Less Is More: Parathyroidectomy and Association with Postoperative Hypocalcemia in Dialysis Patients

Wang, Rongzhi; Disharoon, Mitchell; Frazier, Rachel Marie; Xie, Rongbing; Moses, Cara; Gillis, Andrea; Fazendin, Jessica; Lindeman, Brenessa; Gutiérrez, Orlando M.; Chen, Herbert

doi:10.1097/xcs.0000000000000539

Cited by 4 publications

(3 citation statements)

References 33 publications

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“…Secondary hyperparathyroidism (HPT) is nearly universal in patients with chronic kidney disease (CKD) at dialysis initiation 1 . Successful kidney transplantation (KT) corrects the physiological and metabolic abnormalities responsible for mineral and bone disease 2 .…”

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confidence: 99%

“…(Ann Surg 2023;278:366-375) S econdary hyperparathyroidism (HPT) is nearly universal in patients with chronic kidney disease (CKD) at dialysis initiation. 1 Successful kidney transplantation (KT) corrects the physiological and metabolic abnormalities responsible for mineral and bone disease. 2 Parathyroid hormone (PTH) levels decline profoundly during the first 3 months post-KT, followed by a slow decrease.…”

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

et al. 2023

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“… 6 Secondary HPT is nearly universal in patients with end-stage kidney disease (ESKD). 7 PTH is elevated in response to decreased production of calcitriol from failed kidneys, elevated serum phosphorus, and decreased serum calcium. 8 The Kidney Disease Improving Global Outcomes (KDIGO) guideline recommends maintaining PTH levels in the range of 2 to 9 times the upper normal limit in patients with ESKD.…”

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Treatment of Hypercalcemic Hyperparathyroidism After Kidney Transplantation Is Associated With Improved Allograft Survival

Wang,

Reed,

Price

et al. 2023

The Oncologist

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Background Hyperparathyroidism (HPT) and malignancy are the most common causes of hypercalcemia. Among kidney transplant (KT) recipients, hypercalcemia is mostly caused by tertiary HPT. Persistent tertiary HPT after KT is associated with allograft failure. Previous studies on managing tHPT were subjected to survivor treatment selection bias; as such, the impact of tertiary HPT treatment on allograft function remained unclear. We aim to assess the association between hypercalcemic tertiary HPT treatment and kidney allograft survival. Materials and Methods We identified 280 KT recipients (2015-2019) with elevated post-KT adjusted serum calcium and parathyroid hormone (PTH). KT recipients were characterized by treatment: cinacalcet, parathyroidectomy, or no treatment. Time-varying Cox regression with delayed entry at the time of first elevated post-KT calcium was conducted, and death-censored and all-cause allograft failure were compared by treatment groups. Results Of the 280 recipients with tHPT, 49 underwent PTx, and 98 received cinacalcet. The median time from KT to first elevated calcium was 1 month (IQR: 0-4). The median time from first elevated calcium to receiving cinacalcet and parathyroidectomy was 0(IQR: 0-3) and 13(IQR: 8-23) months, respectively. KT recipients with no treatment had shorter dialysis vintage (P = .017) and lower PTH at KT (P = .002), later onset of hypercalcemia post-KT (P < .001). Treatment with PTx (adjusted hazard ratio (aHR) = 0.18, 95%CI 0.04-0.76, P = .02) or cinacalcet (aHR = 0.14, 95%CI 0.004-0.47, P = .002) was associated with lower risk of death-censored allograft failure. Moreover, receipt of PTx (aHR = 0.28, 95%CI 0.12-0.66, P < .001) or cinacalcet (aHR = 0.38, 95%CI 0.22-0.66, P < .001) was associated with lower risk of all-cause allograft failure. Conclusions This study demonstrates that treatment of hypercalcemic tertiary HPT post-KT is associated with improved allograft survival. Although these findings are not specific to hypercalcemia of malignancy, they do demonstrate the negative impact of hypercalcemic tertiary HPT on kidney function. Hypercalcemic HPT should be screened and aggressively treated post-KT.

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Feasibility of an Online Patient-Driven International Parathyroid Registry

Wang,

McMullin,

Allahwasaya

et al. 2024

Journal of Surgical Research

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Less Is More: Parathyroidectomy and Association with Postoperative Hypocalcemia in Dialysis Patients

Cited by 4 publications

References 33 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

Treatment of Hypercalcemic Hyperparathyroidism After Kidney Transplantation Is Associated With Improved Allograft Survival

Feasibility of an Online Patient-Driven International Parathyroid Registry

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