Subtotal Parathyroidectomy in Renal Failure: Still Needed after All These Years

Total Parathyroidectomy Without Autotransplantation for ESRD Patients With Secondary Hyperparathyroidism; an Effective Alternative

BACKGROUND

The most common operations performed for secondary hyperparathyroidism include subtotal parathyroidectomy (STPX) and total parathyroidectomy with autotransplantation (TPX + AT). We present a series of ESRD patients treated with total parathyroidectomy without autotransplantation (TPX).

METHODS

This is a retrospective cohort analysis of ESRD patients, age 18 years or older, with three or more glands resected on final pathology and follow-up parathyroid hormone levels obtained up to 1.5 years postoperatively. The primary endpoint was recurrence of hyperparathyroidism (defined as PTH > 500 pg/mL).

RESULTS

The incidence of recurrent hyperparathyroidism at 1.5 years was 5.9% (2/34). The incidence of persistent hyperparathyroidism at 1.5 years was 11.8% (4/34). In this series, no patients were hospitalized for symptomatic hypocalcemia or experienced pathologic bone fractures.

CONCLUSIONS

Recurrence rates are low with TPX. The most common cause of recurrent and persistent disease is resection of three rather than four glands. The known complications of TPX, pathologic fractures, and severe hypocalcemia, were not seen in this study.

Subtotal Parathyroidectomy vs Total Parathyroidectomy with Autotransplantation for Secondary Hyperparathyroidism in Dialysis Patients: Short- and Long-Term Outcomes

BACKGROUND

Two operations are performed for management of secondary hyperparathyroidism, subtotal parathyroidectomy (SPTX) and total parathyroidectomy with autotransplantation (TPTX-AT). There is no consensus among endocrine surgeons about which operation is the preferred treatment. This study compares the short- and long-term outcomes of SPTX and TPTX-AT for dialysis patients with secondary hyperparathyroidism.

STUDY DESIGN

This is a retrospective review of 46 dialysis patients undergoing PTX from 2006 to 2017 at a 719-bed tertiary care hospital.

RESULTS

Calcium on postoperative day 1 was 7.7 ± 0.8 mg/dL for SPTX and 7.9 ± 1.3 mg/dL for TPTX-AT (p = 0.49). Parathyroid hormone values on postoperative day 1 were 32.6 ± 26.0 pg/mL for SPTX and 9.5 ± 4.2 pg/mL for TPTX-AT (p ≤ 0.05). Hospital length of stay was 3.7 ± 1.9 days for SPTX and 4.4 ± 3.5 days for TPTX-AT (p = 0.46). The required doses of calcium and calcitriol at discharge did not differ significantly. Reoperation for recurrence or persistence of disease was required in 6 SPTX patients and 2 TPTX-AT patients (p = 0.12). Parathyroid hormone values <15 pg/mL at long-term follow-up occurred in 5.6% of SPTX patients and 26.7% of TPTX-AT patients (p = 0.09). Parathyroid hormone values >200 pg/mL at long-term follow-up occurred in 38.9% of SPTX patients vs 6.7% of the TPTX-AT patients (p ≤ 0.05). Calcium supplementation at more than 6 months was required for 36.8% of SPTX and 71.4% of TPTX-AT patients (p < 0.05).

CONCLUSIONS

The long-term control of parathyroid hormone elevation and avoidance of recurrent disease is improved with TPTX-AT, but carries a higher risk of long-term hypocalcemia.

Parathyroidectomy for tertiary hyperparathyroidism: A systematic review

OBJECTIVE

Analyze the efficacy and indications for parathyroidectomy as an intervention for tertiary hyperparathyroidism.

DATA SOURCES

PubMed, MEDLINE, and Cochrane Library databases.

REVIEW METHODS

A systematic literature search was performed using the. Original research articles in English were retrieved using the search terms ("tertiary hyperparathyroidism" OR "3HPT") AND "parathyroidectomy". Articles were analyzed in regards to their surgical indications, operative endpoints, comparison between different surgical interventions, characterization of disease recurrence rates, and evaluation of alternative medical management.

