Experience with Post Transplant Parathyroidectomy in Gulf Region and Literature Review

Samra Abouchacra, Ahmed Chaaban, Ammar Abdel Baki, Khalid Al Mashari, Saif Al Sobhi, Atia Al Zahrani, Qutaiba Hussain, Nicole Gebran, Mohamed Ahmed, Imran Khan, Bassam Bernieh, Mohammad Budruddin

Armed Forces Hospital, Taif, KSA.
King Faisal Specialist Hospital Research Centre (KFSHRC), Riyadh, KSA.
Sheikh Khalifa Medical City (SKMC), Abu Dhabi, UAE.
Tawam Hospital, Al Ain, UAE.

DOI: 10.4236/ojneph.2013.34036                

Abstract

Sustained elevation of parathyroid hormone (PTH) levels is not uncommon post renal transplantation. Though in the majority of patients, it gradually normalizes, on average 5% of transplanted patients require parathyroidectomy (PTX). However, PTX itself has been associated with deterioration in allograft function and even completes graft loss seen with both total and subtotal PTX as well as an increased rate of acute rejection. The aim of this study was to determine the effect of post transplant partial PTX on allograft function in our patients as well as the incidence of acute rejection. Our results show that post transplantation, subtotal PTX, was successful in achieving metabolic control while preserving graft function without an increased incidence of acute rejection. Retention of sufficient residual parathyroid tissue with partial PTX might account for favorable outcome in our study. Despite this, surgery for advanced hyperparathyroidism should optimally take place in the pre-transplant period.

Keywords

Parathyroidectomy; Renal Transplantation; Parathyroid Hormone; Hyperparathyroidism

