Evaluación de la función paratiroidea en el injerto subcutáneo preesternal tras paratiroidectomía total en el hiperparatiroidismo renal

Material y método Estudio realizado en un hospital universitario y su unidad de diálisis. Diseño: estudio prospectivo sobre la eficacia del procedimiento mediante determinación de paratirina intacta (iPTH) en una cohorte de pacientes quirúrgicos sin pérdida en el seguimiento. Pacientes e intervenciones: 35 (19 mujeres y 16 varones) fueron sometidos a TPT y SCPTx por RHP en el Departamento de Cirugía y Servicio de Nefrología, Hospital de Donostia (San Sebastián, Gipuzkoa, España), entre enero de 2002 y diciembre de 2005. El seguimiento ha variado entre 6 y 42 (media, 15,4) meses. Se evaluó la función del injerto mediante la determinación de las concentraciones plasmáticas de iPTH antes de la operación y 24 horas y 1, 3, 5, 15, 30, 60, 100, 150 y 200 semanas después. Los valores de referencia para la PTH en nuestro laboratorio fueron de 20-65 pg/ml. Resultados Los valores medios preoperatorios ± desviación estándar de iPTH fueron de 1.245 ± 367,9 (rango, 493-2.160) pg/ml. Después de la TPT y el SCPTx, las concentraciones de iPTH llegaron a ser indetectables en todos los casos a las 24 horas. Se estableció 50 pg/ml como criterio de función adecuada de injerto paratiroideo. Los valores obtenidos fueron: 15,54 ± 10,61 (rango, 6-44) pg/ml a la semana, 57,2 ± 1,9 (rango, 43-74) pg/ml a las 5 semanas, 64,21 ± 9,73 (rango, 11,3-89) pg/ml a las 15 semanas, 75,12 ± 9,05 (rango, 24,6-104,2) pg/ml a las 30 semanas, 101,63 ± 19,85 (rango, 65-143) pg/ml a las 60 semanas, 121,63 ± 27,85 (rango, 62-179) pg/ml a las 100 semanas, 63 ± 19,85 (rango, 68-723) pg/ml a las 150 semanas y 102 ± 18,65 (rango, 68-113) pg/ml a las 200 semanas. La frecuencia de hipoparatiroidismo (concentración de iPTH en suero < 20 pg/ml con una concentración normal o baja de calcio en suero) fue 2/35 (5,71%) a la semana 60, y se recuperó para la semana 100. La recidiva relacionada con el injerto fue del 2,85% (1/35). Conclusiones El trasplante subcutáneo preesternal tras paratiroidectomía total y trasplante paratiroideo para el hiperparatiroidismo renal secundario parece un método adecuado como alternativa al trasplante muscular antebraquial y para evitar sus complicaciones. Los resultados funcionales del injerto se comparan favorablemente con los datos publicados sobre otras técnicas quirúrgicas utilizadas para el tratamiento del hiperparatiroidismo renal. El seguimiento a largo plazo de la serie está en curso. Introduction In the setting of total parathyroidectomy (TPT) and parathyroid transplantation (PTx) for renal hyperparathyroidism (RHP), we evaluated long-term parathyroid graft function after subcutaneous presternal transplantation (SCPTx). Hypothesis: Parathyroid glands are surrounded by fatty tissue. Therefore, we postulated that subcutaneous implantation of parathyroid tissue after TPT for RHP could be at least as effective as intramuscular grafting and would avoid the complications of the latter technique. Material and method We performed a study in a university hospital and its dialysis unit. Design: Prospective open efficacy study of a postoperative diagnostic monitoring method of intact parathyroid hormone (iPTH) in a cohort of surgical patients without loss to follow-up. Patients and interventions: Thirtyfive patients (19 women and 16 men) underwent TPT and SCPTx for RHP at the Department of General Surgery and Department of Nephrology, Donostia Hospital, San Sebastián, Gipuzkoa, Spain, from January 2002 to December 2005. Follow-up ranged from 6 to 42 months (mean, 15.4 months). Graft function was evaluated by measurement of plasma iPTH levels before surgery and 24 hours and 1, 3, 5, 15, 30, 60, 100 and 150 weeks after surgery. Reference values for PTH in our laboratory were 20-65 pg/mL. Results The mean preoperative iPTH values were 1245 ± 367.9 pg/mL (mean ± SD) (range, 493-2160). After TPT and SCPTx, iPTH levels became undetectable in all patients at 24 hours. A value of 50 pg/mL was established as the criterion for adequate parathyroid graft function. The following values were obtained: 15.54 ± 10.61 pg/mL (mean ± SD) (range, 6-44) after 1 week, 57.2 ± 1.9 pg/mL (mean ± SD) (range, 43-74) after 5 weeks, 64.21 ± 9.73 pg/mL (mean ± SD) (range, 11.3-89) after 15 weeks, 75.12 ± 9.05 pg/mL (mean ± SD) (range, 24.6-104.2) after 30 weeks, 101.63 ± 19.85 