Does the Parathyroidectomy Endanger the Transplanted Kidney?

doi:10.1016/j.transproceed.2016.01.054

Transplantation Proceedings

Volume 48, Issue 5, June 2016, Pages 1633-1636

https://doi.org/10.1016/j.transproceed.2016.01.054 Get rights and content

Highlights

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A parathyroidectomy impairs transitory renal graft function in the early postoperative period.
•
The differences in preoperative and postoperative glomerular filtration rate in subsequent follow-up periods are insignificant.
•
A parathyroidectomy is not a risk factor for renal graft loss.

Abstract

Background

Some investigators maintain that a parathyroidectomy (PTX) performed for tertiary hyperparathyroidism may potentially cause graft malfunction or even loss of the transplanted kidney after the operation. The goal of this study was to determine if parathyroidectomy affects transplanted kidney function.

Methods

The study group consisted of 48 renal graft recipients who underwent operation due to tertiary hyperparathyroidism. Thirty-nine subtotal parathyroidectomies and 9 more selective, less than subtotal parathyroidectomies were performed. The estimated glomerular filtration rate (eGFR) was calculated retrospectively on days 2 to 3 and 4 to 5 and at 1, 3, 6, 12, 24, and 36 months after PTX; these findings were compared with preoperative values. The cumulative graft survival rate in the postoperative period was assessed.

Results

In the follow-up period, 4 of 48 patients returned to hemodialysis (after 1, 7, 22, and 57 months after PTX). In the first case, the patient had stopped taking the immunosuppressive drugs 1 month after PTX. Cumulative graft survival rate after PTX was 98.0% after 6 months, 96% after 12 months, and 93% after 2 and 3 years. The mean preoperative eGFR was 52 ± 17.15 mL/min/1.73 m², and the median was 48.28 mL/min/1.73 m². Overall and in the subtotal parathyroidectomy group, eGFR was significantly lower (P < .001) only on days 2 to 3. There were no differences between preoperative and postoperative eGFR values in the other follow-up periods. In the more selective, less than subtotal parathyroidectomy group, the decrease in eGFR values was nonsignificant compared with preoperative findings in the early postoperative period as well as in all follow-up periods.

Conclusions

In this study, PTX did not significantly impair transplanted kidney function, but in the early postoperative period, transient reductions in graft function did occur.

Section snippets

Patients and Methods

The study group comprised 48 patients operated on between 1997 and 2014. All PTX were performed for THPT (3 for persistent hyperparathyroidism). We performed 39 subtotal parathyroidectomies (sPTX) and 9 more selective, less than subtotal PTX (<sPTX). Characteristics of the study population, type of parathyroid resection performed, and details of preoperative renal graft function are presented in Table 1, Table 2, Table 3, respectively. After the PTX, kidney function parameters were evaluated on

Results

Overall, in the follow-up period, 4 of 48 patients returned to hemodialysis (after 1, 7, 22, and 57 months after PTX). In 1 case, the patient made an independent decision to stop taking the immunosuppressive drugs and lost the transplanted kidney 1 month after PTX. Three other cases involved chronic renal graft deterioration. Cumulative graft survival rate after PTX was as follows: 98% after 6 months, 96% after 12 months, and 93% after 2 and 3 years (Fig 1).

The mean preoperative eGFR was 52.38

Discussion

Progressive nephrocalcinosis due to THPT-related hypercalcemia correlates with high risk of reducing the function of the transplanted kidney [7]. Theoretically, the rebalanced calcium and phosphate homeostasis after PTX should have positive results for the graft. Conversely, PTH has some influence on eGFR by its vasodilation effect on the afferent arteriole and an indirect vasoconstrictive effect (renin stimulation effect) on the efferent arteriole in the glomerulus. Jespersen et al [8] showed

Conclusions

In this study, we found that PTX did not significantly impair transplanted kidney function. In the early postoperative period, however, a transient reduction in graft function was observed.

