Graft-dependent Hyperparathyroidism Research Articles

Subcutaneous forearm transplantation of autologous parathyroid tissue in patients with renal hyperparathyroidism

Parathyroidectomy is required in up to 5% of patients with chronic renal failure. Intramuscular transplantation of autologous parathyroid tissue in the forearm has been the traditional method of transplantation at the time of total parathyroidectomy. The removal of an intramuscular transplantation can be technically difficult should graft-dependent hyperparathyroidism (GRH) occur. This problem resulted in our initiating a study of subcutaneous transplantation with total parathyroidectomy in patients with renal failure. Twenty-six patients who were receiving dialysis therapy underwent total parathyroidectomy and subcutaneous transplantation. Parathyroid tissue was diced into 1- to 2-mm pieces, and 6 pieces were grafted into 6 subcutaneous pockets of the forearm. Intact parathyroid hormone was measured within 48 hours of operation and in the bilateral antecubital veins 1 to 24 months after the operation to assess completeness of resection and graft function, respectively. No major surgical complications occurred. Symptoms improved in 24 patients (85%). Graft failure rate was 4.3%. No GRH was observed. Follow-up was 4 to 55 months (mean, 27 months). This study indicates that the subcutaneous transplantation function is comparable to intramuscular transplantation and suggests a decreased incidence of GRH. Subcutaneous transplantation is technically easier than intramuscular transplantation and has the additional advantage of easy removal should GRH occur.

Autotransplantation of parathyroid glands into subcutaneous forearm tissue for renal hyperparathyroidism

Background: Autotransplantation of diseased parathyroid glands into subcutaneous adipose tissue has been mentioned previously, but as far as we know there is no previous systemic study concerning parathyroid function after subcutaneous autotransplantation. Methods: From January 1993 to June 1996, total parathyroidectomy and autotransplantation were carried out in 46 patients with renal hyperparathyroidism. The symptoms and signs before operation were intractable pruritus in 29 patients (63%), bone pain in 27 patients (58.7%), general weakness in 17 patients (37%), soft tissue calcification in 15 patients (32.6%), bone fracture in one patient, and failure to thrive in one patient. Twenty-four patients (group A) underwent autotransplantation of 60 mg of a diffuse hyperplastic parathyroid gland into subcutaneous forearm tissue, and 22 patients (group B) underwent autotransplantation of 15 pieces (60 mg) of 1 mm 3 tissue into forearm muscles, as mentioned previously. Four patients in group A and one in group B who had high levels of intact parathyroid hormone (I-PTH) immediately after operation were excluded. After the operation, calcium carbonate, 1.5 to 16 gm daily, and calcitriol, 0.25 to 1.5 μ g/daily, were prescribed according to the patients' calcium levels. Results: After 6 months, all patients in both groups were given calcium carbonate, 1 gm/day, and calcitriol, 0.25 μg/day, for parathyroid suppression, and none had to take more medicine to maintain calcium levels. There were no significant differences between the two groups regarding serum calcium, phosphorous, alkaline phosphatase, and I-PTH levels 1 week, 3 to 6 months, and 1 year after operation. Eighteen patients in group A and 19 patients in group B had normal levels of I-PTH 1 year after operation. In the follow-up period from 1 to 3½ years, only one patient in group A had a subnormal I-PTH level and one in group B had graft-dependent hyperparathyroidism. Conclusions: We therefore suggest that autotransplantation of a parathyroid gland into forearm subcutaneous tissue for renal hyperparathyroidism is as effective as autotransplantation into forearm muscles and can be done easier. (Surgery 1998;124:1-5.)

Secondary hyperparathyroidism: Diagnosis of site of recurrence

Persistent or recurrent hyperparathyroidism after total parathyroidectomy with forearm implant may be caused by hyperplastic grafted tissue, residual parathyroid tissue left in the neck or the presence of a supernumerary gland not found during surgery. A correct assessment of graft function is needed to localize the source of hormone excess and to avoid an unnecessary neck reoperation in cases of graft dependent hyperparathyroidism. In 12 patients with relapsing hyperparathyroidism after total parathyroidectomy with forearm implant, total ischemic blockade of the arm bearing the parathyroid graft produced a "transitory implantectomy" with a significant reduction of serum levels of intact PTH in those with graft hyperfunction. In 6 patients with proved supernumerary glands, total ischemia of the graft was not followed by significant changes in intact PTH. Hyperparathyroidism was reversed after surgical resection of the parathyroid implants in the 6 patients with positive responses to the ischemic maneuver. A repeat neck reoperation removing cervical or mediastinal supernumerary glands was followed by control of recurrent hyperparathyroidism in the 6 patients with a negative response to the ischemic blockade. Total ischemic blockade of the arm bearing the parathyroid graft is a valuable method for a correct assessment of graft function after total parathyroidectomy with forearm autotransplantation.

Repeat parathyroid operation associated with renal disease

One hundred ten patients who had undergone operation for secondary and tertiary hyperparathyroidism have been described. Ninety patients had secondary disease and 20 patients had tertiary disease after renal transplantation. From these two groups, 18 patients had repeat operations for control of recurrent or persistent disease. The incidence of repeat operations was 14 percent. Causes were graft-dependent hyperparathyroidism, supernumerary glands in the neck or mediastinum, and incomplete identification of glands in the neck. The most important risk factor is continued long-term dialysis in functionally anephric patients. We recommend that patients with hyperparathyroidism associated with chronic renal failure undergo total parathyroidectomy with autotransplantation. If repeat operation is necessary, a reduction in glandular mass with autotransplantation is preferred. In selected patients, total parathyroidectomy can be considered because of the increased risk of aluminum bone disease.

Long-term evaluation of patients with primary parathyroid hyperplasia managed by total parathyroidectomy and heterotopic autotransplantation.

Since 1973, we have performed total parathyroidectomy and forearm parathyroid autotransplantation in 36 patients with generalized (four gland) primary parathyroid hyperplasia. Twenty (56%) patients had nonfamilial parathyroid hyperplasia (NFPH) and 16 (44%) patients had familial parathyroid hyperplasia (FPH). Twenty-one patients (Group A) were undergoing operation for the first time and 15 (Group B) were having either second, third or fourth re-explorations for persistent hyperparathyroidism. All patients in Group A and nine patients in Group B had parathyroid resection and immediate autotransplantation as a single procedure. Six Group B patients had hyperfunctioning parathyroid tissue resected, cryopreserved, and subsequently grafted when it was evident that they had been rendered aparathyroid. A sustained differential elevation (13.7 fold +/- 2.7) of parathyroid hormone was detected in the antecubital vein of the grafted compared to the nongrafted arm in 35 (97%) patients. Two (5.6%) of the 36 patients (both with FPH; one Group A and one Group B) required permanent oral calcium and vitamin D replacement therapy and one (3%) patient (NFPH: Group A) had persistent hypercalcemia postoperatively, presumably due to a supernumerary gland. The remaining 33 (92%) patients became normocalcemia after surgery and 23 (70%) of them remained so. Ten (30%) of the 33 patients developed recurrent graft dependent hyperparathyroidism. Eight patients were from the group with FPH (8/14, 57%) and two were from the group with NFPH (2/19, 11%)(FPH vs. NFPH, p < 0.005). Because of symptoms of hypercalcemia or a serum calcium concentration exceeding 11 mg/dl, partial graft resection was performed in five patients and four became normocalcemic. Patients with generalized primary parathyroid hyperplasia may be difficult to cure, especially if the disease is familial. The technique of total parathyroidectomy and heterotopic autotransplantation of fresh or cryopreserved parathyroid tissue offers distinct advantages over alternative techniques.