Scenario 1 - Part 3:

The patient presented again 10 months later with an i-PTH of 1723 pg/mL. He again reported non-adherence to his medications through the past few months. Neck US revealed a large hypoechoic hypervascular mass suggestive of parathyroid adenoma. The patient underwent total parathyroidectomy (PTx) with auto-transplantation to his right forearm. After PTx, his serum i-PTH levels decreased to 30 pg/mL. 

 

F. Discuss the rationale of parathyroidectomy in patients with ESKD and  hyperparathyroidism.

G. What would be your next management plan for this patient?

36 Comments

  • Radwa Ellisy


    It is indicated if failed medical treatment in secondary hyperparathyroidism or in tertiary hyperparathyroidism 
    -supplementation with calcitriol and calcium with frquent monitoring of calcium, ohosphorus and iPTH

  • Amna Kununa


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.

    • As per the guideline, we suggest parathyroidectomy in patients with CKD G3a–G5D with severe hyperparathyroidism who fail to respond to medical or pharmacological therapy (2B).
    • Among such patients, parathyroidectomy may reduce mortality, cardiovascular risk, and fracture risk, although benefits have only been shown in observational studies.

    G. What would be your next management plan for this patient?

    • ESKD patients are more likely to develop transient hypocalcemia after parathyroid surgery due to hungry bone syndrome.
    • Many institutions have protocols in place to administer preoperative Calcitriol and postoperative intravenous Ca, along with oral Ca, Mg, and vit D when necessary.
    • Discharged home on an aggressive oral Ca and vit D replacement regimen.
  • Muhammad Soobadar


    F- secondary hyperparathyroidism that does not respond to medical treatment
    G- calcium and calcitriol and regular monitoring vitamind d calcium pth

  • Asma Aljaberi


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
    In cases of tertiary hyperprathyroidism or secondary hyperparathyroidism not responding to conventional medical treatment, parathyroidectomy is recommended. parathyroidectomy has a positive effect on CKD-MBD and CVS.

    G. What would be your next management plan for this patient?

    Close monitoring of Ca corrected, Phosphate and magnesium as the patient has a high risk of hungary bone syndrome. Such patient needs ICU admission post surgery for IV calcium gluconate infusion and close monitoring of Ca Q3 hrs during first 48 hrs.

  • Mohamed Abdulahi Hassan


    Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
    patients with ESKD with severe hyperparathyroidism with symptoms or PTH >800 should undergo parathyroidectomy for better outcome.
    What would be your next management plan for this patient
    patients phosphate calcium , vitamin D and pth should be monitored. and should give oral calcium and calcitriol.

  • Khaldon Rashed Ahmed Moqbil


    A- surgery is indicate for tertiary hyperparthyrdosim or 2nd not response to medical treatment
    b need to follow ca phos and pth

  • Rania Mahmoud


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.Parathyroidectomy is considered in secondary hyperparathyroidism not responding to medical therapy and in tertiary hyperparathyroidism
    It could improve survival by lowering cardiovascular calcifications and fracture risk.
    G. What would be your next management plan for this patient?Monitor serum calcium , phosphorus , magnesium , PTH and bone specific alkaline phosphatase
    The patients should be maintained on oral calcium and calcitriol. Calcitriol is used for correction of both hypocalcemia and hypophosphatemia.

  • Alaa Abdel Nasser


    Parathyroidectomy is considered in secondary hyperparathyroidism not responding to medical therapy and in tertiary hyperparathyroidism

    monitor serum calcium , phosphorus , pth and bone specific alkaline phosphatase

  • Mahmud ISLAM


    Searching for adenoma or hyperplasia is needed, sometimes reported as normal. Because of the risk of osteoporosis, partial or total parathyroidectomy is needed. After the operation, hungry bone syndrome may occur so we need to monitor closely

  • Rabab Elrefaey


    Answers of the last part of this case:

    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
    Parathyroidectomy is indicated in patients with refractory secondary hyperparathyroidism  who fail with medical treatment and tertiary hyperparathyroidism. It might be associated with better survival, reducing cardiovascular calcifications and risk of fracture

    G. What would be your next management plan for this patient? 
    Serum calcium, phosphorus and magnesium should be monitored post parathyroidectomy. The patients should be maintained on oral calcium and calcitriol. Calcitriol is used for correction of both hypocalcemia and hypophosphatemia.

