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PubMed1993

Double parathyroid adenomas. Clinical and biochemical characteristics before and after parathyroidectomy.

OBJECTIVE: There is considerable debate about whether double parathyroid adenomas are a discrete entity or represent hyperplasia with parathyroid glands of varying sizes. This distinction is important because it impacts on the extent of parathyroid resection and the success of the parathyroid operation. SUMMARY BACKGROUND DATA: Double parathyroid adenomas have been reported to occur in 1.7% to 9% of patients with primary hyperparathyroidism (HPT). It is important for surgeons to differentiate between double adenoma and hyperplasia with glands of varying sizes using gross examination during the initial procedure because microscopic findings of a small biopsy specimen at frozen-section examination may not be diagnostic. METHODS: From 1982 to 1992, 416 unselected patients (309 women and 107 men) with primary HPT without familial HPT or multiple endocrine neoplasia (MEN) were treated by one surgeon at the University of California at San Francisco. Double adenoma occurred in 49 patients, solitary adenoma in 309 patients, and hyperplasia in 58 patients. The authors analyzed the clinical manifestations, the preoperative and postoperative serum levels of calcium, phosphate, and parathyroid hormone (PTH), and the success rate and outcome after parathyroidectomy and compared their results in 49 patients with double adenomas to the results for patients with solitary adenomas or hyperplasia. RESULTS: Ten of the patients with double adenomas (20.4%) were referred for persistent HPT after removal of one abnormal parathyroid gland. The ages of the patients with double adenoma, single adenoma, and hyperplasia were 61 +/- 14, 56 +/- 15, and 58 +/- 7 years, respectively. Fatigue, muscle weakness, and bone pain were common in patients with double adenomas, whereas nephrolithiasis occurred more frequently in patients with solitary adenoma (p = 0.0001). Serum calcium and PTH levels (per cent of upper limit of normal) fell from 11.5 +/- 1.2 mg/dL and 487% to 9.5 +/- 0.8 mg/dL and 61% for patients with double adenomas; from 11.9 +/- 0.9 mg/dL and 378% to 9.3 +/- 1.4 mg/dL and 101% for patients with single adenoma; and from 10.9 +/- 0.5 mg/dL and 418% to 9.1 +/- 0.7 mg/dL and 94% for patients with hyperplasia, respectively. There was no recurrence in the patients with double adenomas with a mean follow-up time of 5.8 years. CONCLUSIONS: Double adenomas are a discrete entity and occur more often in older patients. Patients with double adenomas can be successfully treated by removal of the two abnormal glands.

Adenoma↗

PubMed1986

Total parathyroidectomy and forearm autotransplantation for chronic renal failure: a useful tool for the general surgeon in private practice.

We reviewed 12 cases of chronic renal failure in patients with secondary hyperparathyroidism who had total parathyroidectomy and forearm autotransplantation during the years 1978 to 1984. All had elevated parathyroid hormone and calcium levels before the procedure. Using a technique previously described, with relatively large parathyroid grafts in the forearm, calcium levels were effectively reduced and maintained below the upper limit of the normal range (10.5 mg/dl). Only one patient had symptomatic hypocalcemia postoperatively. Phosphorous levels were also significantly reduced to more physiologic values. When necessary, the forearm autografts allowed simplified titration of calcium levels on an outpatient basis.

Adult↗

PubMed1977

Measurement of whole body calcium in chronic renal failure: effects of 1alpha-hydroxyvitamin D3 and parathyroidectomy.

In vivo neutron activation analysis was used to measure changes in whole body calcium in patients with chronic renal failure. Eight patients, not treated by haemodialysis, showed losses of calcium in contrast to increases noted in twenty-one patients treated by haemodialysis. Changes in whole body calcium were independent of pre-existing renal bone disease. Treatment of bone disease by total parathyroidectomy (six patients) or 1alpha-hydroxyvitamin D3 (eleven patients) resulted in large increases in total body calcium. In patients given 1alpha-hydroxyvitamin D3, changes in total body calcium correlated with histological and radiological indices of response but variable changes in forearm bone mineral content were observed. Neutron activation analysis provides a convenient method for measuring skeletal mass and may also be useful in the assessment of response to 1alpha-hydroxyvitamin D3 of patients with osteitis fibrosa and osteomalacia.

