Imaging Characteristics and Interpretation Strategy for Renal Hyperparathyroidism: A Retrospective 4-Dimensional Computed Tomography Study.

OBJECTIVE: Parathyroidectomy treats uncontrolled renal hyperparathyroidism (RHPT), requiring identification of all glands. Three types of enhancement are proposed. Type A lesions have higher arterial phase attenuation than the thyroid, type B lesions lack higher arterial phase attenuation but have lower venous phase attenuation, and type C lesions have neither higher arterial phase attenuation nor lower venous phase attenuation than the thyroid. We aimed to outline the image features of problematic parathyroid glands in RHPT and propose a 4-dimensional computed tomography (4DCT) interpretation algorithm. METHODS: This retrospective study involved data collection from patients with RHPT who underwent preoperative 4DCT for parathyroidectomy between January and November 2022. Pathologically confirmed parathyroid lesions were retrospectively identified on 4DCT according to the location and size described in the surgical notes. The attenuation of parathyroid lesions and the thyroid glands was assessed in 3 phases, and demographic data of the patients were collected. RESULTS: Ninety-seven pathology-proven parathyroid glands from 27 patients were obtained, with 86 retrospectively detected on 4DCT. In the arterial phase, the attenuation of parathyroid lesions in RHPT did not exceed that of the thyroid gland (P < .001). In the venous phase, parathyroid lesions demonstrated lower attenuation than the thyroid gland (P < .001). A total of 81 parathyroid lesions (94.2%) exhibited type B patterns. CONCLUSION: Unlike primary hyperparathyroidism, lesions in RHPT exhibited more type B enhancement, making them less readily identifiable in the arterial phase. Therefore, we propose a distinct imaging interpretation strategy to locate these problematic glands more efficiently.

A Case of Parathyroid Carcinoma in Renal Hyperparathyroidism.

Introduction: Parathyroid carcinoma is a rare malignant endocrine tumor that is usually associated with primary hyperparathyroidism. The coexistence of parathyroid carcinoma and renal hyperparathyroidism is a rare phenomenon. Hence, we present a case of parathyroid carcinoma in a patient with tertiary hyperparathyroidism. Case Presentation: Our patient is a 31-year-old woman with a past medical history of end-stage renal failure (ESRF), on hemodialysis for the past 18 years. She was referred by her nephrologist to the endocrine surgery department for consideration of parathyroidectomy in view of long-standing tertiary hyperparathyroidism complicated by hypercalcemia. Bedside ultrasonography scan (US) of the thyroid revealed three parathyroid glands and a hypoechoic right lower pole thyroid nodule with central calcification. Fine-needle aspiration cytology was performed for the suspected thyroid nodule on the same day, which eventually yielded a follicular lesion of undetermined significance. A right hemithyroidectomy and total parathyroidectomy with deltoid implantation was performed. Intraoperative exploration revealed that the thyroid nodule noted at initial US was found to be the right superior parathyroid gland invading into the right thyroid itself. The right superior parathyroid gland was excised en bloc with the right hemithyroidectomy. Post-operatively, the patient was hypocalcemic but was discharged well on post-operative day 5. Histopathological diagnosis of the right hemithyroidectomy specimen containing the right superior parathyroid gland was consistent with that of parathyroid carcinoma. Conclusion: Parathyroid carcinoma is a rare entity that is difficult to diagnose. In patients with ESRF, the presence of concurrent tertiary hyperparathyroidism makes this even more challenging.

Forestalling Hungry Bone Syndrome after Parathyroidectomy in Patients with Primary and Renal Hyperparathyroidism.

