TERTIARY HYPERPARATHYROIDISM SONIKA PURI

PERSISTENT HYPERPARATHYROIDISM POST RENAL TRANSPLANT • Serum PTH levels decrease 3-6months post RT • One year post transplant resolution of hyperparathyroidism is seen ~50% patients • Duration of dialysis, parathyroid gland size and development of nodular/ monoclonal hyperplasia are important determinants of persistent hyperparathyroidism ; role of low vitamin D 25oh levels. • Most studies define PTHPT as serum pth level > ULN ; >2-2.5timew uln; or >ULN as defined by KDQI guidelines Torres et al, JASN 2002, Torres et al, NDT 1998

• Long half life of parathyroid cells –cell renewal rate of 5% per year

• protocol biopsies ; 6 weeks/ 3mths and 6mths post tx • 56/213 pts had luminal/ TI calcification • Pre tx variables (graft quality/donor-recip concordance/discordance similar); similar renal function at time of first biopsy ;>80% DDK • Higher ATG use in pts w/ calcification; • Concurrent findings like rejection/ chronic changes/ CIN toxicity similar • Similar vitamin D replacement; higher phos replacement in pts w/calcifications

Gwinner et al, AJT 2005

TERTIARY HYPERPARATHRYOIDISM AND BONE DISEASE POST TRANSPLANT Akaberi et al, Transplantation 2006

Prevalence of persistent hyperparathyroidism (HPT) up to 4 years after successful renal transplantation.

Evenepoel P et al. Nephrol. Dial. Transplant. 2004;19:12811287 Nephrol Dial Transplant Vol. 19 No. 5 © ERA-EDTA 2004; all rights reserved

Prevalence of persistent hyperparathyroidism (HPT) up to 4 years after successful renal transplantation in patients with moderate to severe HPT at the time of transplantation.

Evenepoel P et al. Nephrol. Dial. Transplant. 2004;19:12811287 Nephrol Dial Transplant Vol. 19 No. 5 © ERA-EDTA 2004; all rights reserved

Evenepoel et al, NDT 2004

Torres et al, NDT 1998

Persistent hyperparathyroidism after transplant Messa et al, KI 1998

Post Transplant Hypercalcemia • Attributed to high PTH levels 1) Decreased skeletal resistance towards action of PTH 2) Increased production of calcitriol, increased intestinal ca absorption 3) Resolution of hyperphosphatemia -Incidence 8%-60% in first few months after transplant. -Post transplant hypercalcemia usually resolves after first year of transplantation, 5-10% cases it can be seen upto 4 yrs post transplant -30 ng/ml -27% pts 3mths post tx -Hypercalcemia (Ca-c) 14% pts at 3mths a/w high pth levels/ low phos levels -high FeCa; high FePhos -no significant differnce in Calcidiol

Nakai et al

Hypophosphatemia; Role of FGF-23 • Common s/p renal transplant • Attributed to urinary phosphate wasting • Persistent Hyperparathyroidism; however also seen in pts with normal pth levels, a/w inappropriately low calcitriol levels despite normal allograft function • Prospective longitudinal study -27 pts (15-m/12-w), Caucasian; 66% first transplants, LR= LUR • 85% had s.phos