  • Abdulrahman Almutawakel


    PARATHYROIEDECTOMY INDICATED WHEN THERE IS FAILURE OF MEDICAL TREATMENT DUE TO EATHER NONADHERENCE OR PRIMARY FAILURE OR IF THERE IS TERTIARY HYPERPARA OR ADENOMA
    PLAN OF MANAGMENT NOW CLOSED OBSERVATION FOR CALCIUM , PHOSPHOROUS ,AND PTH WITH CALCIUM SUPPLEMENTATAION AND NITAMIN D ANALOG

  • Asmaa Salih KHUDHUR


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.Parathyroidectomy indicated either after failure of medical treatment
    or in case of tertiary hyperparathyroidism.
    G. What would be your next management plan for this patient?we must wait for the transplanted tissue to grow and work , so monitoring of ca , p , ALP and iPTH regularly .
    if the problem worsen, which mean the development of Hungary bone disease with failure of transplanted tissue, we should use calcium supplementation and calcitriol and even the use of teriparatide to improve BMD .

  • Israa Hammoodi


    F. Parathyroidectomy adviced is in patient with severe hyperparathyroidism and tertiary hyperparathyroidism.
    Is over the calcimimetic drug
    G. This is low PTH
    Monitor s. Ca, phosphorous, Alkaline phosphotase
    Stop calcimimetic drug, give calcium and vitamin D in case of suspecion of hungery bone disease
    Repeate PTH regularly

  • KAMAL ELGORASHI


    The rationale of parathyroidectomy in ESKD with secondary parathyroidectomy

    • Parathyroidectomy is the standard option in case of failure of managing to severe sHPT or tertiary hyperparathyroidism.
    • It is proven t be a potent therapy for uncontrolled hyperparathyroidism over cinacalcet treatment
    • Uncontrolled hyperparathyroidism can lead to bone loss and high risk of fracture and increased mortality.
    • Post-parathyroidectomy care should be done for controlling calcium levels and bone hungry syndrome.
    • Careful monitoring of calcium, PTH, and vitD levels with calcium and dvitD supplements.
    • Careful evaluation for a bone profile to avoid ABD, post parathyroidectomy.

    Further management should include

    • Frequent monitoring of bone profile, PTH, and calcium. Pi, and vitD levels.
    • Calcium and vitD supplements, to avoid bone hungry syndrome.
    • Avoid ABD.
  • Mahmoud Elsheikh


    Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.

    1. Tertiary/autonomous hyperparathyroidism
    2. Failure in response to medical therapy.

     What would be your next management plan for this patient?

    • Osteoanabolic agents such as teriparatide may be attempted to improve BMD.
  • Nour Al Natout


    F. Parathyroidectomy is indicated because of medical treatment failure due to monoclonal transformation to adenoma. VDR and calcium receptors are not more sensitive.

    G. Measure regularly Vitamin D level, pth and calcium phosphorus and ALP level.
    Vitamin D substitution and calcium are very important. The patient should understand that if he continues to be incompliant, he can suffer from cardiac arrythmia, tetany , seizure due to hypocalcemia.

  • Riaan Flooks


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.

    • Indications for Pararthyroidectomy:
    • Tertiary Hyperparathyroidism
    • Medical Failure of secondary hyperparathyroidism

    G. What would be your next management plan for this patient?

    • Monitor Ca, PO4, PTH and 25(OH)D – for Hunfry Bone disease
  • MOHAMMED HAJI HASSAN


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
    Autonomous hyperparathyroidism which fails to respond to the medication is indicated for parathyroidectomy.

    G. What would be your next management plan for this patient?
    Monitor ca, phosphate, PTH and vitamin D
    observe complications such as Hungry Bone disease, give Active Vitamin D, calcium to control the complications.

  • Rabab ALaa Eldin keshk Rabab


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
    It’s indicated mainly for patients with tertiary hyperparathyroidism as they will not respond to medical therapy.
    Parathyroidectomy is also an option for SHPT not responding to medical ttt or patient cannot tolerate the madications
    G. What would be your next management plan for this patient?
    with this level of PTH the patient will suffer from bone hungry disease due to,hypocalcemia. the patient will need high dose of calcitrol and calcium supplemtntation and close monitoring of ca po4 pth mg

  • HASSAN ALYAMMAHI


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
    Patients with tertiary hyperparathyroidism should undergo parathyroidectomy, as they will not respond to medical therapy.
    Parathyroidectomy is also an option for SHPT NOT responding to medical therapy

    G. What would be your next management plan for this patient?
    Patient’s iPTH may pick-up to normal within the next few weeks, we should wait during this period, keeping eyes on Ca, PO4, and iPTH.
    If this iPTH continues to be low and we detect ABD, then we may consider Teriparatide

  • Emad mohamed mokbel Salem


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.refractory hyperparathyroidism with hypercalcemia after falire of medications

    G. What would be your next management plan for this patient?
    fu bone profile (serum calcium )
    and replace by calcium and calcitriol

  • Rihab Elidrisi


    Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.Surgical is the preferred method for refractory HPTH in a symptomatic patient with persistent PTH elevation.