Hungry bone syndrome (HBS), severe hypocalcemia following parathyroidectomy (PTX) due to rapid drop of PTH (parathormone) after a previous long term elevated concentration in primary (PHPT) or renal hyperparathyroidism (RHPT), impairs the outcome of underlying parathyroid disease. OBJECTIVE: overview HBS following PTx according to a dual perspective: pre- and post-operative outcome in PHPT and RHPT. This is a case- and study-based narrative review. INCLUSION CRITERIA: key research words "hungry bone syndrome" and "parathyroidectomy"; PubMed access; in extenso articles; publication timeline from Inception to April 2023. EXCLUSION CRITERIA: non-PTx-related HBS; hypoparathyroidism following PTx. We identified 120 original studies covering different levels of statistical evidence. We are not aware of a larger analysis on published cases concerning HBS (N = 14,349). PHPT: 14 studies (N = 1545 patients, maximum 425 participants per study), and 36 case reports (N = 37), a total of 1582 adults, aged between 20 and 72. Pediatric PHPT: 3 studies (N = 232, maximum of 182 participants per study), and 15 case reports (N = 19), a total of 251 patients, aged between 6 and 18. RHPT: 27 studies (N = 12,468 individuals, the largest cohort of 7171) and 25 case reports/series (N = 48), a total of 12,516 persons, aged between 23 and 74. HBS involves an early post-operatory (emergency) phase (EP) followed by a recovery phase (RP). EP is due to severe hypocalcemia with various clinical elements (<8.4 mg/dL) with non-low PTH (to be differentiated from hypoparathyroidism), starting with day 3 (1 to 7) with a 3-day duration (up to 30) requiring prompt intravenous calcium (Ca) intervention and vitamin D (VD) (mostly calcitriol) replacement. Hypophosphatemia and hypomagnesiemia may be found. RP: mildly/asymptomatic hypocalcemia controlled under oral Ca+VD for maximum 12 months (protracted HBS is up to 42 months). RHPT associates a higher risk of developing HBS as compared to PHPT. HBS prevalence varied from 15% to 25% up to 75-92% in RHPT, while in PHPT, mostly one out of five adults, respectively, one out of three children and teenagers might be affected (if any, depending on study). In PHPT, there were four clusters of HBS indicators. The first (mostly important) is represented by pre-operatory biochemistry and hormonal panel, especially, increased PTH and alkaline phosphatase (additional indicators were elevated blood urea nitrogen, and a high serum calcium). The second category is the clinical presentation: an older age for adults (yet, not all authors agree); particular skeleton involvement (level of case reports) such as brown tumors and osteitis fibrosa cystica; insufficient evidence for the patients with osteoporosis or those admitted for a parathyroid crisis. The third category involves parathyroid tumor features (increased weight and diameter; giant, atypical, carcinomas, some ectopic adenomas). The fourth category relates to the intra-operatory and early post-surgery management, meaning an associated thyroid surgery and, maybe, a prolonged PTx time (but this is still an open issue) increases the risk, as opposite to prompt recognition of HBS based on calcium (and PTH) assays and rapid intervention (specific interventional protocols are rather used in RHPT than in PHPT). Two important aspects are not clarified yet: the use of pre-operatory bisphosphonates and the role of 25-hydroxyitamin D assay as pointer of HBS. In RHPT, we mentioned three types of evidence. Firstly, risk factors for HBS with a solid level of statistical evidence: younger age at PTx, pre-operatory elevated bone alkaline phosphatase, and PTH, respectively, normal/low serum calcium. The second group includes active interventional (hospital-based) protocols that either reduce the rate or improve the severity of HBS, in addition to an adequate use of dialysis following PTx. The third category involves data with inconsistent evidence that might be the objective of future studies to a better understanding; for instance, longer pre-surgery dialysis duration, obesity, an elevated pre-operatory calcitonin, prior use of cinalcet, the co-presence of brown tumors, and osteitis fibrosa cystica as seen in PHPT. HBS remains a rare complication following PTx, yet extremely severe and with a certain level of predictability; thus, the importance of being adequately identified and managed. The pre-operatory spectrum of assessments is based on biochemistry and hormonal panel in addition to a specific (mostly severe) clinical presentation while the parathyroid tumor itself might provide useful insights as potential risk factors. Particularly in RHPT, prompt interventional protocols of electrolytes surveillance and replacement, despite not being yet a matter of a unified, HBS-specific guideline, prevent symptomatic hypocalcemia, reduce the hospitalization stay, and the re-admission rates.

