Evaluation of Parathyroidectomy for Secondary and Tertiary Hyperparathyroidism by the Parathyroid Surgeons' Society of Japan.

Secondary hyperparathyroidism (SHPT) remains a serious complication in patients with chronic kidney disease, and some patients require parathyroidectomy. The Parathyroid Surgeons' Society of Japan (PSSJ) evaluated parathyroidectomy for SHPT and tertiary hyperparathyroidism (THPT) in Japan. The annual numbers of parathyroidectomies between 2004 and 2013 were evaluated using questionnaires. Since 2010, the PSSJ has registered the patients. In total, 826 patients from 42 institutions were registered. The annual number of parathyroidectomies for SHPT and THPT in Japan increased from 2004 to 2007 and then decreased markedly after 2007, with 296 operations performed in 2013. The number of women and men was almost equal (397/427). Median (interquartile range) age of these patients was 59.0 (24-87) years, the duration of hemodialysis before parathyroidectomy was 10.83 (0.0-38.7) years, and diabetic nephropathy was 87/826 (10.5%). Of these patients 59.6% were treated with cinacalcet at undergoing parathyroidectomy. In 75.3% of patients, a total parathyroidectomy with forearm autograft was performed. In 77.7% of patients, four or more parathyroid glands were removed during the initial operation. The incidences of husky voice and wound hemorrhage were 2.9% and 1.1%, respectively. The number of parathyroidectomies for SHPT in Japan decreased markedly after the introduction of cinacalcet. Based on the evaluation of registered patients, parathyroidectomies have been successfully performed at the institutions participating in the PSSJ.

[Effects of raloxifene on bone biomarkers in postmenopausal women on maintenance haemodialysis].

Postmenopausal women on maintenance haemodialysis (MHD) has considerably higher risk of bone fracture than general population with combination of postmenopausal osteoporosis and renal osteodystrophy. However, the treatment of osteoporosis on MHD has not been established. Evidence indicates raloxifene (RLX), a selective estrogen receptor modulator, is effective for a protection of bone fracture without increasing of breast cancer and endometrial cancer. We hereby report short-term use experience of RLX for the postmenopausal MHD patients. Fifteen postmenopausal MHD patients with less than 80% of YAM bone density in DEXA administrated 60 mg RLX on every HD days (3 days/week). Serum NTX level significantly decreased after 6 months (180 +/- 18 vs. 95 +/- 12 nmol/BCE/L, p< 0.05), however, i-PTH did not have the significant difference. (115 +/- 23 vs. 157 +/- 29 pg/mL). RLX is effective for bone biomarker improvement in postmenopausal MHD patients. Further evaluation for the effectiveness and safety of RLX is necessary in the long term.

[Characteristics of the patients who received parathyroidectomy within 5 years after the initiation of hemodialysis].

Thirteen patients, who received parathyroidectomy within 5 years after the initiation of hemodialysis, were discussed on their clinical characteristics and their prognoses. 204 patients received the first parathyroidectomy due to secondary hyperparathyroidism in our department, 13 of which were selected on dialysis duration. 9 patients were female and origin of CRF were analgesics-induced interstitial nephritis in 2 and prune-belly syndrome in 1. There were 2 patients who suffered from renal disease more than 30 years. Concomitant primary hyperparathyroidism was suspected in 1 case. In all cases, PTx achieved adequate control of 2HPT after the operation.

Peculiar histiocytic lesions with massive lanthanum deposition in dialysis patients treated with lanthanum carbonate.

Pathologic lesions caused by lanthanum carbonate (LC), a recently developed phosphate-binding agent, have not been recorded. A peculiar gastroduodenal histiocytic lesion associated with a mucosal lanthanum overload was reported. Our routine gastrointestinal biopsy series included 6 cases with heavy lanthanum burden in the gastroduodenal mucosa. In addition to routine histopathologic examinations, a series of immunohistochemical analysis and electron microscopic examinations associated with x-ray diffraction and elemental analysis were performed. Six cases, 3 of male and 3 of female individuals with ages from 59 to 69 years, were all patients of end-stage renal diseases managed under dialysis and treated with LC for >21 months. Endoscopic examinations demonstrated gastric erosions in 3, gastric polyps in 2, and duodenal ulcer in 1. In the mucosal layer, there were numerous non-Langerhans cell histiocytes, stained with CD68 but not S100 protein, engulfing a large amount of mineral-like materials. An electron microscopic and elemental analysis revealed a similar distribution of lanthanum and phosphorus in the histiocytes. Long-standing LC administration can cause massive mucosal accumulation of lanthanum in the tissue histiocytes associated with several forms of gastroduodenal lesions. A long-standing outcome is not clear at present; hence, careful follow-up studies of these patients may be needed.