Adult↗

PubMed1983

Changes in cyclic AMP and electrolytes after parathyroidectomy in primary hyperparathyroidism.

Changes in the excretion of urinary cyclic AMP, calcium and phosphate, and serum calcium, ionized calcium, and magnesium were studied after parathyroidectomy for primary hyperparathyroidism. Urinary cyclic AMP decreased rapidly and 8 of 11 patients had a significant reduction 1 h postoperatively, but changes in serum calcium and ionized calcium were delayed. Serum calcium concentrations closely parallelled those of serum ionized calcium and phosphate excretion returned to normal almost 7 h later than that of cyclic AMP. Excretion of urinary calcium rose rapidly at 4 h after surgery because calcium clearance improved after the reduction in circulating parathyroid hormone. The fall in urinary calcium at about 24 h was due to the subsequent reduction in serum calcium.

Calcium↗

PubMed1988

Enhanced calcitonin secretion in the rat after parathyroidectomy and during chronic calcium deprivation.

The thyroidal content of calcitonin (CT) and the serum calcitonin responses to acute hypercalcaemia were studied in female rats during chronic hypocalcaemia induced by parathyroidectomy (PTX), a low calcium (Ca) diet, or both. The thyroidal CT content of the PTX animals 50 days after surgery was twice that of intact rats. An acute intraperitoneal (i.p.) calcium load on day 50 after PTX resulted in an increase in serum CT twice as large as that observed in control animals. Reversal of the chronic hypocalcaemia with 1,25(OH)2D3 resulted in a reduction in thyroidal CT as well as a depression of the calcium-induced CT response. In each case the values were similar to those observed in normocalcaemic controls. A low calcium diet increased the thyroidal CT content in intact rats and induced a further increase in PTX rats. The CT response to an acute Ca load was exaggerated by a low calcium diet in intact as well as in PTX rats. These results suggest that in the rat chronic hypocalcaemia enhances CT storage and secretion.

Animals↗

PubMed1988

Fate of long-term parathyroid autografts in patients with chronic renal failure treated by parathyroidectomy: a histopathological study of autografts, parathyroid glands and bone.

The aims of the study were to (1) determine the histopathology of parathyroid autografts in patients with renal failure treated by parathyroidectomy, (2) relate this to any evidence of hyperfunction, such as histological osteitis fibrosa and (3) determine whether there were any features in the donor parathyroid glands which correlated with autograft behaviour. Fourteen patients were studied; 106 implanted parathyroid fragments were identified in nine at necropsy and in the remaining five patients multiple fragments were obtained at the time of autograft surgical reduction. Of the patients studied at necropsy, in two the autografts were small and hypofunctional and in one of these the implants appeared partially involuted. In neither was there osteitis fibrosa. In the others there were varying degrees of hyperplasia and osteitis fibrosa. Four of the surgically excised autografts were markedly hyperplastic but there was no unequivocal evidence of malignancy. In one case, requiring repeated reduction of rapidly growing autograft tissue, there were frequent mitoses in the donor parathyroid gland and in the autograft. The presence of atypical cellular features and frequent mitoses in intraoperative frozen sections of a parathyroid gland militate against its use for implantation.

Adult↗

PubMed1978

Effect of parathyroidectomy on cardiovascular reactivity in rats with mineralocorticoid-induced hypertension.

Previous work has shown that parathyroidectomy protected Sprague-Dawley rats against mineralocorticoid hypertension. 2 In order to explain this protection, we studied vascular reactivity to noradrenaline and angiotensin II in several groups of rats with and without their parathyroid and thyroid glands. Work was performed in vagotomized, anaesthetized rats after ganglionic blockade with pentolinium, and atropine sulphate. 3 The reactivity to noradrenaline was significantly lower in parathyroidectomized rats, especially at the beginning of mineralocorticoid treatment. 4 Autotransplantation of parathyroid glands in thyroparathyroidectomized rats re-established normal cardiovascular reactivity and development of hypertension. 5 Cardiovascular reactivity to angiotensin II was not affected in parathyroidectomized rats and was lowered in thyroparathyroidectomized thyroxine-treated rats.

