Parathyroidectomy For Secondary Hyperparathyroidism Research Articles

Severe calcific uremic arteriolopathy lessions and acute hypocalcemia after parathyroidectomy for secondary hyperparathyroidism in haemodialysis patients: Case series

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Prediction model of recurrence after parathyroidectomy in secondary hyperparathyroidism

Objective:To quantitatively evaluate the risk of recurrence in patients with secondary hyperparathyroidism after parathyroidectomy. Methods:The clinical data of 168 patients who underwent parathyroidectomy（PTX） from June 2017 to May 2019 were collected. The prediction model was constructed by using Akaike information criterion（AIC） to screen factors. A total of 158 patients treated with PTX from June 2019 to September 2021 were included in the validation set to conduct external validation of the model in three aspects of differentiation, consistency and clinical utility. Results:The prediction model we constructed includes different dialysis methods, ectopic parathyroid gland, the iPTH level at one day and one month after surgery, the number of excisional parathyroid and postoperative blood phosphorus. The C index of external validation of this model is 0.992 and the P value of the Calibration curve is 0.886[KG0.5mm]1. The decision curve analysis also shows that the evaluation effect of this model is perfect. Conclusion:The prediction model constructed in this study is useful for individualized prediction of recurrence after PTX in patients with secondary hyperparathyroidism.

Intraoperative intact parathyroid hormone monitoring and frozen section diagnosis are essential for successful parathyroidectomy in secondary hyperparathyroidism.

Total parathyroidectomy (PTx) is often performed to treat secondary hyperparathyroidism (SHPT). Successful PTx is essential to prevent recurrent and persistent SHPT because remnant parathyroid glands (PTGs) in the neck can be stimulated and may secrete excessive parathyroid hormone (PTH) in end-stage renal disease. However, to date, few studies have investigated factors contributing to successful PTx before the completion of surgery. Between August 2010 and February 2020, 344 patients underwent total PTx, transcervical thymectomy, and forearm autograft for SHPT at our institute. Factors contributing to successful PTx before the completion of surgery were investigated. Preoperative imaging diagnoses, including computed tomography, ultrasonography, technetium-99m methoxyisobutylisonitrile (99mTc-MIBI) scintigraphy, intraoperative intact PTH (IOIPTH) monitoring, and frozen section histologic diagnosis, were performed. Successful PTx was defined as intact PTH level < 60 pg/mL on postoperative day 1. A sufficient decrease in IOIPTH level was defined as > 70% decrease in intact PTH levels measured 10 min after total PTx and transcervical thymectomy compared to intact PTH levels measured before skin incision. Logistic regression analysis was conducted to investigate factors contributing to PTx success. Univariate analysis showed that the number of all PTGs identified preoperatively by imaging modalities and the specimens submitted for frozen section diagnosis, which surgeon presumed to be PTGs, were not significant factors contributing to successful PTx. However, multivariate analysis revealed that the number of PTGs identified by frozen section diagnosis (P < 0.001, odds ratio [OR] 4.356, 95% confidence interval [CI] 2.499-7.592) and sufficient decrease in IOIPTH levels (P = 0.001, OR 7.847, 95% CI 2.443-25.204) significantly contributed to successful PTx. Sufficient intact PTH level decrease observed on IOIPTH monitoring and the number of PTGs identified by frozen section diagnosis contributed to successful PTx for SHPT. IOIPTH monitoring and frozen section diagnosis are essential for achieving successful PTx for SHPT.

Outcomes of Limited Parathyroidectomy in Secondary Hyperparathyroidism.

