Clinical Course after Successful Parathyroidectomy

Clinical Manifestations

The overall clinical result is considered good in 70% to 85% of the patients. Bone pain improves in few days in 60% to 80% of patients, joint pain in 85%, and malaise in 75%.4 Abdominal pain and irritated eyes are less likely to improve.4 Muscle weakness is relieved in one third of the patients and radiologic signs improve in 95%.48 Itching decreases overnight in almost all patients and disappears in 60% to 80%.4,48

Successful PTX improves nonvisceral calcification in 50% to 60% but does not change arterial calcification despite reduction in the Ca-P product and PTH. Small peripheral arterial calcification may even develop or progress in as many as 56% of the patients after PTX.65

Bone Disease

A rapid decrease in serum parathyroid hormone level after PTX appears to suppress bone resorption as well as cause a transient marked increase in bone formation and an increase in normal lamellar osteoid seams.72 PTX decreases resorption surfaces and osteoclast number as well as bone formation rate.73

A much debated issue is the development of aluminum-related osteomalacia after PTX. Some reports showed that PTX did not enhance accumulation of bone aluminum or increase the prevalence of clinical bone disease during dialysis,74 whereas other reports clearly demonstrated aluminum accumulation in bone after PTX.75 If aluminum is available to bone (through ingestion of phosphate binders or through the dialysate) or if there was an aluminum-related bone disease before surgery, it deposits in the low-turnover post-PTX bone. If, however, vitamin D levels are maintained and calcium is available, no low-turnover aluminum-related bone disease should arise. Symptomatic osteomalacia after PTX usually indicates that surgery was unnecessary and that the hypercalcemia was due to aluminum toxicity. The bone mass density of the lumbar spine can be significantly increased with postoperative supplementation with vitamin D and calcium.76

Calcium Metabolism

Immediately after PTX, serum PTH and calcium concentrations decline abruptly. Serum alkaline phosphatase, usually elevated before surgery, increases in the immediate postoperative period and then declines with time.77 A strong correlation has been noted between the degree of hypocalcemia after the operation and the level of serum alkaline phosphatase before the operation.78 Circulating levels of calcitriol also decrease after PTX, further contributing to hypocalcemia.79

Anemia

Anemia improves in CRF patients after PTX.80 PTX increases serum erythropoietin and blood reticulocytes in 50% of the patients.81'82 Normalizing levels of PTH, extra-or intracellular calcium and phosphorus, and increased tissue sensitivity to erythropoietin after PTX could all be responsible.8183'84

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