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Cited by (14)

Effects of parathyroidectomy on kidney function in patients with primary hyperparathyroidism: Results of a prospective study
2023, Surgery (United States)
Citation Excerpt :
In a manner similar to kidney transplant recipients undergoing parathyroidectomy for tertiary hyperparathyroidism, who could experience kidney graft impairment,28 the rapid postoperative drop of PTH after surgery for PHPT could explain this acute kidney injury. Indeed, the PTH is suggested to exert a vasoconstrictive effect on the afferent arteriole of the glomerulus.29 Despite these limits, the present study was the first to show prospectively that parathyroidectomy improves kidney function in PHPT in patients with preoperative eGFR impairment, suggesting that, in accordance with the actual recommendations, an eGFR <60 mL/min is an accurate indication for surgery in patients with PHPT.
Altered glomerular filtration rate is a controversial indication for parathyroidectomy in patients with primary hyperparathyroidism. The objective of this study was to evaluate the estimated glomerular filtration rate change 12 months after parathyroidectomy for primary hyperparathyroidism according to preoperative kidney function.
Patients who underwent parathyroidectomy for primary hyperparathyroidism between 2016 and 2021 (n = 381) were enrolled in a monocentric prospective cohort. Patients without 1-year follow-up or with missing data were excluded (n = 135, 35%). Patients were dichotomized according to their baseline estimated glomerular filtration rate: <60 mL/min (group 1) and ≥60 mL/min (group 2). Parameters were measured before and then at 6 and 12 months after parathyroidectomy.
Out of 246 included patients, 27 (11%) were assigned to group 1 and 219 (89%) to group 2. The mean baseline estimated glomerular filtration rate was 46.8 ± 11.5 and 87.3 ± 14.7 mL/min in groups 1 and 2, respectively. Group 1 patients were older (P = .0006) and had a higher median serum parathyroid hormone level (P = .021). At 6 months postoperative, 224 patients (91%) were normocalcemic. The estimated glomerular filtration rate raw change after parathyroidectomy was significantly higher in group 1 than in group 2 (4.2 ± 7.8 vs -2.2 ± 9.1 mL/min, P = .0004). In group 1, 13/27 patients (48%) improved their chronic kidney disease stage after parathyroidectomy, including 6/13 (46%) with postoperative estimated glomerular filtration rate ≥60 mL/min, whereas 2/27 (7%) worsened. The baseline estimated glomerular filtration rate <60 mL/min and elevated serum calcium level were associated with postoperative estimated glomerular filtration rate improvement in multivariable analysis (P = .0023 and .039, respectively).
Parathyroidectomy for primary hyperparathyroidism is more likely to improve kidney function in patients with preoperative estimated glomerular filtration rate <60 mL/min. These results strengthen the current guidelines for surgery.
Surgery is Underutilized in the Management of Tertiary Hyperparathyroidism
2022, Journal of Surgical Research
Citation Excerpt :
Medical management with cinacalcet has been shown to effectively lower serum calcium rates though not with the same consistency as parathyroidectomy.4,5 Surgical intervention with parathyroidectomy has been shown to be safe in the setting of 3HPT with high cure rates.1,6-9 Recent studies comparing cinacalcet to parathyroidectomy suggest that parathyroidectomy may decrease the renal allograft failure rate.6,10,11
Tertiary hyperparathyroidism (3HPT) is observed in up to 40% of renal transplant patients. Standard guidelines defining 3HPT and indications for operative intervention are not well described.
We conducted a retrospective, single-institution cohort study of patients who underwent renal transplant between January 1, 2012 and January 30, 2018, with a minimum of 13-month follow-up and at least 1 y of allograft function. We defined 3HPT as having elevated serum level parathyroid hormone (>88 pg/mL) after successful renal transplantation or multiple instances of elevated serum calcium starting at least 3 mo after transplant. We compared graft failure rates after stratifying the cohort based on management strategy: expectant, medical management with cinacalcet, and parathyroidectomy.
Out of the 381 transplanted patients with functional grafts at 1 y, 178 patients (46.6%) were found to have 3HPT. One hundred twenty-nine patients (72.5%) were managed expectantly without medications, 35 patients (19.7%) were managed medically, and 14 patients (7.8%) were managed with parathyroidectomy. Twenty-two patients (17.1%) in the observation group had graft failure, 4 patients (11.4%) in the medically managed group had graft failure, and 0 patients in the surgery group had graft failure. Surgical intervention was associated with decreased renal allograft failure when compared to the combined cohort of nonoperative 3HPT patients (P = 0.03). All patients who underwent parathyroidectomy were cured and did not have graft failure as of December 30, 2019. Calcium elevation, but not PTH elevation, was associated with referral for parathyroidectomy on multivariable logistic regression analysis (P < 0.01).
