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PubMed1996

Blood pressure reduction after parathyroidectomy for secondary hyperparathyroidism: further evidence implicating calcium homeostasis in blood pressure regulation.

A link between plasma calcium, dietary cations, and blood pressure has been suspected for some time, with human, experimental animal, and epidemiological data adduced to support this hypothesis. We identified 21 patients receiving regular maintenance hemodialysis, but not receiving any regular antihypertensive treatment, who had undergone 22 surgical removals of the parathyroid glands in the period 1978 to 1992. These patients' records were then scrutinized. The group preparathyroidectomy mean systolic blood pressure (BP) was 142.6 +/- 19.4 mm Hg. After the operation, the mean systolic BP was 133.6 +/- 21.9 mm Hg (P = 0.004). Plasma calcium decreased from 2.72 +/- 0.18 mmol/L to 2.52 +/- 0.19 mmol/L (P < 0.001). There was a correlation between the decreases in systolic blood pressure (SBP) (9.4%) and plasma calcium (7.3%); r = 0.60, P = 0.012. The decrease in SBP was not immediate, but delayed some months and complete by approximately 9 months after the operation. Furthermore, using ambulatory BP monitoring in a group of long-term hemodialysis patients, we found that parathyroidectomized patients had lower BP and pulse rates than those with intact parathyroid glands (SBP, 122.9 +/- 16.3 mm Hg v 102.9 +/- 9.9 mm Hg; pulse rates, 87.5 +/- 12.7 v 72.0 +/- 7.5 beats/min, P < .001, nonparathyroidectomy v postparathyroidectomy, both comparisons). These data support a link between plasma calcium and BP in patients receiving maintenance hemodialysis.

Adult↗
PubMed2000

Parathyroidectomy at ito hospital: a review of a thyroid clinic in Japan.

We primarily describe surgical methods and short-stay surgery, which has been recently attracting interest in Japan, in relation to the diagnosis and treatment of parathyroid disease at a special hospital for thyroid diseases. There is a controversy in regard to surgical methods for primary hyperparathyroidism (PHPT), whether it is sufficient to examine only one side or all four glands should be checked. At our hospital, we selected one of the following three different approaches depending on the case: where the lesion was excised after checking all four glands on both sides (Method A), where the lesion was excised after checking two glands by examining one side (Method B), and where the lesion of one gland was directly excised (Method C). A review of the initial operations for 185 cases of PHPT treated at our hospital over 18 years revealed that the patients who underwent Methods B and C under local anesthesia had developed no complications and their long-term postoperative outcome was also favorable. In the future we also intend to adopt the unilateral approach aggressively under local anesthesia and perform short-stay surgery in cases which pathological parathyroid glands have been discovered by preoperative localization.

Adult↗
PubMed2003

Differing histologic findings after bilateral and focused parathyroidectomy.

BACKGROUND: Minimally invasive parathyroid surgery with intraoperative parathyroid hormone testing has been reported to be as successful as a bilateral operation. This study aimed to determine whether the histologic findings and outcomes differ in patients with primary sporadic hyperparathyroidism treated by a focal or a bilateral parathyroid exploration with intraoperative parathyroid hormone testing. To make the two groups comparable all patients had a solitary parathyroid adenoma identified preoperatively. STUDY DESIGN: Eighty unselected patients with primary hyperparathyroidism and a single abnormal parathyroid gland identified preoperatively by sestamibi scanning or ultrasonography were included in this study. All patients had intraoperative parathyroid hormone testing. RESULTS: Forty-five patients had standard bilateral neck explorations and 35 patients had focal neck explorations. In the bilateral neck exploration group a single adenoma was found in 38 patients (84%), a double adenoma in 3 patients (7%), hyperplasia in 3 patients (7%), and carcinoma in 1 patient (2%). In contrast, a single adenoma was identified in all patients in the focal neck exploration group. Sestamibi scanning and intraoperative parathyroid hormone assay were accurate in 87% and 84%, respectively, in the bilateral neck exploration group and in 96.9% and 94.3%, respectively, in the focal neck exploration group. All patients were normocalcemic (mean followup 17 months). CONCLUSIONS: Patients with primary hyperparathyroidism having a bilateral exploration had about a 15% higher rate of multiple parathyroid tumors than did patient having a focal approach. Despite this observation all patients were normocalcemic postoperatively. This suggests that either some histologically abnormal parathyroid glands do not function or there will be recurrences in patients treated by a focused approach. Longterm followup will be necessary to determine whether patients treated by focal neck exploration will develop recurrent primary hyperparathyroidism.

Adenoma↗
PubMed1999

Primary hyperparathyroidism: effect of parathyroidectomy on regional bone mineral density in Danish patients: a three-year follow-up study.