To determine the outcomes of unintended limited parathyroidectomy (LPTX; three or less than three glands removed) in patients with secondary hyperparathyroidism (SHPT). Retrospective cohort study. Jiangmen Central Hospital, China, from January 2012 and December 2019. The operative and biochemical outcomes of LPTX with total parathyroidectomy plus auto-transplantation (PTX+AT) among patients with SHPT were compared. Primary outcomes were persistence and time to recurrence. Secondary outcomes were all-cause death and levels of serum parathyroid hormone (PTH), calcium, alkaline phosphatase (ALP), and phosphate measured pre-surgery, on postoperative day 1 (POD1), and one-year post-PTX in patients cured after the initial surgery. Forty-three patients received LPTX, and 78 underwent PTX-AT. Persistent SHPT was more frequent in the LPTX group (p = 0.001). The area under the receiver operating characteristic curve was 0.89 for POD1 PTH (p <0.001). The frequencies of SHPT recurrence and all-cause mortality were not significantly different. One-year postsurgery, PTH, calcium, ALP, and phosphate levels were significantly decreased in both groups, compared with the respective preoperative values (p <0.001, each). LPTX resulted in a higher proportion of persistent SHPT. However, more than half of the patients could be cured and achieved satisfactory outcomes. Cured patients who underwent LPTX can be identified according to PTH levels on POD1. Limited parathyroidectomy, Secondary hyperparathyroidism, Recurrence, Persistence, All-cause death.

TH8.4 The potential for day case total parathyroidectomy in patients with secondary hyperparathyroidism

Abstract Aims Hypocalcaemia is a common complication after parathyroidectomy for secondary hyperparathyroidism (SHPT) and is often the cause of a prolonged hospital stay post operatively. Although there is no current guidance on targets for total parathyroidectomy for SHPT, current guidance recommends a day-case rate of 90% for patients undergoing surgery for primary hyperparathyroidism. Our centre has developed a safe protocol which allows us to perform total parathyroidectomies as a day-case procedure in patients with SHPT. This protocol, developed in conjunction with the renal physicians, involves giving the patients alpha calcidol pre-operatively for 5 days, to minimise the incidence of hypocalcaemia, and close monitoring of the calcium levels post operatively, to permit safe discharge. Methods We carried out a single centre retrospective study on all patients who underwent a total parathyroidectomy for SHPT between February 2005 and May 2021. All the patients received the alpha calcidol regimen pre-operatively. Data on patient baseline characteristics, peri-operative calcium, potassium and PTH levels, length of hospital stay, operative procedure details, hospital readmission and 30-day morbidity were collected. Results 49 patients underwent a total parathyroidectomy during the study period. 67% of patients were discharged on day 0 or on day 1 post-operatively. Reasons for prolonged hospital stay in the remaining patients included refractory hyperkalaemia requiring dialysis, complications secondary to anaesthesia, as well as hypocalcaemia in a few cases. No patients required readmission during the 30-day post-operative period. Conclusion Day-case surgery for SHPT can be achieved safely with a pre-operative regimen of alpha calcidol and close monitoring of calcium levels post-operatively.

Autotransplantation of parathyroid tissue into subcutaneous subclavicular area following total parathyroidectomy in secondary hyperparathyroidism.

Total parathyroidectomy with autotransplantation is still an excellent treatment option for secondary hyperparathyroidism. Intramuscular or subcutaneous parathyroid autotransplantation has been previously reported; however, there have been no studies to date regarding the implantation of the parathyroid tissue in the subclavian area of the neck. This was a prospective cross-sectional study between 2018 and 2019. Patients who underwent total parathyroidectomy with autotransplantation of parathyroid tissue into subcutaneous subclavicular area due to secondary hyperparathyroidism were included. The patients' demographic information, including age and gender, was gathered, and the length of the dialysis period was asked from the patients. To evaluate the outcome of the study, parathyroid hormone (PTH) was measured and recorded before and after the operation. SPSS software, version 26, was used for data analysis. Forty-two patients with a mean age of 41.05 ± 9.41years were included. The mean length of the dialysis period was 8.07 ± 2.68years. The mean primary PTH was 1770.61 ± 482.97pg/ml (range: 656-2500 <). After 6weeks of operation, 19 patients (45.2%) had functional autotransplanted tissue, and the median PTH was 28pg/ml (IQR: 33.55, range: 0.1-221.8). However, the results showed that after 10weeks, the patients with functional tissue were increased to 22 (52.4%), and the median PTH was 35pg/ml (IQR: 48, range: 5.0-602.9). The functionality of autotransplanted tissue in the 6th and 10th weeks after surgery had no significant association with age, gender, and length of the dialysis period (pvalue > 0.05). Subcutaneous implantation is recommended in the treatment of secondary hyperparathyroidism based on its high success rate and ease of use, suitable vascularization, easy accessibility to the surgery location in case of the need for autographtectomy.

