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Qiu W, Zhou G. Observation of the efficacy of parathyroidectomy for secondary hyperparathyroidism in hemodialysis patients: a retrospective study. BMC Surg 2023; 23:234. [PMID: 37568150 PMCID: PMC10422825 DOI: 10.1186/s12893-023-02143-y] [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: 05/04/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023] Open
Abstract
PURPOSE Parathyroidectomy (PTX) is commonly performed as a treatment for secondary hyperparathyroidism (SHPT) in patients with end-stage renal disease (ESRD). We aimed to evaluate the efficacy of PTX in patients with SHPT who underwent hemodialysis. METHODS This retrospective study analyzed the clinical treatment of 80 hemodialysis patients with SHPT who underwent either total PTX with forearm auto transplantation (TPTX + AT) or subtotal parathyroidectomy (SPTX). We compared the changes in biochemical indices before and after surgery as well as the attenuation of intact parathyroid hormone (iPTH) in the TPTX and SPTX groups. We also evaluated clinical symptoms and quality of life using the Visual Analog Scale (VAS) and the Short Form-36 Questionnaire (SF-36) before and at 3, 6, and 12 months after surgery. RESULTS Serum iPTH and serum phosphorus levels decreased significantly after surgery in 80 patients with SHPT (P < 0.05). Within one month of surgery, there was a difference in iPTH levels between the TPTX + AT and SPTH groups, but there was no difference over time. Patients experienced significant improvement in their clinical symptoms of restless leg syndrome, skin itching, bone pain, and joint pain at 1 week post operation (P < 0.001). Quality of life significantly improved after surgery, as assessed by SF-36 scores (P < 0.05). Hypocalcemia was the most common postoperative complication, occurring in 35% of patients. Within the first 12 months post surgery, 5 patients had a recurrence. CONCLUSION PTX is effective in rapidly reducing iPTH levels, improving calcium and phosphorus metabolism disorders, and enhancing patients' quality of life by safely and effectively relieving clinical symptoms.
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Affiliation(s)
- Wenqiang Qiu
- Department of General Surgery, Jinzhou Medical University Postgraduate Training Base (Liaoyang Central Hospital), Liaoyang, 111000, China
| | - Ge Zhou
- Department of General Surgery, Liaoyang Central Hospital, Liaoyang, China.
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Hiramitsu T, Hasegawa Y, Futamura K, Okada M, Goto N, Narumi S, Watarai Y, Tominaga Y, Ichimori T. Maximal parathyroid gland diameter as a predictive factor for autograft-dependent recurrent secondary hyperparathyroidism after total parathyroidectomy. Front Endocrinol (Lausanne) 2023; 14:1175237. [PMID: 37396185 PMCID: PMC10311438 DOI: 10.3389/fendo.2023.1175237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Following total parathyroidectomy (PTx), transcervical thymectomy, and forearm autograft for secondary hyperparathyroidism (SHPT), recurrent SHPT can occur in the autografted forearm. However, few studies have investigated the factors contributing to re-PTx due to autograft-dependent recurrent SHPT before the completion of the initial PTx. Methods A total of 770 patients who had autografted parathyroid fragments derived from only one of the resected parathyroid glands (PTGs) and who had undergone successful initial total PTx and transcervical thymectomy-defined by serum intact parathyroid hormone level < 60 pg/mL on postoperative day 1-between January 2001 and December 2022 were included in this retrospective cohort study. Factors contributing to re-PTx due to graft-dependent recurrent SHPT before the completion of the initial PTx were investigated using multivariate Cox regression analysis. Receiver operating characteristic (ROC) curve analysis was performed to obtain the optimal maximum diameter of PTG for autograft. Results Univariate analysis showed that dialysis vintage and maximum diameter and weight of the PTG for autograft were significant factors contributing to graft-dependent recurrent SHPT. However, multivariate analysis revealed that dialysis vintage (P=0.010; hazard ratio [HR], 0.995; 95% confidence interval [CI], 0.992-0.999) and the maximum diameter of the PTG for autograft (P=0.046; HR, 1.107; 95% CI, 1.002-1.224) significantly contributed to graft-dependent recurrent SHPT. ROC curve analysis showed that < 14 mm was the optimal maximum diameter of PTG for autograft (area under the curve, 0.628; 95% CI, 0.551-0.705). Conclusions The dialysis vintage and maximum diameter of PTG for autograft may contribute to re-PTx due to autograft-dependent recurrent SHPT, which can be prevented by using PTGs with a maximum diameter of < 14 mm for autograft.
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Hiramitsu T, Hasegawa Y, Futamura K, Okada M, Goto N, Narumi S, Watarai Y, Tominaga Y, Ichimori T. Treatment for secondary hyperparathyroidism focusing on parathyroidectomy. Front Endocrinol (Lausanne) 2023; 14:1169793. [PMID: 37152972 PMCID: PMC10159274 DOI: 10.3389/fendo.2023.1169793] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/07/2023] [Indexed: 05/09/2023] Open
Abstract
Secondary hyperparathyroidism (SHPT) is a major problem for patients with chronic kidney disease and can cause many complications, including osteodystrophy, fractures, and cardiovascular diseases. Treatment for SHPT has changed radically with the advent of calcimimetics; however, parathyroidectomy (PTx) remains one of the most important treatments. For successful PTx, removing all parathyroid glands (PTGs) without complications is essential to prevent persistent or recurrent SHPT. Preoperative imaging studies for the localization of PTGs, such as ultrasonography, computed tomography, and 99mTc-Sestamibi scintigraphy, and intraoperative evaluation methods to confirm the removal of all PTGs, including, intraoperative intact parathyroid hormone monitoring and frozen section diagnosis, are useful. Functional and anatomical preservation of the recurrent laryngeal nerves can be confirmed via intraoperative nerve monitoring. Total or subtotal PTx with or without transcervical thymectomy and autotransplantation can also be performed. Appropriate operative methods for PTx should be selected according to the patients' need for kidney transplantation. In the case of persistent or recurrent SHPT after the initial PTx, localization of the causative PTGs with autotransplantation is challenging as causative PTGs can exist in the neck, mediastinum, or autotransplanted areas. Additionally, the efficacy and cost-effectiveness of calcimimetics and PTx are increasingly being discussed. In this review, medical and surgical treatments for SHPT are described.
