Parathyroid Research Articles

Prevalence of Hyperparathyroidism among Dialysis Patients in Baghdad Teaching Hospital

Chronic kidney disease is common due to the high prevalence of its main causes. Many pathological changes occur in these patients. Hyperparathyroidism is one of the most common pathologies reported in chronic kidney disease patients. High prevalence rates have been reported worldwide in previous studies, and different factors have been implicated to be associated with Hyperparathyroidism. The aim of this study is to assess the prevalence of hyperparathyroidism among Iraqi patients with chronic kidney disease on hemodialysis therapy and to identify the factors associated with hyperparathyroidism. This was a cross-sectional study with analytic utility performed in in Baghdad Teaching Hospital, Dialysis Center during the period from June 2020 to March 2021. The study included 100 patients (60 males and 40 females). Patients with one or more of the following were excluded: primary hyperparathyroidism. Known parathyroid gland disease, malignancy, bone diseases, Kidney transplantation, or history of parathyroid surgery. Data was collected using a data collection form, and analysis was performed using the statistical package for Social Sciences version 26 (SPSS 26). Appropriate statistical tests were applied accordingly at a level of significance of 0.05. The mean age of the patients was 53.1 ± 14.2 (range: 18 – 80) years, male to female ratio was 1.5 to one. Prevalence of hyperparathyroidism was 33%. No significant association between hyperparathyroidism and each of age, the cause of CKD, or comorbidities. Hyperparathyroidism was more frequent in females (P<0.05). Higher prevalence of Hyperparathyroidism was reported among users of calcium tab supplementation\chelating, vitamin D, and Cinacalcit (P<0.05). Hyperparathyroidism was frequent among Iraqi CKD patients treated by hemodialysis in a rate of 33%. Higher prevalence of Hyperparathyroidism appeared to be associated with female gender, longer duration on hemodialysis, using calcium supplementation/chelating, vitamin D, and Cinacalcit.

Effective removal of fluoride ions from contaminated water using electrochemical techniques: A critical review on recent developments and environmental perspective

Worldwide, water pollution poses significant threats to human health, with fluoride contamination emerging as a critical hazard. High fluoride concentrations in water cause severe health impacts, including dental and skeletal fluorosis, neurological damage, and harm to the parathyroid gland, cardiovascular, and reproductive systems. Electrochemical technique is one of the most widely used treatment technologies that has been extensively studied and provides a very effective, low-cost method of removing fluoride from contaminated water. The review reports the comprehensive electrochemical strategies for fluoride ions removal. The sources, toxicity, and impacts of fluoride pollution on health are discussed in this review. A comprehensive analysis of current electrochemical methods, including electrolysis, electrocoagulation, and the electro-fenton process, was provided in the context to facilitate the efficient removal of fluoride ions from wastewater. These methods exhibit high removal efficiencies, reaching up to 95 %, and offer scalability and operational flexibility, making them suitable for both centralized and decentralized water treatment systems. Furthermore, the recent advancements in the development of electrochemical technique for fluoride removal are critically reviewed. This study has prospected the recent developments, recommendations and future outlooks on electrochemical technique for fluoride removal.

Clinical observation of a patient with multiple endocrine neoplasia syndrome type 2a

The article is devoted to the clinical observation of a patient with multiple endocrine neoplasia syndrome 2A, characterized by a combination of pheochromocytoma, medullary thyroid cancer and hyperplasia of the parathyroid glands. The features of diagnostics of this disease, preoperative preparation, as well as principles of observation for several years after surgical treatment are described. In addition, data on the features of diagnostic search and tactics of management of family members with this syndrome are provided.

Induced Pluripotent Stem Cell-Derived Parathyroid Organoids Resemble Parathyroid Morphology and Function.