Morbidity and long-term outcome of surgery for renal hyperparathyroidism: results from a prospective cohort.

PURPOSES: Surgery remains an important treatment option for renal hyperparathyroidism (rHPT). The number of long-term outcome studies of parathyroidectomy is limited. METHODS: All consecutive patients with a parathyroidectomy for rHPT between 09/2009 and 04/2021 in a Belgian tertiary referral hospital were prospectively enrolled. The main outcomes were (long-term) cured proportion and postoperative morbidity (hypocalcemia, recurrent laryngeal nerve (RLN) palsy, re-intervention for bleeding, and wound morbidity). RESULTS: Sixty patients with a median age of 57 years were analyzed, including 23 patients before kidney transplantation, 23 patients without kidney transplantation, and 14 patients after kidney transplantation. Median time to transplant was 15 (6-24) months after parathyroidectomy. Morbidity was low with only two non-urgent returns to theatre (wound infection and non-compressive hematoma), two temporary RLN paralyses, and no 30-day mortality. Length of hospital stay was longer in patients with parathyroidectomy before kidney transplant, due to a more severe and prolonged need for calcium supplementation. After a median follow-up of 63 months, 37 patients (62%) were still alive, and 11 patients (18%) developed a recurrence. CONCLUSIONS: This single-surgeon, single-center cohort with long-term follow-up confirms the safety and excellent 'cure' proportions of surgery for rHPT but stretches the importance of long-term follow-up.

Implementation of a Nurse-Led Etelcalcetide Protocol at the Outpatient Dialysis Unit: A Quality Improvement Project.

This quality improvement project was implemented to improve renal hyperparathyroidism in patients with end stage kidney disease who are on hemodialysis through the implementation of a nurse-led etelcalcetide protocol. Results showed that the post-intervention group had a 16.7% increase of the intact parathyroid hormone (iPTH) range within the target goal compared to the 3-month pre-intervention assessment (95% CI; 20.3% to 48.1%). The odds of being in the PTH target range were 1.73 times higher after the 3-month intervention than measurements obtained before starting the intervention (95% CI for the odds ratio: 0.29 to 10.3). Despite the lack of statistical significance (p = 0.688) due to a small sample size, there was an improvement in reaching goal PTH levels. Further studies are needed to analyze the effectiveness of nurse-led protocols in treating renal hyperparathyroidism in dialysis patients.

Renal hyperparathyroidism.

The number of the patients with chronic kidney disease is now increasing in the world. The pathophysiology of renal hyperparathyroidism is closely associated with Klotho-FGF-endocrine axes, which must be solved definitively as early as possible. It was revealed that the expression of fgf23 is activated by calciprotein particles, which induces vascular ossification. And it is well known that phosphorus overload directly increases parathyroid hormone and hyperparathyroid bone disease develops in those subjects. On the other hand, low turnover bone disease is often recently. Both the patients with chronic kidney disease suffering from hyperparathyroid bone disease or low turnover bone disease are associated with increased fracture risk. Micropetrosis may be one of the causes of increased fracture risk in the subjects with low turnover bone disease. In this chapter, we now describe the diagnosis, pathophysiology and treatments of renal hyperparathyroidism.

Minimally invasive video-assisted parathyroidectomy (MIVAP) versus conventional parathyroidectomy for renal hyperparathyroidism: a retrospective multicenter study.