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Affiliation(s)
- Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
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Li L, He C, Cheng G, Cao J, Wang C, Tang Y, Zhang W. Recurrent renal secondary hyperparathyroidism caused by supernumerary mediastinal parathyroid gland and parathyromatosis: A case report. Front Surg 2023; 10:1135596. [PMID: 37021088 PMCID: PMC10067725 DOI: 10.3389/fsurg.2023.1135596] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 02/27/2023] [Indexed: 04/07/2023] Open
Abstract
Background Surgical parathyroidectomy (PTX) is necessary for patients with severe and progressive secondary hyperparathyroidism (SHPT) refractory to medical treatment. Recurrence of SHPT after PTX is a serious clinical problem. Both supernumerary mediastinal parathyroid gland and parathyromatosis are the rare causes of recurrent renal SHPT. We report a rare case of recurrent renal SHPT due to supernumerary mediastinal parathyroid gland and parathyromatosis. Case presentation A 53-year-old man underwent total parathyroidectomy with autotransplantation due to the drug-refractory SHPT 17 years ago. In the last 11 months, the patient experienced symptoms including bone pain and skin itch, and the serum intact parathyroid hormone (iPTH) level elevated to 1,587 pg/ml. Ultrasound detected two hypoechoic lesions located at the dorsal area of right lobe of the thyroid gland, and both lesions presented as characteristics of hyperparathyroidism in contrast-enhanced ultrasound. 99mTc-MIBI/SPECT detected a nodule in the mediastinum. A reoperation involved a cervicotomy for excising parathyromatosis lesions and the surrounding tissue and a thoracoscopic surgery for resecting a mediastinal parathyroid gland. According to a histological examination, two lesions behind the right thyroid lobe and one lesion in the central region had been defined as parathyromatosis. A nodule in the mediastinum was consistent with hyperplastic parathyroid. The patient remained well for 10 months with alleviated symptoms and stabilized iPTH levels in the range of 123-201 pg/ml. Conclusion Although rare, recurrent SHPT may be caused by a coexistence of both supernumerary parathyroid glands and parathyromatosis, which should receive more attention. The combination of imaging modalities is important for reoperative locations of parathyroid lesions. To successfully treat parathyromatosis, all the lesions and the surrounding tissue must be excised. Thoracoscopic surgery is a reliable and safe approach for the resection of ectopic mediastinal parathyroid glands.
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Affiliation(s)
- Longfei Li
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Chenchen He
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
- Department of Clinical Medicine and Surgery, China Medical University, Shenyang, China
| | - Guangming Cheng
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Junying Cao
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Chunhui Wang
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Yufu Tang
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
- Correspondence: Yufu Tang Wei Zhang
| | - Wei Zhang
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, China
- Correspondence: Yufu Tang Wei Zhang
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Hiramitsu T, Hasegawa Y, Futamura K, Okada M, Goto N, Narumi S, Watarai Y, Tominaga Y, Ichimori T. Intraoperative intact parathyroid hormone monitoring and frozen section diagnosis are essential for successful parathyroidectomy in secondary hyperparathyroidism. Front Med (Lausanne) 2022; 9:1007887. [PMID: 36419788 PMCID: PMC9676982 DOI: 10.3389/fmed.2022.1007887] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/25/2022] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Total parathyroidectomy (PTx) is often performed to treat secondary hyperparathyroidism (SHPT). Successful PTx is essential to prevent recurrent and persistent SHPT because remnant parathyroid glands (PTGs) in the neck can be stimulated and may secrete excessive parathyroid hormone (PTH) in end-stage renal disease. However, to date, few studies have investigated factors contributing to successful PTx before the completion of surgery. MATERIALS AND METHODS Between August 2010 and February 2020, 344 patients underwent total PTx, transcervical thymectomy, and forearm autograft for SHPT at our institute. Factors contributing to successful PTx before the completion of surgery were investigated. Preoperative imaging diagnoses, including computed tomography, ultrasonography, technetium-99m methoxyisobutylisonitrile (99mTc-MIBI) scintigraphy, intraoperative intact PTH (IOIPTH) monitoring, and frozen section histologic diagnosis, were performed. Successful PTx was defined as intact PTH level < 60 pg/mL on postoperative day 1. A sufficient decrease in IOIPTH level was defined as > 70% decrease in intact PTH levels measured 10 min after total PTx and transcervical thymectomy compared to intact PTH levels measured before skin incision. Logistic regression analysis was conducted to investigate factors contributing to PTx success. RESULTS Univariate analysis showed that the number of all PTGs identified preoperatively by imaging modalities and the specimens submitted for frozen section diagnosis, which surgeon presumed to be PTGs, were not significant factors contributing to successful PTx. However, multivariate analysis revealed that the number of PTGs identified by frozen section diagnosis (P < 0.001, odds ratio [OR] 4.356, 95% confidence interval [CI] 2.499-7.592) and sufficient decrease in IOIPTH levels (P = 0.001, OR 7.847, 95% CI 2.443-25.204) significantly contributed to successful PTx. CONCLUSION Sufficient intact PTH level decrease observed on IOIPTH monitoring and the number of PTGs identified by frozen section diagnosis contributed to successful PTx for SHPT. IOIPTH monitoring and frozen section diagnosis are essential for achieving successful PTx for SHPT.
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Affiliation(s)
- Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
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Yajima A, Tsuchiya K, Kuro-O M, Urena P, Tominaga Y, Okada M, Ichimori T, Tomosugi T, Hiramitsu T, Murata T, Nakamura M, Sasaki M, Ito A, Nitta K. Renal hyperparathyroidism. VITAMINS AND HORMONES 2022; 120:305-343. [PMID: 35953115 DOI: 10.1016/bs.vh.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The number of the patients with chronic kidney disease is now increasing in the world. The pathophysiology of renal hyperparathyroidism is closely associated with Klotho-FGF-endocrine axes, which must be solved definitively as early as possible. It was revealed that the expression of fgf23 is activated by calciprotein particles, which induces vascular ossification. And it is well known that phosphorus overload directly increases parathyroid hormone and hyperparathyroid bone disease develops in those subjects. On the other hand, low turnover bone disease is often recently. Both the patients with chronic kidney disease suffering from hyperparathyroid bone disease or low turnover bone disease are associated with increased fracture risk. Micropetrosis may be one of the causes of increased fracture risk in the subjects with low turnover bone disease. In this chapter, we now describe the diagnosis, pathophysiology and treatments of renal hyperparathyroidism.
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Affiliation(s)
- Aiji Yajima
- Department of Anatomy, Cell Biology and Physiology, Indiana University, School of Medicine, Indianapolis, IN, United States; Department of Urology, Tokyo, Teishin Hospital, Tokyo, Japan; Department Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan.
| | - Ken Tsuchiya
- Department Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Makoto Kuro-O
- Division of Anti-aging Medicine, Center for Molecular Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Pablo Urena
- Division of Nephrology, Clinique du Landy, Saint Ouen, France
| | - Yoshihiro Tominaga
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Manabu Okada
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Toshihiro Ichimori
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Toshihide Tomosugi
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Taro Murata
- Department of Urology, Tokyo, Teishin Hospital, Tokyo, Japan
| | - Masaki Nakamura
- Department of Nephrology and Urology, NTT East Kanto Hospital, Tokyo, Japan
| | - Masahiko Sasaki
- Department of Urology, Tokyo, Teishin Hospital, Tokyo, Japan
| | - Akemi Ito
- Ito Bone Histomorphometry Institute, Niigata, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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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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PTH Spikes During Parathyroid Surgery for Renal Hyperparathyroidism: Worth the Wait? World J Surg 2022; 46:1702-1703. [DOI: 10.1007/s00268-022-06542-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 10/18/2022]
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Silveira AA, Brescia MDG, do Nascimento CP, Magnabosco FF, Arap SS, de Menezes Montenegro FL. PTH Spikes During Surgical Treatment for Secondary and Tertiary Hyperparathyroidism: A Prospective Observational Study. World J Surg 2022; 46:1693-1701. [PMID: 35262789 DOI: 10.1007/s00268-022-06506-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of the present study was to determine whether PTH spikes in renal hyperparathyroidism can interfere with the interpretation of intraoperative PTH monitoring and to determine its frequency and characteristics. METHODS This was a prospective observational study of consecutive patients who underwent surgical treatment in a single tertiary institution. Patients were divided into two groups: spike and no spike. Patients with secondary and tertiary hyperparathyroidism were analyzed separately. Intraoperative PTH monitoring by venous serial samples: two samples were taken before the excision of the parathyroid gland, and two others were taken after resection. RESULTS PTH spikes occurred in 23.5% (53 of 226), and their occurrence was similar between secondary and tertiary hyperparathyroidism patients (p = 0.074). The relative PTH spike intensity was higher in transplanted patients than in dialysis patients (55 vs. 20%, p = 0.029). A characteristic of the secondary hyperparathyroidism patients was the highest frequency of surgical failure (23 vs. 7.5%, p = 0.016) and the higher occurrence of supernumerary glands in the spike group (23 vs. 10.3%, p = 0.035). Supernumerary parathyroid was associated with surgical failure [19.1 (6.5-55.7) odds ratio [confidence interval], p < 0.001). In the studies evaluating the diagnostic test validity for patients on dialysis and experiencing spikes, the most significant impacts were in the sensitivity, accuracy, and negative predictive value of the method. CONCLUSIONS PTH spikes occurred in up to 23.5% of renal hyperparathyroidism surgical treatments and can negatively influence the intraoperative parathyroid hormone monitoring. Regarding the phenomenon of PTH spikes, it is prudent to think about the possibility of a hyperplastic supernumerary gland.
