Risk Of Hypoparathyroidism Research Articles

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.

Total Number of Identified Parathyroid Glands During Total Thyroidectomy and Its Relation to Postoperative Hypoparathyroidism.

To evaluate the correlation between the intraoperative number of identified parathyroid glands (PGs) and the risk of developing hypoparathyroidism postoperatively. Also, to determine the risks and prognostic factors in patients with postoperative hypoparathyroidism. A retrospective study of 499 patients who underwent total thyroidectomy at two tertiary care institutions, King Saud University Medical City (KSUMC) and King Fahad Medical City (KFMC) in Riyadh, Saudi Arabia was included. Individual demographic characteristics with detailed clinical information were recorded, focusing mainly on operative reports for a total number of identified PGs intraoperatively and investigating the risk of developing hypoparathyroidism postoperatively. Factors such as age, gender, comorbidity, and number of excised and reimplanted parathyroid glands were investigated to determine the risks and prognostic factors in patients with postoperative hypoparathyroidism. The findings from the analysis showed that the number of identified PGs intraoperatively had a positive correlation with a higher postoperative risk of developing hypoparathyroidism. For zero, one, two, three, and four identified PGs, the risk of hypoparathyroidism in one-hour parathyroid hormone level postoperative was 6.6%, 7.3%, 34.4%, 34.4%, and 17.2% respectively. The greater the number of identified PGs intraoperatively, the less likely it was to prevent inadvertent hypoparathyroidism post-total thyroidectomy.

Risk of Permanent Hypoparathyroidism Requiring Calcitriol Therapy in a Population-Based Cohort of Adults Older Than 65 Undergoing Total Thyroidectomy for Graves' Disease.

Objective: Total thyroidectomy for Graves' disease (GD) is associated with rapid treatment of hyperthyroidism and low recurrence rates. However, it carries the risk of surgical complications including permanent hypoparathyroidism, which contributes to long-term impaired quality of life. The objective of this study was to determine the incidence of permanent hypoparathyroidism requiring calcitriol therapy among a population-based cohort of older adults undergoing total thyroidectomy for GD in the United States. Methods: We performed a population-based cohort study using 100% Medicare claims from beneficiaries older than 65 years with GD who underwent total thyroidectomy from 2007 to 2017. We required continuous enrollment in Medicare Parts A, B, and D for 12 months before and after surgery to ensure access to comprehensive claims data. Patients were excluded if they had a preoperative diagnosis of thyroid cancer or were on long-term preoperative calcitriol. Our primary outcome was permanent hypoparathyroidism, which was identified based on persistent use of calcitriol between 6 and 12 months following thyroidectomy. We used multivariable logistic regression to identify characteristics associated with permanent hypoparathyroidism, including patient age, sex, race/ethnicity, neighborhood disadvantage, Charlson-Deyo Comorbidity Index, urban or rural residence, and frailty. Results: We identified 4650 patients who underwent total thyroidectomy for GD during the study period and met the inclusion criteria (mean age = 72.8 years [standard deviation = 5.5], 86% female, and 79% white). Among this surgical cohort, 104 (2.2% [95% confidence interval, CI = 1.8-2.7%]) patients developed permanent hypoparathyroidism requiring calcitriol therapy. Patients who developed permanent hypoparathyroidism were on average older (mean age 74.1 vs. 72.8 years) than those who did not develop permanent hypoparathyroidism (p = 0.04). On multivariable regression, older age was the only patient characteristic associated with permanent hypoparathyroidism (odds ratio age ≥76 years = 1.68 [CI = 1.13-2.51] compared with age 66-75 years). Conclusions: The risk of permanent hypoparathyroidism requiring calcitriol therapy among this national, U.S. population-based cohort of older adults with GD treated with total thyroidectomy was low, even when considering operations performed by a heterogeneous group of surgeons. These findings suggest that the risk of hypoparathyroidism should not be a deterrent to operative management for GD in older adults who are appropriate surgical candidates.

