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Endocrine, Metabolic & Immune Disorders... 2024This guideline (GL) is aimed at providing a clinical practice reference for the management of sporadic primary hyperparathyroidism (PHPT) in adults. PHPT management in...
AIM
This guideline (GL) is aimed at providing a clinical practice reference for the management of sporadic primary hyperparathyroidism (PHPT) in adults. PHPT management in pregnancy was not considered.
METHODS
This GL has been developed following the methods described in the Manual of the Italian National Guideline System. For each question, the panel appointed by Associazione Medici Endocrinology (AME) and Società Italiana dell'Osteoporosi, del Metabolismo Minerale e delle Malattie dello Scheletro (SIOMMMS) identified potentially relevant outcomes, which were then rated for their impact on therapeutic choices. Only outcomes classified as "critical" and "important" were considered in the systematic review of evidence. Those classified as "critical" were considered for the clinical practice recommendations.
RESULTS
The present GL provides recommendations about the roles of pharmacological and surgical treatment for the clinical management of sporadic PHPT. Parathyroidectomy is recommended in comparison to surveillance or pharmacologic treatment in any adult (outside of pregnancy) or elderly subject diagnosed with sporadic PHPT who is symptomatic or meets any of the following criteria: • Serum calcium levels >1 mg/dL above the upper limit of normal range. • Urinary calcium levels >4 mg/kg/day. • Osteoporosis disclosed by DXA examination and/or any fragility fracture. • Renal function impairment (eGFR <60 mL/min). • Clinic or silent nephrolithiasis. • Age ≤50 years. Monitoring and treatment of any comorbidity or complication of PHPT at bone, kidney, or cardiovascular level are suggested for patients who do not meet the criteria for surgery or are not operated on for any reason. Sixteen indications for good clinical practice are provided in addition to the recommendations.
CONCLUSION
The present GL is directed to endocrinologists and surgeons - working in hospitals, territorial services or private practice - and to general practitioners and patients. The recommendations should also consider the patient's preferences and the available resources and expertise.
Topics: Humans; Hyperparathyroidism, Primary; Italy; Parathyroidectomy; Female; Adult
PubMed: 38644730
DOI: 10.2174/0118715303260423231122111705 -
Endocrinology, Diabetes & Metabolism... Oct 2023Calciphylaxis is a rare disorder characterised by the development of painful necrotic skin lesions. Occlusion of cutaneous arterioles due to ectopic calcification leads...
SUMMARY
Calciphylaxis is a rare disorder characterised by the development of painful necrotic skin lesions. Occlusion of cutaneous arterioles due to ectopic calcification leads to potentially life-threatening widespread skin loss. Most cases occur in patients with chronic renal disease, which leads to dysregulation of calcium and phosphate homeostasis. Only a handful of case reports exist describing calciphylaxis occurring in patients without chronic renal disease but with hypoparathyroidism. We report on a unique case of a 53-year-old man with multiple endocrine neoplasia type 1 syndrome and acquired hypoparathyroidism due to total parathyroidectomy who went on to develop calciphylaxis following cardiac surgery.
LEARNING POINTS
Calciphylaxis most commonly occurs in the context of chronic renal disease but can rarely occur in its absence as a consequence of calcium and phosphate dysregulation. Patients who develop necrotic skin lesions in the presence of hypoparathyroidism require an urgent dermatological opinion. Mortality from calciphylaxis is high, with the majority of deaths occurring secondary to sepsis. Management of calciphylaxis requires a multidisciplinary team approach to manage wound healing, infections and pain. Recovery with full rehabilitation from calciphylaxis can take months to years.
PubMed: 38064896
DOI: 10.1530/EDM-23-0009 -
Asian Journal of Surgery Feb 2024Total parathyroidectomy for secondary hyperparathyroidism has low morbidity and mortality rates and requires a special workup in the preoperative period.
BACKGROUND
Total parathyroidectomy for secondary hyperparathyroidism has low morbidity and mortality rates and requires a special workup in the preoperative period.
METHODS
Neck echography and technetium-99m-sestamibi scintigraphy were performed preoperatively. Cardiac echography, a thallium-201 myocardial perfusion scan, and cardiac catheterization were performed if necessary. During surgery, we removed all the parathyroid glands and the upper thymus and autotransplanted 100 mg of the smallest gland into the subcutaneous tissue of the forearm.