RESULTS

Thirty studies met the criteria for inclusion. Among the studies that report indications for parathyroidectomy, persistent hypercalcemia as well as clinical manifestations of hypercalcemia despite medical therapy predicted which patients would eventually need surgical intervention. The majority of studies comparing the extent of parathyroidectomy recommended a more focused approach to parathyroidectomy when warranted. All studies found that parathyroidectomy was an effective treatment for 3HPT. Three studies discussed alternative conservative approaches.

CONCLUSION

Interestingly, hyperparathyroidism alone is not an indication for surgery without other findings; rather, symptomatic hypercalcemia appears to be the main indication. Most studies recommend limited or subtotal parathyroidectomy for 3HPT. The operative endpoint of surgery is not necessarily a return of PTH to normal, but a >50% drop in PTH level even if PTH remains above normal. Additionally, "success" or "cure" is defined as normal calcium levels regardless of whether or not PTH is elevated. It appears the goal of surgery for 3HPT is not a normal PTH value, but a normal calcium level at least six months postoperatively.

Long-Term Outcomes of Total Parathyroidectomy With or Without Autoimplantation for Hyperparathyroidism in Chronic Kidney Disease: A Meta-Analysis

The aim of the present study was to compare total parathyroidectomy without autotransplantation (TPTX) versus total parathyroidectomy with autotransplantation (TPTX + AT) for renal hyperparathyroidism (RHPT) with respect to long-term outcomes. A literature search was undertaken using Medline and EMBASE from inception to December 2013. Data were analyzed using Review Manager version 5.0. A total of seven cohort studies comprising 931 patients were identified. Compared with TPTX + AT, patients in the TPTX group have lower "recurrence" (odds ratio (OR) 0.08, confidence interval (CI) 0.03 to 0.21; P < 0.00001), lower "recurrence or persistence"(OR 0.11, 95% CI 0.05 to 0.25; P < 0.00001), lower "requiring reoperation because of recurrence or persistence" (OR 0.17, CI 0.06 to 0.54; P = 0.002), and higher "hypoparathyroidism" (OR 2.97, CI 1.09 to 8.08; P = 0.03). None of the patients in these seven studies were recorded as having severe hypocalcemia or adynamic bone disease. Compared with TPTX + AT, TPTX is associated with lower "requiring reoperation because of recurrence or persistence" and without severe hypocalcemia or adynamic bone disease.

Long-term function of parathyroid subcutaneous autoimplantation after presumed total parathyroidectomy in the treatment of secondary hyperparathyroidism. A clinical retrospective study

INTRODUCTION

Parathyroidectomy (PTx) is recommended in patients affected by secondary hyperparathyroidism (2HPT) of chronic kidney disease-mineral bone disorders (CKD-MBD), resistant to medical treatment. Analyzing total parathyroidectomy with muscular or subcutaneous autoimplantation (TPai) outcomes in hemodialysis (HD) 2HPT patients, and monitoring intact parathyroid hormone (iPTH) levels, we evaluated long-term functional results of subcutaneous parathyroid glandular tissue autoimplantation.

METHODS

40 HD 2HPT patients, resistant to medical treatment, and awaiting for renal transplantation, underwent total parathyroidectomy with subcutaneous autoimplantation of 9-12 fragments of not nodular hyperplasia parathyroid tissue in not dominant forearm. iPTH were analyzed 24 h, and 3-6-12-24 months after surgery. The 1.08-6.99 pmol/L range was taken as reference of normal iPTH level based on which eu- (1.08-6.99), hypo- (<1.08), aparathyroidism (0) and persistence or relapse (>6.99) of disease were determined.

RESULTS

In every case PTai determined an extraordinary improvement of quality of life, associated with a notable reduction of iPTH serum level. Immediate normalization of iPTH was achieved in 50% of cases; hypoparathyroidism in 25% of cases and persistence of disease in 25% were observed. Long term follow-up showed a reduction of hypoparathyroidism and an increase of relapse rate up to 20%. Grafting resection was never performed.

DISCUSSION

Subcutaneous autotrasplantation is a very simple and fast surgical technique. Nevertheless, similar success and recurrence rates were reported following muscular or subcutaneous grafting, as confirmed in our experience.