Intraoperative parathyroid hormone measurement facilitates outpatient thyroidectomy in children

IntroductionWe hypothesize that intraoperative parathyroid hormone (ioPTH) measurement after a total thyroidectomy predicts children at risk for hypoparathyroidism and allow for outpatient procedure. MethodsBetween 2015 and 2019, we reviewed all patients under the age of 21 undergoing a thyroidectomy (total or lobectomy). Based on the ioPTH concentration, the patients were treated by the following protocol: a) PTH ≥20 pg/mL: no treatment; b) PTH = 10–19 pg/mL: 1000 mg calcium orally TID; c) PTH = 5–9 pg/mL: calcitriol 250 μg orally BID plus 1000 mg calcium orally TID; or d) PTH <5 pg/mL calcitriol 500 μg orally BID plus 1000 mg calcium orally TID. ResultsFifty-two patients were included with a median age of 16 (range 6–21 years). Thirty-two patients (62%) had normal PTH (≥10 pg/mL) while 20 (38%) had low PTH levels (<10 pg/mL). Of those patients with low PTH, 60% had normalization of levels within 2 weeks of surgery. ConclusionsThyroid surgery in children can be performed as an outpatient procedure. The ioPTH measurements and a protocol to treat patients with low PTH assists in safe discharge.

Efficiency and safety of sclerotherapy for recurrent nodular goiter

At present, patients with recurrent nodular goiter account for a significant portion of patients operated on for nodular goiter. At the same time, the comorbid background characteristic of this age group and the technical difficulties of the intervention on cicatricial tissues of the neck cause a high risk of complications of the operation, 3–7 times higher than with primary thyroid interventions. The aim of the study was to evaluate the effectiveness and safety of treatment of recurrent nodular goiter using an alternative minimally invasive method — sclerotherapy. The study included 30 patients previously operated on for nodular goiter. All had 4 courses of sclerotherapy, each included 5 sessions with a frequency of 1 session per week, followed by a follow-up period of 3 months. Polydocanol was used as a sclerosant. The analysis showed that sclerotherapy for recurrent nodular goiter allows all patients to reduce recurrent nodular formations, and in almost a third of cases, complete reduction of the nodes. On average, the decrease in the volume of thyroid residues was 9.6 ± 1.5 ml, and the size of nodular formations decreased by 17.2 ± 1.3 mm (3.7 times — from 23.6 ± 1.4 mm to 6.4 ± 0.7 mm, P &lt;0.001). Nodes more than 3 cm, initially 19 %, ceased to be detected after the third course of sclerotherapy. In all cases, managed to eliminate hormonal imbalances in patients who initially had functional autonomy, as well as signs of compression of the neck organs. At the same time, sclerotherapy of nodules of the thyroid gland using polydocanol as a sclerosant is a safe minimally invasive treatment method, is not accompanied by severe pain and the risk of hypoparathyroidism and laryngeal paresis.

P1015IMPACT OF DIABETIC DISEASE ON IPTH LEVELS IN DIALYSIS PATIENTS

Abstract Background and Aims Mineral bone disease in dialysis patients is an important predictor of morbimortality.iPTH levels had been previously associated with different parameters, but not clearly to diabetic disease (DBT). We aim to analyze relationship between DBT and iPTH levels in a large cohort of dialysis patients from Fresenius Medical Care LatinAmerica (FMC LA). Method Prevalent dialysis patients (more than 90 days on renal replacement therapy) by November 2019 in FMC LA dialysis units (Argentina, Brasil, Chile, Colombia, Ecuador, Perú) were included into the dataset. We obtained demographic, treatment and laboratory data by November 2019. Patients were identified as DBT when DBT was informed as etiology of renal disease or any DBT related ICD10 code was recorded as comorbid condition into the database. Use of insulin, calcitriol, paricalcitol and cinacalcet was also obtained.To evaluate association between DBT and iPTH level, Student t test for independent samples was used. Kruskal-Wallis and Mann-Whitney tests were also performed as confirmatory non-parametric tests for iPTH. Categorical variables were compared using Chi Square test. Linear regression was used to predict iPTH and analyze association with DBT. All procedures were performed on IBM SPSS Statistics© 21. Results A total of 31,709 prevalent patients were included. DBT prevalence was 29.7%. Main differences found between DBT and non-DBT patients are shown in table 1: Linear regression model to predict iPTH showed variables associated with increase in iPTH: Ca, P, K, use of calcitriol, use of cinacalcet; while others were associated with decrease in iPTH: age, dialyzate Ca, Hb, glucose, albumin, use of calcium carbonate as supplementation and DBT (table 2): Conclusion In our population diabetic patients were older, showed higher male prevalence and higher rate of catheter use. Kt/V, Ca and P serum levels were slightly lower than non-diabetic, but not clinically significant.Remarkable differences in laboratory were higher glucose and lower K and alb in DBT. While these differences were expected and already known and well described, lower iPTH in DBT is not.Diabetic disease affects iPTH level independently from other factors increasing the risk for hypoparathyroidism. Those findings should be analyzed to determine if DBT should be considered as a different group when targeting in mineral bone disease or P-binder prescription.

