Accuracy of intra-operative PTH measurement during subtotal parathyroidectomy for tertiary hyperparathyroidism after renal transplantation

Abstract

Background and aims Intra-operative parathyroid hormone (IOPTH) results are not known in the setting of tertiary hyperparathyroidism (HPT) after renal transplantation. Materials and methods A retrospective analysis of 35 tertiary HPT patients who all underwent subtotal parathyroidectomy and IOPTH monitoring was conducted.Results The mean follow-up time was 2.2±1.4 years. Thirty-four patients were cured; one patient (2.8%) had a persistent disease and was cured after reoperation. Median parathyroid hormone (PTH) (median percent decrease from highest) at baseline and at 5, 10, 20, and 30 min were 244, 78 (69%), 63 (75%), 53 (79%), and 49 pg/ml (83%), respectively. Four patients who were cured had a decrease of <50% at 5 min and two of them had a decrease of <50% at 10 min. The patient with persistent disease had a decrease of >50% at 10 min. The sensitivity of the test was 94% at 10 min using the Miami criteria. Conclusion This study shows that IOPTH in tertiary hyperparathyroidism has a high sensitivity. However, because of the low risk of persistent hyperparathyroidism when a subtotal parathyroidectomy is performed, its potential impact on the overall success rate is very small. We therefore do not recommend the routine use of IOPTH in tertiary hyperparathyroidism.

Outcomes of Total Parathyroidectomy with Autotransplantation versus Subtotal Parathyroidectomy with Routine Addition of Thymectomy to both Groups: Single Center Experience of Secondary Hyperparathyroidism

“…A dramatic drop in iPTH levels below normal has been reported after renal transplant and the recovery of normal renal function (17,23). Successful transplantation was performed on 18% of our patients.…”

The Role of Quick Bio-Intact PTH(1-84) Assay During Parathyroidectomy for Secondary Hyperparathyroidism

“…The role of intraoperative quick PTH assay in patients with primary HPT [5][6][7] and tertiary HPT after renal transplantation [8,9] is well established and has led to shorter operation times, higher cure rates, and even to minimally invasive parathyroidectomy in selected patients. In contrast to primary hyperparathyroidism, in which adequate resection of hyperfunctioning parathyroid glands can be confirmed by intraoperative PTH monitoring with one of the first-generation immunometric quick iPTH assays, it could not be confirmed in secondary HPT, and it was impossible to correctly predict insufficient reduction of hyperactive parathyroid metabolism and persistent secondary HPT [19,20].…”

“…Because of the possibility of ectopic and/or supernumerary glands [3,4], parathyroidectomy for secondary HPT always entails uncertainty as to whether all hypersecreting tissue has been removed. Several groups have reported that the results of the intraoperative quick parathyroid hormone (PTH) assay can be used to predict successful outcome of treatment for primary HPT [5][6][7] and tertiary HPT after renal transplantation [8,9]. However, the role of the quick PTH assay in surgery for secondary HPT is unclear because the results cannot be used to accurately determine whether resection of hyperfunctioning parathyroid tissue is complete [10,11].…”

The surgical management of renal hyperparathyroidism

“…IOPTH has a high positive predictive value of cure, but a poor negative predictive value in patients with renal HPT [58,97]. Eventually, establishing a predictive capability to assure completeness of resection might guide the surgeon regarding the extent of surgery and the decision of whether to perform a thymectomy.…”