Use of monitoring intraoperative parathyroid hormone during parathyroidectomy in patients on waiting list for renal transplantation

This report describes the use of intraoperative parathyroid hormone (ioPTH) assay during parathyroidectomy for patients with secondary hyperparathyroidism on the waiting list for renal transplantation. The levels of ioPTH were determined among waiting list patients undergoing subtotal parathyroidectomy and tertiary hyperparathyroidism patients undergoing procedures. The levels of ioPTH were significantly reduced at 10 minutes by 59.7,3% among with secondary hyperparathyroidism and 68.9% among tertiary hyperparathyroidism. A 15 minutes it was 85% in secondary hyperparathyroidism and 89.7% in tertiary hyperparathyroidism. A decrement of 50% in basal values at 10 minutes and 85% decrement or more at 15 minutes was predictive for the success of abnormal parathyroid gland removal. The application of this technique during subtotal parathyroidectomy results was useful to predict a correct excision of abnormal parathyroid glands among patients with secondary hyperparathyroidism on the waiting list and for tertiary hyperparathyroidism patients.     

Results of systematic subtotal parathyroidectomy with thymectomy for tertiary hyperparathyroidism after renal transplantation - 70 patients

BACKGROUND: Due to the relatively small number of patients involved, there is currently no consensus on what operation should be performed in patients with tertiary hyperparathyroidism after renal transplantation. METHOD: Retrospective analysis of the 70 patients with tertiary hyperparathyroidism who all underwent subtotal parathyroidectomy with transcervical thymectomy in the same institution between 1978 and 2003. RESULTS: The delay between transplantation and parathyroidectomy was 4,1+/-4,3 years. Follow up was available for all patients. Mean follow-up was 5,6+/-5 years. Glomerular filtration rate (GFR) was 53+/-21 ml/min at parathyroidectomy and 42+/-29 ml/min at follow-up [<30 ml/min in 26 patients (37%), 30 - 60 ml/min in 25 patients (36%) et>60 ml/min in 19 patients (27%)]. One patient was successfully reoperated for persistent tertiary hyperparathyroidism during follow-up. No patient was hypercalcemic at follow-up. Four patients with a GFR<30 ml/min had a PTH level>fourfold normal values (6%) without signs or symptoms of hyperparathyroidism. One patient was hypocalcemic (1,5%) and two patients were normocalcemic with undetectable or infranormal PTH level (3%) under oral vitamin D and calcium medication. CONCLUSION: This approach permits not only to cure the majority of patients with tertiary hyperparathyroidism but also to avoid recurrence when the renal function declines. When medical management has failed, we recommend systematic subtotal parathyroidectomy with thymectomy for patients with tertiary hyperparathyroidism and this should usually be performed during the second year after transplantation.     

Recurrent hyperparathyroidism.

Recurrent hyperparathyroidism occurred in 11 of 295 patients from 10 months to 34 years after an initially successful operation. Seven patients with recurrent hyperparathyroidism had either multiple endocrine adenomatosis type I (MEA) or familial hyperparathyroidism (FHP), one patient had parathyroid cancer, and two patients had renal failure at the time of recurrence. Four of these patients ahd their initial operations elsewhere. Recurrence developed in 33% of patients with MEA or FHP but in only 0.4% of 242 patients without MEA or FHP. The presence of MEA or FHP was known before parathyroid exploration in 18 (86%) of the 21 patients. In patients with MEA or FHP, subtotal parathyroidectomy should be performed if there is more than one gland involved. Other patients should be treated by selective removal of an adenoma because recurrence is rare. Subtotal parathyroidectomy should be reserved for patients with diffuse hyperplasia.     

Hyperparathyroidism associated with renal disease. Pathogenesis, natural history, and surgical treatment

Hyperparathyroidism associated with renal failure is due to chronic parathyroid stimulation by hypocalcemia, which, in turn, results from hyperphosphatemia and low circulating 1,25(OH)2D3. If prophylactic measures and medical treatment of hyperparathyroidism fail, parathyroidectomy should be performed to prevent the progression of bone disease. Resolution of renal hyperparathyroidism is often seen after kidney transplantation, but some hypercalcemic patients require prophylactic or therapeutic parathyroidectomy. Hypocalcemia is the most common complication after parathyroidectomy. Our long-term results with subtotal parathyroidectomy are satisfactory. Total parathyroidectomy plus parathyroid autograft should be used in selected cases.     