Risks of Hypoparathyroidism After Total Thyroidectomy in Children: A 21-Year Experience in a High-Volume Cancer Center.

Hypoparathyroidism occurs relatively frequently after thyroid surgery in children. However, few studies have reported risk factors. We aimed to identify risk factors for hypoparathyroidism that occurred after total thyroidectomy for proven or suspected malignancy in children. Children (aged ≤ 18years) who underwent total thyroidectomy for neoplasm or RET germline mutation at our institution between 1997 and 2018 were included. We retrospectively reviewed demographics, surgical indications, perioperative and follow-up laboratory results, pathologic results, and duration of calcium/calcitriol supplementation. Risk factors for hypoparathyroidism were identified by multivariate analysis. Of 184 consecutive patients, 111 had undergone surgery for neoplasm; these diseases were primarily malignancies (106, 95.5%), predominantly papillary carcinoma (103, 92.8%). The remaining 73 patients had undergone early thyroidectomy for RET germline mutation. Among all patients, 67 (36.4%) had hypoparathyroidism: 61 transient and 6 permanent. In a multivariate analysis, central neck dissection (odds ratio 4.3, 95% confidence interval 2.0-9.1) and gross extrathyroidal extension (odds ratio 4.9, 95% confidence interval 2.0-12.1) predicted overall hypoparathyroidism; however, no significant factors were associated with permanent hypoparathyroidism. Most patients with permanent hypoparathyroidism (5 of 6) had undergone therapeutic central neck dissection. When central neck dissection was performed, younger children had a higher risk of overall hypoparathyroidism. In pediatric total thyroidectomies, central neck dissection and gross extrathyroidal extension were major predictors for overall hypoparathyroidism. Surgeons performing thyroidectomy in such patients should be aware of the relatively high risk, preserve parathyroid tissue to the extent possible, and be conscientious regarding postoperative calcium monitoring and replacement.

Can preoperative vitamin D deficiency predict postoperative hypoparathyroidism following thyroid surgery?

Postoperative hypoparathyroidism remains a relevant problem after thyroid surgery. Although the roles of vitamin D deficiency and other risk factors have been discussed in previous studies, variable results have been reported. Predicting the risk of postoperative hypocalcemia could be helpful for individual prognoses and medical treatment. Documentation and analysis of bilateral thyroid operations performed between July 2011 and May 2014 were studied. Results involving age, gender, diagnosis, surgical techniques, pre- and postoperative calcium and parathyroid hormone (PTH) levels, and especially, the role of preoperative vitamin D levels were assessed in uni- and multivariate analyses. Bilateral thyroid surgery was performed in 361 patients with multinodular goiters (n = 224), Graves' disease (n = 40), or thyroid carcinoma (n = 97). In total, 124 patients (34%) with postoperative hypoparathyroidism, defined as having a PTH level ≤10pg/mL, were treated with calcium and vitamin D regardless of their symptoms. The rate of permanent hypoparathyroidism was 3.6% and correlated with the extent of surgery; the highest risks were shown for total thyroidectomy and central lymph node dissection. In univariate analysis, the extent of surgery, parathyroid autotransplantation, and histopathology were the strongest predictors of hypoparathyroidism. Even severe vitamin D deficiency (< 10ng/mL) showed a trend only towards a higher transient hypoparathyroidism risk (p = 0.0514) but failed to predict permanent hypoparathyroidism. Postoperative PTH levels accurately identified patients at risk for hypoparathyroidism. Decreased preoperative vitamin D levels could not predict hypocalcemia, and high vitamin D levels could not prevent permanent hypoparathyroidism.

