Mean Preoperative Serum Calcium Research Articles

Comparison of frequency of Hypoparathyroidism in Total Thyroidectomy (TT) versus Near-Total Thyroidectomy (NTT) patients

BACKGROUND & OBJECTIVE: Hypoparathyroidism in total thyroidectomy and near-total thyroidectomy is debatable. This study will determine the procedure of choice. Our objective is to compare the frequency of hypoparathyroidism in total thyroidectomy versus near-total thyroidectomy patients.
 METHODOLOGY: Prospective observational study was conducted at the Department of Surgery, Allied Hospital, Faisalabad. The study duration was six months. A total of 140 patients having multinodular goiter, 30-70 years of age, were selected. Patients were divided into two groups. In group A; patients underwent total thyroidectomy while in group B; patients were offered near-total thyroidectomy. All the parathyroid glands were preserved. In all patients, serum calcium levels and parathyroid hormone (PTH) levels were checked on 1st & the 2nd day after surgery.
 RESULTS: Mean age in group A was 48.06±8.21 years & in group B was 48.83 ± 7.0 years. The majority of patients, 88 (62.86%) were between 30 to 50 years of age. Out of these 140 patients, 37 (26.43%) were males & 103 (73.57%) were females, with the ratio of 1:2.8. Mean pre-operative serum Parathyroid hormone was 25.67±9.87 pg/mL. The mean postoperative serum Parathyroid hormone was 16.87±2.43 pg/mL. Mean pre-operative serum calcium levels were 11.32 ± 4.52 mg/dl and mean postoperative serum calcium levels were 9.4 ±0.45mg/dl. In this study, the frequency of Hypoparathyroidism in the total thyroidectomy group (28.57%) was significantly higher than near-total thyroidectomy (8.57%) (p=0.002).
 CONCLUSION: Hypoparathyroidism is more common after total thyroidectomy as compared to near-total thyroidectomy.

Differences in the Clinical Presentation and Biochemical Profile of the Patients with Primary Hyperparathyroidism with regard to their Serum Vitamin D Levels: a Single-center Experience.

The association between vitamin D deficiency and primary hyperparathyroidism (PHPT) is common and has clear implications. Vitamin D deficiency is commonly seen in PHPT population and exacerbates its severity with skeletal and metabolic effects. Retrospective data collection and review were done in patients who underwent surgery for PHPT at a tertiary care hospital in India between January 2011 and December 2020. A total of 150 subjects were included in the study and were divided into group 1 (vitamin D < 20ng/ml, deficient), group 2 (vitamin D 21-29ng/ml, insufficient), and group 3 (vitamin D > 30ng/ml, sufficient). There was no difference in the duration of symptoms or the symptomatology between the three groups. Mean pre-operative serum calcium and serum phosphorous levels were also comparable in all the three groups. Mean pre-operative parathyroid hormone (PTH) levels in the three groups were 703 ± 996 vs 343.6 ± 396 vs 343.6 ± 396pg/ml, respectively (P = 0.009). There was a statistically significant difference in group 1 vs groups 2 and 3 in their mean weight of the parathyroid gland (P = 0.018) and high alkaline phosphatase (ALP) levels (P = 0.047). Post-operative symptomatic hypocalcemia was observed in 17.3% of patients. Post-operative hungry bone syndrome occurred in 4 patients, all in group 1. PHPT in patients with low serum vitamin D was associated with higher serum PTH levels, increased frequency of high serum ALP levels, and higher weight of the excised gland, with no difference in the serum calcium and phosphorous.

