Results and complications of parathyroidectomy in secondary hyperparathyroidism

Retrospective study was performed to measure the results of parathyroidectomy in patients with secondary hyperparathyroidism. From 1987 to 2000, 48 patients underwent surgery for secondary hyperparathyroidism. There were 30 of 48 patients on haemodialysis treatment, and 11 patients were in pre-dialysis stage. Parathyroidectomy was performed after successful kidney transplantation in 4 cases. Indication of the surgery was extremely elevated serum level of parathyroid hormone (at least 10 fold elevation), which was resistant for the conservative medical therapy. Subtotal parathyroidectomy (3 1/2) was performed in 30 patients. Five patients underwent total parathyroidectomy and autotransplantation. Only 2 or 3 parathyroid glands have been removed in 13 patients. Haematoma occurred in 3 cases after parathyroidectomy. Recurrent nerve injury or septic complication did not occur. Two patients died in the early postoperative period due to cardiac failure. Tetania was noted in 2 patients after surgery. Permanent postoperative hypocalcaemia (over 6 months) occurred in 3 cases. Persistent hyperparathyroidism was diagnosed in 5 patients. In these patients 2 parathyroid glands were removed during the primary operation. Recurrent hyperparathyroidism was detected in 2 patients. Subtotal parathyroidectomy was carried out in these cases previously. At the reoperation for persistent and recurrent hyperparathyroidism, total parathyroidectomy and autotransplantation was performed. Serum alkaline phosphatase level and serum parathyroid hormone value decreased after surgery, except those patients with persistent hyperparathyroidism. Bone pain decreased in 96% of the cases and pruritus decreased in 92% of the patients after parathyroidectomy. Soft tissue calcification showed improvement in 45% of cases. In conclusion, the subtotal parathyroidectomy or total parathyroidectomy with autotransplantation cause a rapid decrease of PTH level and the improvement of the clinical symptoms in patients with medical treatment resistant secondary hyperparathyroidism. Persistent hyperparathyroidism occurs in those cases when inadequate parathyroidectomy was performed.     

Total Parathyroidectomy and Autotransplantation by the Subcutaneous Injection Technique in Secondary Hyperparathyroidism

PURPOSE: To prospectively assess the effectiveness of total parathyroidectomy and autotransplantation using a subcutaneous injection technique to treat secondary hyperparathyroidism. METHODS: We used this method to treat 14 patients with secondary hyperparathyroidism. The short-term outcome, up to 16 months after surgery, was monitored by measuring calcium, inorganic phosphorus, intact parathyroid hormone (iPTH), and alkaline phosphatase levels. We considered a graft viable when the ratio of iPHT in antecubital venous blood from the grafted arm to that from the nongrafted arm exceeded 1.5. RESULTS: Autografted parathyroid tissue was functional in 12 (85.7%) patients. An iPTH ratio > or =1.5 in the grafted arm relative to the nongrafted arm was observed from 2 weeks after surgery, peaking at 1 month. The grafted tissue continued to be biochemically functional 16 months after surgery in 12 patients. CONCLUSION: These findings suggest that total parathyroidectomy and forearm autotransplantation using the subcutaneous injection technique is a possible alternative to Wells' method for surgical treatment of secondary hyperparathyroidism.     

Intraoperatives Parathormonmonitoring bei der Halsexploration wegen renalem Hyperparathyreoidismus?

Introduction. In operations for renal hyperparathyroidism the value of intraoperative parathormone monitoring was investigated. Patients and methods. Intraoperative intact parathyroid hormone levels were determined (PTH Quick assay) in 40 patients undergoing first cervical exploration and in two patients with graft-dependent recurrence of renal hyperparathyroidism. Results. In 33 patients, total parathyroidectomy with autotransplantation was carried out. The median parathormone levels decreased from 652 pg/ml to 120 pg/ml (19% of initial level) 5 min after total parathyroidectomy. In seven patients, fewer than 4 parathyroid glands each were identified during cervical exploration and “total parathyroidectomy (?)” without autotransplantation was performed. Intraoperatively median parathormone level decreased from 1193 pg/ml to 116 pg/ml (10% of initial level). In one of these seven patients, hyperparathyroidism persisted due to an ectopic fourth gland within the carotid sheath. In two of these patients, hypoparathyroidism occurred and a delayed autotransplantation of cryopreserved parathyroid tissue was carried out. On the first day after total parathyroidectomy with autotransplantation and “total parathyroidectomy (?)”, median levels of intact parathyroid hormone were 1.9 pg/ml and 82.5 pg/ml, respectively. Conclusion. Intraoperative monitoring is not useful in first cervical exploration for renal hyperparathyroidism because it cannot predict complete resection of parathyroid tissue. The parathormone level on the first postoperative day allows precise evaluation of the efficacy of the surgical procedure.     