To compare minimally invasive video-assisted parathyroidectomy (MIVAP) versus conventional surgery for renal hyperparathyroidism (rHPT). Between 2006 and 2020, 53 patients underwent MIVAP and 182 underwent conventional parathyroidectomy for rHPT at the Kliniken Essen-Mitte and Knappschaftskrankenhaus Bochum, respectively. Two propensity score-matched groups were retrospectively analyzed: the MIVAP group (VG; n = 53) and the conventional group (CG; n = 53). To assess long-term results, the patients were questioned prospectively (VG; n = 17, and CG; n = 26). The VG had a smaller incision (2.8 vs. 4.8 cm), shorter operation duration (81.0 vs. 13.9 min), and shorter duration of stay (2.4 vs. 5.7 days) (p < 0.0001) but a smaller drop in parathyroid hormone (PTH) postoperatively (81.3 vs. 85.5%. p = 0.022) than the CG. The conversion rate was 9.4% (n = 5). The VG had better Patient Scar Assessment Scale (PSAS) scores (10.8 vs. 11.7 p = 0.001) but worse SF-12 health survey scores (38.7 vs. 45.8 for physical health and 46.7 vs. 53.4 for mental health) (p < 0.0001). The PTH level at follow-up was higher in the VG (162.7 vs. 59.1 ng/l, p < 0.0001). There were no differences in morbidity, number of removed parathyroid glands, disease persistence, late rHPT relapse and need for repeat surgery between groups. MIVAP was superior to conventional parathyroidectomy regarding aesthetic outcomes and cost effectiveness. Conventional surgery showed better control of PTH levels and health scores on follow-up than MIVAP, without any impact on rHPT relapse and need for repeat surgery.Trail registration number and date of registration: DRKS00022545 on 14.12.2020.

The Usefulness of Intraoperative PTH as a Predictor for Successful Parathyroidectomy in Secondary Hyperparathyroidism.

Introduction: Secondary hyperparathyroidism (SHPT) is a multisystemic syndrome that affects calcium and bone homeostasis in patients with chronic kidney disease (CKD). Despite medical treatment, 1-2% of patients require parathyroidectomy annually. The use of an intraoperative parathormone protocol (IOPTH) to predict cure is still in debate, due to the lack of standardized protocols, the use of different assays, and uneven PTH clearance. This study aimed to determine the diagnostic accuracy of an IOPTH in patients with SHPT for predicting successful surgery after parathyroidectomy. Methods: About 30 patients were enrolled. A prospective observational study (cohort) was performed in patients who were submitted to parathyroidectomy by an endocrine surgeon for SHPT. All were submitted to a bilateral neck exploration with a subtotal parathyroidectomy. Three IOPTH determinations were withdrawn: at anesthetic induction (PTH0), 15 min (PTH15), and 30 min (PTH30) after completion of gland resection. Another sample was taken 24 h after the procedure (PTH24), values <150 pg/mL defined a successful surgery, and patients were assigned to the success or failure group. IOPTH drop was analyzed to predict successful surgery with drops of 70 and 90% at 15 and 30 min, respectively. Results: A total of 26 patients were included, 19 patients were in the successful group. IOPTH showed a significant difference between groups in their absolute PTH15 and PTH30 values. A significant difference was also found in their PTH drop at 30 min (81 vs. 91%, p = 0.08). For predicting a successful surgery, having a PTH drop >90% at 30 min was the most significant factor [Odds Ratio (OR) 3.0 (1.5-4) IC 95%]. Conclusions: This study points toward a stricter and staggered IOPTH protocol to predict a successful surgery. Our results suggest taking a PTH15 expecting a PTH drop of >90%. If this is not achieved, reexploration and a PTH30 sample are suggested to accurately predict success.

Management of primary and renal hyperparathyroidism: guidelines from the German Association of Endocrine Surgeons (CAEK).

