0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Image of the Month—Diagnosis FREE

Arch Surg. 2011;146(7):880. doi:10.1001/archsurg.2011.158-b.
Text Size: A A A
Published online

ANSWER: TERTIARY HYPERPARATHYROIDISM AFTER PARATHYROIDECTOMY WITH AUTOTRANSPLANTATION

In patients with chronic renal failure, secondary hyperparathyroidism is a common sequela, ultimately necessitating parathyroidectomy in 38% of patients within 20 years owing to medically refractory hyperparathyroidism.1,2 Impaired glomerular filtration leads to decreased circulating 1,25-dihydroxycholecalciferol (calcitriol; active vitamin D), increased serum phosphate, and prolonged half-life of parathyroid hormone.3 Together, these factors lead to hyperparathyroidism and hypocalcemia. Eventually, long-standing hyperparathyroidism can progress to tertiary hyperparathyroidism, a state of autonomous parathyroid function that is not suppressed after renal function is restored, as indicated by hypercalcemia and hyperparathormonemia. This phenomenon results from downregulation of calcium-sensing receptors on the chief cells within the parathyroid glands.4 This is most commonly seen in patients with renal failure after undergoing renal transplant.

In recent decades, the percentage of patients with chronic renal failure requiring parathyroidectomy has declined as medical management has improved.5 Medical management of secondary hyperparathyroidism includes dietary phosphorus restriction, phosphorus-binding medications, calcitriol, and calcimimetics (cinacalcet). However, secondary hyperparathyroidism sometimes persists despite these interventions. Indications for surgery include failure of medical management, calciphylaxis, parathyroid hormone level greater than 800 pg/mL, hyperphosphatemia, hypercalcemia, hypercalciuria, osteoporosis, and significant symptoms such as pruritus, pathologic bone fracture, and bone pain.6 Demeure et al7 have argued that patients with secondary hyperparathyroidism are more likely to benefit from parathyroid surgery when they have bone pain, malaise, pruritus, calciphylaxis, or if parathyroid hormone levels are highly elevated (greater than 10 times the reference value). The options for parathyroidectomy in these patients include subtotal (3.5 gland) parathyroidectomy and total (4 gland) parathyroidectomy with autotransplantation. Parathyroid tissue can also be cryopreserved at the time of surgery and autotransplanted later if needed.

The mainstay of treatment for tertiary hyperparathyroidism is surgery.7 Because most patients have developed 4-gland hyperplasia, total parathyroidectomy is generally performed, with autotransplantation of 20 to 75 mg of parathyroid tissue.8 Autotransplantation is performed in a surgically accessible area, traditionally in the sternocleidomastoid or brachioradialis muscles. The rate of autograft-related recurrent hyperparathyroidism has been estimated at 11.6% in patients with tertiary hyperparathyroidism, even after renal transplantation.9

Although notes from this patient's prior operation in his home country were not able to be located, his history suggested a diagnosis of recurrent hyperparathyroidism due to hyperplasia of autotransplanted parathyroid tissue. To confirm this, we performed a fine-needle aspiration biopsy in the clinic, which revealed parathyroid cells.

After discussion with the patient and his nephrologist, excision of the mass was performed using local anesthesia. At the time of surgery, the mass was excised with a cuff of sternocleidomastoid muscle, leaving a small portion of tissue approximately half the size of a normal parathyroid gland in place, pedicled on its blood supply. The postexcision intraoperative parathyroid hormone level was 37.9 pg/mL. Postoperatively, the serum calcium nadir was 7.2 mg/dL, which stabilized with oral calcium supplementation. At the most recent follow-up visit, his calcium level was 8.9 mg/dL and his parathyroid hormone level was 50.5 pg/mL. The final pathologic analysis confirmed hyperplastic parathyroid tissue. The patient will continue to receive close clinical and biochemical surveillance for the possibility of recurrent hyperparathyroidism.

Return to Quiz Case.

Correspondence: Luc G. T. Morris, MD, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065 (morrisl@mskcc.org).

Accepted for Publication: March 16, 2010.

