Effects of parathyroidectomy on bone remodeling markers and vitamin D status in patients with chronic kidney disease–mineral and bone disorder

Background/Aims Chronic renal failure (CRF) is often associated with bone disorders including chronic kidney disease–mineral and bone disorder (CKD–MBD). Parathyroid hormone (PTH) has a relationship to bone remodeling, and so this study was undertaken to evaluate changes in bone remodeling markers after parathyroidectomy (PTX). Methods Twelve adult patients, mean age 43.4 ± 12.7 years, of both genders, were evaluated, prior to and six months after PTX. Analysis of biochemical markers of bone metabolism, such as total and ionized calcium, phosphorus, 25(OH)D₃, total alkaline phosphatase (TAP), bone-specific alkaline phosphatase (BAP), intact PTH, osteoprotegerin (OPG), and tartrate-resistant acid phosphatase isoform 5b (TRAP), were measured. Results No changes were observed after PTX in the serum total and ionized calcium, TAP, BAP, and 25(OH)D₃. After surgery there was a significant decrease in serum phosphorus, iPTH, and TRAP (P < 0.001). No significant change was observed in OPG; however there was a positive correlation between OPG and 25(OH)D₃ before and after surgery (r = 0.774, P = 0.014; and r = 0.706, P = 0.01, respectively). The percentage of patients with vitamin D deficiency decreased from 16.7% to 8.3%, while those with sufficient levels increased from 41.7% to 58.3%. Conclusion The small number of patients in the study notwithstanding, the present study is unique because it provides information on bone metabolism and vitamin D status six months after PTX. The removal of parathyroid glands significantly decreased bone resorption and indicated a tendency of 25(OH)D₃ concentration to increase. However, the precise role of OPG and BAP in the improvement in bone remodeling in patients with CKD–MBD requires further study.     

Surgical strategy for sporadic primary hyperparathyroidism an evidence-based approach to surgical strategy,patient selection,surgical access,and reoperations

Purpose  Progress in parathyroid imaging has brought substantial changes in the surgical strategy to approach patients with sporadic primary hyperparathyroidism (pHPT). The present review is focused on the safety and efficacy of limited parathyroid exploration. Materials and methods  Review of the literature focused on studies dealing with unilateral (two-gland exploration) or selective parathyroidectomy (one-gland exploration) in selected patients with pHPT and on the classification of published reports according to the degree of evidence. Results  Parathyroid exploration limited to a solitary parathyroid adenoma can be considered a minimally invasive procedure that can be performed by the minicervicotomy, video-assisted, or endoscopic approaches. In properly selected patients, it affords results comparable to those of four-gland bilateral exploration in terms of cure and recurrence. It causes less postoperative hypocalcemia. Conclusions  Selective parathyroidectomy is an option for patients with positive preoperative localization tests undergoing first-time surgery who have no family history of pHPT, no goiter for which surgical therapy is proposed, and are not on lithium therapy. This paper was presented at the “Primary HPT Symposium” organized by the European Society of Endocrine Surgeons (Lund, Sweden, March 19–21, 2009).     

Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring

Background

Reoperative parathyroidectomy (R-PTX) in primary hyperparathyroidism (1HPT) has increased failure rates and morbidity. This study evaluated R-PTX during the era of minimal-access PTX with intraoperative parathyroid hormone (IOPTH) monitoring.

Methods

Two thousand sixty-five patients with 1HPT who underwent PTX were assessed for R-PTX. Preoperative studies, operative findings, and outcomes were evaluated.

Results

Two hundred twenty-eight patients underwent 236 R-PTX procedures. Imaging performed included sestamibi (89%), ultrasound (US; 56%), computed axial tomography/magnetic resonance imaging (5%), and selective venous sampling (1%). Sestamibi was more sensitive than US (84% vs 68%). Curative surgery was performed in 89% of patients. IOPTH was 99% sensitive. There was no relationship between cure and the following parameters: preoperative calcium or PTH levels, persistent or recurrent disease, or use of IOPTH. Solitary gland disease and a single previous operation were associated with increased likelihood of cure (P = .06). Hypoparathyroidism was decreased using IOPTH monitoring (2% vs 9%). One patient had recurrent laryngeal nerve palsy.