CONCLUSIONS

Subcutaneous grafting was effective as muscular implantation, with comparable functional results, but avoiding its potential complications.

Impact of parathyroidectomy on cardiovascular outcomes and survival in chronic hemodialysis patients with secondary hyperparathyroidism. A retrospective study of 50 cases prior to the calcimimetics era

BACKGROUND

In chronic hemodialysis patients with secondary hyperparathyroidism, pathological modifications of bone and mineral metabolism increase the risk of cardiovascular morbidity and mortality. Parathyroidectomy, reducing the incidence of cardiovascular events, may improve outcomes; however, its effects on long-term survival are still subject of active research.

METHODS

From January 2004 to December 2006, 30 hemodialysis patients, affected by severe and unresponsive secondary hyperparathyroidism, underwent parathyroidectomy - 15 total parathyroidectomy and 15 total parathyroidectomy + subcutaneous autoimplantation. During a 5-year follow-up, patients did not receive a renal transplantation and were evaluated for biochemical modifications and major cardiovascular events - death, cardiovascular accidents, myocardial infarction and peripheral vascular disease. Results were compared with those obtained in a control group of 20 hemodialysis patients, affected by secondary hyperparathyroidism, and refusing surgical treatment, and following medical treatment only.

RESULTS

The groups were comparable in terms of age, gender, dialysis vintage, and comorbidities. Postoperative cardiovascular events were observed in 18/30 - 54% - surgical patients and in 4/20 - 20%- medical patients, with a mortality rate respectively of 23.3% in the surgical group vs. 15% in the control group. Parathyroidectomy was not associated with a reduced risk of cardiovascular morbidity and survival rate was unaffected by surgical treatment.

CONCLUSIONS

In secondary hyperparathyroidism hemodialysis patients affected by severe cardiovascular disease, surgery did not modify cardiovascular morbidity and mortality rates. Therefore, in secondary hyperparathyroidism hemodialysis patients, resistant to medical treatment, only an early indication to calcimimetics, or surgery, in the initial stage of chronic kidney disease - mineral bone disorders, may offer a higher long-term survival. Further studies will be useful to clarify the role of secondary hyperparathyroidism in determining unfavorable cardiovascular outcomes and mortality in hemodialysis population.

Total Parathyroidectomy versus Subtotal Parathyroidectomy in the Treatment of Tertiary Hyperparathyroidism

The purposes of this study are to evaluate the merits of surgical treatment, including subtotal parathyroidectomy (SP) and total parathyroidectomy (TP), in patients with tertiary hyperparathyroidism (THPT) and compare the outcome of the two surgical options. Medical records of patients undergoing parathyroidectomy for THPT were retrospectively reviewed and long-term outcomes between the two groups were compared. Fourteen out of 488 renal transplantation recipients required parathyroidectomy for THPT during a 24-year follow-up period with a median follow-up of 35.5 [interquartile range (IQR), 19.3–133.3] months. All patients had hypercalcemia, whereas 13 had varying symptoms and one was asymptomatic. Median serum calcium level decreased from 12.4 (IQR, 11.9–12.6) mg/dL preoperatively to 8.9 (IQR, 8.1–9.4) mg/dL postoperatively ( P = 0.001), whereas median intact parathyroid hormone (iPTH) dropped from a preoperative level of 340.5 (IQR, 247–540) pg/mL to 55.1 (IQR, 24.4–66.4) pg/mL after surgery ( P = 0.018). Comparison between patients receiving TP and SP revealed no difference in incidence of recurrence or permanent complications, whereas the former had significantly lower calcium levels ( P = 0.048) and higher phosphorus levels ( P = 0.017) compared with the latter. Moreover, a significant reduction in calcium level was noted in TP group on long-term follow-up compared with their immediately postoperative level (8.1 vs 9.0 mg/dL, respectively, P < 0.05), whereas there was no significant decrease in SP group. We concluded that parathyroidectomy is efficient and safe in treating THPT. Because TP would increase the risk of hypocalcemia, a less radical procedure (SP) is preferred.