Severe primary hyperparathyroidism in a neonate having a parent with hypercalcemia: treatment by total parathyroidectomy and simultaneous heterotopic autotransplantation

Neonatal primary hyperparathyroidism is a life-threatening disease because of marked hypercalcemia and severe respiratory distress caused by the hypoplastic thorax and occasional rib fractures. We report a 29-day-old girl treated by total parathyroidectomy and simultaneous autotransplantation of parathyroid tissue (one fifth of each of the two glands) in the femoral quadriceps muscle near the groin. At the time of operation, all four of the parathyroid glands were markedly enlarged, and their total weight was 900 mg. Part of the resected parathyroid tissue was cryopreserved for further autotransplantation should hypoparathyroidism develop. Two years six months after surgery, the infant was well and had normal levels of serum calcium and immunoreactive parathyroid hormone in the absence of any supplementary treatment. Asymptomatic hypercalcemia in the presence of abnormally low fractional excretion of calcium was found in the father. Based on our experience and review of the literature, we recommend total parathyroidectomy, autotransplantation, and cryopreservation for the neonate with primary hyperparathyroidism.     

Clinical study of parathyroidectomy of secondary hyperparathyroidism in patients with chronic renal failure]

We performed parathyroidectomy for renal osteodystrophy due to secondary hyperparathyroidism on 16 patients with chronic renal failure who were refractory to medical management; subtotal parathyroidectomy on one patient and total parathyroidectomy with autotransplantation on 15 patients. Postoperative clinical improvement, i.e., bone and/or joint pain, pruritus and radiographic signs of renal osteodystrophy, was marked. After the operation, serum calcium decreased rapidly and adequate calcium replacement therapy was necessary. The levels of intact parathyroid hormone decreased rapidly and serum concentration of alkaline phosphatase gradually decreased for a few months postoperatively. Recurrence was diagnosed in one patient, who underwent excision of the transplanted parathyroid tissue. Osteomalasia due to hypoparathyroidism was not seen clinically in this series. In preoperative image diagnosis, ultrasonotomogram (US) showed the highest detective rate of the enlarged parathyroid glands. However, combination of US, computerized tomography and 99mTcO4(-)-201T1C1 scintigram can be recommended as a localizing diagnostic method for compensating the disadvantages of each method. Clinical results after parathyroidectomy for secondary hyperparathyroidism are considered to be good. However, long-term followup is mandatory for early detection of persistent hyperparathyroidism or hypoparathyroidism.     

Total parathyroidectomy and autogenous parathyroid graft placement for treatment of hyperparathyroidism due to chronic renal failure

We treated 33 patients with chronic renal insufficiency and severe hyperparathyroidism with total parathyroidectomy and placement of an autogenous parathyroid graft in the forearm musculature. Postoperative biochemical data, symptomatic data, or both were available in 28 of the patients, of whom all but 1 showed evidence of improvement. Immunoreactive parathyroid hormone studies were made from 9 to 52 months postoperatively in 22 patients. Background immunoreactive parathyroid hormone levels markedly decreased after surgery and were in the optimum range in 18 patients. In the other four patients, immunoreactive parathyroid hormone levels remained above the optimum range, but in only one of the four did symptoms and biochemical parameters fail to improve. Gradients for immunoreactive parathyroid hormone across the forearm musculature were demonstrable in 18 of 22 patients, which proved the secretory function of the graft. One patient required resection of a portion of the grafted tissue on two occasions because of recurrent hypercalcemia. The technique of total parathyroidectomy and autogenous parathyroid grafting seems to be a valid alternative to subtotal parathyroidectomy for the treatment of uremic secondary hyperparathyroidism.     

Transplantation of the parathyroid glands in man: clinical indications and results.

