Subtotal parathyroidectomy with thymectomy for autonomous hyperparathyroidism after renal transplantation (original) (raw)
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The American Journal of the Medical Sciences, 2010
Tertiary hyperparathyroidism (tHPT) usually regresses after renal transplantation. Persistent tHPT after successful renal transplantation may require parathyroidectomy (PTX). PTX has been reported to be associated with deterioration of renal function and graft survival. We retrospectively analyzed 794 kidney transplants performed at our center with at least 3 years of follow-up to examine the effect of PTX on the renal function and graft survival. Forty-nine of the 794 renal transplant recipients were diagnosed with hyperparathyroidism (HPT) before transplant. Nineteen of 49 patients had persistent tHPT and underwent PTX after kidney transplants. Patients with HPT and non-HPT had similar 3year graft survival (88% versus 84%, P = 0.51). PTX was associated with a decreased glomerular filtration rate at 3 years (44.7 ± 20.0 versus 57.7 ± 23.7 mL/min, P = 0.04); however, there was no statistical difference in the 3-year graft survival (71% versus 88%, P = 0.06). PTX in renal transplant recipients seems to be a safe and effective therapy for persistent tHPT. PTX may be associated with worsening glomerular filtration rate, but it may not be associated with significantly decreased longterm graft survival.
Balkan Medical Journal, 2014
Secondary hyperparathyroidism (sHPT) 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 (1). Parathyroidectomy (PTX) is required in about 20% of patients after 3-10 years of dialysis and in up to 40% after 20 years (2, 3). When medical treatment fails, subtotal parathyroidectomy (subtotal PTX) with a cervical remnant and total parathyroidectomy with autotransplantation (total PTX+AT) are the standard procedures, although both are associated with high recurrence rates (4-7). A considerable quantity of functioning parathyroid tissue is left after each of these operations in order to prevent possible hypoparathyroidism and the need for long-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 parathyroid-ectomy 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.
American journal of surgery, 2009
Persistent secondary hyperparathyroidism not responding to medication is treated successfully with surgical excision of parathyroid glands (total parathyroidectomy [PTX]). PTX without autotransplantation of parathyroid glands excludes the risk for recurrence of hyperparathyroidism. During the years 2002 to 2005, 36 total parathyroidectomies were performed in 33 patients: 21 dialysis patients because of end-stage renal disease and 12 renal transplant recipients. PTX without autotransplantation was performed successfully in 33 patients, whereas 3 patients were reoperated for remaining parathyroid glands. Immediate improvement of clinical symptoms and a decrease of serum calcium and parathormone levels were observed after surgical procedures. Oral replacement treatment with vitamin D (1a-calcidiol) and calcium was commenced and long-term follow-up evaluation (23.5 +/- 7.6 mo) showed that calcium homeostasis was controlled adequately. PTX without autotransplantation is a safe and effect...
Persistent Hyperparathyroidism Requiring Surgical Treatment after Kidney Transplantation
World Journal of Surgery, 2000
There are not many publications describing long-term follow-up of persistent hyperparathyroidism requiring surgical treatment after kidney transplantation (PHSKT). In some patients adenomas, rather than multiglandular disease, have been incriminated as the cause of PHSKT. We reviewed the charts of 45 patients followed for 12 to 146 months (median 45 months) after parathyroidectomy for PHSKT. We compared them with (1) those of 951 patients receiving a kidney graft during the same period but not submitted to parathyroidectomy or (2) 90 matched controls selected from this cohort to determine the characteristics of PHSKT patients. The duration of pretransplant dialysis was significantly longer in PHSKT patients than in controls (5.78 ؎ 0.41 vs. 3.41 ؎ 0.24 years; p < 0.0001). A total of 166 glands were removed or biopsied. Except for one questionable case, no true adenoma was observed even when only one gland was enlarged. The outcome of surgery was not influenced by the technique (subtotal parathyroidectomy versus total parathyroidectomy and autografting) but depended on the amount of resected parathyroid tissue: no failures and 4 cases of hypoparathyroidism in 34 cases with no missing gland at cervical exploration; 3 failures and no permanent hypoparathyroidism in 11 cases with one or two missing glands. Excision of the enlarged glands only was sufficient to cure the patient. No recurrence was observed. Our results suggest that single gland enlargement in PHSKT results in most cases from different rates of involution of the parathyroids after successful kidney transplantation. When fewer than four glands are discovered, resection of all visible glands with or without grafting corrects hypercalcemia in more than 70% of the cases.
