|Year : 2021 | Volume
| Issue : 2 | Page : 184-187
Bilateral superior parathyroid adenoma postkidney donation: A riddle, well, solved!! - A case report
Avinash Rao Ullur, Shakuntala V Modi, Nitin M Nayak, Ramakrishnan Santanaraman, Dilip Rangarajan, Padmanabhan Subramanian
Department of Nephrology, NU Hospitals, Bengaluru, Karnataka, India
|Date of Submission||30-Jul-2020|
|Date of Decision||10-Feb-2021|
|Date of Acceptance||05-Apr-2021|
|Date of Web Publication||30-Jun-2021|
Dr. Padmanabhan Subramanian
Department of Nephrology, NU Hospitals, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Kidney transplantation with living kidney donation is an optimal treatment modality for end stage kidney disease. Although the risks after kidney donation are few in number, the unrecognised complications due to suboptimal evaluation have been reported in the literature. We hereby report a case of a kidney donor, who was detected to have parathyroid adenoma on routine evaluation for metabolic bone parameters two years post kidney donation. Although she was treated timely, we learnt the importance of careful evaluation of the donor biochemistry prior to transplant.
Keywords: Calcium, kidney donor, parathyroid adenoma, phosphate, parathyroid hormone
|How to cite this article:|
Ullur AR, Modi SV, Nayak NM, Santanaraman R, Rangarajan D, Subramanian P. Bilateral superior parathyroid adenoma postkidney donation: A riddle, well, solved!! - A case report. Indian J Transplant 2021;15:184-7
|How to cite this URL:|
Ullur AR, Modi SV, Nayak NM, Santanaraman R, Rangarajan D, Subramanian P. Bilateral superior parathyroid adenoma postkidney donation: A riddle, well, solved!! - A case report. Indian J Transplant [serial online] 2021 [cited 2021 Jul 24];15:184-7. Available from: https://www.ijtonline.in/text.asp?2021/15/2/184/319893
| Introduction|| |
Living donor kidney transplantation has gained paramount importance in the field of nephrology., Although kidney donors are chosen for the procedure only after a good outcome and good quality of life are affirmed, there are few complications which could crop up during the follow-up.
| Case Report|| |
A 43-year-old lady donated her left kidney to her husband in February 2017. She had hypothyroidism for 15 years before kidney donation and was on thyroxine supplement. Her physical examination and pretransplant investigations were essentially normal except for marginally high serum calcium [Table 1]. She underwent left laparoscopic donor nephrectomy on February 3, 2017. Postoperatively, her hemoglobin was 9.3 g/dL, serum creatinine was 1.4 mg/dL, and electrolytes were normal. She was monitored in intensive care unit on the day of the surgery. During the postoperative period, she had a culture-positive urinary tract infection which was managed with antibiotics as per the sensitivity. At the time of discharge, she was comfortable, voiding well, and her serum creatinine was 1.4 mg/dL.
One-month postdonation, she underwent routine investigations. Her serum creatinine was 1.18 mg/dL, electrolytes were normal, serum was calcium 9 mg/dL, serum phosphorous was 3.5 mg/dL, and serum alkaline phosphatase was 73 U/L. She was then advised annual follow-up. She remained asymptomatic. Her serum creatinine values remained between 1.1 and 1.2 mg/dL [Table 1]. She underwent an umbilical and incisional hernia repair on November 15, 2018. The surgery and postoperative period were uneventful.