The primary role of the parathyroid glands is to maintain calcium homeostasis through the secretion of parathyroid hormone (PTH). The limited proliferative capacity and differentiation of parathyroid cells hinder the generation of cell therapy options. In this study, parathyroid organoids are successfully generated from human-induced pluripotent stem cells (hiPSCs). At the end of the 20 days of differentiation, the parathyroid organoids exhibited distinct parathyroid morphology. Stereomicroscope, scanning electron microscopy (SEM), and transmission electron microscopy (TEM) analysis demonstrated the 3D arrangement of the cell layers in which intracellular structures of parathyroid cells resemble human parathyroid cellular morphology. Comprehensive molecular analyses, including RNA sequencing (RNA-Seq) and liquid chromatography/mass spectrometry (LC-MS/MS), confirmed the expression of key parathyroid-related markers. Protein expression of CasR, CxCr4, Gcm2, and PTH are observed in parathyroid organoids. Parathyroid organoids secrete PTH, demonstrate active intercellular calcium signaling, and induce osteogenic differentiation via their secretome. The tissue integration potential of parathyroid organoids is determined by transplantation into parathyroidectomized rats. The organoid transplanted animals showed significant elevations in PTH-related markers (CasR, CxCr4, Foxn1, Gcm2, and PTH). PTH secretion is detected in organoid-transplanted animals. The findings represent a significant advancement in parathyroid organoid culture and may offer a cellular therapy for treating PTH-related diseases, including hypoparathyroidism.

Near-Infrared Autofluorescence Signatures of Single- vs Multigland Disease in Primary Hyperparathyroidism

The success of parathyroidectomy depends on accurate intraoperative localization and identification of all diseased glands in parathyroid exploration based on surgeon expertise to prevent persistent hyperparathyroidism. Near-infrared autofluorescence (NIRAF) imaging has recently emerged as a promising adjunctive intraoperative tool for localizing parathyroid glands; however, its potential utility in the assessment of parathyroid glands has yet to be established. To analyze the differences in NIRAF signatures of parathyroid glands in single vs multiple glands in primary hyperparathyroidism (pHPT). This prospective diagnostic study analyzed in vivo NIRAF images of parathyroid glands obtained during parathyroidectomies between November 18, 2019, and December 31, 2023, at a single tertiary referral center. Pixel intensities of the images were measured using third-party software. Patients who underwent parathyroidectomy for sporadic pHPT using a second-generation NIRAF imaging device were included. Patients with multiple endocrine neoplasm disorders were excluded. In vivo NIRAF images obtained during the procedures were analyzed. Near-infrared autofluorescence imaging during parathyroidectomy. The primary outcomes were the autofluorescence intensity and heterogeneity of single adenomas and multigland disease (ie, double adenomas and 3- or 4-gland hyperplasia) in sporadic pHPT. Normalized autofluorescence intensity was calculated by dividing the mean pixel intensity of the parathyroid gland by the background tissue. A heterogeneity index was calculated by dividing the standard deviation by the mean pixel intensity of the gland. The secondary outcome was the visibility of each parathyroid gland on NIRAF imaging before it became apparent to the naked eye during exploration. A total of 1287 in vivo NIRAF images obtained from 377 patients (median [IQR] age, 66 [56-73] years; 299 female [79.3%]) were analyzed. Of all patients, 230 (61.0%) had a single adenoma, 91 (24.1%) had double adenomas, and 56 (14.9%) had 3- or 4-gland hyperplasia. A mean (SD) of 3.4 (1.1) parathyroid glands were identified in the procedures. A comparison of 581 diseased glands (45.1%) and 706 normal glands (54.9%) showed a lower median normalized autofluorescence intensity of 2.09 (95% CI, 1.07-4.01) vs 2.66 (95% CI, 1.43-4.20; effect size = 0.36) and higher heterogeneity index of 0.18 (95% CI, 0.07-0.41) vs 0.11 (95% CI, 0.01-0.27; effect size = 0.45), respectively. Of diseased glands, single adenomas (233 [40.1%]) vs double adenomas (187 [32.2%]) and 3- or 4-gland hyperplasia (161 [27.7%]) had a lower median autofluorescence intensity of 1.92 (95% CI, 1.02-4.44) vs 2.22 (95% CI, 1.10-3.97; effect size = 0.21), respectively. On receiver operating characteristic analysis, the optimal autofluorescence intensity threshold to differentiate between single adenomas vs multigland disease was 2.14, with a sensitivity of 64.4%, specificity of 58.1%, and area under the curve of 0.626. These findings suggest that parathyroid glands in single- vs multigland disease may exhibit different autofluorescence characteristics. Although the effect size was modest, the differences identified should be kept in mind when assessing the parathyroid glands during surgical exploration.

