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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA–AFRICA  
Year : 2021  |  Volume : 32  |  Issue : 5  |  Page : 1424-1430
Surgical management of secondary hyperparathyroidism in dialysis patients in Senegal


Department of Nephrology, Cheikh Anta Diop University, Dakar, Senegal

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Date of Web Publication4-May-2022
 

   Abstract 


Secondary hyperparathyroidism (SHPT) is a common complication of end-stage renal disease. Surgical management occurs in severe forms and/or unresponsive medical treatment. The aim of this study was to outline the indications of parathyroidectomy and its evolution after surgical approach. It was a five-year multicenter backward study in Otorhinolaryngology Department of Fann Hospital and four dialysis centers in Dakar. We include all patients with SHPT who underwent surgery. Preoperative clinical and paraclinical parameters, clinical-biological evolution, and histology findings of the resected parathyroid specimen were collected. Out of 58 patients with hyperparathyroidism, 18 patients required parathyroidectomy, corresponding to a prevalence of 31%. Mean age of patients was 46.6 ± 15.29 years and sex ratio 0.61. Mean duration on dialysis was 44.4 ± 30 months. Ten patients (55.56%) had bone pain and nine patients (50%) had joint pain. Mean serum calcium was 97.27 ± 8.66 mg/L. Mean blood phosphorus levels were 40.47 ± 9.99 mg/L. Mean iPTH rate was 1493.22 ± 1014.93 ng/mL, with a maximum of 5000 ng/mL (77N). Mean value of 25-OH Vitamin D was 32.89 ± 16.02 ng/mL. Parathyroidectomy was indicated after failure of medical treatment with persistence of a serum intact parathyroid hormone concentration above 800 μg/mL in all patients. Subtotal parathyroidectomy (7/8) was performed in 11 patients (61.1%). Two patients (11.11%) benefited from a selective parathyroidectomy (3/4). Evolution was favorable for 13 patients, corresponding to a success rate of 72.2%. It was unfavorable in five patients including one patient with hypoparathyroidism and four patients with recurrent hyperparathyroidism. Surgery for patients with renal hyperparathyroidism in the era of calcimimetics continues to play an important role in selected patients and achieves efficient control of hyperparathyroidism in developing countries.

How to cite this article:
Faye M, Keita N, Lemrabott AT, Algouzmari I, Faye M, Mbengue M, Diagne S, Ba B, Dieng A, Ba MA, Ka EF. Surgical management of secondary hyperparathyroidism in dialysis patients in Senegal. Saudi J Kidney Dis Transpl 2021;32:1424-30

How to cite this URL:
Faye M, Keita N, Lemrabott AT, Algouzmari I, Faye M, Mbengue M, Diagne S, Ba B, Dieng A, Ba MA, Ka EF. Surgical management of secondary hyperparathyroidism in dialysis patients in Senegal. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Jul 2];32:1424-30. Available from: https://www.sjkdt.org/text.asp?2021/32/5/1424/344763



   Introduction Top


Hyperparathyroidism is defined by excessive secretion of intact parathyroid hormone (iPTH) by one or more parathyroid glands. Secondary hyperparathyroidism (SHPT) is a common consequence of chronic kidney disease (CKD) which develops early and simultaneously worsens as the deterioration of kidney function progresses.[1] It is a long-term complication of CKD during which it is associated with an increase (fibroblast growth factor 23), a Vitamin D deficiency, hyperphosphatemia, hypocalcemia, an increase in phosphorous-calcium homeostasis (Ca×P), and an increase PTH. In dialysis patients, secondary hyperparathyroidism is a risk factor for bone damage (renal osteodystrophy) and extra-bone damage (calcifications of soft parts, heart vessels, and valves), hospitalizations, and mortality.[1],[2] The K/DOQI recommendations suggest surgical treatment of SHPT in patients with persistent hypersecretion of PTH >800 pg/mL, associated with hypercalcemia and/or hyperphosphoremia refractory to medical treatment.[3] In Senegal, parathyroidectomy is the front-line proposed treatment for SHPT unresponsive to medical treatment, due to the high cost of calcimimetics. The objective of this study was to assess the clinical, biological, and radiological indications for surgical treatment and to assess the short and long-term progress.


