Cardiovascular and Cerebrovascular Events After Parathyroidectomy in Patients on Renal Replacement Therapy

Abstract

Background A majority of patients with end-stage renal disease suffer from secondary hyperparathyroidism, which is associated with osteoporosis and cardiovascular disease. Parathyroidectomy (PTX) is often necessary despite medical treatment. However, the effect of PTX on cardio-and cerebrovascular events (CVE) remains unclear. Data on the effect of PTX from population-based studies are scarce. Some studies have shown decreased incidence of CVE after PTX. The aim of this study was to evaluate the effect of PTX on risk of CVE in patients on renal replacement therapy. Methods We performed a nested case-control study within the Swedish Renal Registry (SRR) by matching PTX patients on dialysis or with functioning renal allograft with up to five non-PTX controls for age, sex and underlying renal disease. To calculate time to CVE, i.e., myocardial infarct, stroke and transient ischemic attack, control patients were assigned the calendar date (d) of the PTX of the case patient. Crude and adjusted proportional hazards regressions with random effect (frailty) were used to calculate hazard ratios for CVE. Results The study cohort included 20,056 patients in the SRR between 1991 and 2009. Among these, 579 patients had undergone PTX, 423 during dialysis and 156 during time with functioning renal allograft. These patients were matched with 1234 dialysis and 736 transplanted non-PTX patients. The adjusted hazard ratio (HR) with 95% confidence interval (CI) of CVE after PTX was 1.24 (1.03-1.49) for dialysis patients compared with non-PTX patients. Corresponding results for patients with renal allograft at d were HR (95% CI) 0.53 (0.34-0.84). Conclusions PTX patients on dialysis at d had a higher risk of CVE than patients without PTX. Patients with renal allograft at d on the other had a lower risk after PTX than patients without PTX.

Recent advances in understanding and managing secondary hyperparathyroidism in chronic kidney disease

“…The use of PTx in patients with CKD is associated with improvements in biochemical parameters of mineral and bone metabolism 60 – 62 , cardiovascular health 63 , and mortality 64 , 65 . However, this technique is not free of complications, such as persistent hyperparathyroidism, often due to the existence of supernumerary or abnormally located parathyroid glands 66 , or the development of hungry bone syndrome due to PTH oversuppression 67 .…”

Hyperkalemia Following Parathyroidectomy in Patients with Renal Hyperparathyroidism—New Thresholds for Urgent Perioperative Dialysis

“…Secondary hyperparathyroidism (SHPT) is a common and serious sequela of end-stage renal disease (ESRD), requiring surgical parathyroidectomy (PTX) if medical treatment (i.e., calcimimetics and vitamin D analogs) fails [1][2][3][4][5]. PTX is required in 15% of patients after ten years of renal replacement therapy and even in 38% after 20 years of ongoing hemodialysis (HD) [6].…”

“…These benefits of PTX are based on observational studies, not on randomized clinical trials describing the probable beneficial effects of surgery on both short-term laboratory parameters and long-term clinical outcomes such as osteoporotic fractures or increased mortality due to cardiovascular events (CVE) [9,10]. Altogether, PTX increases quality of life and even life expectancy [1,[11][12][13]. Patients with ESRD have a markedly increased incidence and mortality of CVE compared with the agematched general population [1,2,14,15].…”

Microwave ablation versus parathyroidectomy for severe secondary hyperparathyroidism in patients on hemodialysis: a retrospective multicenter study

“…Drugs, including active vitamin D, are the main form of therapy for mild-to-moderate secondary hyperparathyroidism. Parathyroidectomy (PTX) is an effective therapy for severe secondary hyperparathyroidism [5][6][7]. However, some patients, especially those with cardiopulmonary insufficiency, cannot tolerate this surgery.…”