The physiologic function of human parathyroid autografts and allografts has not been demonstrated conclusively. During the past 30 months, we have transplanted parathyroid glands in 29 patients and tested their functional status. One immunosuppressed aparathyroid patient received a parathyroid allograft from a parent who previously had been his renal transplant donor. Twenty-seven patients with renal failure and secondary hyperparathyroidism received parathyroid autografts immediately after total parathyroidectomy, and one patient received a parathyroid autograft at the time of total parathyroidectomy for primary chief cell hyperplasia. At transplantation 1 times 1 mm. parathyroid pieces were grafted into the forearm musculature. Of 11 transplanted patients (one allograft and ten autografts) followed for 1 year, ten are normocalcemic; only two (autografted patients) are on supplemental calcium. Ten of the 29 patients have had biopsies performed, and all have had intact parathyroid architecture and intracellular secretory granules demonstrated by light and electron microscopy. Parathyroid hormone content in the grafted tissue of five patients was 179 plus or minus 118.8 ng. per milligram. In 11 random patients in whom bilateral measurements have been made, the parathyroid hormone content in the antecubital vein blood draining the grafted tissue has been markedly higher than that in the simultaneously sampled antecubital vein blood of the nongrafted arm. These data demonstrate that parathyroid autografts or allografts secret hormone and maintain a normal serum calcium in the host.     

Surgical significance of undescended parathyroid gland in renal hyperparathyroidism

BACKGROUND: In renal hyperparathyroidism, in which basically all parathyroid glands are hyperplastic, overlooking one undescended parathyroid gland becomes important. METHODS: Between July 1973 and December 2004, 1750 patients in our department underwent parathyroidectomy for severely advanced renal hyperparathyroidism. We evaluated the frequency and location of undescended parathyroid glands and the clinical findings and the prognosis of patients with such glands. RESULTS: Undescended parathyroid glands in our series of renal hyperparathyroidism numbered 16 of 1750 cases (0.91%). In 9 patients, the glands were removed at the initial parathyroidectomy in our hospital. Two of these glands were detected by preoperative imaging; 6 glands were removed with an undescended thymus. The mean weight of the undescended parathyroid glands that were removed at initial operations was 470 mg (30 to 1392 mg). In 7 other patients, unrecognized undescended glands were responsible for persistent hyperparathyroidism in 6 patients and recurrent disease in 1 patient. In 4 of these 7 patients, the initial parathyroidectomy was performed at our hospital; in the other 3 patients, the initial parathyroidectomy had been done at another hospital, and the glands were removed on reoperation. The mean weight of these glands was 1295 mg (range, 444-2396 mg). In 12 of a total of 16 patients with undescended glands, there appeared to be an inferior parathyroid gland, and the other 4 glands appeared to be a superior gland. No glands were detected by sestamibi scans. CONCLUSION: In operations for renal hyperparathyroidism, an undescended parathyroid gland can be readily overlooked, which leads to persistent or recurrent hyperparathyroidism. Because an undescended parathyroid gland is not always an inferior gland, in surgery for persistent and/or recurrent renal hyperparathyroidism, it is very important to examine carefully the submandibular portion to detect such an undescended gland.     

Parathyroid autotransplantation. An investigation of parathyroid autograft function

During a four-year period, 27 patients underwent total parathyroidectomy with autotransplantation of parathyroid tissue to the forearm. In order to minimize the risk of persistent or recurrent hyperparathyroidism (HPT), a routine thymic resection and a wide excision of fat tissue around the parathyroids was performed to ensure excision of possible supernumerary glands or rudimentary parathyroid tissue. The indications for operation were HPT secondary to chronic renal failure in 24 patients (22 of whom had hypercalcaemia) and persistent or recurrent primary HPT in 2 cases. One further patient, who had a multiple endocrine neoplasia syndrome type I, underwent this procedure at the primary parathyroid operation. Preoperative hypercalcaemia was reversed in all patients but three during the first postoperative days, concomitantly with a fall in the parathyroid hormone (PTH) level. Fourteen patients showed marked hypocalcaemia postoperatively, necessitating calcium or vitamin D supplementation. This medication could later be discontinued in all of them. Thirteen patients, including two of those with primary HPT, never required any supplemental therapy. Survival of the grafts was documented by several observations. In all patients normal serum calcium values were being maintained without supplemental therapy at follow-up. During induced hypocalcaemia a PTH secretory response was demonstrated in all eight studied patients with a gradient between the grafted and non-grafted arm. In two patients in whom the grafts were examined histologically 19 and 28 months after the transplantation, viable parathyroid tissue was observed. In the initial part of the study excised tissue was cryopreserved. Since persistent hypocalcaemia did not occur in our patients, we have now abandoned this safety precaution. Thus, total parathyroidectomy with autotransplantation of parathyroid tissue is a valuable method for restoring long-term parathyroid function in patients with secondary HPT and uraemia. It also appears of value in selected cases of primary HPT.     