Conclusions

R-PTX can be performed effectively with minimal complications. IOPTH is an accurate predictor of cure and may decrease the frequency of permanent hypoparathyroidism.     

Does homocysteine contribute to bone disease in hyperparathyroidism?

BACKGROUND: Osteoporosis is a complication of hyperparathyroidism (HPT). Hyperhomocysteinemia (HHCy) is an independent risk factor for osteoporotic fractures. We hypothesize that HHCy correlates with bone disease in HPT. METHODS: A prospectively collected database of 250 patients treated for HPT was reviewed. Patients were categorized into 3 groups: group I, normal renal function; group 2, mild renal insufficiency; and group 3, secondary HPT with end-stage renal disease on dialysis. Serum homocysteine levels, markers of bone metabolism, and bone density studies were examined. RESULTS: The prevalence of HHCy in group 1 (208 patients) was 5%, in group 2 (23 patients), 82%, and in group 3 (19 patients), 78%. Mean (+/-SD) preoperative homocysteinemia (HCy) levels in groups 1, 2, and 3 were 9.3 +/- 4.0, 20 +/- 10.2, and 20.6 +/- 12.3 micromol/L, respectively. Elevated serum markers of bone metabolism increased significantly with decreasing renal function. CONCLUSIONS: Prevalence of HHCy is low in HPT patients with normal renal function. It is significantly greater in those with dialysis-independent and -dependent renal insufficiency. HHCy correlates with other serum markers of bone metabolism in HPT and may be useful for monitoring progression or improvement.     

Clinical features and hyperplastic patterns of parathyroid glands in hemodialysis patients with advanced secondary hyperparathyroidism refractory to maxacalcitol treatment and required parathyroidectomy

We have previously suggested that when parathyroid glands progress to nodular hyperplasia, secondary hyperparathyroidism (2HPT) may be refractory to medical treatments, including treatment with Maxacalcitol (OCT). In the present study we evaluated the clinical features and hyperplastic patterns of parathyroid glands in patients who underwent parathyroidectomy (PTx) after being withdrawn from OCT. One hundred and eighty-seven advanced 2HPT patients who had been withdrawn from OCT and required PTx were enrolled. At the start of OCT treatment, the patients had a mean age of 55.3 years and had been receiving hemodialysis (HD) for a mean period of 149 months. At the start of OCT treatment and at PTx, the mean intact PTH (i-PTH) levels were 772.8 +/- 446.0 and 855.5 +/- 420.5 pg/mL, respectively. The main reasons for withdrawal of OCT treatment were persistently high PTH (n = 148), hypercalcemia (n = 79), hyperphosphatemia (n = 65), and progressive symptoms (n = 60). We classified the parathyroid glands by hyperplastic pattern into four categories: diffuse hyperplastic gland (D), early nodularity in diffuse hyperplastic gland (EN), nodular hyperplastic gland (N), and single nodular gland (SN). The mean total excised gland weight was 2592.6 mg. Out of a total of 706 glands, 118 were classified as D, 66 as EN, 436 as N, and 86 as SN. All patients had at least one nodular hyperplastic gland or single nodular gland. The mean number of nodular hyperplastic glands and/or single nodular glands was 2.9. All hemodialysis patients with advanced OCT-refractory 2HPT who underwent PTx had at least one nodular hyperplastic gland or single nodular gland.     