Surgical treatment of secondary hyperparathyroidism in hemodialyzed patients with chronic renal failure. Results and choice of a technic

Results are reported of surgical treatment of hyperparathyroidism secondary to chronic renal failure in 231 patients who had undergone 250 operations over 16 years: 152 total parathyroidectomies associated in 151 cases with an autotransplant, 58 subtotal parathyroidectomies, 9 incomplete parathyroidectomies, I white cervicotomy and 39 repeat operations for persistent or recurrent hyperparathyroidism. Results were evaluated clinically, biologically and radiologically after a mean follow up of 4 years, and were rated good in 71.4% of cases. The quality of the results was independent of the type of parathyroidectomy practised: 71% good results after total parathyroidectomy with autotransplantation and 69% after subtotal parathyroidectomy. No significant difference was demonstrated between the two techniques with respect to mortality, postoperative morbidity and late complications. The only divergence seen was in relation to recurrences: recovery surgery at the cervical level after subtotal parathyroidectomy leaving a clearly identified glandular stump associated with a better result than repeat operation on grafts at brachial level after total parathyroidectomy and autograft. These results led to the adoption of a surgical routine for hyperparathyroidism secondary to chronic renal failure using subtotal parathyroidectomy combined with bilateral thymectomy. The operation of total parathyroidectomy without immediate autotransplant is reserved for cervical recovery surgical procedures. Whatever the technique used, frozen storage of removed tissue is the indispensable complement of parathyroidectomy.     

Surgical management of persistence or recurrence after subtotal parathyroidectomy for primary hyperparathyroidism.

(1) In an experience with 44 patients requiring subtotal parathyroidectomy for primary hyperparathyroidism due to multiple gland involvement, persistence was identified in 3 patients and recurrence in 3, resulting in a failure rate of 14 per cent. (2) The development of chronic renal insufficiency secondary to hyperparathyroidism appears to be an aggravating factor in the failure of subtotal parathyroidectomy to control hypercalcemia in such cases. An associated MEN-1 syndrome may possibly also be a predisposing factor. (3) Overlooked supernumerary hyperfunctioning parathyroid glands may be the cause of persistent hypercalcemia. (4) If reoperation is performed, ultrasonography of the neck and computerized tomography of the mediastinum are justified preoperatively for localization studies. (5) If hyperplasia of the preserved remnant of parathyroid is the only explanation for failure of subtotal parathyroidectomy, its removal is justified with autotransplantation of parathyroid tissue and freezing of additional tissue for possible future use. (6) The presence of moderate or severe chronic renal insufficiency, related to primary hyperparathyroidism, appears to justify total parathyroidectomy with autotransplantation for primary hyperparathyroidism due to multiple gland involvement. (7) Periodic reevaluation is indicated for all patients after operation, especially subtotal parathyroidectomy, for primary hyperparathyroidism due to multiple gland involvement. If mild or borderline hypercalcemia persists or recurs, close follow-up study is indicated.     

Ectopic and supernumerary parathyroid glands in patients with refractory renal hyperparathyroidism

BackgroundThe aims of this study were to determine the rate of ectopic and supernumerary parathyroid glands and the outcome of surgical therapy in patients with refractory renal hyperparathyroidism.Materials and MethodsA retrospective review of all patients who underwent parathyroidectomy for refractory renal hyperparathyroidism was completed. Operative and pathology reports were reviewed, and the number and location of resected parathyroid glands, patient outcomes, and follow-up were determined.ResultsDuring the period 1993–2019, a total of 68 patients underwent subtotal or total parathyroidectomy for renal hyperparathyroidism. Of those, 59 patients (87%) were on dialysis for an average of 6.7 years. We determined that 18 patients (26%) had 24 ectopic parathyroid glands, including 9 (13%) patients with 11 supernumerary glands. A total of 2 patients had a supernumerary gland in a normal anatomic location. Of the 24 ectopic glands, 14 (58%) were in the thymus. After parathyroidectomy, 4 patients (5.9%) had persistent hyperparathyroidism, 6 patients (8.8%) developed recurrent hyperparathyroidism, and 2 patients (3%) had permanent hypoparathyroidism.ConclusionEctopic and supernumerary parathyroid glands occurred in 26% and 16% of patients with renal hyperparathyroidism, respectively, and the thymus was the most common location. Thorough neck exploration and transcervical thymectomy are important to help reduce persistent and recurrent hyperparathyroidism after parathyroidectomy for renal hyperparathyroidism.     