Total parathyroidectomy without autotransplantation as a standard procedure in the treatment of secondary hyperparathyroidism

BACKGROUND: Total parathyroidectomy with autografting of parathyroid tissue and subtotal resection of the parathyroid glands are currently considered as standard surgical procedures for the treatment of severe secondary hyperparathyroidism. However, a considerable recurrence rate following these procedures ranges from 5% to 80%. We present a retrospective analysis of the results of parathyroidectomy with autotransplantation to the forearm versus parathyroidectomy alone. PATIENTS AND METHODS: We analyzed the clinical course of 11 consecutive patients who had undergone parathyroidectomy between 1995 and 1999, and who were not simultaneously autografted. Controls were 11 patients in whom autotransplantation of parathyroid tissue into the forearm had been routinely performed between 1993 and 1996 at our institution. Clinical symptoms and recurrence of hyperparathyroidism were assessed for comparison of the alternative treatment modalities. Recurrence of disease was defined by elevated parathormone (PTH) levels (>7.6 pmol/l) with clinical symptoms and/or need for reoperation. RESULTS: No recurrence of hyperparathyroidism was observed in patients without autotransplantation after a mean follow-up of 23 months (range 1-49). Measurement of intact serum PTH revealed residual PTH secretion even after removal of four glands (mean 2.02 pmol/l). Clinical symptoms improved substantially after surgery. In the historical control group 3 of the 11 autotransplanted patients (27%) required resection of transplanted tissue. Additionally, two patients (18%) presented with increased PTH secretion and clinical symptoms of recurrent hyperparathyroidism during follow-up. Thus, a total of five patients (45%) experienced relapsing hyperparathyroidism caused by the implanted tissue. CONCLUSIONS: Total parathyroidectomy without autotransplantation is a safe procedure with a low rate of recurrent hyperparathyroidism when compared to parathyroidectomy with autotransplantation to the forearm in a historical control. These preliminary results mandates further investigations including a randomized trial.     

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.     

Long-term results of subcutaneous parathyroid grafts in uremic patients

HYPOTHESIS: Parathyroid glands are normally surrounded (entirely or partially) by fatty tissue. Subcutaneous parathyroid grafts are thus located in a normal environment. Therefore, we postulated that the late results of subcutaneous implantation of parathyroid tissue in uremic patients should be at least as good as those reported for intramuscular grafting. We also challenged the idea that the recurrence rate of renal hyperparathyroidism after surgery depended solely on the type of hyperplasia (diffuse vs nodular) observed in the implanted tissue. DESIGN: A retrospective study of a series of patients without loss to follow-up. SETTING: A university hospital and 9 affiliated dialysis units. PATIENTS AND INTERVENTIONS: Fifty-nine patients (33 women and 26 men) operated on for renal hyperparathyroidism underwent the resection of at least 4 parathyroid glands followed by presternal subcutaneous implantation of parathyroid tissue. They were followed up for 12 to 130 months (median, 38 months). MAIN OUTCOME MEASURES: Failure of treatment, recurrence of disease, and hypoparathyroidism. RESULTS: During the study period, 9 patients had to undergo another operation: 2 (3%) for persistent hyperparathyroidism due to a fifth ectopic gland and 7 (12%) for recurrence of hyperparathyroidism resulting from hypertrophy of the subcutaneous grafts. Four patients received a kidney transplant. The prevalence of hypoparathyroidism (intact parathyroid hormone serum level <1.6 pmol/L with a normal or low serum calcium concentration) was 14% (8 of 59 patients), and the curve representing the distribution of intact parathyroid hormone serum concentrations among operated on patients was shifted to the left when compared with the curve of patients who underwent hemodialysis and who had no indication for parathyroid surgery. In this latter group, the peak of the curve was situated between 1 and 2 times the upper normal limit, while it was in the normal range 12 to 130 months after total parathyroidectomy and subcutaneous parathyroid autotransplantation. No relation was observed between the recurrence rate of the disease and the histological characteristics of the parathyroid grafts. Also, their function was not influenced by the presence or absence of aluminum deposits in bone biopsy specimens that were obtained at the time of cervical exploration. CONCLUSIONS: The late results of total parathyroidectomy and presternal subcutaneous grafting compare favorably with the published data on other surgical techniques proposed for the treatment of renal hyperparathyroidism. The ease with which the hypertrophied grafts are removed when the disease recurs warrants further use of this procedure.     