BACKGROUND AND AIMS: The purpose of this review is to provide updated recommendations for the surgical management of primary (pHPT) and renal (rHPT) hyperparathyroidism, formulating a new guideline of the German Association of Endocrine Surgeons (CAEK). METHODS: Evidence-based recommendations for the diagnosis and therapy of pHPT and rHPT were assessed by a multidisciplinary panel using PubMed for a comprehensive literature search together with a structured consensus dialogue (S2k guideline of the Association of the German Scientific Medical Societies, AWMF). RESULTS: During the last 20 years, a variety of new preoperative localization procedures, such as sestamibi-SPECT, 4D-CT, and various PET/CT procedures, were established for pHPT. High-resolution imaging, together with intraoperative parathyroid hormone (IOPTH) measurement, enabled focused or minimally invasive surgery to become the most favored surgical technique. Patients with pHPT and nonlocalizing imaging have a higher risk of multiglandular disease. Surgical therapy provides very high cure rates, with a clear relation to the surgeon's experience in parathyroid procedures. Reoperative parathyroidectomy, children with pHPT or familial forms, and parathyroid carcinoma are addressed and require special surgical expertise. A multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons should assess the diagnosis and treatment of renal HPT. CONCLUSION: Surgery is the only curative treatment for pHPT and should be considered for all patients with pHPT. For rHPT, a more selective approach is required, and parathyroidectomy is indicated only when conservative treatment options fail. In parathyroid carcinoma, the adequacy of local resection influences local disease control.

Surgical Management of Secondary Hyperparathyroidism.

Secondary hyperparathyroidism (SHPT) affects a majority of patients with chronic kidney disease (CKD) of stage 3 or worse. Despite the development of calcimimetics and their effectiveness in treating SHPT, many patients continue to fail medical management and should be referred to a parathyroid surgeon. In this narrative review, we summarize the indications for surgical referral, preoperative planning, intraoperative strategies to guide resection, and postoperative management. In the absence of universal guidelines, it can be difficult to determine when it is appropriate to make this referral. The majority of studies evaluating parathyroidectomy (PTX) for SHPT use the criteria of parathyroid hormone level (PTH) >800 pg/ml with hypercalcemia and/or hyperphosphatemia, which may be accompanied by symptoms such as bone pain and pruritis that can improve after surgery. Although the reported utility of the various imaging modalities (i.e., 99m-technetium-sestamibi scintigraphy with computed tomography [SPECT/CT], CT, or ultrasound) is highly variable in SHPT, SPECT/CT appears to be the most sensitive. Intraoperatively, PTH monitoring is effective in predicting long-term cure of SHPT but not in predicting hypoparathyroidism. Ectopic and supernumerary parathyroid glands are common in these patients and are often implicated in persistent or recurrent disease. Postoperatively, patients are at risk of severe hypocalcemia and hungry bone syndrome requiring close monitoring and replenishment.

Application of Tissue Aspirate Parathyroid Hormone Assay for Imaging Suspicious Neck Lesions in Patients with Complicated Recurrent or Persistent Renal Hyperparathyroidism.

BACKGROUND: Comprehensive pre-reoperative localization is essential in complicated persistent or recurrent renal hyperparathyroidism. The widely used imaging studies sometimes lead to ambiguous results. Our study aimed to clarify the role of tissue aspirate parathyroid hormone (PTH) assay with a new positive assay definition for imaging suspicious neck lesions in these challenging scenarios. METHODS: All patients with complicated recurrent or persistent renal hyperparathyroidism underwent parathyroid sonography and scintigraphy. Echo-guided tissue aspirate PTH assay was performed in suspicious lesions revealed by localization imaging studies. The tissue aspirate PTH level was determined by an immunoradiometric assay. We proposed a newly-developed definition for positive assay as a washout level higher than one-thirtieth of the serum PTH level obtained at the same time. The final diagnosis after re-operation was confirmed by the pathologists. RESULTS: In total, 50 tissue aspirate PTH assays were performed in 32 patients with imaging suspicious neck lesions, including discrepant results between scintigraphy and sonography in 47 lesions (94%), unusual locations in 19 lesions (38%), multiple foci in 28 lesions (56%), and locations over previously explored areas in 31 lesions (62%). Among 39 assay-positive lesions, 13 lesions (33.3%) were not identified by parathyroid scintigraphy, and 28 lesions (71.8%) had uncertain parathyroid sonography findings. The final pathology in patients who underwent re-operative surgery proved the tissue aspirate PTH assays had a 100% positive predictive value. CONCLUSIONS: Our findings suggest tissue aspirate PTH assay with this new positive assay definition is beneficial to clarify the nature of imaging suspicious lesions in patients with complicated persistent or recurrent renal hyperparathyroidism.

