Kemerovo Regional Clinical Hospital,

Kemerovo, Russia

 

The number of patients receiving renal replacement therapy is significant. Improvement in dialysis technique and adequate drug provision allow increasing life period by many years in this large group of patients. However, over time, secondary (renal) hyperparathyroidism (SHPT) develops in 40-70 %, with significant worsening quality of life and shortening life time [7, 8, 9].

According to the leading role of parathyroid glands (PTG) in SHPT pathogenesis it is generally accepted to perform subtotal parathyroidecomy (PTE) or total PTE with tissue autografting from one PTG to the forearm muscles, if conservative therapy is ineffective [3, 5, 8].

We believe that saving PTG tissue results in recurrent SHPT in case of continuing dialysis therapy. It is supported by many authors who perform subtotal or total PTE with autografting, with recurrence rate of 10-83 % during 3 or, more rarely, 4-5 years of observation [1, 4, 6]. On the basis of this fact, we perform total PTE for all patients with severe renal hyperparathyroidism in our clinic [2]. There is no complex long term estimation of patients’ state after such surgery volume in the available literature.

Objective – to show the efficiency of total PTE on the basis of complex estimation of hemodialysis patients’ state before and after intervention. 

 

 MATERIALS AND METHODS

During 2002-2013 52 patients with SHPT were operated (20 men, 32 women). The age was 42.3 ± 1.6. The presurgical duration of dialysis period was 7.8 ± 0.59. In 35 patients the terminal chronic renal insufficiency was the result of chronic glomerulonephritis, in 8 patients – polycystic kidney, in 4 – congenital dysplasia and ureter structure, in 3 ‒ chronic pyelonephritis, in 2 ‒ diabetic nephropathy and Alport's syndrome. For all patients total PTE was carried out. After hospital discharge the analysis of results of surgery was performed. 2 and 3 patients who died in early and late period correspondingly were excluded from the analysis. In 2 patients the causes of death were acute cerebrovascular accident and acute cardiac insufficiency at the background of intestinal bleeding. 5 years after surgery 1 patient died because of progressing renal insufficiency at the background of virus hepatitis C and 2 ‒ from acute cerebrovascular accident. Dialysis therapy period was 11, 12 and 15 years, but 17 years in 2 patients.

The state of the patients was estimated in clinical (frequency of SHPT symptoms) and laboratory conditions. Parathyroid hormone (PTH) monitoring was realized for all patients before surgery, as well as monitoring of phosphorus, total and ionized calcium, hemoglobin. Also PTG ultrasound, scintigraphy, X-ray, bone densimetry and coronary calcium scoring were performed.

The statistical analysis was performed with STATISTICA 6.0. Arithmetic mean (M), standard deviation (σ), error of mean (m) and significance level (p) were estimated.

For complex estimation of each patient’s state we calculated integral value: weighted total values which characterize presence of different symptoms in a patient.

The presurgical and postsurgical values for each patient were compared with Wilcoxon test.

For qualitative interpretation of integral values Harrington’s psychophysical scale was used.

During one-way analysis of variance we compared mean values characterizing subjective estimate (by patients) of health before and after surgery.

The performed study corresponds to the ethic standards of the bioethics committee and was approved by the chairman of the committee of ethics and medical research substantiation, Kemerovo State Medical Academy, protocol number 78/k from 06.04.2011.

RESULTS AND DISCUSSION

47 patients were observed during the period from 10 months to 11 years. The total weight of removed PTG varied from 0.67 to 11 g (4.4 ± 0.4 g). 4 PTG were removed in 39 cases, 3 ‒ in 9 cases, 2 ‒ in 3 cases, 1 ‒ in 1 case.

Clinically, all patients noted significant improvement of health already in the early postsurgical period and it persisted during the whole period of observation.

The integral value summarizing the main SHPT symptoms in each patient was 0.787 before surgery, 0.143 ‒ in early postsurgical period (p = 0.0000001) (table 1).

Table 1

Descriptive statistic values characterizing comprehensive evaluation of patients' state before surgery and in early terms after it

The same values (as application for each SHPT symptom) are reflected in frequency bar charts (Fig. 1, 2).

Figure 1

The histogram of frequency of values of comprehensive assessment of patients’ state before surgery

Figure 2

The histogram of frequency of values of comprehensive assessment of patients’ state in early period after surgery

The presented histogram (Fig. 1) shows the integral value of 0.6-1.0 in 41 patients. It corresponds to presence of SHPT symptoms in most patients. Conversely, it was near 0 or 0 in 42 patients after total PTE. It means disappearance or significant decrease in clinical manifestations of the disease (Fig. 2).

Table 2
Values of comprehensive evaluation of patients' state according to intervals of Harrington's scale in the groups of patients before and after surgery

We distributed the integral value of complex estimation of patients’ state into the intervals of Harrington’s linguistic scale and compared pre- and postsurgical values (table 2) that allowed transferring the values to the linguistic scale, where, as an example, the value of patient’s state 0.38 corresponds to middle severity, and 0.82 – very bad state.

The analysis of the results in the table 2 showed that the absolute majority of the patients evaluated their presurgical state as bad or very bad, and, conversely, after total PTE ‒ as good and very good.

Comparing the clinical manifestations of SHPT in the long term postsurgical period and the presurgical frequency, we received the following results (table 3).

Table 3
The frequency of SHPT before total PTI and in long term period after it

Skin itching disappeared and gait improved in all patients, as well as no pathologic fractures were found; in 95 % of the cases pain in bones, joints and muscles disappeared; in 85 % of the cases arterial pressure normalized.

Because of significant differences in follow-up terms, we compared the mean values characterizing patients’ subjective estimation of their health before PTE and after 1, 1-3, 3-5 and 5-11 years. Here we used one way analysis of variance and presented the results in graphic view (Fig. 3).

Figure 3

The diagram of mean values of complex assessment of patients’ state before and after   parathyroidectomy in the groups with different terms after surgery

 

One way analysis of variance showed that the good effect of total PTE does not depend on observation terms.     

CONCLUSION

The performed study showed that good and very good state of patients persisted during the whole follow-up period (from 10 months till 11 years). It allows considering total parathyroidecomy as the most effective method for treatment of secondary (renal) hyperparathyroidism.