Usefulness of intraoperative parathyroid hormone measurements in patients with renal hyperparathyroidism

Freriks, K.; Hermus, A.R.M.M.; Sévaux, R.G.L. de; Bonenkamp, Han J.; Biert, J.; Heijer, Martin den; Sweep, Fred C.G.J.; Hamersvelt, Henk W. van

doi:10.1002/hed.21328

Cited by 17 publications

(15 citation statements)

References 25 publications

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“…A drop lower than the above-mentioned iPTH concentration values favored a search for supranumerary or ectopic parathyroid tissue and was a prognostic factor of an operative failure—a higher permanent cure rate as compared to patients without intraoperative iPTH monitoring (IOPTH group 201/207 (97.1 %) versus without iPTH group 79/90 (87.8 %), ( p = 0.001)). The values were statistically significant [17, 18]. …”

Section: Discussionmentioning

confidence: 99%

Subtotal parathyroidectomy for secondary renal hyperparathyroidism: a 20-year surgical outcome study

Konturek

Barczyński

Stopa

et al. 2016

Langenbecks Arch Surg

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AimThe aim of this study was to evaluate the outcomes of surgery for patients with secondary renal hyperparathyroidism (rHPT).MethodsThis is a retrospective cohort study. Our institutional database was searched for eligible patients treated in 1995–2014. The inclusion criterion was initial parathyroidectomy for rHPT. Clinical and follow-up data were analyzed to estimate the cure rate (primary outcome), and morbidity (secondary outcome).ResultsThe study group comprised 297 patients (154 females, age 44.5 ± 13.7 years, follow-up 24.6 ± 10.5 months), including 268 (90.2 %) patients who had underwent subtotal parathyroidectomy, and 29 (9.8 %) who had had incomplete parathyroidectomy. Intraoperative iPTH assay was utilized in 207 (69.7 %) explorations. Persistent rHPT occurred in 12/268 (4.5 %) patients after subtotal parathyroidectomy and 5/29 (17.2 %) subjects after incomplete parathyroidectomy (p = 0.005). The patients operated on with intraoperative iPTH assay had a higher cure rate than non-monitored individuals, 201/207 (97.1 %) vs. 79/90 (87.8 %), respectively (p = 0.001). In-hospital mortality occurred in 1/297 (0.3 %) patient. The hungry bone syndrome occurred in 84/268 (31.3 %) patients after subtotal parathyroidectomy and 2/29 (6.9 %) subjects after incomplete parathyroidectomy (p = 0.006). Transient recurrent laryngeal nerve paresis occurred in 14/594 (2.4 %) and permanent in 5/594 (0.8 %) nerves at risk.ConclusionsSubtotal parathyroidectomy is a safe and efficacious treatment for patients with rHPT. Utilization of intraoperative iPTH assay can guide surgical exploration and improve the cure rate.

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Section: Discussionmentioning

confidence: 99%

Subtotal parathyroidectomy for secondary renal hyperparathyroidism: a 20-year surgical outcome study

Konturek

Barczyński

Stopa

et al. 2016

Langenbecks Arch Surg

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“…Patients with CKD have an excess of PTH fragments (as 7-84 PTH) that may cross-react with the iPTH assay [88] (EL 4). It was claimed that whole PTH assays would eliminate this cross-reactivity and therefore would be more accurate in predicting surgical outcome [89] (EL 4) ( Table 8).…”

Section: Does the Type Of Iopth Assay Influence Accuracy Of Iopth Resmentioning

confidence: 99%

“…Level of evidence Recommendation grade Cryopreservation of parathyroid tissue after parathyroidectomy for renal hyperparathyroidism… …is routinely used by less than half of the units reporting results 4 C …will be used for a delayed autotransplantation in only 1-5 % of patients 4 C …will be useful to totally correct hypoparathyroidism in 25-75 % of patients 4 C …should not be expected to function after 2 years of storage 3b B …should be abandoned when not performed in very large and experienced centres 5 D changing the type of PTH assay to whole PTH measurements did not significantly improve the sensitivity and specificity ratio of intraoperative PTH measurements [88] .…”

Section: Statementsmentioning

confidence: 99%

“…The majority of studies are retrospective and emphasise the fact that applying the criteria used for primary hyperparathyroidism yields unacceptable low specificity. In a detailed Dutch report, the sensitivity at both 10 and 20 min was 100 % when using a 50 % intraoperative IOPTH decline as a criterion for cure but the specificity was extremely low (15 and 9 %, respectively), and therefore a 70 % decline from baseline was recommended to declare biochemical cure in surgery of renal HPT [88].…”

