Refractory Hyperparathyroidism Research Articles

SAT212 Collateral Damage A Case Of Refractory Hyperparathyroidism In A Young Woman With End Stage Renal Disease

Abstract Disclosure: E.W. Alvarado: None. V. Alia: None. H. Reinhart: None. R. Giese: None. Background: The Rio Grande Valley (RGV) is a community with the highest incidence of ESRD in the USA. Hyperparathyroidism (HPT), defined as a serum PTH >65 pg/mL, HPT is a secondary complication of ESRD affecting 80% of individuals in this population. Although hyperparathyroidism may be asymptomatic, a severe form, refractory to medication can occur. Refractory HPT is defined as a PTH level 9 times the upper-limit or a serum level >800 pg/mL. This disease causes mutations in parathyroid cells causing parathyroid-gland hyperplasia. Once PTH levels increase to this extent, systemic issues including electrolyte derangements, weight loss, pathologic fractures, osteoporosis, and death can ensue. Due to the high mortality associated with this condition; it is paramount that patients are referred for surgery when medical management is inadequate. Clinical Case: A 31-year-old female with a significant medical history of ESRD on hemodialysis presented for evaluation of a suspected parathyroid carcinoma. Physical examination revealed a frail, short-statured woman who ambulated with a walker. Patient endorsed a 13-year history of uncontrolled HTN on antihypertensives, with a BP of 226/124. The patient presented with a BMI of 16.7, and endorsed a history of multiple fractures, musculoskeletal-pain, fatigue, palpitations, and a 33 pound weight loss over 1.5-years. Labs showed a total calcium of 9.4, phosphorus 6.9, ALP 652, and a PTH of 2423, meeting criteria for refractory HPT. Of note, records received five-months prior to referral showed a PTH of 5343 pg/ml, suggesting earlier surgery could have minimized disease progression. Based on the patient's presentation, MEN was suspected, however workup was negative. The patient was referred to a nearby ER for hemodynamic-stability and further workup of her underlying conditions. Ultrasound revealed two putative inferior parathyroid-glands presumptive for a diagnosis of severe tertiary HPT, but due to PTH>1000 carcinoma could not be excluded. Patient was taken to surgery and intra-operatively 4-gland hypertrophy was noted and a 3.5-gland excision was performed. Intraoperative PTH decreased to 120, and pathology showed benign parathyroid hyperplasia. Post-op day 1 the patient received hemodialysis and lab values revealed severe hypocalcemia prompting close monitoring and aggressive calcium supplementation. The patient’s electrolyte levels stabilized, she was discharged, and follow-up 2-weeks later revealed a PTH of 14.5. Conclusion: This case of a young patient with refractory HPT highlights the region's early onset of ESRD and its subsequent conditions. Noteworthy, the RGV is associated with a multitude of socioeconomic factors that precipitate neglect of chronic illnesses, indicating the substantial need for early identification and intervention to prevent long-term complications to disease in this vulnerable population. Presentation: Saturday, June 17, 2023

Ectopic Mediastinal Parathyroid Adenoma Excision via Video Assisted Thoracoscopic Approach: A Case Report

Ectopic parathyroid adenomas can be a cause of recurrent and refractory hyperparathyroidism. Majority of parathyroid adenomas are located in the neck region, however in very few cases they are located within the mediastinum. In such cases excision via cervical approach is not possible and it becomes a diagnostic as well as surgical challenge. Excision via thoracoscopic approach is a preferred approach in this regard. Here we represent a case of ectopic parathyroid adenoma embedded within thymus gland which underwent surgical excision via thoracoscopic approach.
 Key words: Ectopic, Parathyroid adenoma, Thoracoscopy

Surgical treatment of hyperparathyroidism with a pathologically changed parathyroid gland found in the mediastinum.

