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?
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
F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
G. What would be your next management plan for this patient?
F- secondary hyperparathyroidism that does not respond to medical treatment
G- calcium and calcitriol and regular monitoring vitamind d calcium pth
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.
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.
A- surgery is indicate for tertiary hyperparthyrdosim or 2nd not response to medical treatment
b need to follow ca phos and pth
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.
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
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
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.
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
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 .
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
The rationale of parathyroidectomy in ESKD with secondary parathyroidectomy
Further management should include
Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
What would be your next management plan for this patient?
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.
F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
G. What would be your next management plan for this patient?
Hungry Bone Disease
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.
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
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
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
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
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 .
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
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.
very good dr Weam
plan of management
post parathyroidectomy care – avoid Hungary bone
investigation
ca , pi. alp . vitD
Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
-It has certain indications:
G. What would be your next management plan for this patient?
Excellent dr Ben.
F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
parathyroidectomy done with
G. What would be your next management plan for this patient?
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
F. Discuss the rationale of parathyroidectomy in patients with ESKD and hyperparathyroidism.
G. What would be your next management plan for this patient?
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
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