Case-control study of primary hyperparathyroidism in juvenile vs. adult patients

ObjectivesPrimary hyperparathyroidism in juveniles is extremely rare condition, but in the last few decades the incidence is increasing. The aim of this study was to compare biochemical and clinical characteristics of juvenile and adult primary hyperparathyroidism patients. MethodsA retrospective case-control study was conducted from 2004 until 2017 in high volume endocrine surgery center. Juvenile group consisted of all primary hyperparathyroidism patients younger than 20 who have undergone parathyroidectomy, and two-fold more patients older than 20 were classified in control (adult) group. ResultsA total of 14 patients with the age ≤20 years were included in the juvenile group, while 28 patients older than 20 were selected for the control group. Female-to-male ratio in juveniles was 1:1, and in adults 8:1 (p = 0.005). The most common form of the disease in juveniles was bone disease (42.9%) and most of adults were asymptomatic (39.3%). Mean preoperative serum calcium level was significantly higher in juveniles than in adults, 3.47 ± 0.74 mmol/L vs. 2.96 ± 0.25 mmol/L, p = 0.025. Mean preoperative PTH level was higher in juveniles than in control group, 572.6 ± 533.3 ng/L vs. 331.8 ± 347.5 ng/L, p = 0.089. ConclusionClinical manifestations of primary hyperparathyroidism significantly differ in juvenile and adult patients. Juvenile primary hyperparathyroidism represents more severe form of the disease, often with end-organ damages, and it should be considered in patients with unspecific symptoms.

Single Gland, Ectopic Location: Adenomas are Common Causes of Primary Hyperparathyroidism in Children and Adolescents.

Primary hyperparathyroidism (PHPT) in children and adolescents is uncommon. Data-driven guidelines for management in pediatric patients are limited. We performed a retrospective cohort analysis of all patients (1997-2017) with PHPT ≤ 21years of age who underwent parathyroidectomy at three institutions. Clinical and demographic variables were analyzed. Primary operative outcome was cure (normocalcemia > 6months after surgery); secondary outcome was operative success (intraoperative parathyroid hormone decrease of ≥ 50%). We identified 86 patients with a median age of 17years (IQR: 14, 19); 64% (n = 55) were female. The mean preoperative serum calcium was 11.7mg/dL, median parathyroid hormone (PTH) was 110pg/mL, and median urine calcium was 4.1mg/kg/24h. Preoperatively, sestamibi scan localized in 41/71 patients (58%); neck ultrasound localized in 19/44 (43%). The most common pathology at surgery was a single ectopic parathyroid adenoma in 71% (n = 61). A high incidence of ectopic adenomas (25%, n = 22) was observed, most commonly intrathymic (n = 13), followed by tracheoesophageal groove (n = 5), carotid sheath (n = 2), and intrathyroidal (n = 2). Of 56 patients with retrievable data > 6months postoperatively, cure was achieved in 55 of 56 patients (98%). One patient who presented to us with parathyromatosis require subsequent reoperation. In this multi-institutional series of PHPT in children and adolescents, the majority were sporadic PHPT and were due to a single adenoma. We observed a high incidence of ectopic parathyroid adenomas, most commonly intrathymic. Given the high risk for ectopic adenoma in pediatric patients, parathyroid surgery in children and adolescents should be performed by experienced surgeons.

Pre-opereative Parathormone Levels are Correlated with Mean Diameter of Parathyroid Adenoma and Pre-operative Serum Calcium and Alkaline Phosphatase Levels

Abstract The aim of the present study was to determine the relationship between biochemical parameters, mean diameter of parathyroid adenoma (MDPA) and parathyroid hormone (PTH) levels in patients who underwent parathyroid surgery.Materials and Methods: Data were collected retrospectively from patients with hyperparathyroidism who were operated and followed in our hospital between September 2011 and April 2014. Twenty-nine (male/female = 8/21) patients with a mean age of 58.31 ± 12.59 years were enrolled into the study. The mean pre-operative serum calcium and intact PTH (iPTH) levels were 11.98±1.23 mg/dl and 386.52±374.96 pg/ml, respectively. Serum pre-operative calcium levels were found to be significantly higher in patients who had nephrolithiasis than those who did not, whereas pre-operative serum phosphate levels were lower. Pre-operative iPTH levels were found to be correlated with pre-operative calcium, alkaline phosphatase and MDPA but not with pre-operative serum phosphate. Also, pre-operative calcium levels were found to be significantly correlated with MDPA.Conclusion: Presence of nephrolithiasis is associated with higher pre-operative calcium and lower phosphate levels. Pre-operative iPTH and calcium levels were also found to be significantly correlated with MDPA; this suggests that serum iPTH and calcium levels can be useful in predicting MDPA. Keywords: Hypercalcemia, primary hyperparathyroidism, parathyroid adenoma, parathormone, calcium