Optimal extent of initial parathyroid resection in patients with multiple endocrine neoplasia syndrome type 1: A meta-analysis

BackgroundHyperparathyroidism is an almost universal feature of multiple endocrine neoplasia type 1 syndrome. We present a systematic review and meta-analysis of the postoperative outcomes of patients undergoing initial operative treatment of primary hyperparathyroidism complicating multiple endocrine neoplasia 1.MethodsA comprehensive literature search was performed with a priori defined exclusion criteria for studies comparing total parathyroidectomy, subtotal parathyroidectomy, and less than subtotal parathyroidectomy.ResultsTwenty-one studies incorporating 1,131 patients (272 undergoing total parathyroidectomy, 510 subtotal parathyroidectomy, and 349 less than subtotal parathyroidectomy) were identified. Pooled results revealed increased risk for long-term hypoparathyroidism in total parathyroidectomy patients (relative risk 1.61; 95% confidence interval, 1.12?2.31; P = .009) versus those undergoing subtotal parathyroidectomy. In the less than subtotal parathyroidectomy or subtotal parathyroidectomy comparison group, a greater risk for recurrence of hyperparathyroidism (relative risk 1.37; 95% confidence interval, 1.05?1.79; P = .02), persistence of hyperparathyroidism (relative risk 2.26; 95% confidence interval, 1.49?3.41; P = .0001), and reoperation for hyperparathyroidism (relative risk 2.48; 95% confidence interval, 1.65?3.73; P < .0001) was noted for less than subtotal parathyroidectomy patients, albeit with lesser risk for long-term for hypoparathyroidism (relative risk 0.47; 95% confidence interval, 0.29?0.75; P = .002).ConclusionSubtotal parathyroidectomy compares favorably to total parathyroidectomy, exhibiting similar recurrence and persistence rates with a decreased propensity for long-term postoperative hypoparathyroidism. The benefit of the decreased risk of hypoparathyroidism in less than subtotal parathyroidectomy is negated by the increase in the risk for recurrence, persistence, and reoperation. Future studies evaluating the performance of less than subtotal parathyroidectomy in specific multiple endocrine neoplasia 1 phenotypes should be pursued in an effort to delineate a patient-tailored, operative approach that optimizes long-term outcomes.     

Novel parathyroid hormone (1-84) assay as basis for parathyroid hormone monitoring in renal hyperparathyroidism

HYPOTHESIS: Cross-reactivity of parathyroid hormone (PTH) fragments with immunometric "intact" PTH assays limited the use of intraoperative PTH monitoring in renal hyperparathyroidism. A new assay generation measuring whole PTH (1-84) should be able to predict complete or incomplete resection of hyperfunctioning parathyroid tissue. DESIGN: Consecutive series for evaluation of intraoperative PTH monitoring using a second-generation assay. SETTING: University hospital section of endocrine surgery. PATIENTS: Twenty-two patients received hemodialysis; 9 patients showed good and 4 patients reduced graft function after kidney transplantation. INTERVENTIONS: Total parathyroidectomy, central neck dissection, bilateral thymectomy, and immediate autotransplantation was the standardized approach in 35 consecutive patients. Blood samples were drawn before incision and at 5-minute intervals after excision of the last gland. Stored samples were analyzed using a "second-generation" assay (Bio-Intact PTH [1-84]; Nichols Institute Diagnostics, San Clemente, Calif). Parathyroidectomy was classified as total, subtotal, or insufficient according to first-generation intact PTH values in the first postoperative week. MAIN OUTCOME MEASURES: Intraoperative ability to predict total, subtotal, or incomplete parathyroidectomy. RESULTS: Independent of renal function, Bio-Intact PTH dropped into the normal range in all patients with total and subtotal resections after a maximum of 20 minutes. It indicated insufficient parathyroidectomy in 4 (80%) of 5 patients. One failure was caused by devascularization of remaining parathyroid tissue. An intraoperative differentiation between total and subtotal resection was not possible. CONCLUSIONS: Intraoperative monitoring with quick, second-generation assays for PTH (1-84) seems to be a valuable new tool in surgery for renal hyperparathyroidism because a more accurate differentiation between sufficient and insufficient parathyroidectomy may be achieved. An intraoperative decision about the need for immediate or delayed autotransplantation seems impossible because a differentiation between total or subtotal parathyroidectomy cannot be made. Because of possible devascularization of parathyroid tissue, Bio-Intact PTH monitoring can only be interpreted in the context of the operative findings.     

