Exploring the Effect of Parathyroidectomy for Tertiary Hyperparathyroidism After Kidney Transplantation

Abstract

Tertiary hyperparathyroidism (tHPT) usually regresses after renal transplantation. Persistent tHPT after successful renal transplantation may require parathyroidectomy (PTX). PTX has been reported to be associated with deterioration of renal function and graft survival. We retrospectively analyzed 794 kidney transplants performed at our center with at least 3 years of follow-up to examine the effect of PTX on the renal function and graft survival. Forty-nine of the 794 renal transplant recipients were diagnosed with hyperparathyroidism (HPT) before transplant. Nineteen of 49 patients had persistent tHPT and underwent PTX after kidney transplants. Patients with HPT and non-HPT had similar 3-year graft survival (88% versus 84%, P = 0.51). PTX was associated with a decreased glomerular filtration rate at 3 years (44.7 ± 20.0 versus 57.7 ± 23.7 mL/min, P = 0.04); however, there was no statistical difference in the 3-year graft survival (71% versus 88%, P = 0.06). PTX in renal transplant recipients seems to be a safe and effective therapy for persistent tHPT. PTX may be associated with worsening glomerular filtration rate, but it may not be associated with significantly decreased longterm graft survival. Key Indexing TermsHyperparathyroidism; Parathyroidectomy; Kidney transplant; Graft function; Graft survival Nowadays, the term tertiary hyperparathyroidism (tHPT) is used almost exclusively in the context of persistent hyperparathyroidism (HPT) after successful renal transplantation. Development of tHPT is multifactorial, although phosphate retention and loss of renal 1-hydroxylase activity with low 1,25-(OH) 2 vitamin D 3 level are the principal factors. 1 For hyperparathyroidism in patients with end-stage renal disease, the currently accepted practice for management is initially medical therapy with parathyroidectomy (PTX) reserved for refractory disease. 2 The incidence of tHPT is reported in up to 50% of patients who undergo kidney transplantation,3 and its occurrence is thought to be related to the duration of dialysis before transplantation.3 , 4 Although tHPT has been recognized for a long time, the management of the disease is still controversial. Currently, guidelines for referral of these patients for surgery do not exist. Hypercalcemia usually gradually resolves within the first year after successful kidney transplantation. 4 Therefore, patients with persistent hypercalcemia should be considered for PTX, which includes subtotal or total PTX with auto-transplantation. Indications NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript for surgical intervention include persistent hypercalcemia, symptomatic tHPT, or deterioration of kidney function associated with tHPT. 4 Although it was previously reported that patients with functioning kidney grafts had unaffected renal function after PTX, there are recent reports that PTX might seriously endanger the long-term graft survival. [5][6][7] The purpose of this study was to examine our 10-year experience with patients with end-stage re...

Surgical management of secondary hyperparathyroidism in chronic kidney disease—a consensus report of the European Society of Endocrine Surgeons

“…After PTX, there is a constant decline in renal function, probably due to haemodynamic effects of PTH on the preglomerular and efferent arterioles [49]. It should be noted, however, that current studies suggest that the graft survival is not decreased by PTX [47,132,135,140]. It seems that the risk and intensity of the decrease of renal function are highly dependent on the severity of HPT (high level of PTH) and probably on the slope of decline, and therefore avoiding/reducing post-PTX hypoparathyroidism and hypocalcaemia could reduce the risk of significant decline of the renal function [129] It is therefore expected that a less aggressive parathyroid resection should lead to a less important decline in PTH and therefore to a decreased risk of decline of renal function.…”

“…Therefore, a delay of 3 months should be considered in case of severe HPT and 1 year in the case of persistent HPT [106,109,116,135] (RG C). A serum calcium level greater than 11.5 mg/dl, unexplained renal function deterioration or a progressive bone mineral density loss underscore arguments for PTX (RG C).…”

“…Even if moderately persistent HPT may spontaneously resolve in some patients, the time allowing involution of the parathyroid glands risks increased cardiac, bone and graft complications. Because of potential cardiovascular, bone and graft deterioration, PTX should be discussed not later than 1 year after transplantation (RG C), although several studies demonstrated a longer latency before PTX [106,129,135,136] (EL 2).…”

Tratamento cirúrgico do hiperparatireoidismo secundário: revisão sistematizada da literatura

“…Assim, níveis séricos elevados de fosfato e produção diminuída de vitamina D causam hipocalcemia e elevam os níveis de PTH circulante. Como consequência prolongada, há hiperplasia de células paratireóideas e aumento na secreção de PTH (1,2,4,5,8,13,19,20,22,23,27,31,(36)(37)(38)(39).…”

“…Quando a doença não responde mais ao tratamento clínico, indica-se a paratireoidectomia (PTx) (1)(2)(3)11,13,14,(16)(17)(18)(19)(20)23,24,(27)(28)(29)33,34,37,38,40,(42)(43)(44). A PTx pode reduzir significativamente os níveis de fosfato e PTH.…”