Parathyroidectomy: Whom and when?

Abstract

Hyperparathyroidism (HPT) is common in patients on dialysis, and parathyroidectomy (PTx) is often required. We present a retrospective, descriptive analysis of data corresponding to 148 patients on dialysis undergoing PTx due to severe refractory HPT (PTH 1401 +/- 497 pg/mL, Ca 10.6 +/- 0.8 mg/dL, P 6.9 +/- 1.7 mg/dL). Demographic data were compared with those recorded in 309 patients on dialysis not subjected to PTx who were managed at the same hospital. In the PTx group, the factors age (49.3 +/- 14 years), male gender (48.6%), and diabetes (0.7%) were significantly lower than in the non-PTx group (61.5 +/- 14.9 years, male gender 59%, diabetes 19.4%), while time on dialysis was longer (8.6 +/- 5.8 vs. 5.5 +/- 5.4 years). In 129 of the study patients (87.4%), four or more glands were identified, and total PTx plus autotransplantation (AT) in the forearm was performed. In the remaining 19 patients, two to three glands were identified, and AT was not undertaken. Four of the 19 patients were successfully operated on again for persistent HPT, seven showed PTH levels <250 pg/mL, and eight maintained severe HPT. Perioperative complications included one death due to cardiac insufficiency, two repeat operations due to bleeding, and one patient with chronic hoarseness. Hospital stay was prolonged in 20% of patients due to a hungry bone syndrome. Among those patients with PTx and AT, HPT recurred in 21 patients (16.2%) at 3.1 +/- 2.3 years. In 13 of these patients, autograft was removed at 7.5 +/- 2.9 years. Serum calcium and phosphate levels improved after PTx, and these results were maintained for 5 years (9.6 +/- 0.8 and 4.2 +/- 1.2 mg/dL, respectively). In conclusion, PTx with AT is a safe option for the treatment of severe HPT that is accompanied by low morbidity and mortality and a good outcome. Medical treatment should not be prolonged at the expense of long repeated bouts of hypercalcemia and/or hyperphosphatemia with their irreversible consequences.

The effectiveness and cost-effectiveness of cinacalcet for secondary hyperparathyroidism in end-stage renal disease patients on dialysis: a systematic review and economic evaluation

“…Two studies of people undergoing parathyroidectomy, one in 60 people in the USA and one in 148 people in Spain, both report an 8% failure rate, resulting in continued hyperparathyroidism or reoperation. 90,91 In the model, 8% of people return to having very uncontrolled PTH after surgery ( Table 44). Those that do have a successful operation no longer suffer from SHPT and do not require a repeat operation.…”

Clinical Outcomes after Parathyroidectomy in a Nationwide Cohort of Patients on Hemodialysis

“…This recommendation may have been based on observational, not-randomized clinical trial evidence describing potentially beneficial effects on short-term laboratory parameters and/or on longer-term clinical outcomes including fracture and death (5,6). Some (7)(8)(9)(10)(11)(12) but not all (5) reports suggest that short-term adverse outcomes related to parathyroidectomy produce only modest adverse consequences. However, many of these reports are based on single-center experiences, and may represent highly selected and high-performing surgical units (7)(8)(9)(10)(11)(12).…”

“…Some (7)(8)(9)(10)(11)(12) but not all (5) reports suggest that short-term adverse outcomes related to parathyroidectomy produce only modest adverse consequences. However, many of these reports are based on single-center experiences, and may represent highly selected and high-performing surgical units (7)(8)(9)(10)(11)(12). In addition, the comparability of nonparathyroidectomized control groups in these studies is unknown.…”

Impact of Serum Phosphorus Levels on Outcomes After Implantation of Drug-Eluting Stents in Patients on Hemodialysis

“…Parathyroidectomy is recommended for patients who fail to respond to medical therapy, and has been reported to markedly reduce serum parathyroid hormone, calcium, and phosphorus levels. 51 The lack of this information may also have caused a confounding bias. Third, although serum calcium has been reported to have less effect on outcomes of general HD patients compared with serum phosphorus alone, 14,18 the absence of corrected serum calcium data may have caused an under-detection of confounding bias during logistic regression analyses.…”