Section: Statementsmentioning

confidence: 99%

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

Lorenz

Bartsch

Sancho

et al. 2015

Langenbecks Arch Surg

108

130

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Background Despite advances in the medical management of secondary hyperparathyroidism due to chronic renal failure and dialysis (renal hyperparathyroidism), parathyroid surgery remains an important treatment option in the spectrum of the disease. Patients with severe and complicated renal hyperparathyroidism (HPT), refractory or intolerant to medical therapy and patients with specific requirements in prospect of or excluded from renal transplantation may require parathyroidectomy for renal hyperparathyroidism. Methods Present standard and actual controversial issues regarding surgical treatment of patients with hyperparathyroidism due to chronic renal failure were identified, and pertinent literature was searched and reviewed. Whenever applicable, evaluation of the level of evidence concerning diagnosis and management of renal hyperparathyroidism according to standard criteria and recommendation grading were employed. Results were discussed at the 6th Workshop of the European Society of Endocrine Surgeons entitled Hyperparathyroidism due to multiple gland disease: An evidence-based perspective.Results Presently, literature reveals scant data, especially, no prospective randomized studies to provide sufficient levels of evidence to substantiate recommendations for surgery in renal hyperparathyroidism. Appropriate surgical management of renal hyperparathyroidism involves standard bilateral exploration with bilateral cervical thymectomy and a spectrum of four standardized types of parathyroid resection that reveal comparable outcome results with regard to levels of evidence and recommendation. Specific patient requirements may favour one over the other procedure according to individualized demands. Conclusions Surgery for patients with renal hyperparathyroidism in the era of calcimimetics continues to play an important role in selected patients and achieves efficient control of hyperparathyroidism. The overall success rate and longterm control of renal hyperparathyroidism and optimal handling of postoperative metabolic effects also depend on the timely indication, individually suitable type of parathyroid resection and specialized endocrine surgery.

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“…More recently, total parathyroidectomy has attracted increased interest [3], although no consensus view has emerged as to which approach is best. Intraoperative parathyroid hormone (ioPTH) measurement is a functional diagnostic tool during parathyroid surgery that permits prediction of postoperative outcome and helps the surgeon to decide whether further exploration is necessary [6]. A reduction in ioPTH levels of ≥50% indicates surgical success with a sensitivity of 98% and specificity of 91% in primary hyperparathyroidism, and has been suggested as appropriate for ioPTH monitoring in surgical treatment of sHPT [4,6-10].…”

Section: Introductionmentioning

confidence: 99%

Efficacy of intraoperative parathyroid hormone monitoring to predict success of parathyroidectomy for secondary hyperparathyroidism

2012

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Purpose In secondary hyperparathyroidism (sHPT), it is unclear which criterion for intraoperative parathyroid hormone (ioPTH) decline performs best and whether ioPTH monitoring is sufficiently efficacious in predicting postoperative surgical cure by retrospective review. Methods In 80 parathyroidectomies for sHPT, patients with ioPTH monitoring and follow-up PTH assay were categorized into physiologically accepted and failed groups. Receiver operating characteristic (ROC) curves were used to identify the criterion with the best performance and to determine the regression equation for prediction of surgical success. Results There was a statistically significant difference in the percentage reduction of ioPTHs between the two groups (P < 0.05). With our criterion, cure was predicted with a sensitivity of 86% and specificity that could be improved to 60% using an 85% ioPTH decrease as cut-off level when this value was compared to the Miami Criterion. There was a slightly negative correlation between the natural logarithm of percentage reduction of ioPTH and percentage reduction of PTH at follow-up (R 2 = 0.109, P = 0.003). Conclusion ioPTH measurements are a useful tool for improvement of the cure rate of operations for sHPT. Because this study aimed at 40 minutes (ioPTH3) as an optimal process in the operation, we recommend using a criterion of more than 85% ioPTH decline at 40 minutes by use of the ROC curve, and the use of the presently calculated regression equation may enable prediction of success.

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Usefulness of intraoperative parathyroid hormone measurements in patients with renal hyperparathyroidism

Abstract: Prediction of cure after parathyroidectomy for renal hyperparathyroidism might be improved with a criterion of 70% PTH decrease 10 minutes after excision of all parathyroid glands. Prospective analysis needs to validate this new criterion.

Cited by 17 publications

References 25 publications

Subtotal parathyroidectomy for secondary renal hyperparathyroidism: a 20-year surgical outcome study

Subtotal parathyroidectomy for secondary renal hyperparathyroidism: a 20-year surgical outcome study

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

Efficacy of intraoperative parathyroid hormone monitoring to predict success of parathyroidectomy for secondary hyperparathyroidism

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