Maxillary enlargement is a rare complication of secondary hyperparathyroidism (SHPT). A 35-year-old Korean man undergoing chronic hemodialysis presented with a painless enlargement involving the maxilla and mandible. Plain radiography and CT scan showed bony expansion at the maxilla and mandible with multiple radiolucency. Serum intact parathyroid hormone (iPTH) was >1,600 pg/mL. Tc-99m sestamibi (MIBI) parathyroid scan and neck sonogram were compatible with SHPT. He underwent limited parathyroidectomy and commenced a course of paricalcitol. Fifteen months after surgery, maxillary enlargement and bony resorptions involving both hands markedly improved. Thirty-six months after the surgery, the serum iPTH level was 109.3 pg/mL. This is the first report in Korea documenting a patient with maxillary enlargement in SHPT who was successfully treated with limited parathyroidectomy and paricalcitol.
Adult ; Ergocalciferols ; Hand ; Humans ; Hyperparathyroidism ; Hyperparathyroidism, Secondary ; Korea ; Mandible ; Maxilla ; Neck ; Parathyroid Hormone ; Parathyroidectomy ; Renal Dialysis ; Renal Osteodystrophy

The enlarged parathyroid glands associated with chronic renal failure were recognized during the 1930's. The number of patients on long-term hemodialysis due to chronic renal failure is steadily increasing and the hyperparathyroid state certainly became a clinical problem in the dialysis population. The physiologic mechanisms leading to secondary hyperparathyroidism are multifactorial with renal phosphate retention, skeletal resistance to parathyroid hormone (PTH) action and impairment vitamin D metabolism being some of the known factors. Despite intensive medical management however inadequate control of parathyroid hyperplasia may necessitate surgical intervention. The goal of surgical therapy is to resect sufficient tissue to reverse the hyperparathyroidism without rendering the patient permanently hypoparathyroidism. We experienced a case of secondary hyperparathyroidism and reported its result of total parathyroidectomy, autogenous transplantation and cryopreservation of parathyroid gland.
Cryopreservation ; Dialysis ; Humans ; Hypercalcemia ; Hyperparathyroidism ; Hyperparathyroidism, Secondary* ; Hyperplasia ; Hypoparathyroidism ; Kidney Failure, Chronic ; Metabolism ; Parathyroid Glands ; Parathyroid Hormone ; Parathyroidectomy ; Renal Dialysis ; Renal Osteodystrophy ; Vitamin D

Renal osteodystrophy is used to describe the diverse clinical spectrum and the various histologic bone abnormalities found in patients with chronic renal failure. Although asymptomatic, histologic bone abnormalities begin early in chronic renal failure. The principal types of histologic bone abnormalities observed in patients with chronic renal failure are a high-turnover bone disease associated with secondary hyperparathyroidism and the histologic picture of osteitis fibrosa and a low-turnover bone disease included osteomalacia and adynamic or aplastic bone disease and a mixed bone disease shared histologic evidence of high- and low-turnover bone disease. Bone biopsy is an invasive procedure that remains the only approach for definitive diagnosis of aluminum-related bone disease and the type and severity of renal osteodystrophy. Positive aluminum staining is found mainly patients with low-turnover bone disease. We experienced a case of high-turnover renal osteodystrophy associated with positive aluminum staining. After successful kidney transplantation, serial bone histological studies indicate that aluminum overload resolves and high-turnover renal osteodystrophy improves more slowly. Because aluminum is retained long periods at the tissue, we should keep in mind that even low-dose use of aluminum-based phosphate binders adds to the bone load in dialysis patients and has the risk of aluminum-related bone disease.
Aluminum* ; Biopsy ; Bone Diseases ; Diagnosis ; Dialysis ; Humans ; Hyperparathyroidism, Secondary ; Kidney Failure, Chronic ; Kidney Transplantation ; Osteitis ; Osteomalacia ; Renal Osteodystrophy*