Total parathyroidectomy without autotransplantation in the surgical treatment of secondary hyperparathyroidism of chronic kidney disease

BACKGROUND

Subtotal parathyroidectomy (SP) and total parathyroidectomy (TP) with autotransplantation (TPai) are the most commonly adopted operations for the treatment of secondary hyperparathyroidism (2HPT). TP without autotransplantation had previously been confined to patients with advanced dialytic vintage, not eligible for kidney transplantation. Over the years, the procedure has gained more widespread use, but there is no precise knowledge on the immediate and long-term effects.

METHODS

The authors analyzed the immediate and long-term results of TP without autotransplantation, that is after the systematic removal of at least four glands in 20 patients operated for 2HPT, which were compared with results from TPai in an equal number of cases.

RESULTS

An improvement of the typical clinical symptoms was found in every patient undergoing surgery, and a significant reduction in intact PTH (iPTH) serum levels was achieved. Immediate normalization of iPTH level was observed in 11/20 TP cases, hypoparathyroidism in 4/20 and persistent HPT in 5/20 cases. One year of follow-up showed a slight increase in hypoparathyroidism, with 1/20 (5%) recurrence of the disease. One-year TPai results showed a similar percentage of euparathyroidism, as well as a higher longterm recurrence rate (4/20, 20%), although values do not reach statistical significance.

CONCLUSIONS

TP may still be considered the operation of choice in patients with aggressive forms of 2HPT or of advanced dialytic vintage, with no access to renal transplantation, because of its low recurrence rate (5%). Post-operative aparathyroidism is rare, while hypoparathyroidism and hypocalcemia can be well controled by medical treatment.

Parathyroidectomy in secondary hyperparathyroidism: Is there an optimal operative management?

BACKGROUND

Subtotal parathyroidectomy (SPTX) and total PTX with autotransplantation (TPTX + AT) are both accepted operations for secondary hyperparathyroidism (2HPT). Studies have shown the 2 procedures to have similar rates of recurrent or persistent HPT (0% to 10%). The majority of these reports are small case series and despite apparently similar outcomes; the optimal operative management for 2HPT remains controversial. The purpose of this study was to determine whether there were any clinical outcome differences between these apparently comparable operations.

METHODS

A meta-analysis of 53 publications on reoperative operation for 2HPT from 1983 to 2004 identified 501 patients who had undergone an operation for recurrent or persistent 2HPT. The data evaluated included the type of initial operation, the need for reoperative operation as it related to the type of initial operation, and the intraoperative findings.

RESULTS

The initial operation had been a SPTX in 36% and a TPTX + AT in 64% of patients. Reoperative operation was for persistent 2HPT in 82 of 485 (17%) and for recurrent 2HPT in 403 of 485 (83%) patients. Findings at reoperation included: autograft hyperplasia (49%), supernumerary glands (20%), remnant hyperplasia (17%), a missed in situ gland (7%), and a negative exploration (5%). Supernumerary glands, missed in situ glands, and negative explorations occurred at equal rates for both operations. Reoperation determined that inadequate cervical explorations occurred in 42% of patients who had undergone a SPTX and in 34% of patients who had undergone a TPTX + AT.

CONCLUSIONS

Operative failures occur because of the limitations in preoperative localization, inadequate exploration, and the natural history of hyperplastic parathyroid tissue. The initial operation should include an attempt to localize supernumerary glands both pre- and intra-operatively.

Near-total parathyroidectomy is beneficial for patients with secondary and tertiary hyperparathyroidism

BACKGROUND

Despite several options for the extent of parathyroidectomy in secondary and tertiary hyperparathyroidism, <5% of patients are referred for surgical procedures. The purpose of this study was to identify beneficial outcomes of near-total parathyroidectomy (NTPTX) in this population.

METHODS

NTPTX (a vascularized parathyroid remnant is left in situ, and cryopreservation is performed) was completed in 142 patients with secondary (n = 93 patients) and tertiary (n = 49 patients) hyperparathyroidism, and was guided by intraoperative intact PTH (IOPTH).

