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Severe secondary and tertiary hyperparathyroidism (HPT) in patients undergoing chronic hemodialysis is one of the most important problems of clinical nephrology. The removal of altered parathyroid glands has a number of difficulties due to possible anatomical features of their location. Isolation and differentiated intraoperative visualization of the parathyroid glands is extremely important for an adequate amount of surgical intervention.
32 patients with severe hyperparathyroidism underwent parathyroidectomy. The age of patients was from 26 to 71 years old. Patients were divided into two groups according to the oral administration of 5-aminolevolenic acid for intraoperative imaging of the parathyroid glands: in 12 patients it was used, in 20 patients it was not used. Secondary and tertiary hyperparathyroidism was diagnosed in patients with C5D stage CKD by a significant or persistent increase in the level of intact parathyroid hormone (iPTH) more than 600 pg/ml and enlarged parathyroid glands detected by ultrasound. For intraoperative identification of changed parathyroid glands in the first group the oral administration of a solution of 5-aminolevulinic acid was used (given in 180 minutes before the start of surgery at a dose of 10 -15 mg / kg body weight). Then the surgical field was irradiated with polarized blue light with a wavelength of 395–405 nm to record fluorescence. In both groups if unchanged or less changed areas of the parathyroid gland were found, they were autotransplanted into the forearm. Achievement of the target iPTH level, hypocalcemia in the early postoperative period, and hypoparathyroidism were assessed in the postoperative period. The obtained data were analyzed using nonparametric statistical methods.
Specific bright red fluorescence and luminescence of the parathyroid glands caused by special external sources of polarizing blue light during the operation were observed in all 12 patients of the first group. In the of first group patients operated with 5-aminolevulinic acid: in 9 patients it was possible to achieve the target postoperative reduction in iPTH levels; in 3 patients there was a slight decrease or iPTH was above target values (<130 pg/ml). In the second group, in 13 patients it was possible to achieve a target postoperative reduction in iPTH levels; in 7 patients there was a slight decrease or iPTH was above target values. The use of intraoperative visualization of the PTG significantly influenced the achievement of the target level of iPTH (P = 0.26 (P>0.05). Hypocalcemia in the early postoperative period was detected in 7 patients, hypoparathyroidism in 7 patients in the first group. 13 people had hypocalcemia and 6 people had hypoparathyroidism in the second group of patients. There was no effect of the use of intraoperative imaging with oral administration of 5-aminolevolenic acid on hypocalcemia in the early postoperative period (chi-square<3,84) and on the incidence of postoperative hypoparathyroidism (P<0.05).
Intraoperative fluorescence diagnostics of the parathyroid glands with preoperative oral use of 5-aminolevolenic acid is a simple and effective method of their visualization. This method significantly affects the achievement of target postoperative iPTH level; does not affect the incidence of postoperative hypocalcemia and hypoparathyroidism.