The most common indication for surgical treatment of parathyroid gland pathology is primary hyperparathyroidism where extirpation of the pathologically changed parathyroid gland is the first-choice treatment. Embryonic development of the lower pair of parathyroid glands is quite complex and is closely related to the tissue of the thymus; for this reason it is not uncommon for a parathyroid adenoma to be located in the mediastinum or directly in the tissue of the thymus. The treatment of primary hyperparathyroidism is becoming a multidisciplinary issue in which radiodiagnostics and nuclear medicine methods play a significant role as they are needed to accurately localize the affected gland and to plan an adequate surgery. In case of intrathoracic localization of parathyroid adenoma, the therapy belongs in the hands of thoracic surgery. At our department, the endocrine surgery program, including parathyroid gland surgery, has a long tradition, and complicated patients are concentrated here, often patients with refractory hyperparathyroidism after a previous procedure. In the last 10 years, almost 2,300 procedures for parathyroid pathology have been performed at the IIIrd Department of Surgery of the 1st Faculty of Medicine, Charles University and University Hospital in Motol, of which some pathologies with mediastinal localization were managed using minimally invasive methods, i.e. videothoracoscopy or robotic-assisted surgery.

Metastatic calcinosis cutis in a dialysis patient

Metastatic calcinosis cutis is an uncommon complication of end-stage kidney disease but has severe and disabling effects. Its development is attributed to disorders of calcium and phosphate metabolism associated with secondary hyperparathyroidism. The mainstay of treatment remains medical therapy; however, in refractory cases a parathyroidectomy is indicated. We describe the case of a 22-year-old female with refractory hyperparathyroidism treated with a subtotal parathyroidectomy resulting in complete resolution of metastatic calcinosis cutis of the hands. Clinicians should be aware that this complication can occur soon after the initiation of dialysis and that rapid complete resolution can be achieved with parathyroidectomy.

A single-center experience of parathyroidectomy in 1500 cases for secondary hyperparathyroidism: a retrospective study

Background Chronic kidney disease (CKD) is a global public health problem. With the deterioration of renal function, a certain proportion of CKD patients enter the uremic stage, and secondary hyperparathyroidism (SHPT) becomes a challenge. For refractory hyperparathyroidism, parathyroidectomy (PTX) plays a key role in reducing mortality and improving prognosis. Nevertheless, no consensus has been reached on the optimal surgical method. We aimed to provide evidence for the effectiveness of surgical treatment by summarizing the experience from our center. Methods Clinical data from 1500 patients undergoing parathyroidectomy were recorded, which included 1419 patients in a total parathyroidectomy without autotransplantation (tPTX) group, 54 patients in a total parathyroidectomy plus autotransplantation (tPTX + AT) group, and 27 patients in the other group. Perioperative basic data, intact parathyroid hormone (i-PTH) levels, serum calcium levels, serum phosphorus levels, pathological reports, coexisting thyroid diseases, short-term outcomes and complications were analyzed. Moreover, postoperative complications were compared between the tPTX and tPTX + AT groups. Results Parathyroid hormone, serum calcium and phosphorus levels decreased significantly post-surgery. Two patients died during the perioperative period. As the two most common complications, the incidences of severe hypocalcemia and hyperkalemia were 36.20% (543 cases) and 24.60% (369 cases), respectively. Pre-iPTH levels (OR = 1.001, 95% CI: 1.001–1.001, p < 0.01), serum alkaline phosphatase (ALP) levels (OR = 1.002, 95% CI: 1.001–1.002, p < 0.01) and the mass of excised parathyroid gland (OR = 3.06, 95% CI: 1.24–7.55, p = 0.02) were positively associated with postoperative severe hypocalcemia, while age and serum calcium were negatively associated with it. Pathological reports of resected parathyroid and thyroid glands indicated that 96.49% had parathyroid nodular hyperplasia, 13.45% had thyroid nodular hyperplasia, and 4.08% had thyroid papillary carcinoma. Conclusions Parathyroidectomy is a safe and effective treatment for refractory secondary hyperparathyroidism. Severe hypocalcemia is the main complication, and coexistent thyroid diseases should never be neglected.

Ultrasound-Guided Radiofrequency Ablation: A New Attempt to the Treatment of Refractory Hyperparathyroidism Secondary to Chronic Kidney Disease