On February 6, 2019, the routine annual check showed serum calcium level of 10.32 mg/dL with phosphorous value of 3.4 mg/dL. After a year, during follow-up on February 12, 2020, she was detected to have hypertension with an office blood pressure of 170/110 mmHg in right upper limb, 168/110 mmHg in left upper limb, and 160 mmHg systolic blood pressure in both lower limbs. She was asymptomatic. She had hypercalcemia (S. calcium – 12.15 mg/dl) and hypophosphatemia (S. phosphorous – 2.5 mg/dl) with normal serum creatinine and thyroid-stimulating hormone. Ultrasonography abdomen was normal. In view of a new-onset hypertension, high calcium and low phosphate levels, serum intact parathyroid hormone level (iPTH), and Vitamin D levels were sent. Parathyroid hormone (PTH) was high (321.8 pg/mL) and Vitamin D was low (20 ng/ml). Tc-99m sestamibi parathyroid scan and MIBI-pertechnetate subtraction study done on February 17, 2020, revealed soft tissue nodule measuring 3.7 mm × 4.8 mm and 4.5 mm × 6.5 mm with increased tracer uptake superior to the upper pole of the left thyroid lobe suggestive of left superior parathyroid adenoma. She was advised left superior parathyroid adenoma excision. She was started on tablet cilnidipine 5 mg twice daily. On February 29, 2020, she underwent the surgery. Intraoperatively, both superior parathyroid glands were found enlarged, and a decision to excise both superior parathyroid glands was made by the operating surgeon. Soon after excision, the iPTH dropped to 60 pg/ml from the preoperative value of 303 pg/ml. The excised tissue was sent for histopathology examination. On the 1st postoperative day, her serum calcium was 9.29 mg/dL. Postoperative period was uneventful. The histopathology of the tissue confirmed parathyroid adenoma [Figure 1] and [Figure 2]. She was discharged in stable hemodynamic condition. On follow-up, her serum creatinine was 1.04 mg/dL, serum calcium was 8.42 mg/dL, serum phosphorous was 4 mg/dL, and PTH level was 21 pg/ml [Table 1]. In view of low calcium and Vitamin D levels, she was started on oral calcium and Vitamin D supplements. Her last follow-up with us was on June 08, 2020, when she was asymptomatic with good blood pressure control. Her complete hemogram, electrolytes, and urine examination were normal. Her serum creatinine was 1.02 mg/dL, serum calcium level was 9.03 mg/dL, and serum phosphorous level was 3.9 mg/dL. She was continued on thyroid supplement, antihypertensive, calcium, and Vitamin D supplement.
|Figure 2: Parathyroid adenoma with solid nest and trabecular arrangement of chief cells with delicate capillary network|
Click here to view
| Discussion|| |
There is an expanding need for transplantation in the end-stage renal disease patients in India which is estimated to be between 151 and 232 per million population. However, as per the current data, approximately only 7500 kidney transplantations/year are being performed in 250 kidney transplant centers in India among which 90% is living donor transplantation. A thorough donor workup is vital before transplant. As per the United States donor registry data from 2008 to 2012 which included data from 98 academic hospitals, 16.8% of donors experienced perioperative complications including 2.5% major complications. The immediate postoperative complications which are possible include ileus, hemorrhage, pneumothorax, pneumonia, wound complications, urinary tract infections, and deep vein thrombosis. The long-term complications in the living donors include low risk of renal disease, hypertension, risk of preeclampsia in female donor, gout, and mineral bone disease. The Amsterdam forum guidelines published in 2005 addressing the criteria for donor evaluation do not highlight the importance of bone profile in donors. Again, the Kidney Disease: Improving Global Outcomes (KDIGO) living donor guideline checklist also does not highlight the importance of evaluating for metabolic profile and PTH in the donor.
A 3-year follow-up of the ALTOLD study which included 182 of the original donors and 173 of the original controls showed a persistent increase in PTH, uric acid, homocysteine, and potassium and a decrease in hemoglobin among donors compared with control individuals. Similarly, the CRIB-Donor Study cited above reported larger increases in serum fibroblast growth factor (FGF-23), PTH, and uric acid at 12-month postdonation versus predonation compared with prospective changes in these parameters among healthy nondonors. Hollands and Williams reported a case of hyperparathyroidism unmasked by donor nephrectomy in 1983. They had postulated that hypercalcemia was unmasked by the reduction in glomerular filtration rate following uninephrectomy. In the present case, the patient developed hyperparathyroidism 3-year postkidney donation. Two possibilities which can be thought of here are (1) development of a new adenoma postdonation and (2) possibility of a missed adenoma during donor evaluation. The explanation of the first possibility is that as the donor postsurgery had a single functioning kidney, due to drop in the glomerular filtration, an underlying parathyroid hypersecretion could have been unmasked. In a study by Gossmann et al., of the 135 donors evaluated, 19% patients had increased iPTH levels at follow-up. It has been suggested to follow-up iPTH and Vitamin D levels shortly after donor nephrectomy as there could be a possibility of accelerated bone loss in view of decreased tubular absorption of phosphate due to raised PTH levels. As far as the second possibility is concerned, the pretransplant low serum phosphorous level and borderline high calcium level would have been the indicators to check for the PTH levels which were missed in the purview of the patient being vegan, and there was only a slight increase in serum calcium level which got corrected in the immediate postoperative period. In a prospective study in living kidney donors by Ponte et al., it has been proposed that after the first 6-month postdonor nephrectomy, there is a possibility of development of a secondary hyperparathyroidism related to decreased in Vitamin D levels and plasma phosphate levels which is independent of FGF23 levels. However, in the present case, the raised PTH levels were definitely related to parathyroid adenoma which got corrected postparathyroidectomy. This throws a light on the importance of the baseline investigations done pretransplant which could indicate an underlying pathology, which ideally, should be tackled before transplantation. This also rises a query on whether routinely iPTH level is to be done pretransplant in the donor. This has to be answered in the future with systematic studies.
