the 2nd Annual Nephrology Meeting, CKD-MBD, NMGH, 28.10.2014

2. Ahmed Halawa
MSc PGCE FRCS MD FRCS(Gen)
Consultant Surgeon
Sheffield Teaching Hospitals
Senior Lecturer
University of Sheffield
University of Liverpool

3. Failed medical treatment to control the
hyperparathyroidism in a well dialysed
patient indicated by:
High PTH
High Ca with normal PTH.
Hyperphosphataemia.
Vit D level 25(OH)D is >50 nmol/l (20
ng/ml).

5.  3 glands 3%
 4 glands 84%
 5 or more 13%
 Superior glands are posterior to the nerve
(more consistent)
 Inferior glands are anterior to the nerve
(less consistent)

7.  PTH
Due to bone resistance, level above 3-5 times
the absolute value is considered abnormal
 Ca (Normal or high)
 Hyperphosphataemia
 Vit D level
 No radiological investigations are required

8.  High-resolution ultrasound
Sensitivity 6655--8855%% for adenoma; 3300--9900%% for enlarged gland
Results suboptimal in pts with multinodular thyroid disease, pts with
short thick neck, ectopic glands ((1155--2200%%))
May be useful in detecting Sestamibi scan negative adenomas
 CT with contrast/thin section
Sensitivity of 4466--8877%%
Good for ectopic glands in the chest
 MRI
Sensitivity of 6655--8800%%
Good for ectopic glands
 Sestamibi
8855--9955%% accurate in localizing adenoma in primary HPT
 Sestamibi-SPECT
Sensitivity 6600%% for enlarged gland and 9988%% for solitary adenomas

9. Only Required for Redo
Parathyroidectomy

13. TTcc--SSeessttaammiibbii
SSeennssiittiivviittyy MMeettaa--aannaallyyssiiss
SSeennssiittiivviittyy ((%%)) 9955%% CCII
SSoolliittaarryy
aaddeennoommaa
8888..44 8877 -- 8899
HHyyppeerrppllaassiiaa 4444..44 4411 -- 4488
DDoouubbllee
3300 --22 -- 6622
aaddeennoommaa
CCaarrcciinnoommaa 3333 3333
Johnson N, AJR Am J Roentgenol. 2007 Jun;188(6):1706-15.

14. 67-year-old woman with hyperparathyroidism and left
tracheoesophageal groove adenoma that could easily be
mistaken for posterior thyroid nodule.

15. TTcc--SSeessttaammiibbii
SSeennssiittiivviittyy MMeettaa--aannaallyyssiiss
LEFT- 99mTc-sestamibi SPECT image shows physiologic uptake in salivary glands and thyroid
gland, with focus of more intense uptake overlying superior pole of right thyroid lobe (arrow).
RIGHT-52-year-old woman with hyperparathyroidism and right superior parathyroid adenoma.
Two-hour delayed SPECT image shows radiotracer retention in adenoma (arrow) but clearing
of tracer from overlying thyroid.

16. 40-year-old woman who presented with recurrent
hypercalcaemia and hyperparathyroidism after
resection of both left-sided glands.

17. 39-year-old woman with left superior adenoma
showing typical MRI signal characteristics .

18. No place for a “Cowboy Surgeon”

20.  Previous dialysis line generates fibrosis (damage)
 Vascular calcification (bleeding)
 Engorged neck veins (bleeding)
 Anticoagulation on dialysis (bleeding)
 Anaemia and platelet abnormality (bleeding)
 The glands are closely related to RLN (damage)
 Inconstancy of the inferior glands (recurrence)
 Supernumerary gland(s) (recurrence)
 Thymectomy (bleeding into the chest)

21.  Only 5-10% will come to
surgery
 Bilateral Neck Exploration
If 4 glands found, minimum 3 ½ glands
removed and thymectomy

22.  Total parathyroidectomy
 Thymectomy
 No auto-transplantation

23.  Total parathyroidectomy
 Thymectomy
 No auto-transplantation?

24.  Undescended thymus is associated with
undescended inferior para thyroid gland
 The inferior parathyroid glands may be higher
that the superior glands, but stays anterior to
the RLN

25. Fat

26.  PTH should be >100 pm/ml to prevent the disease,
but no guarantee
 Reduced osteoblasts and osteoclasts, no
accumulation of osteoid and markedly low bone
turnover
 Induced by overtreatment of secondary
hyperparathyroidism and not a disease
 Fractures

27.  No adequately powered RCT
 Recurrence
 Adynamic bone disease (ABD)

28.  Develops from third pharyngeal pouch like the
inferior parathyroid
 Has some parathyroid rests that become active
by persistent stimulation (CKD), they may
develop into a full gland.