Secondary Hyperparathyroidism After Kidney Transplantation: A Cross-Sectional Study
Transplantation Proceedings, 2009
Introduction. The purpose of the present study was to investigate the prevalence of hyperparathyroidism among a population of kidney graft recipients. Patients and Methods. We investigated biochemical bone parameters of 509 renal transplant recipients with a mean follow-up of 113 Ϯ 76 months. Among these patients, 257 patients were treated with either vitamin D or calcium supplements or both. Results. The mean estimated glomerular filtration rate (eGFR) was 47.2 Ϯ 18.4 mL/min/1.73 m 2 and the mean intact parathyroid hormone (iPTH) level was 144 Ϯ 149 pg/mL. A total of 70 patients (13.7%) had hypercalcemia defined by a corrected serum calcium Ͼ10.2 mg/dL. When the patients were classified according to iPTH concentrations following the Kidney Disease Outcome Quality Initiative (K/DOQI) clinical practice guidelines: 22.4% had iPTH Ͻ70 pg/mL; 30.8% between 70 and 110 pg/mL; 16.5% between 110 and 150 pg/mL; 24.3% between 150 and 300 pg/mL; and 6.9% Ͼ300 pg/mL. There were no differences in biochemical bone parameters between those that were or were not on calcium and vitamin D supplements, but there was a higher percentage of patients with normal iPTH among the treated group (28.0% vs 16.7%; P ϭ 0.003). In patients not receiving calcium and/or vitamin D supplements, multiple linear regression demonstrated that only time on dialysis, eGFR, and serum 25-hydroxyvitamin D (25OHD) levels were significantly predictive of iPTH concentrations (R 2 ϭ 0.21; P ϭ .000). Conclusions. About 80% of patients displayed high iPTH concentrations. The persistence of hyperparathyroidism was associated with graft dysfunction, longer time on dialysis, and low concentrations of 25OHD. Treatment with vitamin D produced a slight improvement in the prevalence of hyperparathyroidism.
Near Total Parathyroidectomy is Effective Therapy for Tertiary Hyperparathyroidism
The American Surgeon, 2014
Tertiary hyperparathyroidism (3°HPT) is defined as persistent hyperparathyroidism with hypercalcemia after renal transplantation. Near total parathyroidectomy (NTPTX) is the current standard for surgical intervention. The purpose of this study was to identify outcomes of NTPTX. A retrospective review was conducted of surgeries performed between 1994 and 2013. NTPTX resulted in resolution of 96.9 per cent of patients’ hypercalcemia at a median follow-up of three years (interquartile range [IQR], 1 to 8). However, 3.1 per cent of patients remained hypercalcemic with a mean calcium of 10.5 ± 0.2 mg/dL. A total of 78.4 per cent of patients had parathyroid hormone (PTH) levels below 250 pg/mL at a median follow-up of two years (IQR, 2 to 8). The remaining 21.6 per cent had a median PTH of 535 (IQR, 345 to 857). PTH levels dropped from a median of 745 (IQR, 285.75 to 1594.25) pg/mL to 97 (IQR, 60 to 285) pg/mL one month post-NTPTX ( P < 0.01). The most frequent complication was transie...
Nephron, 2017
In dialysis and renal transplant patients with secondary and tertiary hyperparathyroidism (HPT), the value of intraoperative parathyroid hormone (ioPTH) during parathyroidectomy (PTX) and its association with long-term PTH levels are unknown. The present study aims at evaluating the relationship of ioPTH with long-term PTH levels post-PTX in dialysis and renal transplant patients in a single-center study. The ioPTH was measured in 57 dialysis patients (33 females and 24 males) and 18 renal transplant recipients (12 males and 6 females) who underwent PTX from 2005 to 2015 for refractory HPT. Near-total PTX was performed in 56 patients and total PTX with autotransplantation in 20 patients. The PTH monitoring included 3 samples: pre-intubation, 10- and 20-min (pre-ioPTH, 10-ioPTH, and 20-ioPTH) post parathyroid gland excision. Patients were followed up for up to 5 years. In the dialysis group, the median (25th-75th percentile) pre-, 10-, and 20-ioPTH levels were 1,447 pg/mL (938-2,176)...
Post-transplantation tertiary hyperparathyroidism
Annals of transplantation: quarterly of the Polish Transplantation Society
Tertiary hyperparathyroidism is intended as a state of excessive autonomous excretion of parathyroid hormone after longstanding secondary hyperparathyroidism. It is a condition of a severe hyperparathyroidism that persists in the renal recipient despite a successful transplantation. The high levels of parathyroid hormone lead to a worsening of graft function accompanied by systemic symptoms. This article reviews the main aspects related to tertiary hyperparathyroidism from mechanism of pathogenesis to prevention and treatment, suggesting some indications about the best management of patients on a waiting list for kidney transplant.
Langenbeck's Archives of Surgery, 2006
Background and aims Intra-operative parathyroid hormone (IOPTH) results are not known in the setting of tertiary hyperparathyroidism (HPT) after renal transplantation. Materials and methods A retrospective analysis of 35 tertiary HPT patients who all underwent subtotal parathyroidectomy and IOPTH monitoring was conducted. Results The mean follow-up time was 2.2±1.4 years. Thirty-four patients were cured; one patient (2.8%) had a persistent disease and was cured after reoperation. Median parathyroid hormone (PTH) (median percent decrease from highest) at baseline and at 5, 10, 20, and 30 min were 244, 78 (69%), 63 (75%), 53 (79%), and 49 pg/ml (83%), respectively. Four patients who were cured had a decrease of <50% at 5 min and two of them had a decrease of <50% at 10 min. The patient with persistent disease had a decrease of >50% at 10 min. The sensitivity of the test was 94% at 10 min using the Miami criteria. Conclusion This study shows that IOPTH in tertiary hyperparathyroidism has a high sensitivity. However, because of the low risk of persistent hyperparathyroidism when a subtotal parathyroidectomy is performed, its potential impact on the overall success rate is very small. We therefore do not recommend the routine use of IOPTH in tertiary hyperparathyroidism.