Intraoperative Monitoring of Intact PTH in Surgery for Renal Hyperparathyroidism as an Indicator of Complete Parathyroid Removal

Abstract

In the setting of total parathyroidectomy and autotransplantation surgery (TPT x AS) as treatment for secondary hyperparathyroidism (SHPT), we evaluated whether intraoperative parathyroid hormone (iPTH) monitoring is useful as a reference for total parathyroid removal. We conducted a prospective, open, single value measurement efficacy study of the intraoperative (i.o.) diagnostic monitoring of iPTH in a cohort of surgical patients. All patients (n = 25) underwent TPT x AS at the Department of Surgery, Donostia Hospital from January 2002 to October 2004. The primary outcome measures were kinetics of serum levels of iPTH during surgery and prediction time of the of descent of PTH levels (measured in the clinic on the day of admission and intraoperatively during induction of anesthesia, every 5 and 10 minutes after removal of the adenoma, and again 24 hours thereafter). iPTH levels returned to normal in all 25 patients, decreasing from pathological levels at the beginning of the operation (1302.24 + 424.9 pg/ml) to half (50%) values at the third intraoperative determination, minute 10 (614.8 +/- 196.62), becoming undetectable at 24 hours. Frozen sections were conclusive for parathyroid tissue (20.56 + 10.3 minutes after removal). Intraoperative measurement of iPTH is useful in the prediction complete removal of all parathyroid tissue prior to autotransplantation, thus avoiding persistence of disease because of incomplete surgery.

How radical is total parathyroidectomy in patients with renal hyperparathyroidism?

“…A biochemical definition of total PTX, as mentioned earlier by Rayes et al, would allow a better comparability of data [13]. According to the literature, PTH levels shortly after intended primary total PTX for RHPT are undetectable in up to 100% [11–13, 26]. …”

Efficacy of intraoperative parathyroid hormone monitoring to predict success of parathyroidectomy for secondary hyperparathyroidism

“…We categorized patients into two groups -a physiologically acceptable group and a surgically failed group-based on a PTH level of 300 pg/mL. The ideal blood concentration of PTH is not known for uremic subjects, but the levels advocated by different researchers vary from 75 to 175 pg/mL [10]. Our criterion was based on the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines for the target range of intact plasma PTH according to the stage of CKD [14].…”

“…Intraoperative parathyroid hormone (ioPTH) measurement is a functional diagnostic tool during parathyroid surgery that permits prediction of postoperative outcome and helps the surgeon to decide whether further exploration is necessary [6]. A reduction in ioPTH levels of ≥50% indicates surgical success with a sensitivity of 98% and specificity of 91% in primary hyperparathyroidism, and has been suggested as appropriate for ioPTH monitoring in surgical treatment of sHPT [4,6-10]. Nonetheless, there is no standard definition of success in sHPT.…”

Quick parathyroid hormone assays: a comprehensive review of their utility in clinical practice

“…Employing IPM has been reported to be useful in predicting complete removal of the hyperfunctioning parathyroid tissue, including suspected aberrant tissue. 46,47 Thirdly, pathobiologically speaking, MGD, including hyperplasia and double adenomas, and parathyroid cancer (PC) account for 15% and 1% of PHPT, respectively; nevertheless, they have been reported in 28.4% to 60% and 2% to 3.4%, respectively, of reoperative PHPT patients. 45 Persistence/recurrence rates of PHPT have been reported to be incrementally higher following surgery for single adenoma, hyperplasia and double adenoma.…”