The patient was initially treated with cinacalcet, followed by parenteral bisphosphonates for three months with good initial effect on serum calcium levels, however, the PTH remained elevated (PTH 597 pg/mL). Notably, serum calcium started to increase again despite bisphosphonates.
E. Suggest a management plan for this patient.
F. Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidence.
E. Suggest a management plan for this patient.
Parathyroidectomy is indicated since the patient is failing the non-operative management; asymptomatic patients who do not undergo surgery require long-term monitoring for worsening hypercalcemia, renal impairment, and bone loss. Developing any of these findings indicates disease progression and the need for surgical intervention.
Before proceeding to the surgical option, I will make sure the Preventive measures are implemented:
E. Suggest a management plan for this patient.it would be good to mention what doses o parental BP was used. Myself I dont use more than 2.5 mg IV zoledronic acid Q12-18 months in patient with ESRD on HD. Was the used dose in this patient is malignancy dose – 5 mg IV Q3-4 weeks?
Since the patient is failing medical Rx and still has High PTH, I was rescan the patient for better localization. Starts with US parathyroid, NM parathyroid uptake scan, 4 D triphasic CT neck scan, and if all failed will send for PET choline study. This patient is definitely has a remaining active parathyroid tissue, and removal is the definite Rx.
F. Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidenceCinacalcet is used to control PTH and hypercalcemia in patient with mild to moderate disease. Cinacalcet used in patient with severe hyperparathyroidism if the patient is not a candidate for surgery.
Parathyroidectomy is the definite Rx for tertiary hyperparathyroidism with very high PTH and failing to respond to medical therapy. Parathryoidectomy has a positive effect on BMD and CV system.
Total parathyroidectomy
cin failed to decrase death and strongly going with parathyrdoctomy
E. Suggest a management plan for this patient.
Failture of calcimmitics and bisphosphonate is indication for surgery therefore i suggest total parathyroidectomy for this patient
F. Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidence.
Studies have shown parathyroidectomy is associated with overall better survival than Cinacalcet in patients with secondary hyperparathyroidism on hemodialysis.
Cinacalcet failed to reduce the risk of death or major cardiovascular events. Surgery should be strongly considered particularly in patients with PTH levels higher than 1000 pg/dL.
E.Suggest a management plan for this patient.since the patient was taking cinacalcet and biphosphonate is an indication for invasive parathyroidectomy
F. Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidence.
cinacalcet will only improve the PTH and s calcium levels , but will not improve cardiovascular outcome
Surgical intervention( Total parathyroidectomy).
While Cinacalcet has been shown to lower PTH levels and improve calcium-phosphorus homeostasis, it failed to reduce the risk of death or major cardiovascular events as shown in the EVOLVE trial.
Parathyroidectomy is associated with an overall better survival than Cinacalcet in patients with secondary hyperparathyroidism on hemodialysis. Surgery should be strongly considered particularly in patients with PTH levels higher than 1000 pg/dL.
Management plan
Cinacalcet versus Parathyroidectomy
A study compares cinacalcet versus parathyroidectomy in treatment patients with parathyroidectomy
a) PTH after 1 week decreased by 97%.
b) In all (except one) ALP decreases to a normal level.
c) The perioperative symptoms of pruritus and bone pain, are completely resolved or significantly improved.
a) After a 4-month follow-up of daily cinacalcet, the PTH decreased by 48% from baseline.
b) No significant reduction of the ALP.
c) The pre-operative symptoms were not significantly improved.
The study concluded that; Surgery was superior to medical parathyroidectomy.
References
E. Suggest a management plan for this patient.
3 to 6 months with calcimmitics & bisphosphonate without improvement is an indication for surgery
F. Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidence.
There is a study to compare the long-term outcomes and survival between cinacalcet and parathyroidectomy in the treatment of secondary hyperparathyroidism in hemodialysis patients.It showed
Cinacalcet has been shown to lower PTH levels and improve calcium-phosphorus homeostasis, it failed to reduce the risk of death or major cardiovascular events
while parathyroidectomy has better prognosis and improve all cause mortality.
