Thromboelastographic Profile of Patients with Hyperparathyroidism Secondary to Chronic Kidney Failure Submitted to Total Parathyroidectomy

doi:10.4236/ojanes.2013.38077

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Open Journal of Anesthesiology, 2013, 3, 363-366

http://dx.doi.org/10.4236/ojanes.2013.38077 Published Online October 2013 (http://www.scirp.org/journal/ojanes)

363

Thromboelastographic Profile of Patients with

Hyperparathyroidism Secondary to Chronic Kidney

Failure Submitted to Total Parathyroidectomy

—Case Series

Walkíria Wingester Vilas Boas, Cristiano Barbosa de Oliveira, Thadeu Alves Máximo,

Carlos Alexandre de Freitas Trindade, Alexandre de Andrade Sousa

Developed in Hospital das Clínicas da Universidade Federal de Minas Gerais HC-UFMG, Belo Horizonte, Brazil

Email: [email protected]

Received July 23rd, 2013; revised August 24th, 2013; accepted September 25th, 2013

tribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is prop-

erly cited.

ABSTRACT

Coagulopathy in surgical patients can cause perioperative complications, as both bleeding and thromboembolic events

increase surgical morbimortality. The recognition of preexisting disorders and the understanding of the dynamic

changes in hemostasis during surgery are prerequisites of safe patient management. The perioperative management of

patients with chronic kidney failure is a huge challenge due to both the hypercoagulable state and increased risk of

bleeding. Classic laboratory exams performed for the evaluation of blood clotting seem insufficient regarding the de-

termination of the risk of bleeding and thrombosis in surgical patients. As patients with chronic kidney failure develop

secondary hyperparathyroidism, the aim of the present study was to describe a case series and correlate the periopera-

tive thromboelastographic profile of patients with chronic kidney failure submitted to parathyroidectomy with their

secondary hyperparathyroidism.

Keywords: Thromboelastography; Chronic Renal Failure; Hyperparathyroidism; Total Thyroidectomy

1. Background and Objectives

Coagulopathy in surgical patients can cause perioperative

complications, as both bleeding and thromboembolic

events increase surgical morbimortality [1]. The recogni-

tion of preexisting disorders and the understanding of the

dynamic changes in hemostasis during surgery are prere-

quisites of safe patient management.

While patients with chronic kidney failure are tradi-

tionally considered to be at risk for perioperative bleed-

ing due to the platelet dysfunction related to uremia,

anemia and frequent dialysis [2,3], clotting disorders that

favor a hypercoagulable state have also been demon-

strated in such patients [2,4,5]. Therefore, the periopera-

tive management of patients with chronic kidney failure

is a huge challenge due to both the hypercoagulable state

and increased risk of bleeding. This apparent dichotomy

has important implications regarding clinical and anes-

thesiological management. A blood product reserve, pe-

rioperative thromboprophylaxis and thrombosis preven-

tion of the arteriovenous fistula are directly related to

knowledge regarding the coagulation profile of patients

with chronic kidney failure.

Classic laboratory exams performed for the evaluation

of blood clotting seem insufficient regarding the deter-

mination of the risk of bleeding and thrombosis in surgi-

cal patients [6]. Thus, different dynamic coagulation

monitors have been tested, including the thromboelasto-

graph [6,7]. Thromboelastography allows the analysis of

different phases of coagulation, the quality of the throm-

bus formed and fibrinolysis through the determination of

five main indices on the readout. The R index (reaction

time) is equivalent to the blood clotting time and has

some correlation with other tests of the initial formation

of fibrin. The K value (clot formation time) is the time

the formed clot takes to reach a fixed degree of viscoe-

lasticity. The alpha angle (α) is an indicator of the clot

formation rate. Maximum amplitude (MA) is influenced

Thromboelastographic Profile of Patients with Hyperparathyroidism Secondary to

Chronic Kidney Failure Submitted to Total Parathyroidectomy—Case Series

364

by platelet function. The lysis index (Ly) is the determi-

nation of the lysis of the clot in time.