Cryopreservation of Parathyroid Tissue after Parathyroid Surgery for Renal Hyperparathyroidism: Does it Really Make Sense?

Metachronous autotransplantation of cryopreserved parathyroid tissue is a technique for treating postoperative hypoparathyroidism after parathyroid surgery for renal hyperparathyroidism (rHPT). The aim of the present study was to evaluate our institution's experience with metachronous autotransplantation to analyze the role of cryopreservation in the treatment of rHPT and to determine for whom and when cryopreservation of parathyroid tissue should be deemed necessary. A prospective database of patients with rHPT who underwent surgery between 1976 and 2011 was screened for patients with hypoparathyroidism who received a metachronous autotransplantation. Data were analyzed regarding clinical data, histopathological findings of the cryopreserved parathyroid tissues, and patient outcome after metachronous replantation of parathyroid tissue. Fifteen of 883 patients with rHPT underwent a metachronous autotransplantation under local anesthesia at a mean time of 23 months following the last cervical surgery. Histopathology of the parathyroid tissue chosen for transplantation revealed a necrosis rate of 0 % in 14 and 70 % in one patient. Mean preoperative serum calcium and parathyroid hormone (PTH) levels were 2.0 mmol/l and 3.7 pg/ml, respectively. Autotransplantation raised mean serum calcium and PTH levels to 2.2 mmol/l and 97.5 pg/ml, respectively, after a mean follow-up of 78 months. Metachronous autotransplantation following parathyroid surgery in patients with rHPT effectively normalizes PTH and calcium levels. The success rate is high if an adequate cryopreservation procedure is applied. However, it is rarely necessary, and therefore the cryopreservation of parathyroid tissue in all patients has to be questioned, at least from an economic point of view.

Primary hyperparathyroidism in the underinsured: A study of 493 patients

Disparities may exist in the care of patients with primary hyperparathyroidism (HPT). This study examines the presentation and outcomes of underinsured patients undergoing parathyroidectomy. We divided 493 HPT patients who underwent initial parathyroidectomy from 2000 to 2008 at a single institution into 2 groups: underinsured patients (group 1; n = 94) evaluated and treated at a county hospital, and patients with insurance (group 2; n = 399). Univariate and multivariate analysis adjusting for race and ethnicity were conducted to determine the association of being underinsured with several clinical variables. More patients in group 1 compared with group 2 were of black or Hispanic background (92% vs. 44%; P < .0001). Group 1 patients had higher mean preoperative serum calcium and PTH levels: 12.1 vs. 11.8 mg/dL (P = .009) and 263 vs. 198 pg/mL (P = .03), respectively. Seven group 1 (7.4%) and 7 group 2 (1.8%) patients presented with hypercalcemic crisis (P = .003). On multivariate analysis, underinsurance was associated with higher serum calcium levels (P = .011) and hypercalcemic crisis at presentation (odds ratio, 5.59; 95% confidence interval, 1.45-21.51; P = .012). Follow-up was shorter in group 1 patients (15 vs. 24 months; P < .001) and postoperative PTH levels were higher (76 vs. 48 pg/mL; P < .001). Other perioperative data were not different between the groups. Underinsured patients with HPT may present with higher serum calcium and PTH levels, are more likely to have hypercalcemic crisis, and less likely to return for follow-up. Underfunded health insurance coverage may account for differences seen in this study.

