Surgical treatment of persistent hyperparathyroidism after renal transplantation. Ann Surg. Parathyroidectomy in patients on renal replacement therapy: an epidemiologic study. J Am Soc Nephrol. Indications for parathyroidectomy and extent of treatment for patients with secondary hyperparathyroidism. Surg Clin North Am.
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The Journal publishes articles on basic or clinical research relating to nephrology, arterial hypertension, dialysis and kidney transplants. It is governed by the peer review system and all original papers are subject to internal assessment and external reviews. The journal accepts submissions of articles in English and in Spanish languages. The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years.
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Home Articles in press Archive. ISSN: Previous article Next article. August Pages Renal hyperparathyroidism's control after ubtotal parathyroidectomy. Download PDF. Salgueira, N. Villar, A. This item has received. Article information. Volumen University Hospital Virgen Macarena.
SUMMARY Parathyroidectomy, in any of its forms, is considered an effective short-term treatment of renal hyperparathyroidism in patients who are not being controlled with drugs. Nevertheless, the outcome in the medium and long term of the various surgical procedures is still unclear and seems a controversial issue. We conducted a prospective study of 15 patients undergoing subtotal parathyroidectomy who were followed up for a period of 48 months after surgery.
All patients were included in hemodialysis programmes. Elevated levels of parathyroid hormone which did not decrease with drug therapy recommended parathyroidectomy. The aim of our study is to determine whether subtotal parathyroidectomy is an effective technique in the medium and long term. As regards the results obtained, the levels of parathyroid hormone and calcemia remarkably decreased during the follow-up period, if compared to pre-surgery levels. The phosphorus and Ca-P product levels only showed a significant reduction immediately after surgery but showed an increment from the first year after surgery onwards.
Hemoglobin levels did not show any alteration after parathyroidectomy. In two patients we observed a relapse of hyperparathyroidism.
The anatomopathological examination revealed nodular hyperplasia in most of the cases, including the two relapses. Conclusion: Subtotal parathyroidectomy is an effective surgical procedure in the medium-term treatment of renal hyperparathyroidism. Key words: Secondary Hyperparathyroidism. Chronic renal failure. El seguimiento postoperatorio fue de 48 meses. En dos casos hubo recurrencia del hiperparatiroidismo.
Palabras clave: Hiperparatiroidismo secundario. Its onset is early, and it is well-known that, among other factors, serum calcium levels decrease, vitamin D efficiency and serum phosphate levels increase as a consequence of renal function impairment are implicated in the pathogenesis.
All this results in parathyroid gland increase due to cell hyperplasia and an increase of parathyroid hormone PTH 3. At the beginning, this hyperplasia is diffuse but may become nodular, with a decrease in calcium and vitamin D cellular receptors that explains the lack of response to pharmacological treatment. Actually, the most frequent histological pattern in parathyroidectomy sections is nodular hyperplasia Parathyroidectomy PTX becomes necessary for secondary HPT treatment when its management is not possible with dialysis and drug therapy.
Currently, it seems clear that all of them are effective, achieving HPT control and symptoms relieve, however, there is no uniform thinking about which is the best procedure for an intermediate-long term management9, The aim of this study is to analyze intermediateterm subtotal PTX outcomes in our dialysis patients presenting our experience with this technique.
Within this six-year period, 22 PTX were performed 4. All procedures were done by the same surgeon at the Endocrine Surgery Unit of the General Surgery Department of our hospital. The procedure type was always subtotal PTX, excising the three largest glands and two thirds of the remaining one that was left in situ, in its original location. Exclusions from the study were seven patients for having a post-PTX follow-up time shorter than one year, 5 patients for death, and two patients for renal transplantation.
Mean age of the patients was The renal failure causes were: chronic glomerulonephritis 8 cases ; nephroangiosclerosis 1 case ; focal and segmentary glomerulonephritis 1 case ; type II mesangiocapilar glomerulonephritis 1 case ; interstitial nephropathy 2 cases ; chronic pyelonephritis 1 case ; Alport' s syndrome 1 case. All presented secondary PTH with no response to medical treatment, and most of the cases had been treated with oral or intravenous vitamin D and with phosphorus chelation at the doses recommended in the literature prior to surgery.
The lack of response to treatment was the indication for surgical treatment. To diagnose HPT we used both biochemistry parameters and imaging tests such as cervical ultrasound and Tcm-sestamibi scintigraphy. The revised analytical determinations were: iPTH, calcium, phosphorus, Ca-P product, alkaline phosphatase, and hemoglobin, measured immediately before and after surgery hours after surgery , and at the second and fourth year after.
In each patient, blood pressure was recorded with the same frequency. At two years, we analyzed 14 patients, and at 4 years only 8, since one of them died and 6 have a post-PTX follow-up shorter than 4 years. The statistical method used has been a non-parametric test for paired data Wilcoxon's test.
RESULTS As expected, all biochemistry parameters studied after surgery present a significant change as compared to pre-surgical levels. Blood pressure levels do not significantly change after surgery, so that patients need to keep on taking antihypertensive treatment. Scintigraphy was done in 6 patients, being of diagnostic value in 5, and in one patient was reported as not valid for diagnosis. With regards to size and weight of the surgical specimen, it was observed that in nodular hyperplasia the diameter varied between mm, and weight between 0.
In diffuse hyperplasia cases, the diameter was never greater than 10 mm mm. All glands with nodular hyperplasia had more than one nodule, none of them being dominant with regards to the others. There was no relationship observed between glandular size and number of nodules. It is assumed that the gland left in situ has the same histopathological characteristics than the excised part of the same gland. In all cases, the study of all glands, included the partially excised one, coincided.
In one case, the patient presented an iPTH increase at the second year after surgery, with detection of a mediastinal parathyroid gland Table I. Ca: calcium; P: phosphorus; FA: alkaline phosphatase; Hb: hemoglobin. The remaining patients presented iPTH levels. Subscribe to our newsletter. See more. Print Send to a friend Export reference Mendeley Statistics.
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The Journal publishes articles on basic or clinical research relating to nephrology, arterial hypertension, dialysis and kidney transplants. It is governed by the peer review system and all original papers are subject to internal assessment and external reviews. The journal accepts submissions of articles in English and in Spanish languages. The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years. CiteScore measures average citations received per document published.