IntroductionTo evaluate clinical application value of radiofrequency ablation (RFA) in refractory hyperparathyroidism secondary to chronic kidney disease (CKD) by comparing the safety and effectiveness of RFA with parathyroidectomy with autotransplantation (PTX + AT).MethodsA retrospective study was conducted on 80 patients with CKD with refractory hyperparathyroidism who underwent RFA or PTX + AT between January 2018 and February 2021. Serum parathyroid hormone (PTH), calcium, and phosphorus levels, complications, clinical symptoms, visual analogue scale (VAS) scores, hospital stay duration, and postoperative recurrence rate were compared between the 2 groups.ResultsSerum PTH, phosphorous, and calcium levels and the VAS scores improved significantly after RFA and PTX + AT (P < 0.05). Significant differences were observed between the 2 groups in postoperative (day 1 and week 1) levels of serum PTH and postoperative day 1 of serum calcium and phosphorus levels (P < 0.05), with more pronounced reduction after PTX + AT. Although the incidence of recurrent laryngeal nerve (RLN) injury was slightly higher in the RFA group compared with the PTX + AT group (26.67% vs. 16.67%; P > 0.05), RFA markedly decreased the risk of severe hypocalcemia (SH) (20% vs. 46.67%; P < 0.05) and shortened hospital stay (7.53 ± 2.67 days vs. 12.13 ± 3.86 days; P < 0.05). The 6-month recurrence rate was 23.3% (7 of 30) in the RFA group and 30% (9 of 30) in the PTX + AT group (P > 0.05).ConclusionRFA can treat refractory secondary hyperparathyroidism (SHPT) with similar clinical efficacy as surgery and achieve faster recovery and a lower incidence of postoperative SH.

Serum osteocalcin level in end-stage renal disease patients on maintenance hemodialysis after parathyroidectomy in relation to parathyroid hormone level

BackgroundParathyroidectomy (PTX) is an effective treatment for refractory hyperparathyroidism in end-stage renal disease (ESRD) patients on maintenance hemodialysis (MHD). However, adynamic bone disease, a possible complication, is associated with persistent bone pain and increased fracture risk. Osteocalcin (OC) is a bone formation marker, produced by osteoblasts, stimulated by parathyroid hormone and active vitamin D, associated with overall survival. Late changes in its level after PTX need to be evaluated.AimThe aim of this study was to determine serum OC and its relation to intact parathyroid hormone (iPTH) in patients on MHD with and without a history of PTX.Patients and methodsThis case–control study was conducted on 50 patients with ESRD on MHD, subdivided into two groups (group I and group II), according to the history of PTX. Patients having diabetic mellitus or autoimmune disease were excluded. Patients were inquired about manifestations of bone disease. Serum concentrations of ionized total calcium, magnesium, phosphorus, alkaline phosphatase (ALP), iPTH, and OC (by ELISA) were determined. Serum OC concentration was also measured in the samples of 20 healthy participants (group III) to evaluate its reference value.ResultsBone fracture was present in nine patients with or without PTX, with no significant difference from the other patients, as regards the studied parameters. Patients with ESRD on MHD had a significantly higher serum OC level than controls (P<0.001). Serum OC in patients who underwent PTX, and with adynamic bone disease (iPTH<150 pg/ml) (group IA), was significantly lower than that in the corresponding subgroup without PTX (group 2A) (P=0.001); similarly, the two subgroups were different, as regards serum ALP (P<0.001) and serum iPTH (P<0.001). There were significant positive correlations between serum OC and total ALP and iPTH in the total patient sample (P<0.001 and <0.001, respectively).ConclusionAdynamic bone disease after PTX in patients on MHD in comparison with those who have not undergone PTX is associated with a lower level of bone formation marker OC.

Fatal Hypocalcaemia Due to Hungry Bone Syndrome with Secondary Refractory HyperParathyroidism after Parathyroidectomy: A Case Report

IntroductionHungry bone syndrome (HBS) refers to the rapid, profound, and prolonged hypocalcaemia associated with hypophosphatemia and hypomagnesaemia, and is exacerbated by suppressed parathyroid hormone (PTH) levels, which follows parathyroidectomy in patients with severe primary hyperparathyroidism (PHPT) and preoperative high bone turnover. [1]Case reportThis report concerns a dialysed patient who underwent surgical treatment for secondary refractory hyperparathyroidism. Haemodialysis was carried out pre-operatively, and subsequently, a total parathyroidectomy with auto-transplantation of parathyroid tissue in the sternocleidomastoid muscle (SCM) was performed. Rapid and progressive hypocalcaemia symptoms developed during the second day postoperatively. Acute cardiac symptoms with tachyarrhythmia, haemodynamic instability and finally asystole occurred, which required cardiopulmonary resuscitation (CPR). The ionic calcium level was 2.2 mg/dL being consistent with a diagnosis of HBS. A second cardiac arrest unresponsive to CPR followed an initial period of normal sinus rhythm. Death ensued shortly after. Before death, the ionic calcium was 3.1 mg/dL.ConclusionHBS, after parathyroidectomy in patients with secondary hyperparathyroidism (SHPT), may be severe, prolonged and sometimes fatal. Generally, HBS symptomatology is that of a mild hypocalcaemia. It can, however, include heart rhythm disturbances with haemodynamic alterations requiring intensive care measurements and even cardiopulmonary resuscitation. A close clinical and laboratory post-parathyroidectomy monitoring of dialysed patients is of the utmost importance.

