|Year : 2019 | Volume
| Issue : 3 | Page : 773-779
Parathyroidectomy with and without autografting in management of secondary hyperparathyroidism in hemodialysis patients
Fatma M Kotb
Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
|Date of Submission||24-Nov-2019|
|Date of Decision||24-Nov-2019|
|Date of Acceptance||17-Dec-2019|
|Date of Web Publication||10-Feb-2020|
Source of Support: None, Conflict of Interest: None
Background Secondary hyperparathyroidism (sHPT) develops in most, if not all, patients with end-stage renal disease. It is known as long-term parathyroid hyperplasia, which results in the formation of functionally independent parathyroid adenoma. sHPT can lead to high-turnover bone disease, interstitial and vascular calcifications, as well as cardiovascular mortality and morbidity.
Objective To study the value of parathyroid autografting following parathyroidectomy in cases of sHPT with chronic renal failure.
Patients and methods A total of 30 patients with end-stage renal disease on dialysis with sHPT were enrolled in this study. All patients are subjected to parathyroidectomy (15 patients with autografting vs. 15 patients without autografting). Clinical evaluation and laboratory investigations (including serum intact parathormone, total and ionized calcium, phosphorus, and alkaline phosphatase) were done preoperatively and postoperatively.
Results There was a significant difference between preoperative and postoperative clinical and laboratory parameters in both groups. Moreover, there was a significant decrease in hospital and intravenous calcium in the group subjected to autografting. Otherwise, there was a nonsignificant difference between the two groups regarding calcium, phosphorus, intact parathormone, and alkaline phosphatase.
Conclusion Parathyroid autografting following parathyroidectomy in patients with sHPT has a significant effect in decreasing postparathyroidectomy hospital stay and intravenous calcium.
Keywords: autografting, hyperparathyroidism, parathyroidectomy
|How to cite this article:|
Kotb FM. Parathyroidectomy with and without autografting in management of secondary hyperparathyroidism in hemodialysis patients. Sci J Al-Azhar Med Fac Girls 2019;3:773-9
|How to cite this URL:|
Kotb FM. Parathyroidectomy with and without autografting in management of secondary hyperparathyroidism in hemodialysis patients. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2020 Dec 2];3:773-9. Available from: http://www.sjamf.eg.net/text.asp?2019/3/3/773/278029
| Introduction|| |
Secondary hyperparathyroidism (sHPT) is the overproduction of parathyroid hormone secondary to a chronic abnormal stimulus for its production, typically as in case of low-vitamin D level chronic kidney disease .
End-stage renal disease (ESRD) is characterized by reduced vitamin D levels, hyperphosphatemia, a tendency toward hypocalcemia, and increased levels of parathormone (PTH), and sHPT. sHPT is an adaptive response to ESRD and the disruptions in the homeostatic control of serum phosphorus, calcium, and vitamin D that are associated with ESRD. Excess circulating levels of PTH, phosphate, and calcium–phosphate product have been linked to high-turnover bone disease, vascular calcification, cardiovascular mortality and morbidity, and death .
The need for parathyroidectomy in patients with ESRD is common and increases with the duration of dialysis; thereby, the poor response or specific contraindications to medical treatment direct the choice towards parathyroidectomy .
| Patients and methods|| |
This study was carried out on 30 patients with ESRD on regular hemodialysis with sHPT. All patients were operated with parathyroidectomy at Al-Zahraa University Hospital from November 2017 to April 2019. All patients of different ages and sex were included. All patients had sHPT with serum intact parathormone (iPTH) above 700 pg/ml after failure of medical treatment for at least 6 months with variable symptoms and signs.
Patients’ inclusion criteria
The following were the inclusion criteria:
- Symptomatic patients in spite of regular medical treatment, that is, bone pain and arthralgia.
- iPTH more than 700 pg/ml.
- Serum calcium normal or less than 10.4 mg/dl.
- Serum phosphorus more than 6 mg/dl.
- Patients with chronic renal failure on regular hemodialysis.
After approval of local ethical committee, all patients included in the study have been informed well about the procedure and have signed an informed written consent before carrying the procedure. The steps of the study, the aim, the potential benefits, and hazards all were discussed with the patients.
Method of preoperative assessment
All patients were subjected to the following:
- Thorough history taking with special emphasis upon the onset of hemodialysis.
- Thorough clinical evaluation regarding symptoms and signs of hyperparathyroidism:
- Symptoms: bone pain, arthralgia, pathological fractures, pruritus, renal stones, gastrointestinal upset, and psychic moods.
- Examination: systematic examination including vital signs, skin lesions, and fractures.
- Laboratory investigations:
- Serum iPTH: the determination of serum iPTH was performed using e411 analyzer by solid-phase two-site chemiluminescent enzyme-labeled immunometric assay (Erlangen, Germany).
- Calcium (total and ionized), phosphorus, and serum alkaline phosphatase were performed on Cobas 311 autoanalyzer (Roche Diagnostics GmbH, Manheim, USA) by colorimetric techniques.
- Imaging modalities: ECG, echocardiography, and high-resolution neck ultrasound. Localization of parathyroid glands had been performed in all patients by neck ultrasound.
