Parathyroidectomy in-esrd-menya

1. Parathyroidectomy in ESRD
A single Center Experience
Dr. Osama El-Shahat
Consultant Nephrologist
Head of Nephrology Department
New Mansoura General Hospital (international)
ISN Educational Ambassador

2. • iPTH: 1775 pg/ml.
• S.Ca: 10.7 mg/ dl.
• S. po4: 7.1 mg/dl.
• iPTH: 1600 pg/ml.
• S.Ca: 8.9 mg/ dl.
• S. po4: 4.6 mg/dl.
Medical ttt
• Alfacalcidol
• Cinacalcet
 62 year old female patient, HTN, ESRD on HD 4 years ago.
 C/O: Generalized bone aches 6 months ago.
Case

4. So medical treatment alone
may be ineffective.
15.1 Parathyroidectomy should be considered in patients with severe
hyperparathyroidism (persistent serum levels of PTH >1,000 pg/mL [110
pmol/L]), and disabling bone deformities associated with hypercalcemia and/or
hyperphosphatemia that are refractory to medical therapy. (OPINION)
15.2 Effective surgical therapy of severe hyperparathyroidism can be accomplished
by subtotal parathyroidectomy OR total parathyroidectomy with parathyroid
tissue autotransplantation. (EVIDENCE)

5. Subtotal
OR
Total with
autotransplantation

6. Case
 48 year old male patient, HTN, DM, ESRD on HD 4 years ago.
 C/O: Difficulty in walking 2 years ago.
• iPTH: 2400 pg/ml.
• US: 2 hypoechoic masses ??
Parathyroid adenoma
• SEASTAMIBI Scan: Adenoma
of lower Lt. parathyroid gland.
• Persistent elevation of iPTH.
• SEASTAMIBI Scan (after 7m):
Negative( successful excision of
previous adenoma) .
?? Parathyroid hyperplasia
2nd parathyroidectomy
For upper& lower Rt. parathyroid
Normal parathyroid tissue
SEASTAMIBI Scan (after 2m):
Lt inferior paratyroid gland close to
sternoclavicular region
Lower
Lt. parathyroid
adenoma
excision
iPTH
2030 pg/ml
Referred to us for 3rd operation
Rt. vocal cord fixation

7. Cost of Treatment
30 mg, net price 28-tab pack
= £ 125.75
= 2892 Egyptian
Pounds/month

9.  We started our project in 2013 in cooperation with
Sheffield Kidney Institute, University of Sheffield.
 We established a tertiary referral center in Egypt to
treat this disease and also train surgeons to
perform this operation safely and effectively.
Introduction

10. 1st parathyroidectomy
“hands on” course Feb.2013

11. 2nd parathyroidectomy
“hands on” course Oct. 2014

12. 2nd
Conference

14. 3rd parathyroidectomy
“hands on” course Oct. 2015

15. 3rd
Conference

16. 4th parathyroidectomy
“hands on” course Oct. 2016

17. 4th
Conference

19. New Mansoura General Hospital
team

20. Aim of the work
To present our experience in management of
secondary hyperparathyroidism in
hemodialysis patients.

21. Parathyroidectomy
Sheffield Teaching Hospital data file
Cost of parathyroidectomy

22.  A retrospective review of 100 cases underwent total parathyroidectomy,
thymectomy and auto-transplantation, performed over four years period.
 iPTH level of 1000 pg/ml and above with persistent hypercalcemia or
hyperphosphatemia.
 Symptoms of CKD-MBD.
 Not responding to medical treatment.
 No pre-operative imaging was required except in redo cases due to the
known lack of sensitivity and specificity in a multi-gland disease.
Patient selection
Subjects & Methods

23.  In the 72 hours prior to theatre, the patients received a loading
dose of alpha Calcidol (2 to 3 µg daily) .
 Three/four glands excision was performed.
 Tiny portions of a relatively healthy gland (equivalent to the size of a
normal gland) were auto-transplanted into the sternomastoid muscle
pouches if 4 or more glands were found.
 Serum calcium checked on return from theatre and every 6 hours
thereafter until stable, if necessary calcium was infused intravenously.
Patient preparation
Subjects & Methods

24. Results
Male Female Total
Count 61 39 100
Age (y) 42.05 41.69 41.91
Duration of HD(y) 7.63 7.06 7.42
61%
39%
Male
Femal

25. PTH
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Pre-op Post-op
1972.5
40.68
Pre-op
Post-op

26. S. Ca
9
9.05
9.1
9.15
9.2
9.25
9.3
Pre-op Post-op
9.38
9.32
Pre-op
Post-op

27. S. Po4
0
1
2
3
4
5
6
Pre-op Post-op
5.93
4.76
Pre-op
Post-op

28. Post operative S. Ca
9.32
9.06
9.26
9.30
9.13
8.85
8.9
8.95
9
9.05
9.1
9.15
9.2
9.25
9.3
9.35
1 2 3 4 5

29. 80%
(21.26)
10%
(208.22)
10%
(890.56)
less than 100
100-400
more than 400
Post operative iPTH
follow up
1st week

30. Post operative iPTH
follow up
75%
(18.7)
15.4%
(164.11)
9.6%
(951.61)
less than 100
100-400
more than 400
1 Month

31. Post operative iPTH
follow up
66.6%
(31.89)
27.7%
(151.03)
5.7%
(1122.64)
less than 100
100-400
more than 400
6 Months

32. 50%
(40.47)
33.30%
(225.44)
16.70%
(966.47)
less than 100
100-400
more than 400
Post operative iPTH
follow up
1 Year

33. Post operative iPTH
follow up
21.26 18.7 31.89
40.47
208.22 164.11 151.03 225.44
890.56
951.61
1122.64 966.47
0
200
400
600
800
1000
1200
1400
1 Weak 1 Month 6 Months 1 Year
more than
400
100 - 400

34. Complications
 8 patients had persistent hyperparathyroidism (8%).
 2 patient had recurrence of Hyperparathyroidism one year
after potential curative surgery (2%). .
 3 patients have symptomatic hypocalcaemia requiring hospital
admission (3%).
 A single case of reversible voice change, but no nerve injury .
 5 cases of thrombophlebitis related to calcium infusion (5%).

35. 5 cases ( 5% )had papillary thyroid cancer
accidently discovered treated by total
thyroidectomy
Unexpected Event

36. Conclusion
 Surgical management of 2ry HPT is safe and
effective at correcting bone mineralization and
metabolic disturbances.
 Preoperative localization is not essential
except in redo cases.
 Cinacalcet is unaffordable

37. 28 patients had curative surgery with the mean postoperative
PTH 95.9 pg/ml. Two patients had persistent
hyperparathyroidism where one or 2 glands were not found in
the neck. One patient had recurrence , No surgical
complications were reported.

41. Minya parathyroidectomy
“hands on” course Jan. 2018