   Patients and Methods Top


This was a descriptive retrospective multi-center study carried out in Fann Hospital Otorhinolaryngology Department, four hemodialysis (HD) centers, and a peritoneal dialysis (PD) center, from January 1, 2011, to December 31, 2016. All chronic dialysis patients operated for secondary or tertiary hyperparathyroidism were included. Epidemiological, clinical, biological, radiographic, ultrasound data were collected. The indications for parathyroidectomy, postoperative complications, and anatomopathological findings of the resected parathyroid tissue were also collected. The normal values used for the biological parameters were those recommended by the Kidney Disease Improving Global Outcomes 2009.[3] The data were entered by Sphinx software version 5.1.0.2 and analyzed using Statistical Package for the Social Sciences software version 18.0. The quantitative variables are expressed as the mean ± standard deviation and the qualitative variables as percentage.


   Results Top


Out of 58 patients with hyperparathyroidism, 18 patients had a parathyroidectomy, corresponding to a prevalence of 31%. Seventeen were under HD and one patient under PD. There were 13 women (72.2%) and five men, a sex ratio of 0.38. The mean age of the patients was 46.6 ± 15.29 years [Table 1]. The initial nephropathy was hypertensive nephropathy in 38.9% of cases, polycystic kidney disease in 16.7%, chronic glomerulonephritis in 5.6% of cases, and chronic tubulointerstitial nephritis in 5.6% of cases. The mean duration on dialysis was 44.4 ± 30 months [Table 1]. Thirteen patients (76.5%) had duration on dialysis between 12 and 60 months and 5.9% of the cases over 120 months (10 years). Fourteen (14) patients (82.35%) had 3 dialysis sessions per week while three patients had two sessions per week. The PD patient was on continuous ambulatory PD with four exchanges daily. Clinically, bone pain was present in 10 patients (55.56%), joint pain in nine patients (50%), muscle cramps in five patients (27.7%), and one patient presented pathological fracture [Table 1]. On biological approach, the mean serum calcium level was 97.27 ± 8.66 mg/L. It was normal in 12 patients (67%). Two (11%) patients had hypocalcemia and four (22%) had hypercalcemia. The mean serum phosphorous level was 40.47 ± 9.99 mg/L. The average iPTH was 1493.22 ± 1014.93 ng/mL. The mean value of 25-OH Vitamin D was 32.89 ± 16.02 ng/mL. Five patients had a 25-OH-Vit D deficiency [Table 2]. On radiological investigations, three patients benefited from a standard X-ray revealing a dystrophic reorganization of the bone spans in one case. The cervical ultrasound was performed for all patients and outlined pathological findings in 11 cases (61.11%). It highlighted parathyroid nodules of which five were single and six double. Thyroid abnormalities were associated in three patients (16.66%) with nodules and multinodular goiter. None of the patients benefited from parathyroid scan. On therapeutical approach, 17 patients had received calcium supplementation. One patient had received treatment with noncalcium phosphorus chelators (lanthanum). Twelve patients had received Vitamin D (native and/or alpha). Three patients experienced calcimimetics [Table 3]. The indication of parathyroidectomy was made in these 18 patients due to the failure of medical treatment with persistence of a serum iPTH concentration >800 pg/mL and before the persistence of clinical signs of hyperparathyroidism. The surgery allowed performing a subtotal parathyroidectomy (7/8) in 11 patients (61.1%) with removal of the three parathyroid glands and half of the gland, which appeared macroscopically normal. Two patients (11.11%) experienced selective parathyroidectomy (3/4) [Figure 1]. The pathology report was available in nine patients. The histological study of the resected parathyroid glands had shown diffuse hyperplasia without histological signs of malignancy in six cases and nodular hyperplasia in three cases. In the immediate postoperative period, no patient had experienced titanic attacks, no case of recurrent nerve palsy or hematoma of the thyroid gland was observed. Daily monitoring of serum calcium was systematic in all postoperative patients until normalization. Four patients (22.22%) had hypocalcemia, suggesting calcium supplementation. The remaining 14 had serum calcium levels within normal limits but lower than the preoperative values. The iPTH measurement was performed during the postoperative week in six patients; the values had dropped by 35.8% compared to the preoperative values. iPTH levels remained elevated in three patients. The evolution after 24 to 28 months of the intervention was marked by a persistence of bone pain in two patients. The mean serum calcium levels was 87.33 ± 10.09 mg/L, the mean serum phosphorous levels was 32.39 ± 12.86 mg/L, and the mean iPTH was 514.90 ± 527.23 pg/mL. In one patient, an iPTH of <15 pg/mL was noted, and in four patients, an iPTH of more than 500 pg/mL was found, three of which (16.6%) required reoperation [Table 4].
Table 1: Baseline clinical of patients.