The Necessity and Reliability of Intraoperative Parathyroid Hormone (PTH) Testing in Patients with Mild Hyperparathyroidism and PTH Levels in the Normal Range

To the Editor, We read with interest the article by Alhefdhi et al. [1] and discussed it in our journal club. We congratulate the authors for raising the issue of using intraoperative parathyroid hormone (PTH) monitoring in mild primary hyperparathyroidism (PHPT). Because of the mild biochemical and clinical indicators and the indolent natural course of the disease, surgical intervention and its benefits remain controversial [2]. It is particularly difficult to apply intraoperative adjuncts to decide the surgical cure of the patient when the serum PTH level is within the normal range. Very few studies have focused on this issue [3], and we believe the utility of intraoperative PTH (IOPTH) monitoring in mild PHPT needs to be studied, as the incidence of mild PHPT, common in Western countries, is also becoming prevalent in developing countries. To improve our understanding of the authors’ approach, we would like clarification on several points: First, did the authors perform preoperative localization? If so, how many of their patients were diagnosed preoperatively with multigland disease? The authors mention that they investigated the patients undergoing ‘‘standard targeted parathyroidectomy’’; we are not clear what that means. Also, how did they approach patients with multiglandular disease? It would be particularly informative to know the clinicopathological and surgical details of the five patients who did not have IOPTH decline [50% until the end of the procedure. Routine cases can be managed by any means, but the characteristics of this problem group need to be addressed for improved outcome. When it became apparent that the IOPTH level had not decreased, what was done? The reported cure rate in the present study was 100%; however, the mean preoperative serum calcium level was 10.8 ± 0.1 mg/dl, and there might have been some patients with normal serum calcium with normal serum PTH (as per the inclusion criteria) Given this possibility, how did the authors decide that operative cure had been effected, especially in those five patients with no decline in the PTH level until the end of the operation?

Intra-operative parathyroid hormone measurements - experience of a non-academic hospital.

Surgery is the treatment of choice for symptomatic primary hyperparathyroidism. The majority of research concerning intra-operative parathyroid hormone (ioPTH) measurements is conducted in university hospitals. Whether ioPTH measurements are feasible and useful in predicting the presence of remaining hyperfunctioning parathyroid tissue in a non-academic hospital remains uncertain. Data were collected on all patients with biochemically proven and surgically treated primary hyperparathyroidism treated at the Reinier de Graaf Hospital from August 2002 to December 2007. Sixty-five patients were included. The mean pre-operative serum calcium level was 2.78 mmol/l (range 2.28 - 3.80 mmol/l, normal range 2.20 - 2.65 mmol/l) and the mean serum parathyroid hormone level 17.0 pmol/l (range 4.0 - 90.3 pmol/l, normal range 1.0 - 5.5 pmol/l). All patients were operated on for primary hyperparathyroidism, using ioPTH measurements during their first operation. Sensitivity and specificity rates of ioPTH measurements were 98% and 89%, respectively. The ioPTH test accurately indicated incomplete removal of all hyperfunctioning parathyroid tissue in 8 patients (12%). Five patients (8%) were re-explored immediately, of whom 4 were successfully treated in this single operative session. One patient was operated on successfully the next day. Two patients were operated on with a successful result during a second admission. In all the ioPTH measurements there was 1 false-positive result (1.5%) and 1 false-negative result (1.5%). The mean postoperative calcium value for the successfully treated patients was 2.34 mmol/l (range 2.14 - 2.71 mmol/l, normal range 2.20 - 2.65 mmol/l). The mean postoperative PTH level for the successfully treated patients was 3.76 pmol/l (range 0.40 - 7.1 pmol/l). Our data suggest that ioPTH measurements are feasible and useful in a non-academic hospital.