pg/mL (mean ± SD) (range, 65-143) after 60 weeks, 121.63 ± 27.85 pg/mL (mean ± SD) (range, 62-179) after 100 weeks, 63 ± 19.85 pg/mL (mean ± SD) (range, 68-723) after 150 weeks and 102 ± 18.65 pg/mL (mean ± SD) (range, 68-113) after 200 weeks. The prevalence of hypoparathyroidism (serum iPTH level of < 20 pg/mL with a normal or low serum calcium concentration) was 2 out of 35 patients (5.71%) by week 60, with recovery of normal values by week 100. Graft-related recurrence occurred in one out of 35 patients (2.85%). Conclusions SCPTx after TPT and PTx for secondary RHP is an adequate method to replace muscular forearm parathyroid transplantation and avoid its complications. The functional results of TPT and SCPTx compare favorably with published data on other surgical techniques proposed for the treatment of RHP. Long-term follow-up of this series is currently being performed. Palabras clave Hiperparatiroidismo renal Paratiroidectomía iPTH Key words Renal hyperparathyroidism Parathyroidectomy iPTH Bibliografía 1. S.A. Wells Jr J.C. Gunnells J.D. Shelburne A.B. Schneider L.M. Sherwood Transplantation of parathyroid glands in man: clinical indications and results Surgery 78 1975 34 44 2. J.A. Olson Jr G.S. Leight Jr Surgical management of secondary hyperparathyroidism Adv Ren Replace Ther 9 2002 209 218 3. S. Ockert F. Willeke A. Richter J. Jonescheit P. Schnuelle F. Van Der Woude Total parathyroidectomy without autotransplantation as a standard procedure in the treatment of secondary hyperparathyroidism Langenbecks Arch Surg 387 2002 204 209 4. J.M. Monchik C. Bendinelli M.A. Passero Jr K.K. Roggin Subcutaneous forearm transplantation of autologous parathyroid tissue in patients with renal hyperparathyroidism Surgery 126 1999 1152 1158 5. P. Kinnaert C. Tielemans M. Dhaene C. Decoster-Gervy Evaluation of surgical treatment of renal hyperparathyroidism by measuring intact parathormone blood levels on first postoperative day World J Surg 22 1998 695 699 6. S. Jansson L.E. Tisell Autotransplantation of diseased parathyroid glands into subcutaneous abdominal adipose tissue Surgery 101 1987 549 556 7. P. Kinnaert L. De Pauw L. Hooghe Subcutaneous parathyroid autografts Surgery 125 1999 462 463 8. F.F. Chou H.M. Chan T.J. Huang C.H. Lee K.T. Hsu Autotransplantation of parathyroid glands into subcutaneous forearm tissue for renal hyperparathyroidism Surgery 124 1998 1 5 9. K.A. Skinner L. Zuckerbraun Recurrent secondary hyperparathyroidism. An argument for total parathyroidectomy Arch Surg 131 1996 724 727 10. P. Kinnaert I. Salmon C. Decoster-Gervy A. Vienne L. De Pauw L. Hooghe Long-term results of subcutaneous parathyroid grafts in uremic patients Arch Surg 135 2000 186 190 11. M. Echenique Elizondo J. Diaz Aguirregoitia J.A. Amondarain F. Vidaur Parathyroid graft function after total parathyroidectomy and subcutaneous presternal transplantation for renal hyperparathryroidism Arch Surg 141 2006 33 38 12. M. Echenique Elizondo J. Diaz Aguirregoitia J.A. Amondarain F. Vidaur Intraoperative iPTH determination in parathyroidectomy for renal hyperparathryroidism as indicator of complete parathyroid removal World J Surg 29 2005 1504 1509 13. F.F. Chou C.H. Lee J.B. Chen K.T. Hsu S.M. Sheen-Chen Intraoperative parathyroid hormone measurement in patients with secondaryhyperparathyroidism Arch Surg 137 2002 341 344 14. H. Yamashita P. Gao T. Cantor S. Noguchi S. Uchino S. Watanabe Comparison of parathyroid hormone levels from the intact and whole parathyroid hormone assays after parathyroidectomy for primary and secondary hyperparathyroidism Surgery 135 2004 149 156 15. D. Ljutic J.S. Cameron C.S. Ogg C. Turner J.A. Hicks W.J. Owen Long-term follow-up after total parathyroidectomy without parathyroid reimplantation in chronic renal failure Q J Med 87 1994 685 692 16. M. Kaye Parathyroid surgery in renal failure: a review Semin Dial 3 1990 86 92 17. L. Knudsen L. Brandi H. Daugaard K. Olgaard K. Lockwod Five to 10 years follow-up after total parathyroidectomy and autotransplantation of parathyroid tissue: evaluation of parathyroid function by use of ischaemic blockade manoeuvre Scand J Clin Lab Invest 56 1996 47 51 18. P. Nichols J.P. Owen H.A. Ellis J.R. Farndon P.J. Kelly M.K. Ward Parathyroidectomy in chronic renal failure: a nine-year follow-up study Q J Med 283 1990 1175 1193 19. J.D. Punch N.W. Thompson R.M. Merion Subtotal parathyroidectomy in dialysis-dependent