The study showed that parathyroidectomy was superior to Cinacalcet in achieving normocalcemia and improving bone mass density (BMD)
In advanced cases, the decreased response and number of CAsR as well as VDR leads to hypo responsiveness and inferiority relative to surgical management So, temporarily, we can use the paricalcitol iv after each session with cinacalcet or etelcalcetide.
In (Alvarado L, Sharma N, Lerma R, Dwivedi A, Ahmad A, Hechanova A, Payan-Schober F, Nwosu A, Alkhalili E. Parathyroidectomy Versus Cinacalcet for the Treatment of Secondary Hyperparathyroidism in Hemodialysis Patients. World J Surg. 2022 Apr;46(4):813-819. doi: 10.1007/s00268-022-06439-7. Epub 2022 Jan 12. PMID: 35022799; PMCID: PMC8885484.) study, the surgical management was fund more beneficial.
E. Suggest a management plan for this patient. Failure of medical treatment so need to do sestamibi scan to detect active tissue and then go ahead for surgery.
F. Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidence. The research showed that surgery outperformed Cinacalcet in terms of survival after 10 years.
Parathyroidectomy in ESRD patients has high perioperative hazards, including a 2% 30-day postoperative death rate in the literature and a 3.7% rate in our research.
Clinicians follow KDIGO recommendations and only send severely refractory patients for surgery because of these risks.
While Cinacalcet has been shown to lower PTH levels and improve calcium-phosphorus homeostasis, it failed to reduce the risk of death or major cardiovascular events, as shown in the EVOLVE trial.
Parathyroidectomy is associated with overall better survival than Cinacalcet in patients with secondary hyperparathyroidism on hemodialysis. Surgery should be strongly considered particularly in patients with PTH levels higher than 1000 pg/dL.
E)re scan detect active tissue and surgery
F)surgical parathyroidectomy offers better survival advantage for patient with sever SHPT, this advantage has not been shown with Cinacalcet in the same population
E. Parathyroidectomy because of tertiary hyperparathyroidism
F. Cinacalcit can reduce the calcium and PTH but will not improve cardiovascular and all causes mortality while parathyroidectomy has better prognosis and improve all cause mortality
.Suggest a management plan for this patient.
3 to 6 months with calcimmitics & bisphosphonate without improvement is an indication for surgery
Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidence.
The research showed that surgery outperformed Cinacalcet in terms of survival after 10 years.Parathyroidectomy in ESRD patients has high perioperative hazards, including a 2% 30-day postoperative death rate in the literature and a 3.7% rate in our research.
Clinicians follow KDIGO recommendations and only send severely refractory patients for surgery because of these risks. While Cinacalcet has been shown to lower PTH levels and improve calcium-phosphorus homeostasis, it failed to reduce the risk of death or major cardiovascular events, as shown in the EVOLVE trial. Parathyroidectomy is associated with overall better survival than Cinacalcet in patients with secondary hyperparathyroidism on hemodialysis. Surgery should be strongly considered particularly in patients with PTH levels higher than 1000 pg/dL.
E-Suggest a management plan for this patient.
Failure of medical treatment so need to do sestamibi scan to detect active tissue and then go ahead for surgery.
F. Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidence.
Cinacalcit improve the biochemical parameters but has no effect on survival rates, while PTX improve all cause mortality rate.
refer for parathyroidectomy most dialysis patients who have persistent hyperparathyroidism (PTH levels >800 pg/mL), which is refractory to medical therapies and is accompanied by clearly related signs and symptoms. Parathyroidectomy is effective in mitigating most hyperparathyroidism-associated signs and symptoms. It is important to exclude other potential causes of the signs and symptoms prior to parathyroidectomy.
perform parathyroidectomy for selected dialysis patients who have very severe, sustained hyperparathyroidism (PTH levels >1000 pg/mL) that is refractory to medical therapies, even if not accompanied by associated signs and symptoms. The selection of patients must be individualized, depending on age and comorbidities. We generally reserve parathyroidectomy for younger patients (ie, <65 years) and with few comorbidities. Potential but unproven benefits may include improved survival, fracture risk, nutrition, and anemia.
For patients with refractory hyperparathyroidism who are actively awaiting transplantation, decisions regarding parathyroidectomy should be jointly made with the transplant center. Hyperparathyroidism often, but not always, resolves after kidney transplantation.