Angiotensin II↗

PubMed1976

Chondrocalcinosis after parathyroidectomy.

In this retrospective study of 57 patients with primary hyperparathyroidism who underwent parathyroidectomy, the overall incidence of chondrocalcinosis was 40%. Neither joint symptoms nor chondrocalcinosis regressed after the operation. In several patients the condition appeared to deteriorate both clinically and radiologically after the operation, while in a few both the chondrocalcinosis and the associated symptoms first appeared some time after the operation.

Aged↗

PubMed1982

Hypophosphataemia after parathyroidectomy in chronic renal failure.

Out of 24 patients receiving haemodialysis who were subjected to parathyroidectomy, 13 developed hypophosphataemia; this persisted for 3-52 weeks (mean 10.6 weeks). Before operation these 13 patients had had significantly higher plasma alkaline phosphatase activities (p less than 0.01) and significantly higher values in iliac crest bone biopsy samples for active resorption surface and active formation surface (p less than 0.05 in each case) than the group who remained normophosphataemic. Significantly more of the patients who remained normophosphataemic had shown periarticular calcification in preoperative skeletal radiographs (p less than 0.001). Hypophosphataemia may result from reduced mobilisation of phosphate from bone or its increased accretion into bone, and resorption of phosphate from periarticular mineral deposits may protect against development.

Adult↗

PubMed1981

Improvement in renal function in primary hyperparathyroidism following parathyroidectomy.

Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were measured pre- and post-parathyroidectomy in 9 patients with primary hyperparathyroidism. Radiological studies had shown no sign of renal calculi or nephrocalcinosis in these patients. Before operation, GFR ranged from 98.5 to 23.4 ml/min/1.7 m2 and ERPF ranged from 510 to 127 ml/min/1.7 m2. After operation, GFR rose to a range of 108.8 to 48.7 ml/min/1.7 m2, and ERPF ranged from 556 to 189 ml/min/1.7 m2. The results suggest that early diagnosis and surgery are important, both to prevent progressive renal damage and to improve the possibility of recovery where functional damage has occurred.

Adolescent↗

PubMed1987

Effect of parathyroidectomy on respiratory muscle strength in uremic myopathy.

We report the case of a uremic dialysis patient with severe secondary hyperparathyroidism, proximal muscle weakness and impaired respiratory muscle strength, the latter being assessed by maximal inspiratory pressure. After subtotal parathyroidectomy, we observed a marked improvement in respiratory muscle strength (27 vs. 87 cm H2O) and disappearance of proximal muscle weakness.

Adult↗

PubMed1989

Effect of parathyroidectomy on T cell functions in patients with primary hyperparathyroidism.

The notion that parathyroid hormone (PTH) can serve as an immunomodulator was examined. T cell function tests were performed in 3 patients with primary hyperparathyroidism before and 1 month after parathyroidectomy (PTX). Three normal volunteers, age and sex matched, were used as controls. One patient with lipoma of the neck was also examined before and after surgical removal of the lesion. In the primary hyperparathyroidism patients the total T cells were lower, the suppressors were higher and the helper to suppressor ratio was significantly lower than in control subjects. The lectin-stimulated lymphocyte transformation was significantly inhibited. All these abnormalities were restored to normal after PTX. Depressed lymphocyte activity was found also in the patient with lipoma. However, no change occurred after surgery. These results support the assumption that excess blood levels of PTH may have an immunosuppressive effect.

Adjuvants, Immunologic↗

PubMed1989

Diagnostic dilemma of an unsuspected hyperfunctioning accessory parathyroid gland after total parathyroidectomy with autotransplantation in a peritoneal dialysis patient.