Thromboelastographic indices demonstrate that dif-

ferent coagulation aspects in the thromboelastographic

readout are altered in patients with chronic kidney failure,

including initial formation of fibrin (R), the fibrin-plate-

let interaction (K and α) and qualitative platelet function

(MA) [2]. There is also a reduction in fibrinolysis [2,5].

The mechanisms of the increase blood clotting in patients

with chronic kidney failure that lead to thrombotic com-

plications are less known and seem have a multi-factor

nature [3,4]. It has recently been demonstrated that pa-

tients with primary hyperparathyroidism and normal

kidney function have a hypercoagulable and hypofibri-

nolytic profile, which may contribute to an increased risk

of atherosclerotic and atherothrombotic complications

[8].

As patients with chronic kidney failure develop sec-

ondary hyperparathyroidism, the aim of the present study

was to describe a case series and correlate the periopera-

tive thromboelastographic profile of patients with chronic

kidney failure submitted to parathyroidectomy with their

secondary hyperparathyroidism.

2. Case Series

The case series involved 11 patients with chronic kidney

failure in dialysis treatment who were submitted to total

parathyroidectomy with a forearm implant of a fragment

of the parathyroid gland, with a mean surgical duration

of two hours. All patients had hyperparathyroidism sec-

ondary to kidney failure and signed a statement of in-

formed consent authorizing the collection of blood sam-

ples for perioperative laboratory exams and the publica-

tion of the findings. Regarding the etiology of chronic

kidney disease, four cases were due to glomerulonephri-

tis, two were due to polycystic kidneys, two were due to

diabetic hypertensive nephropathy, one was due to

nephrocalcinosis and two were due to hypertensive neph-

ropathy. Table 1 displays the demographic data and re-

sults of the preoperative laboratory exams.

All patients were submitted to balanced general anes-

thesia (sufentanil—0.5 μg/kg; propofol—2.5 mg/kg; atra-

curium—0.5 mg/kg; sevorane—1.5 CAM) and moni-

tored with continuous ECG, invasive blood pressure, pul-

se oximetry, gas analysis and capnography throughout

the surgery. Arterial blood samples were collected im-

mediately following anesthesia induction and at the end

of the surgery (prior to extubation) for gasometry, iono-

gram, erythrogram, coagulogram and thromboelastogra-

phy. The total intravenous volume administered during

surgery was 462.5 ± 50.42 mL.

Table 2 displays the results of the laboratory exams

and thromboelastogram of the patients in the intraopera-

tive period.

The MA and α angle of the thromboelastogram imme-

diately following anesthesia induction demonstrated a

pro-thrombotic profile (means above values considered

normal). In the comparison of laboratory exams after

anesthesia induction and prior to extubation, only the

number of platelets and ionic calcium underwent signifi-

cant reductions, but remained within the range of refer-

ence values. A negative correlation was found between

the parathyroid hormone (PTH) concentration and the K

parameter of the thromboelastogram (Figure 1) and a

positive correlation was found between PTH and the α

angle of the thromboelastogram (Figure 2).

3. Conclusions

The thromboelastographic profile of the patients with

chronic kidney failure and secondary hyperparathyroid-

ism submitted to total parathyroidectomy with the fore-

arm implant of parathyroid fragments demonstrated a

state of prothrombotic coagulation. As in primary hyper-

parathyroidism [8], hyperparathyroidism secondary to

Table 1. Preoperative data.

Age 44 ± 3.9 years

Gender 8/3 (M/F)

Urea 137.1 ± 15.7 mg/dl

Creatinine 8.7 ± 0.9 mg/dl

Last preoperative dialysis 22.5 ± 0.6 hours earlier

Parathyroid hormone (n = 9) 1753 ± 170

Table 2. Comparative data before and just after anestehetic

induction.