MO816: Bone Turnover Markers as Risk Factors of Severe Hypocalcemia After Parathyroidectomy for Secondary Hyperparathyroidism

Abstract BACKGROUND AND AIMS Hungry bone syndrome is a common postoperative complication after parathyroidectomy (PTx) for severe secondary hyperparathyroidism (SHPT). We aimed to evaluate whether preoperative levels of serum alkaline phosphatase (AP) and β-crosslaps (CTX) are associated with the development of severe hypocalcemia after PTx for SHPT in dialysis-dependent patients. METHOD The retrospective study included 127 severe SHPT dialysis-dependent patients who underwent subtotal (SPTx) or total parathyroidectomy with autotransplantation of parathyroid tissue (PTx + AT) in a single high-volume centre of endocrine surgery between 2011 and 2014. Severe postoperative hypocalcemia was defined as an ionized serum calcium level &amp;lt;0.9 mmol/L on a day 3 after surgery. RESULTS Severe hypocalcemia was observed in 83 (65.4%) patients after PTx. Comparing to those with mild hypocalcemia, hypoCa patients were significantly younger (mean age 44.2 ± 11.3 years versus 49.7 ± 10.4 years in a non-hypoCa group; P = .0089). Patients in two groups did not differ in terms of gender (P = .198), dialysis vintage (P = .24) and type of surgery (TPTx + AT or SPTx; P = .127). Preoperative PTH level was significantly higher in hypoCa group comparing to non-hypo Ca group [134 (Q1–Q3: 103–190) pmol/L versus 93.9 (Q1–Q3: 74.6–124.3) pmol/L, respectively; P &amp;lt; .0001]. In univariate analysis preoperative AP level was associated with the risk of postoperative severe hypocalcemia [363.2 (Q1–Q3: 180.9–726.3) IU in hypoCa group versus 142.1 (Q1–Q3: 97.2–223.7) IU in non-hypoCa group; P &amp;lt; 0.0001) (Figure 1). AP level above the cut-off value of 238.5 IU/L caused a 5-fold increase risk of severe hypocalcemia. We observed a moderate negative correlation between preoperative AP level and serum ionized calcium level on the third postoperative day after PTx {ρ = –0.637 [95% confidence interval (95% CI) –0.51 to –0.74]; P &amp;lt; .0001}. In contrast, preoperative CTX level was not associated with postoperative severe hypocalcemia [5.34 (Q1–Q3: 4.06–6.03) µg/L in hypoCa group versus 4.6 (Q1–Q3: 3.42–5.69) µg/L in non-hypoCa group; P = .191] (Figure 2). Moreover, the correlation between preoperative AP and CTX levels was weak, even though it was statistically significant [ρ = 0.27 (95% CI 0.08–0.44); P = .006]; and we observed no statistically significant correlation between preoperative CTX and PTH levels (P = .07). The multivariate logistic regression revealed AP level as the only independent risk factor of severe hypocalcemia development after PTx [ОR 1.006 (95% CI 1.002–1.009) per each IU; P = .005]. CONCLUSION We identified serum AP level, but not CTX, as an independent risk factor of severe hypocalcemia development after surgical treatment of SHPT. The correlation between CTX and other bone turnover markers (PTH, AP) is weak in dialysis-dependent patients with severe SHPT.