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Table 2: Baseline biological of patients.

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Table 3: Distribution of patients according to the medical treatment received.

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Figure 1: Distribution of patients according to the PTX.
PTX: Parathyroidectomy.


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Table 4: Patients evolution after parathyroidectomy at 24 months

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   Discussion Top


In our series, parathyroidectomy was performed in 18 patients, accounting for a prevalence of 31%. The mean age of our patients was 46.6 ± 15.29 years. This matched most of the recent African series where the patients were young.[5],[7],[8] This could be explained by the fact of insufficient financial resources, poor access to care for early detection of kidney disease, the young age of the general population,[9] and the fact that the surgical treatment is avoided in the elderly due to an anesthetic risk.[4],[10] The sex ratio in favor of women in our series may be linked to hypersensitivity to the action of PTH associated with ovarian dysfunction (an ovulation and amenorrhea), predisposing to an increase in the bone consequences of hyperparathyroidism;[11] the female gender is thus associated with a higher risk of using parathyroidectomy. The average duration of dialysis in our series was 44.4 ± 30 months, which is consistent with the results found by several Tunisian series.[5] The clinical signs were present in our study, mainly in the form of bone or joint pain with a case of pathological fracture due to the severity of the damage as well as the delay in the care of these patients. In our work, we noted very high iPTH levels above 5000 pg/mL (77N) indicating a lack of correction and stopping. The mean iPTH was 1493.22 ± 1014.93 ng/mL, higher than that found in the African[5],[7] and French series. However, the high rate of iPTH in our series could be explained by the fact that there are currently, on the market, different kits for the assay of PTH, with great variability in the values obtained, as well as a difference in the definition of hyperparathyroidism according to the series [Table 5]. The most common indication for parathyroidectomy in the literature was the persistence of a serum PTH levels >800 pg/mL after six to eight weeks of treatment with calcitriol or one of its analogs, associated with the persistence of clinical hyperparathyroidism signs. In fact, in our study, this indication was asked in the 18 patients (100%). A well-conducted surgical exploration allowed the localization of four parathyroid glands in 17 patients and three parathyroid glands in one patient. The surgical procedure performed was a subtotal parathyroidectomy (7/8) in 11 patients (61.1%) with removal of the three parathyroid glands and half of the gland which appeared macroscopically normal; the choice depended on the surgeon’s preference. In our study, the patients did not have an extemporaneous biopsy or an intraoperative PTH test. This would lend support to determine the hyperplasia state and to ensure the effectiveness of the surgical procedure. However, all patients had a pathological examination later highlighting that the pathological tissue originnated from the parathyroid gland. The most common etiology of SHPT was diffuse hyperplasia accounting for 55.5% of cases, which was similar to other series.[4],[11] Parathyroidectomy seems to be an effective and economical way to treat a SHPT giving good results on PTH secretion blockage and on bone signs. However, this surgical procedure remains charged with complications, in particular, the surgical postoperative mortality, even though it remains low, varying from 0% to 7% depending on the major series.[12] In our study, one death related to surgery was reported. The main immediate complication of the procedure is low serum calcium levels, which was found in 22.2% of patients in our series. The latter was secondary to the abrupt low secretion of PTH, induced by the reduction of parathyroid tissue, in a context where the skeleton, experiencing secondary hyperparathyroidism for a long time is very crave for calcium.
Table 5: Summary of recent studies on parathyroidectomy in chronic kidney disease patients.

