Abstract
Background
Parathyroid surgery (PTX) in patients with tertiary hyperparathyroidism (tHPT) may endanger the long-term survival of transplanted renal grafts. The mechanism by which graft function deteriorates is unknown. We reviewed our experience in regard to the operative procedures and postoperative outcome.
Methods
Sixty-nine patients were operated on for tHPT between 1987 and 2006 at our institution. Serum (s) calcium, s-creatinine, and levels of intact parathyroid hormone (PTH) were measured before and after PTX. The Modification of Diet in Renal Disease (MDRD) equation was used to estimate glomerular filtration rate (GFR).
Results
The entire patient group developed a deterioration of kidney graft function after PTX. Nineteen of 69 patients developed a decrease in GFR of more than 20% during the hospital stay, persisting for more than one year after PTX. Ten of them had to restart dialysis during the first year after PTX. Mean preoperative s-creatinine was 4.4 ± 0.6 mg/dl in these patients. When divided according to the surgical procedure performed, only the subgroup who underwent total parathyroidectomy showed a significant worsening of graft function when compared to subtotal or reoperative PTX.
Conclusions
PTX is an efficient way to treat tHPT but represents a risk for impairing graft function, especially for patients that already demonstrate poor kidney function at the time of surgery. In the aim to prevent transient hypoparathyroidism, which may provoke reduced graft perfusion, as one possible cause of kidney graft deterioration associated with PTX, one should consider subtotal instead of total parathyroidectomy.
Similar content being viewed by others
References
Apaydin S, Sariyar M, Erek E, et al. (1999) Hypercalcemia and hyperparathyroidism after renal transplantation. Nephron 81(3):364–365
McCarron DA, Lenfesty B, Thier A, Vetto M, Barry J, Krutzik S, Bennett WM (1980) Total parathyroidectomy for post-transplantation hyperparathyroidism. Proc Clin Dial Transplant Forum 10:51–55
McCarron DA, Lenfesty B, Vetto M, Barry J, Bennett WM (1985) Total parathyroidectomy for posttransplantation hyperparathyroidism. Transplantation 40(3):266–269
D’Alessandro AM, Melzer JS, Pirsch JD, et al. (1989) Tertiary hyperparathyroidism after renal transplantation: operative indications. Surgery 106(6):1049–1055
Pletka PG, Strom TB, Hampers CL, et al. (1976) Secondary hyperparathyroidism in human kidney transplant recipients. Nephron 17(5):371–381
Dotzenrath C, Goretzki PE, Roher HD (1993) Renal hyperparathyroidism following kidney transplantation. Ann Ital Chir 64(4):381–384
Dotzenrath C, Goretzki PE, Roher HD (1993) [Surgical therapy of secondary hyperparathyroidism after kidney transplantation]. Langenbecks Arch Chir 378(2):121–124
Schlosser K, Zielke A, Rothmund M (2004) Medical and surgical treatment for secondary and tertiary hyperparathyroidism. Scand J Surg 93(4):288–297
Kerby JD, Rue LW, Blair H, et al. (1998) Operative treatment of tertiary hyperparathyroidism: a single-center experience. Ann Surg 227(6):878–886
Sitges-Serra A, Esteller E, Ricart MJ, et al. (1984) Indications and late results of subtotal parathyroidectomy for hyperparathyroidism after renal transplantation. World J Surg 8(4):534–539
Sitges-Serra A, Gores P, Hesse U, et al. (1986) Serum calcium as an early indicator for surgical treatment of hyperparathyroidism after renal transplantation. World J Surg 10(4):661–667
Triponez F, Dosseh D, Hazzan M, et al. (2005) Subtotal parathyroidectomy with thymectomy for autonomous hyperparathyroidism after renal transplantation. Br J Surg 92(10):1282–1287
Alfrey AC, Jenkins D, Groth CG, et al. (1968) Resolution of hyperparathyroidism, renal osteodystrophy and metastatic calcification after renal homotransplantation. N Engl J Med 279(25):1349–1356
Johnson JW, Hattner RS, Hampers CL, et al. (1971) Secondary hyperparathyroidism in chronic renal failure. Effects of renal homotransplantation. JAMA 215(3):478–480
Wilson RE, Hampers CL, Bernstein DS, et al. (1971) Subtotal parathyroidectomy in chronic renal failure: a seven-year experience in a dialysis and transplant program. Ann Surg 174(4):640–654
