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Original article
Normocalcemic hyperparathyroidism after successful parathyroidectomy for single parathyroid adenoma: Prevalence, etiological factors, predictive markers, treatment and evolution
Hiperparatiroidismo normocalcémico tras paratiroidectomía exitosa por adenoma único paratiroideo: prevalencia, factores etiológicos, marcadores predictivos, tratamiento y evolución
Luis García Pascuala,
Corresponding author
23566LGP@comb.cat

Corresponding author.
, Andreu Simó-Servata, Carlos Puig-Jovéa, Lluís García-Gonzálezb
a Servei d’Endocrinologia, Hospital Universitari Mútua de Terrasa, Terrassa, Spain
b Servei de Cirurgia General i Aparell Digestiu, Hospital Universitari Arnau de Vilanova, Lleida, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The biochemical cure of hyperparathyroidism &#40;HPPT&#41; after surgical treatment is confirmed when parathyroid hormone &#40;PTH&#41; and albumin-adjusted calcium &#40;AAC&#41; levels remain normal for at least six months after surgery&#46; Hypercalcaemia with elevated PTH in this time period indicates persistent HPPT&#44; and hypercalcaemia observed beyond six months after a period of normocalcaemia is considered to be recurrent HPPT&#46; An intermediate situation between the cure and persistence of HPPT results from elevated PTH with normocalcaemia following the curative surgical resection of a primary HPPT &#40;PPNCHPPT or post-parathyroidectomy normocalcaemic hyperparathyroidism&#41;&#46; On average&#44; this disorder has a prevalence of 30&#37; outside of our setting&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">PPNCHPPT represents a complex clinical situation whose pathological significance has not been sufficiently defined and for which there is no consensus on follow-up and treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;5</span></a> At this moment in time there is no evidence that PPNCHPPT is a consequence of surgical failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> In 30&#37;&#8211;60&#37; of these patients&#44; PTH levels will normalise within 12&#8211;18 months of the procedure&#44; and in the remainder this may mean an autonomisation of PTH secretion that should be monitored to assess for the recurrence of HPPT&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;6</span></a><span class="elsevierStyleBold"><span class="elsevierStyleSup">&#8722;</span></span><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Some predictive markers of PPNCHPPT have been described&#44; although not unanimously&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;8&#44;10&#8211;15</span></a> and a number of potentially responsible causes such as vitamin D deficiency&#44; bone remineralisation syndrome&#44; inadequate calcium intake or absorption&#44; chronic kidney disease and hypercalciuria have been hypothesised&#46; A further two aetiopathogenic mechanisms have also been proposed&#58; an increase in the PTH secretion regulation point prompted by changes in the calcium-sensing receptors in the remaining parathyroid glands and a reduction in peripheral sensitivity to PTH&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;7&#8211;9&#44;10&#8211;13&#44;16&#8211;21</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of this study is to determine&#44; in our setting&#44; the prevalence of PPNCHPPT in the first six months after a successful parathyroidectomy for a single adenoma&#44; to evaluate the possible aetiological factors and associated predictive markers&#44; the treatment given and outcome after more than 12 months of follow-up&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This was a retrospective observational study based on routine clinical practice in a hospital setting&#46; In total&#44; 42 patients undergoing a parathyroidectomy between May 2017 and May 2022&#44; with anatomopathological findings of single parathyroid adenoma were included to compare those with PPNCHPPT and those who had normal post-parathyroidectomy PTH and calcium levels&#46; All of them had a postoperative follow-up of more than six months&#44; and those with PPNCHPPT had a follow-up of more than 12 months&#46; Patients who exhibited a reduction in PTH of less than 60&#37; in the first 24&#8239;h post-parathyroidectomy were excluded on the grounds that the procedure may not have been successful&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> as were those who received preoperative cinacalcet treatment&#44; which may have modified PTH values and the calcium-mediated PTH secretion regulation point&#46; The study was approved by the Independent Ethics Committee of the Fundaci&#243; Assistencial M&#250;tua de Terrassa&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The variables collected from the clinical history were&#58; personal data &#40;sex&#44; age and weight at the time of the parathyroidectomy&#41;&#44; results of the dorsolumbar spine bone X-ray and preoperative bone densitometry&#59; change over time of preoperative and postoperative analytical parameters in the first eight and 24&#8239;h&#44; first week&#44; first month&#44; sixth month and subsequent follow-up of PTH&#44; AAC&#44; calcifediol&#44; 24-h urinary calcium&#44; plasma creatinine and glomerular filtration rate estimated according to the 2009 CKD-EPI creatinine equation&#44; and plasma phosphate and magnesium in cases of hungry bone syndrome&#59; preoperative and postoperative treatment with calcium salts&#44; vitamin D supplements and bone antiresorptive agents&#44; and patient follow-up time&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The primary endpoints were&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Prevalence of PPNCHPPT identified by lab test at six months post-parathyroidectomy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Possible aetiological factors associated with PPNCHPPT<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">o</span><p id="par0050" class="elsevierStylePara elsevierViewall">Bone remineralisation syndrome&#58; defined according to the appearance of hungry bone syndrome &#40;AAC of less than 8&#8239;mg&#47;dL in the first 24&#8239;h of the postoperative period prolonged for more than four days with hypophosphataemia and hypomagnesaemia&#41; and&#47;or pathological fractures in the dorsal or lumbar spine and&#47;or bone densitometry prior to surgery with osteoporosis values in the lumbar spine and&#47;or femur&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">o</span><p id="par0055" class="elsevierStylePara elsevierViewall">Calcifediol deficiency six months after the parathyroidectomy&#58; plasma calcifediol less than 30&#8239;ng&#47;mL&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">o</span><p