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Affiliation(s)
- Andre Albuquerque Silveira
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, n 255, Cerqueira Cesar, São Paulo, SP, 05403-000, Brazil. .,Head and Neck Surgery, Department of Surgery, University Hospital, Federal University of Paraiba, João Pessoa, Brazil.
| | - Marilia D'Elboux Guimaraes Brescia
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, n 255, Cerqueira Cesar, São Paulo, SP, 05403-000, Brazil
| | - Climerio Pereira do Nascimento
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, n 255, Cerqueira Cesar, São Paulo, SP, 05403-000, Brazil
| | - Felipe Ferraz Magnabosco
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, n 255, Cerqueira Cesar, São Paulo, SP, 05403-000, Brazil
| | - Sergio Samir Arap
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, n 255, Cerqueira Cesar, São Paulo, SP, 05403-000, Brazil
| | - Fabio Luiz de Menezes Montenegro
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, n 255, Cerqueira Cesar, São Paulo, SP, 05403-000, Brazil
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Chen Y, Liang B, Dong X, Huang T, Liu TQ. Diagnostic Accuracy of Intraoperative Intact Parathyroid Hormone Monitoring for Surgical Outcomes of Secondary Hyperparathyroidism. Med Sci Monit 2021; 27:e932556. [PMID: 34839345 PMCID: PMC8638211 DOI: 10.12659/msm.932556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Intraoperative intact parathyroid hormone (IO-iPTH) monitoring has not reached a consensus in predicting surgical outcomes of secondary hyperparathyroidism. Here, we explore the predictive effect of IO-iPTH monitoring on surgical outcomes of secondary hyperparathyroidism as a potentially effective standard. MATERIAL AND METHODS We enrolled 119 patients who underwent total parathyroidectomy with autotransplantation from January 2016 to August 2019. Intact parathyroid hormone (iPTH) levels were tested 1 day before surgery (iPTHpre), 10 min after glands resection (iPTH10min), and 1 and 7 days after the operation (iPTHd1, iPTHd7). According to iPTHpre levels, patients were divided into a <2000 pg/ml group and a ≥2000 pg/ml group, and the cutoff values were compared. In patients with successful parathyroidectomy, the value of iPTHpre minus iPTH10min (iPTHdec) and relative-iPTH10min were compared between groups. RESULTS Using cutoff values, the predictive criterion was defined as iPTH10min ≤314.5 pg/ml or relative-iPTH10min ≤12.4%. In the iPTHpre ≥2000 pg/ml group, iPTH10min had a higher predictive value (318 pg/ml vs 218 pg/ml) whereas relative-iPTH10min had a lower predictive value (12.1% vs 20.3%). In patients with successful PTX, the iPTHdec value of the iPTHpre ≥2000 pg/ml group was significantly higher than that of the <2000 pg/ml group. Additionally, the relative-iPTH10min was significantly lower in the ≥2000 pg/ml group than in the <2000 pg/ml group. CONCLUSIONS An intraoperative predictive criterion of iPTH10min ≤314.5 pg/ml or relative-iPTH10min ≤12.4% is associated with effectively predicting surgical success of secondary hyperparathyroidism. The predictive value is affected by iPTHpre level; therefore, a variable prediction standard based on iPTHpre levels shall be established.
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Affiliation(s)
- Yuanyuan Chen
- Department of Hepatobiliary and Gland Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China (mainland)
| | - Bin Liang
- Department of Hepatobiliary and Gland Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China (mainland)
| | - Xiaofeng Dong
- Department of Hepatobiliary and Gland Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China (mainland)
| | - Tao Huang
- Department of Hepatobiliary and Gland Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China (mainland)
| | - Tian-Qi Liu
- Department of Hepatobiliary and Gland Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China (mainland)
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Chávez KV, Márquez-González H, Chavez-Tostado M. The Usefulness of Intraoperative PTH as a Predictor for Successful Parathyroidectomy in Secondary Hyperparathyroidism. Front Surg 2021; 8:696469. [PMID: 34262935 PMCID: PMC8273272 DOI: 10.3389/fsurg.2021.696469] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Secondary hyperparathyroidism (SHPT) is a multisystemic syndrome that affects calcium and bone homeostasis in patients with chronic kidney disease (CKD). Despite medical treatment, 1–2% of patients require parathyroidectomy annually. The use of an intraoperative parathormone protocol (IOPTH) to predict cure is still in debate, due to the lack of standardized protocols, the use of different assays, and uneven PTH clearance. This study aimed to determine the diagnostic accuracy of an IOPTH in patients with SHPT for predicting successful surgery after parathyroidectomy. Methods: About 30 patients were enrolled. A prospective observational study (cohort) was performed in patients who were submitted to parathyroidectomy by an endocrine surgeon for SHPT. All were submitted to a bilateral neck exploration with a subtotal parathyroidectomy. Three IOPTH determinations were withdrawn: at anesthetic induction (PTH0), 15 min (PTH15), and 30 min (PTH30) after completion of gland resection. Another sample was taken 24 h after the procedure (PTH24), values <150 pg/mL defined a successful surgery, and patients were assigned to the success or failure group. IOPTH drop was analyzed to predict successful surgery with drops of 70 and 90% at 15 and 30 min, respectively. Results: A total of 26 patients were included, 19 patients were in the successful group. IOPTH showed a significant difference between groups in their absolute PTH15 and PTH30 values. A significant difference was also found in their PTH drop at 30 min (81 vs. 91%, p = 0.08). For predicting a successful surgery, having a PTH drop >90% at 30 min was the most significant factor [Odds Ratio (OR) 3.0 (1.5–4) IC 95%]. Conclusions: This study points toward a stricter and staggered IOPTH protocol to predict a successful surgery. Our results suggest taking a PTH15 expecting a PTH drop of >90%. If this is not achieved, reexploration and a PTH30 sample are suggested to accurately predict success.
