Prospektive Beobachtungsstudie zur operativen Therapie des renalen Hyperparathyreoidismus

Abstract

A prospective long-term follow-up study in patients who had had surgical therapy for renal hyperparathyroidism was launched to investigate the results of surgical treatment and to evaluate possible correlations between preoperative laboratory values and the course of symptoms. From August 1987 to December 1995, 79 patients underwent surgery for renal hyperparathyroidism. It was the first neck exploration for 72 patients. Total parathyroidectomy with autotransplantation to a forearm was our preferred procedure (n = 67). The postoperative course of all patients is know. We carried out one to nine reexaminations (median 4) in 74 of 79 patients. The follow-up period ranged from 1 month to 5 years with a median of 18 months. After the operation transient hypocalcaemia occurred in 84.4% of patients. Postoperative hypocalcaemia correlated negatively with the preoperative levels of alkaline phosphatase and intact parathyroid hormone. Within the first month after surgery 60% of the preoperatively affected patients completely recovered from pruritus, whereas the skeletal syndrome took longer to disappear. One year after surgery 75% of the patients with pruritus and 79% of those with skeletal syndrome had became asymptomatic. After total parathyroidectomy with autotransplantation, patients with preoperatively elevated concentrations of alkaline phosphatase (> 200 U/I) experienced faster relief from joint pain than patients with preoperatively normal concentrations (P = 0.0297). To date 4.5% of the patients developed recurrent hyperparathyroidism after total parathyroidectomy with autotransplantation. Morbidity of surgery for renal hyperparathyroidism is influenced by patients' risk factors. Postoperative hypocalcaemia correlates negatively with the grade of renal osteopathy at the time of operation. Preoperative concentrations of alkaline phosphatase influence the rapidity of the relief from joint pain.

Prospective Evaluation of Parathyroid Graft Function after Total Parathyroidectomy and Heterotopic Autotransplantation in Renal Hyperparathyroidism by Bilateral Determination of Intact Parathormone in Cubital Venous Blood

“…In the present patient population PTH levels in both arms were low, and gradients of approximately 1 were detected on the third day after total parathyroidectomy and autotransplantation. This finding may be due to incomplete revascularization of the graft, leading to a higher rate of postoperative hypocalcemia after total parathyroidectomy and autotransplantation (in 84.4% of our patients [10]) than after subtotal parathyroidectomy, which is known to be followed by hypocalcemia in 53.3% of cases [11]. Parathyroid function should be restored 4 weeks after total parathyroidectomy/autotransplantation.…”

Indikation zur operativen Therapie des renalen Hyperparathyreoidismus

“…Demgegenüber soll der Systemcharakter der Störungen des Mineral-und Knochenhaushalts bei Niereninsuffizienz durch das Akronym CKD-MBD (s. oben) hervorgehoben werden [25]. Derzeit wird folgende Verteilung des Knochenphänotyps bei Niereninsuffizienz angenommen: [8,30,33,39], wobei allerdings ein signifikanter Unterschied zwischen Dialyse-(75-82%) und Transplantationspatienten (14-52%) besteht. Die Besserung der Knochenschmerzen nach Parathyreoidektomie konnte durch zahlreiche Studien belegt werden [29,30,33,39].…”

“…Der Operationserfolg wird hinsichtlich des Pruritus in einigen Fallreihen als durchaus positiv bewertet [15,30,39]. Ob bei therapieresistentem Pruritus der sonographische Nachweis deutlich vergrö-ßerter Nebenschilddrüsen bei hohem Parathormon eine zusätzliche Operationsindikation darstellt, wird diskutiert [6].…”