id="par0060" class="elsevierStylePara elsevierViewall">Kidney failure six months after parathyroidectomy&#58; estimated glomerular filtration rate less than 60&#8239;mL&#47;min&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">o</span><p id="par0065" class="elsevierStylePara elsevierViewall">Hypercalciuria in the first six months after parathyroidectomy&#58; 24-h urinary calcium greater than 4&#8239;mg&#47;kg&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Possible aetiopathogenic mechanisms associated with PPNCHPPT&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">o</span><p id="par0075" class="elsevierStylePara elsevierViewall">Change in the calcium-mediated PTH secretion regulation point&#44; evaluated by the percentage decrease in PTH and AAC in the first 24&#8239;h after surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">o</span><p id="par0080" class="elsevierStylePara elsevierViewall">Decreased peripheral sensitivity to PTH evaluated as the preoperative PTH&#47;AAC ratio&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Possible predictive markers of PPNCHPPT<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">o</span><p id="par0090" class="elsevierStylePara elsevierViewall">Patient age&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">o</span><p id="par0095" class="elsevierStylePara elsevierViewall">PTH&#44; AAC and calcifediol concentrations preoperatively and during the first six months postoperative&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">o</span><p id="par0100" class="elsevierStylePara elsevierViewall">PTH ratios over time&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Intraoperative post-exeresis PTH&#47;intraoperative pre-exeresis PTH ratio&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">8-h post-exeresis PTH&#47;preoperative PTH ratio&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">24-h post-exeresis PTH&#47;preoperative PTH ratio&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">24-h post-exeresis PTH&#47;8-h post-exeresis PTH ratio&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">o</span><p id="par0125" class="elsevierStylePara elsevierViewall">Preoperative and postoperative PTH&#47;AAC ratio&#46;</p></li></ul></p></li></ul></p><p id="par0130" class="elsevierStylePara elsevierViewall">Secondary endpoints were outcome after six or more months of follow-up of PPNCHPPT evaluated as normalisation of PTH &#40;at least the last two PTH tests are normal&#41;&#44; persistence of PTH elevation or recurrence of HPPT and the effect of treatment with calcium salts&#44; vitamin D supplements and&#47;or bone antiresorptive agents&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Calcium levels were determined using the 5-nitro-5&#39;-methyl-BAPTA method&#59; urinary calcium with o-cresolphthalein complexone&#44; plasma albumin using bromocresol green and intact PTH and calcifediol using electrochemiluminescence immunoassay&#46; The reference values for calcium were 8&#46;6&#8211;10&#46;0&#8239;mg&#47;dL&#44; with a coefficient of variation of 0&#46;61&#37;&#44; while for intact PTH they were 15&#46;0&#8211;65&#46;7&#8239;pg&#47;mL&#44; with a coefficient of variation of 3&#46;05&#37; and an assay sensitivity of 5&#46;5&#8239;pg&#47;mL&#46; All the other biochemical parameters were performed by standard procedures&#46; In the dorsal and lumbar spine X-rays&#44; the presence of vertebral fractures was assessed by a reduction of 20&#37; or more in the anterior&#44; middle or posterior height of the vertebral body&#46; Bone mineral density in the lumbar spine &#40;L2&#8211;L4&#41; and proximal femur was assessed by dual X-ray absorptiometry &#40;Lunar PRODIGY device&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">A descriptive analysis of the variables collected was performed&#46; The univariate analysis of differences between continuous and categorical variables was analysed with the Student&#39;s t-test&#44; and the relationship between the categorical variables with the Chi-square or Fisher&#39;s F-test&#46; A binary logistic regression analysis was performed to investigate the independence of the predictive variables for PPNCHPPT&#46; ROC curves were generated to determine sensitivity and specificity in predicting PPNCHPPT&#46; Statistical significance was established at <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;05 &#40;2-tailed&#41;&#46; The statistical analysis was performed using the software Epidat&#44; version 3&#46;1 &#40;Servizo Galego de Sa&#250;de &#91;Galician Health Service&#93;&#44; Galicia&#44; Spain&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0145" class="elsevierStylePara elsevierViewall">In total&#44; 42 patients were included&#44; 39 women &#40;92&#46;9&#37;&#41; and three men &#40;7&#46;1&#37;&#41;&#44; with a mean age of 58&#46;6&#8239;&#177;&#8239;11 years&#46; The prevalence of patients with PPNCHPPT was 12 cases &#40;28&#46;6&#37;&#41;&#46; The related causes&#44; treatment received and outcome are detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">There were no cases with postoperative hungry bone syndrome among the remineralisation syndrome cases&#46; More than one cause was identified in some patients&#58; in the group of patients with PPNCHPPT there was one case of hypercalciuria and vitamin D deficiency and one case of remineralisation and vitamin D deficiency&#44; and in the group of patients without PPNCHPPT there were nine cases of vitamin D deficiency and remineralisation&#46; All the bone antiresorptive agents administered were bisphosphonates&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Regarding status at the end of follow-up&#44; in the non-PPNCHPPT group there were four cases of normocalcaemic HPPT as a consequence of vitamin D deficiency&#46; In the PPNCHPPT group&#44; there was only one recurrence of HPPT in one patient with chronic renal failure&#44; and in the 5 cases that persisted with elevated PTH and normal calcium at the end of follow-up&#44; the causes recognised were remineralisation in one case&#44; vitamin D deficiency in two cases&#44; hypercalciuria and vitamin D deficiency in one case and vitamin D deficiency and remineralisation in one case&#59; no patient received preoperative treatment with calcium salts or bisphosphonates&#44; although all cases were given vitamin D supplements&#44; and in the postoperative period no patient had received treatment with calcium salts&#44; four received vitamin D supplements and one bisphosphonates&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> details the possible predictive markers for PPNCHPPT&#46; In the logistic regression analysis&#44; only the one-week post-surgery PTH&#47;AAC ratio variable