RESULTS

One hundred thirty-six of 142 patients (96%) remain cured at a mean follow-up time of 23 +/- 26 months. Six patients had missed mediastinal (n = 4 patients) or cervical (n = 2 patients) parathyroid glands. No patient required re-resection of a cervical parathyroid remnant. One patient had hypoparathyroidism and underwent autografting with cryopreserved tissue. NTPTX reduced parathyroid mass (4526 +/- 4515 mg to 77 +/- 56 mg) and IOPTH (1171 +/- 1252 pg/mL to 101 +/- 127 pg/mL). Fatigue and musculoskeletal pain resolved promptly after operation. Patients with tertiary hyperparathyroidism experienced an improvement in bone density of 3.6% per year. NTPTX achieved full healing of extremity ulcers without amputations or perioperative death in 22 patients with calciphylaxis.

CONCLUSIONS

NTPTX effectively treats secondary and tertiary hyperparathyroidism in >95% patients. IOPTH monitoring and cryopreservation are valuable procedural adjuncts. Limb salvage in calciphylaxis, symptomatic relief, and improved bone density are substantial benefits to recommend this procedure to patients with renal hyperparathyroidism.

Early identification of risk factors for refractory secondary hyperparathyroidism in patients with long-term renal replacement therapy

BACKGROUND

Secondary hyperparathyroidism can complicate renal replacement therapy (RRT) in patients with end-stage renal disease. Current medical therapies often result in hypercalcaemia and fail to correct hyperparathyroidism, but might be more effective at an early stage of disease. The aim of this study was to identify prognostic factors at the start and during the first year of RRT for refractory secondary hyperparathyroidism needing parathyroidectomy (PTx) during long-term follow-up.

METHODS

A total of 202 consecutive patients starting RRT between August 1988 and August 1996 at our centre with at least 1 year of follow-up were included. Biochemical and treatment data at the start and during the first year of RRT were collected. Univariate and multivariate analyses were used to identify risk factors for PTx during follow-up.

RESULTS

Thirty-three patients (16%) needed PTx after 52+/-23 months of RRT. Need for PTx was not different between patients undergoing haemodialysis and peritoneal dialysis, but was associated with parameters reflecting calcium and phosphate control at start and after 1 year of RRT. In a Cox multivariate model, serum parathyroid hormone [relative risk (RR): 1.02 per pmol/l; P<0.001], phosphate (RR: 1.107 per 0.1 mmol/l; P = 0.002) and alkaline phosphatase (RR: 1.004 per U/l; P = 0.049) after 1 year of RRT were independently associated with increased risk for PTx.

CONCLUSIONS

Failure of control of calcium-phosphate metabolism at the start of and early during RRT is strongly associated with PTx during long-term follow-up. Given the high prevalence of insufficient phosphate control, patients may benefit from aggressive correction of serum phosphate in the pre-dialysis and early dialysis period.

Calciphylaxis and nonhealing wounds: the role of the vascular surgeon in a multidisciplinary treatment

OBJECTIVE

Calciphylaxis, a disorder of calcium-phosphate metabolism that can result in arterial calcification, skin and solid organ calcium deposits, and nonhealing ulcerations, is associated with significant morbidity and mortality. Although its most common cause is secondary hyperparathyroidism in patients with renal failure, vascular surgeons are frequently called on to evaluate these nonhealing extremity wounds. We reviewed our experience of a multidisciplinary approach in treating patients with calciphylaxis and nonhealing ulcers.

PATIENTS AND METHODS

Over a 14-month period at a tertiary center, five patients were seen with calciphylaxis and nonhealing leg wounds. Demographics, disease characteristics, surgical treatment, and outcomes were analyzed.