RESULTS
The success rate in three months after total parathyroidectomy was 91.7% without mortality. In the elderly (age ≤65 years, n = 35), bone pain, skin itching, general weakness, and insomnia improved three months after surgery, and grip strength increased significantly. One year after parathyroidectomy, the serum levels of Ca, P, alkaline phosphatase, and intact parathyroid hormone were all within the normal ranges. Except for the bone mineral density (BMD) of the radial distal one-third, the BMD of the lumbar spine (L2 to L4), femoral neck, femoral global, and radial global increased significantly. Furthermore, the bone density T-scores of the lumbar spine (L2 to L4), femoral neck, femoral global, radial distal one-third, and radial global improved significantly.
CONCLUSIONS
After a meticulous preoperative workup, parathyroidectomy plus autotransplantation can be performed safely for the treatment of symptomatic secondary hyperparathyroidism in the elderly to improve their quality of life and decrease their incidence of bone fractures.
Topics: Humans; Aged; Parathyroidectomy; Quality of Life; Hyperparathyroidism, Secondary; Parathyroid Glands; Parathyroid Hormone
PubMed: 37989683
DOI: 10.1016/j.asjsur.2023.10.003 -
Frontiers in Endocrinology 2023Cardiovascular mortality is significantly higher in patients with primary hyperparathyroidism (PHPT) compared to the general population. The role of the...
INTRODUCTION
Cardiovascular mortality is significantly higher in patients with primary hyperparathyroidism (PHPT) compared to the general population. The role of the renin-angiotensin-aldosterone system (RAAS) as a mediator of cardiovascular pathology in PHPT is unclear, as is the question whether successful parathyroidectomy (PTX) mitigates hypertension (HT), and left-ventricular (LV) dysfunction.
METHODS
In 45 consecutive, hypercalcemic PHPT patients (91% female, 20 normotensive, mean age 54.6 ± 14.6), laboratory examinations, and 24 h ambulatory blood pressure monitoring (ABPM) were performed before, one and six months after successful PTX, while transthoracic echocardiography (TTE) pre- and six months post-PTX.
RESULTS
Both in patients with normotension (NT) and HT, lower calcemia and parathyroid hormone (PTH) as well as higher phosphatemia were observed on follow-up, while B-type natriuretic peptide, aldosterone, plasma renin activity, and aldosterone-to-renin ratios were comparable. Six months post-PTX, only in patients with HT, median 24-hour SBP/DBP decreased by 12/6 mmHg, daytime SBP by 10, and nighttime DBP by 5 mmHg. Improvement in BP was observed in approximately 78% of patients with HT. Six months post-PTX, TTE revealed: 1) decrease in median LV mass index (by 2 g/m2) and end-diastolic dimension (by 3 mm) among patients with HT; 2) normalization of global longitudinal strain in 22% of patients (comparable between those with NT and HT); 3) a mean 12.7% reduction in left-atrium volume index among patients with HT, which underlay normalization of indeterminate diastolic function in 3 out of 6 patients with HT, who exhibited it at baseline (dysfunction persisted in 2).
CONCLUSIONS
PTX was shown to significantly reduce BP, LV hypertrophy and diastolic dysfunction parameters in PHPT patients with HT, and improve systolic function in all PHPT patients.
Topics: Humans; Female; Adult; Middle Aged; Aged; Male; Hyperparathyroidism, Primary; Aldosterone; Renin; Blood Pressure Monitoring, Ambulatory; Hypertension; Ventricular Function, Left; Ventricular Dysfunction, Left; Hypercalcemia
PubMed: 37492200
DOI: 10.3389/fendo.2023.1163877 -
Frontiers in Endocrinology 2023Parathyroidectomy (PTX) is an effective treatment for primary hyperparathyroidism (PHPT) patients. Postoperative hypocalcemia is a common complication after PTX. This...
BACKGROUND
Parathyroidectomy (PTX) is an effective treatment for primary hyperparathyroidism (PHPT) patients. Postoperative hypocalcemia is a common complication after PTX. This study aimed to analyze the factors influencing serum calcium levels and the incidence of hypocalcemia after parathyroidectomy in primary hyperparathyroidism patients.
METHODS
The retrospective study included 270 PHPT patients treated with PTX and collected their demographic and clinical information and their laboratory indices. Factors influencing serum calcium levels and hypocalcemia after PTX in PHPT patients were analyzed using univariate and multifactorial analyses.
