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Seib CD, Ganesan C, Furst A, Pao AC, Chertow GM, Leppert JT, Suh I, Montez-Rath ME, Harris AHS, Trickey AW, Kebebew E, Kurella Tamura M. Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism. Ann Intern Med 2023; 176:624-631. [PMID: 37037034 PMCID: PMC10866201 DOI: 10.7326/m22-2222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Multidisciplinary guidelines recommend parathyroidectomy to slow the progression of chronic kidney disease in patients with primary hyperparathyroidism (PHPT) and an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2. Limited data address the effect of parathyroidectomy on long-term kidney function. OBJECTIVE To compare the incidence of a sustained decline in eGFR of at least 50% among patients with PHPT treated with parathyroidectomy versus nonoperative management. DESIGN Target trial emulation was done using observational data from adults with PHPT, using an extended Cox model with time-varying inverse probability weighting. SETTING Veterans Health Administration. PATIENTS Patients with a new biochemical diagnosis of PHPT in 2000 to 2019. MEASUREMENTS Sustained decline of at least 50% from pretreatment eGFR. RESULTS Among 43 697 patients with PHPT (mean age, 66.8 years), 2928 (6.7%) had a decline of at least 50% in eGFR over a median follow-up of 4.9 years. The weighted cumulative incidence of eGFR decline was 5.1% at 5 years and 10.8% at 10 years in patients managed with parathyroidectomy, compared with 5.1% and 12.0%, respectively, in those managed nonoperatively. The adjusted hazard of eGFR decline did not differ between parathyroidectomy and nonoperative management (hazard ratio [HR], 0.98 [95% CI, 0.82 to 1.16]). Subgroup analyses found no heterogeneity of treatment effect based on pretreatment kidney function. Parathyroidectomy was associated with a reduced hazard of the primary outcome among patients younger than 60 years (HR, 0.75 [CI, 0.59 to 0.93]) that was not evident among those aged 60 years or older (HR, 1.08 [CI, 0.87 to 1.34]). LIMITATION Analyses were done in a predominantly male cohort using observational data. CONCLUSION Parathyroidectomy had no effect on long-term kidney function in older adults with PHPT. Potential benefits related to kidney function should not be the primary consideration for PHPT treatment decisions. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine; Division of General Surgery, Palo Alto Veterans Affairs Health Care System; and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (C.D.S.)
| | - Calyani Ganesan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (C.G., M.E.M.)
| | - Adam Furst
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California (A.F., A.W.T.)
| | - Alan C Pao
- Division of Nephrology, Department of Medicine, and Department of Urology, Stanford University School of Medicine, Palo Alto, California (A.C.P., J.T.L.)
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, and Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, California (G.M.C.)
| | - John T Leppert
- Division of Nephrology, Department of Medicine, and Department of Urology, Stanford University School of Medicine, Palo Alto, California (A.C.P., J.T.L.)
| | - Insoo Suh
- Department of Surgery, New York University Grossman School of Medicine, New York, New York (I.S.)
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (C.G., M.E.M.)
| | - Alex H S Harris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, and Center for Innovation to Implementation, Veterans Affairs Palo Alto, Palo Alto, California (A.H.S.H.)
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California (A.F., A.W.T.)
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California (E.K.)
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (M.K.T.)