Persistent or recurrent hyperparathyroidism in patients with chronic renal failure may be a frustrating problem. We report a case history of a peritoneal dialysis patient who underwent total parathyroidectomy with autotransplantation for secondary hyperparathyroidism, developed tertiary hyperparathyroidism, and in an attempt to control hypercalcemia underwent seven partial resections of the autotransplant. Subsequently, a total excision of the parathyroid autograft was performed, but the patient continued to have hyperparathyroidism and unexpectedly was found to have a hyperplastic fifth parathyroid gland identified by thallium-technetium subtraction scan. The fifth gland was removed, and a part was implanted in the right forearm; however, the autoimplant had to be completely removed because of rapidly developing hypercalcemia. Hypercalcemia was controlled, but elevated levels of parathormone persisted. Remaining parathyroid tissue could not be found.

Female↗

PubMed1977

Effect of subtotal parathyroidectomy on dialysis dementia.

A case of dialysis dementia syndrome is reported which apparently responded to parathyroidectomy. Serial electroencephalograms reflected the changing clinical condition of the patient. Her brain calcium level was elevated which may inplicate secondary hyperparathyroidism as a cause of this neurologic syndrome. Further studies are indicated to elucidate the relationship of this disorder to parathormone excess.

Dementia↗

PubMed1983

Parathyroidectomy in chronic renal failure.

Parathyroidectomy was carried out in 26 patients over a 14-year period. Excellent results were obtained in patients with severe hyperparathyroidism. Vascular calcification, hypercalcaemia and pruritus did not justify surgery unless associated with unequivocal hyperparathyroidism. 13 patients required intravenous calcium infusion for up to 2 weeks to control post-operative hypocalcaemia. Calcium requirements could be predicted from the pre-operative plasma alkaline phosphatase level. Following operation continued treatment with vitamin D was necessary to prevent hypocalcaemia. Hyperparathyroidism recurred in 1 patient after 8 years and 4 patients developed osteomalacia. Since parathyroid hormone may have toxic effects other than those on bone, maintenance of normal levels should be a long-term objective in the treatment of patients with chronic renal failure. Where large parathyroid glands are present, surgical reduction in gland mass is a logical prelude to long-term suppression of parathyroid hormone with vitamin D and phosphate-binding agents.

Adolescent↗

PubMed1987

Effects of parathyroidectomy on blood pressure in spontaneously hypertensive rats.

The long-term effects of parathyroidectomy (PTX) on blood pressure, intravascular volume, pressor hormones, and on acute vascular effects of intravenous parathyroid hormone (PTH) were evaluated in spontaneously hypertensive (SH) and normotensive Wistar-Kyoto (WK) rats. PTX or sham operation (CO) were done at 4-5 weeks of age, and a high calcium diet was offered to PTX rats to study them at eucalcemic calcium levels. The cardiovascular effects of PTX, determined after 11-13 weeks, were qualitatively similar in SH and WK rats: mean arterial blood pressure (conscious unrestrained rats) was lower, intravascular volume was higher, total body sodium was slightly higher, and plasma angiotensin II or norepinephrine levels were not different from CO groups. The acute hypotensive and chronotrophic effect of intravenous PTH was unchanged in PTX groups. When parathyroid intact SH rats and PTX SH rats were both examined on an 1.6% Ca diet, blood pressure was significantly lower in PTX than in parathyroid-intact SH rats. The results are compatible with the hypothesis that PTH has a permissive action on blood pressure maintenance in eucalcemic SH and WK rats by mechanisms unrelated to volume status or circulating pressor hormone concentrations.

Animals↗

PubMed1977

Parathyroidectomy reduces 25-hydroxyvitamin D3-1 alpha-hydroxylase activity in the hypocalcemic vitamin D-deficient chick.