Early effects of parathyroidectomy on erythropoietin production in secondary hyperparathyroidism.

BACKGROUND: Secondary hyperparathyroidism (2-HPT) has an adverse effect on renal anemia and may cause a hyporesponsiveness to recombinant human erythropoietin (rHuEpo) in patients with chronic renal failure. The early effects of parathyroidectomy (PTx) on renal anemia, erythropoietin production, and nutritional state were examined. METHODS: Twenty-nine patients under hemodialysis therapy received a PTx for 2-HPT. They were prospectively studied regarding hematological parameters, rHuEpo use, plasma erythropoietin levels, and nutritional condition until 12 months after PTx. RESULTS: The hemoglobin level showed a significant increase from 3 months after PTx (10.2% +/- 1.5% to 11.2% +/- 1.3%; P <0.01), associated with a consistent increase of the reticulocyte count. These changes lasted until 12 months after PTx. The plasma erythropoietin level showed a gradual increase of up to about 5 times the level of the preoperative value, until 12 months after PTx (22.6 +/- 10.1 to 106.3 +/- 112.1 mU/mL; P <0.001). The weekly dose of rHuEpo administration decreased after 3 months. The serum levels of albumin and total protein also significantly and gradually improved until 12 months after PTx. CONCLUSIONS: PTx caused a significant early improvement in renal anemia in patients with secondary hyperparathyroidism. This effect may be caused by an enhanced erythropoietin production and may also be partially due to the improved nutritional state after PTx.

Impaired taste acuity in patients with diabetes mellitus on maintenance hemodialysis.

AIMS: It has been reported that taste acuity for the four primary tastes, sour, sweet, salty and bitter, is impaired in hemodialysis (HD) patients. However, there have been no studies reported on taste acuity of diabetic HD patients. The present study aimed to quantify and compare the taste acuity of diabetic and non-diabetic HD patients, and further to determine if there were correlations between diminished taste acuity and certain blood serum parameters typically askew in hemodialysis patients. METHODS: In a test group of 24 diabetic and 24 non-diabetic HD patients matched for age, body mass index and duration of HD, taste acuity for the four tastes was determined by asking patients to identify them at varying concentrations. RESULTS: Statistical analyses indicate that bitter and total taste acuity were significantly impaired in diabetic HD patients. In diabetic HD patients, correlation was found between sweet, salty or total taste acuity and blood urea nitrogen or normalized protein catabolic rate. CONCLUSIONS: We conclude that taste acuity is partially impaired in diabetic HD patients, and suggest this contributes to reduced appetite, leading to malnutrition and poor prognoses.

Intussusception of the appendix that reduced spontaneously during follow-up in a patient on hemodialysis therapy.

A 63-year-old man on long-term hemodialysis therapy was hospitalized due to right lower abdominal pain. CT scan demonstrated a multiple concentric structure in the ileocecal region. Colonoscopy showed a polyp-like tumor arising from the expected location of the appendix, with a dimple at the top. Barium enema study revealed a submucosal tumor-like filling defect in the cecum with non-filling of the appendix. A diagnosis of intussusception of the appendix (IA) was made. During the follow-up, IA reduced spontaneously. The present case report is the first description of IA in a patient on hemodialysis therapy. Furthermore, spontaneous reduction of IA is indeed rare.

A case of cell-free and concentrated ascites reinfusion therapy effective for refractory ascites in spontaneous bacterial peritonitis in a renal transplant patient.