Analytical and Clinical Validation of a New Immunoenzymatic Method for the Measurement of Canine Parathyroid Hormone.

Renal hyperparathyroidism (RHPT) is one of the main complications in dogs affected with Chronic Kidney Disease (CKD). The measurement of serum parathyroid hormone (PTH) could be of clinical utility for the disease's treatment and follow-up; however, PTH is not routinely determined due to limited available methods, often not fully validated in dogs. The aims of this study were the analytical validation of an immunoenzymatic method for the measurement of PTH in canine serum and the analysis of preliminary association of the obtained results with renal function. Twenty-six samples obtained from dogs healthy or affected with CKD were analysed. PTH was measured using a two-site immunoenzymometric human assay (ST AIA-PACK® Intact PTH, Tosoh Bioscience). The analytical validation protocol evaluated the assay precision and accuracy. Also, the PTH's storage stability at 20 °C, 4 °C and -20 °C was assessed. Clinical validation was performed by comparing PTH values with creatinine, phosphorus and International Renal Interest Society (IRIS) stage. The method showed optimal precision and accuracy, whereas stability was adequate up to 4 h at 20 °C, 24 h at 4 °C and 6 months at -20 °C. PTH was positively associated with creatinine, phosphorus and IRIS stage. The investigated method was thus successfully validated in dogs, allowing its use for clinical purpose.

Evaluation of Electrolyte Concentration and Pro-Inflammatory and Oxidative Status in Dogs with Advanced Chronic Kidney Disease under Dietary Treatment.

An integrated study on the effect of renal diet on mineral metabolism, fibroblast growth factor 23 (FGF-23), total antioxidant capacity, and inflammatory markers has not been performed previously. In this study, we evaluated the effects of renal diet on mineral metabolism, oxidative stress and inflammation in dogs with stage 3 or 4 of chronic kidney disease (CKD). Body condition score (BCS), muscle condition score (MCS), serum biochemical profile, ionized calcium (i-Ca), total calcium (t-Ca), phosphorus (P), urea, creatinine, parathyroid hormone (PTH), FGF-23, interleukin 6 (IL-6), interleukin 10 (IL-10), tumor necrosis factor alpha (TNF-α) and total antioxidant capacity (TAC) were measured at baseline (T0) and after 6 months of dietary treatment (T6). Serum urea, P, t-Ca, i-Ca, PTH, FGF-23, IL-6, IL-10, TNF-α and TAC measurements did not differ between T0 and T6. Serum creatinine (SCr) was increased at T6 and serum PTH concentrations were positively correlated with serum SCr and urea. i-Ca was negatively correlated with urea and serum phosphorus was positively correlated with FGF-23. Urea and creatinine were positively correlated. The combination of renal diet and support treatment over 6 months in dogs with CKD stage 3 or 4 was effective in controlling uremia, acid-base balance, blood pressure, total antioxidant capacity, and inflammatory cytokine levels and in maintaining BCS and MCS.

Protocol driven outcomes in renal parathyroid surgery.

BACKGROUND: Patients who require surgery for renal hyperparathyroidism represent a special population that is at high risk for postoperative complications. To optimize their treatment, we developed a multidisciplinary approach to the perioperative management of these patients undergoing parathyroidectomy. METHODS: The Augusta University endocrine surgery parathyroid database was interrogated to identify dialysis-dependent patients undergoing parathyroidectomy from 2005 to 2015. Numerous clinical parameters were quantified. Patients were stratified into protocol patients and nonprotocol patients. RESULTS: A total of 42 patients undergoing renal parathyroidectomy who met the inclusion criteria were identified. Serious adverse events were nearly twice as common in the patients not treated on protocol. The length of stay was nearly 2 days shorter in the protocol group. Lowest calcium level and ionized calcium was higher in the protocol cohort despite a lower postoperative parathyroid hormone. The protocol group had fewer laboratory draws. CONCLUSION: Implementation of a multidisciplinary renal hyperparathyroidism protocol has resulted in improved perioperative outcomes.