Hypercalcemic Crisis in the Era of Targeted Parathyroidectomy

Hypercalcemic crisis patients are appropriately treated by expeditious parathyroidectomy. Previous studies have suggested that crisis patients may have lower operative success rates compared to non-crisis patients. This study reviews the outcomes for hypercalcemic crisis in the era of targeted parathyroid surgery. The records of 839 patients with primary hyperparathyroidism who underwent parathyroidectomy at a single institution from 1993 to 2009 were reviewed. From this group, 34 patients were surgically treated for hypercalcemic crisis, defined as having signs and symptoms of acute calcium intoxication and serum calcium levels≥14 mg/dL. All patients underwent parathyroidectomy guided by preoperative localization studies and intra-operative PTH hormone monitoring (IPM). Pre- and postoperative symptoms and laboratory values and rates of operative failure and recurrence were compared to 805 patients without crisis. Mean preoperative serum calcium (15.8 versus 11.6 mg/dL) and parathyroid hormone (PTH) (719 versus 175 pg/mL) levels were significantly higher among patients presenting with hypercalcemic crisis (P<0.0001). Postoperatively, the mean calcium and PTH levels were similar (9.4 versus 9.4 mg/dL, P=0.7) and (82 versus 51 pg/mL, P=0.1), respectively. Alteration in mental status as a presenting symptom was significantly more prevalent among those in crisis (24% versus 3%, P<0.0001), as was pancreatitis (6% versus 0.2%, P=0.001). The crisis patients were more likely to have an ectopic gland in the mediastinum (15 versus 2%, P<0.0001), significantly larger glands (2.4 versus 1.8 cm, P=0.001), and parathyroid carcinoma (6% versus 0.3%, P=0.015). Crisis patients had similar rates of operative success 34/34 (100%), compared with 787/805 (97.8%) non-crisis patients (P=0.9). There was no difference in recurrence rates (3% versus 1.4%, P=0.3). Mean overall follow-up was 36 mo. Despite presenting with more ectopic glands and parathyroid cancer, crisis patients have similar parathyroidectomy success rates compared with non-crisis patients. The high rate of success in the era of targeted parathyroidectomy may be due to the widespread use of localization studies and IPM.

Normalization of 2‐Week Postoperative Parathyroid Hormone Values in Patients with Primary Hyperparathyroidism: Four‐Gland Exploration Compared to Focused‐Approach Surgery

Elevation of parathyroid hormone (PTH) levels is commonly seen in patients with primary hyperparathyroidism (PHPT) who have undergone parathyroidectomy. This study evaluates differences in 2-week postoperative PTH levels in patients having focused-approach surgery versus four-gland exploration. Over 6 years, patients at Rhode Island Hospital (RIH) and the Cleveland Clinic (CCF) who had PHPT and underwent localization studies suggestive of single adenoma were analyzed. At RIH patients underwent focused-approach surgery, and at CCF routine four-gland exploration was performed. Postoperative calcium supplementation was routine at RIH and selective at CCF. There were 308 patients at RIH and 370 at CCF. They were similar in age (59.2 +/- 13.0 years at RIH and 60.4 +/- 12.9 years at CCF), and sex (76.9 and 80.0% female at RIH and CCF, respectively). The mean preoperative serum calcium measured 10.9 +/- 0.7 mg/dl at RIH and 11.1 +/- 0.7 mg/dl at CCF (P < 0.001). Preoperative PTH values were similar, measuring 143.8 +/- 104.8 pg/ml in the focused-approach group (RIH) and 157.6 +/- 150.3 pg/ml in the four-gland exploration group (CCF). Preoperative 25-hydroxyvitamin D (vitamin D-25) levels were 24.1 +/- 12.0 ng/ml at RIH and 27.4 +/- 10.6 ng/ml at CCF; and the prevalence of vitamin D-25 deficiency (level <20 ng/ml) was 43.9% at RIH and 27% at CCF (P = 0.017). The proportion of patients whose intraoperative PTH value dropped by >or=50% prior to completion of surgery was 95.0% at RIH and 95.5% at CCF. The total gland weight resected per patient was 942 mg at RIH versus 1,394 mg at CCF (P = 0.003). The 2-week postoperative serum PTH was >65 pg/ml in 18.8% at RIH and in 38.7% at CCF (P < 0.001). The 2-week postoperative serum calcium values dropped to 9.2 +/- 0.6 mg/dl at RIH and to 9.5 +/- 0.8 mg/dl at CCF (P < 0.001). The incidence of multigland disease was 5.8% at RIH and 21.9% at CCF (P <or= 0.001). Among patients with PHPT who underwent a localizing study indicating unilateral disease, a significant proportion had eucalcemic PTH elevation 2 weeks after parathyroidectomy. The elevation was more frequent in the four-gland exploration group and correlated most strongly with greater adenoma mass.