Secondary and tertiary hyperparathyroidism: causes of recurrent disease after 446 parathyroidectomies

OBJECTIVE: To determine, in a series of patients with secondary and tertiary parathyroid hyperplasia, whether the type of parathyroidectomy (subtotal, total with autotransplantation, or total), the histologic pattern of the parathyroid tissue, or the proliferative index, as determined by Ki-67 analysis, could predispose patients to recurrent hyperparathyroidism. SUMMARY BACKGROUND DATA: Recurrent hyperparathyroidism appears in 10--70% of the patients undergoing surgery for secondary or tertiary hyperparathyroidism. The incidence could be related to the type of operation (Rothmund) but also depends on the histologic pattern of the glands removed (Niederle). METHODS: The retrospective investigation was performed on 446 patients undergoing parathyroid surgery. They were also studied in relation to the possibility of renal transplantation. In this population, two homogeneous groups were subsequently identified (23 patients with clear signs of recurrence and 27 patients apparently cured); they were studied from the histologic and immunohistochemical point of view using antibody to Ki-67 antigen. RESULTS: Subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, and total parathyroidectomy produced similar results when considering the regression of osteodystrophy, pruritus, and ectopic calcification. As one could anticipate, total parathyroidectomy increased the incidence of hypoparathyroidism. The percentage of recurrence was 5% to 8% after subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, and total parathyroidectomy, and only after incomplete parathyroidectomy did this percentage climb to 34.7%. In the recurrence group, the nodular form was more common and the proliferative fraction detected by Ki-67 was 1.9%; it was 0.81% in the control group. CONCLUSIONS: Because more radical procedures were not more effective, the authors favor a less radical procedure such as subtotal parathyroidectomy. Histologic patterns and proliferative fraction could be useful indices of a recurrence, and these patients should be watched closely after surgery.     

Outcome of parathyroidectomy for patients with renal disease and hyperparathyroidism: predictors for recurrent hyperparathyroidism

Background: A small group of patients with renal disease‐related secondary or tertiary hyperparathyroidism require surgical parathyroidectomy. Among them, 5–20% require further re‐exploration and excision of parathyroid tissue because of recurrent disease. The aims of the present study were to review the characteristics and outcomes of patients undergoing parathyroidectomy for renal disease related hyperparathyroidism and to identify the risk factors for recurrent hyperparathyroidism. Methods: Review of data from a dedicated head and neck database at Royal Prince Alfred Hospital between 1988 and 2004. Results: There were 115 patients of whom 68 (59%) patients were treated with subtotal parathyroidectomy (STP), 43 (37%) were treated with total parathyroidectomy (TP) and 4 (3%) were treated with TP with autotransplant. Of those, 11 (9.6%) patients developed recurrent hyperparathyroidism (9 had STP, 1 had TP and 1 had TP with autotransplant). On re‐exploration, persistent hyperplastic parathyroid tissue was located at the site of partially excised parathyroid gland (64%), autotransplanted parathyroid tissue (9%), anterior mediastinum (18%) and intrathyroidal parathyroid (9%). Predictors for recurrent hyperparathyroidism are STP (P= 0.049), preoperative symptom of calciphylaxis or calcinosis (P= 0.024), elevated preoperative calcium level (P= 0.007) and elevated post‐operative PTH levels (P= 0.014). Post‐operative PTH levels less than 10 pmol/L has a positive predictive value of 97.5% for cure (P= 0.02). Conclusion: More aggressive surgical approach could be indicated in patients with preoperative hypercalcaemia and calcinosis/calciphylaxis. Post‐operative PTH can be utilized as a marker for cure after parathyroidectomy in hyperparathyroidism of renal disease.     