Outcomes in patients with renal hyperparathyroidism requiring cinacalcet pre-operatively followed by parathyroidectomy.

BACKGROUND: Cinacalcet is an effective treatment for renal hyperthyroidism when traditional medical therapy has failed. We studied the impact of pre-operative cinacalcet administration on post-surgical outcomes. METHODS: A retrospective analysis was performed of patients from 2002 to 2017 diagnosed with renal hyperparathyroidism requiring parathyroidectomy to evaluate the need for post-operative supplementation and outcomes. RESULTS: 102 patients were identified; 34 patients were treated with cinacalcet prior to undergoing parathyroidectomy. The cinacalcet treatment cohort (CT) demonstrated a greater duration of renal replacement therapy (p = 0.03) relative to the untreated cohort (NC). NC had greater proportion receiving peritoneal dialysis (p=<0.0001) compared to other forms of renal replacement, greater pre-operative PTH levels (p = 0.001) and greater decrease in PTH after resection (p = 0.0086). Post-operative vitamin D supplementation was more frequent in the CT group (p = 0.02). After propensity matching for pre-operative PTH and duration of renal replacement therapy, there were no differences in post-operative supplementation or outcomes. CONCLUSIONS: Cinacalcet patients may have advanced disease. These patients have longer duration of renal failure and higher PTH levels. After propensity matching, no significant differences were noted in terms of need for supplementation or outcomes.

Parathyromatosis type 2 detected by 99mTc-MIBI SPECT/CT.

Parathyromatosis, which is defined as multiple foci of benign hyperfunctioning parathyroid tissue in neck or mediastinum, is a rare but severe cause of persistent/recurrent renal hyperparathyroidism (rHPT) after parathyroidectomy (PTX). It is hard to detect and remove all the foci. We present a case of parathyromatosis in a haemodialysed patient, who had three PTXs for persistent/recurrent rHPT and was free of recurrence during 31-month follow-up after the third PTX. 99mTc-MIBI SPECT/CT scan prior to the third PTX located all the lesions. The presented case suggests that preoperative 99mTc-MIBI SPECT/CT is useful for successful surgical removal of parathyromatosis.

How radical is total parathyroidectomy in patients with renal hyperparathyroidism?

PURPOSE: Total parathyroidectomy (tPTX) in patients with renal hyperparathyroidism (RHPT) aims at the complete removal of all hyperfunctioning parathyroid tissue. Whenever parathyroidectomy is termed "total," undetectable postoperative parathyroid hormone (PTH) levels within the first postoperative week are expected. The aim of this study was to evaluate if tPTX is technically possible using a radical surgical procedure. METHODS: In 109 consecutive patients with RHPT (on hemodialysis: n = 50; after kidney grafting n = 59), removal of all visible parathyroid tissue, bilateral thymectomy, bilateral central neck dissection (level VI), and immediate autotransplantation (AT) was performed. Intact PTH (iPTH) levels were measured in the first postoperative week. PTX was classified "total" when iPTH dropped below 10 pg/ml, "subtotal" between 10 and 65 pg/ml, and "insufficient" where levels stayed above 65 pg/ml. RESULTS: According to the postoperative PTH value, tPTX was achieved in 80 of 109 (73.4%) patients (hemodialysis n = 27, normal kidney function: n = 43, restricted: n = 10). PTX was "subtotal" in 25 patients (22.9%), 19 on hemodialysis, 2 had normal, and 4 had restricted kidney graft function. PTX turned out to be insufficient in four patients (3.7%); all of them were on hemodialysis. Insufficient PTX was not observed in kidney-grafted patients. Postoperative temporary laryngeal nerve morbidity was 1.8% (no permanent paresis). CONCLUSIONS: Although applying a very radical concept in patients with RHPT, PTX was "total" in only 73.4%. Persistence of disease was avoided in 91.7%, and low morbidity was documented. In conclusion, it seems difficult to remove all parathyroid tissue from the neck which has to be considered when choosing the surgical procedure.

