Therapeutic experience of severe and recurrent secondary hyperparathyroidism in a patient on hemodialysis for 18 years

Abstract

Introduction:For patients with refractory secondary hyperparathyroidism (SHPT), parathyroidectomy (PTX) has received increasing attention. However, evidence-based medicine shows that there is still controversy regarding surgical methods, efficacy, and safety. We retrospectively analyzed the process of diagnosis and treatment in one patient with severe SHPT and long-term chronic renal failure (CRF), so as to further improve the therapeutic effect.Case presentation:A 61-year-old female with SHPT and CRF manifested as no urine for 18 years, underwent PTX 4 times since September 2010, with satisfactory final recovery. The first operation involved resection of 3 parathyroid glands in the normal position; the second operation involved removal of an ectopic parathyroid gland, combined with parathyroid gland autotransplantation; the third operation was performed to resect suspected recurrent parathyroid gland; the fourth operation involved partial excision of the autotransplanted parathyroid glands.Conclusion:Accurate preoperative localized diagnosis and optimal surgical approach play key roles in the prevention and treatment of SHPT; postoperative recurrence of SHPT caused by ectopic or autotransplanted parathyroid gland should receive more attention.

Secondary Hyperparathyroidism in Dialysis Patients: Short- and Long-Term Outcomes of Conservative Parathyroidectomy

“…The 2009 KDIGO guidelines contraindicate tPTX in candidates for renal transplantation due to the risk of permanent hypoparathyroidism after transplantation [18]. Subtotal PTX (sPTX) allows for the preservation of a parathyroid volume ranging from 30 to 50 mg [19]. The incidence of postoperative hypocalcaemia and hypoparathyroidism is low.…”

Advances in the treatment of secondary and tertiary hyperparathyroidism

“…tPTX involves the removal of all parathyroid glands and suspected parathyroid tissue. The risk of postoperative recurrence is low ( 52 ), but chronic hypoparathyroidism is more likely ( 53 ). This is not generally considered a first-line treatment.…”

“…sPTX retains normal vascular parathyroid tissue that is approximately 30-50 mg or two to three parathyroid glands in size ( 43 ). The advantage of this procedure is that the incidence of postoperative hypocalcemia is low; however, the residual parathyroid tissue is prone to recurrence ( 52 ). On this basis, some experts have proposed a “near total parathyroidectomy,” which leaves very small (3 mm × 3 mm × 3 mm) islands of parathyroid residues in situ.…”

“…This procedure avoids postoperative hypocalcemia, is more effective at improving quality of life than PTX alone, and the iPTH level is not affected by the quantity and quality of graft fragments ( 43 )( Table 1 ). However, a limitation of this procedure is that autologous parathyroid transplantation may lead to HPT recurrence ( 52 ), but the persistence and recurrence probability of HPT are much less than sPTX ( 41 , 42 )( Table 1 ). Thus, some experts recommend tPTX-AT as the preferred surgical management method for SHPT, because reoperation at the forearm autograft site is simpler than in the neck after sPTX ( 43 ).…”