At our institution, the referral rate for parathyroidectomy among patients with 3HPT remains low. Parathyroidectomy was associated with high cure rates and reduced graft failure. Surgery may be underutilized in the management of 3HPT.
Parathyroidectomy or cinacalcet: Do we still not know the best option for graft function in kidney-transplanted patients? A meta-analysis
2021, Surgery (United States)
Citation Excerpt :
Eighteen out of 47 studies were eligible in the meta-analysis to evaluate the evolution of renal graft function 6 and 12 months after the beginning of parathyroidectomy or cinacalcet treatment. Twenty-nine studies had to be excluded because of the lack of workable data on renal function (results of eGFR as percentages of baseline [unknown]),19 graphic data without numerical data,20–22 no numbered postoperative data,23 eGFR before and after parathyroidectomy given as median,24 eGFR given in modification of diet in renal disease equation,25–29 insufficient or unclear duration of follow-up,16,30–43 or patients treated with a combination of parathyroidectomy and cinacalcet.44 Two studies were excluded from the meta-analysis owing to the possible overlap of the cohorts.11,45
Tertiary hyperparathyroidism occurs in 25% to 50% of kidney-transplanted patients. Indication of parathyroidectomy is now discussed, since the calcimimetic agent, cinacalcet, is an alternate option. The effects of either of these treatments on graft function remain controversial, studied only in small cohorts showing either decrease or absence of modification. We performed a meta-analysis to evaluate the evolution of graft function after surgical or medical treatment.
Studies assessing graft function in tertiary hyperparathyroidism after parathyroidectomy or cinacalcet introduction were enrolled into quantitative analysis using Pubmed, Embase, and Cochrane databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelines. Among 68 screened studies, 18 had no missing data and were included for statistical analyses. We performed random effect meta-analysis to determine changes in serum creatinine and estimated glomerular filtration rate.
Seven studies assessing the evolution of graft function 6 and/or 12 months after parathyroidectomy and 13 after administration of cinacalcet were included. Meta-analysis found no significant variations after parathyroidectomy in serum creatinine (6 studies, 314 patients) and estimated glomerular filtration rate (2 studies, 105 patients). No significant variation was found after administration of cinacalcet in serum creatinine (10 studies, 404 patients) and estimated glomerular filtration rate (6 studies, 149 patients). A significant heterogeneity between the studies (P < .01, Cochran’s Q) was found.
Meta-analysis shows that parathyroidectomy and cinacalcet do not significantly impair graft function in patients with tertiary hyperparathyroidism. However, the significant heterogeneity between selected studies, partially explained by the lack of consensual definition of tertiary hyperparathyroidism, limits the conclusions of all previously published series.
Influence of Parathyroidectomy on Kidney Graft Function in Secondary and Tertiary Hyperparathyroidism
2020, Transplantation Proceedings
Citation Excerpt :
This is in contrast to various retrospective series that were recently published describing the negative effect of PTX after kidney transplantation both postoperatively and during long-term follow-up [2,31]. In contrast to other retrospective series, we did not see a significant rise in creatinine levels immediately or late after PTX [32–34]. In both our patient groups, we saw a rapid decline of PTH and calcium levels postoperatively with stable values during follow-up.
Timing of parathyroidectomy (PTX) remains controversial in candidates for kidney transplant with concomitant renal hyperparathyroidism (HPT). The aim of this retrospective study was to identify the influence of early vs late posttransplant PTX compared to pretransplant PTX on renal graft function and morbidity.
This single-center cohort study includes 57 patients with renal HPT and kidney transplantation treated between 2007 and 2017. Ninety-six patients had surgery for renal HPT between 2007 and 2017 as a consecutive sample. Group 1 (n = 30; tertiary HPT), group 2 (n = 66; secondary HPT). Of group 1, 4 patients were excluded for PTX before and after kidney transplantation. In group 2, 20 patients were excluded since they had not undergone kidney transplantation during follow-up. Twelve patients were excluded because of short follow-up (kidney transplantation in 2018), and 3 patients were excluded because of transplant failure within 90 days.
