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Onoda 2008
Onoda 2008
Onoda 2008
doi: 10.1093/ndtplus/sfn083
Noritaka Onoda, Masafumi Fukagawa, Yoshihiro Tominaga, Masafumi Kitaoka, Tadao Akizawa,
Fumihiko Koiwa, Takatoshi Kakuta and Kiyoshi Kurokawa for the Japanese Society for Parathyroid
Intervention
1. Therapy is indicated for those who meet all three of the following criteria:
(i) Difficult cases for continuous treatment, despite of medical treatments, showing intact PTH ≥ 400 pg/mla or hyperphosphataemia and/or
hypercalcaemia induced by treatmentb
(ii) Enlarged parathyroid glands with suspected nodular hyperplasiac on ultrasonographyd
(iii) Patients who have given informed consent to undergo PEITe
Exclusion criteria
(i) Enlarged parathyroid gland located where ultrasonographic-guided puncture is impossible
(ii) Paralysis of the recurrent laryngeal nerve on the opposite sidef
(iii) Operation in the neck region for thyroid carcinoma, etc. is scheduled
2. PEIT equipment and techniques
(i) Equipment: an electronic linear or convex ultrasound scan system with a frequency ≥7.5 MHz and colour Doppler function
(ii) Needles: ∼22 g, visible under ultrasonographic guidance (special needles for PEIT are commercially available)
(iii) Technique: advance the needle visually, using ultrasonographic guidance to check the location of the tip. Flush with a minimum amount
a The value of 1–84 PTH is converted to i-PTH by the formula: Intact PTH = 1–84 PTH × 1.7.
b PEIT can be considered in patients with concentrations of i-PTH < 400 pg/ml if hyperphosphataemia and/or hypercalcaemia is present.
c Estimated volume (calculated by length× width × depth × π/6) >0.5 cm3 or abundant blood flow inside the gland suggests nodular hyperplasia.
d If two or more glands have progressed to nodular hyperplasia, PEIT will probably be ineffective in the long term.
e An explanation of the importance of regular checkup, restricted diet and compliance after PEIT should be given to the patient before obtaining informed
consent for the procedure.
f Because the paralysis caused by ethanol results in diplegia of the recurrent laryngeal nerves, concurrent bilateral injection of ethanol should not be
considered, even if there is no paralysis of either laryngeal nerve before PEIT.
procedures among facilities, there are no major revisions in 7. Drueke TB. The pathogenesis of parathyroid gland hyperplasia in
the chapter on techniques in the new guidelines. chronic renal failure. Kidney Int 1995; 48: 259–272
8. Fukagawa M. Cell biology of parathyroid hyperplasia in uremia. Am
J Med Sci 1999; 317: 377–382
Post-PEIT management 9. Kitaoka M, Fukagawa M, Ogata E et al. Reduction of functioning
parathyroid cell mass by ethanol injection in chronic dialysis patients.
The use of active vitamin D is mandatory to prevent the re- Kidney Int 1994; 46: 1110–1117
currence of hyperparathyroidism, since glands with diffuse 10. Kakuta T, Fukagawa M, Fujisaki T et al. Prognosis of parathy-
hyperplasia, which are not injected, are usually responsive roid function after successful percutaneous ethanol injection therapy
to vitamin D therapy. guided by color Doppler flow mapping in chronic dialysis patients.
Understanding the limits of PEIT is important. If the Am J Kidney Dis 1999; 33: 1091–1099
11. Nakamura M, Fuchinoue S, Teraoka S. Clinical experience with percu-
target parathyroid is surrounded with leaked ethanol, sub-
taneous ethanol injection therapy in hemodialysis patients with renal
sequent surgical detachment will be difficult due to tissue hyperparathyroidism. Am J Kidney Dis 2003; 739–745
adhesion. The average number of treatment sessions is 2.9 12. Tanaka M, Itoh K, Matsushita K et al. Efficacy of percutaneous ethanol
in the good-responder group, with an average duration of injection therapy for secondary hyperparathyroidism in patients on
3.4 ± 2.5 months [21]. Similarly, if the PTH concentration hemodialysis as evaluated by parathyroid hormone levels according
does not decrease even after five sessions of PEIT, then such to K/DOQI guidelines. Ther Apher Dial 2005; 9: 48–52
cases are considered PEIT refractory and PTx is indicated 13. Fukagawa M, Kitaoka M, Tominaga Y et al. Selective percutaneous