Surgical findings and results of subtotal and total parathyroidectomy in hypercalcemic patients with uremic hyperparathyroidism

Surgical and histopathologic findings and results of subtotal resection and total parathyroidectomy with autotransplantation were evaluated in 82 hypercalcemic patients with uremic hyperparathyroidism. The mean preoperative serum calcium concentration was 2.89 mM, and the highest values were associated with more rapidly progressing hypercalcemia. Despite greatly increased total weight of the parathyroid tissue (mean 1,509 mg), 34 patients had one to five normal-sized parathyroid glands. The incidence of such glands decreased with total gland weight. Nodular hyperplasia was found in 74% of the patients, and was characterized by considerable intraindividual size difference, while diffuse hyperplasia was associated with more moderate and symmetric glandular enlargement. During follow-up averaging 4.5 years, the incidence of persistent or recurrent hypercalcemia was slightly higher after subtotal than after total parathyroidectomy (11 and 11%, vs. 9 and 7%). Biochemical and/or radiologic signs of parathyroid bone disease were present in 36 (44%) of the patients before neck exploration and normalized postoperatively in all but seven. The outcome of parathyroid surgery thus was favorable in uremic patients with hypercalcemic hyperparathyroidism.     

Parathyroidectomy can improve bone mineral density in patients with symptomatic secondary hyperparathyroidism

HYPOTHESIS: The recovery of osteoporosis or bone mineral density (BMD) after parathyroidectomy and autotransplantation can be improved in patients with symptomatic secondary hyperparathyroidism. DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: Forty-five patients with symptomatic secondary hyperparathyroidism who underwent total parathyroidectomy and autotransplantation were included. They were divided into an osteoporotic group (n = 20) and a nonosteoporotic group (n = 25) according to preoperative T scores less than -2.5 at either the lumbar spine (L1-L4) or the femoral neck (FN). INTERVENTIONS: Serum levels of calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone were checked before surgery and 1 day, 1 week, and 3 months after surgery. The BMDs of the FN and L1-L4 were measured using dual-energy x-ray absorptiometry before surgery and 6 months after surgery. RESULTS: Patients with osteoporosis were older (mean +/- SD, 50.2 +/- 14.0 years) than those without osteoporosis (42.7 +/- 9.1 years) (P =.04). Except for bone fractures found in 2 women in the osteoporotic group, there were no significant differences between the 2 groups in sex, clinical manifestations, duration of dialysis, weight of removed parathyroid tissue, and types of dialysis. Also, serum levels of calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone were similar in both groups. Both 1 day and 1 week after total parathyroidectomy and autotransplantation, serum levels of calcium and intact parathyroid hormone decreased rapidly and then gradually increased 3 months later; however, serum levels of alkaline phosphatase increased rapidly and then gradually decreased 3 months later. Six months after parathyroidectomy, BMD, T score, and Z score at L1-L4 and the FN increased significantly (P<.001). The increment was much better in the osteoporotic group than in the nonosteoporotic group (P<.001). Also, osteopenia or osteoporosis improved significantly after parathyroidectomy at both L1-L4 and the FN (P<.001 for both). CONCLUSION: Parathyroidectomy and autotransplantation can improve BMD of symptomatic secondary hyperparathyroidism at L1-L4 and the FN.     

Total parathyroidectomy with forearm autograft for secondary hyperparathyroidism in chronic renal failure.

One hundred twenty-eight patients with chronic renal failure and secondary hyperparathyroidism underwent total parathyroidectomy with forearm autograft. Postoperative clinical improvement was remarkable. In all cases, the grafted tissue functioned well, and reimplantation of the cryopreserved parathyroid tissues was unnecessary. Intact 1-84 parathyroid hormone was more sensitive than C-terminal parathyroid hormone in parathyroid hormone level (PTH) gradient assays of grafted and nongrafted forearm. The study of hypocalcemia was also helpful in obtaining more distinct PTH gradients. Five of 119 patients had supernumerary parathyroid glands (4.2%), which preoperative noninvasive image diagnosis of parathyroid glands was helpful in detecting.     