| Conclusion|| |
A careful evaluation of the donor biochemistry is essential before transplant. Subtle abnormalities should be addressed immediately. This report highlights the need for doing iPTH level pretransplant in those donors with high normal or marginally elevated serum calcium. The loss of nephron mass after donor nephrectomy is likely to unmask hyperparathyroidism in the immediate and even late postnephrectomy period. Further systematic studies need to be carried out to justify the need for routine iPTH measurement as a part of pretransplant donor evaluation.
Declaration of patient consent
The authors certify that the patient has obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Modi G, Jha V. Incidence of ESRD in India. Kidney Int 2011;79:573.
Shroff S. Current trends in kidney transplantation in India. Indian J Urol 2016;32:173-4.
] [Full text]
Lentine KL, Lam NN, Axelrod D, Schnitzler MA, Garg AX, Xiao H, et al.
Perioperative complications after living kidney donation: A national study. Am J Transplant 2016;16:1848-57.
O'Keeffe LM, Ramond A, Oliver-Williams C, Willeit P, Paige E, Trotter P, et al.
Mid- and long-term health risks in living kidney donors: A systematic review and meta-analysis. Ann Intern Med 2018;168:276-84.
Sanchez OA, Ferrara LK, Rein S, Berglund D, Matas AJ, Ibrahim HN. Hypertension after kidney donation: Incidence, predictors, and correlates. Am J Transplant 2018;18:2534-43.
Reisaeter AV, Røislien J, Henriksen T, Irgens LM, Hartmann A. Pregnancy and birth after kidney donation: The Norwegian experience. Am J Transplant 2009;9:820-4.
Lam NN, McArthur E, Kim SJ, Prasad GV, Lentine KL, Reese PP, et al.
Gout after living kidney donation: A matched cohort study. Am J Kidney Dis 2015;65:925-32.
Young A, Hodsman AB, Boudville N, Geddes C, Gill J, Goltzman D, et al.
Bone and mineral metabolism and fibroblast growth factor 23 levels after kidney donation. Am J Kidney Dis 2012;59:761-9.
The Ethics Committee of the Transplantation Society the Consensus Statement of the Amsterdam Forum on the Care of the Live Kidney Donor. Transplantation 2005;78:491-2.
Lentine KL, Kasiske BL, Levey AS, Adams PL, AlberúJ, Bakr MA, et al.
KDIGO clinical practice guideline on the evaluation and care of living kidney donors. Transplantation 2017;101 8S Suppl 1:S1.
Kasiske BL, Anderson-Haag T, Israni AK, Kalil RS, Kimmel PL, Kraus ES, et al.
A prospective controlled study of living kidney donors: Three-year follow-up. Am J Kidney Dis 2015;66:114-24.
Moody WE, Ferro CJ, Edwards NC, Chue CD, Lin EL, Taylor RJ, et al.
Cardiovascular effects of unilateral nephrectomy in living kidney donors. Hypertension 2016;67:368-77.
Hollands MJ, Williams G. Primary hyperparathyroidism unmasked by donor nephrectomy. Postgrad Med J 1983;59:118-9.
Gossmann J, Wilhelm A, Kachel HG, Jordan J, Sann U, Geiger H, et al.
Long-term consequences of live kidney donation follow-up in 93% of living kidney donors in a single transplant center. Am J Transplant 2005;5:2417-24.
Ponte B, Trombetti A, Hadaya K, Ernandez T, Fumeaux D, Iselin C, et al.
Acute and long term mineral metabolism adaptation in living kidney donors: A prospective study. Bone 2014;62:36-42.
[Figure 1], [Figure 2]