PURPOSE: The cause of renal hyperparathyroidism is unclear and the role of hyperphosphatamia is the only well established cause of renal osteodystrophy. The long life span of the parathyroid cells and the absence of a definite tissue marker for nodular parathyroid gland prohibit the timing of surgical intervention. The discrepancy between proliferation and apoptosis has been proposed as one possible cause of nodular development of the parathyroid gland in patients suffering with renal osteodystrophy. In the present study, we investigated the apoptotic labeling index of the parathyroid tissue in patients with renal hyperparathyroidism. METHODS: The parathyroid tissues of 76 patients with renal hyperparathyroidism and those of 33 normal glands were used for determining the level of apoptosis by performing a Tdt-mediated dUTP nick end labeling (TUNEL) assay. The patients' information was collected by a review of the clinical charts. Statistical comparison was done via two tailed t-tests. RESULTS: The averages of the TUNEL indices were 0.19 in the normal parathyroid glands and 1.84 in the hyperplastic parathyroid glands (P=0.00). The TUNEL index was higher in the oxyphil type of cells than in the chief cells and the water clear cell types (P=0.01). There was statistically significant correlation of the TUNEL index with the duration of the dialysis and less than 10 years dialysis showed a 2.23 index, which was higher than that of the longer term dialysis patients (P=0.00). The preoperative PTH level, recurrence, the Ki-67 labeling index and the pathologic type didn't show any statistical correlation with the TUNEL index (P>0.05). CONCLUSION: Our findings showed that the TUNEL index is useful for separating the cases of advanced renal hyperparathyroidism from the early ones and the TUNEL index is well correlated with hyperplastic types of cells. A decrease of apoptosis could be a probable cause of the progression of parathyroid hyperplasia in renal patients who are on dialysis support.
Apoptosis ; Dialysis ; Humans ; Hyperparathyroidism ; Hyperparathyroidism, Secondary* ; Hyperplasia ; In Situ Nick-End Labeling ; Kidney Failure, Chronic* ; Parathyroid Glands ; Recurrence ; Renal Osteodystrophy ; Tail ; Water

Metastatic calcinosis cutis of the penis and scrotum seen in a patient with End Stage Renal Disease (ESRD) on hemodialysis is a case not usually encounter in urology clinics. Review of the available literature mostly showed compromised erectile function of patients with metastatic calcinosis cutis of the penis. Presented is a case of a patient with ESRD on hemodialysis for five years who developed metastatic calcinosis of the penis and scrotum causing dysmorphic changes, however maintaining full erectile function. Preserving the erectile function after successful excision of the penile and scrotal calcification is imperative to maintain good quality of life.
Erectile Dysfunction ; Hyperparathyroidism, Secondary

The role of surgery in parathyroid disease has shown a recent decrease with development of calcinomimetics such as cinacalcet. During thyroid surgery, every endocrine surgeon makes every effort to preserve the parathyroid gland. However, postoperative hypoparathyroidism cannot be completely prevented. Knowledge of the precise anatomy of the parathyroid, including embryological movement of parathyroid glands, is needed. Surgical indications of parathyroidectomy include primary hyperparathyroidism, secondary hyperparathyroidism, tertiary hyperparathyroidism and parathyroid carcinoma. Parathyroidectomy for primary hyperparathyroidism has shown a significant change due to introduction of the sestamibi scan, intraoperative PTH assay, and focused parathyroidectomy. Minimally invasive surgery has now become standard operation for primary hyperparathyroidism. However, focused unilateral parathyroid operation should be done very cautiously because you can lose the chance of cure. Recurrence rate after parathyroidectomy is approximately 5% and experience of a surgeon can only reduce this rate. Surgery for secondary hyperparathyroidismis performed in only 1~2% of CKD patients. Surgical methods include subtotal parathyroidectomy, total parathyroidectomy, and total parathyroidectomy with autotransplantation and the results of the operation are not different. With the introduction of cinacalcet, comparison between surgery and medication showed an effective drop down of serum PTH level and increase of BMD only in surgery. Cincalcet did not show improvement of mortality, vascular calcification, and nephrplithiasis. According to oneJapanese report, PTH more than 500 pg/ml, size larger than 1 cm, and more than two enlarged parathyroid favor parathyroidectomy in renal osteodystrophy. During parathyroid surgery, high suspicion for carcinoma gives the only chance for cure because en bloc resection is important. Parathyroid disease has evolved since introduction of Cinacalcet and endocrine surgeons should join with physicians as a team for development of a treatment plan.
Autografts ; Cinacalcet Hydrochloride ; Humans ; Hyperparathyroidism ; Hyperparathyroidism, Primary ; Hyperparathyroidism, Secondary ; Hypoparathyroidism ; Minimally Invasive Surgical Procedures ; Mortality ; Parathyroid Diseases ; Parathyroid Glands ; Parathyroid Neoplasms ; Parathyroidectomy ; Recurrence ; Renal Osteodystrophy ; Surgeons ; Thyroid Gland ; Transplantation, Autologous ; Vascular Calcification