Our experience with autotransplantation and cryopreservation of parathyroid tissue in thyro-parathyroid surgery

Results are reported of four and a half years of experience with autotransplantation and cryopreservation of parathyroid tissue in thyro-parathyroid surgery. One hundred patients with hyperparathyroidism secondary to renal insufficiency were treated by total parathyroidectomy and partial autotransplantation, immediate in 98 cases and secondarily using their frozen stored tissue in the other two cases. Results were compared with those in 13 other patients treated during the same period by subtotal parathyroidectomy. Seven of 46 patients with primary parathyroid hyperplasia underwent total parathyroidectomy with immediate partial autotransplantation. Grafts were not used in the other two previously cervicotomized patients. All parathyroid tissue removed during these operations was frozen and stored if not used for grafting. Of 116 patients treated by enlarged total thyroidectomy for cancer, 34 received parathyroid autotransplants; complementary in 19 cases and substitutive in 15. Technique and results are described, and respective indications for autotransplantation and parathyroid cryopreservation discussed with respect to primary, secondary, persisting or recurrent hyperparathyroidism, and to total thyroidectomy for cancer.     

Prospective study of parathyroid graft function in patients with renal hyperparathyroidism after total parathyroidectomy and heterotopic autotransplantation by measurement of the intact parathyroid hormone concentrations in both antecubital veins.

OBJECTIVE: Evaluation of the value of gradients for intact parathyroid hormone after total parathyroidectomy and heterotopic autotransplantation for renal hyperparathyroidism. DESIGN: Prospective long-term follow-up study. SETTING: Teaching hospital, Germany. SUBJECTS: A total of 115 patients operated on for renal hyperparathyroidism between 1 August 1987 to 15 August 1997. INTERVENTIONS: 100/115 had total parathyroidectomy with autotransplantation. MAIN OUTCOME MEASURES: Analyses of serum calcium, alkaline phosphatase, and intact parathormone in serum 1, 4, 8, 12, 18 and 24 months postoperatively and annually thereafter. Parathormone gradients were calculated as the ratio of the parathormone concentrations in the antecubital venous blood of the grafted and the non-grafted arm. RESULTS: During follow-up (mean 32 months, range 1 month to 9 years), 111 of the 115 patients had one to 10 re-examinations (mean: 4) and in the patients who had had total parathyroidectomy with autotransplantation a total of 437 gradients could be calculated, 91% of which were < or =20. Postoperative hypocalcaemia caused by calcium deficiency of the skeleton led to an increase in parathormone secretion and gradients. Increasing parathormone gradients during follow-up as a result of excessive parathormone secretion in the grafted-arm indicated graft-dependent recurrence. In 6 of the 9 patients with graft-dependent recurrences the gradients exceeded 20. CONCLUSION: The combined sequential assessment of gradients for intact parathyroid hormone and of serum calcium concentrations permits objective evaluation of parathyroid graft function.     

Graft-dependent Renal Hyperparathyroidism Despite Successful Kidney Transplantation

Introduction Only a few reports can be found on the recurrence or persistence of hyperparathyroidism after total parathyroidectomy and autotransplantation (PTX + AT) following kidney transplantation (KTX). The objective of the present study was to assess the frequency and pathophysiological mechanisms responsible for the development of graft-dependent renal hyperparathyroidism (rHPT) after KTX. Patients and methods Between 1986 and 2006, 69 patients underwent surgery for rHPT after KTX at our institution. Patients with reoperations at the parathyroid autograft (AT) were identified. Kidney graft function (KGF) was assessed by the glomerular filtration rate (GFR). Representative parts of the parathyroid gland chosen for autotransplantation during the initial parathyroidectomy and of the excised AT at reoperation were reanalyzed according to the morphologic pattern and the proliferative index. Results Eight of the 69 patients underwent reoperation of the AT. All patients had undergone initial PTX + AT before KTX. The GFR before parathyroid reoperation was 66.6 ± 9.6 ml/min per1.73 m2 (mean ± SEM). Histopathological re-examination revealed nodular hyperplasia in the parathyroid tissue for autotransplantation and in the excised parathyroid autografts. The Ki67 index was increased in the glands chosen for autotransplantation prior to KTX, but was overall low in the excised autografts. Discussion Although not reported in the literature to date, tertiary hyperparathyroidism (tHPT) may arise from parathyroid autografts even in patients with a good KGF. In these cases, graft-dependent tHPT represents the inability of autonomous, nodular parathyroid tissue to regress despite the recovery of renal function. Non-nodular tissue should be selected for parathyroid autotransplantation to decrease the incidence of graft-dependent recurrent rHPT.     

