All these patients were on hemodialysis and Neuronal Signaling vreceiving optimal medical therapy in the form of dietary restriction, calcium supplements, phosphate binders, and vitamin D sterols. One cohort of 20 patients was treated with surgical parathyroidectomy, the other cohort of 34 patients with cinacalcet. Serum PTH and bone profile was measured before and at monthly intervals after intervention. A comparison in the effectiveness of each intervention was made based on the average control of PTH, alkaline phosphatase, serum albumin corrected calcium, phosphate, and calcium 3 phosphate product over an average period of 18 6 6 months. Ethical approval by the South West Wales Research Ethics Committee is not required for historical cohort studies. Surgical Cohort Twenty patients were referred for parathyroidectomy to a single surgeon by the renal physicians. Indication for surgical intervention were failure of maximal medical management with hypercalcemia and persistently raised PTH, pathological bone fractures, ectopic Hedgehog Pathway soft tissue calcification, severe vascular calcification or bone pain, calciphylaxis, and when medical observation was not possible.
The preoperative investigations included a neck ultrasonography and technetium 99mTc Histamine Receptor sestamibi scan to determine the number, size, and location of the parathyroid glands and the presence of ectopic parathyroid tissue. The routine operative procedure involved a bilateral cervical neck exploration and a total parathyroidectomy. All 4 abnormal glands were removed, and in 2 patients, this was followed by autotransplantation. In total parathyroidectomy with autotransplantation, parathyroid tissue was reimplanted into the sternocleidomastoid and marked with a nonabsorbable nylon suture. The remaining 18 patients had a total parathyroidectomy. Cervical thymectomy was not routinely performed. Intraoperative frozen sections were conducted in all cases for confirmation of the resected specimen being parathyroid tissue in origin. Within 6 hours postoperatively, PTH, calcium, and phosphate levels were measured. Hypocalcemia with calcium levels below 1.8 mmol/L or symptomatic hypocalcemia was treated with 10 mL of 10% calcium gluconate infused over 30 minutes to 1 hour. This treatment was withdrawn once the serum Dienogest calcium had risen to at least 1.9 mmol/L.
On initiation of oral feeding, calcium carbonate and the active vitamin D alfacalcidol were recommenced. Patients were discharged from the hospital once the serum calcium levels had symptomatic stabilized. The PTH, calcium, phosphate, and alkaline phosphatase were routinely monitored at monthly intervals in an outpatient setting. Conventional medical care was modified by the renal physicians for optimal biochemical control with no specific preset criteria. Medical Cohort Between 2007 and 2009, 34 patients were prescribed cinacalcet in an outpatient clinic by the renal physicians. All patients had a PTH level.300 ng/dL despite being on optimal conventional medical therapy. The initiating dose of cinacalcet was 30 mg once a day and sequentially increased by 30 mg at 4 weekly intervals if the PTH level remained above 300 ng/L and the serum calcium levels were at least 1.95 mmol/L. The dose was not increased if the patient had a serum calcium level below 1.95 mmol/l, developed symptom.