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	P. Evenepoel, K. Claes, D. R. Kuypers, F. Debruyne and Y. Vanrenterghem, “Parathyroidectomy after Successful Kidney Transplantation: A Single Centre Study,” Nephrology Dialysis Transplantation, Vol. 22, No. 6, 2007, pp. 1730-1737. http://dx.doi.org/10.1093/ndt/gfm044
[2]	K. Schlosser, N. Endres, I. Celik, V. Fendrich, M. Rothmund and E. D. Fernandez, “Surgical Treatment of Tertiary Hyperparathyroidism: The Choice of Procedure Matters!” World Journal of Surgery, Vol. 31, 2007, pp. 1947-1953. http://dx.doi.org/10.1007/s00268-007-9187-z
[3]	E. Lewin and K. Olgaard, “Parathyroidectomy vs Calcimimetics for Treatment of Persistent Hyperparathyroidism after Kidney Transplantation,” Nephrology Dialysis Transplantation, Vol. 21, No. 7, 2006, pp. 1766-1769.
[4]	A. M. D’Alessandro, J. S. Melzer, J. D. Pirsch, et al., “Tertiary Hyperparathyroidism after Renal Transplantation: Operative Indications,” Surgery, Vol. 106, 1989, pp. 1049-1055.
[5]	A. M. Parfitt, “Hypercalcemic Hyperparathyroidism Following Renal Transplantation: Differential Diagnosis, Management, and Implications for Cell Population Control in the Parathyroid Gland,” Mineral and Electrolyte Metabolism, Vol. 8, 1982, pp. 92-112.
[6]	W. Reinhardt, H. Bartelworth, F. Jockenhovel, H. Schmidt-Gayk, O. Witzke, K. Wagner, U. W. Heemann, D. Reinwein, T. Philipp and K. Mann, “Sequential Changes of Biochemical Bone Parameters after Kidney Transplantation,” Nephrology Dialysis Transplantation, Vol. 13, 1998, pp. 436-442. http://dx.doi.org/10.1093/oxfordjournals.ndt.a027843
[7]	T. Schmid, P. Muller and F. Spelsberg, “Parathyroidectomy after Renal Transplantation: A Retrospective Analysis of Long-Term Outcome,” Nephrology Dialysis Transplantation, Vol. 12, No. 11, 1997, 2393-2396.
[8]	C. Dotzenrath, P. E. Goretzki and H. D. Roher, “Surgical Therapy of Secondary Hyperparathyroidism after Kidney Transplantation,” Langenbecks Archiv fü Chirurgie, Vol. 378, No. 2, 1993, pp. 121-124.
[9]	J. W. Johnson, R. S. Hattner, C. L. Hampers, D. S. Bernstein, J. P. Merrill and L. M. Sherwood “Secondary Hyperparathyroidism in chronic Renal Failure. Effects of renal Homotransplantations,” The Journal of the American Medical Association, Vol. 215, No. 3, 1971, pp. 478-480. http://dx.doi.org/10.1001/jama.1971.03180160074025
[10]	R. E. Wilson, C. L. Hampers, D. S. Bernstein, J. W. Johnson and J. P. Merrill, “Subtotal Parathyroidectomy in Chronic Renal Failure: A Sever-Year Experience in a Dialysis and Transplant Program,” Annals of Surgery, Vol. 174, No. 4, 1971, pp. 640-654. http://dx.doi.org/10.1097/00000658-197110000-00009
[11]	A. G. Diethelm, R. P. Edwards and J. D. Whelchel, “The Natural History and Surgical Treatment of Hypercalcemia before and after Renal Transplantation,” The Journal of Surgery, Gynaecology and Obstetrics, Vol. 154, No. 4, 1982, pp. 481-490.
[12]	A. Schwarz, G. Rustein, S. Merkel, J. Radermacher and H. Haller, “Decreased Renal Transplant Function after Parathyroidectomy,” Nephrology Dialysis Transplantation, Vol. 22, No. 2, 2007, pp. 584-591. http://dx.doi.org/10.1097/00000658-197110000-00009
[13]	A Garcia, A Mazuecos, T Garcia, P. González, M. Ceballos and M. Rivero, “Effect of Parathyroidectomy on Renal Graft Function,” Transplantation Proceedings, Vol. 37, No. 3, 2005, pp. 1459-1461. http://dx.doi.org/10.1016/j.transproceed.2005.02.009
[14]	P Evenepoel, K Claes, D Kuypers, B. Maes and Y. Vanrenterghem, “Impact of Parathyroidectomy on Renal Graft Conation, Blood Pressure and Serum Lipids in Kidney Transplant Recipients: A Single Centre Study,” Nephrology Dialysis Transplantation, Vol. 20, No. 8, 2005, pp. 1714-1720. http://dx.doi.org/10.1093/ndt/gfh892