was independently associated with PPNCHPPT &#40;odds ratio 3&#46;929&#44; 95&#37; CI&#58; 1&#46;054&#8211;14&#46;647&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;05&#41;&#46; When this variable was extracted from the model&#44; the one-week post-surgery PTH variable was the only variable independently associated with PPNCHPPT &#40;odds ratio 1&#46;130&#44; 95&#37; CI&#58; 1&#46;002&#8211;1&#46;275&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;05&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">In the ROC curves to distinguish between patients with and without PPNCHPPT&#44; the variables with the largest area under the curve&#44; with a similar magnitude&#44; were the PTH&#47;AAC ratio and PTH&#44; both at one-week post-surgery &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0170" class="elsevierStylePara elsevierViewall">To the best of our knowledge&#44; this is the first series of patients in our country in whom PPNCHPPT is analysed&#46; The prevalence of 28&#46;6&#37; found is in line with previously documented series&#44; although it should be noted that the reference range for this prevalence is very broad&#44; from 8&#37; to 44&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;5&#8211;15&#44;19&#44;24</span></a> The reason for this disparity is unknown&#44; but it may have to do with the cause of the PPNCHPPT that is not always easy to detect or to assess&#44; which in our case proved to be predominantly vitamin D deficiency&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Most of the previous studies assess only some of the aetiologies responsible for PPNCHPPT&#44; so there are no data on the actual incidence of each one&#44; and comparisons cannot be drawn&#46; Vitamin D deficiency is common and occurs more frequently in patients with HPPT due to increased vitamin D catabolism&#44; which in turn can lead to secondary HPPT&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6&#44;11&#44;12</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In our series&#44; it proved to be the most frequent aetiological factor related to PPNCHPPT&#44; and was less present&#44; albeit without statistical significance&#44; perhaps because of the small number of cases in patients without PPNCHPPT&#46; The vast majority of patients in each group received preoperative and postoperative treatment with vitamin D supplementation and their levels normalised within the first month&#44; although in the group of patients with PPNCHPPT&#44; levels fell by the sixth month post-parathyroidectomy&#44; which could be reflected in a supranormal rise in PTH&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Bone remineralisation can be a very influential factor in PPNCHPPT and its effect can last between one and four years&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10&#44;11&#44;21</span></a> This can be explained by the deposition of calcium salts in the bone&#44; which leads to a decrease in serum calcium&#44; resulting in elevated PTH levels to maintain normal extracellular calcium&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The significant densitometric improvement in osteoporosis one year after parathyroidectomy in patients with primary HPPT provides valuable evidence of the bone remineralisation that occurs in these cases&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The classic hungry bone syndrome&#44; the ultimate example of bone remineralisation&#44; with acute post-surgical presentation&#44; is a rare occurrence not usually documented in series of patients with primary HPPT in recent decades due to its early diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;21</span></a> The definition of bone remineralisation syndrome is not very precise&#44; as it is based on certain characteristics associated with bone demineralisation&#44; such as the presence of pathological fractures&#44; lower bone mineral density&#44; elevated alkaline phosphatase or osteocalcin levels&#44; lower postoperative calcium and higher postoperative PTH&#44; improved biochemical profile of PTH and calcium with treatment based on calcium salts with or without vitamin D supplementation&#44; and its tendency to post-parathyroidectomy evolutionary extinction&#46; In the actual clinical practice of patients with HPPT&#44; we have sufficient densitometric&#44; radiological and clinical data on pathological fractures to be able to justify a bone remineralisation phenomenon&#46; However&#44; there is no validated&#44; accurate and stratified way of recognising it&#44; whereby &#8220;less severe&#8221; forms of remineralisation may go undetected&#46; In our series&#44; bone remineralisation based on densitometric criteria of osteoporosis with or without pathological fractures was recognised in a small proportion of patients with PPNCHPPT and was surprisingly more frequent in the group of patients without PPNCHPPT&#44; probably influenced by their older age&#59; the higher frequency of preoperative treatment with bone antiresorptive agents and postoperative treatment with calcium salts may have helped to prevent supranormal PTH elevation&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Renal insufficiency is clearly a contributing factor to PPNCHPPT&#46; Glomerular filtration rates below 70&#8239;mL&#47;min already give rise to an increase in PTH values&#44; and supranormal PTH levels are reached below 60&#8239;mL&#47;min&#44; albeit without a substantial effect on calcium until the glomerular filtration rate is below 20&#8239;mL&#47;min&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#44;12&#44;13</span></a> The same is not true for hypercalciuria&#44; as its effect on PPNCHPPT is not fully understood&#46; The first isolated cases were reported in the 1970s and 1980s&#44; in which hypercalciuria was associated with HPPT recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In 2005&#44; Farooki et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> insisted that hypercalciuria should be regarded as a cause of PPNCHPPT&#46; Idiopathic hypercalciuria is a metabolic abnormality that may be accompanied by urinary bladder stones and decreased bone mineral density&#44; although characteristically patients do not have supranormal PTH values&#44; unlike those with hypercalciuria secondary to HPPT&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;26&#8211;28</span></a> This does not tally with other studies in which elevated PTH values were attributed to some patients with idiopathic hypercalciuria&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> and has led current reviews to continue to consider idiopathic hypercalciuria as a cause of supranormal PTH levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> In