Is preoperative parathyroid localization necessary for tertiary hyperparathyroidism?

Wang, Rongzhi; Abraham, Peter; Lindeman, Brenessa; Chen, Herbert; Fazendin, Jessica

doi:10.1016/j.amjsurg.2022.05.002

Cited by 9 publications

(5 citation statements)

References 26 publications

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“…Of these 73 patients, 69 were in the hypercalcemic HPT group, and 4 were in the normocalcemic HPT group. The median (IQR) length from KT to PTx was 12 (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24) months. The mean ( ± SD) length of follow-up after PTx was 39.4 ± 19.0 months.…”

Section: Resultsmentioning

confidence: 99%

“…Kidney Disease: Improving Global Outcomes guidelines provide limited guidance on the management of HPT and bone disease post-KT 15 Parathyroidectomy (PTx) is believed to be the treatment of choice for KT recipients with HPT. [16][17][18][19] Due to a lack of consensus and lack of patient enthusiasm for additional surgery, referral for parathyroidectomy is often delayed, in many cases up to a year after KT. 20 In our study, we sought to study the prevalence and risk factors for persistent HPT post-KT at our high-volume institution and its effect on long-term graft survival.…”

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confidence: 99%

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Resolution of Secondary Hyperparathyroidism after Kidney Transplantation and the Effect on Graft Survival

et al. 2023

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Objective: Hyperparathyroidism (HPT) is nearly universal in patients with end-stage kidney disease. Kidney transplantation (KT) reverses HPT in many patients, but most studies have only focused on following calcium and not parathyroid hormone (PTH) levels. We sought to study the prevalence of persistent HPT post-KT at our center and its effect on graft survival. Methods: Patients who underwent KT from January 2015 to August 2021 were included and characterized by post-KT HPT status at the most recent follow-up: resolved (achieving normal PTH post-KT) versus persistent HPT. Those with persistent HPT were further stratified by the occurrence of hypercalcemia (normocalcemic versus hypercalcemic HPT). Patient demographics, donor kidney quality, PTH and calcium levels, and allograft function were compared between groups. Multivariable logistic regression and Cox regression with propensity score matching were conducted. Results: Of 1554 patients, only 390 (25.1%) patients had resolution of renal HPT post-KT with a mean (±SD) follow-up length of 40±23 months. The median (IQR) length of HPT resolution was 5 (0–16) months. Of the remaining 1164 patients with persistent HPT post-KT, 806 (69.2%) patients had high PTH and normal calcium levels, while 358 (30.8%) patients had high calcium and high PTH levels. Patients with persistent HPT had higher parathyroid hormone (PTH) at the time of KT [403 (243–659) versus 277 (163–454) pg/mL, P<0.001] and were more likely to have received cinacalcet treatment before KT (34.9% vs. 12.3%, P<0.001). Only 6.3% of patients with persistent HPT received parathyroidectomy. Multivariable logistic regression showed race, cinacalcet use pre-KT, dialysis before KT, receiving an organ from a deceased donor, high PTH, and calcium levels at KT were associated with persistent HPT post-KT. After adjusting for patient demographics and donor kidney quality by propensity score matching, persistent HPT (HR 2.5, 95% CI 1.1–5.7, P=0.033) was associated with a higher risk of allograft failure. Sub-analysis showed that both hypercalcemic HPT (HR 2.6, 95% CI 1.1–6.5, P=0.045) and normocalcemic HPT (HR 2.5, 95% CI 1.3–5.5, P=0.021) were associated with increased risk of allograft failure when compared with patients with resolved HPT. Conclusion: Persistent HPT is common (75%) after KT and is associated with a higher risk of allograft failure. PTH levels should be closely monitored after kidney transplantation so that patients with persistent HPT can be treated appropriately.

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Section: Resultsmentioning

confidence: 99%

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confidence: 99%

Resolution of Secondary Hyperparathyroidism after Kidney Transplantation and the Effect on Graft Survival

et al. 2023

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“…Ear-Nose-Throat (ENT) and endocrine surgeons at our institution performed parathyroidectomies, with ENT surgeons preferring total parathyroidectomy with auto-transplantation and endocrine surgeons using subtotal PTX as the technique of choice [6]. Details of PTX have been previously described [22][23][24][25]. As the optimum PTH is not known, for the purposes of our analysis, surgical success was defined as achieving normal calcium and postoperative PTHB 300 pg/mL before KT or PTHB 150 pg/mL after KT for more than 6 months after PTx.…”

Section: Methodsmentioning

confidence: 99%

Making the Cut: Parathyroidectomy Before or After Kidney Transplantation?

Wang

Saad²,

McLeod³

et al. 2022

World j. surg.

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Background Hyperparathyroidism is common in patients with end-stage kidney disease and may persist after kidney transplantation (KT). Parathyroidectomy (PTx) is curative, but whether PTx should be performed before or after KT remains controversial. There is concern that PTx can adversely affect renal allograft function if performed post-KT and result in persistent hypocalcemia. This study evaluated outcomes and postoperative complications of PTx before and after KT at our institution. Methods We performed a retrospective review of patients at our center (1/2012-2/2019) who had PTx either pre-KT or post-KT. Data on patient demographics, surgical outcomes, and postoperative complications of PTx were collected. Results Ninety-eight patients were included in this study, with 23 patients undergoing PTx before KT and 75 after KT. The length of follow-up after KT was 67.7 ± 25.5 months. In post-KT PTx patients, 30-day allograft function was unchanged after PTx. Calcium oxalate and phosphate crystals were less common on allograft biopsies in pre-KT PTx patients (10.0% vs. 34.8%, p = 0.038). Patients in the pre-KT group required more calcium supplementation after PTx than the post-KT group (p \ 0.001). At one-year post-PTx, 17 (19.1%) patients required [ 1000 mg elemental calcium per day and 7 (7.9%) patients required [ 2000 mg/day. There was no difference in surgical success or postoperative complications between the two groups. Conclusions Parathyroidectomy before or after kidney transplantation does not adversely affect allograft function. The incidence of persistent hypocalcemia was low. Parathyroidectomy is safe and effective either before or after kidney transplantation.

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“…All hyperparathyroidism patients undergo a radio-guided approach for all parathyroid surgery, except where contraindicated, as described previously [ 34 , 35 ]. We do not routinely obtain focused parathyroid or thyroid imaging unless in cases of a re-operative field (4D CT is obtained) or suspicion of concomitant thyroid disease.…”

Section: Materials/methodsmentioning

confidence: 99%

“…For patients with tertiary hyperparathyroidism and normal graft function, we prefer a subtotal parathyroidectomy approach, resecting 3.5 glands routinely. Radio-guidance and intraoperative PTH monitoring is similarly employed as supported by the literature [ 35 , 36 ]. We employ a dedicated nurse practitioner to ensure that patients are prepared preoperatively (i.e.…”

Section: Materials/methodsmentioning

confidence: 99%

Reducing disparities in the treatment of hyperparathyroidism

Gillis,

Wang,

Zmijewski

et al. 2024

Heliyon

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Is preoperative parathyroid localization necessary for tertiary hyperparathyroidism?

Cited by 9 publications

References 26 publications

Resolution of Secondary Hyperparathyroidism after Kidney Transplantation and the Effect on Graft Survival

Resolution of Secondary Hyperparathyroidism after Kidney Transplantation and the Effect on Graft Survival

Making the Cut: Parathyroidectomy Before or After Kidney Transplantation?

Reducing disparities in the treatment of hyperparathyroidism

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