Changes in voice quality, swallowing, and pulmonary function after parathyroidectomy for secondary hyperparathyroidism

ObjectiveTo find changes in voice quality, airway invasion during swallowing, pharyngeal residue after swallowing, acoustic and aerodynamic measurements and pulmonary function tests after total parathyroidectomy plus auto-transplantation for secondary hyperparathyroidism. MethodsWe recruited 38 patients who underwent successful surgery for secondary hyperparathyroidism in this study. Voice quality was evaluated using voice handicap index (VHI-10), eating assessment tool (EAT-10), voice impairment, and the grade, roughness, breathiness, asthenia, strain (GRBAS) scale. Acoustic and aerodynamic measurements included fundamental frequency (F0), maximal phonation time, high pitch, jitter, s/z, shimmer and noise-to-harmonic ratio. Vocal cord mobility, vocal cord closure, premature spillage, the penetration–aspiration scale and the Yale pharyngeal residue severity rating scale (PRSRS) after swallowing were examined using fiber-optic endoscopy. Pulmonary function tests included forced vital capacity, forced expiratory volume in 1 s, bronchodilator test, total lung capacity, diffusion capacity of the lung for carbon monoxide, alveolar volume, and distance and O2 desaturation of the 6 min walking test (6MWT). ResultsFour months after successful parathyroidectomy, VHI-10 improved significantly (p < 0.01); incomplete vocal cord closure decreased significantly (p < 0.01); the Yale PRSRS for vallecula and pyriform sinus improved significantly (p = 0.02 and p = 0.02); F0 and high pitch increased significantly (p < 0.01 and p = 0.01); O2 desaturation (<4%) of 6MWT improved significantly (p = 0.04). ConclusionsParathyroidectomy for secondary hyperparathyroidism can improve the voice quality, vocal cord closure, the Yale PRSRS for vallecular and pyriform sinus and O2 desaturation of 6MWT, and increase F0 and high pitch.

EP.WE.103223-hour stay following total parathyroidectomy in renal patients

Abstract Aim Total parathyroidectomy in end-stage renal failure (ESRF), is an effective way to improve or stabilise calcium and parathormone levels and thus improve renal osteodystrophy. Previous BAEST guidelines were not in favour of true day-case neck surgery due to the risk of airway compromise from bleeding. Additionally, ESRF patients are at risk of profound hypocalcaemia after total parathyroidectomy. Patients undergoing total parathyroidectomy are prescribed Alfacalcidol 4mcg daily for 5 days prior to surgery. Following surgery under GA on a morning list, the potassium and calcium levels are checked in the afternoon. Calcium levels are then monitored daily for 3 days and subsequently when required. Oral Alfacalcidol is continued at the same dose until the nephrologists advise otherwise. Methods All ESRF patients undergoing total parathyroidectomy for secondary hyperparathyroidism were identified between 01/01/2005 and 31/12/2019 from a prospectively maintained electronic database. Demographics, biochemistry, length of stay (LoS) and outcomes were analysed. Results There were 43 (30 male) total parathyroidectomies. The median age was 53 (range 14 – 78), and median LoS 1 day (range 0 -13). 26 patients (60%) were discharged within 23 hours (26% were day-case). Prolonged stay was due to calcium replacement (n = 8) or dialysis (n = 4) requirements. Pre- and post-operative calcium values over 2.49mmol/L were significantly related to 23-hour stay (p = 0.010482 and p = 0.000263 respectively). No 30-day re-admissions were observed Conclusions Careful patient selection and adherence to a perioperative management protocol in total parathyroidectomy may enable early discharge within 23 hours. Preoperative calcium levels help predict this outcome.

The Usefulness of Intraoperative PTH as a Predictor for Successful Parathyroidectomy in Secondary Hyperparathyroidism.