Audit of hypocalcemia as a clinical marker following total thyroidectomy: a retrospective chart review

Background: Surgical removal is one of the most important treatment options for the thyroid swellings. Metabolic derangement due to injury to parathyroid glands is one of the complication to be dealt with frequently. The aim of this study is to assess the incidence of postoperative hypocalcemia after total thyroidectomy and to analyze various pre-operative risk factors that lead to the same. Methods: A retrospective study was conducted on patients who underwent total thyroidectomy at department of ENT and head and neck surgery over a period of 2 years. The level of post-operative serum calcium was analyzed, to determine the incidence of hypocalcemia. In all the patients the following parameters were assessed – age, gender, pre and post-operative serum calcium and type of thyroid disease. Unpaired t test and Mann-Whitney U test was used for statistical analysis. Results: The total study population was 65. The mean age of the patients was 45.5 and 83% of the patients were female. The incidence of postoperative hypocalcemia was noted to be 37%. Pre-operative serum calcium (p<0.0001) was found to be significant risk factor (p<0.05) for prediction of post-operative hypocalcaemia. The same was not noted between variables like age, gender and type of thyroid disease and incidence of hypocalcemia. Conclusions: A thorough knowledge of normal anatomy of neck, possible anatomical variations and parathyroid physiology is of paramount importance to prevent complications during thyroid surgery. Early identification of hypocalcemia can be achieved only by stringent postoperative monitoring, which in turn will reduce morbidity to the patient.

Guideline From the Brazilian Society of Surgical Oncology and Brazilian College of Surgeons in Preventing and Managing Acute Hypoparathyroidism After Thyroid Surgery.

The risk of hypoparathyroidism and hypocalcemia is a critical concern in thyroid surgery. Preserving parathyroid gland vascularization during surgery is essential for effective prevention. Preoperative and postoperative management, including calcium and Vitamin D supplementation, is paramount. Measurement of parathyroid hormone levels after surgery is the best predictor of hypoparathyroidism. This guideline offers recommendations for the prevention, diagnosis, and treatment of acute hypoparathyroidism and hypocalcemia after thyroid surgery.

The effect of local injections of a vitamin d receptor activator into the parathyroid glands on the level of parathyroid hormone and mineral metabolism in patients with secondary hyperparathyroidism in chronic kidney disease

Aim: to assess the dynamics of laboratory parameters (total calcium, inorganic phosphorus, albumin, and alkaline phosphatase levels) and parathyroid hormone (PTH) concentrations after administrating local injections of vitamin D receptor activators into the parathyroid glands of patients with secondary hyperparathyroidism in chronic kidney disease. The intial PTH concentration ranged from 300 to 600 pg/ml. This range was chosen to explore a more active strategy for managing the disease at its early stages and preventing the induction and progression of cardiovascular complications associated with secondary hyperparathyroidism.Methods: the study included 48 patients diagnosed with end-stage of chronic kidney disease, who were treated in the nephrology and dialysis department. The main group consisted of 34 patients who received two consecutive injections of a vitamin D receptor activator (Paricalcitol) into the most enlarged and technically accessible parathyroid gland under ultrasound guidance. The control group included 14 patients who continued with conservative treatment due to technical infeasibility of performing the injections. Effectiveness was assessed by comparing laboratory parameters before the intervention and six months after the injections in the main group, and among patients continuing standard medical therapy for secondary hyperparathyroidism.Results: the results showed a statistically significant reduction in parathyroid hormone levels after 3 and 6 months of treatment. In the control group, which continued to receive standard drug therapy, PTH and blood phosphate levels continued to rise. No undesirable effects or complications, such as hypocalcemia, bleeding, allergic reactions, and recurrent laryngeal nerve paralysis, were not observed throughout the observation period.Conclusion: this research confirms the efficacy of local injections of vitamin D receptor activators (Paricalcitol) in reducing PTH levels without significant complications or changes in calcium levels. This method could be employed to correct and prevent secondary hyperparathyroidism complications in early stages among patients with end-stage chronic kidney disease, offering a safer and more effective treatment option.