Diagnosis and surgical treatment of renal hyperparathyroidism

Forty-three patients with chronic renal failure and secondary hyperparathyroidism underwent parathyroid surgery. The first 20 patients were submitted to subtotal parathyroidectomy, and the last 23 patients underwent total parathyroidectomy and parathyroid autotransplantation in the forearm. Non-invasive image diagnosis, CT, ultrasonography and scintigraphy are valuable for 1) making a definite diagnosis of secondary hyperparathyroidism, 2) locating the tumor 3) determining the effectiveness of treatment, and 4) differentially diagnosing thyroid tumors. For surgical treatment, we recommend total parathyroidectomy and autotransplantation in the forearm because the second operation for recurrence may be done more safely and easily than after subtotal parathyroidectomy.     

Reoperation for secondary uremic hyperparathyroidism: are technical difficulties influenced by initial surgical procedure?

BACKGROUND: Parathyroid surgery in patients with uremia and secondary hyperparathyroidism is performed either by subtotal parathyroidectomy or total parathyroidectomy with immediate reimplantation. The aim of this study was to compare the results of reoperation for persistent or recurrent hyperparathyroidism after parathyroidectomy according to which initial operative procedure was used. PATIENTS AND METHODS: Eighty-nine patients had reoperation for persistent (28 patients) or recurrent (61 patients) hyperparathyroidism after 53 subtotal parathyroidectomies and 36 total parathyroidectomies with immediate reimplantation. Results of the reoperation were assessed in terms of success rate, morbidity, and operative findings. RESULTS: The success rate of reoperation in patients with persistent hyperparathyroidism was 89% and was independent of the initial type of surgery. Success rates of reoperation for recurrent hyperparathyroidism after initial subtotal parathyroidectomy and total parathyroidectomy with immediate reimplantation were 87% and 70%, respectively (P = .02). Hypertrophy of the parathyroid remnant was the main cause of recurrence after subtotal parathyroidectomy. After total parathyroidectomy with immediate reimplantation, recurrence was located in the graft in half the patients, while hyperplastic tissue was found in the neck or the mediastinum in the other half. CONCLUSIONS: Subtotal parathyroidectomy provides the best conditions for successful reoperation in case of recurrent hyperparathyroidism and should become the surgical treatment of choice for secondary hyperparathyroidism.     

Assessment of ultrasound guided percutaneous ethanol injection and parathyroidectomy in patients with tertiary hyperparathyroidism

Background. Tertiary hyperparathyroidism continues to cause significant morbidity in patients with chronic renal failure. This is frequently resistant to medical management and may ultimately require a surgical parathyroidectomy. Recent studies have reported upon the technique of percutaneous ethanol ablation for both primary and tertiary hyperparathyroidism. In this study we report on a 5 year experience using ethanol injection and compare the results with surgical parathyroidectomy. Methods. A prospective study in 39 patients with tertiary hyperparathyroidism, 25 were dialysis dependent and 14 had a functioning renal allograft. Twenty-two patients underwent percutaneous fine needle ethanol injection (PFNEI) and 17 underwent surgical parathyroidectomy. Results. A >30% reduction in intact parathyroid hormone (iPTH) was achieved in 11 of 22 patients undergoing PFNEI after a mean of 1.8±1.4 injections per gland. In four patients, symptomatic hyperparathyroidism recurred and they required further PFNEI or surgical parathyroidectomy at 17, 28, 46, and 48 months later. There was no significant reduction in iPTH in 11 patients following PFNEI after a mean of 2.5±1.3 injections per gland. They all required a subsequent surgical parathyroidectomy for symptomatic hyperparathyroidism. Four patients developed a laryngeal nerve palsy following PFNEI, two of which were permanent. Seventeen patients underwent successful surgical parathyroidectomy as a primary procedure. Conclusion. Whilst PFNEI is successful in primary hyperparathyroidism, when typically only one adenoma is present, the effectiveness of PFNEI is unpredictable and the long term results are poor compared with those of surgical parathyroidectomy in tertiary hyperparathyroidism. The procedure is not without complications and makes subsequent surgery more difficult. Therefore it can only be recommended for patients with a known single parathyroid gland such as patients in whom hyperparathyroidism has recurred following a previous surgical subtotal parathyroidectomy and who are unsuitable for further surgery.     

