Living Donor Kidney and Parathyroid Transplant Successful

By David Douglas

February 03, 2016

NEW YORK (Reuters Health) - A young woman with end-stage nephrocalcinosis secondary to congenital absence of parathyroid glands has received a simultaneous living donor kidney and parathyroid gland transplant, Chicago-based researchers report.

In a January 12 online paper in Transplantation, Dr. Enrico Benedetti and colleagues report on their patient, a 23-year-old woman whose 25-year old sister had haploidentical human leukocyte antigen (HLA) and was ABO compatible.

The sister underwent simultaneous left robotic-assisted donor nephrectomy and robotic single parathyroid excision via the transaxillary approach. There were no complications and she was discharged home after four days.

The recipient received a kidney transplant and simultaneous single parathyroid gland transplant in the right iliac fossa. The parathyroid tissue was fragmented into several small portions and implanted in the rectus muscle during the exposure for kidney transplantation.

At a month after transplant, serum calcium and phosphorus levels remained in normal range, and the parathyroid hormone (PTH) level progressively increased. At nine months the patient remains asymptomatic, has not required any hospital admission and, wrote the researchers, "has enjoyed a level of physical fitness and well-being never experienced before."

The investigators then went on to review information on parathyroid transplant starting with the first conducted in 1911. They noted that although PTH formulations are available, "the restoration of the parathyroid tissue should provide the most physiological therapy to regain normal calcium metabolism."

Parathyroid tissue can be provided from deceased donors, from patients with hyperparathyroidism requiring surgical removal of the glands, or from healthy donors willing to part with a single parathyroid gland. However, in the absence of an HLA-identical donor, the recipients should be prepared for "lifelong immunosuppression to maintain gland function."

The researchers noted that simultaneous parathyroid and renal transplantation was previously reported from a deceased donor with 14 hours of ischemia time.

Recipients in such need would benefit from simultaneous transplantation from a single donor reducing exposure to a variety of HLA antigens. Also, they wrote, "From the living donor perspective, a single procedure to procure the parathyroid and the kidney has minimal added risk."

Summing up, Dr. Benedetti told Reuters Health by email, "Living donor combined kidney and parathyroid transplant is technically feasible and safe in experienced hands. The minimally invasive approach removes barriers for the donor. For example, our first donor had initially refused the parathyroid donation because of the cosmetic implication of the incision at the base of her neck."

"The combined procedure, in patients with renal failure and severe hypoparathyroidism, addresses both issues at once and improves their health and quality of life," he added.

Overall, the investigators concluded, "Parathyroid allotransplantation is a valid option for patients with debilitating hypocalcemia and can be justified in patients receiving immunosuppression for another organ."

Commenting by email, Dr. Rasa Zarnegar, of Weill Cornell Medical College, New York, told Reuters Health, "This is an interesting study on parathyroid and kidney transplantation simultaneously. I think this case report brings to light that this may need to be investigated further in a large study with a longer follow-up."

Dr. Zarnegar, who is an associate professor of surgery (endocrine/minimally invasive surgery), added, "The transaxillary approach is a nice technique but a simpler cervical approach may reduce operative time during these cases. I think overall the population of patients who will need both kidney and parathyroid transplantation simultaneously is low, however."

The authors reported no funding or disclosures.


Transplantation 2016.