Minimally invasive parathyroidectomy without intraoperative parathyroid hormone monitoring in patients with primary hyperparathyroidism

Minimally invasive parathyroidectomy (MIP) is the preferred operation for patients with primary hyperparathyroidism (HPT) and positive preoperative imaging. This non-randomized case series assessed the long-term results of MIP performed without the use of intraoperative parathyroid hormone (ioPTH) monitoring. The study involved prospective collection of demographic, biochemical and operative details on a consecutive, unselected cohort of 298 patients who underwent surgery for non-familial primary HPT during a 5-year interval. The mean preoperative serum calcium level was 3.00 mmol/l with a mean parathyroid hormone concentration of 25.8 pmol/l. (99m)Tc-labelled sestamibi scanning and neck ultrasonography were performed in 262 patients. Sestamibi scan showed unilateral uptake in 182 patients and a single parathyroid adenoma was confirmed on ultrasonography in 161 patients. MIP was performed in 150 patients. The mean duration of operation was 25 (range 8-65) min. Four patients needed conversion to conventional neck exploration. There was one postoperative haematoma and three cases of temporary recurrent laryngeal nerve neuropraxia. All but four patients were normocalcaemic after MIP. All the parathyroid tumours removed were adenomas, with a mean weight of 1.3 (range 0.1-17.4) g. No patient developed recurrent HPT after a median follow-up of 16 (range 3-48) months. The outcome of MIP without ioPTH monitoring was comparable to that reported in series that used ioPTH monitoring.

The Outcome of Cervical Exploration for Asymptomatic and Symptomatic Patients with Primary Hyperparathyroidism

This study examined the success and safety of cervical exploration in patients with primary hyperparathyroidism (HPT). The presentation, pathologic findings, and outcome of patients with asymptomatic primary HPT were compared with those with symptomatic disease. Records of patients undergoing cervical exploration for primary HPT from January 1993 until December 31, 2003, were reviewed. Information collected consisted of preoperative symptoms, calcium and parathormone (PTH) levels, imaging studies, operative findings, pathology, and outcome of the patients. The groups with asymptomatic and symptomatic primary HPT were compared. In all, 139 patients were studied; 31 (22.3%) were asymptomatic (group I), and 108 (77.7%) had symptoms (group II). The two groups were also comparable regarding mean age, sex, and the yield of the imaging studies. The mean preoperative serum calcium level was comparable in the two groups (11.1 mg/dl versus 11.3 mg/dl). However, PTH levels were significantly lower in group I than in group II (142 pg/dl versus 283 pg/dl, P = 0.01). The weight of the adenoma was also significantly less in group I than in group II (1082 mg versus 1679 mg P = 0.079). The outcome of the surgical exploration was comparable in the two groups with an immediate success rate close to 98% and a long-term success rate of 95.4%. Cervical exploration and parathyroidectomy in patients with primary HPT is a safe procedure with a high success rate and favorable outcome.

Are Preoperative Serum Calcium, Parathyroid Hormone, and Adenoma Weight Predictive of Postoperative Hypocalcemia?

