Renal failure after surgery for primary hyperparathyroidism: is acute reduction of parathyroid function a risk factor?

Acute and long-term kidney function after parathyroidectomy for primary hyperparathyroidism

Background

In kidney transplant patients, parathyroidectomy is associated with an acute decrease in renal function. Acute and chronic effects of parathyroidectomy on renal function have not been extensively studied in primary hyperparathyroidism (PHPT).

Methods

This retrospective cohort study included 494 patients undergoing parathyroidectomy for PHPT. Acute renal changes were evaluated daily until day 4 post-parathyroidectomy and were stratified according to acute kidney injury (AKI) criteria. Biochemical assessment included serum creatinine, total and ionized calcium, parathyroid hormone (PTH), and 25-hydroxyvitamin D (25OHD). The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation. We compared preoperative and postoperative renal function up to 5 years of follow-up.

Results

A total of 391 (79.1%) patients were female, and 422 (85.4%) were non-African American. The median age was 58 years old. The median (first and third quartiles) preoperative serum creatinine, PTH and total calcium levels were 0.81 mg/dL (0.68–1.01), 154.5 pg/mL (106–238.5), and 10.9 mg/dL (10.3–11.5), respectively. The median (first and third quartiles) preoperative eGFR was 86 mL/min/1.73 m² (65–101.3). After surgery, the median acute decrease in the eGFR was 21 mL/min/1.73 m² (p<0.0001). Acutely, 41.1% of patients developed stage 1 AKI, 5.9% developed stage 2 AKI, and 1.8% developed stage 3 AKI. The acute eGFR decrease (%) was correlated with age and PTH, calcium and preoperative creatinine levels in univariate analysis. Multivariate analysis showed that the acute change was related to age and preoperative values of ionized calcium, phosphorus and creatinine. The change at 12 months was related to sex, preoperative creatinine and 25OHD. Permanent reduction in the eGFR occurred in 60.7% of patients after an acute episode.

Conclusion

There was significant acute impairment in renal function after parathyroidectomy for PHPT, and almost half of the patients met the criteria for AKI. Significant eGFR recovery was observed during the first month after surgery, but a small permanent reduction may occur. Patients treated for PHPT seemed to present with prominent renal dysfunction compared to patients who underwent thyroidectomy.

Does the Parathyroidectomy Endanger the Transplanted Kidney?

BACKGROUND

Some investigators maintain that a parathyroidectomy (PTX) performed for tertiary hyperparathyroidism may potentially cause graft malfunction or even loss of the transplanted kidney after the operation. The goal of this study was to determine if parathyroidectomy affects transplanted kidney function.

METHODS

The study group consisted of 48 renal graft recipients who underwent operation due to tertiary hyperparathyroidism. Thirty-nine subtotal parathyroidectomies and 9 more selective, less than subtotal parathyroidectomies were performed. The estimated glomerular filtration rate (eGFR) was calculated retrospectively on days 2 to 3 and 4 to 5 and at 1, 3, 6, 12, 24, and 36 months after PTX; these findings were compared with preoperative values. The cumulative graft survival rate in the postoperative period was assessed.

RESULTS

In the follow-up period, 4 of 48 patients returned to hemodialysis (after 1, 7, 22, and 57 months after PTX). In the first case, the patient had stopped taking the immunosuppressive drugs 1 month after PTX. Cumulative graft survival rate after PTX was 98.0% after 6 months, 96% after 12 months, and 93% after 2 and 3 years. The mean preoperative eGFR was 52 ± 17.15 mL/min/1.73 m(2), and the median was 48.28 mL/min/1.73 m(2). Overall and in the subtotal parathyroidectomy group, eGFR was significantly lower (P < .001) only on days 2 to 3. There were no differences between preoperative and postoperative eGFR values in the other follow-up periods. In the more selective, less than subtotal parathyroidectomy group, the decrease in eGFR values was nonsignificant compared with preoperative findings in the early postoperative period as well as in all follow-up periods.

CONCLUSIONS

In this study, PTX did not significantly impair transplanted kidney function, but in the early postoperative period, transient reductions in graft function did occur.

Bilateral femoral fractures in a 21-year-old man following a simple fall

We present a case of a 21-year-old man with hip pain to the orthopaedic team. During the initial assessment he was found to be hypercalcaemic (adjusted calcium 3.55) due to the primary hyperparathoidism (PTH 1285), with all other screening for multiple endocrine neoplasia negative. During his time on the ward while being treated for the hypercalcaemia he had a fall resulting in bilateral femoral fractures, requiring surgical management. He underwent an emergency exploration of neck and excision of a large parathyroid adenoma, measuring 5.5 cm. He also developed renal failure as a result of nephrocalcinosis. This case highlights the importance of early detection and management of hyperparathyroidism with the aim of preventing long-term complications. This patient ultimately required a renal transplant and multiple orthopaedic procedures as a result of undiagnosed PTH and recently underwent excision of the remaining parathyroid glands.