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Affiliation(s)
- Karla Verónica Chávez
- Department of Human Reproduction, Health Sciences University Center, University of Guadalajara, Guadalajara, Mexico
| | | | - Mariana Chavez-Tostado
- Department of Human Reproduction, Health Sciences University Center, University of Guadalajara, Guadalajara, Mexico
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Hiramitsu T, Tomosugi T, Okada M, Futamura K, Goto N, Narumi S, Watarai Y, Tominaga Y, Ichimori T. Intraoperative recurrent laryngeal nerve monitoring using endotracheal electromyography during parathyroidectomy for secondary hyperparathyroidism. J Int Med Res 2021; 49:3000605211000987. [PMID: 33745322 PMCID: PMC7989137 DOI: 10.1177/03000605211000987] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate the factors associated with adherence of an enlarged parathyroid gland to the recurrent laryngeal nerve (RLN) and the effectiveness of intraoperative neural monitoring (IONM). Methods This single-center retrospective study involved samples from 197 consecutive patients (394 RLNs; 733 parathyroid glands) who underwent parathyroidectomy and transcervical thymectomy between September 2010 and December 2014. The presence of parathyroid gland adhesion to the RLN and the clinical characteristics of patients with and without nerve adhesion were recorded. All patients underwent intraoperative monitoring of the electromyographic responses of the vocal cords using the endotracheal NIM-Response 3.0 system. The patients’ postoperative clinical outcomes were recorded. Results Parathyroid gland adhesion to the RLN was significantly associated with maximum gland diameter (>15 mm), weight (>500 mg), and the presence of nodular hyperplasia. IONM demonstrated a sensitivity of 97.8%, specificity of 43.5%, and accuracy of 94.7% for detecting nerve damage. Parathyroid gland adhesion to 17 RLNs occurred in 3 cases (17.6%) of vocal cord paralysis, whereas the 377 glands without nerve adhesion resulted in vocal cord paralysis in 20 cases (5.3%). Conclusion Our findings demonstrated the effectiveness of IONM using endotracheal electromyography in patients who underwent parathyroidectomy for secondary hyperparathyroidism.
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Affiliation(s)
- Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Toshihide Tomosugi
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Manabu Okada
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yoshihiro Tominaga
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Toshihiro Ichimori
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
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Xu F, Huang Y, Zeng M, Zhang L, Ren W, Qian H, Cui Y, Yang G, Zhou W, Wang S, Huang H, Chen H, Xiao Y, Gao X, Gao Z, Wang J, Liu C, Zhang J, Zhao B, Bian A, Li F, Wan H, Xing C, Zha X, Wang N. Diagnostic Values of Intraoperative (1-84) Parathyroid Hormone Levels are Superior to Intact Parathyroid Hormone for Successful Parathyroidectomy in Patients With Chronic Kidney Disease. Endocr Pract 2021; 27:1065-1071. [PMID: 33895317 DOI: 10.1016/j.eprac.2021.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Persistent secondary hyperparathyroidism (SHPT) may occur because of residual cervicothoracic parathyroids in parathyroidectomy (PTX) patients with chronic kidney disease. We prospectively compared the predictive values of intraoperative plasma (1-84) parathyroid hormone (PTH) and intact PTH (iPTH) levels to improve the safety and efficacy of PTX. METHODS We included 100 healthy controls, 162 stage 5 chronic kidney disease patients without SHPT, and 214 patients who underwent PTX because of SHPT. Plasma iPTH and (1-84) PTH levels were measured before incision (io-iPTH0 and io-[1-84]PTH0, respectively) and 10 minutes (io-iPTH10 and io-[1-84]PTH10, respectively) and 20 minutes (io-iPTH20 and io-[1-84]PTH20, respectively) after removing all parathyroids. The percentage reduction of iPTH and (1-84) PTH at 10 minutes (io-iPTH10% and io-[1-84]PTH10%, respectively) and 20 minutes (io-iPTH20%, and io-[1-84]PTH20%, respectively) was calculated. iPTH and (1-84) PTH were measured using second- and third-generation PTH assays, respectively. RESULTS Compared with the controls and non-PTX patients, the PTX group had more obvious mineral metabolism disorders. There were 187 successful PTXs, 19 patients with persistent SHPT, and 8 patients lost to follow-up. The receiver operating characteristic curves revealed that io-(1-84)PTH10% >86.6% and io-(1-84)PTH20% >87.5% suggested successful PTX. The sensitivity of io-iPTH20% and io-(1-84)PTH20% were higher than those at the timepoint of 10 minutes. Moreover, the specificity and sensitivity of the (1-84) PTH reduction percentage were superior to that of iPTH. CONCLUSION Intraoperative reduction percentages of plasma (1-84) PTH levels are superior to iPTH for accurately predicting successful PTX, especially at 20 minutes after all cervicothoracic parathyroids had been resected.
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Affiliation(s)
- Fangyan Xu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Yaoyu Huang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Lina Zhang
- Department of Nephrology, Henan Provincial Key Laboratory of Kidney Disease and Immunology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Henan, China
| | - Wenkai Ren
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Hanyang Qian
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Ying Cui
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China; Department of Nephrology, Northern Jiangsu People's Hospital, Jiangsu, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Wenbin Zhou
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu, China
| | - Shui Wang
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu, China
| | - Hui Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Jiangsu, China
| | - Huimin Chen
- Department of Nephrology, Taizhou People's Hospital, Jiangsu, China
| | - Yujie Xiao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Xueyan Gao
- Department of General Medicine, Geriatric Hospital of Nanjing Medical University, Jiangsu, China
| | - Zhanhui Gao
- Department of Nephrology, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Jiangsu, China
| | - Jing Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Cuiping Liu
- Department of Biological Specimen Repository, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu, China
| | - Jing Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Baiqiao Zhao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Anning Bian
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Fan Li
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Huiting Wan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Xiaoming Zha
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Jiangsu, China.
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu, China.
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Hiramitsu T, Tomosugi T, Okada M, Futamura K, Goto N, Narumi S, Watarai Y, Tominaga Y, Ichimori T. Intact parathyroid hormone levels localize causative glands in persistent or recurrent renal hyperparathyroidism: A retrospective cohort study. PLoS One 2021; 16:e0248366. [PMID: 33793603 PMCID: PMC8016254 DOI: 10.1371/journal.pone.0248366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/24/2021] [Indexed: 11/19/2022] Open
Abstract
Persistent or recurrent renal hyperparathyroidism may occur after total parathyroidectomy and transcervical thymectomy with forearm autograft under continuous stimulation due to uremia. Parathyroid hormone (PTH) levels may reflect persistent or recurrent renal hyperparathyroidism because of the enlarged autografted parathyroid glands in the forearm or remnant parathyroid glands in the neck or mediastinum. Detailed imaging requires predictive localization of causative parathyroid glands. Casanova and simplified Casanova tests may be convenient. However, these methods require avascularization of the autografted forearm for >10 min with a tourniquet or Esmarch. The heavy pressure during avascularization can be incredibly painful and result in nerve damage. An easier method that minimizes the burden on patients in addition to predicting the localization of causative parathyroid glands was developed in this study. Ninety patients who underwent successful re-parathyroidectomy for persistent or recurrent renal hyperparathyroidism after parathyroidectomy between January 2000 and July 2019 were classified according to the localization of causative parathyroid glands (63 and 27 patients in the autografted forearm and the neck or mediastinum groups, respectively). Preoperatively, intact PTH levels were measured from bilateral forearm blood samples following a 5-min avascularization of the autografted forearm. Cutoff values of the intact PTH ratio (intact PTH level obtained from the non-autografted forearm before re-parathyroidectomy/intact PTH level obtained from the autografted forearm before re-parathyroidectomy) were investigated with receiver operating characteristic curves to localize the causative parathyroid glands. Intact PTH ratios of <0.310 with an area under the curve (AUC) of 0.913 (95% confidence interval [CI]: 0.856–0.970; P < 0.001) and >0.859 with an AUC 0.744 (95% CI: 0.587–0.901; P = 0.013) could predict causative parathyroid glands in the autografted forearm and the neck or mediastinum with diagnostic accuracies of 81.1% and 83.3%, respectively. Therefore, we propose that the intact PTH ratio is useful for predicting the localization of causative parathyroid glands for re-parathyroidectomy.