Long-term follow-up of patients with tertiary hyperparathyroidism treated by resection of a single or double adenoma

OBJECTIVE: To determine whether patients with tertiary hyperparathyroidism due to single- or two-gland disease undergoing limited resection have similar long-term outcomes compared with patients with hyperplasia undergoing subtotal or total parathyroidectomy. SUMMARY BACKGROUND DATA: Tertiary hyperparathyroidism occurs in less than 2% of patients after renal transplantation. Approximately 30% of these cases are caused by one or two hyperfunctioning glands. Nevertheless, the standard operation for this disease has been subtotal or total parathyroidectomy with autotransplantation. METHODS: Seventy-one patients underwent surgery for tertiary hyperparathyroidism. At the time of surgery, 19 patients who had a single or double adenoma underwent limited resection of the enlarged glands only (adenoma group). The remaining 52 patients with three- or four-gland hyperplasia had subtotal or total parathyroidectomy with implantation (hyper group). Long-term cure rates between the two groups were compared. RESULTS: In the adenoma group, 7 patients had a single adenoma and 12 underwent resection of a double adenoma. In the hyper group, 49 patients had subtotal and 3 had total parathyroidectomies. After surgery, 70 of 71 patients (99%) were cured of their hypercalcemia. The incidence of postoperative transient hypocalcemia was significantly higher in the hyper group (27% vs. 5%). No patients in either group had permanent hypocalcemia requiring long-term supplementation. With up to 16 years of follow-up, there have been no recurrences in the adenoma group, whereas three patients (6%) in the hyper group have had recurrent or persistent hyperparathyroidism. CONCLUSIONS: Patients with tertiary hyperparathyroidism who underwent limited resection of a single or double adenoma only had equivalent long-term cure rates compared with patients undergoing more extensive resections. Therefore, the authors recommend in patients with tertiary hyperparathyroidism and enlargement of only one or two parathyroid glands that the resection be limited to these abnormal glands only.     

Parathyroidectomy in chronic renal failure

Between 1978 and 1984, 19 patients at Royal Perth Hospital (RPH) underwent parathyroidectomy for secondary (renal) hyperparathyroidism. This represented 6.0% of the overall dialysis population treated at RPH during this period of time. The mean duration of pre-operative dialysis for these 19 patients was 48 months, compared with a mean duration of 30 months for the overall dialysis population. The principal indications for parathyroidectomy were symptomatic hyperparathyroid bone disease (10), hypercalcaemia (six), progressive lower limb ischaemia (two) and painful peri-articular calcification (one). The complications of chronic renal failure that were most consistently improved by parathyroidectomy were the clinical, radiological and biochemical manifestations of hyperparathyroid bone disease and hypercalcaemia. Features such as pruritus, soft tissue calcification, vessel wall calcification and peripheral ischaemia responded less predictably. Hyperparathyroid bone disease and hypercalcaemia remain the principal indications for parathyroidectomy in chronic renal failure. Profound postoperative hypocalcaemia was the major early postoperative management problem (seven patients) and was closely linked with the severity of pre-operative hyperparathyroid bone disease. It was also seen more frequently in those patients undergoing total parathyroidectomy with immediate autotransplantation of parathyroid tissue (TP-A), than in those in whom residual parathyroid tissue was left in situ (subtotal parathyroidectomy or STP). Recurrent hyperparathyroidism (four patients) was the major late postoperative complication, but was more frequently the result of a supernumerary or previously overlooked fourth parathyroid gland (three), than due to hyperplasia of residual parathyroid tissue (one). STP and TP-A were equally effective in controlling or reversing renal hyperparathyroidism, but the former was associated with a lower incidence of postoperative management problems and should be the preferred operation in this group of patients.     