MEDICAL PARATHYROIEDECTOMY IS LESS EFFECTIVE THAN SURGICAL , PATIENT NEEDS FOR ISOTOP SCAN TO DETECT THE ACTIVE LESION AND TO BE REMOVED
denosumab can be use for treatment of hyperparathyroidism associated hypercalcemia
Luis Alvarado and et al compare treatment with parathyroidectomy vs ttt with cinacalcet,they conclude that parathyroidectomy is associated with an overall better survival than Cinacalcet in patients with secondary hyperparathyroidism on hemodialysis.Alvarado L, Sharma N, Lerma R, et al. Parathyroidectomy Versus Cinacalcet for the Treatment of Secondary Hyperparathyroidism in Hemodialysis Patients. World J Surg. 2022;46(4):813-819. doi:10.1007/s00268-022-06439-7
E.
parathyroidectomy (surgical or via alcohol injection) is a valid choice for this patient.
F.
contrary to what is previously reported, surgical parathyroidectomy offers better survival advantage for patient with sever SHPT, this advantage has not been shown with Cinacalcet in the same population
E-Suggest a management plan for this patient.
The patient still has persistent hyperparathyroidism with an associated hypercalcaemia and failure on medical treatment so need further investigation as sistamibi to detect active tissue site and do another operation.
F- patient already on cinacalcite and little improvement in ca level and pth so the risk of high mortality still high so need surgical parathyroidectomy
E. Surgery PTx because of failure of conservative treatment.
F. PTX is more effective in reducing mortality compared to cinacalcet
(Prospective cohort study of japanese society of dialysis therapy data registery
https://pubmed.ncbi.nlm.nih.gov/35277957/
Conclusion: PTx compared with cinacalcet is associated with a lower risk of mortality, particularly among patients with severe secondary hyperparathyroidism.
E. Suggest a management plan for this patient.F. Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidence.
the pt. not responding to medical treatment
Still hypercalcemia and HPTH
refractory to medical conservative managment with cinacalcit and biphsphonate
so indication for parathyrodectomy
E. Suggest a management plan for this patient.failed medical treatment for management of hyperparathyroidism and rising serum calcium >>indication for parathyroidectomy
F. Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBDCinacalcet improved the biochemical parameters in CKD patients, but did not improve all-cause mortality and cardiovascular mortality. Moreover, cinacalcet can cause some adverse events.
Tx leads to a normalization of both serum calcium and PTH concentrations. sPTX was associated with decreased all-cause mortality
Suggest a management plan for this patient.
Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidence.
E. Suggest a management plan for this patient.The patient now has hyperparathyroidism and hypercalcemia refractory to medical treatment.
the remaining option is surgery(parathyroidectomy)
F. Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidence.
The research showed that surgery outperformed Cinacalcet in terms of survival after 10 years.
Parathyroidectomy in ESRD patients has high perioperative hazards, including a 2% 30-day postoperative death rate in the literature and a 3.7% rate in our research.
Clinicians follow KDIGO recommendations and only send severely refractory patients for surgery because of these risks.
While Cinacalcet has been shown to lower PTH levels and improve calcium-phosphorus homeostasis, it failed to reduce the risk of death or major cardiovascular events, as shown in the EVOLVE trial.
Parathyroidectomy is associated with overall better survival than Cinacalcet in patients with secondary hyperparathyroidism on hemodialysis. Surgery should be strongly considered particularly in patients with PTH levels higher than 1000 pg/dL.
E.Suggest a management plan for this patient.
F.F. Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidence.-The key message is to start early medical treatment to avoid parathyrodiectomy
E- Suggest a management plan for this patient.
prepare for surgical parathyroidectomy . calcitonin .
gallium nitrat
prostaglandine
F. Cinacalcet versus surgical parathyroidectomy in patients with CKD-MBD: summarize the current evidence.
study done to compare the long-term outcomes between cinacalcet and parathyroidectomy in the treatment of hyperparathyroidism in CKD .
The study showed that parathyroidectomy is prefer to correct the hypercalcemia and improving CKD-MBD.
guidelines also recommend treatment of hyperparathyroidism by parathyroidectomy in patient fail to respond to medical therapy