Transitory increase in creatinine levels after parathyroidectomy: evidence of another action of the parathyroid glands?

OBJECTIVE

Little information is available on glomerular function changes after surgical treatment of primary hyperparathyroidism. The acute effects of some head and neck operations on renal function were studied.

MATERIAL AND METHODS

Retrospective analysis of changes in creatinine levels and estimated glomerular filtration rate (eGFR) after surgery. Preoperative values were compared with values available until 72 hours after the operation.

RESULTS

In tertiary hyperparathyroidism, mean preoperative and postoperative eGFR values were 57.7 mL/min and 40.8 mL/min (p < 0.0001), respectively. A similar decrease was observed after parathyroidectomy for primary hyperparathyroidism, from 85.4 mL/min to 64.3 mL/min (p < 0.0001). After major head and neck procedures, there was a slight increase in eGFR (from 94.3 mL/min to 105.4 mL/min, p = 0.002).

CONCLUSION

Parathyroidectomy may be followed by a transient decrease in eGFR that is not often observed in other head and neck operations.

Parathyroidectomy after kidney transplantation: short-and long-term impact on renal function

INTRODUCTION

Kidney transplantation corrects endocrine imbalances. Nevertheless, these early favorable events are not always followed by rapid normalization of parathyroid hormone secretion. A possible deleterious effect of parathyroidectomy on kidney transplant function has been reported. This study aimed to compare acute and longterm renal changes after total parathyroidectomy with those occurring after general surgery.

MATERIALS AND METHODS

This was a retrospective case-controlled study. Nineteen patients with persistent hyperparathyroidism underwent parathyroidectomy due to hypercalcemia. The control group included 19 patients undergoing various general and urological operations.

RESULTS

In the parathyroidectomy group, a significant increase in serum creatinine from 1.58 to 2.29 mg/dl (P < 0.05) was noted within the first 5 days after parathyroidectomy. In the control group, a statistically insignificant increase in serum creatinine from 1.49 to 1.65 mg/dl occurred over the same time period. The long-term mean serum creatinine level was not statistically different from baseline either in the parathyroidectomy group (final follow-up creatinine = 1.91 mg/dL) or in the non-parathyroidectomy group (final follow-up creatinine = 1.72 mg/dL).

CONCLUSION

Although renal function deteriorates in the acute period following parathyroidectomy, long-term stabilization occurs, with renal function similar to both preoperative function and to a control group of kidney-transplanted patients who underwent other general surgical operations by the final follow up.

Pulse wave velocity in primary hyperparathyroidism and effect of surgical therapy

The study was aimed at investigating the arterial stiffness assessed by aortic pulse wave velocity (PWV) in the presence of primary hyperparathyroidism (PH), with and without concomitant hypertension. Subsequently, we examined the effect of parathyroidectomy (PTX) on arterial stiffness. A total of 28 patients with PH and concomitant hypertension, and 16 with PH without hypertension were investigated in comparison with 28 essential hypertensive patients and 18 healthy controls, respectively. Patients were matched for age, blood pressure (BP), body mass index, lipid profile and fasting glucose. Six months after PTX, 15 patients were examined again (hypertensive as well as normotensive). PWV was obtained using the SphygmoCor applanation tonometer (AtCor Medical, West Ryde, Australia). PWV was significantly higher in patients with PH and hypertension when compared with patients with essential hypertension (10.1 vs. 8.5 ms(-1), P=0.013). PWV remained significant even after adjustment for age and BP (P=0.02). Similarly, PWV was significantly higher in PH patients without hypertension in comparison with healthy controls (7.6 vs. 5.8 ms(-1), P<0.001). Six months after surgery, in addition to a normalization of calcium metabolism, a significant decrease in systolic BP (131 vs. 123 mmHg, P=0.004) and PWV (9.1 vs. 8.5 ms(-1), P=0.024) was observed. After adjusting for BP reduction, the decrease in PWV appeared non-significant. Our data indicate that PH increases PWV as a marker of arterial stiffness, in both hypertensive and non-hypertensive patients. However, neither the calcium serum level nor the parathyroid hormone level has been associated with PWV. Specific treatment by PTX significantly decreases PWV, which may be determined primarily by improved BP control after surgery.