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Affiliation(s)
- Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan
- * E-mail:
| | - Toshihide Tomosugi
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan
| | - Manabu Okada
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan
| | - Yoshihiro Tominaga
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan
| | - Toshihiro Ichimori
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Aichi, Japan
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15
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Silveira AA, Brescia MDG, do Nascimento CP, Arap SS, Montenegro FLDM. Critical analysis of the intraoperative parathyroid hormone decrease during parathyroidectomy for secondary and tertiary hyperparathyroidism. Surgery 2020; 168:1079-1085. [PMID: 32811697 DOI: 10.1016/j.surg.2020.06.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 06/10/2020] [Accepted: 06/30/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study aims to determine whether intraoperative parathyroid hormone monitoring helps to predict early surgical outcomes in patients with renal hyperparathyroidism and evaluate the impact on decision making during surgery. METHODS A prospective study was conducted. Serial samples of the intraoperative parathyroid hormone were collected; 2 of these were taken before the excision, and 2 were taken after the planned parathyroid resection (10 minutes and 15 minutes). We tested the criterion of an intraoperative parathyroid hormone percentage decay ≥80% of the highest value of the basal samples as a predictor of success. RESULTS Of the 228 patients, parathyroidectomy achieved success in 92.1%. In patients with secondary hyperparathyroidism, the failure group showed a tendency to stabilize or even increase the intraoperative parathyroid hormone values from the 10-minute measure (577 pg/mL) to the 15-minute measure (535 pg/mL) (P = .903). Conversely, intraoperative parathyroid hormone continued to drop in those with a successful outcome: 245 pg/mL (10 minutes) and 206 pg/mL (15 minutes) (P < .001). The failure group had a significantly lower percentage decay (P < .001) from baseline when compared with the success group. The intraoperative parathyroid hormone influenced the surgical management in up to 7% of the cases. The intraoperative parathyroid hormone dosage method showed an accuracy of 86%, a sensitivity of 88%, and specificity of 67%. CONCLUSION In patients with renal hyperparathyroidism undergoing parathyroidectomy, the use of intraoperative parathyroid hormone may help to predict an early therapeutic outcome with high sensitivity and accuracy by indicating the operation's success when there is an 80% reduction of baseline intraoperative parathyroid hormone 15 minutes after removal of the enlarged glands, an associated continuous decrease in serum intraoperative parathyroid hormone levels between 10 and 15 minutes, and achievement of plasma target values <500 pg/mL.
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Affiliation(s)
- Andre Albuquerque Silveira
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil.
| | - Marilia D'Elboux Guimaraes Brescia
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Climerio Pereira do Nascimento
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Sergio Samir Arap
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
| | - Fabio Luiz de Menezes Montenegro
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brazil
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16
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Yang G, Wang J, Sun J, Zha X, Wang N, Xing C. Perioperative hyperkalemia in hemodialysis patients undergoing parathyroidectomy for renal hyperparathyroidism. Intern Emerg Med 2019; 14:1065-1071. [PMID: 30648222 DOI: 10.1007/s11739-019-02031-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/08/2019] [Indexed: 02/06/2023]
Abstract
The present study investigates the incidence of perioperative hyperkalemia and the influence factors of serum potassium levels during and after parathyroidectomy (PTX) in hemodialysis patients with renal hyperparathyroidism (rHPT). A total of 204 hemodialysis patients with refractory rHPT undergoing successful total parathyroidectomy with autotransplantation (tPTX + AT) were analyzed retrospectively. Hyperkalemia was defined as serum potassium levels ≥ 5.5 mmol/L. The preoperative baseline level of serum potassium (K base+ ) was defined as a mean of the three preoperative prehemodialysis serum potassium levels. The higher levels of serum potassium during and immediately after surgery were recorded as K d0+ and the peak prehemodialysis serum potassium levels 3 days after surgery as K d3+ . 136/204 (66.7%) patients suffered from hyperkalemia during or immediately after surgery and 65/204 (31.9%) patients were affected with prehemodialysis hyperkalemia 3 days after surgery. K base+ was the only influencing factor for K d0+ . Serum K base+ , preoperative serum alkaline phosphatase, and total calcium supplement dosage during intravenous calcium supplement were the influencing factors for K d3+ . In the case of PTX, the serum potassium levels of patients with higher serum K base+ and severe postoperative hypocalcemia need to be monitored with extended attention perioperatively.
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Affiliation(s)
- Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Jing Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Jie Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Xiaoming Zha
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu, China.
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Casarim ALM, Arcadipane FAMC, Martins AS, Del Negro A, Rodrigues AAN, Tincani AJ, Marchi E. Pattern of Intraoperative Parathyroid Hormone and Calcium in the Treatment of Tertiary Hyperparathyroidism. Otolaryngol Head Neck Surg 2019; 161:954-959. [PMID: 31359817 DOI: 10.1177/0194599819866819] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Tertiary hyperparathyroidism, an autonomous hyperproduction of parathyroid hormone (PTH), has a challenge in its treatment. This study asked whether the intraoperative PTH and calcium drop can confirm the resection of all parathyroid tissues. STUDY DESIGN Case series with planned data collection. SETTING Tertiary referral medical center. SUBJECTS AND METHODS The study assessed patients with tertiary hyperparathyroidism who were treated at the Hospital of the State University of Campinas from 2007 to 2015. All patients underwent total parathyroidectomy with autotransplantation of parathyroid fragments. PTH and calcium were collected during the preoperative period; at 10, 20, and 240 minutes after resection of the glands; and at 1 year after the procedure. Data were analyzed by analysis of variance and logistic regression analysis with statistical values of P < .05. RESULTS Thirty-five patients were assessed: 17 women (48.57%) and 18 men (51.43%). The percentage of PTH drop was statistically significant at all times, unlike the calcium analysis, but only PTH collected at 20 minutes was able to confirm the removal of all parathyroid tissues (P = .029). Based on the receiver operating characteristic curve, the 71.2% drop obtained high sensitivity and specificity (P = .028). CONCLUSIONS Treatment success can be predicted by analyzing the decrease of intraoperative PTH and not by calcium. The 71.2% PTH drop at 20 minutes after parathyroidectomy had high sensitivity and specificity to predict surgical cure.