[15]	G. Dumoulin, B. Hory, N. U. Nguyen, C. Bresson, V. Fournier, M. Bouhaddi, J. M. Chalopin, Y. Saint-Hillier and J. Regnard, “No Trend toward a Spontaneous Improvement of Hyperparathyroidism and high Bone Turnover in Normocalcemic Long-Term Renal Transplant Recipients,” American Journal of Kidney Diseases, Vol. 29, 1997, pp. 746-753. http://dx.doi.org/10.1016/S0272-6386(97)90129-3
[16]	D. A. McCarron, R. S. Muther, B. Lenfesty and W. M. Bennett, “Parathyroid Function in Persistent Hyperparathyroidism: Relationship to Gland Size,” Kidney International, Vol. 22, 1982, pp. 662-670. http://dx.doi.org/10.1038/ki.1982.227
[17]	P. Messa, C. Sindici, G. Cannella, V. Miotti, A. Risaliti, M. Gropuzzo, P. L. Di Loreto, F. Bresadola and G. Mioni, “Persistent Secondary Hyperparathyroidism after Renal Transplantation,” Kidney International, Vol. 54, 1998, pp. 1704-1713. http://dx.doi.org/10.1046/j.1523-1755.1998.00142.x
[18]	A. Torres, V. Lorenzo and E. Salido, “Calcium Metabolism and Skeletal Problems after Transplantation,” Journal of American Society of Nephrology, Vol. 13, 2002, pp. 551-558.
[19]	M. Rix, E. Lewin and K. Olgaard, “Posttransplant Bone Disease, ” Transplantation Reviews, Vo. 17, 2003, pp. 176-186. http://dx.doi.org/10.1016/j.trre.2003.08.003
[20]	F. Triponez, E. Kebebew, D. Dosseh, Q. Y. Duh, M. Hazzan, C. Noel, G. M. Chertow, F. Wambergue, D. Fleury, V. Lemaitre, C. A. Proye and O. H. Clark, “Less-Than-Subtotal Parathyroidectomy Increases the Risk of Persistent/Recurrent Hyperparathyroidism after Parathyroidectomy in Tertiary Hyperparathyroidism after Renal Transplantation,” Surgery, Vol. 140, No. 6, 2006, pp. 990-997. http://dx.doi.org/10.1016/j.surg.2006.06.039
[21]	F. N. Ozdemir, B. Afsar, A. Akgul, et al., “Persistent Hypercalcemia is a Significant rrsk Factor for Graft Dysfunction in Renal Transplantation Recipients,” Transplantation Proceedings, Vol. 38, No. 2, 2006, pp. 480-482. http://dx.doi.org/10.1016/j.transproceed.2005.12.065
[22]	O. Traindl, F. Langle, S. Reading, et al., “Secondary Hyperparathyroidism and Acute Tubular Necrosis Following Renal Transplantation,” Nephrology Dialysis Transplantation, Vol. 8, No. 2, 1993, pp. 173-176.
[23]	F. Triponez, D. Dosseh, M. Hazzan, C. Noel, P. Vanhille and C. A. Proye, “Subtotal Parathyroidectomy with Thymectomy for Autonomous Hyperparathyroidism after Renal Transplantation,” British Journal of Surgery, Vol. 92, No. 10, 2005, pp. 1282-1287. http://dx.doi.org/10.1002/bjs.5080
[24]	F. Triponez, D. Dosseh, M. Hazzan, et al., “Results of Systematic Subtotal Parathyroidectomy with Thymectomy for Tertiary Hyperparathyroidism after Renal Transplantation-70 Patients,” Annales de Chirurgie, Vol. 131, No. 3, 2006, pp. 203-210. http://dx.doi.org/10.1016/j.anchir.2005.12.007
[25]	C. Dotzenrath, P. E. Goretzki and H. D. Roher, “Renal Hyperparathyroidism Following Kidney Transplantation,” Annali Italiani di Chirurgia, Vol. 64, No. 4, 1993, pp. 381-384.
[26]	K. Schlosser, A. Zielke and M. Rothmund, “Medical and Surgical Treatment for Secondary and Tertiary Hyperparathyroidism,” Scand Journal of Surgery, Vol. 93, No. 4, 2004, pp. 288-297.
[27]	J. D. Kerby, L. W. Rue, H. Blair, et al., “Operative Treatment of Tertiary Hyperparathyroidism: A Single-Center Experience,” Annals of Surgery, Vol. 227, No. 6, 1998, pp. 878-886. http://dx.doi.org/10.1097/00000658-199806000-00011
[28]	A. Sitges-Serra, E. Esteller, M. J. Ricart, et al., “Indications and Late Results of Subtotal Parathyroidectomy for Hyperparathyroidism after Renal Transplantation,” World Journal of Surgery, Vol. 8, No. 4, 1984, pp. 534-539. http://dx.doi.org/10.1007/BF01654931
[29]	A. Sitges-Serra, P. Gores, U. Hesse, et al., “Serum Calcium as an Early Indicator for Surgical Treatment of Hyperparathyroidism after Renal Transplantation,” World Journal of Surgery, Vol. 10, No. 4, 1986, pp. 661-667. http://dx.doi.org/10.1007/BF01655550