RESULTS
First, in patients with normal preoperative serum calcium levels (2.20-2.74 mmol/L), the higher the preoperative alkaline phosphatase and serum phosphorus levels, the lower the postoperative serum calcium levels. Furthermore, the higher the preoperative serum calcium levels and the accompanying clinical symptoms, the higher the postoperative serum calcium levels. Low preoperative serum calcium levels were shown to be a risk factor for postoperative hypocalcemia (OR=0.022), and the optimal preoperative serum calcium threshold was 2.625 mmol/L (sensitivity and specificity were 0.587 and 0.712, respectively). Second, in the mild preoperative hypercalcemia group (2.75-3.00 mmol/L), the older the patient, the higher the preoperative and postoperative serum calcium levels, the higher the postoperative serum calcium; the lower the alkaline phosphatase and calcitonin levels, the higher the postoperative serum calcium levels. On the other hand, the younger the patient was, the more likely hypocalcemia blood was (OR=0.947), with an optimal age threshold of 47.5 years (sensitivity and specificity were 0.543 and 0.754, respectively). Third, in the preoperative moderate to severe hypercalcemia group (>3.0mmol/L), patients undergoing a combined contralateral thyroidectomy and a total thyroidectomy had low postoperative serum calcium levels.
CONCLUSION
Patients with different preoperative serum calcium levels had various factors influencing their postoperative serum calcium levels and postoperative hypocalcemia, which facilitated the assessment of their prognosis.
Topics: Humans; Middle Aged; Hypocalcemia; Parathyroidectomy; Calcium; Retrospective Studies; Hyperparathyroidism, Primary; Hypercalcemia; Alkaline Phosphatase; Incidence
PubMed: 38116316
DOI: 10.3389/fendo.2023.1276992 -
Alternative Therapies in Health and... Oct 2023The objective of this study is to evaluate the efficacy and safety of the gasless trans-axillary parathyroidectomy approach for the treatment of primary...
OBJECTIVE
The objective of this study is to evaluate the efficacy and safety of the gasless trans-axillary parathyroidectomy approach for the treatment of primary hyperparathyroidism in our medical center.
METHODS
A retrospective analysis was conducted on patients with single parathyroid adenoma who underwent parathyroidectomy using the gasless trans-axillary approach.
RESULTS
Between June 2020 and June 2022, 41 patients (37 women and 4 men) with primary hyperparathyroidism underwent endoscopic parathyroidectomy utilizing the gasless trans-axillary approach. Postoperative levels of parathyroid hormone and calcium showed a significant decline following the procedure. No permanent damage to the recurrent laryngeal nerve was observed. The mean adenoma size was 19.2 mm, with a volume of 2.66 mL. Successful identification and resolution of hyperparathyroidism were achieved for all patients.
CONCLUSIONS
Endoscopic gasless trans-axillary parathyroidectomy is a safe and viable option for patients with primary hyperparathyroidism who wish to avoid cervical scarring. The surgical outcomes were favorable, and no major complications were encountered.
PubMed: 37442194
DOI: No ID Found -
Journal of the Endocrine Society Aug 2023Patients with primary hyperparathyroidism (PHPT) can present with variable signs, symptoms, and end-organ effects. Clinical practice guidelines influence referral for...
CONTEXT
Patients with primary hyperparathyroidism (PHPT) can present with variable signs, symptoms, and end-organ effects. Clinical practice guidelines influence referral for consideration of parathyroidectomy.
OBJECTIVE
This study compared the demographic, biochemical, and symptom profile and examine indications for surgery in patients older than 50 years who underwent parathyroidectomy to determine how changes to current guidelines may affect recommendations for parathyroidectomy.
METHODS
A retrospective review was conducted of patients age 50 years or older who underwent initial parathyroidectomy for sporadic PHPT from 2012 to 2020. Patients were classified by indications for surgery per guideline criteria (classic, asymptomatic, and no criteria met) and age group (AG): 50 to 59 years; 60 to 69 years; 70 years or older. Patients were treated at a high-volume tertiary medical center by endocrine surgeons.