Introduction: Secondary hyperparathyroidism (SHPT) is a multisystemic syndrome that affects calcium and bone homeostasis in patients with chronic kidney disease (CKD). Despite medical treatment, 1–2% of patients require parathyroidectomy annually. The use of an intraoperative parathormone protocol (IOPTH) to predict cure is still in debate, due to the lack of standardized protocols, the use of different assays, and uneven PTH clearance. This study aimed to determine the diagnostic accuracy of an IOPTH in patients with SHPT for predicting successful surgery after parathyroidectomy.Methods: About 30 patients were enrolled. A prospective observational study (cohort) was performed in patients who were submitted to parathyroidectomy by an endocrine surgeon for SHPT. All were submitted to a bilateral neck exploration with a subtotal parathyroidectomy. Three IOPTH determinations were withdrawn: at anesthetic induction (PTH0), 15 min (PTH15), and 30 min (PTH30) after completion of gland resection. Another sample was taken 24 h after the procedure (PTH24), values <150 pg/mL defined a successful surgery, and patients were assigned to the success or failure group. IOPTH drop was analyzed to predict successful surgery with drops of 70 and 90% at 15 and 30 min, respectively.Results: A total of 26 patients were included, 19 patients were in the successful group. IOPTH showed a significant difference between groups in their absolute PTH15 and PTH30 values. A significant difference was also found in their PTH drop at 30 min (81 vs. 91%, p = 0.08). For predicting a successful surgery, having a PTH drop >90% at 30 min was the most significant factor [Odds Ratio (OR) 3.0 (1.5–4) IC 95%].Conclusions: This study points toward a stricter and staggered IOPTH protocol to predict a successful surgery. Our results suggest taking a PTH15 expecting a PTH drop of >90%. If this is not achieved, reexploration and a PTH30 sample are suggested to accurately predict success.

Predictors of Bone Mineral Density Improvement after Parathyroidectomy for Secondary Hyperparathyroidism: A Retrospective Single-Center Analysis

BackgroundParathyroidectomy (PTx) reportedly increases bone mineral density (BMD) in patients with severe secondary hyperparathyroidism (SHPT). To date, however, there has not been sufficient evidence on predictors of BMD improvement post-PTx for SHPT, an issue the present retrospective cohort study aimed to address.MethodsA total of 173 SHPT patients who underwent total PTx with forearm autograft between 2009 and 2017 were included in the present study. Demographic information, perioperative laboratory data and pre- and post-PTx BMD values (measured by dual-energy X-ray absorptiometry) were collected from their medical records. The change in BMD post-PTx in the lumbar spine was evaluated as the primary outcome. Then, a multivariate logistic regression analysis was performed for a ≥ 10% increase in BMD post-PTx.ResultsOverall, the median BMD in the lumbar spine was increased by 8.7% post-PTx. The multivariate logistic regression analysis revealed that age ≥ 70 years (P = 0.005; odds ratio [OR], 0.138; 95% confidence interval [CI]: 0.034–0.555), serum Ca level (P = 0.017; OR, 0.598; 95% CI: 0.392–0.911) and pre-PTx BMD in the lumbar spine (P = 0.003; OR, 0.013; 95% CI: 0.001–0.229) were negatively associated with a ≥ 10% increase in BMD post-PTx.ConclusionOur study demonstrated that presurgical age, serum Ca levels and BMD values could better predict an improvement in BMD post-PTx in SHPT patients.

Risk Factors for Severe Hypocalcemia in Patients with Secondary Hyperparathyroidism after Total Parathyroidectomy.

Background Hypocalcemia is the most common complication of total parathyroidectomy in secondary hyperparathyroidism (SHPT) and is associated with adverse consequences such as spasms, epilepsy, and arrhythmia and even death if the serum calcium level decreases rapidly. Previous studies have identified several risk factors for postoperative severe hypocalcemia (SH) in patients with SHPT, but the sample sizes were small and thus the results may not be reliable. Objectives This study was performed to investigate the risk factors for SH after total parathyroidectomy without autotransplantation (tPTX) in a large sample of patients with uremic hyperparathyroidism. Methods We retrospectively investigated the records of 1,095 patients with SHPT treated with tPTX between January 2008 and December 2018. Based on the postoperative serum calcium concentration, the patients were grouped into SH and non-SH groups. The clinical characteristics and biochemical results were analyzed, and binary logistic regression analysis was used to identify the risk factors for SH. Results After surgery, 25.9% of the patients developed SH. Age, diastolic blood pressure (DBP), heart rate, frequency of bone pain, weight of resected glands, preoperative serum calcium, intact parathyroid hormone (iPTH), alkaline phosphatase (ALP), and hemoglobin levels differed between the two groups. Binary logistic regression analyses identified preoperative serum calcium, iPTH, and ALP levels as independent predictors of SH after surgery. Conclusions The preoperative serum calcium, iPTH, and ALP levels can be used to assess the risk of postoperative SH in patients with SHPT. Such patients should thus be monitored closely in order to initiate prompt interventions to avoid SH.

