The deceptive concept of hypoparathyroidism and recurrence after parathyroidectomy in dialysis patients: are we offering a Procrustean bed to some patients?

Montenegro, Fábio Luiz de Menezes; Brescia, Marília D’Elboux Guimarães; Júnior, Climério Pereira Nascimento; Neto, Ledo Mazzei Massoni; Arap, S; Santos, Stênio Roberto Castro Lima; Goldenstein, Patricia Taschner; Bueno, Rodrigo O.; Custódio, Melani Ribeiro; Jorgetti, Vanda; Moysés, Rosa Maria Affonso

doi:10.1590/0100-69912016005002

Cited by 6 publications

(4 citation statements)

References 17 publications

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“…Hence, while most dialysis patients undergoing PTX have biochemical ‘hypoparathyroidism’ in the form of low or very low PTH levels, there is only weak evidence that they form a major risk group for ABD or bone fragility. Thus low bone turnover after PTX may need careful interpretation in the light of both PTH levels and the overall risk profile for ABD …”

Section: Hypoparathyroidism After Parathyroidectomymentioning

confidence: 99%

“…Clearly then, extrapolating the KDIGO targets for maintaining PTH between two and nine times the ULN for the assay after PTX could be inappropriate . Indeed, Montenegro et al, highlighting the paucity of evidence in this regard, likened the arbitrariness of defining post‐PTX hyper‐ or hypo‐ parathyroidism to a Procrustean bed …”

Section: Hypoparathyroidism After Parathyroidectomymentioning

confidence: 99%

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Long‐term outcomes and management considerations after parathyroidectomy in the dialysis patient

Kakani

Sloan

Sawaya

et al. 2019

Seminars in Dialysis

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Parathyroidectomy (PTX) remains an important intervention for dialysis patients with poorly controlled secondary hyperparathyroidism (SHPT), though there are only retrospective and observational data that show a mortality benefit to this procedure. Potential consequences that we seek to avoid after PTX include persistent or recurrent hyperparathyroidism, and parathyroid insufficiency. There is considerable subjectivity in defining and diagnosing these conditions, given that we poorly understand the optimal PTH targets (particularly post PTX) needed to maintain bone and vascular health. While lowering PTH after PTX decreases bone turnover, long‐term changes in bone activity have been poorly explored. High turnover bone disease, usually present at the time a PTX is considered, often swings to a state of low turnover in the setting of sufficiently low PTH levels. It remains unclear if all low bone turnover equate with disease. However, such changes in bone turnover appear to predispose to vascular calcification, with positive calcium balance after PTX being a potential contributor. We know little of how the post‐PTX state resets calcium balance, how calcium and VDRA requirements change or what kind of adjustments are needed to avoid calcium loading. The current consensus cautions against excessive reduction of PTH although there is insufficient evidence‐based guidance regarding the management of chronic kidney disease ‐ mineral bone disease (CKD‐MBD) parameters in the post‐PTX state. This article aims to compile existing research, provide an overview of current practice with regard to PTX and post‐PTX chronic management. It highlights gaps and controversies and aims to re‐orient the focus to clinically relevant contemporary priorities in CKD‐MBD management after PTX.

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Section: Hypoparathyroidism After Parathyroidectomymentioning

confidence: 99%

Section: Hypoparathyroidism After Parathyroidectomymentioning

confidence: 99%

Long‐term outcomes and management considerations after parathyroidectomy in the dialysis patient

Kakani

Sloan

Sawaya

et al. 2019

Seminars in Dialysis

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“…Recently, the Kidney Disease: Improving Global Outcome (KDIGO) guidelines suggested that PTH should be maintained between two and nine times the upper limit of the method 5 . The best postoperative PTH levels have not been defined yet 6,7 .…”

Section: Introductionmentioning

confidence: 99%

Parathyroid hormone levels after parathyroidectomy for secondary hyperparathyroidism

Nascimento

Arap

Custódio

et al. 2021

Rev. Assoc. Med. Bras.

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OBJECTIVE:The parathormone level after parathyroidectomy in dialysis patients are of interest. Low levels may require cryopreserved tissue implantation; however, the resection is necessary in case of recurrence. We analyzed post parathyroidectomy parathormone levels in renal hyperparathyroidism.METHODS: Prospective observation of postoperative parathormone levels over defined periods in a cohort of dialysis patients that underwent total parathyroidectomy and immediate forearm autograft from 2008 to 2010, at a single tertiary care hospital. RESULTS:Of 33 patients, parathormone levels until 36 months could be divided into four patterns. Patients with stable function (Pattern 1) show relatively constant levels after two months (67% of the cases). Early function and later failure (Pattern 2) were an initial function with marked parathormone reduction before one year (18%). Graft recurrence (Pattern 3) showed a progressive increase of parathormone in four cases (12%). Complete graft failure (Pattern 4) was a nonfunctioning implant at any period, which was observed in one patient (3%). Parathormone levels of Pattern 3 became statistically different of Pattern 1 at 36 months. CONCLUSIONS:Patients that underwent the total parathyroidectomy and autograft present four different graft function patterns with a possible varied therapeutic management.

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“…As evidências atuais não suportam essa ideia teórica, pois sabe-se que a PTX sem autoenxerto imediato associa-se a maior frequência de doença óssea adinâmica41 , além de haver a preocupação de que níveis muito baixos de PTH após a paratireoidectomia possam se associar a menor sobrevida42 . Ainda que o órgão internacional KDIGO recomende níveis de PTH sistêmico entre duas a nove vezes o limite superior da normalidade30 , os níveis ideais de PTH após a paratireoidectomia em pacientes com DRC em diálise ainda é incerto43 . Na nossa série, encontramos maior proporção de pacientes com PTH dentro dos níveis sugeridos pelo KDIGO no subgrupo submetido a paratireoidectomia subtotal.…”

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Análise da qualidade de vida nos pacientes com doença renal crônica dialítica submetidos a paratireoidectomia

Filho¹

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The deceptive concept of hypoparathyroidism and recurrence after parathyroidectomy in dialysis patients: are we offering a Procrustean bed to some patients?

Abstract: O emprego de diferentes recomendações de níveis de PTH em pacientes dialíticos após paratireoidectomia pode levar a classificações incorretas de hipoparatireoidismo ou hiperparatireoidismo recidivado e implicar em condutas terapêuticas discordantes.

Cited by 6 publications

References 17 publications

Long‐term outcomes and management considerations after parathyroidectomy in the dialysis patient

Long‐term outcomes and management considerations after parathyroidectomy in the dialysis patient

Parathyroid hormone levels after parathyroidectomy for secondary hyperparathyroidism

Análise da qualidade de vida nos pacientes com doença renal crônica dialítica submetidos a paratireoidectomia

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