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Gosavi V, Lila A, Memon SS, Sarathi V, Goroshi M, Jamale T, Thakare S, Phadte A, Patil V, Bandgar T. Spectrum of renal dysfunction after curative parathyroidectomy in symptomatic primary hyperparathyroidism. ANNALES D'ENDOCRINOLOGIE 2023; 84:14-20. [PMID: 36563936 DOI: 10.1016/j.ando.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/22/2022] [Accepted: 10/30/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The long-term renal consequences of curative parathyroidectomy (PTX) in symptomatic primary hyperparathyroidism (sPHPT) are not well characterized. We aimed to assess renal glomerular and tubular functions in an sPHPT cohort at ≥1 year's follow-up. DESIGN Retrospective-prospective study. METHODS sPHPT patients with preoperative eGFR ≥60mL/min/1.73m2 and in remission (normocalcemic) for ≥1 year after PTX underwent clinical and biochemical assessment (calcium profile, renal parameters). Ammonium chloride and bicarbonate loading tests were performed in patients with renal tubular dysfunction (RTD). RESULTS Forty-eight patients (31 females) with median plasma PTH 1,029 (338-1604) pg/mL and mean eGFR 109.2±26.0mL/min/1.73m2 at diagnosis were evaluated at 5.62±3.66 years after curative PTX. At follow-up, eGFR was <60mL/min/m2 in 5 patients (10.4%). Patients with >10% drop in eGFR (n=31) had significantly higher pre-PTX plasma PTH (1,137 vs. 687pg/mL), and longer time to post-PTX evaluation (6.8 vs. 3.4 years). RTD was seen in 11 patients (22.9%): urinary low molecular weight proteinuria (14.6%), distal renal tubular acidosis (12.5%), hypophosphatemia (8.3%), and hypokalemia (8.3%); RTD was associated with significantly lower post-PTX eGFR (72.7 vs. 95.4mL/min/m2). Five of the 7 RTD patients undergoing loading test had impaired urinary acidification, whereas none had impaired bicarbonate resorption. CONCLUSIONS Reduction in eGFR and subclinical RTD were prevalent at long-term follow-up in the present Asian-Indian cohort with cured sPHPT. Further studies are warranted to understand the clinical implications of these various renal abnormalities.
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Affiliation(s)
- Vikrant Gosavi
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, 103, 1st floor, OPD building, KEM Hospital Campus, Parel, Mumbai, Maharashtra 400012, India
| | - Anurag Lila
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, 103, 1st floor, OPD building, KEM Hospital Campus, Parel, Mumbai, Maharashtra 400012, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, 103, 1st floor, OPD building, KEM Hospital Campus, Parel, Mumbai, Maharashtra 400012, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
| | | | - Tukaram Jamale
- Department of Nephrology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Sayali Thakare
- Department of Nephrology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Aditya Phadte
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, 103, 1st floor, OPD building, KEM Hospital Campus, Parel, Mumbai, Maharashtra 400012, India
| | - Virendra Patil
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, 103, 1st floor, OPD building, KEM Hospital Campus, Parel, Mumbai, Maharashtra 400012, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, 103, 1st floor, OPD building, KEM Hospital Campus, Parel, Mumbai, Maharashtra 400012, India.
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Frey S, Wargny M, Blanchard C, Caillard C, Hadjadj S, Cariou B, Figueres L, Mirallié E. Effects of parathyroidectomy on kidney function in patients with primary hyperparathyroidism: Results of a prospective study. Surgery 2023; 173:146-153. [PMID: 36167701 DOI: 10.1016/j.surg.2022.05.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Altered glomerular filtration rate is a controversial indication for parathyroidectomy in patients with primary hyperparathyroidism. The objective of this study was to evaluate the estimated glomerular filtration rate change 12 months after parathyroidectomy for primary hyperparathyroidism according to preoperative kidney function. METHOD Patients who underwent parathyroidectomy for primary hyperparathyroidism between 2016 and 2021 (n = 381) were enrolled in a monocentric prospective cohort. Patients without 1-year follow-up or with missing data were excluded (n = 135, 35%). Patients were dichotomized according to their baseline estimated glomerular filtration rate: <60 mL/min (group 1) and ≥60 mL/min (group 2). Parameters were measured before and then at 6 and 12 months after parathyroidectomy. RESULTS Out of 246 included patients, 27 (11%) were assigned to group 1 and 219 (89%) to group 2. The mean baseline estimated glomerular filtration rate was 46.8 ± 11.5 and 87.3 ± 14.7 mL/min in groups 1 and 2, respectively. Group 1 patients were older (P = .0006) and had a higher median serum parathyroid hormone level (P = .021). At 6 months postoperative, 224 patients (91%) were normocalcemic. The estimated glomerular filtration rate raw change after parathyroidectomy was significantly higher in group 1 than in group 2 (4.2 ± 7.8 vs -2.2 ± 9.1 mL/min, P = .0004). In group 1, 13/27 patients (48%) improved their chronic kidney disease stage after parathyroidectomy, including 6/13 (46%) with postoperative estimated glomerular filtration rate ≥60 mL/min, whereas 2/27 (7%) worsened. The baseline estimated glomerular filtration rate <60 mL/min and elevated serum calcium level were associated with postoperative estimated glomerular filtration rate improvement in multivariable analysis (P = .0023 and .039, respectively). CONCLUSION Parathyroidectomy for primary hyperparathyroidism is more likely to improve kidney function in patients with preoperative estimated glomerular filtration rate <60 mL/min. These results strengthen the current guidelines for surgery.
