mark D Jäger
- Klinik für Allgemein-, Viszeral- and Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany.
| | - Nikos Emmanouilidis
- Klinik für Allgemein-, Viszeral- and Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Steffan Jackobs
- Klinik für Allgemein-, Viszeral- and Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Holger Kespohl
- Klinik für Allgemein-, Viszeral- and Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Julian Hett
- Klinik für Allgemein-, Viszeral- and Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Denis Musatkin
- Klinik für Allgemein-, Viszeral- and Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | | | - Harald Schrem
- Klinik für Allgemein-, Viszeral- and Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Jürgen Klempnauer
- Klinik für Allgemein-, Viszeral- and Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Georg F W Scheumann
- Klinik für Allgemein-, Viszeral- and Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany
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Kuo E, Kemp EH, Sandhu HK, Brown EM, Weetman AP, Huang CL. Acquired hypocalciuric hypercalcemia in a patient with CKD. Am J Kidney Dis 2013; 62:1151-4. [PMID: 23810542 DOI: 10.1053/j.ajkd.2013.04.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 04/16/2013] [Indexed: 12/30/2022]
Abstract
We present a case of an 82-year-old woman with elevated parathyroid hormone (PTH) levels, hypocalciuria, hypercalcemia, and stage 3 chronic kidney disease. Hypocalciuria initially was attributed to chronic kidney disease, and hypercalcemia was attributed to primary hyperparathyroidism. Subsequent laboratory studies showed autoantibodies in the patient's serum directed against the calcium-sensing receptor (CaSR). Functional testing in a CaSR-transfected human embryonic kidney-293 cell line showed that the patient's antibodies inhibited CaSR-mediated intracellular signaling that ordinarily would have been stimulated by extracellular calcium ions. Her serum calcium and PTH levels were normalized by treatment with the calcimimetic cinacalcet. We advise consideration of the presence of inhibitory autoantibodies directed at the CaSR in patients with hypercalcemic hyperparathyroidism and unexplained hypocalciuria or with confounding conditions affecting interpretation of urinary calcium measurement. A calcimimetic is an effective treatment for the hypercalcemia and elevated PTH levels in acquired hypocalciuric hypercalcemia caused by inhibitory anti-CaSR autoantibodies.
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Affiliation(s)
- Elizabeth Kuo
- Department of Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX.
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Tertiary hyperparathyroidism: choosing an appropriate treatment--an enigma. Transplantation 2012; 94:e64; author reply e64-5. [PMID: 23222739 DOI: 10.1097/tp.0b013e31826cc9c3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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