Parathyroidectomy in dialysis patients: Indications, methods, and consequences.

Secondary hyperparathyroidism, characterized by increased PTH synthesis and secretion, is often seen in advanced stages of chronic kidney disease. Excessive proliferation of parathyroid cells leads to the development of diffuse hyperplasia that subsequently progresses to nodular histology. Refractory hyperparathyroidism occurs when parathyroid glands fail to respond to medical therapy. Parathyroidectomy (PTX), surgical resection of parathyroid glands, is usually performed in cases of persistent serum levels of PTH above 1000pg/mL associated with hypercalcemia or when hyperparathyroidism is refractory to conservative therapy. Parathyroidectomy can be carried out using different procedures: subtotal PTX or total PTX with or without parathyroid autotransplantation. Parathyroid surgery may have undesirable consequences due to PTH oversuppression, such as the development of adynamic bone disease; hungry bone syndrome is quite common after this surgery. However, PTX improves survival and parameters of mineral metabolism. Parathyroidectomy needs to be considered in those patients with severe hyperparathyroidism with a poor response to pharmacological treatment and with distinct undesirable effects of PTH on bone and mineral metabolism parameters.

Cinacalcet as rescue therapy for refractory hyperparathyroidism in young children with advanced chronic kidney disease.

Studies in the use of the calcimimetic, cinacalcet, in pediatric chronic kidney disease (CKD) are few and limited to older children with secondary hyperparathyroidism (sHPT), a major morbid complication contributing to poor growth, bone deformities, and cardiovascular disease. Our objectives were to determine a safe and effective dosing regimen of cinacalcet in the treatment of infants and young children with sHPT that was refractory to standard care and to examine their growth during treatment. Ten young pediatric patients with advanced CKD were studied retrospectively during 11 courses of treatment with cinacalcet. All had severe sHPT with intact parathyroid hormone (iPTH) levels ≥ 500pg/ml and were refractory to standard therapy with phosphate binders and active vitamin D analogs at high doses for > 30days. The cinacalcet dose was advanced by 50% every 2-4weeks to achieve a decline in the iPTH to a goal of 150-300pg/ml. Linear growth was assessed at 6-month intervals by change in z-scores (△SDS) for length before and during cinacalcet therapy. Median age at initiation of cinacalcet was 18months (IQR 6, 36) with an average starting dose of 0.7 ± 0.2mg/kg/day. Median effective dose required to reach iPTH goal of 150-300pg/ml was 2.8mg/kg/day (IQR 2.0, 3.1), and time to goal was 112days (IQR 56, 259) with a median overall decline in iPTH of 82% from baseline by 6months (p < 0.0001). No subject experienced a clinical adverse event, although 4 had biochemical asymptomatic hypocalcemia. Linear growth improved significantly during cinacalcet therapy (△SDS - 0.62 ± 1.2 versus + 0.91 ± 1.4; p < 0.005). By multiple regression analysis, the primary determinants of growth were concurrent treatment with growth hormone and age < 2years (R2 = 89.6%; p < 0.001). A shorter treatment time required to achieve iPTH goals also was associated with improved growth (r = - 0.75; p < 0.01). Cinacalcet may be used effectively and safely in infants and small children with refractory sHPT in advanced CKD using a cautious dosing regimen. Cinacalcet successfully brings iPTH to target level and supports growth when other treatments have been ineffective.

Total Parathyroidectomy with Subcutaneous Parathyroid Forearm Autotransplantation in the Treatment of Secondary Hyperparathyroidism: A Single-Center Experience.