Hypoparathyroidism in Total Thyroidectomy due to Benign Thyroid Diseases

PurposeOur aim was to compare the effects of exposing the recurrent laryngeal nerve throughout its entire course with exposing the nerve only at its entry to the larynx in patients undergoing total thyroidectomy due to benign thyroid diseases, and to evaluate the effects of these methods on the risk for hypoparathyroidism. MethodsThe medical records of 437 patients who had undergone total thyroidectomy at the ear, nose, and throat clinic between 2001 and 2015 for benign thyroid diseases were evaluated retrospectively. Mean patient age was 46.7 years (range 18–79 years). Eighty-six patients were male and 351 were female. Patients were divided into 2 groups according to recurrent laryngeal nerve exposure during surgery. In the first group, the nerve was observed as it entered the larynx, and its course was not completely exposed. In the second group, the nerve was identified in the tracheoesophageal groove, and its course was fully exposed. Group 1 consisted of 256 patients (47 male and 209 female) and group 2 consisted of 181 patients (39 male and 142 female). There were no statistically significant differences between the groups in terms of age and gender, and the groups were homogeneously distributed. FindingsTransient hypoparathyroidism was observed in 15 (5.8%) patients and permanent hypoparathyroidism was observed in 3 (1.1%) patients in group 1, and transient hypoparathyroidism was observed in 23 (12.7%) patients and permanent hypoparathyroidism was observed in 7 (3.8%) patients in group 2. The rates of both transient and permanent hypoparathyroidism were higher in the patients in group 2, and the difference was statistically significant (P < 0.001). Transient recurrent nerve palsy was seen in 1 patient in each group. Permanent recurrent nerve palsy occurred in 1 patient in group 2, although the difference between groups was not statistically significant (P = 0.28). ImplicationsTransient and permanent hypoparathyroidism were less common in thyroidectomies that involved detection of the recurrent laryngeal nerve at the site of entry to the larynx and keeping its dissection minimal; this technique was also more reliable.

Potential role for carbon nanoparticles identification and preservation in situ of parathyroid glands during total thyroidectomy and central compartment node dissection.

e17048 Background: Patients undergoing thyroid surgery are at risk for hypoparathyroidism. We hypothesized that carbon nanoparticles identification of parathyroid glands might help maximize parathy...

Pathophysiology and treatment of nonfamilial hyperparathyroidism.

Primary hyperparathyroidism (HPT) is the main cause of hypercalcemia and the most common parathyroid glands disease. The diagnosis is easy in patients with hypercalcemia and elevated PTH serum level. Minimally invasive parathyroidectomy (PTx) represents the treatment of choice for symptomatic patients, leading to several advantages, including immediate normalization of hypercalcemia and significant improvement of bone mineral density, cardiovascular dysfunctions, neuropsychological symptoms and quality of life. Secondary and tertiary HPT are relatively common complications in patients with chronic kidney disease (CKD) or advanced kidney failure, and in kidney transplant recipients who did not achieve complete calcium/phosphate metabolism normalization, respectively. The drugs available for patients with secondary HPT, and to treat hyperphosphatemia include non-calcium-containing phosphate binder, calcitriol analogues, calcimimetic agents, or a combination of two or more drugs. Although recent studies report that PTx significantly improves survival also in patients with CKD and severe secondary HPT, the indications for surgery are not yet well established. Subtotal or total PTx with or without autotransplantation are the surgical options for treating all patients with secondary HPT. Total PTx leads to a faster reduction in serum calcium level and normalization of PTH, but the risk of hypoparathyroidism is higher than after subtotal PTx. Further studies are needed to confirm the usefulness of the drugs currently recommended, and others will have to be tested in the near future.

Sternotomy for substernal goiter: retrospective study of 52 operations.

