CASE STUDIES

A case of recidivant Hyperparathyroidism in a dialysis patient

A 52 year old white female with end stage renal failure, secondary to polycistic kidney disease, was studied at the outpatient clinic having serum creatinine 6.3 mg/dl in June, 1989. At that moment her calcium levels ranged between 8-9 mg/dl, phosphorus between 7.0-7.6 mg/dl. and PTH was 114 pg/ml (normal 15-65 pg/ml).

Question 1

The patient started haemodialysis in October 1990 and she was included in the waiting list for renal transplantation. Calcium dialysate was 1.50 mmol/l and the patient was on erythropoietin, calcium antagonist, small doses of calcitriol and calcium carbonate. Since November 1991 she developed persistent high calcium phosphorous product: serum calcium 10.5-10.9 mg/dl, phosphorous 8.1- 8.7 mg/dl. In fact PTH was 338 pg/ml and serum aluminium 6 ug/l. Calcium carbonate and calcitriol were stopped. Calcium ranged between 9-10 mg/dl and phosphorous ranged between 7.6-9.0 mg/. PTH was 480 pg/dl.

 

Question 2

 

Figure 1	Figure 2
Figure 3

 

During the next two years of haemodialysis she presented bone tenderness and pruritus with acute joint inflammation. X ray survey showed resorption in the subperiosteal area on the radial side of the middle phalanges, skull and acromioclavicular joint (Fig 1). Another radiological finding was vascular (Fig 2) and soft tissue calcification (Fig 3). Calcium levels ranged between 10-11 mg/dl, phosphorous between 8.5-10 mg/dl, serum aluminium was 65 ug/l and intact PTH was 1050 pg/ml in December 1993.

Question 3, 4 and 5

 

Figure 4

 

In January 1994 total parathyroidectomy with forearm autograft was indicated. Four glands were excised weighing 2.600 mg, 1.100 mg, 600 mg and 280 mg respectively (Fig 4). The surgeons performed excision of the fat tissue surrounding the parathyroids glands, bilateral removal of the timic tonge and bilateral opening of the carotid sheats.

 

Question 6 and 7

One year after parathyroidectomy she was asymptomatic without bone pain and the skeletal survey showed vascular calcifications and improvement in resorption in skull. No other metastatic calcifications were observed. At that time serum calcium ranged between 8.5 and 9.5 mg/dl with calcium carbonate and calcitriol therapy, phosphorous between 6.0 and 7 mg/dl and his serum intact PTH was 180 pg/dl. In May 1995 she received a cadaveric kidney transplant which failed. In January 1997, three years after parathyroidectomy she developped bone pain and pruritus. Serum calcium was 11mg/dl, serum phosphorous 8.0 mg/dl and iPTH 456 pg/dl. Oral calcium and calcitriol were stopped and in April 1997 serum calcium ranged between 9.0 and 10 mg/dl, phosphorous between 6.0 and 7.0 mg/dl and intact PTH 786 pg/dl

 

Question 8

 

Figure 5	Figure 6

PTH levels of the contralateral arm, after total ischaemic blockade of the graft bearing arm, revealed the following results: Basal 656; 1 min 678; 2 min 564; 3 min 546; 5 min 324; 10 min 212. pg/dl Positive MIBI scintigraphy was observed in the arm bearing the graft. Visualization of residual parathyroid hyperplastic gland in the neck was not observed. The arm bearing the graft was explored on three occasions and the last operation taking a wide excision removing the entire brachioradialis muscle (Fig 5). A marked improvement in symptoms of bone pain and proximal muscle weakness was reported five months later. At that time the PTH level was < 10 pmol/l. In January 2002, at the age of 65, the patient had carpal tunnel syndrome, amyloid artropathy and bone pain. Calcium was 10 mg/dl, phosphorous 6.7 mg/dl and intact PTH undetectable. A bone biopsy was then performed (Fig 6)

Question 9 and 10

 

The patient was referred to the surgery department for carpal tunnel syndrome decompression. Plain x-rays showed linear vascular calcifications in the aorta, the pelvis and upper and lower extremities bilaterally.

Question 11

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