Parathyroid hormone levels after parathyroidectomy for secondary hyperparathyroidism.

The parathormone level after parathyroidectomy in dialysis patients are of interest. Low levels may require cryopreserved tissue implantation; however, the resection is necessary in case of recurrence. We analyzed post parathyroidectomy parathormone levels in renal hyperparathyroidism. Prospective observation of postoperative parathormone levels over defined periods in a cohort of dialysis patients that underwent total parathyroidectomy and immediate forearm autograft from 2008 to 2010, at a single tertiary care hospital. Of 33 patients, parathormone levels until 36 months could be divided into four patterns. Patients with stable function (Pattern 1) show relatively constant levels after two months (67% of the cases). Early function and later failure (Pattern 2) were an initial function with marked parathormone reduction before one year (18%). Graft recurrence (Pattern 3) showed a progressive increase of parathormone in four cases (12%). Complete graft failure (Pattern 4) was a nonfunctioning implant at any period, which was observed in one patient (3%). Parathormone levels of Pattern 3 became statistically different of Pattern 1 at 36 months. Patients that underwent the total parathyroidectomy and autograft present four different graft function patterns with a possible varied therapeutic management.

Association Between Treatment of Secondary Hyperparathyroidism and Posttransplant Outcomes.

Secondary hyperparathyroidism (SHPT) affects nearly all patients on maintenance dialysis therapy. SHPT treatment options have considerably evolved over the past 2 decades but vary in degree of improvement in SHPT. Therefore, we hypothesize that the risks of adverse outcomes after kidney transplantation (KT) may differ by SHPT treatment. Using the Scientific Registry of Transplant Recipients and Medicare claims data, we identified 5094 adults (age ≥18 y) treated with cinacalcet or parathyroidectomy for SHPT before receiving KT between 2007 and 2016. We quantified the association between SHPT treatment and delayed graft function and acute rejection using adjusted logistic models and tertiary hyperparathyroidism (THPT), graft failure, and death using adjusted Cox proportional hazards; we tested whether these associations differed by patient characteristics. Of 5094 KT recipients who were treated for SHPT while on dialysis, 228 (4.5%) underwent parathyroidectomy, and 4866 (95.5%) received cinacalcet. There was no association between treatment of SHPT and posttransplant delayed graft function, graft failure, or death. However, compared with patients treated with cinacalcet, those treated with parathyroidectomy had a lower risk of developing THPT (adjusted hazard ratio, 0.56; 95% confidence interval, 0.35-0.89) post-KT. Furthermore, this risk differed by dialysis vintage (Pinteraction = 0.039). Among patients on maintenance dialysis therapy for ≥3 y before KT (n = 3477, 68.3%), the risk of developing THPT was lower when treated with parathyroidectomy (adjusted hazard ratio, 0.43; 95% confidence interval, 0.24-0.79). Parathyroidectomy should be considered as treatment for SHPT, especially in KT candidates on maintenance dialysis for ≥3 y. Additionally, patients treated with cinacalcet for SHPT should undergo close surveillance for development of tertiary hyperparathyroidism post-KT.