Clinical analyses of 75 parathyroidectomy (PTE) patients and 69 adrenalectomy (AE) patients including saliva-type amylase-secreting secondary parathyroid hyperplasia (SPTH) and insulinoma with adrenal adenoma (AA) showing primary aldosteronism

Seventy-five parathyroidectomy (PTE) and 69 adrenalectomy (AE) patients were analyzed. The 75 PTE included 56 of secondary parathyroid hyperplasia (SPTH) with chronic renal failure (CRF) and 19 of primary parathyroid hyperplasia (PPTH) without CRF. The 69 AE included 23 with Cushing’s syndrome, 30 with primary aldosteronism, four with cortical carcinoma (three virilizing and one feminizing carcinomas), seven with pheochromocytoma (two multiple endocrine neoplasia 2A), two with paraganglioma, one with schwannoma, one with non-functional adenoma, and one with hepatic cancer metastasis. The 56 SPTH showed higher levels of intact (I)-parathyroid hormone (PT) of 1,359 ± 1,036 pg/ml than the 292 ± 372 pg/ml of the 19 PPTH. Measured vitamin D of 1, 25(OH)₂D was higher in the nine PPTH (88.0 ± 34.7 pg/ml) than in the 46 SPTH (15.5 ± 13.9). High serum amylase of >350 IU/l and cyst formations were found in ten (18%) and 16 (29%) of the SPTH but none of the PPTH. At least ten (18%) of the SPTH had polycystic kidney disease (PKD). Saliva-type amylase of the SPTH resolved the high I-PTH. High levels (>6.0%) of Hb A1C (8.1%) were measured only in one SPTH case with mediastinal ectopic SPTH and PKD. High urine 17 ketosteroid (17 KS) levels of 161.5 ± 72.9 mg/l were measured in three virilizing carcinomas with metastases to the bone, liver, and/or lung. Low-grade feminizing carcinoma was observed in a 6-year-old boy. Cysts of the kidney and/or liver were found in 17 (74%) with Cushing’s syndrome, 12 (40%) with primary aldosteronism, and three (43%) with pheochromocytoma. One paraganglioma had liver and pancreatic cysts, and one schwannoma had polycystic ovary. High levels of Hb A1C were detected in six (26%) with Cushing’s syndrome, five (17%) with primary aldosteronism showing insulinoma, and two (29%) with pheochromocytoma. In all 13 patients with diabetes mellitus (DM), AE was an effective DM treatment.     

Conservative three-quarter versus subtotal seven-eighths parathyroidectomy in secondary hyperparathyroidism

Objective

There is at present no consensus concerning surgical techniques for secondary hyperparathyroidism (SHPT) in end-stage renal disease (ESRD). Although both subtotal and total parathyroidectomy provide low rates of recurrence, they may induce hypoparathyroidism, damaging the bone and cardiovascular systems. The aim of our study was to compare 3/4 and 7/8 parathyroidectomy in this population and to discuss the potential benefit of more conservative treatment.

A faster parathyroidectomy: Techniques to shorten non-surgical operating room time

ObjectiveTo assess the capacity of different techniques to reduce non-operative times during parathyroid surgery. The impact of monitored anesthesia care (MAC) instead of general anesthesia, and the pre-operative placement of a second peripheral intravenous catheter (PIV) were analyzed.MethodsA retrospective case series at an academic medical center was performed to study patients undergoing parathyroidectomy by a single surgeon between November 2013 and October 2016. Three operating room (OR) time measurements were compared: pre-incision time, post-closure time, and total OR time.ResultsSurgeries performed under MAC (n = 21) had statistically shorter pre-incision (33.2 min vs. 39.7 min, p < .001), post-closure (10.1 min vs. 16.2 min, p = .002), and total operative times (113.0 min vs. 151.5 min, p < .001) compared to those in which general anesthesia (n = 169) was used. Of the 169 patients who underwent general anesthesia, 25 had a second PIV placed preoperatively and 144 had only a single PIV. All 3 time periods were statistically shorter in patients who had a second PIV versus those who had only a single PIV (pre-incision 32.2 min vs. 41.0 min, p < .001; post-closure 12.2 min vs. 16.9 min, p < .001; total 117.9 min vs. 157.4 min, p < .001).ConclusionsIn patients undergoing parathyroid surgery in which ioPTH levels will be used, the placement of a second PIV in the pre-operative holding area and performance of surgery under MAC can significantly shorten non-operative and total OR time.