Total parathyroidectomy with forearm auto-transplantation improves the quality of life and reduces the recurrence of secondary hyperparathyroidism in chronic kidney disease patients

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Abstract

Background:

Our study aims to explore the effect of total parathyroidectomy (PTX) with forearm autotransplantation (FAT) on the quality of life and recurrence of secondary hyperparathyroidism (SHPT) in chronic kidney disease patients.

Methods:

A total of 104 chronic kidney disease patients with SHPT were enrolled and divided into the PTX (n = 62) and PTX + FAT (n = 42) groups. The operation efficacy was evaluated by analyzing preoperative and postoperative values, including levels of intact parathyroid hormone (iPTH), serum phosphorus, serum calcium, alkaline phosphatase (ALP), calcium-phosphorus product, signs and symptoms, and MOS 36-item short-form health survey (SF-36) scores. Moreover, complications and recurrences were followed up for 12 months after the operation. Binary logistic regression was to present the risk factors for the recurrence of chronic kidney disease patients with SHPT.

Results:

Compared with the preoperative values, the PTX and PTX + FAT groups showed decrease postoperative levels of iPTH, serum phosphorus, serum calcium, calcium-phosphorus product, bone pain, and skin pruritus at all time periods. The PTX and PTX + FAT groups demonstrated decreased ALP, fracture or deformity, and coronary artery calcification at 1 month, decreased short stature at 3 months after the operation but increased SF-36 score after operation. Compared with the PTX group, the level of iPTH decreased and the levels of serum calcium, calcium-phosphorus product increased at 3, 6, and 12 months after the operation in the PTX + FAT group. The levels of ALP, fracture or deformity, short stature, and SF-36 decreased separately at 1 week and 6 and 12 months after the operation, along with the decrease of coronary artery calcification and the recurrence rate, respectively, at 6 and 12 months after the operation in the PTX + FAT group when compared with those in the PTX group. Logistic regression analysis evidenced that the preoperative iPTH level, SF-36 score, and operation type were the risk factors for the recurrence of chronic kidney disease with SHPT.

Conclusion:

Total PTX combined with FAT is more effective in improving the quality of life and reducing the recurrence of chronic kidney disease with SHPT than PTX alone.

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Most cited references 33

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Bone histomorphometry before and after long-term treatment with cinacalcet in dialysis patients with secondary hyperparathyroidism

Geert J Behets, Goce Spasovski, Lulu R Sterling … (2014)

The multicenter, single-arm BONAFIDE study characterized the skeletal response to cinacalcet in adult dialysis patients with plasma parathyroid hormone (PTH) levels of 300 pg/ml or more, serum calcium of 8.4 mg/dl or more, bone-specific alkaline phosphatase over 20.9 ng/ml and biopsy-proven high-turnover bone disease. Of 110 enrolled patients, 77 underwent a second bone biopsy with quantitative histomorphometry after 6–12 months of cinacalcet treatment. The median PTH decreased from 985 pg/ml at baseline to 480 pg/ml at the end of study (weeks 44–52). Bone formation rate/tissue area decreased from 728 to 336 μm2/mm2/day, osteoblast perimeter/osteoid perimeter decreased from 17.4 to 13.9%, and eroded perimeter/bone perimeter decreased from 12.7 to 8.3%. The number of patients with normal bone histology increased from none at baseline to 20 at 12 months. Two patients had adynamic bone at the end of study with a PTH under 150 pg/ml, and one patient with overt hypophosphatemia at baseline that reoccurred during follow-up developed osteomalacia. Thus, long-term treatment with cinacalcet substantially reduced PTH, diminished the elevated bone formation rate/tissue area, lowered several biochemical markers of high-turnover bone disease toward normal, and generally improved bone histology. Twenty patients had normal bone histology at follow-up, whereas most had mild hyperparathyroidism or mixed uremic osteodystrophy.

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Randomized controlled clinical trial of surgery versus no surgery in patients with mild asymptomatic primary hyperparathyroidism.