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Affiliation(s)
- André Luís Maion Casarim
- Head and Neck Surgery Service, Department of Surgery, Faculdade de Medicina de Jundiaí, Jundiaí, Brazil.,Head and Neck Surgery Service, Department of Surgery, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, Brazil
| | | | - Antonio Santos Martins
- Head and Neck Surgery Service, Department of Surgery, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, Brazil
| | - André Del Negro
- Head and Neck Surgery Service, Department of Surgery, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, Brazil
| | | | - Alfio Jose Tincani
- Head and Neck Surgery Service, Department of Surgery, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, Brazil
| | - Evaldo Marchi
- Thoracic Surgery Service, Department of Surgery, Faculdade de Medicina de Jundiaí, Jundiaí, Brazil
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Ge Y, Yang G, Wang N, Zha X, Yu X, Mao H, Sun B, Zeng M, Zhang B, Xing C. Bone metabolism markers and hungry bone syndrome after parathyroidectomy in dialysis patients with secondary hyperparathyroidism. Int Urol Nephrol 2019; 51:1443-1449. [PMID: 31264087 DOI: 10.1007/s11255-019-02217-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/18/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To explore the short-term variation in bone metabolic markers and the characteristics of hungry bone syndrome (HBS) after parathyroidectomy (PTX) with forearm autotransplantation in uremic patients with secondary hyperparathyroidism (SHPT) and to provide a basis for the pathogenesis, diagnosis and treatment of metabolic bone disease in SHPT. METHODS A total of 115 patients with SHPT receiving PTX from July 2015 to December 2017, hospitalized at the First Affiliated Hospital of Nanjing Medical University, were enrolled in our study. We retrospectively analyzed the baseline clinical data, the levels of bone metabolism markers before and on the third day after PTX, and the risk factors predicting HBS. RESULTS Preoperative baseline data showed that the levels of bone metabolic markers such as bone metabolism-regulating hormones: iPTH, calcitonin (CT); bone formation markers: phosphatase (ALP), osteocalcin (OC); bone resorption markers: type I collagen cross-linked N-telopeptides (NTX), type I collagen cross-linked C-telopeptides (CTX), tartrate-resistant acid phosphatase 5b (TRAP-5b) were all increased compared to normal levels. The levels of postoperative serum iPTH, CT, CTX and TRAP-5b decreased significantly compared to preoperative levels, while the levels of OC and ALP increased significantly. Of the 115 patients, 101 (87.8%) developed HBS after PTX. High preoperative serum ALP and low preoperative serum calcium level independently predicted the occurrence of HBS. Younger preoperative age, high preoperative serum ALP and iPTH level independently predicted the severity of HBS. CONCLUSIONS In severe SHPT, both bone formation and resorption were active, which suggested the presence of high-turnover bone diseases characterized by up-regulation of osteoclasts-osteoblasts functionally coupling activation in the patients. PTX could promote osteoblast activity and reduce osteoclast activity. HBS was common after PTX. Preoperative higher serum ALP and lower calcium were independent predictors of the occurrence of HBS. Younger patients with higher preoperative ALP and PTH may need to closely monitor serum calcium levels and intensive calcium supplementation after PTX.
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Affiliation(s)
- Yifei Ge
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Xiaoming Zha
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Xiangbao Yu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Bin Sun
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Bo Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu, China.
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Uslu A, Okut G, Tercan IC, Erkul Z, Aykas A, Karatas M, Simsek C, Tatar E. Anatomical distribution and number of parathyroid glands, and parathyroid function, after total parathyroidectomy and bilateral cervical thymectomy. Medicine (Baltimore) 2019; 98:e15926. [PMID: 31169711 PMCID: PMC6571243 DOI: 10.1097/md.0000000000015926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The normal distribution of parathyroid glands is well documented. However, this study aims to evaluate the efficacy of total parathyroidectomy (TPTx) and bilateral cervical thymectomy (BCTx) for the treatment of secondary hyperparathyroidism (SHPT) through identifying the location of parathyroid glands with attention to the pattern and frequency of orthotopic and ectopic glands.Between 2013 and 2018, sixty chronic hemodialysis patients with medically refractory SHPT underwent TPTx & BCTx. The adequacy of the operation was defined by the pathological confirmation of at least 4 parathyroid glands, accompanied by an intact parathormone (iPTH) value of <60 pg/mL on postoperative day 1(POD1). Based on their anatomical localizations, four distinct sites were identified for both the upper (Zone I-IV) and lower parathyroid glands (Zone V-VIII).The mean follow-up was 15.2 ± 14.6 months. The mean iPTH values on POD1 were normal in 50 patients, with an average of 11.7 ± 14.4 pg/mL. Ten patients (16.6%) had persistent HPT after the operation, three of whom underwent complementary parathyroidectomy. The surgical success rates after first and second operations were both 83.3%. A total of 235 parathyroid glands were detected. Ninety-two percent of the upper parathyroids were located in Zones I and II. However, almost 28% of the lower parathyroids were ectopic and located in Zones VII and VIII.At least one fourth of the lower parathyroids are ectopic; for this reason, Zones VII and VIII require careful investigation during surgery. For upper parathyroids not found in Zone I-III, total thyroidectomy on the same side is recommended.
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Affiliation(s)
- Adam Uslu
- Department of General Surgery and Transplantation
| | - Gokalp Okut
- Department of General Surgery and Transplantation
| | | | | | - Ahmet Aykas
- Department of General Surgery and Transplantation
| | | | - Cenk Simsek
- Department of General Surgery and Transplantation
| | - Erhan Tatar
- Department of Nephrology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Izmir, Turkey
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20
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Yang G, Ge Y, Zha X, Mao H, Wang N, Xing C. Peritoneal dialysis can alleviate the clinical course of hungry bone syndrome after parathyroidectomy in dialysis patients with secondary hyperparathyroidism. Int Urol Nephrol 2019; 51:535-542. [PMID: 30689179 DOI: 10.1007/s11255-019-02076-7] [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: 09/21/2018] [Accepted: 01/03/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE It is unclear whether clinical courses of hungry bone syndrome (HBS) after parathyroidectomy (PTX) in peritoneal dialysis (PD) and hemodialysis (HD) patients are different. The present study aimed to investigate the possible differences of postoperative hypocalcemia and hyperkalemia between PD and HD patients. METHODS We performed retrospectively 29 PD patients as the PD group and 169 HD patients as the HD group undergoing successful total PTX with autotransplantation. Calcium supplement after surgery was recorded. Higher levels of serum potassium during and immediately after surgery were recorded as K+d0. K+d3 was recorded as peak pre-dialysis serum potassium level 3 days post-surgery. RESULTS There were 157 (92.90%) patients in HD group and 22 (75.86%) patients in PD group suffered from HBS after surgery, with significant difference between the groups (P = 0.004). Patients in PD group had significantly shorter intravenous calcium supplement duration (P = 0.037) and significantly smaller intravenous calcium supplement dosage (P = 0.042) and total calcium supplement dosage during hospitalization (P = 0.012) than patients in HD group. The levels of serum K+d0 (P < 0.001) and K+d3 (P < 0.001) were both significantly lower in PD group than those in HD group. Peritoneal dialysis was one of the independent influencing factors with negative correlation for calcium supplement, serum K+d0 and serum K+d3. CONCLUSIONS Compared with HD patients, the clinical course of HBS after PTX in PD patients was alleviated. Efforts should be devoted to individual perioperative management for PD patients undergoing PTX.