Preoperative preparation of all patients
To reduce the risk of worsening renal failure and the risk of morbidity and mortality, the following measures were taken: (a) ensure that blood volume is normal, employing measurement of central venous pressure if necessary; (b) avoid hypotension using inotropes such as dopamine if necessary; (c) delay surgery if hyperkalemia (serum potassium >6 mmol l) or fluid overload is present preoperatively until these have been corrected; and (d) monitor urea, electrolyte, and creatinine concentrations carefully.
All patients were subjected to either of the following:
- Total parathyroidectomy with autografting (where all four glands were removed with part or slices of a gland autotransplanted in the forearm).
- Total parathyroidectomy without autotransplantation ([Figure 1]a–c and [Figure 2]).
|Figure 1 (a) Delivery of one parathyroid gland. (b) Delivery of another one parathyroid gland. (c) Delivery of another one parathyroid gland.|
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Because identification of parathyroid glands is reliant on subtle shades of color and consistency, the recognition of parathyroid tissue can be impossible in a blooded surgical field; meticulous hemostasis is therefore critical.
A curvilinear incision is placed in a skin crease approximately two finger breadths above the sternal notch between the medial borders of the sternocleidomastoid muscles.
Delivery of thyroid towards midline
The infrahyoid (sternohyoid, sternothyroid, and omohyoid) strap muscles are retracted laterally with a right-angled retractor. The thyroid gland is delivered medially by applying gentle digital traction to the gland.
Division of middle thyroid vein
The vein is the first key vascular structure to be encountered and is tightly stretched by medial traction on the gland. Dividing the vein facilitates additional mobilization of the gland and permits delivery of the bulk of the thyroid lobe into the wound.
Identifying superior parathyroid full mobilization and anterior delivery of the upper pole of the thyroid brings the region of the superior parathyroid gland into direct view. The superior parathyroid gland is normally located in a posterior position at the level of the upper two-thirds of the thyroid. It has a characteristic rich orange/yellow color.
Identification of inferior parathyroid
The inferior gland is initially looked for at the inferior aspect of the lower pole of the thyroid or within the thyrothymic ligament. Its location is more varied than with the superior gland, but if it is at its expected location, then it is generally simpler to identify. Removal of the gland and closure is done after that.
Postoperatively all cases had been followed up by regular clinical assessment and serum total and ionized calcium, phosphorus, alkaline phosphatase, and iPTH.
| Results|| |
Our study was carried out on 30 patients with chronic renal failure on regular hemodialysis experiencing sHPT and were divided into two groups:
- Fifteen patients were operated with total parathyroidectomy without autografting.
- Fifteen patients were operated with total parathyroidectomy with autografting.
All patients had symptoms and included 20 male and 10 female patients ([Table 1]). Their minimum age was 29 years and the maximum was 55 years, and the mean age was 39.00±9.489 ([Table 2]).
All patients in this study were subjected to regular hemodialysis where the minimum period of dialysis was 4 years and maximum was 15 years. The mean period of dialysis was 9.717±3.527 ([Table 3]).
|Table 3 Descriptive statistics for the duration of dialysis in all patients|
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Regarding clinical assessment, there was a significant improvement regarding bone pain (preoperatively, 30 patients, compared with postoperatively, three patients, with P<0.001) and gastrointestinal tract troubles (preoperatively, 21 patients, compared with postoperatively, five patients, with P<0.001) but nonsignificant improvement regarding pruritus (preoperatively, nine patients, compared with postoperatively, three patients, with P=0.107) and bone fracture (preoperatively, nine patients, compared with postoperatively, nine patients, with P=0.778) ([Table 4]).
|Table 4 Descriptive statistics for preoperative and postoperative bone pain, fracture, gastrointestinal tract and pruritus|
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The serum iPTH significantly decreased postoperatively (117.667±74.956) compared with preoperatively (1430.633±427.216), with P value less than 0.001 ([Table 5]).
|Table 5 Descriptive statistics of preoperative and postoperative serum parathyroid hormone level|
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There was a significant decrease in serum total calcium postoperatively (5.922±2.238) compared with preoperatively (9.134±0.780), with P value less than 0.001 ([Table 6]).
|Table 6 Descriptive statistics of preoperative and postoperative serum total calcium level|
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The postoperative level of serum ionized calcium (3.993±0.819) significantly decrease compared with preoperative level (4.863±0.653), with P value of 0.001 ([Table 7]).
|Table 7 Descriptive statistics of preoperative and postoperative serum ionized calcium level|
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The postoperative serum phosphorus level (4.116±1.159) significantly decrease compared with preoperative level (7.330±0.787), with P value of 0.001 ([Table 8]).
|Table 8 Descriptive statistics of preoperative and postoperative serum phosphorus level|
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Serum alkaline phosphate level significantly decreased postoperatively (190.167±95.777) compared with preoperative level (811.433±289.562), with P value less than 0.001 ([Table 9]).
|Table 9 Descriptive statistics of preoperative and postoperative serum alkaline phosphatase level|
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Moreover, serum alkaline phosphatase mildly increased in the early postoperative period and then decreased gradually postoperatively.