patients with PPNCHPPT and hypercalciuria&#44; it should be considered that hypercalciuria may be secondary to PPNCHPPT or that there are two concomitant diseases&#44; idiopathic hypercalciuria and another factor leading to elevated PTH levels&#46; In our series&#44; there was one recognised case of hypercalciuria in the group with PPNCHPPT&#44; associated with vitamin D deficiency&#44; treated preoperatively&#44; but not postoperatively&#44; with vitamin D supplementation&#46; The patient&#39;s calcifediol levels failed to normalise and supranormal PTH levels persisted during follow-up&#46; In this case we were unable to establish the role of hypercalciuria in PTH elevation&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">A change in the calcium regulation point on PTH secretion has been ruled out in two studies with different methodologies after evaluating this possible aetiopathogenesis of PPNCHPPT&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;10</span></a> A lower percentage of early postoperative PTH decrease in patients with PPNCHPPT suggests an increase in the calcium-mediated PTH secretion regulation point&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> although this was also not observed in our patients&#44; hence it seems reasonable to rule out this phenomenon as a cause of PPNCHPPT&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Peripheral resistance to the action of PTH has also been considered as a possible aetiopathogenic mechanism of PPNCHPPT&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Resistance to the renal effect of PTH was initially reported in patients with HPPT secondary to vitamin D deficiency due to a diminished response in the generation of cyclic adenosine monophosphate after the exogenous administration of PTH&#44; which normalised after treatment with vitamin D&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In another study&#44; six weeks after parathyroidectomy&#44; after an infusion of PTH&#44; the rise in calcium and decrease in phosphataemia were seen to be lower in patients with PPNCHPPT than in those with normal PTH&#44; which was interpreted as a reduction in peripheral sensitivity to PTH&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> This phenomenon of peripheral resistance to PTH could be caused by lower vitamin D levels and&#47;or more severe preoperative HPPT&#44; which would lead to a down-regulation in the number of PTH receptors&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;18</span></a> In the study by Dhillon et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> the lower 1&#44;25 dihydroxyvitamin D&#47;PTH ratio found in patients with PPNCHPPT was interpreted as renal resistance to PTH&#44; endorsed by the group of Yamashita et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> due to a higher preoperative PTH&#47;renal cyclic adenosine monophosphate ratio&#44; stressing that this resistance to PTH was greater in cases with renal insufficiency and vitamin D deficiency&#46; Studies on peripheral resistance to the action of PTH are scant and do not provide a uniform and validated formula that can be applied routinely in clinical practice&#46; They are based on response to the administration of PTH or on the ratio of PTH to a metabolite produced as a consequence of its action&#46; Our study evaluated the preoperative PTH&#47;AAC ratio&#44; since AAC is a metabolite directly related to the action of PTH&#44; and in the preoperative period it is not influenced by the dynamic changes of the postoperative period&#46; This PTH&#47;AAC ratio&#44; described for the first time here&#44; was significantly higher in patients with PPNCHPPT&#44; indicating that a higher PTH level does not result in proportionally higher calcium&#44; which could be consistent with peripheral resistance to the action of PTH&#46; This could be related to more severe cases of HPPT given the higher preoperative PTH levels&#44; to vitamin D deficiency and to the greater proportion of patients with chronic renal failure in this group of PPNCHPPT patients&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Regarding the predictive markers of PPNCHPPT&#44; most authors report a higher preoperative PTH concentration<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;10&#8211;15&#44;19</span></a> and a larger resected adenoma size&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;13&#44;18</span></a> Elevated osteocalcin&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> lower bone mineral content&#44; lower vitamin D levels and lower postoperative calcium<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;11&#8211;13&#44;15</span></a> have also been described as predictive markers for PPNCHPPT&#46; Older patient age has been found to be a predictor of PPNCHPPT in relation to a higher associated vitamin D deficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;10&#44;13&#8211;15&#44;21</span></a> In our study&#44; the age of the cases with PPNCHPPT was significantly lower&#44; contrary to expectations&#44; possibly because other factors such as a higher preoperative PTH level had an impact on this group&#46; Similarly&#44; the higher bone mineral density values in these patients may be related to their younger age&#46; Furthermore&#44; PTH values&#44; and particularly the PTH&#47;AAC ratio in the early postoperative period&#44; at one week after surgery&#44; have made it possible to obtain previously undescribed cut-off points with high sensitivity and specificity for predicting PPNCHPPT&#46; The slight elevation of AAC one month after surgery may have been due to the significant increase in PTH over the previous weeks&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">A large proportion of patients with PPNCHPPT achieve normalisation of PTH during follow-up&#44; as was the case in 50&#37; of our patients&#46; In other series&#44; normalised PTH is reported in 30&#37;&#8211;60&#37; of patients at a follow-up time of 1&#8211;1&#46;5 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;6&#8211;11&#44;13&#44;19&#44;25</span></a> This normalisation of PTH could be a result of a spontaneous postoperative or treatment-induced correction of vitamin D deficiency and the deficit in intestinal calcium intake or absorption&#44; as well as the resolution of bone remineralisation&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10&#44;11&#44;25</span></a> Our series suffers from a low percentage of patients treated with calcium salts&#44; which could have worsened their outcome&#46; Occasionally&#44; patients with PPNCHPPT progress to recurrent HPPT by developing hypercalcaemia&#44; which occurs in 0&#37;&#8211;4&#46;8&#37; at a 10-year