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Affiliation(s)
- Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Yifei Ge
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Xiaoming Zha
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China.
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21
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Challenges and controversies in the surgical management of uremic hyperparathyroidism: A systematic review. Am J Surg 2018; 216:713-722. [DOI: 10.1016/j.amjsurg.2018.07.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 05/19/2018] [Accepted: 07/17/2018] [Indexed: 01/08/2023]
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Yang G, Zha X, Mao H, Yu X, Wang N, Xing C. Hypocalcemia-based prediction of hungry bone syndrome after parathyroidectomy in hemodialysis patients with refractory secondary hyperparathyroidism. J Int Med Res 2018; 46:4985-4994. [PMID: 30064280 PMCID: PMC6300944 DOI: 10.1177/0300060518788744] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective This study was performed to explore the risk factors for hungry bone syndrome (HBS) and establish prediction equations for calcium supplementation after parathyroidectomy in hemodialysis patients with secondary hyperparathyroidism. Methods We retrospectively analyzed data from 252 hemodialysis patients undergoing successful total parathyroidectomy with autotransplantation. HBS was defined according to a minimum postoperative serum corrected calcium (PcCa) concentration of <2.0 mmol/L. Independent predictors of HBS were analyzed, and prediction equations for HBS were derived accordingly. Results The incidence of HBS was 71.4%. The serum corrected calcium and preoperative serum alkaline phosphatase (ALP) concentrations were independent predictors of HBS. The preoperative serum ALP, intact parathyroid hormone (iPTH), and hemoglobin concentrations were independent factors influencing the average descending velocity of the PcCa concentration before calcium supplementation (PcCa-V), intravenous calcium supplement holding time (IVCa-T), and intravenous calcium supplement dosage (IVCa), while the serum ALP and iPTH concentrations were independent predictors of the oral calcium supplement dosage (OCa). Four prediction equations for PcCa-V, IVCa-T, IVCa, and OCa were established. Conclusions Establishment of prediction equations for HBS may contribute to a new individualized therapy for patients with HBS.
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Affiliation(s)
- Guang Yang
- 1 Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaoming Zha
- 2 Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Huijuan Mao
- 1 Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiangbao Yu
- 1 Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ningning Wang
- 1 Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Changying Xing
- 1 Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Fülöp T, Koch CA, Farah Musa AR, Clark CM, Gharaibeh KA, Lengvársky Z, Hamrahian M, Pitman KT, Dixit MP. Targeted surgical parathyroidectomy in end-stage renal disease patients and long-term metabolic control: A single-center experience in the current era. Hemodial Int 2018; 22:394-404. [PMID: 29446565 DOI: 10.1111/hdi.12639] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The long-term results of surgical parathyroidectomy (PTX) in end-stage renal disease (ESRD) patients are less well known in the modern era of newer activated vitamin-D analogs, calcimimetics and intraoperative monitoring of parathyroid hormone (PTH). METHODS We performed a retrospective chart review of all ESRD patients undergoing PTX at the University of Mississippi Medical Center between January 2005 and August 2011, with follow-up data as available up to 4 years. All PTXs were performed with intraoperative second-generation PTH monitoring and targeted gland size reduction. RESULTS The cohort (N = 37) was relatively young with a mean (±SD) age of 48.4 ± 13.9. 94.6% of the subjects were African American and 59.5% female. Preoperatively, 45.9% received cinacalcet (CNC) at a mean dose of 63.5 ± 20.9 mg. The size of the largest removed glands measured 1.7 ± 0.8 cm and almost all (94.6%) glands had hyperplasia on histology. The mean length of inpatient stay was 5.5 ± 2.4 days. Preoperative calcium/phosphorus measured 9.6 ± 1.2/6.6 ± 1.7 mg/dL with PTH concentrations of 1589 ± 827 pg/mL. Postoperative PTH values measured 145.4 ± 119.2 pg/mL. Preoperative PTH strongly correlated (P < 0.0001) with both alkaline phosphatase (ALP) levels (r: 0.596) and the number of inpatient days (r: 0.545), but not with CNC administration. Independent predictors for the duration of hospitalization were preoperative ALP (beta 0.469; P = 0.001) and age (beta -0.401; P = 0.005) (R2 0.45); for postoperative hypocalcemia, age (beta: -0.321; P = 0.006) and preoperative PTH (beta: 0.431; P = 0.036) were significant in linear regression models with stepwise selection. CONCLUSION Gland-sparing PTX achieved acceptable control of ESRD-associated hyperparathyroidism in most patients from a socioeconomically challenged, underserved population of the United States.
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Affiliation(s)
- Tibor Fülöp
- Division of Nephrology, Diabetes and Metabolism, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Christian A Koch
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA.,G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi, USA.,Cancer Institute, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Abdeen R Farah Musa
- Division of Nephrology, Diabetes and Metabolism, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Christopher M Clark
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Kamel A Gharaibeh
- Division of Nephrology, Diabetes and Metabolism, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Zsolt Lengvársky
- Department of Mathematics, Louisiana State University Shreveport, Shreveport, Louisiana, USA
| | | | - Karen T Pitman
- Johns Hopkins Department of Otolaryngology, Milton J. Dance Jr. Head and Neck Center, Baltimore, Maryland, USA
| | - Mehul P Dixit
- Division of Pediatric Nephrology, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Chen LS, Singh RJ. Niche point-of-care endocrine testing - Reviews of intraoperative parathyroid hormone and cortisol monitoring. Crit Rev Clin Lab Sci 2018; 55:115-128. [PMID: 29357735 DOI: 10.1080/10408363.2018.1425975] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Point-of-care (POC) testing, which provides quick test results in near-patient settings with easy-to-use devices, has grown continually in recent decades. Among near-patient and on-site tests, rapid intraoperative and intra-procedural assays are used to quickly deliver critical information and thereby improve patient outcomes. Rapid intraoperative parathyroid hormone (ioPTH) monitoring measures postoperative reduction of parathyroid hormone (PTH) to predict surgical outcome in patients with primary hyperparathyroidism, and therefore contributes to the change of parathyroidectomy to a minimally invasive procedure. In this review, recent progress in applying ioPTH monitoring to patients with secondary and tertiary hyperparathyroidism and other testing areas is discussed. In-suite cortisol monitoring facilitates the use of adrenal vein sampling (AVS) for the differential diagnosis of primary aldosteronism and adrenocorticotropic hormone (ACTH)-independent Cushing syndrome. In clinical and psychological research settings, POC testing is also useful for rapidly assessing cortisol in plasma and saliva samples as a biomarker of stress. Careful resource utilization and coordination among stakeholders help to determine the best approach for implementing cost-effective POC testing. Technical advances in integrating appropriate biosensors with microfluidics-based devices hold promise for future real-time POC cortisol monitoring.