After anesthesia

induction

Before anethesia

induction

Hemoglobine (g/dL) 11.1 ± 0.58 10.67 ± 0.48

Platelets (/mm3) 207.875 ± 19.837 206.222 ± 21.627*

RNI 1.13 ± 0.02 1.12 ± 0.02

APTT (p/c) 1.04 ± 0.05 0.99 ± 0.05

Ionic Calcium (mmol/L)1.22 ± 0.02 1.13 ± 0.02*

R time 26.23 ± 1.62 27.64 ± 3.86

K time 8.77 ± 1.05 9.29 ± 1.29

Ang α

(ângulo α-VR = 29˚ - 43˚)47.07 ± 3.70 46.80 ± 4.92

MA 71.94 ± 3.27 61.28 ± 3.40

Ly60 0 0

*p < 0.05.

Thromboelastographic Profile of Patients with Hyperparathyroidism Secondary to

Chronic Kidney Failure Submitted to Total Parathyroidectomy—Case Series

365

Figure 1. Negative correlation between parathormone and

K thromboelastogram parameter.

Figure 2. Positive correlation between parathormone and

alpha angle thromboelastogram parameter.

chronic kidney failure may be related to the prothrom-

botic thromboelastographic profile presented.

While the traditional concern of anesthesiologists and

surgeons during surgery on patients with chronic kidney

failure is the possibility of greater surgical bleeding [9],

clinical evidence has demonstrated that chronic kidney

disease is also associated with blood clotting abnormali-

ties that favor a pro-thrombotic hypercoagulable state

[3-5,10], with an increased risk of thromboembolic phe-

nomena that may increase with the decline in kidney

function [3]. While the risk of bleeding may be due to

uremia (abnormal platelet function) and anemia (altera-

tion from normal flow in blood vessels) [3,5,9], the ten-

dency toward hypercoagulability likely also has a multi-

factor nature (increased levels of pro-coagulation factors,

reductions in endogenous anticoagulants and fibrinolytic

activity and the use of erythropoietin) [3]. The reduction

in uremia with dialysis less than 24 hours prior to surgery

helps improve platelet function [9]. The patients studied

had a normal coagulogram, with no risk of bleeding. In-

deed, no significant perioperative bleeding occurred in

any of the surgeries. Dialysis on average 22.5 ± 0.6 hours

prior to surgery may have contributed to adequate plate-

let function despite the chronic kidney failure of the pa-

tients.

Important differences in hemostatic parameters have

been demonstrated between patients with primary hy-

perparathyroidism (with normal kidney function) and

healthy controls [8]. Such patients have a hypercoagu-

lable and hypofibrinolytic profile [8]. The PTH levels of

patients with primary hyperparathyroidism are correlated

with this pro-thrombotic profile and likely contribute

toward the increase in cardiovascular mortality [8]. The

patients studied here had an indication for total parathy-

roidectomy due to hyperparathyroidism secondary to

kidney failure. An increase in α angle and MA and re-

duction in fibrinolysis in 60 minutes were demonstrated

in the patients studied, indicating a hypercoagulable pat-

tern, as described in the literature [2]. The statistical

analysis also demonstrated a positive correlation between

PTH and tromboelastographic parameters (a higher PTH

level denotes greater hypercoagulability). Therefore, as

with primary hyperparathyroidism, secondary hyperpara-

thyroidism in patients with chronic kidney failure may

participate in the hypercoagulable state found in these

patients.

The patients in the present study with chronic kidney

failure and secondary hyperparathyroidism submitted to

total parathyroidectomy exhibited pro-thrombotic trom-

boelastographic parameters. Hyperparathyroidism sec-

ondary to chronic kidney failure may be related to this

hypercoagulable profile. If confirmed in larger clinical

trials, the positive correlation between the pro-thrombotic

state and PTH levels in patients with chronic kidney fail-

ure will likely lead to the development of strategies for

the prophylaxis and treatment of thromboembolic events

(including arteriovenous fistulas) and could be consid-

ered yet another criterion for parathyroidectomy in these

patients.

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