Parathyroid Carcinomas: A Series of 6 Cases and Literature Review

Parathyroid carcinoma (PC) is a rare endocrine malignancy. We report 6 cases of PCs operated on in our department, during a period of 12 years (2010-2021). All of our patients presented severe hyperparathyroidism, high calcium levels, and very elevated parathormone (PTH) rates. Five were between the fifth and sixth decades of life and 1 patient was 37 years old. The parathyroid gland was only palpable in 1 case. All of our patients underwent cervical ultrasound and 5 of them underwent 99m Tc-MIBI scintigraphy. One of the patients presented bilateral parathyroid masses. All our patients were treated surgically: a parathyroidectomy was performed in all cases. In 1 patient, parathyroidectomy was performed in conjunction with a homolateral loboisthmectomy, as the diagnosis of PC was suspected preoperatively due to pulmonary metastases. The final anatomopathological study revealed PC in all cases. Follow-up was uneventful in 5 cases and 1 patient was lost to follow-up. Clinicians should suspect PC in patients with severe hypercalcemia, extremely elevated PTH levels, large parathyroid lesions, and distant metastases. Complete surgical resection, extended to the homolateral thyroid lobe, remains the recommended treatment.

Long-Term Efficacy and Safety of Upacicalcet in Japanese Hemodialysis Patients with Secondary Hyperparathyroidism: Open-Label 52-Week Study

Plain Language SummaryCalcimimetics are widely used for the treatment of secondary hyperparathyroidism (SHPT) in hemodialysis (HD) patients. However, conventional calcimimetics have risks of upper gastrointestinal disturbances and hypocalcemia. Upacicalcet, a novel intravenous calcimimetic, is expected to reduce these risks. To assess the long-term efficacy and safety of upacicalcet, a phase 3 open-label, 52-week study in HD patients with SHPT was conducted in Japan. A total of 157 Japanese HD patients with serum intact parathyroid hormone (iPTH) levels >240 pg/mL and corrected calcium (cCa) levels ≥8.4 mg/dL were enrolled. Of those, 138 completed the 52-week upacicalcet treatment. Upacicalcet achieved the target serum iPTH level (60–240 pg/mL) in 94.2% of patients at 52 weeks. Moreover, upacicalcet decreased bone metabolism markers, intact fibroblast growth factor-23 levels, and parathyroid gland volume. Upacicalcet reduced corrected calcium-phosphate product levels even in patients with mild SHPT, i.e., serum iPTH level ≤300 pg/mL. Upacicalcet caused neither symptomatic hypocalcemia nor cCa levels <7.5 mg/dL despite the negligible increase of concomitant vitamin D receptor activators and calcium carbonate. Gastrointestinal symptoms leading to upacicalcet dose reduction were not occurred. In conclusion, upacicalcet stably reduced the serum iPTH levels in HD patients with mild-to-severe SHPT, with few safety concerns. Serum cCa and P levels were well controlled, with a low incidence of hypocalcemia. Upacicalcet is a novel calcimimetic that may provide safe and appropriate long-term treatment of SHPT.

Posterior reversible encephalopathy syndrome and parkinsonism as the first manifestation of primary hyperparathyroidism - a report of two cases.