Diethelm AG, Edwards RP, Whelchel JD (1982) The natural history and surgical treatment of hypercalcemia before and after renal transplantation. Surg Gynecol Obstet 154(4):481–490
Schwarz A, Rustien G, Merkel S, et al. (2007) Decreased renal transplant function after parathyroidectomy. Nephrol Dial Transplant 22(2):584–591
Triponez F, Dosseh D, Hazzan M, et al. (2006) [Results of systematic subtotal parathyroidectomy with thymectomy for tertiary hyperparathyroidism after renal transplantation - 70 patients]. Ann Chir 131(3):203–210
Triponez F, Kebebew E, Dosseh D, et al. (2006) Less-than-subtotal parathyroidectomy increases the risk of persistent/recurrent hyperparathyroidism after parathyroidectomy in tertiary hyperparathyroidism after renal transplantation. Surgery 140(6):990–997
Ozdemir FN, Afsar B, Akgul A, et al. (2006)Persistent hypercalcemia is a significant risk factor for graft dysfunction in renal transplantation recipients. Transplant Proc 38(2):480–482
Traindl O, Langle F, Reading S, et al. (1993) Secondary hyperparathyroidism and acute tubular necrosis following renal transplantation. Nephrol Dial Transplant 8(2):173–176
Milas M, Weber CJ (2004) Near-total parathyroidectomy is beneficial for patients with secondary and tertiary hyperparathyroidism. Surgery 136(6):1252–1260
Schmid T, Muller P, Spelsberg F (1997) Parathyroidectomy after renal transplantation: a retrospective analysis of long-term outcome. Nephrol Dial Transplant 12(11):2393–2396
Lee PP, Schiffmann L, Offermann G, et al. (2004) Effects of parathyroidectomy on renal allograft survival. Kidney Blood Press Res 27(3):191–196
Garcia A, Mazuecos A, Garcia T, et al. (2005) Effect of parathyroidectomy on renal graft function. Transplant Proc 37(3):1459–1461
Evenepoel P, Claes K, Kuypers D, et al. (2005) Impact of parathyroidectomy on renal graft function, blood pressure and serum lipids in kidney transplant recipients: a single centre study. Nephrol Dial Transplant 20(8):1714–1720
Massfelder T, Parekh N, Endlich K, et al. (1996) Effect of intrarenally infused parathyroid hormone-related protein on renal blood flow and glomerular filtration rate in the anaesthetized rat. Br J Pharmacol 118(8):1995–2000
Wolzt M, Schmetterer L, Dorner G, et al. (1997) Hemodynamic effects of parathyroid hormone-related peptide-(1–34) in humans. J Clin Endocrinol Metab 82(8):2548–2551
Shigematsu T, Caverzasio J, Bonjour JP (1993) Parathyroid removal prevents the progression of chronic renal failure induced by high protein diet. Kidney Int 44(1):173–181
Ogata H, Ritz E, Odoni G, et al. (2003)Beneficial effects of calcimimetics on progression of renal failure and cardiovascular risk factors. J Am Soc Nephrol 14(4):959–967
Tominaga Y, Uchida K, Haba T, et al. (2001) More than 1,000 cases of total parathyroidectomy with forearm autograft for renal hyperparathyroidism. Am J Kidney Dis 38(4 Suppl 1):S168–S171
Stanbury SW, Lumb GA, Nicholson WF (1960) Elective subtotal parathyroidectomy for renal hyperparathyroidism. Lancet 1:793–799
Kebebew E, Duh QY, Clark OH (2004) Tertiary hyperparathyroidism: histologic patterns of disease and results of parathyroidectomy. Arch Surg 139(9):974–977
Kilgo MS, Pirsch JD, Warner TF, et al. (1998) Tertiary hyperparathyroidism after renal transplantation: surgical strategy. Surgery 124(4):677–683
Nichol PF, Starling JR, Mack E, et al. (2002) Long-term follow-up of patients with tertiary hyperparathyroidism treated by resection of a single or double adenoma. Ann Surg 235(5):673–678
Gioviale MC, Gambino G, Maione C, et al. (2006) Intraoperative parathyroid hormone monitoring during parathyroidectomy for hyperparathyroidism in waiting list and kidney transplant patients. Transplant Proc 38(4):1003–1005
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Schlosser, K., Endres, N., Celik, I. et al. Surgical Treatment of Tertiary Hyperparathyroidism: The Choice of Procedure Matters!. World J Surg 31, 1947–1953 (2007). https://doi.org/10.1007/s00268-007-9187-z
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00268-007-9187-z