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Affiliation(s)
- Samuel Frey
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France; Université de Nantes, France; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France. https://twitter.com/samuelfrey13
| | - Matthieu Wargny
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France; CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11: Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des Données, France
| | - Claire Blanchard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France; Université de Nantes, France; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Cécile Caillard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France
| | - Samy Hadjadj
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Bertrand Cariou
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Lucile Figueres
- Université de Nantes, France; Service de Néphrologie-Immunologie Clinique, CHU de Nantes, France
| | - Eric Mirallié
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France; Université de Nantes, France.
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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: 25] [Impact Index Per Article: 12.5] [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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Agrawal K, Arya AK, Sood A, Kumari P, Singh P, Sapara M, Rastogi A, Behera A, Bhadada SK. A detailed appraisal of renal manifestations in primary hyperparathyroidism from Indian PHPT registry: Before and after curative parathyroidectomy. Clin Endocrinol (Oxf) 2021; 94:371-376. [PMID: 32789888 DOI: 10.1111/cen.14311] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) is a systemic disorder characterized by hypercalcaemia and inappropriately elevated parathyroid hormone (PTH). Renal manifestations are one of the main presenting features both in symptomatic and asymptomatic PHPT patients. OBJECTIVES We aimed to compare demographic, clinical and biochemical parameters of PHPT patients with and without renal manifestations and also analysed the influence of curative parathyroidectomy on renal functions. METHODS We retrospectively analysed the data of PHPT patients from the last 25 years (1995- March 2019) and compared the demographic and clinical presentation and biochemical measurements between patients with and without renal manifestations and evaluated the changes in renal functions after 1 year of curative parathyroidectomy. RESULTS Of the total 544 PHPT patients, 299 (55%) including 91 out of 141 (65%) males had renal manifestations. Among renal manifestations, nephrolithiasis and nephrocalcinosis were found in 41.7% and 27.6% PHPT patients, respectively. PHPT patients with renal manifestations had significantly higher creatinine (109.7 vs 79.6 µmol/L; P < .0001) and lower eGFR level (78.8 vs 93.9 mL/min/1.73 m2 ; P < .0001) compared to patients without renal manifestations. Parathyroidectomy resolved the clinical symptoms with biochemical cure in the patients from both the groups. Patients with renal manifestations showed improvement in creatinine and eGFR levels after 1 year of curative parathyroidectomy; however, patients without renal manifestations showed no change in creatinine and eGFR levels. CONCLUSION Young age and male gender are predictors of renal manifestations in PHPT. Curative parathyroidectomy improves renal functions in PHPT patients with renal manifestations compared to PHPT patients without renal manifestation.
