Surgical and Medical Management of Tertiary Hyperparathyroidism

Abstract

Persistent hyperparathyroidism (HPT) after successful kidney transplantation (RTx) (tertiary HPT; THPT) is a common complication in patients with RTx and may affect bone disease, deterioration of graft function and cardiovascular events. Parathyroidectomy (PTx) is the most successful treatment for resolving advanced HPT in patients with THPT. However, the surgical indications for THPT and timing of the operation are problematic because hypercalcemia can be resolved spontaneously. Subtotal and total PTx with autotransplantaion are widely accepted for THPT. The evidence to know which procedure is more appropriated could not be found. Recently the deterioration of kidney graft function after PTx for THPT has been reported and hypoparathyroidism after PTx may be avoided. Recently cinacalcet has been applied for patients with THPT and the medicine can dramaticaly control HPT and hypercalcemia. Possible risks of cinacalcet are hypocalcemia and increased calciuria and the approval for THPT remains highly controversial. A large number of prospective controlled clinical trial should be required.

Advantages of total parathyroidectomy in patients with secondary hyperparathyroidism induced by end stage renal disease

“…Most authors and the latest consensus for the treatment of secondary hyperparathyroidism support indications for surgical treatment. Although there is still discussion about iPTH values (above 500pg/ml or 800pg/ml) for surgical indication, these will also be clarified in the future by new methods of standardization of iPTH dosing (17,18).…”