Introduction Secondary hyperparathyroidism is common in chronic kidney disease. Parathyroidectomy is indicated in refractory hyperparathyroidism when medical treatments and so the parathyroid hormone levels cannot be lowered to acceptable values without causing significant hyperphosphatemia or hypercalcemia. The aim of this study is to compare the efficacy and safety of total parathyroidectomy with subcutaneous forearm autotransplantation with total parathyroidectomy with intramuscular forearm autotransplantation. Materials and Methods A single-center retrospective cohort study of total parathyroidectomy with forearm autotransplantation from January 2002 to February 2013 was performed. According to the surgical technique, patients were divided into an intramuscular group (Group 1) and a subcutaneous group (Group 2). 38 patients with secondary hyperparathyroidism were enrolled; 23 patients were subjected to total parathyroidectomy with parathyroid tissue replanting in the subcutaneous forearm of the upper nondominant limb, while 15 patients were subjected to replanting in the intramuscular seat. Results A total of 38 patients (56 ± 13 years) were enrolled. In both groups, the preoperative iPTH value was markedly high, 1750 ± 619 pg/ml in the intramuscular autotransplantation group and 1527 ± 451 pg/ml in the subcutaneous autotransplantation group (p = 0.079). Transient hypoparathyroidism was shown in 7 patients, and 1 patient showed persistent hypoparathyroidism (p = 0.387). 2 patients showed persistent hyperparathyroidism (p = 0.816), and in 2 others was found recurrent hyperparathyroidism (p = 0.816); 3 of them underwent autograftectomy. The anterior compartment of the forearm nondominant limb was sacrificed in 1 case of intramuscular autotransplantation with functional arm deficit. Conclusions The efficacy and safety of parathyroid tissue autotransplantation in the subcutaneous forearm of the upper nondominant limb is confirmed with a good rate of tissue engraftment and with a comparable number of postsurgical transient and persistent hypoparathyroidism and hyperparathyroidism incidence in both techniques. Furthermore, this technique preserves arm functionality in the case of autograftectomy. Consequently, it is our opinion that total parathyroidectomy with subcutaneous forearm autotransplantation is currently the best choice.

Secondary and tertiary hyperparathyroidism in chronic kidney disease

In the treatment of secondary hyperparathyroidism of end-stage chronic kidney disease, vitamin D receptor activation and allosteric modulators of the calcium-sensing receptor – inhibit glandular hyperplasia, reduce parathyroid hormone levels, impact on bone turnover and mineral density. But the use of calcimimetic and vitamin D analogs or mimetics did not reduce the need for parathyroidectomy for refractory hyperparathyroidism. The enlarged parathyroid gland and gland nodular transformation became refractory to medical therapy and patient need for parathyroidectomy. Tertiary hyperparathyroidism is a state of excessive secretion of parathyroid hormone after a long period of secondary hyperparathyroidism and renal transplantation.&#x0D; In this article, we present the case of a Caucasian male with chronic kidney disease (end-stage on chronic hemodialysis and after kidney transplantation) and different forms of hyperparathyroidism (secondary and tertiary). Our case study shows that only a multi-interventional strategy is likely to be more effective treatment in cases of severe and refractory to medical therapy hyperparathyroidism.

Value of Intraoperative Parathyroid Hormone Assay during Parathyroidectomy in Dialysis and Renal Transplant Patients with Secondary and Tertiary Hyperparathyroidism

Background: In dialysis and renal transplant patients with secondary and tertiary hyperparathyroidism (HPT), the value of intraoperative parathyroid hormone (ioPTH) during parathyroidectomy (PTX) and its association with long-term PTH levels are unknown. The present study aims at evaluating the relationship of ioPTH with long-term PTH levels post-PTX in dialysis and renal transplant patients in a single-center study. Methods: The ioPTH was measured in 57 dialysis patients (33 females and 24 males) and 18 renal transplant recipients (12 males and 6 females) who underwent PTX from 2005 to 2015 for refractory HPT. Near-total PTX was performed in 56 patients and total PTX with autotransplantation in 20 patients. The PTH monitoring included 3 samples: pre-intubation, 10- and 20-min (pre-ioPTH, 10-ioPTH, and 20-ioPTH) post parathyroid gland excision. Patients were followed up for up to 5 years. Results: In the dialysis group, the median (25th–75th percentile) pre-, 10-, and 20-ioPTH levels were 1,447 pg/mL (938–2,176), 143 pg/mL (78–244) and 112 pg/mL (59–153) respectively. In the renal transplant group, pre-, 10-, and 20-ioPTH levels were 273 pg/mL (180–403), 42 pg/mL (25–72), and 34 pg/mL (23–45) respectively. All patients in the transplant group had a functional kidney transplant at the time of PTX with a median serum creatinine of 1.3 mg/dL (1.2–1.7) and estimated glomerular filtration rate of 55 mL/min (40–60). The median time between renal transplant and PTX surgeries was 22 months (7–81). The last median follow-up PTH level was 66 pg/mL (15–201) in the dialysis group and 54 pg/mL (17–72) in the transplant group (p = 0.438). The mean time for last PTH post-PTX was 2.3 ± 2.0 years. In both groups, there was no significant difference between 20-ioPTH and any-time post-PTX PTH levels (p = 0.6 and p = 0.9). Nineteen patients (25%) were readmitted within 90 days because of hypocalcemia. One patient in the dialysis group was readmitted for post-PTX hematoma evacuation. No patient required repeat PTX because of recurrent HPT that was refractory to medical therapy. Only one dialysis patient required repeat PTX because the first procedure failed. Conclusions: The 20-ioPTH is a good indicator of long-term PTH levels in dialysis and renal transplant patients. Hypocalcemia is a common complication, particularly in dialysis patients, and it is the main reason for readmission after PTX. Hypoparathyroidism is a potential concern after PTX in dialysis patients.