follow-up<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8&#44;11&#44;13</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;19</span></a> and up to 5&#46;4&#37; if patients with multiglandular disease are included&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;24</span></a> Patients with a recurrence of HPPT have been associated with increased preoperative HPPT involvement&#44; increased preoperative calcium and impaired renal function<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and increased postoperative calcium&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The recurrence rates described have not been uniformly higher than those found in patients without PPNCHPPT&#44; as was the case in our study&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;15</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">There is currently no consensus on the management of patients with PPNCHPPT&#46; Regardless&#44; it would seem advisable to ensure that they have appropriate vitamin D levels and sufficient dietary intake of calcium&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Treatment based on calcium salts with or without vitamin D supplementation has resulted in increased bone mineral density and significant decreases and normalisation of postoperative PTH&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;12&#44;21</span></a> In some centres&#44; it has been routinely recommended for all patients undergoing parathyroidectomy for HPPT&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> whereas in others only for patients with PPNCHPPT&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Postoperative vitamin D treatment is also known to reduce the incidence of PPNCHPPT<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and has been recommended for patients with PPNCHPPT based on renal resistance to the action of PTH in vitamin D-deficient cases&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In our series&#44; almost all the patients had received vitamin D supplementation&#44; but in the PPNCHPPT group this was insufficient to maintain adequate calcifediol levels for six months post-parathyroidectomy&#46; In contrast&#44; few&#44; and significantly fewer patients in the PPNCHPPT group&#44; were given calcium salts&#46; Preoperative treatment with bisphosphonates in patients with osteoporosis and HPPT has a clear beneficial effect&#44; improving bone mineral density by significantly decreasing or normalising bone turnover&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> This effect may also have been significant in the group of patients without PPNCHPPT&#44; as they had received bisphosphonates more frequently&#46; The utility of bisphosphonates for less expressive cases of bone remineralisation&#44; without osteoporosis&#44; remains to be studied&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">This study has certain limitations&#46; Its retrospective nature led to some data being missed in the recording of variables&#44; which was taken into account in each statistical analysis carried out&#46; The sample size was relatively small&#44; moderate compared to other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8&#8211;10&#44;12&#44;18&#44;19</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">25</span></a> and may have resulted in lower statistical power for detecting significant differences&#46; The mean postoperative follow-up period of PPNCHPPT cases was limited to about 2&#46;5 years&#59; a longer period might have different outcomes&#46; The definition of bone remineralisation syndrome is imprecise&#44; as there are no diagnostic criteria for its severity&#44; whereby less severe forms than those reported here may have gone undetected&#46; We were unable to assess inadequate calcium intake or absorption as a cause of PPNCHPPT&#44; as other retrospective studies have done&#46; Bisphosphonate treatment in the group of patients without PPNCHPPT may have slightly increased PTH values and reduced calcium values&#44; although this effect did not prevent the recognition of higher PTH and PTH&#47;AAC ratio values in the PPNCHPPT group&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">In conclusion&#44; PPNCHPPT is a complex and common clinical situation&#46; This is the first study in Spain to demonstrate an average prevalence of patients with PPNCHPPT and recognises that in most cases it is related to vitamin D deficiency and possible peripheral resistance to the action of PTH&#44; taking into account that a precise and operational definition and stratification of post-parathyroidectomy bone remineralisation is not available&#46; Continuing to consider hypercalciuria and a change in the calcium-mediated PTH secretion regulation point as causes of PPNCHPPT is also questionable&#46; We describe the PTH&#47;AAC ratio and PTH one week after surgery as accurate predictive markers of PPNCHPPT&#46; Half of the cases with PPNCHPPT evolve to normal PTH and the recurrence rate of HPPT was not higher in this group of patients&#46; Preoperative treatment with bisphosphonates in cases of osteoporosis and postoperative vitamin D supplementation may minimise the frequency of PPNCHPPT&#44; although we would draw attention to the scant use of postoperative treatment with calcium salts&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Authors</span><p id="par0225" class="elsevierStylePara elsevierViewall">Each author has contributed materially to the research and preparation of the article&#46; Specifically&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0230" class="elsevierStylePara elsevierViewall">Luis Garc&#237;a Pascual&#58; study conception and design&#44; data acquisition and analysis&#44; interpretation of results&#44; writing of the draft and approval of the final version&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0235" class="elsevierStylePara elsevierViewall">Andreu Sim&#243;-Servat&#44; Carlos Puig-Jov&#233;&#44; Llu&#237;s Garc&#237;a-Gonz&#225;lez&#58; study conception and design&#44; interpretation of results&#44; critical review and approval of the final version&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical declarations</span><p id="par0240" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0245" class="elsevierStylePara elsevierViewall">Protection of people and animals&#46; The authors declare that no experiments were performed on humans or animals for this study&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">-</span><p id="par0250" class="elsevierStylePara elsevierViewall">Data confidentiality&#46; The authors declare that they have adhered to their workplace protocols on the publication of patient data&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0255" class="elsevierStylePara elsevierViewall">This study received no specific funding from public&#44; private or non-profit organisations&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0260" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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    "fechaRecibido" => "2023-07-22"