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Affiliation(s)
- Kanhaiya Agrawal
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Ashutosh Kumar Arya
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Ashwani Sood
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Poonam Kumari
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Priyanka Singh
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Mohin Sapara
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Ashu Rastogi
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Arunanshu Behera
- Department of General Surgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Sanjay Kumar Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
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Belli M, Martin RM, Brescia MDG, Nascimento CP, Massoni Neto LM, Arap SS, Ferraz-de-Souza B, Moyses RMA, Peacock M, Montenegro FLDM. Acute and long-term kidney function after parathyroidectomy for primary hyperparathyroidism. PLoS One 2020; 15:e0244162. [PMID: 33382714 PMCID: PMC7774859 DOI: 10.1371/journal.pone.0244162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 12/03/2020] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Marcelo Belli
- Division of Head and Neck Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
- * E-mail:
| | - Regina Matsunaga Martin
- Divison of Endocrinology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | | | - Climério Pereira Nascimento
- Division of Head and Neck Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Ledo Mazzei Massoni Neto
- Division of Head and Neck Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Sergio Samir Arap
- Division of Head and Neck Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Bruno Ferraz-de-Souza
- Divison of Nephrology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Rosa Maria Affonso Moyses
- Divison of Nephrology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Munro Peacock
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Fábio Luiz de Menezes Montenegro
- Division of Head and Neck Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
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Gawrychowski J, Kowalski GJ, Buła G, Bednarczyk A, Żądło D, Niedzielski Z, Gawrychowska A, Koziołek H. Surgical Management of Primary Hyperparathyroidism-Clinicopathologic Study of 1019 Cases from a Single Institution. J Clin Med 2020; 9:jcm9113540. [PMID: 33147842 PMCID: PMC7693783 DOI: 10.3390/jcm9113540] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Primary hyperparathyroidism (pHPT) is an endocrine disorder characterized by hypercalcemia and caused by the presence of disordered parathyroid glands. Parathyroidectomy is the only curative therapy for pHPT, but despite its high cure rate of 95-98%, there are still cases where hypercalcemia persists after this surgical procedure. The aim of this study was to present the results of a surgical treatment of patients due to primary hyperparathyroidism and failures related to the thoracic location of the affected glands. METHODS We present a retrospective analysis of 1019 patients who underwent parathyroidectomy in our department in the period 1983-2018. RESULTS Among the group of 1019 operated-on patients, treatment failed in 19 cases (1.9%). In 16 (84.2%) of them, the repeated operation was successful. In total, 1016 patients returned to normocalcemia. CONCLUSIONS Our results confirm that parathyreoidectomy is the treatment of choice for patients with primary hyperparathyroidism. The ectopic position of the parathyroid gland in the mediastinum is associated with an increased risk of surgical failure. Most parathyroid lesions in the mediastinum can be safely removed from the cervical access.
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Miyaoka D, Imanishi Y, Kato E, Toi N, Nagata Y, Kurajoh M, Yamada S, Inaba M, Emoto M. Effects of denosumab as compared with parathyroidectomy regarding calcium, renal, and bone involvement in osteoporotic patients with primary hyperparathyroidism. Endocrine 2020; 69:642-649. [PMID: 32621048 DOI: 10.1007/s12020-020-02401-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/24/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE To evaluate the effects of denosumab (Dmb) on calcium, renal, and bone involvement in osteoporotic patients with primary hyperparathyroidism (PHPT) and compare with those who underwent a parathyroidectomy (PTX) procedure. METHODS This retrospective, longitudinal study included patients treated with Dmb (60 mg) once every 6 months (n = 19) and those who successfully underwent a PTX procedure (n = 19) corrected calcium (cCa), eGFR, bone mineral density (BMD) in the lumbar spine (LS), total hip (TH), and femoral neck (FN) and LS-trabecular bone score (TBS) changes at 1 year after beginning Dmb or undergoing PTX were measured. RESULTS Dmb group had older age, and showed milder disease activity and lower eGFR as compared with PTX group. In PTX group, cCa and eGFR were significantly decreased following surgery, while those were stable in Dmb group. There were significant increases in LS, TH, and FN-BMD in both Dmb (LS: 6.0 ± 0.8%, TH: 3.7 ± 1.0%, FN: 4.3 ± 1.5%) and PTX (LS: 11.2 ± 1.5%, TH: 7.5 ± 1.5%, FN: 7.9 ± 2.1%) groups. In Dmb group, LS-TBS was significantly improved by 3.0 ± 1.0%, while TBS change in PTX group approached significance (2.8 ± 1.5%). Percent change in TH-BMD was significantly correlated with baseline tartrate-resistant acid phosphatase-5b (TRACP-5b) in both groups. CONCLUSIONS Dmb treatment not only increased BMD, dependent on bone turnover status, the same as PTX, but also improved LS-TBS. In addition, it did not decrease the level of eGFR, whereas PTX did. These results suggest that Dmb treatment help in the clinical management of osteoporotic patients with PHPT who do not undergo surgery as alternative to PTX.
