PTH monitoring after total parathyroidectomy with forearm auto-transplantation: Potential for spuriously high levels from grafted forearm

Abstract

BackgroundWe have identified a cause of falsely elevated parathyroid hormone (PTH) levels after total parathyroidectomy with forearm auto-transplantation (TPT-ATx). Our cases highlight the need to draw PTH samples remotely, away from forearm graft sites, to ensure accurate levels.Case presentationsWe report on four patients who were referred to our surgical team at an academic tertiary care center for what was perceived to be recurrent hyperparathyroidism 2–5 years following total parathyroidectomy with auto-transplantation. Further evaluation revealed highly discrepant results in these patients depending on where the blood was drawn, with spuriously high levels in blood drawn from the grafted arm (Range 337–3885 ng/l), and much lower levels when blood was drawn remotely away from the graft site (Range 9–242 ng/l). The difference in PTH level between the grafted forearm and remote site for these patients ranged between 328 and 3643 ng/l.Over the period these cases were accrued (2008–2012), 89 patients underwent TPT-ATx in our institution. Therefore, our case report series suggests that this phenomenon will be evident to a clinically important extent in at least 4% of patients.ConclusionsOne can acquire spuriously high PTH levels from grafted forearms, leading to the false diagnosis of recurrent hyperparathyroidism. We recommend PTH levels be drawn remotely from graft sites to ensure accurate systemic levels are reflected.

Advances in the treatment of secondary and tertiary hyperparathyroidism

“…This is associated with hypertension, elevated creatinine, and elevated alkaline phosphatase ( 77 ). In combined forearm autograft surgery, it is recommended to extract PTH from the distal end of the graft site to avoid obtaining falsely high PTH levels, leading to a misdiagnosis of recurrent HPT ( 78 ). Reoperation is a safe and effective treatment for recurrence after PTX ( 79 ).…”