Parathyroidectomy Improves Survival In Patients with Severe Hyperparathyroidism: A Comparative Study

Abstract

Background and objectivesSecondary hyperparathyroidism (SHPT) in CKD is associated with an increased risk for mortality, but definitive data showing that parathormone control decreases mortality is still lacking. This study aimed to compare the mortality of patients with severe SHPT submitted to parathyroidectomy(PTX) with those who did not have access to surgery.MethodsThis is a retrospective study in a cohort of 251 CKD patients with severe SHPT who were referred to a CKD-MBD Center for PTX from 2005 until 2012.ResultsMost of our patients had indication of PTX, but only 49% of them had access to this surgical procedure. After a mean follow-up of 23 months, 72 patients had died. Non-survivors were older; more often had diabetes, lower serum 25 vitamin D and mostly had not been submitted to surgery. The relative risk of death was lower in the PTX patients (0.428; 95% CI, 0.28 to 0.67; p<0.0001). After adjustments, mortality risk was dependent on age (1.04; 95% CI, 1.01 to 1.07; p = 0.002), 25 vitamin D (0.43; 95% CI, 0.24 to 0.81; p = 0.006) and no access to PTX (4.13; 95% CI, 2.16 to 7.88; p<0.0001). Results remained the same in a second model using the PTX date as the study start date for the PTX group.ConclusionsOur data confirms the benefit of PTX on mortality in patients with severe SHPT. The high mortality encountered in our population is significant and urges the need to better treat these patients.

Long–term mortality after parathyroidectomy among chronic kidney disease patients with secondary hyperparathyroidism: a systematic review and meta-analysis

“…Of them, 37 studies were retrieved for detailed evaluation, and finally 24 studies were excluded due to absence of information on the outcomes of interest (19 articles) or provision of data only in abstract form (5 articles). Finally, 13 studies [19][20][21][22][23][24][25][26][27][28][29][30][31] fulfilled the eligibility criteria ( Figure 1), with 10052 PTx-treated patients and 12001 medically-treated patients (totally 22053 patients). The 13 studies were all cohort studies with sample sizes from 20 to 4558 patients, and reported prevalence rates of diabetes from 0% to 44.3%.…”

“…Most studies adjusted a wide range of potential confounders to investigate the association between PTx and all-cause mortality, including age, sex, body mass index (BMI), diabetes, duration of dialysis, and dialysis modality. Twelve studies presented data with all-cause mortality [19][20][21][22][23][24][25][26][27][28][29]31 and six studies with cardiovascular mortality. 19,20,23,26,28,30 Table 1 lists the key characteristics of the 13 studies.…”

“…We examined the 11 trials [19][20][21][22][23][24][25][26]28,29,31 that investigated the effect of PTx versus medical treatment on mortality against follow-up duration (<36 vs. 36 months). In the six trials with follow-up duration <36 months, the mortality rates are significantly different between PTxtreated and medically-treated patients (Figure 4).…”

Tratamento cirúrgico do hiperparatireoidismo secundário: revisão sistematizada da literatura

“…A conclusão foi que o cinacalcet não reduz significativamente o risco de manifestação de doença entre tais pacientes, apesar da melhora de parâmetros bioquímicos (26). Entretanto, alguns critérios podem ter alterado os achados, como a não separação dos pacientes por grupo etário ou a alta taxa de PTx no grupo controle, o que pode ter diminuído o número de eventos nesses pacientes (29). Um estudo de custo-efetividade bem conduzido mostrou que a operação é mais custo-efetiva no paciente que tem condições cirúrgicas e que o cinacalcet é superior ao tratamento clínico com análogos do calcitriol em pacientes sem condições cirúrgicas (59).…”

“…Quando a doença não responde mais ao tratamento clínico, indica-se a paratireoidectomia (PTx) (1)(2)(3)11,13,14,(16)(17)(18)(19)(20)23,24,(27)(28)(29)33,34,37,38,40,(42)(43)(44). A PTx pode reduzir significativamente os níveis de fosfato e PTH.…”