Primary hyperparathyroidism (PHPT) may be asymptomatic or present with renal calculi, secondary osteoporosis, fractures and neuropsychiatric manifestations. Posterior reversible encephalopathy syndrome (PRES) and parkinsonism are atypical manifestations that may be rarely associated with PHPT. We report two patients who presented with the conditions mentioned above. The first patient involved a 38-year-old woman who presented with diminution of vision, seizures, altered behavior and hypertension over eight months. An MRI of the brain done had shown vasogenic edema involving the parieto-occipital regions, suggestive of PRES. A metabolic screen revealed PTH-dependent hypercalcemia that was localized to the left inferior parathyroid gland. Following focused parathyroidectomy, there was improvement in sensorium, vision and normalization of blood pressure. The second patient was of a 74-year-old man who presented with progressive extrapyramidal symptoms of gait abnormalities and rigidity since the past eight months. He was initiated on Selegeline and Levodopa for the same purpose, and subsequently reported minimal improvement in symptoms. Investigations revealed PHPT associated with a right inferior parathyroid adenoma. Within two weeks following surgery, there was an improvement in rigidity and gait and he was able to ambulate without support. PRES has been reported to occur in the context of preeclampsia, hypertension, infection, sepsis and autoimmune conditions. PRES associated with hypercalcemia is rarely reported. While extra-pyramidally related manifestations are described in hypoparathyroidism, PHPT related parkinsonism is not commonly encountered. Identifying the underlying aetiology and initiation of corrective measures may lead to amelioration of patient symptomatology. The occurrence of PRES and parkinsonism is rare in primary hyperparathyroidism; the two patients described above highlight the importance of screening for hypercalcemia in the setting of neurological manifestations.

Vascular mimicry and mosaic vessels in parathyroid tumours: a new diagnostic approach?

AimsEvaluation of ‘alternative’ vascularisation in human cancer is considered an important prognostic parameter; the 2022 WHO classification of parathyroid tumours despite progresses in clinical triaging of patients strongly emphasises new...

Complicações pós tireoidectomias: revisão narrativa

Introduction: Thyroid disorders are one of the most prevalent endocrine disorders, with thyroidectomy being the most common endocrine surgery for malignant and benign thyroid diseases. Thyroidectomy, despite its effectiveness, is a delicate procedure due to the proximity to important structures, such as the nerves, the lymph nodes and the parathyroid glands. Thus, the incidence of surgical complications is influenced by the extent of the surgery, the thyroid pathology, the anatomical differences, in addition to the surgeon's experience and the association with other procedures. Objective: To carry out a survey regarding the main complications after thyroidectomy and the factors related to the manifestations. Methodology: The literature review was carried out over the months of January and March 2023, through the PubMed, BVS and LILACS databases, using the terms validated by the DeCS “Thyroidectomy”, “Postoperative Complications” and “Postoperative Period”. Results: Eighteen studies were used in the writing of this article after applying the inclusion and exclusion criteria and, subsequently, a table was made with their main findings. Hypocalcemia, hypoparathyroidism and recurrent laryngeal nerve injury are the most common complications after thyroidectomy, the latter being the most serious, with different incidences, causes and prevention. Regarding risk factors, female gender, involuntary parathyroidectomy, parathyroid autograft, surgical extension, and central lymph node dissection were related to a higher incidence of complications. The parathyroid hormone levels were used with predictive value for hypocalcemia and hypoparathyroidism. Conclusion: Thyroidectomy is characterized as a well-established procedure in the medical community, however its approach can bear complications. Studies emphasize hypocalcemia, hypoparathyroidism and recurrent laryngeal nerve injury as the most prevalent, in addition to addressing their causes and risk factors. However, further studies are needed to validate means of prevention to ensure the maintenance of patients' quality of life.

Observational cohort study on safety and efficacy of robotic thyroidectomy with super-meticulous capsular dissection versus open surgery for thyroid cancer: Postoperative dynamic risk assessment of radioactive iodine therapy.