EFFECT OF ULTRASOUND-GUIDED DIRECT VITAMIN D INJECTIONS INTO PARATHYROID GLANDS ON LABORATORY MARKERS AND SURVIVAL OF PATIENTS WITH REFRACTORY SECONDARY HYPERPARATHYROIDISM

Aim. To evaluate the effect of local vitamin D injections into parathyroid glands on laboratory markers and survival in refractory hyperparathyroidism. Materials and methods. A comparison of the dynamics of secondary hyperparathyroidism laboratory markers and survival was performed in 37 patients with local vitamin D injections into the parathyroid glands under ultrasound guidance and in 62 patients with PTH higher than 600 pg/ml without reduction in PTH levels by more than 10% during 6 months, who continued to receive available conservative therapy. The mean duration of follow-up for groups was 40.5 and 33.2 months, respectively.Results. In the local injection group (LIG) PTH level reduced by 347 ± 360 pg/ml (38%) during the first month after injection course, and by 214 ± 255 pg/ml (28%) between annual average levels before and after injection course, while in control group (CG) it rose by 84 ± 277 pg/ml (11%). In LIG phosphate level significantly reduced by 0.18 ± 0.24 mmol/l (9%) after injection course and annual average level did not change. In CG annual average phosphate level significantly rose by 0.15 ± 0.37 mmol/l (7%). Cumulative survival by Kaplan–Maier was significantly higher in LIG (p = 0.025). Differences in survival in univariate and multivariate Cox regression models were significantly associated only with the fact of local injections course (p =0.04 inboth models).Conclusion. In current clinical practice the application of ultrasound-guided local vitamin D injections into parathyroid glands in patients with refractory hyperparathyroidism leads to a better control over laboratory markers and to significantly improved survival.

Open label study to assess the safety and efficacy of cinacalcet in refractory hyperparathyroidism with chronic renal failure

Background: Secondary hyperparathyroidism a common consequence of chronic kidney disease is associated with many complications like renal osteodystrophy, vascular and soft tissue calcification. This study is to assess the safety and efficacy of Cinacalcet a calcimimetic drug in patients with refractory hyperparathyroidism due to chronic renal failure. Methods: Patients with chronic kidney disease stage 5 on maintenance haemodialysis diagnosed to have refractory hyperparathyroidism who do not attain the target range for hyper-parathyroid indicators serum PTH ≤300, Serum Ca (8.4-9.5), serum phosphorous (3.5-5.5) with the use of calcitriol and phosphate binders were included in the study. Twenty patients satisfying the case definition of refractory hyperparathyroidism due to chronic renal failure received 30mg Cinacalcet therapy. Total duration of treatment was 6 weeks. Standard serum calcium, serum phosphorous, PTH was assessed before and after 6 weeks. Results: Cinacalcet significantly reduces serum PTH level when results were compared by paired t test. P=0.016 &lt;0.05 (significant). No statistically significant reduction in serum calcium and phosphorous. Serum calcium P value=0.599&gt;0.05, serum phosphorous P=0.132&gt;0.05. In this study after overall assessment. Conclusions: Cinacalcet is more efficacious and safe in treating refractory hyperparathyroidism due to chronic renal failure.