    "fechaAceptado" => "2023-09-14"
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            0 => "Postoperative hyperparathyroidism"
            1 => "Primary hyperparathyroidism"
            2 => "Parathyroidectomy"
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          "clase" => "keyword"
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          "palabras" => array:3 [
            0 => "Hiperparatiroidismo postoperatorio"
            1 => "Hiperparatiroidismo primario"
            2 => "Paratiroidectom&#237;a"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Postparathyroidectomy normocalcemic hyperparathyroidism &#40;PPNCHPPT&#41; is a frequent situation for which we have no information in our country&#46; The objective is to know our prevalence of PPNCHPPT&#44; the associated etiological factors&#44; the predictive markers&#44; the treatment administered and the evolution&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and method</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Retrospective observational cross-sectional study on 42 patients&#46; Twelve patients with PPNCHPPT and 30 without PPNCHPPT are compared&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">HPPTNCPP prevalence&#58; 28&#46;6&#37;&#46; Etiological factors&#58; vitamin D deficiency&#58; 75&#37;&#59; bone remineralization&#58; 16&#46;7&#37;&#59; renal failure&#58; 16&#46;7&#37;&#59; hypercalciruria&#58; 8&#46;3&#37;&#46; No change in the set point of calcium-mediated parathormone &#40;PTH&#41; secretion was observed&#44; but an increase in the preoperative PTH&#47;albumin-corrected calcium &#40;ACC&#41; ratio was observed&#46; Predictive markers&#58; PTH&#47;ACC ratio &#40;AUC 0&#46;947&#59; sensitivity 100&#37;&#44; specificity 78&#46;9&#37;&#41; and PTH &#40;AUC 0&#46;914&#59; sensitivity 100&#37;&#44; specificity 73&#46;7&#37;&#41; one week postparathyroidectomy&#46; Evolution&#58; follow-up 30&#8239;&#177;&#8239;16&#46;3 months&#58; 50&#37; normalized PTH and 8&#46;3&#37; had recurrence of hyperparathyroidism&#46; Patients with PPNCHPPT less frequently received preoperative treatment with bisphosphonates and postoperative treatment with calcium salts&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">This is the first study in our country that demonstrates a mean prevalence of PPNCHPPT&#44; mainly related to a vitamin D deficiency and a probable resistance to the action of PTH&#44; which can be predicted by the PTH&#47;ACC ratio and PTH a week post-intervention and often evolves normalizing the PTH&#46; We disagree with the etiological effect of hypercalciuria and the change in the PTH&#47;calcemia regulation set point&#44; and we acknowledge the scant treatment administered with calcium salts in the postoperative period&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Background and objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and method"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El hiperparatiroidismo normocalc&#233;mico postparatiroidectom&#237;a &#40;HPPTNCPP&#41; es una situaci&#243;n frecuente de la que no tenemos informaci&#243;n de nuestro pa&#237;s&#46; El objetivo es conocer nuestra prevalencia del HPPTNCPP&#44; los factores etiol&#243;gicos asociados&#44; los marcadores predictivos&#44; el tratamiento administrado y la evoluci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo observacional transversal sobre 42 pacientes&#46; Se comparan 12 pacientes con HPPTNCPP y 30 sin HPPTNCPP&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Prevalencia del HPPTNCPP&#58; 28&#44;6&#37;&#46; Factores etiol&#243;gicos&#58; d&#233;ficit de vitamina D&#58; 75&#37;&#59; remineralizaci&#243;n &#243;sea&#58; 16&#44;7&#37;&#59; insuficiencia renal&#58; 16&#44;7&#37;&#59; hipercalciuria&#58; 8&#44;3&#37;&#46; No se observ&#243; cambio en el punto de regulaci&#243;n de la secreci&#243;n de parathormona &#40;PTH&#41; mediada por la calcemia&#44; pero s&#237; un aumento del cociente PTH&#47;calcio corregido por alb&#250;mina &#40;CCA&#41; preoperatorio&#46; Marcadores predictivos&#58; cociente PTH&#47;CCA &#40;AUC 0&#44;947&#59; sensibilidad 100&#37;&#44; especificidad 78&#44;9&#37;&#41; y PTH &#40;AUC 0&#44;914&#59; sensibilidad 100&#37;&#44; especificidad 73&#44;7&#37;&#41; una semana postparatiroidectom&#237;a&#46; Evoluci&#243;n&#58; seguimiento 30&#8239;&#177;&#8239;16&#44;3 meses&#58; 50&#37; normaliz&#243; PTH y 8&#44;3&#37; tuvo recurrencia del hiperparatiroidismo&#46; Los pacientes con HPPTNCPP recibieron con menor frecuencia tratamiento preoperatorio con bifosfonatos y posoperatorio con sales de calcio&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Es el primer estudio en nuestro pa&#237;s que demuestra una prevalencia media del HPPTNCPP&#44; relacionado principalmente con un d&#233;ficit de vitamina D y con una probable resistencia a la acci&#243;n de la PTH&#44; que puede ser predicho mediante el cociente PTH&#47;CCA y la PTH a la semana postintervenci&#243;n&#44; que con frecuencia evoluciona normalizando la PTH&#46; Disentimos del efecto etiol&#243;gico de la hipercalciuria y del cambio en el punto de regulaci&#243;n PTH&#47;calcemia&#44; y reconocemos el escaso tratamiento administrado con sales de calcio en el posoperatorio&#46;</p></span>"
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                  \t\t\t\t">Number of cases &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30 &#40;71&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">12 &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">---&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Bone remineralisation&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21 &#40;70&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Vitamin D deficiency&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Kidney failure&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;16&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>None of the above&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;16&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Other possible aetiopathogenic mechanisms</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Change in the PTH secretion regulation point</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Percentage PTH