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In our cohort, after a follow-up of 24.28 months, the clinical course was favorable in 16 patients (or 88.8% of the cases). However, bone pain persisted in two patients. Various studies have reported a recurrence rate of hyperparathyroidism after parathyroidectomy, ranging from 5% to 15%.[13],[14] In our study, 16.6% of the patients had surgical reintervention. This percentage varies in the literature between 4.3% and 14%.[2],[13] Despite careful cervical exploration and an experienced team, persistent or recurrent hyperparathyroidism cannot be avoided in some situations. In most cases, it is related to a failure of the initial surgery in the optimal reduction of the parathyroid parenchyma, particularly due to topographic anatomical variations issues, the presence of ectopic glands or sometimes hyperplasia of the remaining stump. In our study, persistent hyperparathyroidism was reported in three patients, two of who had partial parathyroidectomy of one gland and the third of two glands.


   Conclusion Top


Parathyroidectomy is an effective therapeutic approach to curb the parathyroid hormone hypersecretion with satisfactory clinical, biological, and radiological outcomes in our study. However, prevention and early management of phosphorous-calcium disturbances would reduce the frequency of secondary hyperparathyroidism and the indication for parathyroidectomy if it were known to be a surgical procedure with potential complications.

Conflict of interest: None declared.



 
   References Top

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Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG, Chertow GM. Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol 2004;15:2208-18.  Back to cited text no. 1
    
2.
Moe SM, Drüeke TB. Management of secondary hyperparathyroidism: The importance and the challenge of controlling parathyroid hormone levels without elevating calcium, phosphorus, and calcium-phosphorus product. Am J Nephrol 2003;23:369-79.  Back to cited text no. 2
    
3.
National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003;42:S1-201.  Back to cited text no. 3
    
4.
Rothmund M, Wagner PK. Total parathyroidectomy and auto-transplantation of parathyroid tissue for renal hyperparathyroi-dism. A one to six-year follow-up. Ann Surg 1983;197:7-16.  Back to cited text no. 4
    
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Hamouda M, Ben Dhia N, Aloui S, et al. Surgical treatment of secondary hyperparathyroidism in patients with chronic renal failure. Nephrol Ther 2011;7:105-10.  Back to cited text no. 5
    
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Fau M. Surgical management of secondary hyperparathyroidism in patients with end-stage renal disease: About 230 cases. Thesis of Medicine. Nancy (France), No..101, 200.  Back to cited text no. 6
    
7.
Radoui A, Hanin H, Slimani Houti M, et al. Surgical management of secondary hyperparathyroidism in hemodialysis patients. J Chir 2010;147:133-8.  Back to cited text no. 7
    
8.
Zitouni SN, Bouchair A, Daoudi A, et al. Surgical management of secondary hyperparathyroidism in patients with end-stage renal disease. Ann Otolaryngol Chir Cervicofac 2012;129:A38.  Back to cited text no. 8
    
9.
NASD: National Agency for Statistics and Demography. General Census of Population and Housing, Agriculture and Livestock. Senegal: NASD: National Agency for Statistics and Demography; 2014. Available from: https://www.ansd.sn. [Last accessed on 2016 Dec 01].  Back to cited text no. 9
    
10.
Kim HC, Cheigh JS, David DS, et al. Long term results of subtotal parathyroidectomy in patients with end-stage renal disease. Am Surg 1994; 60:641-9.  Back to cited text no. 10
    
11.
Nasri H, Kheiri S. Effects of diabetes mellitus, age, and duration of dialysis on parathormone in chronic hemodialysis patients. Saudi J Kidney Dis Transpl 2008;19 :608-13.  Back to cited text no. 11
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12.
Stracke S, Jehle PM, Sturm D, et al. Clinical course after total parathyroidectomy without autotransplantation in patients with end-stage renal failure. Am J Kidney Dis 1999;33:304-11.  Back to cited text no. 12
    
13.
Drüeke TB, Zingraff J. The dilemma of parathyroidectomy in chronic renal failure. Curr Opin Nephrol Hypertens 1994; 3:386-95.  Back to cited text no. 13
    
14.
Drueke TB, Eckardt KU. Role of secondary hyperparathyroidism in erythropoietin resistance of chronic renal failure patients. Nephrol Dial Transplant 2002; 17 :28-31.  Back to cited text no. 14
    

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Correspondence Address:
Maria Faye
Department of Nephrology, Aristide Le Dantec University Hospital, Dakar
Senegal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.344763

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