Regarding comparison between two groups
Period of hospital stay for patients with parathyroidectomy with autografting ranged from 6 to 14 days but for patients operated with parathyroidectomy without autografting ranged from 10 to 35 days with control of calcium level before discharge.
On the contrary, the need for intravenous calcium postoperatively was increased in the group without autografting compared with the group with autografting.
Otherwise, there was a nonsignificant difference between two groups postoperatively regarding calcium, phosphorus, iPTH, and alkaline phosphatase, with P value more than 0.05 ([Table 10]).
| Discussion|| |
Our study was carried out on 30 patients having sHPT owing to chronic renal failure on regular hemodialysis for at least 4 years, of both sex and different ages.
Fifteen patients were operated with total parathyroidectomy without auto-implantation and 15 patients were operated with total parathyroidectomy with auto-implantation.
Our results demonstrated that all clinical symptoms had been significantly ameliorated by the successful surgery.
In our study, there was a postoperative difference between patients who were subjected to total parathyroidectomy with autotransplantation and patients who were subjected to total parathyroidectomy without autotransplantation.
In early postoperative period, there was no difference related to autografting as the autotransplanted parathyroid tissue required about 2 weeks to work in the patients; therefore, the patients who were operated with parathyroidectomy without autotransplantation required longer time for calcium level to be controlled and they were admitted more longer time to reach a normal calcium level.
Thus, they believed that total parathyroidectomy with autotransplantation of trace amounts of parathyroid tissue might be a feasible, safe, and effective surgical option for the patients with sHPT.
During our follow-up, the postoperative overall period result was more perfect for patients who underwent parathyroidectomy with autografting, with less intravenous calcium required, earlier discharge from hospital, and more accepted level of postoperative PTH level on the long run.
He et al.  demonstrated that total parathyroidectomy with forearm transplantation (PTX+FAT) procedure was a safe, feasible, and effective surgical option for patients with sHPT owing to the results that revealed no deaths among 47 study participants. The result indicated that the quality of life in the PTX and PTX+FAT groups significantly increased after the operation compared with preoperatively.
Jing et al.  found that calcitriol was in need for postoperative patients suffering from uremia sHPT, and also the muscle weakness and bone pain were much relieved in patients after parathyroidectomy with autotransplantation (PTX+AT) operation.
Sakman et al.  presented a comparative study of 50 patients who underwent parathyroid surgery for sHPT. The patients were divide into two group: total parathyroidectomy with autotransplantation and subtotal parathyroidectomy. The short-term follow-up included PTH, ionized calcium and alkaline phosphatase levels, bone pain, bone fracture, and persistent or recurrent disease. The mean ionized calcium decreased significantly in total parathyroidectomy with autotransplantation group (P=0.016), and the length of hospital stay was 5 (3–10) days. No serious postoperative complications occurred, and postoperatively, intravenous calcium was given. Preoperative bone symptoms, hypercalcemia, hyperphosphatemia, and increased alkaline phosphatase were improved in all patients, so total parathyroidectomy with autotransplantation is a beneficial and safe surgical procedure for patients with chronic renal failure on dialysis, and patients who underwent total PTX+AT had lower rate of recurrence than those who had subtotal PTX.
In our study, we preferred the forearm for autografting for better and easy access to remove hyperplastic tissue in case of recurrence, and this is the same choice of Jia Gen and colleagues, but in the study of He and colleagues, they preferred sternomastoid muscle for autotransplantation.
Santos et al. , in the study on 66 patients with chronic renal failure who underwent parathyroidectomy reported presternal intramuscular autotransplantation of parathyroid tissue is a feasible and safe surgical option in sHPT and tertiary HPT treatment.
In other large study, Maria et al.  assessed 26 patients with renal disease who underwent total parathyroidectomy only without autotransplantation. They found out that total parathyroidectomy without autotransplantation in renal transplant patients appeared to be protective against persistent and recurrent disease. To the best of our knowledge, this is the largest series with the longest follow-up available in the literature of this specific patient population. Based on this study, we can conclude that for our population with renal disease who underwent total parathyroidectomy, we could avoid persistent or recurrent hyperparathyroidism if we omitted transplanting any parts of the parathyroid gland for these patients.
Zavvos et al.  studied a subset of renal transplant patients who developed persistent hyperparathyroidism and found out that long-term treatment with cinacalcet was effective in controlling hypercalcemia and correcting hypophosphatemia.
| Conclusion|| |
Regular evaluation of patients with chronic renal failure by estimation of iPTH is very important to detect and diagnose sHPT to avoid complication. Specific localization of the parathyroid glands is very important. Autografting of parathyroid tissue is a useful and easy procedure for treatment of the patient with sHPT, especially to decrease hospital stay and intravenous calcium postoperative. However, other large studies are needed to assess usefulness of autografting of parathyroid tissue following parathyroidectomy in management of sHPT after failure of medical treatment.
The authors thank Clinical Pathology Department at Al-Zahraa University Hospital for their valuable contribution to this paper especially for their vital and selfless help in the laboratory investigation of the study.
All authors thank the patients for participation in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]