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Affiliation(s)
- Daichi Miyaoka
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Yasuo Imanishi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Eiko Kato
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Norikazu Toi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yuki Nagata
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masafumi Kurajoh
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinsuke Yamada
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masanori Emoto
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
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Hassan-Smith ZK, Criseno S, Gittoes NJL. Mild primary hyperparathyroidism-to treat or not to treat? Br Med Bull 2019; 129:53-67. [PMID: 30576424 DOI: 10.1093/bmb/ldy042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/20/2018] [Accepted: 11/26/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The presentation of primary hyperparathyroidism (PHPT) has shifted from a disease characterized by renal and skeletal complications to a mild or asymptomatic condition. Modern imaging allows localization of a surgical target in the majority of cases. SOURCES OF DATA Data were collected from literature searches of online databases including PUBMED, MEDLINE and Cochrane. A narrative review was performed. AREAS OF AGREEMENT Parathyroidectomy is the only therapy with curative potential with good outcomes and low risk of complications in experienced hands. Current guidelines advocate that surgery is offered in all symptomatic cases and in those who meet criteria depending on age, serum calcium concentration, skeletal and renal parameters. A structured monitoring approach should be offered to those who do not undergo surgery. AREAS OF CONTROVERSY Thresholds for intervention to improve skeletal and renal outcomes are debatable. In addition, controversy persists over the benefit of surgery for non-skeletal/renal outcomes. GROWING POINTS The role of medical management of PHPT using agents such as bisphosphonates, denosumab and cinacalcet are discussed. AREAS TIMELY FOR DEVELOPING RESEARCH In summary, further data on the natural history and effects of treatment of mild and asymptomatic PHPT are required to determine thresholds for surgery. In particular, further investigations of non-skeletal and non-renal parameters, such as neurocognitive quality of life and cardiovascular disease are required. Data on normocalcaemic PHPT are lacking. Large-scale randomized controlled trials would be welcome in these areas, however in view of the cost implications a more pragmatic approach may be to develop collaborative multi-centre registries.