Persistent and Recurrent Hyperparathyroidism After Total Parathyroidectomy With Autotransplantation

OBJECTIVE: To conduct a retrospective study of 15 patients with persistent (n = 4) and recurrent (n = 11) hyperparathyroidism. SUMMARY BACKGROUND DATA: Secondary hyperparathyroidism may persist or recur because of hyperfunction of the parathyroid remnant or transplanted parathyroid tissue. It is a great challenge to localize the parathyroid tissue either in the neck or at the arm before surgery. METHODS: From June 1994 to June 2000, 15 patients with recurrent and persistent secondary hyperparathyroidism were selected for surgery for the removal of parathyroid tissue. The indications for surgery included bone pain, hypercalcemia, general weakness, and skin itching. Their ages ranged from 23 to 66 years. The average period of persistent hyperparathyroidism after total parathyroidectomy with autotransplantation was 3.8 months; that of recurrent hyperparathyroidism was 53 months. Serum levels of calcium, phosphorus, parathyroid hormone (iPTH), and alkaline phosphatase were measured before surgery and 1 week after surgery. Before surgery, the parathyroid gradient in the blood draining the graft-bearing arm versus the contralateral arm was measured. A 99mTc-sestamibi (MIBI) scan was performed including the neck and the arm area, and a computed tomography (CT) scan of the neck was performed to confirm the localization. The neck and mediastinal exploration was done directly at the side of localization under general anesthesia to remove the parathyroid tissue that had been located with the MIBI scan or CT scan. An arm exploration was done under local anesthesia to remove all parathyroid tissues detected in the MIBI scan or palpable masses during surgery. If all glands were removed, 0.5 x 0.5 x 0.5 cm of tissue (60-100 mg) was maintained in situ or the same amount of tissue was reimplanted. RESULTS: The average ratio of iPTH in the graft-bearing arm to the contralateral arm in the 5 patients with parathyroid tissue in the neck was 1.17 +/- 0.16, and that in the 10 patients with parathyroid at the arm was 14.15 +/- 16.62. A significant difference was found between the two groups. MIBI scans showed parathyroid tissues in the neck in four of five patients and in seven of eight patients at the arm. Computed tomography showed the parathyroid tissues in the neck and mediastinum in five of five patients (100%). Five glands were removed from these five patients, three in the neck, one in the mediastinum, and one in the carotid sheath. In total, 20 glands and 2 half-glands were removed from 10 patients; among these, 14 glands were shown in the MIBI scan. All patients had improvements of symptoms and signs after surgery. Serum levels of calcium, phosphorus, and iPTH decreased rapidly after surgery, but alkaline phosphatase did not. CONCLUSIONS: With the results obtained from the ratio of iPTH of the graft-bearing arm to the contralateral arm, clinical palpation of the arm, MIBI scan, CT scan, careful surgical exploration, and adequate resection, recurrent and persistent secondary hyperparathyroidism can be successfully treated with surgery in the neck or at the arm.     

Surgical treatment of secondary hyperparathyroidism

BACKGROUND: Surgical treatment in the patient effected by secondary hyperparathyroidism consists in subtotal parathyroidectomy or total parathyroidectomy plus autotransplantation of parathyroid tissue. METHODS: The results obtained with surgical treatment of 6 patients observed in the years 1995-1996 are analyzed. Two glands were hyperplastic in four patients, 3 in the others. Every patient was submitted to a subtotal parathyroidectomy. RESULTS: Postoperative course was marked by transient hypoparathyroidism in one case. After 18 months of follow-up, no recurrences were observed. CONCLUSIONS: It is pointed out that in case of secondary hyperparathyroidism subtotal parathyroidectomy represents the surgical treatment of choice, according with literature data. Otherwise total parathyroidectomy plus autotransplantation, characterized by a more complex surgical technique, lead to the same results.