D. C. Rao, George Divine, Scott E. Phillips … (2004)

Parathyroidectomy is the definitive therapy for patients with symptomatic primary hyperparathyroidism. However, the role of surgery in mild asymptomatic primary hyperparathyroidism remains controversial. Accordingly, we conducted a prospective, randomized, controlled clinical trial of parathyroidectomy to determine the benefits of surgery vs. adverse effects of no surgery. Fifty-three patients were randomly assigned to either parathyroidectomy (n = 25) or regular follow-up (n = 28). Bone mineral density (BMD), biochemical indices of the disease, quality of life, and psychological function were measured at 6- or 12-month intervals for at least 24 months. Twenty-three of the 25 patients randomized to parathyroidectomy had surgery within the specified time of the protocol and three of the 28 patients randomized to regular follow-up had parathyroidectomy during follow-up. After parathyroidectomy, there was an increase in BMD of the spine (1.2%/yr, P < 0.001), femoral neck (0.4%/yr, P = 0.031), total hip (0.3%/yr, P = 0.07), and forearm (0.4%/yr, P < 0.001) and an expected fall in serum total and ionized calcium, serum PTH, and urine calcium (P < 0.001 for all). In contrast, patients followed up without surgery lost BMD at the femoral neck (-0.4%/yr, P = 0.117) and total hip (-0.6%/yr, P = 0.007) but gained at the spine (0.5%/yr; P = ns) and forearm (0.2%/yr, P = 0.047), with no significant changes in biochemical indices of disease. Consequently, a significant effect of parathyroidectomy on BMD was evident only at the femoral neck (a group difference of 0.8%/yr; P = 0.01) and total hip (a group difference of 1.0%/yr; P = 0.001) but not at the spine (a group difference of 0.6%/yr) or forearm (a group difference of 0.2%/yr). Quality-of-life scores as measured by a 36-item short-form health survey showed significant declines in five of the nine domains (social functioning, physical problem, emotional problem, energy, and health perception) in patients followed up without surgery but in only one of the nine domains (physical function) in the patients who had parathyroidectomy. Consequently, a modest measurable benefit of parathyroidectomy was evident in social and emotional role function (P = 0.007 and 0.012, respectively). Psychological function as assessed by the symptom checklist revised did not change significantly in either group, except for a significant decline in anxiety (P = 0.003) and phobia (P = 0.024) in patients who had surgery in comparison with those who did not. We conclude that it is feasible to conduct a randomized, controlled clinical trial of parathyroidectomy in patients with mild asymptomatic primary hyperparathyroidism, and measurable benefits of surgery on BMD, quality of life, and psychological function can be demonstrated. However, the small but significant benefits of parathyroidectomy must be weighed against the risks of surgery in these otherwise healthy individuals.

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Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve.

Wen-Lin Kuo, Ling Wang, Pei-Yu Chiang … (2005)

The aim of this study was to assess the risk of recurrent laryngeal nerve palsy (RLNP) after thyroidectomy with routine identification of the recurrent laryngeal nerve (RLN) during the operation. The present study was confined to 521 patients, 348 total lobectomies and 178 total thyroidectomies, treated by the same surgeon. Temporary and permanent RLNP rates were analyzed for patient groups with stratification of primary operation for benign thyroid disease, thyroid cancer, Graves' disease, and reoperation. Measurement of the RLNP rate was based on the number of nerves at risk. Twenty-six RLNs in 20 thyroid cancer patients with intentional sacrifice were excluded from analysis. Forty RLNs (40 patients) developed postoperative RLNP. Complete recovery of RLN function was documented for 35 of the 37 patients (94.6%) whose RLN integrity had been ensured intraoperatively. Recovery from temporary RLNP ranged from 3 days to 4 months (mean, 30.7 days). Overall incidence of temporary and permanent RLNP was 5.1% and 0.9%, respectively. The rates of temporary/permanent RLNP were 4.0/0.2%, 2.0/0.7%, 12.0/1.1%, and 10.8/8.1% for groups classified according to benign thyroid disease, thyroid cancer, Graves' disease, and reoperation, respectively. Operations for thyroid cancer, Graves' disease, and recurrent goiter demonstrated significantly higher RLNP rates. Invasion of RLN was identified in 19.4% of patients with thyroid cancer. Postoperatively, the RLN recovered in most of the patients without documented nerve damage during the operation. Total lobectomy with routine RLN identification is recommended as a basic procedure in thyroid operations.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date Collection: December 2017

Publication date (Electronic): 08 December 2017

Volume: 96

Issue: 49

Electronic Location Identifier: e9050

Affiliations

[a ]Department of Thyroid Breast Surgery

[b ]Department of Nephrology, Yinzhou Hospital of Ningbo University Medical College, Ningbo, China.

Author notes

[∗ ]Correspondence: Jia-Gen Li, Department of Thyroid Breast Surgery, Yinzhou Hospital of Ningbo University Medical College, No. 251, Baizhang East Road, Ningbo 315040, Zhejiang Province, China (e-mail: lijiagen_mr@ 123456163.com ).

Article

Publisher ID: MD-D-17-00113 Accession ID: 09050

DOI: 10.1097/MD.0000000000009050

PMC ID: 5728923

PubMed ID: 29245308

SO-VID: 9912fa87-5e5b-403e-873e-513e5cb04bf2

License:

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

History

Date received : 6 January 2017

Date revision received : 14 October 2017

Date accepted : 13 November 2017

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Keywords: forearm autotransplantation,quality of life,recurrence,secondary hyperparathyroidism,total parathyroidectomy

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Keywords: forearm autotransplantation, quality of life, recurrence, secondary hyperparathyroidism, total parathyroidectomy

Total parathyroidectomy with forearm auto-transplantation improves the quality of life and reduces the recurrence of secondary hyperparathyroidism in chronic kidney disease patients

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Asian Journal of Quality of Life (AjQoL)

Most cited references 33

Bone histomorphometry before and after long-term treatment with cinacalcet in dialysis patients with secondary hyperparathyroidism

Randomized controlled clinical trial of surgery versus no surgery in patients with mild asymptomatic primary hyperparathyroidism.

Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve.

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