RESULTS
Of 1182 patients, 367 (31%) classic and 660 (56%) asymptomatic patients met the criteria for surgery. The most common indications for surgery were extent of hypercalcemia (51%), osteoporosis (28%), and nephrolithiasis (27%). Of the 155 (13%) patients who did not meet the criteria, neurocognitive symptoms (AG1: 88% vs AG2: 81% vs AG3: 70%; = .14) and osteopenia (AG1: 53% vs AG2: 68% vs AG3: 68%; = .43) were frequently observed regardless of patient age. If the age threshold of younger than 50 years was expanded to 60, 65, or 70 years, an additional 61 (5%), 99 (8%), and 124 (10%) patients in the entire cohort would have met the guideline criteria for surgery, respectively.
CONCLUSION
Expanding current guidelines for PHPT to include a broader age range, osteopenia, and neurocognitive symptoms may allow for earlier surgical referral and evaluation for definitive treatment.
PubMed: 37873505
DOI: 10.1210/jendso/bvad098 -
Frontiers in Endocrinology 2023Secondary hyperparathyroidism, as a result of chronic kidney disease could be treated medically or surgically. When pharmacotherapy fails, patients undergo surgery -...
INTRODUCTION
Secondary hyperparathyroidism, as a result of chronic kidney disease could be treated medically or surgically. When pharmacotherapy fails, patients undergo surgery - parathyroidectomy, the curative treatment of secondary hyperparathyroidism (SHPT). There are currently 3 accepted surgical techniques, each with supporters or opponents - total parathyroidectomy, subtotal parathyroidectomy and parathyroidectomy with immediate autotransplantation.
METHODS
In this paper we described our experience on a series of 160 consecutive patients diagnosed with secondary hyperparathyroidism who underwent surgery, in 27 cases it was totalization of the intervention (patients with previously performed subtotal parathyroidectomy or with supernumerary glands and SHPT recurrence). We routinely perform total parathyroidectomy, the method that we believe offers the best results.
RESULTS
The group of patients was studied according to demographic criteria, paraclinical balance, clinical symptomatology, pre- and postoperative iPTH (intact parathormone) values, SHPT recurrence, number of reinterventions. In 31 cases we found gland ectopy and in 15 cases we discovered supernumerary parathyroids. A percentage of 96.24% of patients with total parathyroidectomy did not show recurrence.
DISCUSSIONS
After analyzing the obtained results, our conclusion was that total parathyroidectomy is the intervention of choice for patients suffering from secondary hyperparathyroidism when pharmacotherapy fails in order to prevent recurrence of the disease and to correct the metabolic parameters.
Topics: Humans; Parathyroidectomy; Recurrence; Hyperparathyroidism, Secondary; Parathyroid Glands; Kidney Failure, Chronic
PubMed: 38075043
DOI: 10.3389/fendo.2023.1191914 -
Endocrinology and Metabolism (Seoul,... Jun 2024Parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23) each play a central role in the pathogenesis of chronic kidney disease (CKD)-mineral and bone disorder.... (Review)
Review
Parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23) each play a central role in the pathogenesis of chronic kidney disease (CKD)-mineral and bone disorder. Levels of both hormones increase progressively in advanced CKD and can lead to damage in multiple organs. Secondary hyperparathyroidism (SHPT), characterized by parathyroid hyperplasia with increased PTH secretion, is associated with fractures and mortality. Emerging evidence suggests that these associations may be partially explained by PTH-induced browning of adipose tissue and increased energy expenditure. Observational studies suggest a survival benefit of PTHlowering therapy, and a recent study comparing parathyroidectomy and calcimimetics further suggests the importance of intensive PTH control. The mechanisms underlying the regulation of FGF23 secretion by osteocytes in response to phosphate load have been unclear, but recent experimental studies have identified glycerol-3-phosphate, a byproduct of glycolysis released by the kidney, as a key regulator of FGF23 production. Elevated FGF23 levels have been shown to be associated with mortality, and experimental data suggest off-target adverse effects of FGF23. However, the causal role of FGF23 in adverse outcomes in CKD patients remains to be established. Further studies are needed to determine whether intensive SHPT control improves clinical outcomes and whether treatment targeting FGF23 can improve patient outcomes.
Topics: Humans; Fibroblast Growth Factor-23; Fibroblast Growth Factors; Parathyroid Hormone; Renal Insufficiency, Chronic; Hyperparathyroidism, Secondary; Animals
PubMed: 38752265
DOI: 10.3803/EnM.2024.1978 -
Gland Surgery May 2024
PubMed: 38845838
DOI: 10.21037/gs-23-534