Persistent hyperparathyroidism requiring surgical treatment after kidney transplantation.

There are not many publications describing long-term follow-up of persistent hyperparathyroidism requiring surgical treatment after kidney transplantation (PHSKT). In some patients adenomas, rather than multiglandular disease, have been incriminated as the cause of PHSKT. We reviewed the charts of 45 patients followed for 12 to 146 months (median 45 months) after parathyroidectomy for PHSKT. We compared them with (1) those of 951 patients receiving a kidney graft during the same period but not submitted to parathyroidectomy or (2) 90 matched controls selected from this cohort to determine the characteristics of PHSKT patients. The duration of pretransplant dialysis was significantly longer in PHSKT patients than in controls (5.78 +/- 0.41 vs. 3.41 +/- 0.24 years; p < 0.0001). A total of 166 glands were removed or biopsied. Except for one questionable case, no true adenoma was observed even when only one gland was enlarged. The outcome of surgery was not influenced by the technique (subtotal parathyroidectomy versus total parathyroidectomy and autografting) but depended on the amount of resected parathyroid tissue: no failures and 4 cases of hypoparathyroidism in 34 cases with no missing gland at cervical exploration; 3 failures and no permanent hypoparathyroidism in 11 cases with one or two missing glands. Excision of the enlarged glands only was sufficient to cure the patient. No recurrence was observed. Our results suggest that single gland enlargement in PHSKT results in most cases from different rates of involution of the parathyroids after successful kidney transplantation. When fewer than four glands are discovered, resection of all visible glands with or without grafting corrects hypercalcemia in more than 70% of the cases.

Long-term results of subcutaneous parathyroid grafts in uremic patients.

HYPOTHESIS: Parathyroid glands are normally surrounded (entirely or partially) by fatty tissue. Subcutaneous parathyroid grafts are thus located in a normal environment. Therefore, we postulated that the late results of subcutaneous implantation of parathyroid tissue in uremic patients should be at least as good as those reported for intramuscular grafting. We also challenged the idea that the recurrence rate of renal hyperparathyroidism after surgery depended solely on the type of hyperplasia (diffuse vs nodular) observed in the implanted tissue. DESIGN: A retrospective study of a series of patients without loss to follow-up. SETTING: A university hospital and 9 affiliated dialysis units. PATIENTS AND INTERVENTIONS: Fifty-nine patients (33 women and 26 men) operated on for renal hyperparathyroidism underwent the resection of at least 4 parathyroid glands followed by presternal subcutaneous implantation of parathyroid tissue. They were followed up for 12 to 130 months (median, 38 months). MAIN OUTCOME MEASURES: Failure of treatment, recurrence of disease, and hypoparathyroidism. RESULTS: During the study period, 9 patients had to undergo another operation: 2 (3%) for persistent hyperparathyroidism due to a fifth ectopic gland and 7 (12%) for recurrence of hyperparathyroidism resulting from hypertrophy of the subcutaneous grafts. Four patients received a kidney transplant. The prevalence of hypoparathyroidism (intact parathyroid hormone serum level <1.6 pmol/L with a normal or low serum calcium concentration) was 14% (8 of 59 patients), and the curve representing the distribution of intact parathyroid hormone serum concentrations among operated on patients was shifted to the left when compared with the curve of patients who underwent hemodialysis and who had no indication for parathyroid surgery. In this latter group, the peak of the curve was situated between 1 and 2 times the upper normal limit, while it was in the normal range 12 to 130 months after total parathyroidectomy and subcutaneous parathyroid autotransplantation. No relation was observed between the recurrence rate of the disease and the histological characteristics of the parathyroid grafts. Also, their function was not influenced by the presence or absence of aluminum deposits in bone biopsy specimens that were obtained at the time of cervical exploration. CONCLUSIONS: The late results of total parathyroidectomy and presternal subcutaneous grafting compare favorably with the published data on other surgical techniques proposed for the treatment of renal hyperparathyroidism. The ease with which the hypertrophied grafts are removed when the disease recurs warrants further use of this procedure.

Evaluation of surgical treatment of renal hyperparathyroidism by measuring intact parathormone blood levels on first postoperative day.

Intact parathormone (inPTH) has a short half-life. Its blood level on the first day after total parathyroidectomy and subcutaneous parathyroid implantation (PTX + G) should therefore allow an early diagnosis of missed residual parathyroid tissue. We tested this hypothesis in 72 uremic patients who were followed for 6 to 110 months after operation. Nine were reoperated for recurrence of the disease. Graft removal was successful in four patients who had post-PTX inPTH levels of 16 pg/ml or lower. In five patients, an overlooked parathyroid gland had to be resected. All of them had elevated post-PTX inPTH blood levels ranging from 72 to 791 pg/ml (upper normal limit 55 pg/ml). Three of these patients had presented with hypocalcemia after PTX. We conclude that the inPTH blood concentration on the first day after PTX allows more precise evaluation of the efficacy of the surgical procedure than the postoperative evolution of blood calcium levels. It is also useful for localizing the source of excessive PTH secretion (graft or overlooked gland) when the disease recurs.