A 58-year-old Japanese male with chronic hepatitis C underwent kidney transplantation from an unrelated donor in October 1998. In December 2004, the patient was admitted for spontaneous bacterial peritonitis (SBP). Abdominal paracentesis and albumin transfusion were performed, but control of ascites was poor. A randomized, controlled study of patients with SBP showed that patients receiving cefotaxime with a high-volume albumin transfusion (50-75 g/50 kg) were significantly less likely to have irreversible renal failure and had lower mortality. Japan, however, relies on imports for 70% of its albumin formulations, which complicates high-volume albumin transfusion. Consequently, albumin transfusion is often limited to single treatments in the range of only 25 g (25%, 100 ml). A single cell-free and concentrated ascites reinfusion therapy (CART) treatment can reinfuse approximately 60 g of albumin, corresponding to a high-volume albumin transfusion capable of reducing the associated risk of infection or allergic reaction. Though this case was an SBP patient, after the ascites were found to be negative for endotoxins, CART was performed, and control of ascites was achieved without observation of fever, hypotension, or other adverse effects. CART provides greater supplementation of albumin than albumin transfusion and can be an effective modality of treatment for hypoalbuminemia in SBP patients if ascites are negative for endotoxins.

A multicenter prospective cohort study of tonsillectomy and steroid therapy in Japanese patients with IgA nephropathy: a 5-year report.

Tonsillectomy combined with corticosteroids has been performed for IgA nephropathy (IgAN) mainly in Japan. We, the Japanese Multicenter Study Group on the Treatment of IgA Nephropathy (JST-IgAN), have conducted a multicenter prospective cohort study including the combination therapy from 1999. A total of 101 patients (43 male, 58 female) were observed for 5 years. Their average age was 34.4 +/- 11.8 (15-55). Subjects were classified by daily proteinuria (UP) and serum creatinine (sCr); UP excreted below 0.5 g/day was defined as stage 1, 0.5-1.0 g/da y defined as stage 2, more than 1.0 g/da y and sCr < or =1.2 mg/dl in females or < or =1.4 mg/dl in males defined as stage 3, and sCr >1.2 mg/dl in females or >1.4 mg/dl in male defined as stage 4. Both tonsillectomy and high-dose corticosteroid were performed in 75 patients. Of these, 29 patients were stage 1, 26 were stage 2, 16 were stage 3, and 4 were stage 4. The number of subjects with steroid monotherapy were 1 (stage 1), 7 (stage 2), 9 (stage 3) and 1 (stage 4). The primary endpoint in this study was normalized urinalysis as clinical remission. The remission rate treated with combined therapy was 86.2% in stage 1, 73.1% in stage 2, and 43.8% in stage 3. On the other hand, it was 71.4% in stage 2, and 11.1% in stage 3 in steroid monotherapy subjects. Although the number in each treatment group varied because of the non-randomized study, tonsillectomy combined with 3 courses of high-dose corticosteroid therapy was more effective for clinical remission in the higher proteinuria group. We concluded that the goal should be cure and release from disease at an earlier stage of IgAN.

A huge fecalith associated with dialysis-related gastrointestinal amyloidosis.

A 60-year-old man who had been receiving dialysis for more than 30 years was admitted for treatment of cellulitis in his right thigh on November 7, 2003. He suffered from an ileus on December 14 and was found to have a huge, 7-cm-diameter, well-circumscribed fecalith, incarcerated at the splenic flexure of the colon. It was proving difficult to pass this naturally and surgical removal was thought to be too risky. Using a colonoscope and a water-jet probe, the fecalith was broken up; the ileus then improved and the patient was able to take oral fluids. Unfortunately, he died of cardiac failure on February 13, 2004. We conducted an autopsy, with his family's consent, and found generalized amyloidosis. Deposits of amyloid were seen in all layers of the colon. Because of this, we hypothesized that peristalsis had been poor and this had led to paralytic ileus due to stasis, which, in turn, had led to the formation of the huge fecalith. In Japan it is not rare for a patient to be on dialysis for more than 25 years and it may be that this is a cause of generalized amyloidosis. There have been no such cases of fecalith associated with gastrointestinal amyloidosis described previously, which is why we decided to report this case here.