Factors associated with calcium requirements after parathyroidectomy in chronic kidney disease patients.

BACKGROUND: Renal hyperparathyroidism is a common complication of chronic kidney disease (CKD). Parathyroidectomy (PTX) for these patients continues to be a valuable option in the era of calcimimetics. Postoperative hypocalcemia is common after surgery. The aim of this study was to identify clinical factors to define postoperative calcium requirements. METHODS: From February 2013 to May 2017, 68 patients with chronic kidney disease 5 (CKD5) who underwent PTX were reviewed. We collected clinical and laboratory data preoperatively and calculated the total calcium requirement in a week after surgery. Univariate and multiple analyses were performed to study whether these clinical and laboratory factors were associated with calcium requirement. RESULTS: Univariate analysis showed that preoperative alkaline phosphatase (ALP), calcium (Ca), parathyroid hormone and hemoglobin were independently associated with calcium requirement. Multivariate model showed that the preoperative ALP was the only independent factor that could predict the requirement of calcium. CONCLUSIONS: In the context of a high dCa (1.75 mmol/l) and a stable dose of calcitriol, preoperative ALP levels were significantly associated with calcium requirement in patients with CKD5 undergoing PTX.

Treatment of renal hyperparathyroidism: Cinacalcet or surgery? / 中华内分泌外科杂志

Patients with end-stage renal disease have a 30％-50％ incidence of hyperparathyroidism.Renal hyperparathyroidism causes multiple systemic diseases,which affect the life quality of patients,and seriously endangers patients' life.Now there are two major treatments,Cinacalcet and surgery.This article is aimed to discuss the characteristics of the two methods and review the latest research on renal hyperparathyroidism.It is advised that Cinacalcet may apply to:1,patients with mild to moderate secondary hyperparathyroidism;2,patients who do not accept the surgery;3,patients with surgical contraindication.And surgical procedures are applicable to:1,patients with tertiary hyperparathyroidism after kidney transplantation;2,patients with invalid Cinacalcet treatment;3,patients who cannot tolerate the side-effect of Cinacalcet;4,patients unable to undertake economic burden of Cinacalcet.However,these conclusions still require higher levels of clinical trials to be validated.

Subtotal parathyroidectomy for secondary renal hyperparathyroidism: a 20-year surgical outcome study.

AIM: The aim of this study was to evaluate the outcomes of surgery for patients with secondary renal hyperparathyroidism (rHPT). METHODS: This is a retrospective cohort study. Our institutional database was searched for eligible patients treated in 1995-2014. The inclusion criterion was initial parathyroidectomy for rHPT. Clinical and follow-up data were analyzed to estimate the cure rate (primary outcome), and morbidity (secondary outcome). RESULTS: The study group comprised 297 patients (154 females, age 44.5 ± 13.7 years, follow-up 24.6 ± 10.5 months), including 268 (90.2 %) patients who had underwent subtotal parathyroidectomy, and 29 (9.8 %) who had had incomplete parathyroidectomy. Intraoperative iPTH assay was utilized in 207 (69.7 %) explorations. Persistent rHPT occurred in 12/268 (4.5 %) patients after subtotal parathyroidectomy and 5/29 (17.2 %) subjects after incomplete parathyroidectomy (p = 0.005). The patients operated on with intraoperative iPTH assay had a higher cure rate than non-monitored individuals, 201/207 (97.1 %) vs. 79/90 (87.8 %), respectively (p = 0.001). In-hospital mortality occurred in 1/297 (0.3 %) patient. The hungry bone syndrome occurred in 84/268 (31.3 %) patients after subtotal parathyroidectomy and 2/29 (6.9 %) subjects after incomplete parathyroidectomy (p = 0.006). Transient recurrent laryngeal nerve paresis occurred in 14/594 (2.4 %) and permanent in 5/594 (0.8 %) nerves at risk. CONCLUSIONS: Subtotal parathyroidectomy is a safe and efficacious treatment for patients with rHPT. Utilization of intraoperative iPTH assay can guide surgical exploration and improve the cure rate.