Long-term results after surgical treatment of renal hyperparathyroidism when fewer than four glands are identified at operation.

BACKGROUND: When fewer than four parathyroid glands are discovered during cervical exploration in cases of renal hyperparathyroidism, some have suggested that the glands could be resected and that no parathyroid tissue should be grafted. The aim of the present study was to evaluate this approach. Indeed, no detailed follow-up of such patients has been reported so far. STUDY DESIGN: Between September 1979 and July 1995, 157 patients underwent a cervical exploration for renal hyperparathyroidism in our department. In 23 cases, fewer than four parathyroid glands were found. The present study reports the results of 16 of these patients who did not undergo autotransplantation with parathyroid tissue after resection of all identified glands. RESULTS: At their last visit, four patients had normal blood levels of intact parathyroid hormone 14 to 71 months (median 60 months) after parathyroidectomy. The parathyroid hormone was not detectable in 2 patients at 16 and 76 months after operation. It was elevated in the 10 remaining patients, but the disease required no treatment or could be controlled medically in 7 patients with a follow-up ranging from 12 to 100 months (median 33 months). Two patients needed reoperation, one at 14 and one at 45 months after the first operation. An ectopic gland was found in both cases. The last patient refused further surgical treatment and died after 13 months. CONCLUSIONS: In most cases, autotransplantation of parathyroid tissue is not necessary when fewer than four glands are identified during parathyroidectomy. When grafting was omitted, 14 of 16 patients had normal or elevated blood levels of intact parathyroid hormone 10 to 100 months after parathyroidectomy (median 45 months). However, in two patients, intact parathyroid hormone was persistently undetectable for 16 to 76 months. This suggests that parathyroid tissue should be cryopreserved for delayed autotransplantation when the surgeon chooses not to graft parathyroid tissue.

Total parathyroidectomy and presternal subcutaneous implantation of parathyroid tissue for renal hyperparathyroidism.

When hyperparathyroidism recurs in patients previously treated by total parathyroidectomy and intramuscular parathyroid autotransplantation, excision of the graft is not always technically easy and it is often necessary to resect the portion of the muscle containing the implants. During November 1986, we began a program to test the feasibility of presternal subcutaneous autotransplantation of parathyroid tissue. We hoped this technique would make removal of the grafts simpler. Thirty-six patients with renal hyperparathyroidism (RHPT) received subcutaneous parathyroid implants. Persistent or recurrent hyperparathyroidism was observed in three patients during the follow-up period. The presence of active parathyroid tissue was demonstrated after some time in all the patients. The parathyroid implants were easily excised in three instances (one persistent RHPT and two recurrences). Microscopic examination of the resected specimens did not show any sign of malignant transformation. We conclude that presternal subcutaneous implantation of parathyroid tissue after total parathyroidectomy is a quick, safe and efficient surgical procedure in the treatment of RHPT.

Modulation of inflammatory reactions by surgical trauma: lack of relationship with corticosteroid secretion.

The effect of surgery on inflammation was studied in male Wistar R/A rats using the carrageenin-induced edema model. Swelling of the paw was measured in standardized arbitrary units 2, 4, and 6 hr after a subcutaneous injection of carrageenin iota in the subplantar region of the right hind limb. It was significantly depressed in rats submitted to laparotomy (5.0 +/- 0.4, 8.0 +/- 1.0, 13.7 +/- 1.9) when compared with controls simply anesthetized with ether (6.2 +/- 0.5, 15.5 +/- 1.2, 23.7 +/- 0.6) (p less than 0.001 at 4 and 6 hr). This inhibition lasted for at least 24 hr and was also observed after amputation, although in these experiments, the difference between operated animals and controls was not significant. Alterations of the inflammatory cellular infiltrate were studied using polyurethane sponges soaked with carrageenin lambda implanted subcutaneously in control animals and rats undergoing laparotomy or amputation. The total number of cells recovered from these sponges 5 hr after implantation was smaller in operated rats (2.9 +/- 0.4 x 10(6) cells after laparotomy, 3.1 +/- 1.0 x 10(6) cells after amputation) when compared with controls (11.1 +/- 1.9 x 10(6) cells and 10.3 +/- 1.3 x 10(6) cells) (p less than 0.001 for laparotomy and p less than 0.005 for amputation). The inhibitory effect of operative trauma was not abolished by bilateral adrenalectomy performed 12 days before laparotomy. In rats, surgical trauma induces a depression of remote inflammatory reactions. This phenomenon is not related to increased corticosterone levels.