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Affiliation(s)
- Zaki K Hassan-Smith
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Sherwin Criseno
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Neil J L Gittoes
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
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¿Mejora la función renal tras la paratiroidectomía en el hiperparatirodismo primario? Nefrologia 2019; 39:160-167. [DOI: 10.1016/j.nefro.2018.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/29/2018] [Accepted: 08/09/2018] [Indexed: 11/21/2022] Open
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11
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Dewi F, Egan RJ, Abdelrahman T, Morris C, Stechman MJ, Lewis WG. Prognostic Significance of Acute Kidney Injury Following Emergency Laparotomy: A Prospective Observational Cohort Study. World J Surg 2018; 42:3575-3580. [PMID: 30097705 DOI: 10.1007/s00268-018-4744-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AIMS Post-operative acute kidney injury (AKI) is a common and independent mortality risk factor carrying high clinical and economic cost. This study aimed to establish the incidence of AKI in patients undergoing emergency laparotomy (EL), to determine patients' risk profile and consequent mortality. METHODS Consecutive 239 patients of median age 68 (IQR 51-76) years, undergoing EL in a UK tertiary hospital, were studied. Primary outcome measure was AKI and in-hospital operative mortality. RESULTS Ninety-five patients (39.7%) developed AKI, which was associated with in-hospital mortality in 32 patients (33.7%) compared with 7 patients (4.9%) without AKI. AKI occurred in 81.1% of all mortalities, but none occurred when AKI resolved within 48 h of EL. AKI was associated with chronic kidney disease, age, serum lactate, white cell count, pre-EL systolic blood pressure and tachycardia (p < 0.010). Median length of hospital stay in AKI survivors was 15 days compared with 11 days in the absence of AKI (p < 0.001). On multivariable analysis, only AKI at 48 h post-EL was significantly and independently associated with mortality [HR 10.895, 95% CI 3.152-37.659, p < 0.001]. CONCLUSION Peri-operative AKI after EL was common and associated with a more than sixfold significant greater mortality. Pre-operative risk profile assessment and prompt protocol-driven intervention should minimise AKI and reduce EL mortality.
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Affiliation(s)
- F Dewi
- Wales Postgraduate Medical and Dental Education Deanery, Cardiff, UK
| | - R J Egan
- Wales Postgraduate Medical and Dental Education Deanery, Cardiff, UK
| | - T Abdelrahman
- Wales Postgraduate Medical and Dental Education Deanery, Cardiff, UK
| | - C Morris
- Department of Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - M J Stechman
- Department of Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - W G Lewis
- Department of Surgery, University Hospital of Wales, Cardiff, CF14 4XW, UK.
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Egan RJ, Iliff H, Stechman MJ, Scott-Coombes DM. Intraoperative Parathyroid Hormone Assay Remains Predictive of Cure in Renal Impairment in Patients with Single Parathyroid Adenomas. World J Surg 2018; 42:2835-2839. [DOI: 10.1007/s00268-018-4544-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Verdelli C, Corbetta S. MECHANISMS IN ENDOCRINOLOGY: Kidney involvement in patients with primary hyperparathyroidism: an update on clinical and molecular aspects. Eur J Endocrinol 2017; 176:R39-R52. [PMID: 27601015 DOI: 10.1530/eje-16-0430] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/12/2016] [Accepted: 09/02/2016] [Indexed: 12/27/2022]
Abstract
Primary hyperparathyroidism (PHPT) is the third most common endocrine disease. Kidney is a target of both chronic elevated PTH and calcium in PHPT. The classic PHPT complications of symptomatic kidney stones and nephrocalcinosis have become rare and the PHPT current presentation is asymptomatic with uncertain and long-lasting progression. Nonetheless, the routine use of imaging and of biochemical determinations have revealed the frequent occurrence of asymptomatic kidney stones, hypercalciuria and reduced kidney function in asymptomatic PHPT patients. Though the pathogenesis is far from being elucidated, PHPT is associated with reduced renal function, in terms of estimated glomerular filtration rate, and related increased morbidity and mortality. In the last decade, the effort of the Kidney Disease: Improving Global Outcomes (KDIGO) panel of experts highlighted that even mild reduction of kidney function is associated with increased risk of cardiovascular disease. These considerations provided the basis for the Fourth Workshop recommendations of a more extensive diagnostic workout about kidney features and of wider criteria for parathyroid surgery including asymptomatic kidney disease. Moreover, kidney involvement in PHPT is likely to be affected by variants of genes coding the key molecules regulating the calcium and ions renal handling; these features might have clinical relevance and should be considered both during diagnostic workout and follow-up. Finally, the effects of parathyroid surgery and of medical treatment on kidney involvement of PHPT are reviewed.
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Affiliation(s)
- C Verdelli
- Laboratory of Experimental EndocrinologyIRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - S Corbetta
- Laboratory of Experimental EndocrinologyIRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Endocrinology ServiceDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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