Secondary and Tertiary Hyperparathyroidism: The Utility of ioPTH Monitoring

Abstract

Background The aim of this study was to examine the utility of intraoperative parathyroid hormone (ioPTH) monitoring in patients with secondary (2) and tertiary (3) hyperparathyroidism (HPT). Materials and methods We identified 105 patients with 2HPT (n=33) and 3HPT (n=72) who underwent ioPTH monitoring during parathyroidectomy. Data are reported as mean ± SEM. Results The 2HPT patients underwent 17 subtotal, 10 total, and 6 re-exploratory parathyroidectomies, while 3HPT patients underwent 54 subtotal, 15 limited, and 3 re-exploratory parathyroidectomies. The percent decrease from the baseline ioPTH level at 5, 10, and 15 minutes after parathyroid resection respectively were 72 ± 3%, 76 ± 3%, and 76 ± 3% in patients with 2HPT, and 52 ± 6%, 60 ± 4%, and 69 ± 4% in patients with 3HPT. IoPTH levels failed to drop >50% from baseline in 5 patients (2HPT: n=2, 3HPT: n=3) who were normocalcemic at last follow-up. IoPTH did not alter the surgical approach in any 2HPT patients, but did alter management in 25% of 3HPT patients (15 limited resections and 3 supernumerary glands). Normocalcemia was achieved in 97% of 2HPT and 99% of 3HPT patients and 2 patients developed recurrent disease. Conclusion IoPTH levels fell by >50% in nearly 95% of patients with 2HPT and 3HPT, and reliably predicted post-operative cure. While the use of ioPTH did not alter surgical management in any patient with 2HPT, this rapid PTH assay impacted the surgical care of a quarter of the patients with 3HPT and may prove to be a useful adjunct in this group of patients.

Surgical management of secondary hyperparathyroidism in chronic kidney disease—a consensus report of the European Society of Endocrine Surgeons

“…In sharp contrast, other authors consider IOPTH of no or limited practical utility. Pitt et al concluded that in 33 consecutive patients with refractory renal HPT, IOPTH levels did predict outcome but did not alter surgical management in any patient [84] (EL 3). Roshani et al reported that IOPTH predicted biochemical resolution of hyperparathyroidism but failed to predict persistent hypoparathyroidism [85] (EL 4).…”

Tratamento cirúrgico do hiperparatireoidismo secundário: revisão sistematizada da literatura

“…Em alguns estudos, HPT terciário corresponde à persistência do HPT após transplante renal bem-sucedido; pode significar também secreção autônoma de PTH decorrente de HPT secundário prolongado (2,3,(5)(6)(7)10,12,13,27,37,38,40,45). Em outros, HPT secundário e terciário são processos relacionados, mas entidades distintas e separadas (13).…”

“…Existiam cerca de 90 mil pacientes em tratamento dialí-tico no Brasil em 2011, com tendência de aumento ao longo dos anos (35). Estima-se que o HPT secundário seja diagnosticado em cerca de 90% dos pacientes com DRC em hemodiálise (4,7,13,27). A prevalência da doença é elevada, mesmo sendo pouco diagnosticada e tratada (20).…”

“…Assim, níveis séricos elevados de fosfato e produção diminuída de vitamina D causam hipocalcemia e elevam os níveis de PTH circulante. Como consequência prolongada, há hiperplasia de células paratireóideas e aumento na secreção de PTH (1,2,4,5,8,13,19,20,22,23,27,31,(36)(37)(38)(39).…”

“…Quando a doença não responde mais ao tratamento clínico, indica-se a paratireoidectomia (PTx) (1)(2)(3)11,13,14,(16)(17)(18)(19)(20)23,24,(27)(28)(29)33,34,37,38,40,(42)(43)(44). A PTx pode reduzir significativamente os níveis de fosfato e PTH.…”