The Parathyroids and the Kidney: Fuller Albright Revisited

Abstract

In 1948, Albright and Reifenstein stated that ‘‘almost all patients with hyperparathyroidism have a marked oliguria immediately following the successful removal of a parathyroid adenoma. In some instances it may be sufficient to cause alarm’’ [1]. This scenario appears to have changed. Today, the risk of hypocalcemia is a great concern after a parathyroid adenoma resection. Some patients are discharged on the day of the operation or on a next-day basis. We have observed, however, that the phenomenon that caused the postoperative course described by Albright and Reifenstein is still occurring, although it is silent in most patients. Notwithstanding, it may cause clinical acute kidney injury, as observed by Laroche et al. [2]. After parathyroidectomy for hyperparathyroidism after renal transplantation, Schwarz et al. correlated the transitory decrease in renal function with a decrease of parathormone (PTH) levels [3]. As PTH reduction is also observed after surgery for primary hyperparathyroidism, we retrospectively analyzed creatinine levels before and during the first 72 h after the operation, when available. A transient increase in creatinine levels above 10% was noted in 77 of 105 cases, and was higher than 50% in 18 cases (17.1%), including one patient that required dialysis [4]. We think that the issue may therefore be of clinical interest. In 38 patients with a preoperative creatinine level less than 1.4 mg/dl (ages varied from 20 to 81 years), it was possible to compare preoperative creatinine levels with the highest levels observed in the first 48 h after the operation. They were significantly increased. The preoperative mean ± standard deviation was 0.84 ± 0.19 mg/dl and, after 48 h, it was 1.13 ± 0.38 mg/dl (p \ 0.0001, Student’s paired test). Astonishingly, in nine patients (23%), the relative increase of creatinine was higher than 50%. Figure 1 illustrates the patterns of creatinine changes observed in these patients. Fortunately, the creatinine levels declined in most patients during the long-term follow-up (they were only slightly elevated when compared to the preoperative levels). Of interest, these observations are in accordance with the effects described by Edvall in 1958 [5]. Perhaps Albright and Reifenstein’s phrase is still valid, but with a small change: ‘‘almost all patients with hyperparathyroidism have a marked creatinine increase immediately following the successful removal of a parathyroid adenoma. In some instances it may be sufficient to cause alarm.’’ Notably, the underlying mechanism of this increase is yet to be explained. We think that until this condition is better understood, nephrotoxic agents or other potential risk factors for kidney injury should be avoided in patients undergoing parathyroidectomy. One may think that the effect here described would be an argument against performing parathyroidectomy in asymptomatic patients. We strongly disagree: parathyroidectomy should be considered very early after the diagnosis, even in asymptomatic cases, before any renal damage caused by hyperparathyroidism ensues. F. Montenegro (&) Department of Head and Neck Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil e-mail: fabiomonte@uol.com.br