Subtotal parathyroidectomy with thymectomy for autonomous hyperparathyroidism after renal transplantation

Triponez, Frédéric; Dosseh, David; Hazzan, Marc; Noël, Christian; Vanhille, Philippe; Proye, C

doi:10.1002/bjs.5080

Cited by 45 publications

(57 citation statements)

References 22 publications

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“…These treatments included parathyroidectomy, vitamin D, and cinacalcet hydrochloride [47,48,49,50,51,52,53,54,55,56,57,58]. In general, while these treatments were associated with some improvement in laboratory values, the lack of control groups makes inferences about efficacy difficult.…”

Section: Discussionmentioning

confidence: 99%

Abnormal Bone and Mineral Metabolism in Kidney Transplant Patients – A Review

et al. 2007

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Background/Aims: Abnormal bone and mineral metabolism is common in patients with kidney failure and often persists after successful kidney transplant. Methods: To better understand the natural history of this disease in transplant patients, we reviewed the literature by searching MEDLINE for English language articles published between January 1990 and October 2006 that contained Medical Subject Headings and key words related to secondary or persistent hyperparathyroidism and kidney transplant. Results: Parathyroid hormone levels decreased significantly during the first 3 months after transplant but typically stabilized at elevated values after 1 year. Calcium tended to increase after transplant and then stabilize at the higher end of the normal range within 2 months. Phosphorus decreased rapidly to within or below normal levels after surgery and hypophosphatemia, if present, resolved within 2 months. Low levels of 1,25(OH)₂ vitamin D typically did not reach normal values until almost 18 months after transplant. Conclusion: This review provides evidence demonstrating that abnormal bone and mineral metabolism exists in patients after kidney transplant and suggests the need for treatment of this condition. However, better observational and interventional research is needed before advocating such a treatment guideline.

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Section: Discussionmentioning

confidence: 99%

Abnormal Bone and Mineral Metabolism in Kidney Transplant Patients – A Review

et al. 2007

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“…All patients underwent a complete bilateral neck parathyroid exploration, a transcervical thymectomy, and a subtotal parathyroidectomy, leaving a single remnant of the size of two normal parathyroid glands, as previously described [7]. All patients underwent IOPTH monitoring.…”

Section: Methodsmentioning

confidence: 99%

“…When hypercalcemia persists for more than 1 year after kidney transplantation or when patients develop complication related to hyperparathyroidism, parathyroidectomy is currently the only available curative treatment. The standard surgical approach for patients with tertiary hyperparathyroidism is subtotal parathyroidectomy or total parathyroidectomy with autotransplantation [1][2][3][4][5][6][7]; however, some authors have advocated a less-than-subtotal resection in some patients, describing up to one third of their patients with limited gland involvement (single or double 'adenoma') [8][9][10][11]. Because it is sometimes difficult to find all parathyroid glands, particularly when patients have more than four glands, and to leave a remnant of adequate size (big enough to avoid hypoparathyroidism but small enough to avoid persistent and recurrent disease), it would be helpful to have a reliable intra-operative indicator of cure.…”

Section: Introductionmentioning

confidence: 99%

Accuracy of intra-operative PTH measurement during subtotal parathyroidectomy for tertiary hyperparathyroidism after renal transplantation

Triponez

Dosseh²,

Hazzan³

et al. 2006

Langenbecks Arch Surg

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Background and aims Intra-operative parathyroid hormone (IOPTH) results are not known in the setting of tertiary hyperparathyroidism (HPT) after renal transplantation. Materials and methods A retrospective analysis of 35 tertiary HPT patients who all underwent subtotal parathyroidectomy and IOPTH monitoring was conducted.Results The mean follow-up time was 2.2±1.4 years. Thirty-four patients were cured; one patient (2.8%) had a persistent disease and was cured after reoperation. Median parathyroid hormone (PTH) (median percent decrease from highest) at baseline and at 5, 10, 20, and 30 min were 244, 78 (69%), 63 (75%), 53 (79%), and 49 pg/ml (83%), respectively. Four patients who were cured had a decrease of <50% at 5 min and two of them had a decrease of <50% at 10 min. The patient with persistent disease had a decrease of >50% at 10 min. The sensitivity of the test was 94% at 10 min using the Miami criteria. Conclusion This study shows that IOPTH in tertiary hyperparathyroidism has a high sensitivity. However, because of the low risk of persistent hyperparathyroidism when a subtotal parathyroidectomy is performed, its potential impact on the overall success rate is very small. We therefore do not recommend the routine use of IOPTH in tertiary hyperparathyroidism.