To assess the efficacy and safety of robotic thyroidectomy (RT) with super-meticulous capsular dissection (SMCD) versus open thyroidectomy (OT) we used a dynamic risk assessment system incorporating 131I-WBS along with radioactive iodine (RAI) efficacy evaluation. Currently, the therapeutic efficacy of robotic surgery remains controversial. The 131I whole-body scan (131I-WBS) dynamic risk assessment system can detect small residual thyroid tissues and lesions, which may be used as indicators for the surgical efficacy of RT or OT thyroidectomy in differentiated thyroid cancer (DTC). This retrospective cohort study included 2,349 patients who underwent total thyroidectomy followed by RAI therapy in our department between August 2017 and June 2023. Propensity score matching was performed at a ratio of 1:3 based on surgical type and mean follow-up duration to minimize selection bias after excluding those lost to follow-up. The primary outcome was surgical completeness, assessed using a dynamic risk system incorporating 131I-WBS along with RAI efficacy evaluation. There was no significant difference in the number of metastatic lymph nodes removed between the two groups (P=0.45). The incidence rate of parathyroid gland transplantation was 395 (68.7%) in the OT group and 8 (3.8%) in the RT group (P<0.001). There were no differences in the thyroidectomy completeness based on the 3-hour iodine uptake rate and 99mTcO4- thyroid imaging between the two groups. The dynamic risk assessment with and without 131I-WBS showed significant differences (P<0.001). The postoperative and post-RAI dynamic risk scores, evaluated at the time of RAI and 6 months after RAI, did not differ significantly between the two groups (P>0.05). The rates of transient and permanent hypoparathyroidism were higher in the OT group than in the RT group (P<0.05). The local recurrence rates showed no significant difference between the groups. This study demonstrates that RT with SMCD can achieve outcomes equivalent to those of traditional open surgery when integrating the 131I-WBS dynamic evaluation system and the therapeutic effects of RAI. Additionally, robot surgery demonstrated a notable advantage in protecting parathyroid function.

Incidental parathyroidectomy after thyroid surgery and relationship with postoperative hypocalcemia: a single tertiary center analysis.

Incidental parathyroidectomy (IP) is a complication seen at varying rates after thyroid surgery, and its relationship with postoperative hypocalcemia has not been clarified. In this study, our goal was to identify the frequency and risk factors for IP in a large patient cohort and assess its correlation with postoperative hypocalcemia. A total of 4052 patients who underwent thyroid surgery between 2008 and 2020 were reviewed retrospectively. The patients were divided into two groups, the IP and non-IP groups, and compared in terms of demographics, surgical procedures, pathological diagnosis, and specimen weight. The relationships between IP and hypocalcemia were also evaluated. There were 587 (14.5%) IPs out of 4052 cases. In these patients, mostly one gland was removed (84.6%), and 23.2% of these glands were intrathyroidal. The rate of transient hypocalcemia was 39.9%, and that of permanent hypocalcemia was 1.7%. Female gender, malignancy, lower preoperative thyroid volume, presence of central lymph node dissection, lower specimen weight, presence of autotransplantation and capsule invasion in malignant cases were determined to be risk factors for IP. After excluding hemithyroidectomy and autotransplantation, transient and permanent hypocalcemia were found to be significantly higher in cases with IP (p < 0.001). Multivariate analysis showed that female sex, no multinodular goiter, central dissection, and low thyroid volume were risk-adjusted independent variables. Our findings highlight the significant role of IP in postoperative hypocalcemia. Given that most IPs are located in the perithyroidal region, precise surgical dissection is vital to preserve parathyroid gland function and prevent IP and subsequent hypocalcemia.

Parathyroid gland identification and angiography classification using simple machine learning methods.