Surgical treatment of substernal goiter occasionally involves sternotomy. Classification and handling of these operations are widely discussed. We aimed to review surgical results after thyroid operations including median sternotomy. A retrospective review of all thyroid operations performed in the department from 01.01.95 to 31.12.12. In 55 of 2065 thyroid operations (2.7 %), median sternotomy was performed. All hospital journals of the patients were collected and carefully reviewed. We included 52 of 55 identified patients. Pathologic examinations discovered malignant disease in 4 patients (8 %) and multinodular goiter in 48 patients (92 %). Mean operation time was 4 h and 5 min (n = 48). Mean estimated blood loss was 464 ml (n = 48). Blood transfusion was given in nine operations (17 %). Median duration of postoperative hospitalization was 7 days (range 4-27 days). Pulmonary complications occurred in 11 patients (21 %): six with pneumonia or atelectasis, three with pneumothorax, and two with pleural effusion. Three patients (6 %) had postoperative hypocalcaemia (permanent in two patients (4 %)). Three patients (6 %) had transient voice changes. Permanent vocal cord paresis was not observed in this series of patients. Thyroid operations with sternotomy are complicated procedures accompanied with considerable pulmonary complications. In spite of a large invasive procedure, the risk of hypoparathyroidism or recurrent laryngeal nerve injury was not increased.

Relationship between the Number of Preserved Parathyroid Glands and Clinical Aspects after Thyroidectomy in PTC

Objectives: Identify the relationship between the preservation status of the parathyroid gland and risk of hypoparathyroidism after total thyroidectomy in papillary thyroid carcinoma. Methods: Medical records of 63 patients with papillary thyroid carcinoma who satisfied our inclusion criteria were reviewed retrospectively. Patients with PTC who underwent total thyroidectomy with central lymph node dissection (CLND) were included. Patients were grouped according to the number of intact preserved parathyroid glands into Group 1 (more than four), Group 2 (three), Group 3 (under two). The total and ionized serum calcium, intact parathyroid hormone (PTH) levels of each group were monitored after the surgery. Patients with postoperative symptomatic hypocalcemia were considered to have postoperative hypoparathyroidism and received calcium/vitamin D therapy. The hypoparathyroidism was considered to be permanent when calcium/vitamin D therapy was still required six months after surgery. Results: 31 cases (49.2%) showed postoperative hypoparathyroidism as demonstrated by laboratory findings. Permanent hypoparathyroidism did not occur in this case. The development of hypoparathyroidism was not significantly related with the number of preserved parathyroid glands. Conclusions: To prevent postoperative and permanent hypoparathyroidism following total thyroidectomy, at least two parathyroid glands should be preserved in situ with an intact blood supply. Patients with more extensive CLND procedure did not necessarily show an increased rate of transient hypoparathyroidism. With PTC, the rates of metastasis and recurrence in central lymph nodes are high. Therefore, this study suggests that CLND should be more routinely done for PTC. Hypoparathyroidism can be kept to a minimum by a thorough knowledge of the anatomy and by meticulous hemostasis and delicate surgical technique.

Younger Age is Associated With Increased Risk of Hypoparathyroidism After Thyroidectomy for Graves Disease

Younger Age is Associated With Increased Risk of Hypoparathyroidism After Thyroidectomy for Graves Disease

The Relationship between the Number of Preserved Parathyroid Glands and Clinical Aspects after Total Thyroidectomy and Central Lymph Node Dissection in Papillary Thyroid Carcinoma

