title: Graft-dependent renal hyperparathyroidism despite successful kidney transplantation.
abstract: BACKGROUND
  Only a few reports can be found on the recurrence or persistence of hyperparathyroidism after total parathyroidectomy and autotransplantation (PTX + AT) following kidney transplantation (KTX). The objective of the present study was to assess the frequency and pathophysiological mechanisms responsible for the development of graft-dependent renal hyperparathyroidism (rHPT) after KTX.
  
  
  METHODS
  Between 1986 and 2006, 69 patients underwent surgery for rHPT after KTX at our institution. Patients with reoperations at the parathyroid autograft (AT) were identified. Kidney graft function (KGF) was assessed by the glomerular filtration rate (GFR). Representative parts of the parathyroid gland chosen for autotransplantation during the initial parathyroidectomy and of the excised AT at reoperation were reanalyzed according to the morphologic pattern and the proliferative index.
  
  
  RESULTS
  Eight of the 69 patients underwent reoperation of the AT. All patients had undergone initial PTX + AT before KTX. The GFR before parathyroid reoperation was 66.6 +/- 9.6 ml/min per1.73 m(2) (mean +/- SEM). Histopathological re-examination revealed nodular hyperplasia in the parathyroid tissue for autotransplantation and in the excised parathyroid autografts. The Ki67 index was increased in the glands chosen for autotransplantation prior to KTX, but was overall low in the excised autografts.
  
  
  CONCLUSIONS
  Although not reported in the literature to date, tertiary hyperparathyroidism (tHPT) may arise from parathyroid autografts even in patients with a good KGF. In these cases, graft-dependent tHPT represents the inability of autonomous, nodular parathyroid tissue to regress despite the recovery of renal function. Non-nodular tissue should be selected for parathyroid autotransplantation to decrease the incidence of graft-dependent recurrent rHPT.
authors.affiliation: Department of Visceral, Thoracic and Vascular Surgery, Philipps-University, Baldingerstrasse 35033 Marburg, Germany. pluntke@med.uni-marburg.de
authors.forename: K
authors.initials: K
authors.lastname: Schlosser
authors.forename: M
authors.initials: M
authors.lastname: Rothmund
authors.forename: K
authors.initials: K
authors.lastname: Maschuw
authors.forename: P J
authors.initials: PJ
authors.lastname: Barth
authors.forename: T P
authors.initials: TP
authors.lastname: Vahl
authors.forename: K L
authors.initials: KL
authors.lastname: Suchan
authors.forename: E Domínguez
authors.initials: ED
authors.lastname: Fernández
mesh_terms: D000704:Analysis of Variance; D002118:Calcium / Q000097:blood; D003404:Creatinine / Q000097:blood; D005260:Female; D005919:Glomerular Filtration Rate / Q000502:physiology; D006801:Humans; D006962:Hyperparathyroidism, Secondary / Q000209:etiology* / Q000601:surgery; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D010280:Parathyroid Glands / Q000473:pathology / Q000637:transplantation; D016105:Parathyroidectomy / Q000009:adverse effects*; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D013997:Time Factors; D014182:Transplantation, Autologous
chemical_list: D003404:Creatinine; D002118:Calcium