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Affiliation(s)
- Li-Sheng Chen
- a Bureau of Laboratories , Michigan Department of Health and Human Services , Lansing , MI , USA
| | - Ravinder J Singh
- b Laboratory Medicine and Pathology , Mayo Clinic , Rochester , MN , USA
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El-Husseini A, Wang K, Edon A, Saxon D, Lima F, Sloan D, Sawaya BP. Value of Intraoperative Parathyroid Hormone Assay during Parathyroidectomy in Dialysis and Renal Transplant Patients with Secondary and Tertiary Hyperparathyroidism. Nephron Clin Pract 2017; 138:119-128. [PMID: 29131092 DOI: 10.1159/000482016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/05/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND 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. METHODS 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. RESULTS In the dialysis group, the median (25th-75th percentile) pre-, 10-, and 20-ioPTH levels were 1,447 pg/mL (938-2,176), 143 pg/mL (78-244) and 112 pg/mL (59-153) respectively. In the renal transplant group, pre-, 10-, and 20-ioPTH levels were 273 pg/mL (180-403), 42 pg/mL (25-72), and 34 pg/mL (23-45) respectively. All patients in the transplant group had a functional kidney transplant at the time of PTX with a median serum creatinine of 1.3 mg/dL (1.2-1.7) and estimated glomerular filtration rate of 55 mL/min (40-60). The median time between renal transplant and PTX surgeries was 22 months (7-81). The last median follow-up PTH level was 66 pg/mL (15-201) in the dialysis group and 54 pg/mL (17-72) in the transplant group (p = 0.438). The mean time for last PTH post-PTX was 2.3 ± 2.0 years. In both groups, there was no significant difference between 20-ioPTH and any-time post-PTX PTH levels (p = 0.6 and p = 0.9). Nineteen patients (25%) were readmitted within 90 days because of hypocalcemia. One patient in the dialysis group was readmitted for post-PTX hematoma evacuation. No patient required repeat PTX because of recurrent HPT that was refractory to medical therapy. Only one dialysis patient required repeat PTX because the first procedure failed. CONCLUSIONS The 20-ioPTH is a good indicator of long-term PTH levels in dialysis and renal transplant patients. Hypocalcemia is a common complication, particularly in dialysis patients, and it is the main reason for readmission after PTX. Hypoparathyroidism is a potential concern after PTX in dialysis patients.
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Affiliation(s)
- Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA.,Division of Nephrology, Mansoura University, Mansoura, Egypt
| | - Kevin Wang
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Annick Edon
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - David Saxon
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Florence Lima
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - David Sloan
- Section of Endocrine Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - B Peter Sawaya
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
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Okada M, Tominaga Y, Yamamoto T, Hiramitsu T, Narumi S, Watarai Y. Location Frequency of Missed Parathyroid Glands After Parathyroidectomy in Patients with Persistent or Recurrent Secondary Hyperparathyroidism. World J Surg 2016; 40:595-9. [PMID: 26563219 DOI: 10.1007/s00268-015-3312-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Reoperative parathyroidectomy (RPTX) because parathyroid glands have been missed is frequently required in patients with secondary hyperparathyroidism (SHPT). The usual locations of these missed glands in patients with SHPT are yet to be fully elucidated. METHODS We retrospectively investigated the locations of missed glands in 165 patients who underwent RPTX for persistent or recurrent SHPT at our institution from August 1982 to July 2014. At our institution, total parathyroidectomy with forearm autograft is the routine operative procedure for SHPT. We also routinely resect the thymic tongue. RESULTS Of 165 patients, 82 underwent initial parathyroidectomy at our institution (Group A), and the remaining 83 underwent initial parathyroidectomy at other institutions (Group B). A total of 239 parathyroid glands were resected (Group A, 93; Group B, 146). Missed glands were most commonly located in the mediastinum (Group A, 22/93) and the thymic tongue (Group B, 31/146). CONCLUSIONS In patients with persistent or recurrent SHPT, ectopic parathyroid glands are frequently located in the mediastinum and thymic tongue. Therefore, resecting the thymic tongue during the initial operation may reduce the need for RPTX.
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Affiliation(s)
- Manabu Okada
- Department of Transplantation and Endocrine Surgery, Nagoya 2nd Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 466-8650, Japan.
| | - Yoshihiro Tominaga
- Department of Transplantation and Endocrine Surgery, Nagoya 2nd Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 466-8650, Japan
| | - Takayuki Yamamoto
- Department of Transplantation and Endocrine Surgery, Nagoya 2nd Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 466-8650, Japan
| | - Takahisa Hiramitsu
- Department of Transplantation and Endocrine Surgery, Nagoya 2nd Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 466-8650, Japan
| | - Shunji Narumi
- Department of Transplantation and Endocrine Surgery, Nagoya 2nd Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 466-8650, Japan
| | - Yoshihiko Watarai
- Department of Transplantation and Endocrine Surgery, Nagoya 2nd Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 466-8650, Japan
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Zhang L, Xing C, Shen C, Zeng M, Yang G, Mao H, Zhang B, Yu X, Cui Y, Sun B, Ouyang C, Ge Y, Jiang Y, Yin C, Zha X, Wang N. Diagnostic Accuracy Study of Intraoperative and Perioperative Serum Intact PTH Level for Successful Parathyroidectomy in 501 Secondary Hyperparathyroidism Patients. Sci Rep 2016; 6:26841. [PMID: 27231027 PMCID: PMC4882599 DOI: 10.1038/srep26841] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/09/2016] [Indexed: 11/15/2022] Open
Abstract
Parathyroidectomy (PTX) is an effective treatment for severe secondary hyperparathyroidism (SHPT); however, persistent SHPT may occur because of supernumerary and ectopic parathyroids. Here a diagnostic accuracy study of intraoperative and perioperative serum intact parathyroid hormone (iPTH) was performed to predict successful surgery in 501 patients, who received total PTX + autotransplantation without thymectomy. Serum iPTH values before incision (io-iPTH0), 10 and 20 min after removing the last parathyroid (io-iPTH10, io-iPTH20), and the first and fourth day after PTX (D1-iPTH, D4-iPTH) were recoded. Patients whose serum iPTH was >50 pg/mL at the first postoperative week were followed up within six months. Successful PTX was defined if iPTH was <300 pg/mL, on the contrary, persistent SHPT was regarded. There were 86.4% patients underwent successful PTX, 9.8% remained as persistent SHPT and 3.8% were undetermined. Intraoperative serum iPTH demonstrated no significant differences in two subgroups with or without chronic hepatitis. Receiver operating characteristic (ROC) curves showed that >88.9% of io-iPTH20% could predict successful PTX (area under the curve [AUC] 0.909, sensitivity 78.6%, specificity 88.5%), thereby avoiding unnecessary exploration to reduce operative complications. D4-iPTH >147.4 pg/mL could predict persistent SHPT (AUC 0.998, sensitivity 100%, specificity 99.5%), so that medical intervention or reoperation start timely.
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Affiliation(s)
- Lina Zhang
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Changying Xing
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Chong Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu Province, 211166, People's Republic of China
| | - Ming Zeng
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Guang Yang
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Huijuan Mao
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Bo Zhang
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Xiangbao Yu
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Yiyao Cui
- Department of General Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Bin Sun
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Chun Ouyang
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Yifei Ge
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Yao Jiang
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Caixia Yin
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Xiaoming Zha
- Department of General Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
| | - Ningning Wang
- Department of Nephrology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, People's Republic of China
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