Nephrol Dial Transplant (2003) 18: III31-III33
© 2003 European Renal Association-European Dialysis and Transplant Association
Original Article
Guidelines for percutaneous ethanol injection therapy of the parathyroid glands in chronic dialysis patients
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Abstract |
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Percutaneous ethanol injection therapy (PEIT) of the parathyroid was originally introduced as an alternative to surgical parathyroidectomy. After the recent elucidation of the pathogenesis of parathyroid hyperplasia in uraemia, ‘selective PEIT of the parathyroid glands' was developed, in which enlarged parathyroid glands with nodular hyperplasia are ‘selectively’ destroyed by ethanol injection, and other glands with diffuse hyperplasia are then managed by medical therapy. The ‘Guidelines for percutaneous ethanol injection therapy of the parathyroid glands in chronic dialysis patients' proposed by the Japanese Society for Parathyroid Intervention are presented, including indications, techniques, and post-PEIT management. These guidelines also apply to direct injection therapy using drugs other than ethanol, such as calcitriol and 22-oxacalcitriol.
Keywords: secondary hyperparathyroidism; percutaneous ethanol injection therapy (PEIT); ultrasonography; nodular hyperplasia
Percutaneous ethanol injection therapy (PEIT) was first introduced for the management of parathyroid hyperplasia by Italian pioneers in the early 1980s [1], initially as an alternative to surgical parathyroidectomy. Because of the technical difficulties of detecting relatively small parathyroid glands, most of the published literature on this technique only consists of sporadic reports of a few cases until the early 1990s [2–7].
The subsequent accumulation of clinical and basic data clearly suggests that in chronic dialysis patients it is the parathyroid glands with nodular hyperplasia that are resistant to medical therapy [8–10]. Based on that pathophysiological model, we have refined this technique further and developed ‘selective PEIT’ of the parathyroid glands [11–13].
The basis of PEIT is that enlarged parathyroid glands with nodular hyperplasia are destroyed ‘selectively’ by ethanol injection, and other glands with diffuse hyperplasia are then managed by medical therapy (Figure 1
), including intravenous vitamin D analogues. Thus, medical management after the PEIT procedure is as important as the destruction of the hyperplastic tissue itself. In this respect, ‘selective PEIT’ is no longer an alternative to surgical parathyroidectomy, but rather has become a powerful adjunct to medical therapy.
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According to a survey in 1998, >600 patients had already been treated by PEIT in Japan. At that time, however, selection of patients, selection of glands to be destroyed, the PEIT procedure and medical management after PEIT were not standardized. Furthermore, there was a significant variation in the occurrence of complications such as recurrent nerve palsy, probably because of differences in the PEIT procedure and the operators' skills. Thus, it became mandatory to establish practical guidelines of PEIT in order to optimize its efficacy and minimize the risks. A tentative guideline was made public in 1999, and several changes have been made as a result of suggestions by the members of a working group that included nephrologists, endocrinologists and surgeons.
Here, we present the ‘Guidelines for Percutaneous Ethanol Injection Therapy (PEIT) of the Parathyroid Glands in Chronic Dialysis Patients' (Table 1), which is a modified version of the guidelines originally published in 2000 in Japanese by the Japanese Working Group of PEIT of the Parathyroid. Although not included in the guidelines, it has been suggested at this present symposium that hyperplasia developed in a gland undiscovered at the time of initial parathyroidectomy may also be a good indication for PEIT.
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This group now has changed its name to the Japanese Society for Parathyroid Intervention, because several agents other than ethanol recently have been tested for direct injection into enlarged parathyroid glands under utrasonographic guidance [14,15]. As detailed in this supplement, these agents include calcitriol, 22-oxacalcitriol and acetic acid. We assume that these guidelines can also be applied to those new modalities of parathyroid intervention. Nevertheless, modifications may be needed for the other modes of parathyroid intervention by comparing their efficacy with that of PEIT. Furthermore, different indications for parathyroid intervention, including surgical parathyroidectomy, also need to be established from the accumulation of clinical experience in the near future [16].
Finally, we should all be conscious of the importance of preventing parathyroid hyperplasia from the early stages of dialysis therapy. Furthermore, early application of parathyroid intervention, including surgical parathyroidectomy, should also be considered for the prevention of irreversible bone diseases and metastatic calcification of blood vessels.
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Acknowledgments |
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The council for these Guidelines expresses its appreciation for the discussion with members of the Japanese Society for Parathyroid Intervention, formerly known as the Japanese Working Group for PEIT of the Parathyroid.
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Notes |
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Correspondence and offprint requests to: Masafumi Fukagawa, MD, PhD, FJSIM, Associate Professor and Director, Division of Nephrology and Dialysis Center, Kobe University School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. Email: fukagawa{at}med.kobe-u.ac.jp
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