A 35-year-old man on long-term hemodialysis presented with increasing bone and joint pain, deformities, and fractures over several years. His parathyroid hormone levels had risen progressively to over 4,000 pg/mL despite medical management. He underwent parathyroidectomy where 3 lobes were removed and 1 was left in place. Post-operatively his PTH levels initially dropped but rose again to 1,500 pg/mL after 3 months. He has since suffered fractures of both femurs. The doctor is seeking input on the likely causes of recurrence and the best treatment approach.

2. CASE
PRESENTATION
DR.AHMED MOHAMED ALBEYALY
Nephrology Specialist
Nephrology ModeratorIn Dakahlia Health
directorate

3. - 35 years old male married.
- Hypertensive , non diabetic.
- Non smoker.
- On regular hemodialysis for 13 years ago.

4. 2 years ago
the patient complaining of :
Generalized bone ache and difficulty in walking, then
the condition deteriorate gradually and bone deformity
developed (clubbing of the fingers , genu varum and
kyphosis) and repeated bone fractures.

5. invistigations
PTH level during this duration gradually increase as the
following :
1500 (pg/mL) 12/10/2010
2000 (pg/mL) 28/3/2011
30/3/2012 3500 (pg/mL)
• Serum calcium 9.5 - 10 mg/dl
• Serum phosphorus 5.4-5.9 mg/dl
• Hb 9 -10 mg/dl

6. • The patient had received treatment in the
form of One-Alpha (alfacalcidol) amp
• 1mic after every HD session for 2 months.
• then 2 mic / every HD session with no
improvement either clinically or laboratory.

7. • Cinacalcet 30 mg twice daily was
prescribed for the patient for only
1month !! (limited due to financial cost without improvement detected )

8. • Other current medications :
• Ateno 100 once.
• Capotrile 25 once.
• Maxical 600 twice.
• Epiao 4000 once/week .

9. * After medical treatment :
• no improvement detected clinically
• PTH levels still rising .

10. • 16/9/2012 PTH level was
4158 (pg/mL)

11. After failure of medical treatment Doctors
recommended to do
parathyroidectomy

12. • Parathyroid U/S :
showed parathyroid adenoma .

13. In preoperatIve assessment
:
• serum calcium was 10.9
• and PTH was 4158 (pg/mL) .
• the patient take One-Alpha (alfacalcidol)
tab 2 mic/day for 2weeks before the
operation. ( why ? )

14. the operatIon :
28/11/2012
• 3 lobes of parathyroid gland was removed
and one lobe was left , no manifestation of
hypocalcaemia developed .
• No complications occurred during surgery .

15. Post
operative ?!

16. post operatIve
• The general condition of the patient was
good .
• the patient received calcium IV ( 1Amp Ca
/ hour for 1 week ) then gradual
withdrawal of Ca IV ( 20 Amp /day then
15 Amp /day then 8 amp/day then 6
amp/day) ( according
to serum Ca level )
• One-Alpha (alfacalcidol) tab 2 mic/day .

17. • Now: 8 Ca tab /day ( maxical 600 )
2 Ca gluconate amp every
hemodialysis cession
( according to serum Ca level ) .
• NB : serum Ca level now : 10 mg/dL

19. Post oPerative
• PTH level was 512 (pg/mL)
• then 750 (pg/mL) after one
month from operation
• 1500 (pg/mL) 3/1/2013

20. • Unfortunately …… he had
fractured neck of both femurs
now .

21. - What is the d.d for the causes of this recurrence ?
- is the removal of only 3 lobes of
Parathyroid ideal ?
- What Will We do ?!! redo oPeration ?

22. thank
you