Parathyroidectomy for tertiary hyperparathyroidism after second kidney transplantation: a case report
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CASE REPORT
Parathyroidectomy for tertiary hyperparathyroidism after second kidney transplantation: a case report Chiaki Masaki1 · Shoto Ogawa1 · Hisato Shima2 · Taro Banno3 · Masaru Tsuyuguchi4 · Naoki Nagasaka3 · Manabu Tashiro2 · Tomoko Inoue2 · Hiroaki Tada1 · Seiichiro Wariishi5 · Keiko Miya6 · Kazuhiko Kawahara2 · Norimichi Takamatsu1 · Kazuyoshi Okada2 · Jun Minakuchi2 Received: 19 August 2020 / Accepted: 4 October 2020 © Japanese Society of Nephrology 2020
Abstract Successful kidney transplantation usually resolves secondary hyperparathyroidism (SHPT). However, some patients fail to normalize, and their condition is often referred to as tertiary hyperparathyroidism (THPT). Surgical consensus on the timing of post-transplant parathyroidectomy (PTX) for THPT has not been reached. Herein, we report a case of a 58-yearold post-transplant woman, considering the concrete timing of PTX for both SHPT and THPT. She initiated hemodialysis with end-stage renal disease at the age of 24, and underwent first kidney transplantation at the age of 28. When peritoneal dialysis (PD) was induced due to the worsening kidney function at the age of 50, the serum intact parathyroid hormone (iPTH) level remarkably increased (2332 pg/mL). Although cinacalcet was administered, the patient’s iPTH levels were not sufficiently suppressed for seven years. Diagnostic images including ultrasound, computed tomography, and 99mTc-methoxyisobutylisonitrile scintigraphy indicated THPT as the reason for prolonged post-transplant hypercalcemia. Therefore, PTX was performed 14 months after the second transplantation. Histology showed nodular hyperplasia of all parathyroid glands, indicating autonomous secretion of parathyroid hormone. In general, patients with more severe THPT are recognized with more severe SHPT prior to transplantation during the dialysis period. We should consider a referral for surgery based on the individual risk factors. We recommend to perform parathyroidectomy earlier, before the kidney transplantation in the clinical suspicion of severe SHPT. Keywords Secondary hyperparathyroidism · Tertiary hyperparathyroidism · Hypercalcemia · Parathyroidectomy · Second kidney transplantation
Introduction * Hisato Shima [email protected] 1
Department of Laboratory, Kawashima Hospital, 1‑39 Kitasakoichiban‑cho, Tokushima 770‑0011, Japan
2
Department of Kidney Disease, Kawashima Hospital, 1‑39 Kitasakoichiban‑cho, Tokushima 770‑0011, Japan
3
Department of Urology, Kawashima Hospital, 1‑39 Kitasakoichiban‑cho, Tokushima 770‑0011, Japan
4
Department of Surgery, Kawashima Hospital, 1‑39 Kitasakoichiban‑cho, Tokushima 770‑0011, Japan
5
Department of Cardiovascular Surgery, Kawashima Hospital, 1‑39 Kitasakoichiban‑cho, Tokushima 770‑0011, Japan
6
Department of Internal Medicine, Kawashima Hospital, 1‑39 Kitasakoichiban‑cho, Tokushima 770‑0011, Japan
Secondary hyperparathyroidism (SHPT) commonly occurs in patients with end-stage renal disease. The mechanism remains unclear but is involved in calcium, phosphorus, and v
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