A short-term non-randomized controlled study of ultrasound-guided microwave ablation and parathyroidectomy for secondary hyperparathyroidism

Background To compare the short-term clinical outcomes of ultrasound-guided microwave ablation (MWA) and parathyroidectomy (PTX) for severe secondary hyperparathyroidism(SHPT). Methods In a prospective multi-center study, we compared the outcomes of MWA and PTX for severe SHPT. The outcome measures were case rate of successful treatment, improvement of clinical symptoms, incidence of complications, and differences in treatment parameters and costs between the two groups. Results A total of 167 eligible patients were included in the study, of which 79 underwent MWA and 88 underwent PTX. There was no significant difference in rate of successful treatment between the MWA and PTX groups (χ2=2.299, p = 0.125). However, the MWA group showed significantly lower range of intact parathyroid hormone (iPTH) decrease than the PTX group (t=−2.352, p = 0.023). Postoperative clinical symptoms improved in both groups, with no significant difference between the two groups (p > 0.05). Postoperative hypocalcemia was significantly more common in the PTX group (p < 0.05). The operative time, incision and postoperative pain of the MWA group were significantly better than those of the PTX group (p < 0.05), while postoperative recurrent laryngeal nerve injury and hematoma showed no significant difference between the two groups (p > 0.05). The cost of MWA was significantly less than PTX (p = 0.000). Conclusions Both MWA and PTX are effective and safe for severe secondary hyperparathyroidism. PTX is more thorough and traumatic, while MWA is minimally invasive and postoperative iPTH is more consistent with the Kidney Disease: Improving Global Outcomes (KDIGO) recommendation.

Changes to bone mineral density, the trabecular bone score and hip structural analysis following parathyroidectomy: a case report

BackgroundReduction in bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) occurs in secondary hyperparathyroidism associated with chronic kidney disease. BMD generally increases following parathyroidectomy, however longitudinal changes to other DXA-derived parameters, the trabecular bone score (TBS) and hip structural analysis (HSA), have not been described. Postoperative calcium requirements and positive calcium balance raise concerns for an increased risk of vascular calcification. This case illustrates the dramatic increase in BMD that can follow parathyroidectomy in a patient on dialysis, and for the first time demonstrates improvements to HSA parameters and to the TBS.Case presentationA 30-year old woman on haemodialysis underwent subtotal parathyroidectomy for secondary hyperparathyroidism. She developed a post-operative ‘hungry bone syndrome’ requiring substantial calcium and calcitriol supplementation. Six months post-parathyroidectomy, BMD increased by 42% at the lumbar spine, 30% at the femoral neck and 25% at the total proximal femur, with increases sustained over the following 18 months. The TBS increased by 8%. HSA showed a 63% increase in femoral neck cortical thickness and 38% reduction in the buckling ratio, consistent with increased femoral neck stability. The abdominal aortic vascular calcification score (0–24) increased from zero 8-years pre-parathyroidectomy to 2/24 at 18-months post-parathyroidectomy.ConclusionBMD losses incurred by secondary hyperparathyroidism recover rapidly after parathyroidectomy, particularly at sites of trabecular bone. Bone architectural parameters, measured as the TBS and by HSA, also improve. Greater BMD gains may be associated with higher post-operative calcium requirements. While bone is the major reservoir for post-parathyroidectomy calcium supplementation, positive calcium balance may contribute to vascular calcification risk.

Improved Outcomes Amidst a Sicker Population: Evolution in Parathyroidectomy for Secondary Hyperparathyroidism from 2004-2016

Fligor, Scott C. MD; Li, Chun MD; Hamaguchi, Ryoko BS; Maeda, Anthony MD; Hasselgren, Per-Olof MD, FACS; William, Jeffrey H. MD; James, Benjamin MD, FACS Author Information