Changes in skeletal remodeling (biochemical bone markers) and regional bone mineral density (spine, hip, and forearm bone mineral density [BMD]) were observed for 3 years in 20 patients (15 women and 5 men; age 54 +/- 11 years, range 29-69 years) after successful surgery for primary hyperparathyroidism (PHPT). Fifteen PHPT patients were compared with 15 normal controls who were exactly matched with respect to age, gender, and menopausal status (10 women and 5 men; age 53 +/- 12 years, range 29-65 years [PHPT] and 29-66 years [controls]). All bone markers (serum osteocalcin, bone alkaline phosphatase, and type I collagen telopeptide [ICTP], and urinary hydroxyproline and NTx/creatinine ratio) declined significantly and reached normal levels within 6 months. No major changes took place during the remaining 2.5 years, apart from urine hydroxyproline, which disclosed a small peak around 12 months with a further decline towards study end (p < 0.05). Bone mineral density increased significantly in all regions (p < 0.001). At all locations, except the intertrochanteric region of the hip, the increase continued from 6 months until study end (p < 0.05). The increase in BMD was unequally distributed among regions (p < 0.001). The increase at the proximal forearm was less than in the spine (p < 0.05), the trochanteric region of the hip (p < 0.05), and the distal forearm (p < 0.05). No difference in BMD increase was observed between men, and pre- and postmenopausal women. Compared with the matched control group, PHPT patients had significantly lower BMD at baseline in the proximal (p < 0.02) and distal (p < 0.05) forearm. Furthermore, during the 3-year follow-up period, the PHPT patients showed a significant increase in BMD compared with controls in the spine (p < 0.005), the trochanteric and intertrochanteric regions of the hip (p < 0.005 and p < 0.05, respectively), and the distal forearm (p < 0.005). In conclusion, bone remodeling is normalized within the first 6 months after successful parathyroid surgery, with no major changes during the following 2.5 years. Bone mineral density increases at both cancellous and cortical sites, but in predominantly cortical bone, the recovery in BMD is less than in cancellous bone-rich areas.

Adenoma↗
PubMed1990

Somatosensory evoked potentials in acute renal failure: effect of parathyroidectomy.

Effects of acute renal failure (ARF) on somatosensory evoked potentials (SEP) were studied in rats. Cervical and cortical SEPs were measured both before and after bilateral ureteral ligation. A significant augmentation of amplitudes and an increase in latencies of the cortical SEP were observed in ARF. The peripheral nerve conduction velocities were unchanged. Serum parathyroid hormone (PTH) levels in uremic rats were significantly elevated after the bilateral ureteral ligation. In previously parathyroidectomized rats, the bilateral ureteral ligation had no effects on amplitudes of SEP or serum PTH levels.

Acute Kidney Injury↗
PubMed1991

Calcemic response to parathyroid hormone in renal failure: role of calcitriol and the effect of parathyroidectomy.

Hyperparathyroidism due to renal failure begins in the early stages of renal insufficiency and is in part secondary to skeletal resistance to the calcemic action of parathyroid hormone (PTH). Factors which have been reported to reduce the calcemic response to PTH include: decreased calcitriol levels, hyperphosphatemia and down regulation of PTH receptors in bone. While hyperphosphatemia may directly decrease the calcemic response to PTH, it may also act indirectly by a suppression of calcitriol synthesis. In this study, the effect of calcitriol on the calcemic response to PTH was evaluated in normal rats and in rats with moderate and advanced renal failure. To determine the combined effect of calcitriol and phosphorus on the calcemic response to PTH, rats receiving calcitriol were fed either a high (1.0%) or low (0.2%) phosphorus diet during a 48-hour PTH infusion. In advanced renal failure, calcitriol administration increased the calcemic response to PTH independent of the dietary phosphorus intake. During ingestion of a low phosphorus diet, a 48 hour PTH infusion resulted in a serum calcium level of 13.7 +/- 0.5 and 12.1 +/- 0.2 mg/dl (P less than 0.02) with and without calcitriol administration, respectively. In normal rats and in rats with moderate renal failure, calcitriol administration improved the calcemic response only during a high phosphorus intake. After a 48-hour PTH infusion in normal rats, the serum calcium levels with and without calcitriol were 16.1 +/- 0.9 and 14.8 +/- 0.6 mg/dl, P less than 0.01 respectively; in rats with moderate renal failure, calcitriol administration increased serum calcium, 13.2 +/- 0.5 versus 11.2 +/- 0.4 mg/dl, P less than 0.01.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1995

Parathyroidectomy does not prevent the renal PTH/PTHrP receptor down-regulation in uremic rats.