Near-infrared indocyanine green angiography allows experienced surgeons to reliably evaluate parathyroid gland vitality during thyroid and parathyroid operations in order to predict postoperative function. To facilitate equal performance between surgeons, we developed an automatic computational quantification method using computer vision that portrays expert interpretation of visualized parathyroid gland near-infrared indocyanine green angiographic fluorescence signals. Near-infrared indocyanine green-parathyroid gland angiography video recordings (Fluobeam® LX, Fluoptics, Grenoble-part of Getinge-Göteborg) from patients undergoing endocrine cervical surgery in a high-volume unit were used for model development. Computation (MATLAB, Mathworks, Ireland) included segmentation-identification of the parathyroid gland (by autofluorescence), image stabilization (by linear translation) and adjusted time-fluorescence intensity profile generation. Relative upslope and maximum intensity ratios then trained a simple logistic regression model based on expert interpretation and outcome (including hypoparathyroidism), with subsequent unseen testing for validation. The model was trained on 37 patient videos (45 glands, 29 judged well perfused by parathyroid gland angiography experts), achieving feature data separation with 100% accuracy, and tested on 22 unseen videos (27 glands, 15 judged well perfused), including four in real time. Segmentation-guided parathyroid gland detection correctly identified all parathyroid glands during unseen testing along with three additional non-parathyroid gland regions (90% positive predictive value). Subsequent time-fluorescence intensity profile extraction with vitality prediction was shown feasible in all cases within 5 min, with a 96.3% model accuracy (sensitivity and specificity were 93.3 and 100% respectively) when compared with expert judgement. Automatic parathyroid gland perfusion quantification using simple machine learning computational methods discriminates parathyroid gland perfusion in concordance with expert surgeon interpretation, providing a means for near-infrared indocyanine green-parathyroid gland signal evaluation.

Calcified Maxillary Fibroma in a Patient on Hemodialysis for Seven Years.

The presentation of mineral bone disorder (MBD) in individuals with chronic kidney disease (CKD) may vary. Consequently, physicians should be capable of recognising this condition when there is a suspicion of its existence. This case report will describe a calcified maxilla tumour as a manifestation of CKD-MBD. Initially asymptomatic, a 32-year-old female presented with progressive swelling of the upper left jaw. She had a history of routine haemodialysis. Further laboratory, radiological, and histopathological workup revealed the mass was indeed calcified maxillary fibroma arising from the manifestation of CKD-MBD. This study underscores the significance of clinical comprehension of the broad-spectrum manifestations of CKD-MBD, including an initially asymptomatic mass. In addition, the screening of the patient's biochemical was required to determine the necessity of early intervention and improve the patient's outcome. The case emphasises the importance of recognising atypical presentations of chronic kidney disease-mineral bone disorder (CKD-MBD), such as a calcified mass, which are rarely reported but critical for timely intervention.This report underscores the necessity for routine screening for secondary hyperparathyroidism in CKD patients, as early detection can significantly impact patient outcomes.Surgical management of the overlying mass and underlying parathyroid gland hyperplasia should always be considered in the management of the symptomatic CKD-MBD patient.

Unveiling the Emerging Role of Klotho: A Comprehensive Narrative Review of an Anti-aging Factor in Human Fertility.

Klotho, an anti-aging protein, plays a vital role in diverse biological functions, such as regulating calcium and vitamin D levels, preventing chronic fibrosis, acting as an antioxidant and anti-inflammatory agent, safeguarding against cardiovascular and neurodegenerative conditions, as well as exerting anti-apoptotic, anti-senescence effects. Additionally, it contributes to metabolic processes associated with diabetes and exhibits anti-cancer properties. This protein is commonly expressed in organs, such as kidneys, brain, pancreas, parathyroid glands, ovaries, and testes. Recent research has highlighted its significance in human fertility. This narrative review provides insight into the involvement of Klotho protein in male and female fertility, as well as its potential role in managing human infertility in the future. In this study, a search was conducted on literature spanning from November 1997 to June 2024 across multiple databases, including PUBMED, SCOPUS, and Google Scholar, focusing on Klotho proteins. The search utilized keywords, such as "discovery of Klotho proteins," "Biological functions of Klotho," "Klotho in female fertility," "Klotho and PCOS," "Klotho and cryopreservation," and "Klotho in male infertility." Inclusion criteria comprised full-length original or review articles, as well as abstracts, discussing the role of Klotho protein in human fertility, published in English in various peer-reviewed journals. Exclusion criteria involved articles published in languages other than English. Hence, due to its anti-aging characteristics, Klotho protein presents potential roles in male and female fertility and holds promising prospects for reproductive medicine. Further, it holds the potential to become a valuable asset in addressing infertility concerns for both males and females.