decrease<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#46;56&#8239;&#177;&#8239;12&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#46;65&#8239;&#177;&#8239;18&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Percentage AAC reduction<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;63&#8239;&#177;&#8239;7&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;45&#8239;&#177;&#8239;6&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Decreased peripheral sensitivity to PTH</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Preoperative PTH&#47;AAC ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;22&#8239;&#177;&#8239;4&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;66&#8239;&#177;&#8239;5&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Preoperative treatment with</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Calcium salts&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Vitamin D supplementation&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;76&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;91&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Bone antiresorptive agents&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Postoperative treatment with</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Calcium salts&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;36&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Vitamin D supplementation&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;93&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;91&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Bone antiresorptive agents&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Follow-up time &#40;mean&#8239;&#177;&#8239;SD&#44; months&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;9&#8239;&#177;&#8239;18&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#8239;&#177;&#8239;16&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Status at the end of follow-up</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>PTH and AAC normal&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;86&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Elevated PTH with normal AAC&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;13&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;41&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Elevated PTH and AAC&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age &#40;mean&#8239;&#177;&#8239;SD&#44; years&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;3&#8239;&#177;&#8239;10&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&#46;8&#8239;&#177;&#8239;9&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Preoperative bone mineral density</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>In proximal femur &#40;g&#47;cm<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;733&#8239;&#177;&#8239;0&#46;105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;914&#8239;&#177;&#8239;0&#46;161&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>In lumbar spine &#40;g&#47;cm<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;933&#8239;&#177;&#8239;0&#46;193&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;119&#8239;&#177;&#8239;0&#46;151&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Preoperative laboratory tests</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AAC &#40;mean&#8239;&#177;&#8239;SD&#44; mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;44&#8239;&#177;&#8239;0&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;59&#8239;&#177;&#8239;0&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PTH &#40;mean&#8239;&#177;&#8239;SD&#44; pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">116&#46;19&#8239;&#177;&#8239;40&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">166&#46;80&#8239;&#177;&#8239;57&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Calcifediol &#40;mean&#8239;&#177;&#8239;SD&#44; ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;53&#8239;&#177;&#8239;14&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;56&#8239;&#177;&#8239;8&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PTH&#47;AAC ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;22&#8239;&#177;&#8239;4&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;66&#8239;&#177;&#8239;5&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">8-h postoperative laboratory tests</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AAC &#40;mean&#8239;&#177;&#8239;SD&#44; mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;87&#8239;&#177;&#8239;0&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;25&#8239;&#177;&#8239;0&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PTH &#40;mean&#8239;&#177;&#8239;SD&#44; pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;51&#8239;&#177;&#8239;27&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;92&#8239;&#177;&#8239;19&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PTH&#47;AAC ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;19&#8239;&#177;&#8239;2&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;92&#8239;&#177;&#8239;1&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">24-h postoperative laboratory tests</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AAC &#40;mean&#8239;&#177;&#8239;SD&#44; mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PTH &#40;mean&#8239;&#177;&#8239;SD&#44; pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PTH&#47;AAC ratio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">One-week postoperative laboratory tests</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AAC &#40;mean&#8239;&#177;&#8239;SD&#44; mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PTH &#40;mean&#8239;&#177;&#8239;SD&#44; pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Calcifediol &#40;mean&#8239;&#177;&#8239;SD&#44; ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PTH&#47;AAC ratio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">One-month postoperative laboratory tests</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AAC &#40;mean&#8239;&#177;&#8239;SD&#44; mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PTH &#40;mean&#8239;&#177;&#8239;SD&#44; pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">56&#46;14&#8239;&#177;&#8239;18&#46;15&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Calcifediol &#40;mean&#8239;&#177;&#8239;SD&#44; ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">31&#46;72&#8239;&#177;&#8239;11&#46;38&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PTH&#47;AAC ratio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Six-month postoperative laboratory tests</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AAC &#40;mean&#8239;&#177;&#8239;SD&#44; mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PTH &#40;mean&#8239;&#177;&#8239;SD&#44; pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">45&#46;27&#8239;&#177;&#8239;17&#46;06&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">84&#46;15&#8239;&#177;&#8239;24&#46;73&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Calcifediol &#40;mean&#8239;&#177;&#8239;SD&#44; ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;91&#8239;&#177;&#8239;12&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;45&#8239;&#177;&#8239;5&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PTH&#47;AAC ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;84&#8239;&#177;&#8239;1&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;11&#8239;&#177;&#8239;2&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Changes in PTH levels</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ratio &#40;intraoperative post-exeresis PTH&#47;pre-exeresis PTH&#41;&#8239;&#215;&#8239;100 &#40;mean&#8239;&#177;&#8239;SD&#44; &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;87&#8239;&#177;&#8239;19&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#46;95&#8239;&#177;&#8239;18&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ratio &#40;8-h post-exeresis PTH&#47;preoperative PTH&#41;&#8239;&#215;&#8239;100 &#40;mean&#8239;&#177;&#8239;SD&#44; &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;80&#8239;&#177;&#8239;31&#46;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;42&#8239;&#177;&#8239;10&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ratio &#40;24-h post-exeresis PTH&#47;preoperative PTH&#41;&#8239;&#215;&#8239;100 &#40;mean&#8239;&#177;&#8239;SD&#44; &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;44&#8239;&#177;&#8239;12&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;35&#8239;&#177;&#8239;18&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ratio &#40;24-h post-exeresis PTH&#47;18-h post-exeresis PTH&#41;&#8239;&#215;&#8239;100 &#40;mean&#8239;&#177;&#8239;SD&#44; &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">128&#46;82&#8239;&#177;&#8239;67&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">187&#46;51&#8239;&#177;&#8239;111&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Area under the curve &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cut-off point&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sensitivity &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Specificity &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PTH&#47;AAC one week postoperative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;947 &#40;0&#46;839&#8722;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#37; &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#46;9&#37; &#40;64&#46;3&#37;&#8211;93&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PTH one week postoperative&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;914 &#40;0&#46;780&#8722;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">49&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">100&#37; &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">73&#46;7&#37; &#40;58&#46;0&#37;&#8211;89&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                0 => array:2 [
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46; Oltmann"
                            1 => "N&#46;M&#46; Maalouf"
                            2 => "S&#46; Holt"
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                        ]
                      ]
                    ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Endoc Pract&#46;"
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                        "volumen" => "17"
                        "paginaInicial" => "57"
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                  "contribucion" => array:1 [
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                      "titulo" => "Elevated par4athyroid hormona levels after successful parathyroidectomy for primary hyperparathyroidism&#58; a clinical review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; de la Plaza Llamas"
                            1 => "J&#46;M&#46; Rami Angel"
                            2 => "V&#46; Arteaga Peralta"
                            3 => "C&#46; Garc&#237;a Amador"
                            4 => "A&#46;J&#46; L&#243;pez Marcano"
                            5 => "A&#46;A&#46; Medina Velasco"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur Arch Otorhinolaryngol&#46;"
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                        "volumen" => "275"
                        "paginaInicial" => "659"
                        "paginaFinal" => "669"
                      ]
                    ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "European expert consensus on practical management of specific aspects of parathyroid disorders in adults and in pregnancy&#58; recommendations of the ESE Educational Program of Parathyroid Disorders &#40;PARAT 2021&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Bollerslev"
                            1 => "L&#46; Rejnmark"
                            2 => "A&#46; Zahn"
                            3 => "A&#46; Heck"
                            4 => "N&#46; Appelman-Dijkstra"
                            5 => "L&#46; Cardoso"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1530/EJE-21-1044"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Endocrinol&#46;"
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                        "volumen" => "186"
                        "paginaInicial" => "R33"
                        "paginaFinal" => "R63"
                        "link" => array:1 [
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                          ]
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                    0 => array:2 [
                      "titulo" => "Prevalence of abnormal serum vitamin D&#44; PTH&#44; calcium&#44; and phosphorus in patients with chronic kidney disease&#58; results of the study to evaluate early kidney disease"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Levin"
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                            4 => "J&#46; Tian"
                            5 => "L&#46;A&#46; Williams"
                          ]
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                      ]
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                        "fecha" => "2007"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Persistently elevated PTH after parathyroidectomy at one year&#58; experience in a tertiary referral center"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
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