Effect of cinacalcet cessation on hyperparathyroidism in kidney transcaplant patients after long-term dialysis therapy.

Cinacalcet is a promising therapy widely used in dialysis patients with hyperparathyroidism resistant to conventional therapy. However, reports regarding the influence of cinacalcet cessation after long-term use on kidney transplantation patients are few. This retrospective observational study included 40 dialysis patients who underwent kidney transplantation. Creatinine, corrected calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone levels were assessed before and after kidney transplantation according to pretransplant treatment of chronic kidney disease-mineral and bone disorder. Ultrasonography revealed enlargement of the parathyroid in all patients treated with cinacalcet. Although the data at the time of kidney transplantation were comparable, the serum levels of calcium, alkaline phosphatase, and intact parathyroid hormone after kidney transplantation were higher in patients treated with cinacalcet than in those treated without. However, serum phosphate levels in the cinacalcet group were slightly higher at the time of kidney transplantation and significantly lower 3months later. Mineral abnormalities persisted in kidney transplant patients with enlarged parathyroid glands after discontinuation of cinacalcet treatment. Parathyroidectomy should be considered in kidney transplant candidates with the risk of developing refractory hyperparathyroidism after transplantation.

Supernumerary Parathyroid Glands in a Patient with Tertiary Hyperparathyroidism : Case Report

Supernumerary parathyroid glands could be affected by tertiary hyperparathyroidism after long-term phosphate therapy in an adult-onset hypophosphatemic Osteomalacia, and it may be the cause of refractory hyperparathyroidism. We Report a 63-years old Jordanian man who has been diagnosed at age of 26 years as having sporadic adult-onset hypophosphatemic Osteomalacia and developed tertiary hyperparathyroidism as a complication of prolonged oral phosphate therapy, which requires repeated surgical interventions. This patient had six parathyroid glands all ended with tertiary hyperparathyroidism, the 5th and the 6th gland were activated serially. This rare association is discussed along with a review of literature.

Cardiopulmonary complications of end-stage renal disease and severe refractory hyperparathyroidism

A 46-year-old man was referred for management of dyspnoea thought due to severe calcific stenosis of his tricuspid aortic valve: mean gradient 49 mmHg; valve area 1.1 cm2 ( Panels A and B ; Supplementary material online, Video S1). He had a history of end-stage renal disease maintained on haemodialysis following transplant failure …

Parathyroidectomy for Refractory Secondary Hyperparathyroidism with Severe Bone Disease

Advances in the medical management of secondary hyperparathyroidism due to renal failure have decreased the use of parathyroidectomy as a treatment option. However, some patients with end-stage renal disease still progress to refractory hyperparathyroidism and debilitating bone disease, for which parathyroidectomy may be warranted. We describe a case of a 35-year-old female on chronic hemodialysis who presented with bone pains, deformities, decrease in height and recurrent pathologic fractures. She had markedly elevated parathyroid hormone (PTH), vitamin D deficiency, persistent hyperphosphatemia and hypocalcemia despite therapeutic measures. Subtotal parathyroidectomy was done with eventual improvement of biochemical abnormalities, resolution of bone pains and healing of fractures.

Differential Gene Expression by Oxyphil and Chief Cells of Human Parathyroid Glands

Parathyroid oxyphil cells, whose function is unknown, are thought to be derived from chief cells. Oxyphil cells increase in number in parathyroid glands of patients with chronic kidney disease (CKD) and are even more abundant in patients receiving treatment for hyperparathyroidism with calcitriol and/or the calcimimetic cinacalcet. We examined oxyphil and chief cells of parathyroid glands of CKD patients for differential expression of genes important to parathyroid function. Parathyroid tissue from CKD patients with refractory hyperparathyroidism was immunostained for gene expression studies. Immunostaining for PTH, PTHrP, calcium-sensing receptor, glial cells missing 2, vitamin D receptor, 25-hydroxyvitamin D-1α-hydroxylase, and cytochrome c was quantified and expression reported for oxyphil and chief cells. Expression of all proteins analyzed, except for the vitamin D receptor, was higher in oxyphil cells than in chief cells. Human parathyroid oxyphil cells express parathyroid-relevant genes found in the chief cells and have the potential to produce additional autocrine/paracrine factors, such as PTHrP and calcitriol. Additional studies are warranted to define the secretory properties of these cells and clarify their role in parathyroid pathophysiology.