Effect of incomplete parathyroidectomy preserving entire parathyroid glands on renal graft function.

HYPOTHESIS: Parathyroidectomy (PT) corrects tertiary hyperparathyroidism in patients who have received renal grafts but can result in deterioration of renal function. OBJECTIVE: To compare different surgical procedures for their effect on renal function and efficacy to cure tertiary hyperparathyroidism. DESIGN: A retrospective cohort study. SETTING: University clinic. PATIENTS: Eighty-three patients with functioning renal grafts receiving PT for the first time. INTERVENTIONS: Group 1 received an incomplete PT, with at least 1 entire parathyroid gland (PG) remaining in situ (n = 12). Group 2 received an incomplete PT, with the most morphologically conserved PG partially resected (n = 22). Group 3 received a complete PT, with autotransplantation of PG tissue (n = 49). MAIN OUTCOMES MEASURES: The primary end point was the postoperative change in glomerular filtration rate. Secondary end points were rates of redialysis, hypercalcemia, and hyperparathyroidism within 5 years. RESULTS: A decrease in glomerular filtration rate occurred postoperatively in 75 patients (90%) and correlated significantly with the extent of PG resection. Recovery of renal function at month 6 was observed in group 1, but not in groups 2 and 3 (P < .001). Seven patients (8%) needed permanent dialysis (1 in group 2 and 6 in group 3). Hypercalcemia was abrogated in 78 patients (94%), without significant differences among the groups. Assessment of parathyroid hormone levels in accordance with target ranges from the Kidney Disease Outcomes Quality Initiative guidelines did not reveal significant differences in the rates of recurrent hyperparathyroidism. CONCLUSION: Incomplete PT preserving at least 1 entire PG does not cause deterioration of renal graft function and provides long-term correction of hypercalcemia and tertiary hyperparathyroidism.

Observations with impact on the indication for kinetic therapy in critically ill liver transplant patients.

BACKGROUND: Severe pulmonary complications following orthotopic liver transplantation are a major cause of postoperative deaths. Kinetic therapy (KT) has been reported to prevent and treat respiratory complications in selected critically ill patients, but little has been reported about the value of different criteria for the use of this therapy and its side effects in liver transplant recipients. MATERIAL/METHODS: We performed a prospective observational study of 27 patients treated post-transplantation in our ICU. 12 of 27 patients were treated with KT in case of either high number of blood transfusions (>20) or respiratory insufficiency (PaO2/FiO2 ratio <250 mmHg) or pretransplant pulmonary disease. Over a period of nine days we measured the PaO2/FiO2 ratio to evaluate the beneficial effect of KT. Liver perfusion was quantified by doppler ultrasound. Transplant function was measured by INR (international normalised ratio) and determination of indocyanine green elimination rate. RESULTS: Side effects on graft perfusion and graft function were not seen. 7 of 12 patients decreased in their PaO2/FiO2 ratio significantly 48 hours postoperative to 53% as compared to early postoperative level and recovered under KT during the observed time period nearly to the early postoperative level (95%; p<0.001). The units of perioperative blood transfusions, the MELD-score, the decrease of PaO2/FiO2 ratio 24 h after transplantation and retransplantation for initial non-functioning of the graft all pointed to a likely beneficial effect of KT. CONCLUSIONS: We conclude that these criteria may be helpful to identify patients who are likely to benefit from KT.

Surgery and radioablation therapy combined: introducing a 1-week-condensed procedure bonding total thyroidectomy and radioablation therapy with recombinant human TSH.

OBJECTIVE: The objective of this study was to determine whether the use of recombinant human TSH (rhTSH) to stimulate radioiodine uptake after thyroidectomy is as efficacious as a period of withholding thyroid hormones, while at the same time avoiding hypothyroidism, reducing sick leave time and shortening the hospital stay. DESIGN: Our aim was to compare the standard procedure of differentiated thyroid cancer treatment, which consists of thyroidectomy followed by 4 weeks of hypothyroidism and a conclusive ablative activity of (131)iodine, with a new shortened treatment in which l-thyroxine (T(4)) medication is initiated a day after thyroidectomy, followed by application of rhTSH stimulation and subsequent ablation a few days after surgery. We presumed our treatment to represent the most sophisticated strategy for the reduction in sick leave days overall without any reduction in safety or the efficacy of ablative therapy. METHODS: Patients (n=25) were randomized either for surgery and rhTSH stimulation or surgery and l-T(4) abstinence before the first application of radioiodine. Ablation success was determined by neck ultrasound and serum thyroglobulin during follow-up. RhTSH receivers were monitored for an average of 635 days (s.d.+/-289) and patients in l-T(4) abstinence for an average of 624 days (s.d.+/-205). Both groups were statistically compared for significant differences in treatment efficacy, safety and overall time of sick leave. RESULTS AND CONCLUSIONS: Our shortened treatment proved to be equally efficacious and safe in comparison with the conventional therapy regimen. At the same time, it showed economic advantages through the reduction in average sick leave time from approximately 29 days (l-T(4) abstinence) down to approximately 6 days (rhTSH stimulation) as well as sustaining the patient's quality of life by the complete avoidance of hypothyroidism.