[30]	L. Rostaing, X. Moreau-Gaudry, E. Baron, J. M. Cisterne, P. Monrozies-Bernadet and D. Durand, “Changes in Blood Pressure and Renal function Following Subtotal Parathyroidectomy in Renal Transplant Patients Presenting with Persistent Hypercalcemic Hyperparathyroidism,” Clinical Nephrology, Vol. 47, 1997, pp. 248-255.
[31]	P. P. Lee, L. Schiffmann, G. Offermann and J. Beige, “Effects of Parathyroidectomy on Renal Allograft Survival,” Kidney and Blood Pressure Research, Vol. 27, 2004, pp. 191-196. http://dx.doi.org/10.1159/000079810
[32]	T. Shigematsu, J. Caverzasio and J. P. Bonjour, “Parathyroid Removal Prevents the Progression of Chronic Renal Failure Induced by High Protein Diet,” Kidney International, Vol. 44, No. 1, 1993, pp. 173-181. http://dx.doi.org/10.1038/ki.1993.228
[33]	H. Ogata, E. Ritz, G. Odoni, et al., “Beneficial Effects of Calcimimetics on Progression of Renal Failure and Cardiovascular Risk Factors,” Journal of American Society of Nephrology, Vol. 14, No. 4, 2003, pp. 959-967. http://dx.doi.org/10.1097/01.ASN.0000056188.23717.E5
[34]	W. Gwinner, S. Suppa, M. Mengel, et al., “Early Calcification of Renal Allografts Detected by Protocol Biopsies: Causes and Clinical Implications,” American Journal of Transplantation, Vol. 5, 2005, pp. 1934-1941. http://dx.doi.org/10.1111/j.1600-6143.2005.00938.x
[35]	M. Milas and C. J. Weber, “Near-Total Parathyroidectomy Is Beneficial for Patients with Secondary and Tertiary Hyperparathyroidism,” Surgery, Vol. 136, No. 6, 2004, pp. 1252-1260. http://dx.doi.org/10.1016/j.surg.2004.06.055
[36]	E. Kebebew, Q. Y. Duh and O. H. Clark, “Tertiary Hyperparathyroidism: Histologic Patterns of Disease and Results of Parathyroidectomy,” JAMA, Vol. 139, No. 9, 2004, pp. 974-977. http://dx.doi.org/10.1001/archsurg.139.9.974
[37]	M. C. Gioviale, G. Gambino, C. Maione, E. Luna, F. Calderone, A. Di Bona, G. Buscemi, M. Romano and A. I. Lo Monte, “Intraoperative Parathyroid Hormone Monitoring during Parathyroidectomy for Hyperparathyroidism in Waiting List and Kidney Transplant Patients,” Transplantation Proceedings, Vol. 38, No. 4, 2006, pp. 1003-1005. http://dx.doi.org/10.1016/j.transproceed.2006.02.140
[38]	T. Massfelder, N. Parekh, K. Endlich, C. Saussine, M. Steinhausen and J. J. Helwig, “Effect of Intrarenally Infused Parathyroid Hormone-Related Protein on Renal Blood Flow and Glomerular Filtration Rate in the Anaesthetized Rats,” British Journal of Pharmacology, Vol. 118, No. 8, 1996, pp. 1995-2000. http://dx.doi.org/10.1111/j.1476-5381.1996.tb15635.x
[39]	M. Wolzt, L. Schmetterer, G. Dorner, G. Zelger, J. Entlicher, S. Kapiotis and H.-G. Eichler, “Hemodynamic Effects of Parathyroid Hormone-Related Peptide-(1-34) in Humans,” Journal in Clinical Endocrinology & Metabolism, Vol. 82, No. 8, 1997, pp. 2548-2551. http://dx.doi.org/10.1210/jc.82.8.2548
[40]	A. L. Serra, A. A. Schwarz, F. H. Wick, H. P. Marti and R. P. Wuthrich, “Successful Treatment of Hypercalcemia with Cinacalcet in Renal Transplant Recipients with Persistent Hyperparathyroidism,” Nephrology Dialysis Transplantation, Vol. 20, No. 7, 2005, pp. 1315-1319. http://dx.doi.org/10.1093/ndt/gfh925
[41]	A. E. Kruse, U. Eisenberger, F. J. Frey and M. G. Mohaupt, “The Calcimimetic Cinacalcet Normalizes Serum Calcium in Renal Transplant Patients with Persistent Hyperparathyroidism,” Neprhology Dialysis Transplantation, Vol. 20, No. 7, 2005, pp. 1311-1314. http://dx.doi.org/10.1093/ndt/gfh924
[42]	T. R. Srinivas, J. D. Schold, K. L. Womer, B. Kaplan, R. J. Howard, C. M. Bucci and H.-U. Meier-Kriesche, “Improvement in Hypercalcemia with Cinacalcet after Kidney Transplantation,” Clinical Journal of American Society of Nephrology, Vol. 1, No. 2, 2006, pp. 323-326. http://dx.doi.org/10.2215/CJN.00500705