Rapid onset intratubular calcification following renal transplantation requiring urgent parathyroidectomy

Sewpaul, Avinash; Sayer, JA; Mohamed, Mostafa; Ahmed, Ashraf; Shaw, Matthew; Prabhu, Vinay; Wood, Kyle; Jones, Nigel R.; Talbot, David; Kanagasundaram, Nigel S.

doi:10.5414/cnp68047

Cited by 7 publications

(4 citation statements)

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“…To date, no strong evidence has been presented that suggests that cinacalcet worsens kidney graft function or that it is associated with other severe adverse effects after transplantation. Urgent parathyroidectomy was recommended by a previous case report to improve graft function in a poorly-controlled hyperparathyroidism patient who experienced graft dysfunction due to acute tubular necrosis associated with intratubular calcification [12]. The use of calcimimetic agent in this condition has not been previously reported.…”

Section: Discussionmentioning

confidence: 99%

Successful treatment of early allograft dysfunction with cinacalcet in a patient with nephrocalcinosis caused by severe hyperparathyroidism: a case report

Cheunsuchon

Sritippayawan

2017

BMC Res Notes

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BackgroundHyperparathyroidism is common in patients undergoing kidney transplantation. Occasionally, this condition can cause early allograft dysfunction by inducing calcium phosphate deposition in the allograft, which results in nephrocalcinosis. Although nephrocalcinosis occurs occasionally in kidney allografts, it has only rarely been reported in the literature.Case presentationHere, we present the case of a 58-year-old Thai woman with severe hyperparathyroidism who received a living-related kidney transplant from her 35-year-old son. Our patient developed allograft dysfunction on day 2 post-transplantation despite good functioning graft on day 1. Allograft biopsy showed extensive calcium phosphate deposition in distal tubules. She was treated with cinacalcet (a calcimimetic agent) and aluminum hydroxide. Allograft function was restored to normal within 1 week after transplantation with greatly reduced intact parathyroid hormone level.ConclusionHyperparathyroidism in early functioning allograft causes elevated calcium and phosphate concentration in distal tubules resulting in nephrocalcinosis. The massive calcium phosphate precipitation obstructs tubular lumens, which leads to acute tubular dysfunction. Treatment of nephrocalcinosis with cinacalcet is safe and may improve this condition by increasing serum phosphate and reducing serum calcium and intact parathyroid hormone.

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Section: Discussionmentioning

confidence: 99%

Successful treatment of early allograft dysfunction with cinacalcet in a patient with nephrocalcinosis caused by severe hyperparathyroidism: a case report

Cheunsuchon

Sritippayawan

2017

BMC Res Notes

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“…In addition, a high index of suspicion should be given for those patients with delayed allograft function to look for nephrocalcinosis-related renal damage, especially in the context of suboptimal serum calcium–phosphate control. Although there has not been any prospective study on the treatment strategy, some previous case reports seem to suggest some benefits with aggressive interventions such as intensive haemodialysis and urgent parathyroidectomy [ 2 , 3 , 10 ]. In any case, these treatments should be considered promptly once the diagnosis is made.…”

Section: Discussionmentioning

confidence: 99%

Kidney allograft failure due to acute phosphate nephropathy associated with severe secondary hyperparathyroidism

Wong

Chan

et al. 2011

Clinical Kidney Journal

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Intratubular calcification is a common finding in renal allografts. However, possible harmful effect of this calcification is not well recognized, and allograft failure purely due to this condition has not been reported. We report a kidney transplant recipient who suffered from severe secondary hyperparathyroidism and unexplained early allograft failure. A diagnosis of acute phosphate nephropathy was made subsequently based on serial allograft biopsy findings. This case calls for a high index of suspicion to look for this rare cause of allograft dysfunction among high-risk patients. It also highlights the importance of good calcium–phosphate control before renal transplantation.

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“…Assessment and treatment of psychosis in a patient with hyperparathyroidism is difficult until hypercalcaemia is removed as a confounding factor. Progressive nephrocalcinosis. This indication for parathyroidectomy occurs when renal function is compromised or a transplanted kidney is threatened 10 Calciphylaxis.…”

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confidence: 99%

“…Progressive nephrocalcinosis. This indication for parathyroidectomy occurs when renal function is compromised or a transplanted kidney is threatened 10 …”

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confidence: 99%

Urgent parathyroidectomy

Biggar

Lennard

2012

ANZ Journal of Surgery

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Urgent parathyroidectomya ns_6002 193..197 Endocrine surgery is increasingly seen as a '23-hour specialty'; 1 calcium and parathyroid hormone assays are readily available, and localizing studies in hyperparathyroidism are improving. Consequently, parathyroidectomy in asymptomatic hyperparathyroidism and expanding indications for minimally invasive parathyroidectomy (MIP) 2 are being debated. Patients are requesting and endocrine surgical trainees are seeking experience in MIP. Profound hypercalcaemia from hyperparathyroidism (a metabolic emergency), when localizing studies may be unavailable and an urgent parathyroidectomy is indicated, also occurs. Training in MIP risks being ill prepared for such emergencies and the formal neck exploration technique often required. Following patient stabilization and transfer to a specialist centre, it is essential that surgical teams are equipped to manage these sick and vulnerable patients appropriately.Hypercalcaemic crisis is the presenting feature in 1.6-6.7% of hyperparathyroid patients 3-7 and may occur in primary or secondary disease. It typically presents with gastrointestinal symptoms and fatigue culminating in weakness, impaired cognition, cardiac arrhythmias or even coma and death, 7 either on a background of long-standing hyperparathyroidism or as the first presentation. 5 Precipitating events include haemorrhage into a cystic adenoma, introduction of thiazide diuretics, parturition and intercurrent illness. 5 Crisis patients have higher calcium and parathyroid hormone levels, greater weights of the pathological parathyroid glands 3,5 and increased rates of ectopic mediastinal glands (10-50%) 3,5 compared with non-crisis populations. However, the underlying pathology is similar in the two groups: a single adenoma (80-85%), multi-gland disease (10-15%) and parathyroid carcinoma (3.6-4.6%). [3][4][5] Treatment is initially with rehydration, which enhances calcium excretion through diuresis. Bisphosphonates and cinacalcet are useful in lowering calcium levels, as a bridge to surgery. The former are contraindicated in pregnancy, the latter (a calcimimetic agent that effectively lowers calcium), used mostly in secondary hyperparathyroidism, has funding limitations for its use in Australasia in primary hyperparathyroidism. Urgent parathyroidectomy within 72 h of presentation is advised; 5,7 however, a longer period may be required for patient stabilization. General anaesthesia in the presence of severe hypercalcaemia can induce cardiac arrhythmia; therefore, efforts to achieve eucalcaemia should be made preoperatively. 5 The average time to surgery from presentation was 5 days in one recent series. 4 Other situations requiring urgent parathyroidectomy include: PERSPECTIVESANZJSurg.com

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Rapid onset intratubular calcification following renal transplantation requiring urgent parathyroidectomy

Cited by 7 publications

References 0 publications

Successful treatment of early allograft dysfunction with cinacalcet in a patient with nephrocalcinosis caused by severe hyperparathyroidism: a case report

Successful treatment of early allograft dysfunction with cinacalcet in a patient with nephrocalcinosis caused by severe hyperparathyroidism: a case report

Kidney allograft failure due to acute phosphate nephropathy associated with severe secondary hyperparathyroidism

Urgent parathyroidectomy

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