and post-renal transplant patients: a 25-year single-center experience Arch Surg 130 1995 538 542 20. D.B. Jovanovic S. Pejanovic L. Vukovic L. Djukanovic R. Jankovic N. Kalezic Ten years’ experience in subtotal parathyroidectomy of hemodialysis patients Ren Fail 27 2005 19 24 21. R.M. Higgins A.J. Richardson P.J. Ratcliffe C.G. Woods D.O. Oliver P.J. Morris Total parathyroiddectomy alone or with autograft for renal hyperparathyroidism Q J Med 88 1991 323 332 22. M.L. Nicholson P.S. Veitch J. Feehally Parathyroidectomy in chronic renal failure: comparison of three operative strategies J R Coll Surg Edinb 41 1996 382 387 23. P. Ureña M. Kubrusly M. Mannstadt E. Drüeke T. Sarfati Total or subtotal parathyroidectomy in uremic patients? Clin Nephrol 41 1994 59 60 24. M. Milas C.J. Weber Near-total parathyroidectomy is beneficial for patients with secondary and tertiary hyperparathyroidism Surgery 136 2004 1252 1260 25. M.E. Cohen Solal J.L. Sebert B. Boudailliez Comparison of intact, mid region, and carboxyterminal assays of parathyroid hormone for the diagnosis of bone disease in hemodialyzed patients J Clin Endocrinol Metab 73 1991 516 524 26. L.D. Quarles B. Lobaugh G. Murphy Intact parathyroid hormone overestimates the presence and severity of parathyroid mediated osseous abnormalities in uremia J Clin Endocrinol Metab 75 1992 145 150 27. A. Torres V. Lorenzo D. Hernández Bone disease in predialysis, hemodialysis and CAPD patients: evidence of a better bone response to PTH Kidney Int 47 1995 1434 1442 28. P. Kinnaert I. Salmon C. Decoster-Gervy Total parathyroidectomy and presternal subcutaneous implantation of parathyroid tissue for renal hyperparathyroidism Surg Gynecol Obstet 176 1993 135 138 29. V. Pino Rivero M. Marcos Garcia G. Trinidad Ruiz T. Keituqwa Yanez C. Montero Garcia E. Rejas Ugena Hyperparathyroidism due to chronic renal failure. Analysis of 32 operated patients An Otorrinolaringol Ibero Am 31 2004 549 556 30. Y. Hibi Y. Tominaga K. Uchida H. Takagi T. Imai H. Funahashi Cases with fewer than four parathyroid glands in patients with renal hyperparathyroidism at initial parathyroidectomy World J Surg 26 2002 314 317 31. M. Rothmund P.K. Wagner C. Schark Subtotal parathyroidectomy versus total parathyroidectomy and autotransplantation in secondary hyperparathyroidism: a randomized trial World J Surg 15 1991 745 750 32. L. Falvo A. Catania S. Sorrenti V. D’Andrea M. Santulli E. De Antoni Relapsing secondary hyperparathyroidism due to multiple nodular formations after total parathyroidectomy with autograft Am Surg 69 2003 998 1002 33. K. Schlosser A. Zielke M. Rothmund Medical and surgical treatment for secondary and tertiary hyperparathyroidism Scand J Surg 93 2004 288 297 34. B. Niederle H. Horandner R. Roka W. Woloszczuk Morphological and functional studies to prevent graft dependent recurrence in renal osteodystrophy Surgery 106 1989 1043 1048 35. C.H. Wallfelt R. Larsson E. Gylfe S. Lunghall J. Rastad G. Akerström Secretary disturbance in hyperplastic parathyroid nodules of uremic hyperparathyroidism: implication for parathyroid autotransplantation World J Surg 12 1988 431 438 36. U. Neyer H. Hoerandner A. Haid G. Zimmermann B. Niederle Total parathyroidectomy with autotransplantation in renal hyperparathyroidism: low recurrence after intra-operative tissue selection Nephrol Dial Transplant 17 2002 625 629 37. E.R. Gagné P. Ureña S. Leite-Silva J. Zingraff A. Chevalier E. Sarfati Short- and long-term efficacy of total parathyroidectomy with immediate autografting compared with subtotal parathyroidectomy in hemodialysis patients J Am Soc Nephrol 3 1992 1008 1017 38. T. Akizawa E. Kinugasa T. Akiba Y. Tsukamoto M. Kurokawa Incidence and clinical characteristics of hypoparathyroidism in dialysis patients Kidney Int 52 Suppl 62 1997 S72 S74 39. Q. Quanle M. Monier-Fauchere Z. Geng H. Malluche Predictive value of serum parathyroid levels for bone turnover in patients on chronic maintenance dialysis Am J Kidney Dis 26 1995 622 631 40. R.S. Sippel Y.T. Becker J.S. Odorico S.R. Springman H. Chen Does propofol anesthesia affect intraoperative parathyroid hormone levels? A randomized, prospective trial Surgery 136 2004 1138 1142 41. Y. Berland M. Charbit J.F. Henry M. Toga J.P. Cano M. Olmer Aluminum overload of parathyroid glands in haemodialysed patients with hyperparathyroidism: effect on bone remodeling Nephrol Dial Transplant 3 1988 417 422