Received March 27, 2013 Revised May 17, 2013 Accepted June 8, 2013 Address for correspondence Jin-Choon Lee, MD, PhD Department of OtorhinolaryngologyHead and Neck Surgery, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea Tel +82-51-240-7335 Fax +82-51-246-8668 E-mail ljc0209@hanmail.net Background and ObjectivesZZTo identify the relation between the preservation status of the parathyroid glands and the risk of hypoparathyroidism after total thyroidectomy and central lymph node dissection in papillary thyroid carcinoma. Subjects and MethodZZA retrospective review was carried out for the medical records of 63 patients with papillary thyroid carcinoma (PTC), who satisfied our inclusion criteria and received treatment at the Department of Otolaryngology-Head and Neck Surgery, Hospital from May 2010 to December 2011. Patients with PTC who underwent total thyroidectomy with central lymph node dissection (CLND) were included and grouped according to the number of preserved parathyroid glands as follows: Group 1 (with four intact glands), Group 2 (three intact glands), Group 3 (less than two intact glands). The total and ionized serum calcium and intact parathyroid hormone levels of each group were monitored after the surgery. Patients with postoperative symptomatic hypocalcemia were considered to have postoperative hypoparathyroidism and received calcium/vitamin D therapy. The hypoparathyroidism was considered to be permanent when calcium/vitamin D therapy was still required six months after surgery. ResultsZZOut of 63 cases of total thyroidectomy with CLND, 31 (49.2%) showed postoperative hypoparathyroidism as demonstrated by laboratory findings. Permanent hypoparathyroidism, however, was not observed in these cases. The development of hypoparathyroidism was not significantly related with the number of preserved parathyroid glands. ConclusionZZTo prevent postoperative hypoparathyroidism following total thyroidectomy and CLND, at least two parathyroid glands should be preserved in situ with an intact blood supply in order to prevent permanent hypoparathyroidism after the surgery. Korean J Otorhinolaryngol-Head Neck Surg 2013;56:431-5

Potential role for intraoperative gamma probe identification of normal parathyroid glands

Background Patients undergoing central neck surgery are at risk for hypoparathyroidism. We hypothesized that gamma probe identification of sestamibi-labeled parathyroid glands might help maximize parathyroid preservation. Methods Records of 351 patients who underwent central neck surgery were reviewed. A subgroup of patients underwent sestamibi injection followed by gamma probe-directed parathyroid gland identification. Results Operation was performed for malignancy in 73% of patients and represented a reoperation in 34%. Persistent hypoparathyroidism was more common in patients who underwent reoperation versus a primary operation (6.8% versus 1.7%; P = 0.02). Thirteen patients underwent gamma probe-directed identification of sestamibi-labeled parathyroid glands; in 6 of these patients, sestamibi-labeled parathyroid glands were salvaged from the resected specimens and autografted. None of these 13 patients developed persistent hypoparathyroidism. Conclusions Patients undergoing reoperative central neck surgery are at increased risk for postoperative hypoparathyroidism. Gamma probe-directed salvage of sestamibi-labeled parathyroid glands may help maximize parathyroid preservation, especially in complex or reoperative central neck surgery.

The Use of Radioactive Iodine in the Management of Hyperthyroidism in Children

Graves' disease is the most common form of hyperthyroidism in childhood. Current treatment options include antithyroid medications, surgery, and radioactive iodine. Medical therapy is generally associated with long-term remission rates of less than 25% and a small risk of serious adverse reactions that include hepatic failure and bone marrow suppression. Total thyroidectomy is associated with very high cure rates and a small risk of hypoparathyroidism and recurrent laryngeal nerve damage. When radioactive iodine is used at appropriate doses, there is a very high cure rate without increased risks of thyroid cancer or genetic damage. Because of the theoretical risk of thyroid cancer after thyroid irradiation in individuals less than 20 years of age, relatively high doses of radioactive iodine should be administered to minimize residual thyroid tissue.

Risk of hypoparathyroidism after surgery for carcinoma of the thyroid

The reported incidence of postoperative hypoparathyroidism varies from 3% to 32%, and many surgeons are reluctant to perform a total thyroidectomy because of the risk of permanent damage to the parathyroid glands. We prospectively studied three groups of patients for evidence of acute parathyroid damage: group A consisted of 29 patients with total thyroidectomies; group B, 21 controls with partial thyroidectomies; and group C, 29 patients with total thyroidectomies that had been performed several months to years earlier. Functional status of the glands was measured by serum parathormone, calcium, and phosphorus levels. Although these levels fell postoperatively, they remained within normal limits. None of the long-term follow-up patients (group C) was found to have hypoparathyroidism, leading us to conclude that this risk may be overstated in the literature.