APPROACH TO A PATIENT WITH CLINICALLY AND BIOCHEMICALLY ACTIVE PRIMARY HYPERPARATHYROIDISM DESPITE NEGATIVE SESTAMIBI 99MTC

Introduction: Primary hyperparathyroidism (PHPT) resulting from increased parathyroid hormone (PTH) secretion. In 80% of cases the cause is a solitary adenoma. It occurs more often in women. The gold standard in the diagnosis of PHPT is MIBI 99m Tc scintigraphy. Patient presentation. A 35-year-old women is referred to outpatient clinic due to high values of PTH, calcium and frequent recurring nephrolithiasis. From the laboratory analysis we show: PTH 317 pg/ml, Ionized calcium 1.71 (1.16 to 1.31 mmol/L); phosphates 0.73mmol/L; Vitamine D3 18.68 ng/ml. The patient is referred for neck ultrasound and bone densitometry (DEXA). A hypoechoic nodule with dimensions of 0.69x0.63x0.67 cm is visualized on ultrasound under the right lobe of the thyroid gland. In the DEXA scan, osteopenia is detected (T-score -2.2). Sestamibi scintigraphy was performed in two repetitions where no adenoma of the parathyroid gland was detected. The patient is referred for neck computed tomography (CT); a small nodule suspicious for parathyroid adenoma is visualized. Due to the clinical manifestation and the constant high values of hypercalcemia, the patient is referred for parathyroidectomy. After the operation, a few days later, the values of PTH (63.5 pg/ml) and ionized calcium (1.18 mmol/L) were normal. Conclusion. Sestamibi scintigraphy is rarely negative during clear clinical and biochemical signs. The sensitivity of Sestamibi is 80-100%, and in cases where it is negative, especially when the volume of the nodule in PHPT is small, additional analyzes such as neck CT, 18FCholine PET/CT enable the decision-making of the definitive treatment – parathyroidectomy in PHPT.

Addressing the challenges of missed parathyroid glands in ultrasonography for secondary hyperparathyroidism: a retrospective observational study.

Preoperative localization plays an important role in secondary hyperparathyroidism (SHPT) surgery. The advantages of neck ultrasound (US) include high availability and low cost. However, the reported sensitivity of US is 54%-76%, and the reason for missed parathyroid glands (PGs) on US has been rarely addressed. Fifty-four patients who were diagnosed with renal SHPT from September 2020 to March 2022 were included in this retrospective study. Preoperative localization included surgeon-oriented US and technetium 99m-sestamibi single-photon emission CT (SPECT)/CT. A total of 212 PGs were pathologically confirmed, resulting in a success rate of 96.2% (52 of 54). Using echo, 193 PGs (91.0%) were accurately localized, while 19 glands (9.0%) were not identified, including those in ectopic positions (n = 12, at thymus or intrathyroid or others), of small size (<1 cm, n = 6), or overlapping with an ipsilateral PG (n = 1). US accurately detected 4 PGs in 36 (66.7%) patients, while SPECT/CT localized 4 glands in 19 patients (35.2%). Although the number of US-detectable PGs was not associated with success rate, it showed a significant negative correlation with surgical time (rs = -0.459, P = 0.002). US detected 4 glands in 66% of SHPT patients with a sensitivity of 90% for localization. Ectopic position and small size were the most common reasons for the failure to detect PG on US. Complete preoperative echo localization might shorten operating time.