OBJECTIVES: Renal osteodystrophy has been recognized as one of the major complications in long-term hemodialysis patients. Bone histomorphology is the definite method for diagnosis but plasma intact PTH level has predictive value for diagnosis of renal osteodystrophy. We performed this study to evaluate the prevalence and correlating factors of secondary hyperparathyroidism in ESRD patients. METHODS: we analyzed the intact PTH level (normal value: 12-72 pg/ml) and clinical parameters in 309 maintance hemodialysis patients retrospectively. RESULTS: The causes of ESRD were chronic glomerulonephritis (32%) diabetic nephropathy (25%) and hypertensive nephropathy (13%). In hemodialysis patients, the mean duration were 48+/-43 months, the serum phosphorus levels were 5.0+/-1.8 mg/dl, and the serum albumin levels were 3.9+/-0.6 gm/dl. The intact PTH levels were 175+/-266 pg/ml. The incidence of hypercalcemia (>10.5 mg/dl) in patients was 4.6% and the incidence of hypocalcemia (<8.5mg/dl) was 26.4%. Twenty-five percent of the patients had iPTH level more than three times normal. Another 42% had a less than normal iPTH level. In multiple regression, serum calcium (r=-0.24), age (r=-0.17) and duration of dialysis (r=0.15) correlated significantly with iPTH level. The iPTH levels between diabetic (82+/-139 pg/ml) and nondiabetic (229+/-320 pg/dl) patients were significantly different (P<0.01). But there are no significant correlation between sugar control and iPTH level. CONCLUSION: We conclude that the iPTH levels were significantly correlated with the age, durations of hemodialysis and the serum calcium levels. Level of intact iPTH in diabetic group were significantly lower than nondiabetes in hemodialysis.
Calcium ; Diabetic Nephropathies ; Diagnosis ; Dialysis ; Glomerulonephritis ; Humans ; Hypercalcemia ; Hyperparathyroidism, Secondary* ; Hypocalcemia ; Incidence ; Kidney Failure, Chronic ; Parathyroid Hormone ; Phosphorus ; Plasma ; Prevalence* ; Renal Dialysis* ; Renal Osteodystrophy ; Retrospective Studies ; Serum Albumin

No abstract available.
Hyperparathyroidism, Secondary* ; Kidney Failure, Chronic*

No abstract available.
Hyperparathyroidism, Secondary ; Renal Insufficiency, Chronic

Secondary hyperparathyroidism is the condition is which parathyroid hormone(PTH) is over secreted to compensate for a chronically low serum calcium level and chronic renal failure is the most common cause. In 1934, Albreight reported an association between hyperparathyroidism and the chronic renal failure and in 1960, Stanbury first reported subtotal parathyroidectomy for the treatment of secondary hyperparathyroidism. The physiologic mechanism leading to secondary hyperparathyroidism in the chronic renal failure are well known and relatively well controled with medical management, but sometimes may necessitate surgical intervention in medically intractable cases. In Korea, the surgery for secondry hyperparathyroidism is not frequently performed yet as in western countries. We experienced two cases of secondary hyperparathyroidism recently and report its results of subtotal parathyrodiectomy.
Calcium ; Hyperparathyroidism ; Hyperparathyroidism, Secondary* ; Kidney Failure, Chronic ; Korea ; Parathyroidectomy