To test the hypothesis that in the vitamin D-deficient state the activity of 25-hydroxyvitamin D3-1 alpha-hydroxylase (25-OHD3-1 alpha-hydroxylase) is modulated by parathyroid hormone and the plasma concentration of phosphate only in the presence of small amounts of 1,25-dihydroxyvitamin D3 (or some other metabolite of vitamin D), we measured the activity of this enzyme 24 h after parathyroidectomy (PTX) in frankly hypocalcemic, vitamin D-deficient chicks that were not supplemented with vitamin D or one of its metabolites. The otherwise predictable complications of PTX in this metabolic setting (hypocalcemia of increasing severity, tetany, moribundity, and death) were prevented by continuous intravenous administration of calcium (as a solution of calcium chloride/calcium gluconate 1:1) through a catheter in the external jugular vein placed at the time of PTX. The findings were as follows: (a) The activity of 25-OHD3-1 alpha-hydroxylase was significantly less in the parathyroidectomized group than in the sham-operated control chicks (P less than 0.001). (b) The reductive effect of PTX on the activity of this enzyme was significantly attenuated when hypophosphatemia was increased in severity by administration of glucose. (c) In the post-PTX state the activity of 25-OHD3-1 alpha-hydroxylase and plasma concentration of phosphate were significantly, inversely related (P less than 0.001). (d) In the sham-operated control group the activity of this enzyme and the plasma concentration of phosphate were not significantly correlated. These findings indicate that in the vitamin D-deficient state, both circulating parathyroid hormone and the plasma concentration of phosphate can significantly modulate the activity of 25-OHD3-1 alpha-hydroxylase in the absence of vitamin D or its metabolites. The findings also suggest that in the vitamin D-deficient state the plasma concentration of phosphate modulates the activity of this enzyme only when the concentration of circulating parathyroid hormone is not increased.

25-Hydroxyvitamin D3 1-alpha-Hydroxylase↗

PubMed1981

Effect of thyroparathyroidectomy and parathyroidectomy on renal function and the nephrotic syndrome in rat nephrotoxic serum nephritis.

Dietary phosphorus restriction (PR) prevents uremia in rats with nephrotoxic serum nephritis (NSN). One possible mechanism by which PR could be protective would be through the suppression of parathyroid hormone. To evaluate this possibility two separate protocols were designed. In the first rats were thyroparathyroidectomized (TPTX) before (n = 11) or 5 wk after (n = 7) NSN induction and compared to sham-operated parathyroid intact rats with NSN (n = 12). At the end of the 23-wk study, intact rats were azotemic, plasma creatinine 3.80+/-0.81 mg/100 ml vs. 0.65+/-0.07 for TPTX rats (P < 0.001). During the study 75% of intact rats died of uremia in contrast to none of the TPTX rats (P < 0.001). Renal histological damage was greatly diminished and calcification prevented in TPTX rats. The proteinuria of the heterologous phase was unaffected, but the protein excretion and hypertriglyceridemia (HTG) of the autologous phase were markedly decreased in the TPTX rats. The degree of HTG and proteinuria had a high positive correlation (P < 0.001). Late TPTX also produced significant decreases in proteinuria and HTG regardless of the degree of azotemia, and prevented azotemia if the plasma creatinine at the time of TPTX was </=0.85 mg/100 ml. In additional studies selective parathyroidectomy (PTX) was performed. The adequacy of this procedure was documented by showing a similar fall in plasma Ca and urinary cyclic AMP in PTX animals as found in TPTX animals. However, selective PTX had no effect on proteinuria, histologic damage, or functional deterioration. These studies further showed that early, histologic damage and functional deterioration preceeded renal parenchymal calcification. Because animals were pair fed and both groups were given 1,25-dihydroxycholecalciferol to normalize serum Ca and P levels these studies exclude alterations in plasma Ca and P levels, dietary intake, urinary P excretion, and vitamin D administration in promoting the protective effect of TPTX on renal function. We conclude that TPTX is equally effective in preventing functional deterioration and more effective in reducing proteinuria in NSN than PR. The mechanism of this protective effect remains to be elucidated, since it does not primarily involve either the elimination of parathyroid hormone or the prevention of renal parenchymal calcification.

Animals↗