1 of 20

2 of 20

Effects of Parathyroidectomy

On

Post Transplant

Allograft Function

​

Donnie Aultman, MD

Advanced Surgery Center

Willis Knighton Health System

3 of 20

Disclosure Statement

I have no relationship(s) with industry to disclose relevant to the content of this CME activity

4 of 20

Learning Objective

  • Evaluate patient’s serum calcium levels routinely

​

  • Evaluate patient’s PTH post-transplant regularly

5 of 20

Hyperparathyroidism

Primary - 85% Single Adenoma

10% Double Adenoma

5% 4 gland hyperplasia

​

​

Secondary - most commonly seen in dialysis

population all 4 glands effected

​

​

Tertiary - post transplant autonomous function

6 of 20

  • Successful kidney transplant ameliorates the endocrine and metabolic effects of secondary HPTH

​

  • Usually occurs in few months post transplant

Successful Transplants

7 of 20

Up to 20% of patients may need Parathyroidectomy post transplant and usually wait about 1 year post transplant prior to performing Parathyroidectomy

Parathyroidectomy

8 of 20

  • Tubulointerstitial calcification and inferior graft outcomes

​

  • Increase vascular calcification

Persistent HPTH

9 of 20

Indications for Parathyroidectomy

(routine population)

  • Hypercalcemia

​

  • Osteoporosis

​

  • Renal Stones

​

  • Peptic Ulcer Disease (PUD)

​

  • Bone/joint pain

10 of 20

Indications for Parathyroidectomy

(post transplant)

  • Hypercalcemia

​

  • Progressive renal insufficiency

11 of 20

Parathyroidectomy has been shown to adversely affect allograft function

12 of 20

  • Several Studies have shown an early decline in allograft function with persistence in some patients

​

  • More recent data shows no adverse impact on long term graft function

Effects of Parathyroidectomy

13 of 20

Retrospective Study OSUMC – 1988-2008

  • 4052 Kidney Transplant performed

​

  • 32 (0.8%) underwent Parathyroidectomy

14 of 20

  • 51 ml/min decreases to 44 ml/min

​

  • 12 months post-op = 50 ml/min

​

​

Estimated Glomerular Filtration Rate (EGFR)

15 of 20

Positive Correlation Between PTH & GFR

  • 15x decline in PTH leads to 9% decrease GFR

​

  • Positive correlation between calcium & GFR 20% decline in calcium leads to 1% decrease in GFR

16 of 20

  • 4- (25%) Nephrocalcinosis

​

  • 3- (20%) Moderate Fibrosis

​

  • 8- (50%) Acute Rejection

Kidney Biopsy in 16 Patients Pre-op Parathyroid

17 of 20

Post Parathyroidectomy

  • 2 episode of acute rejection within 1 year

​

  • No graft losses in 1st year

​

  • 4 patients re-admitted for hypocalcemia

​

  • 6 patients lost graft 37.2 + 21.6 months

​

  • Cause of graft loss

a) rejection - 2

b) pyelonephritis - 1

c) Chronic allograft nephropathy - 3

18 of 20

Parathyroid Hormone (PTH)

  • Significant vasodilator effects in renal vascular beds in animal models. The increase in blood flow is by stimulating adenylate cyclase activity in renal vasculature

​

  • Increases nitric oxide production in endothelial cells leading to vasodilation

​

  • Over time, kidney develops a reliance in the increase of blood flow then an abrupt decrease in PTH leads to decrease renal perfusion & transient graft dysfunction

​

19 of 20

Factors That Potentially Effect GFR

  • Decrease PTH loss of vasodilation leads to decrease in blood flow

​

  • Transient hemodynamic effects of surgery

​

  • Existing Nephrocalcinosis

​

20 of 20

FUTURE:

  • Use of calcimimetic in persistent HPTH