Author Contributions:Study concept and design: Morris. Acquisition of data: Lieberman, Vouyiouklis, Elangovan, and Morris. Analysis and interpretation of data: Morris. Drafting of the manuscript: Lieberman, Vouyiouklis, Elangovan, and Morris. Critical revision of the manuscript for important intellectual content: Morris. Administrative, technical, and material support: Lieberman, Vouyiouklis, Elangovan, and Morris. Study supervision: Morris.

Financial Disclosure: None reported.

Drüeke TB, Ritz E. Treatment of secondary hyperparathyroidism in CKD patients with cinacalcet and/or vitamin D derivatives.  Clin J Am Soc Nephrol. 2009;4(1):234-241
PubMed   |  Link to Article
Fassbinder W, Brunner FP, Brynger H,  et al.  Combined report on regular dialysis and transplantation in Europe, XX, 1989.  Nephrol Dial Transplant. 1991;6:(suppl 1)  5-35
PubMed
Fraser WD. Hyperparathyroidism.  Lancet. 2009;374(9684):145-158
PubMed   |  Link to Article
Grzela T, Chudzinski W, Lasiecka Z,  et al.  The calcium-sensing receptor and vitamin D receptor expression in tertiary hyperparathyroidism.  Int J Mol Med. 2006;17(5):779-783
PubMed
Cohen EP, Moulder JE. Parathyroidectomy in chronic renal failure: has medical care reduced the need for surgery?  Nephron. 2001;89(3):271-273
PubMed   |  Link to Article
Pitt SC, Sippel RS, Chen H. Secondary and tertiary hyperparathyroidism, state of the art surgical management.  Surg Clin North Am. 2009;89(5):1227-1239
PubMed   |  Link to Article
Demeure MJ, McGee DC, Wilkes W, Duh QY, Clark OH. Results of surgical treatment for hyperparathyroidism associated with renal disease.  Am J Surg. 1990;160(4):337-340
PubMed   |  Link to Article
Kebebew E, Duh QY, Clark OH. Tertiary hyperparathyroidism: histologic patterns of disease and results of parathyroidectomy.  Arch Surg. 2004;139(9):974-977
PubMed   |  Link to Article
Schlosser K, Rothmund M, Maschuw K,  et al.  Graft-dependent renal hyperparathyroidism despite successful kidney transplantation.  World J Surg. 2008;32(4):557-565
PubMed   |  Link to Article

Figures

Tables

References

Drüeke TB, Ritz E. Treatment of secondary hyperparathyroidism in CKD patients with cinacalcet and/or vitamin D derivatives.  Clin J Am Soc Nephrol. 2009;4(1):234-241
PubMed   |  Link to Article
Fassbinder W, Brunner FP, Brynger H,  et al.  Combined report on regular dialysis and transplantation in Europe, XX, 1989.  Nephrol Dial Transplant. 1991;6:(suppl 1)  5-35
PubMed
Fraser WD. Hyperparathyroidism.  Lancet. 2009;374(9684):145-158
PubMed   |  Link to Article
Grzela T, Chudzinski W, Lasiecka Z,  et al.  The calcium-sensing receptor and vitamin D receptor expression in tertiary hyperparathyroidism.  Int J Mol Med. 2006;17(5):779-783
PubMed
Cohen EP, Moulder JE. Parathyroidectomy in chronic renal failure: has medical care reduced the need for surgery?  Nephron. 2001;89(3):271-273
PubMed   |  Link to Article
Pitt SC, Sippel RS, Chen H. Secondary and tertiary hyperparathyroidism, state of the art surgical management.  Surg Clin North Am. 2009;89(5):1227-1239
PubMed   |  Link to Article
Demeure MJ, McGee DC, Wilkes W, Duh QY, Clark OH. Results of surgical treatment for hyperparathyroidism associated with renal disease.  Am J Surg. 1990;160(4):337-340
PubMed   |  Link to Article
Kebebew E, Duh QY, Clark OH. Tertiary hyperparathyroidism: histologic patterns of disease and results of parathyroidectomy.  Arch Surg. 2004;139(9):974-977
PubMed   |  Link to Article
Schlosser K, Rothmund M, Maschuw K,  et al.  Graft-dependent renal hyperparathyroidism despite successful kidney transplantation.  World J Surg. 2008;32(4):557-565
PubMed   |  Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Response

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com