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“…tHPT can cause serious problems, including hypercalcaemia, osteitis fibrosa cystica, osteoporosis leading to increased risk of fracture, soft tissue calcification, bone pain, myopathy with muscular weakness, tendon rupture, anaemia (refractory to erythropoietin), arterial hypertension, and hypercalciuria that increases the risk of kidney stone disease, which is particularly deleterious in a renal graft [4,[6][7][8][9][10][11][12].…”

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confidence: 99%

Surgical treatment of tertiary hyperparathyroidism after renal transplantation: A 31-year experience in a single institution

et al. 2011

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TerTiary hyperparathyroidism (tHPT) can develop after any long-standing period of hypocalcemia, such as those seen with chronic dialysis or gastrointestinal malabsorption; however, tHPT occurs most commonly in the setting of kidney transplantation (KTX), whereby patients with secondary HPT continue to have elevated parathyroid hormone (PTH) levels after KTX. tHPT has been reported in up to 50% of patients who underwent KTX [1, 2] and its occurrence is thought to be related to severity of pretransplant HPT [3] and duration of dialysis prior to transplantation [1,4,5]. Tertiary hyperparathyroidism (tHPT) most commonly refers to a persistent secondary hyperparathyroidism even after successful renal transplantation. Parathyroidectomy (PTX) is an efficient method for treatment of tHPT. In this study, we examined our 31-year experience with patients who underwent PTX for tHPT after KTX and assessed the effects of PTX on graft function according to the type of surgery. Among 2,981 recipients who underwent renal allograft between April 1979 and Dec. 2010, 15 patients (0.5%) were identified as having tHPT and underwent PTX. Levels of intact parathyroid hormone (iPTH) and serum calcium were measured before and after PTX for evaluation of the therapeutic effect, and glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease (MDRD) equation for investigation of any effect on graft function. One patient showed persistent hyperparathyroidism and hypercalcemia after limited PTX. We experienced 14 successful PTXs, including 3 total PTX with autotransplantations, 8 subtotal PTXs, and 3 limited PTXs. Levels of iPTH and serum calcium were at normal range after PTX. Estimated GFR decreased after PTX. Total PTX with autotransplantation showed a tendency of more decrease in the values of iPTH, and GFR after PTX than Subtotal PTX. PTX can cure tHPT-specific symptoms and signs by recovery of hypercalcemia, but may carry the risk of deterioration of kidney graft function. We suspect that subtotal PTX, rather than total PTX with AT, prevent any risk of kidney graft deterioration in surgical treatment of tHPT, and, in selective tHPT patients, limited PTX might be recommended.

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Subtotal parathyroidectomy with thymectomy for autonomous hyperparathyroidism after renal transplantation

Abstract: Systematic subtotal parathyroidectomy associated with thymectomy is effective in treating most renal transplant recipients with tertiary HPT and also minimizes the recurrence of HPT in patients with declining renal function.

Cited by 45 publications

References 22 publications

Abnormal Bone and Mineral Metabolism in Kidney Transplant Patients – A Review

Abnormal Bone and Mineral Metabolism in Kidney Transplant Patients – A Review

Accuracy of intra-operative PTH measurement during subtotal parathyroidectomy for tertiary hyperparathyroidism after renal transplantation

Surgical treatment of tertiary hyperparathyroidism after renal transplantation: A 31-year experience in a single institution

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