RESULTS

All five patients were black women aged 40 +/- 8.9 years with hypertensive renal failure undergoing long-term hemodialysis (80 +/- 43 months). They had large, painful lower extremity wounds or necrotic ulcers (mean size, 135 cm(2)) that had developed over 2 to 4 months. Three patients had palpable pedal pulses, one patient had Doppler pedal signals, and one patient had absent pedal flow. Arteriogram was performed in the latter two patients, and one patient underwent lower extremity revascularization because of superficial femoral artery stenosis with symptomatic improvement. Four patients underwent aggressive debridement by the vascular surgical service, and two needed plastic surgeon-performed skin grafting. All patients had elevated parathyroid hormone levels (mean, 1735 pg/mL; > 25 x normal level); mean preoperative calcium levels were normal (10 mg/dL). After either subtotal (n = 4) or total (n = 1) parathyroidectomy by an experienced endocrine surgeon, a significant reduction in parathyroid hormone and calcium levels was seen (122 pg/mL and 7.9 mg/dL, respectively; P <.05). There were no postoperative complications or amputations; one patient died 12 months after parathyroidectomy of severe preexisting cardiopulmonary disease. Complete wound healing was observed by 4.8 +/- 2 months. During a mean follow-up period of 9 months (range, 1 to 18 months), all wounds remained healed without ulcer recurrence.

CONCLUSION

The diagnosis of calciphylaxis should be considered in patients with end-stage renal disease with atypical tissue necrosis or subcutaneous nodules. Early recognition of calciphylaxis and multidisciplinary treatment, including diligent wound care, frequent debridement, parathyroidectomy, and appropriate skin grafting or revascularization, can result in improved wound healing and limb salvage.

Surgical management of secondary hyperparathyroidism

Most patients with renal failure maintained on chronic dialysis have elevated parathyroid hormone (PTH) levels and PTH-mediated bone disease (secondary hyperparathyroidism [sHPT]). Elevated PTH production in this setting represents a progressive, exaggerated physiologic response to hypocalcemia by the parathyroid glands, and generalized growth of the parathyroids is an adaptive response to chronic stimulation. Effective medical strategies to reduce PTH secretion and PTH-mediated bone turnover in sHPT (eg, controlling hyperphosphatemia, normalizing serum calcium, and administering vitamin D analogs) has decreased the need for parathyroidectomy in recent years. However, failure of medical therapy because of inadequate treatment, persistent hyperphosphatemia, or acquired parathyroid neoplasia still leads to recommendations for parathyroidectomy in select patients. Furthermore, increased awareness of potential long-term, irreversible cardiovascular effects of uncorrected hyperparathyroidism has led some to advocate parathyroidectomy earlier in the course of this disease. This monograph will review parathyroidectomy for secondary and tertiary hyperparathyroidism.

Long-term follow-up of patients with tertiary hyperparathyroidism treated by resection of a single or double adenoma

OBJECTIVE

To determine whether patients with tertiary hyperparathyroidism due to single- or two-gland disease undergoing limited resection have similar long-term outcomes compared with patients with hyperplasia undergoing subtotal or total parathyroidectomy.

SUMMARY BACKGROUND DATA

Tertiary hyperparathyroidism occurs in less than 2% of patients after renal transplantation. Approximately 30% of these cases are caused by one or two hyperfunctioning glands. Nevertheless, the standard operation for this disease has been subtotal or total parathyroidectomy with autotransplantation.

METHODS

Seventy-one patients underwent surgery for tertiary hyperparathyroidism. At the time of surgery, 19 patients who had a single or double adenoma underwent limited resection of the enlarged glands only (adenoma group). The remaining 52 patients with three- or four-gland hyperplasia had subtotal or total parathyroidectomy with implantation (hyper group). Long-term cure rates between the two groups were compared.

RESULTS

In the adenoma group, 7 patients had a single adenoma and 12 underwent resection of a double adenoma. In the hyper group, 49 patients had subtotal and 3 had total parathyroidectomies. After surgery, 70 of 71 patients (99%) were cured of their hypercalcemia. The incidence of postoperative transient hypocalcemia was significantly higher in the hyper group (27% vs. 5%). No patients in either group had permanent hypocalcemia requiring long-term supplementation. With up to 16 years of follow-up, there have been no recurrences in the adenoma group, whereas three patients (6%) in the hyper group have had recurrent or persistent hyperparathyroidism.

CONCLUSIONS

Patients with tertiary hyperparathyroidism who underwent limited resection of a single or double adenoma only had equivalent long-term cure rates compared with patients undergoing more extensive resections. Therefore, the authors recommend in patients with tertiary hyperparathyroidism and enlargement of only one or two parathyroid glands that the resection be limited to these abnormal glands only.