Frequency of Ectopic and Supernumerary Intrathymic Parathyroid Glands in Patients with Renal Hyperparathyroidism: Analysis of 461 Patients Undergoing Initial Parathyroidectomy with Bilateral Cervical Thymectomy

Background  

The frequency of intrathymic parathyroid glands (IPGs) in patients undergoing parathyroidectomy for renal hyperparathyroidism (rHPT) varies considerably between 14.8% and 45.3%. Total parathyroidectomy with autotransplantation and subtotal parathyroidectomy are the most accepted surgical procedures to treat patients with rHPT. However, routine bilateral cervical thymectomy (BCT) is still discussed, although controversially.     

Long-term results of a randomized study comparing parathyroidectomy with cinacalcet for treating tertiary hyperparathyroidism

Tertiary hyperparathyroidism is a common cause of hypercalcemia after kidney transplantation (KT) and has been associated with renal dysfunction, bone mineral density loss, and increased risk of fracture and cardiovascular events. In a previous 12-month clinical trial, we demonstrated that subtotal parathyroidectomy was more effective than cinacalcet for controlling hypercalcemia. In the current study, we retrospectively evaluate whether this effect is maintained after 5 years of follow-up. In total, 24 patients had data available at 5 years, 13 in the cinacalcet group and 11 in the parathyroidectomy group. At 5 years, 7 of 11 patients (64%) in the parathyroidectomy group and 6 of 13 patients (46%) in the cinacalcet group (P = .44) showed normocalcemia. However, recurrence of hypercalcemia was only observed in the cinacalcet group (P = .016). Subtotal parathyroidectomy retained a greater reduction in intact parathyroid hormone (iPTH) compared with cinacalcet group. No differences were observed in kidney function and incidence of fragility fractures between both groups. Cinacalcet was discontinued in 5 out of 13 patients. In conclusion, in kidney transplant patients with tertiary hyperparathyroidism recurrence of hypercalcemia after 5-year follow-up is more frequent in cinacalcet than after subtotal parathyroidectomy.     

Subtotal parathyroidectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism

A retrospective review of patients treated for secondary hyperparathyroidism by total parathyroidectomy with parathyroid autotransplantation (tPTX) and subtotal parathyroidectomy (sPTX) is presented. Ten patients underwent tPTX, and 22 patients underwent sPTX between 1977 and 1982. Hypocalcemia and complications of its treatment were a problem in the tPTX patients. One patient in the tPTX group and no patients in the sPTX group have required reoperation for recurrence. Both procedures were highly successful in relieving symptoms of secondary hyperparathyroidism and in reversing renal osteodystrophy. The authors believe that sPTX is a proven, effective operation and the operative treatment of choice for secondary hyperparathyroidism.     

Parathormone levels after subtotal and total (autotransplantation): Parathyroidectomy for secondary hyperparathyroidism

To compare results of subtotal versus total parathyroidectomy with autotransplantation in dialysis patients with secondary hyperparathyroidism, pre- and postoperative calcium, phosphorus, alkaline phosphatase, and immunoreactive parathormone (iPTH) were measured. In eight patients with subtotal parathyroidectomy, the mean preoperative iPTH of 903 ± 139 μl-eq/ml decreased to a mean of 26.6 ± 9 μl-eq/ml, 6 to 29 months postoperatively. In six patients with total parathyroidectomy and autotransplantation the mean preoperative iPTH of 1289 ± 248 μl-eq/ml decreased to a mean peripheral iPTH of 32 ± 7 μl-eq/ml, 4 to 18 months postoperatively. Both groups were similar in (1) pre- and postoperative iPTH levels, (2) the absence of postoperative clinical or chemical hyperparathyroidism, (3) improvement in symptoms, and (4) demonstrable functioning parathyroid tissue. None of the patients required reexploration for persistent hyperparathyroidism. Subtotal parathyroidectomy and total parathyroidectomy with autotransplantation appear to be equally effective modalities for treatment of secondary hyperparathyroidism in patients with end-stage renal disease.