In a recent study we demonstrated that the PTH/PTHrP receptor (PTH-R) mRNA was markedly down-regulated in the remnant kidney of uremic rats with severe secondary hyperparathyroidism. Among the factors potentially implicated in this down-regulation, to date only PTH has been demonstrated to modulate PTH-R expression. Here, we examined the effect of thyroparathyroidectomy (TPTX) on the renal expression of PTH-R in rats with normal renal function or with chronic renal failure (CRF) induced by 5/6 nephrectomy. Four groups of rats were studied: control, TPTX, CRF, and CRF + TPTX. Moderate-degree renal failure was documented by mean (+/- SD) creatinine clearances (microliter/min/100 g body wt) of 259 +/- 40 and 212 +/- 45 in CRF and CRF + TPTX rats, compared with 646 +/- 123 and 511 +/- 156 in control and TPTX rats, respectively. Plasma phosphorus, calcitriol, and ionized calcium were significantly lower in CRF and CRF + TPTX than in control animals. Plasma ionized calcium and calcitriol were also lower in TPTX than in control rats. Plasma PTH levels (pg/ml) were increased in CRF rats (41.8 +/- 29.4), and markedly decreased in TPTX (10.1 +/- 7.8) and CRF + TPTX (8.0 +/- 3.8) rats compared with control rats (21.7 +/- 7.5). Northern blot analysis showed that the level of the steady-state PTH-R mRNA in the kidney of CRF and CRF + TPTX rats was markedly decreased compared with that of control rats, the ratios of PTH-R mRNA/beta-actin mRNA being 0.28 +/- 0.04 and 0.27 +/- 0.03 versus 0.54 +/- 0.05, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenylyl Cyclases↗
PubMed2003

Forearm bone density in primary hyperparathyroidism: long-term follow-up with and without parathyroidectomy.

OBJECTIVE: The long-term effects of primary hyperparathyroidism (PHPT), whether treated or untreated, on cortical bone are unclear, but the balance of evidence suggests that fracture risk is modestly increased in this patient group. We therefore compared changes in forearm cortical bone mineral density (BMD), at the site most relevant for PTH-mediated bone loss, in two groups of patients with PHPT; one with and one without surgery. DESIGN AND PATIENTS: We followed the course of forearm bone mineral/bone width (BM/BW, g/cm2) measured by single-energy photon absorptiometry at the standard proximal site, and Z-scores (deviations from the mean value expected for age, sex and race, calculated from a large local reference population) in 108 patients who underwent successful surgery (mean duration 47 months, range 12-120 months) and 108 who remained unoperated (mean duration 52 months, range 12-132 months). Criteria for recommending surgery had been formulated in 1975 and were generally similar to those of the NIH consensus conference published in 1991. At the time of diagnosis the Z-score was significantly reduced in both groups, indicating an earlier period of accelerated cortical bone loss. RESULTS: In the entire operated population there was no difference between the initial and final BM/BW. As the age-expected mean value declined, the Z-score became significantly less negative, and if the rate of change remained constant the values would have reached zero, indicating recovery of all bone lost as a result of the disease, after about 20 years. In the unoperated patients BM/BW fell significantly but there was no change in Z-score, indicating that the rate of bone loss was the same as expected for normal ageing. CONCLUSIONS: It is reasonable to assume that cessation of further bone loss consequent on successful parathyroid surgery would eventually lead to abatement of the excess fracture risk, but the benefit to individual patients will depend mainly on their remaining life expectancy.

Adult↗
PubMed2003

Minimally invasive parathyroidectomy for recurrent or persistent hyperparathyroidism using carbon track localization.

BACKGROUND: The present study documents the use of carbon tracking to localize parathyroid adenomas in three patients with persistent or recurrent parathyroid disease. METHODS: Three patients requiring second or third operations for hyperparathyroidism were operated upon after the parathyroid lesion had been localized preoperatively using a suspension of carbon particles in water. The enlarged parathyroid glands were identified by using one or more of the following: computed axial tomography, magnetic resonance imaging, ultrasound or Sestamibi nuclear scan. The lesion was then localized with ultrasound or computed axial tomography and a carbon track was inserted from the lesion to the skin, leaving a small skin tattoo as a marker for the surgeon. Each patient underwent a minimally invasive parathyroid operation. RESULTS: For each of the three patients the recurrent or persistent parathyroid adenoma was successfully identified and removed via a small incision. CONCLUSION: Minimally invasive techniques for primary hyperparathyroidism are changing our approach to parathyroid surgery. However, a minimally invasive technique is less applicable when the disease is persistent or recurrent. Although, when the recurrent or persistent parathyroid adenoma can be identified, localization and carbon tracking have proved useful in allowing the surgeon to remove the lesion via a minimally invasive technique.

Adolescent↗