Twenty-six patients underwent posttransplant PTX (10 patients within 12 months after transplant), and 31 patients had undergone PTX prior to kidney transplantation. Graft function, serum calcium concentrations, parathyroid hormone (PTH) levels, postoperative morbidity, and 90-day mortality were recorded.
Median age was 53.1 years in group 1 and 49.1 years in group 2. Most patients were male (53.8% in group 1; 54.8% in group 2). Median preoperative PTH levels were significantly different with 331.6 pg/mL in group 1 and 667.5 pg/mL in group 2 (P = .003). Creatinine levels changed little from 1.4 mg/dL (range, 0.8-2.5) to 1.7 mg/dL (range, 0.7-7.3) in group 1, and no difference was seen between early or late PTX after transplantation. In group 2, creatinine levels were 8.5 mg/dL (range, 4.6-11.7) before PTX and 8.7 mg/dL (range, 5.1-11.9) after PTX.
We saw no correlation between postoperative PTH and kidney function. Thirty-five patients with postoperative PTH < 15 pg/mL displayed a mean postoperative creatinine of 5.5 mg/dL (range, 4.3-6.8), similar to other patients. Both the 30-day and 90-day mortality rates were zero.
PTX had no negative effect on graft function, whether performed before or after (early or late) kidney transplantation. Surgical cure of renal HPT should be performed as soon as possible to prevent secondary complications and can also be safely carried out early after transplantation.
Surgical Treatment of Hyperparathyroidism After Kidney Transplant
2019, Transplantation Proceedings
Citation Excerpt :
The surgical procedure may be associated with transient kidney allograft dysfunction, but it does not seem to decrease long-term allograft survival [7]. Conversely, Chudzinski et al found fast improvement in glomerular filtration rate in the early postoperative period in a single-center clinical study [8]. Our data also showed that there was no significant impairment in the graft function when we compared the pre- and postoperative serum creatinine and estimated glomerular filtration rate levels.
Chronic renal impairment is often associated with complex bone disorders. Improvement of secondary hyperparathyroidism (HPT) is expected after kidney transplant (KT) if the glomerular filtration rate is normalized.
There were 888 KTs performed between 1996 and 2017 at our department. A total of 558 general patients have been operated on for HPT during the same period. The 2 populations had a common part: out of the 558, a total of 69 (12.4%) were in end-stage renal failure when operated on because of secondary HPT. That also means that 7.8% of all KTs were associated with HPT. Retrospective, single-center analysis was performed using the patients' medical records. The aim of our study was to analyze the results of parathyroidectomies after KT.
Parathyroid surgery was performed on 19 patients (2.14%) because of HPT after KT. The applied surgical technique was total parathyroidectomy with autotransplant in 6 cases, subtotal parathyroidectomy in 3 cases, and selective parathyroidectomy in 10 cases. In all cases, histology revealed benign disease. Complications were observed in 10 cases (52%); there were 6 cases of postoperative hypocalcaemia (31.58%), 1 case of transient laryngeal recurrent nerve paresis (5.26%), and 6 cases of recurrent HPT (31.58%).
The first step of HPT management is calcimimetic drug treatment. It is essential to prevent possible complications with regular laboratory monitoring. If the proper conservative therapy is refractory or severe in complications, surgery should be chosen. If the patient is already waiting for a KT, it is worth performing the parathyroid surgery before KT. Close collaboration with endocrinologists and nephrologists is needed to achieve successful therapy.
Management of de novo nephrolithiasis after kidney transplantation: a comprehensive review from the European Renal Association CKD-MBD working group
2024, Clinical Kidney Journal

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12th Congress of the Polish Transplantation SocietyRenal transplantationDoes the Parathyroidectomy Endanger the Transplanted Kidney?

Highlights

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Discussion

Conclusions

Kidney Int

Am J Transplant

Am J Hypertens

Am J Med Sci

Clinics (Sao Paulo)

Am J Surg

Surgery

Transplant Proc

Hyperparathyroidism in chronic kidney disease

The role of calcium, phosphorus and vitamin D metabolism in the development of secondary hyperparathyroidism

Nephrol Dial Transplant

12th Congress of the Polish Transplantation Society
Renal transplantation
Does the Parathyroidectomy Endanger the Transplanted Kidney?