The objective of this study is to determine whether preoperative serum calcium, parathyroid hormone, or adenoma weight is predictive of postoperative hypocalcemia after removal of a parathyroid adenoma. A retrospective chart review was performed for consecutive parathyroidectomy patients over a 6-year period at a community-based teaching institution. Patients with renal failure (serum creatinine >1.7), hyperplastic disease, and parathyroid carcinoma were excluded. The outcome measures were postoperative serum calcium and the presence of signs or symptoms such as paresthesias, anxiety, or Chvostek's sign. One hundred forty-one patients underwent parathyroidectomy during the study period. Fifty-four patients were excluded as a result of hyperplastic disease, renal failure, carcinoma, or unavailable records. Of the remaining 87 patients 25 (28.7%) developed hypocalcemia (serum calcium < 8.0), and ten patients (11.5%), developed symptoms. The mean preoperative calcium levels for the normocalcemic and hypocalcemic groups were 10.9 and 10.6, respectively (P < 0.217). The mean preoperative parathyroid hormone levels (normal 10-54) were 214 and 139, respectively (P < 0.305), and the mean adenoma weights were 1.059 and 1.337 g respectively (P < 0.343). This study demonstrates no statistically significant difference in the mean preoperative serum calcium levels, parathyroid hormone levels, or adenoma weight between normocalcemic and hypocalcemic patients postoperatively.

Unique clinical characteristics of primary hyperparathyroidism in India.

The features of primary hyperparathyroidism (PHPT) in developing countries have rarely been examined. This study explored the clinical characteristics of PHPT in India with the hypothesis that this may improve understanding of the pathogenesis of the disease worldwide. Consecutive patients with PHPT (24 women, five men) were examined prospectively before and after parathyroidectomy. All patients had osteitis fibrosa cystica with a median symptom duration of 2.5 (range 1-26) years. Single or multiple fragility fractures were present in 14 patients (eight were bedridden); 20 had brown tumours. Mean preoperative serum calcium was 3.1 mmol/l, while mean serum intact parathyroid hormone (iPTH) and total alkaline phosphatase (ALP) levels were 17-fold and 12-fold higher than normal respectively. Nine patients had overt renal damage, mainly nephrocalcinosis. Parathyroidectomy invariably resulted in severe hypocalcaemia, necessitating long-term vitamin D treatment. The mean parathyroid gland weight was 8.6 (range 2.0-36.6) g and features of carcinoma were found in four patients. Serum calcidiol level correlated inversely (P < 0.05) with serum iPTH and ALP, and parathyroid gland weight. PHPT in Indians is a severe, symptomatic disorder with skeletal, muscular and renal manifestations at a young age. The presence of this severe variant of PHPT in vitamin D-sufficient Indians, and the lack of skeletal disease in other vitamin D-deficient populations, raises the possibility of additional pathogenetic factors.

Total parathyroidectomy for posttransplantation hyperparathyroidism.

The acute and short-term clinical course of 19 subjects who underwent total parathyroidectomy and forearm implantation for persistent hyperparathyroidism following successful kidney transplantation (mean [+/- SD] time after transplant 43.7 +/- 29.5 months) is described. Their mean preoperative serum calcium level of 10.8 +/- 0.5 mg% decreased to a nadir of 7.9 +/- 0.9 mg%, 62.5 +/- 27.7 hr after the operation. The lowest serum ionized calcium (1.80 +/- 0.2 mEq/L) was recorded 57 +/- 49 hr postoperatively. After an average of five hospital days, the patients were discharged with a mean serum total calcium concentration of 8.3 +/- 1.0 mg%. Three months following the operation, the mean serum total calcium concentration was 9.5 +/- 0.6 mg%. With an average follow-up of 19 months (range 3-36 months) serum total calcium was 9.6 +/- 0.6 mg%, with only one subject requiring calcium supplementation. Total parathyroidectomy with forearm implantation was associated with normalization of serum-immunoreactive parathyroid hormone concentrations and maintenance of stable allograft function. Our experience suggest that this procedure is an effective modality with a predictable postoperative recovery of parathyroid function when used to treat persistent hyperparathyroidism in the long-term survivor of renal transplantation.