     What would be your next management plan for this patient?post-surgery, the patient will have which is called hungry bone syndrome with severe hypocalcemia,at this stage, we need to start them on high dose of calcium and calcitriol

  • Ahmed Altalawy


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism. Refractory patients not responding to medications are candidate for parathyroidectomy
    G. What would be your next management plan for this patient? monitoring of calcium , P and Mg .
    follow up PTH mostly will improve with time .

  • Ahmed Wagih


    the decision of parathyroidectomy will depend on the constellation of clinical parameters and PTH level,so we can divide these patients into into main groups:- asymptomatic and symptomatic. regarding asymptomatic patients with high level > 1000pm/ml, parathyroidectomy is considered wise. symptomatic patients (hypercalcemia, bony pain ), should considered for parathyroidectomy if refractory to treatment and level is presistenlty elevated above 800pm/ml.
    What would be your next management plan for this patientwith this level of PTH the patient will suffer from adynamic bone disease,hypocalcemia. the patient will need high dose of calcitrol and calcium supplemtntation

  • Weam El Nazer


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
    Refractory hyperparathyroidism has no agreed-upon PTH level. In symptomatic individuals, parathyroidectomy is commonly recommended for refractory hyperparathyroidism with a PTH >800 pg/mL with the following symptoms:Calciphylaxis 
    Bone pain, pruritus, and myopathy
    hypercalcemia and refractory hyperphosphatemia.

    G. What would be your next management plan for this patient?
    Just needs to wait a few weeks until the proliferation of the implanted gland occurs.
    Follow up on the calcium, PO4, alkaline phosphatase, and PTH.
    The patient will need vitamin D supplements.

  • Elsayed Ghorab


    plan of management
    post parathyroidectomy care – avoid Hungary bone
    investigation
    ca , pi. alp . vitD

  • Ben Lomatayo


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
    -It has certain indications:

    1. Tertiary/autonomous hyperparathyroidism
    2. Or Failure of hyperplastic, overactive gland to suppress adequately in response to medical therapy.

    G. What would be your next management plan for this patient?

    • Unfortunately, this patient’s disease profile is shifted from high turnover to low or adynamic bone disease (ABD)
    • This is one of the serious drawbacks of parathyroidectomy.
    • His auto-transplant of the parathyroid tissue has probably failed, and it is not working for him so far.
    • Usually, this patient is severely hypocalcemic and high doses of calcium and vitamin D supplementations are needed. They may develop the so-called hungry bone syndrome.
    • Osteoanabolic agents such as teriparatide may be attempted to improve BMD.
    • In conclusion, we have treated one disease and now we have to deal with another disease due to the treatment of the former.
  • Ashraf Ahmed Mahmoud


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.

    parathyroidectomy done with

    • persistant SHPT.
    • tertiary hyperparathyroidism.
    • persistantand sever symptoms of HPT.

    G. What would be your next management plan for this patient?
    

    • follow up PTH .S Ca .S. ph. and b ALK ph
    • start Teriparatide therapy in addition to non-calcium based phosphate binders
  • Hagar Ali


    F)Parathyroidectomy is indicated in THPT not responding to conventional medication.
    G) follow up the patient may be his PTH will raise to normal levels due to auto implantation
    If not teriparatide need to be considered to avoid ADBD

  • Ibrahim Omar


    F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.

    • it should be done in tertiary hyperparathyroidism or severe refractory 2ry hyperparathyroidism or intractable pruritis or osteoporotic pathological fractures

    G. What would be your next management plan for this patient?

    • this patient now developed adynamic bone disease and needs Teriparatide therapy in addition to non-calcium based phosphate binders
  • Mark Nagy Zaki Amin Mark


    F- surgical solution is indicated in cases with tertiary hyperparathyroidism with elevated ca and po4 and persistant elevation inspite of medical ttt and sumptoms like pruritis are present
    G – use of PTH analouges as Teriparatide

    • Rabab Elrefaey


      Serum calcium, phosphorus and magnesium should be monitored post parathyroidectomy. The patients should be maintained on oral calcium and calcitriol. Calcitriol is used for correction of both hypocalcemia and hypophosphatemia

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