SUN-230 CUTANEOUS MANIFESTATIONS IN HEMODIALYSIS PATIENTS

Cutaneous manifestations in end stage renal disease (ESRD) are polymorphic and diverse. Hemodialysis (HD) patients may suffer from different dermatological manifestations after initiation of dialysis. The aim of our study was to assess the prevalence and characteristics of different cutaneous manifestations in patients on hemodialysis. We led a cross sectional investigation of all HD patients in our unit during three months ( from July to September 2019). The patients' age, gender, medications and present cutaneous symptoms were noted. We performed for each patient a peer review including: a careful history and the details about the onset of skin lesions, the circumstances of their discoveries, triggering factors, their clinical characteristics and evolution. Then we completed a full clinical examination including a specialized mucocutaneous examination. Data were entered and analyzed using SPSS software. Chi-squared test with a level of significance of 0.05 was used for the qualitative variables. We included 25 patients. They were 15 men and 10 women (sex ratio M/F =1.5). The mean age was 45 years old (range 27 -78). The mean dialysis duration was 31 months (range 3 - 228). Fourteen patients (56%) suffered from hypertension, five of them were diabetic. Ethylism was observed in 1 patient and smoking in 7 patients (28%). Initial causes of nephropathy were diabetic, vascular and undeterminate in respectively 52%, 32% and 12% of cases. Uremic pruritus was reported in 20 cases (80%). Pruritus was continuous in 7 patients (28%), nocturnal increasing in 17patients (68%) and diurnal increasing in 1 patients (4%). Xerosis was noted in 1 case (4%), hair loss in 8 cases (32%). Three patients had cutaneous manifestations of bullous dermatoses(4%). Four patients had dyspigmentation (16%). Staphylococcal pustulosis was noted in a patient after jugular catheter placement. Anemia was noted in 10 patients (40%). The mean hemoglobin level was 9 g/l. Hyperphosphoremia was observed in 18 patients (72%). Treatment was prescribed in 14 cases such as antihistamines in 05 cases (20%), emollient preparation in 3 cases (12%), parathyroidectomy for secondary hyperparathyroidism in 6cases (24%). Diabetes, anemia and hyperphosphoremia were independent risk factors of cutaneous abnormalities with respectively (p=0.04, p=0.008 and p=0.01). Skin disorders are frequently the subject of patients’ complaints. Factors such as diagnostic accuracy, climate, and early treatment are all required to decrease the morbidity and mortality of dermatological disorders in ESRD patients and improve their quality of life.

Minimally Invasive Video-Assisted Total Parathyroidectomy for Secondary Hyperparathyroidism with Superior Mediastinal Ectopic Parathyroid

Minimally Invasive Video-Assisted Total Parathyroidectomy for Secondary Hyperparathyroidism with Superior Mediastinal Ectopic Parathyroid

Effects of Social Disparities on Management and Surgical Outcomes for Patients with Secondary Hyperparathyroidism.

Nearly 80% of chronic renal failure patients have secondary hyperparathyroidism. Cinacalcet is used to lower parathyroid hormone; however, it is expensive and has side effects. When secondary hyperparathyroidism is resistant to medication or medications are inaccessible, parathyroidectomy is performed. Race and socioeconomic status influence access to care and surgical outcomes. We sought to evaluate the effect of race and socioeconomic status on parathyroidectomy rate as well as surgical outcomes of patients with secondary hyperparathyroidism. We undertook cross-sectional analysis of adults diagnosed with secondary hyperparathyroidism in the USA between 2012 and 2014, using the National Inpatient Sample. Univariate and multivariate analyses were used to determine associations between social disparities, likelihood to undergo parathyroidectomy, and surgical outcomes. Between 2012 and 2014, a national estimate of 724,170 hospitalizations wereidentified where patients had a diagnosis of secondary hyperparathyroidism. Operative rate was 0.67%. By socioeconomic status, differences in rates of surgery in the poorest compared to the richest were not significant (0.74% vs. 0.55%, OR 1.08, p = 0.5). African-American patients had higher rates of parathyroidectomy compared to Caucasians (1 vs. 0.74%, OR 1.49, p < 0.001). African-American patients also had a trend toward more complications and greater length of stay. According to a large administrative dataset, parathyroidectomy for secondary hyperparathyroidism is seldom used in the USA. African-American patients have higher rates of surgical management. Surgical outcomes may be affected by race. Clinicians treating secondary hyperparathyroidism should be aware of existing disparities within their health system.