Safety and efficacy of subtotal or total parathyroidectomy for patients with secondary or tertiary hyperparathyroidism in four academic centers in the Netherlands

Safety of radiofrequency ablation in patients with hyperparathyroidism: a 10-year real-world multicenter experience

BACKGROUND

US-guided percutaneous radiofrequency ablation (RFA) is a validated procedure for hyperparathyroidism (HPT). However, it is associated with potentially significant complications, and data regarding the incidence and risk factors associated with RFA-related complications are limited.

OBJECTIVE

To assess the complication rates associated with RFA for HPT and identify the potential influential factors.

METHODS

This retrospective study was to investigate the associated complications in HPT patients who underwent RFA between January 2013 and April 2024. We collected and analyzed complications for these patients, focusing on their categories and rates. Logistic regression analysis was used to assess the crucial factors.

RESULTS

Three hundred twenty patients were included, including 117 cases of primary hyperparathyroidism (pHPT) and 203 cases of secondary hyperparathyroidism (sHPT). The overall complication rate was 22.2% (71/320), with 9.4% (30/320) being major complications and 14.7% (47/320) minor complications. Six patients experienced both major and minor complications. Among sHPT patients, 54 cases (26.6%, 54/203) experienced complications, including 22 major cases and 36 minor cases; however, among pHPT patients, 17 cases experienced complications (14.5%, 17/117), with 8 being major and 11 being minor. sHPT was identified as a risk factor for overall complications (odds ratio, 2.132; p = 0.014) and minor complications (odds ratio, 2.077; p = 0.046). Maximum diameter was the only risk factor for major complications (odds ratio, 1.508, p = 0.047).

CONCLUSIONS

RFA is a well-tolerated technique with an acceptably low incidence of major complications for HPT. Enhanced management strategies involving patients with sHPT and large hyperplastic glands may help mitigate complications.

KEY POINTS

Question Is ultrasound-guided RFA a safe nonsurgical alternative to traditional parathyroidectomy for patients with pHPT and sHPT who require intervention? Findings Ultrasound-guided RFA is a safe procedure for treating HPT. However, patients with sHPT and large hyperplastic glands are more likely to develop complications. Clinical relevance RFA is a well-accepted technique with a relatively low complication rate and can be used as a non-surgical alternative in the management of HPT.

Retrospective cohort study of trends in the use of outpatient parathyroidectomy by surgical indication

BACKGROUND

A shift toward outpatient parathyroidectomy was seen in the early 2000s. Recent trends, especially for secondary and tertiary hyperparathyroidism, have not been described. This study evaluates temporal trends in same-day, overnight, and inpatient parathyroidectomy by surgical indication.

METHODS

Adult patients who underwent parathyroidectomy were identified in the Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery Databases from 2013 to 2019. Admission type was defined by length of stay as same-day, overnight, or inpatient. Parathyroidectomy indications were classified using International Classification of Diseases, Ninth and Tenth Revision, codes. Patient and hospital characteristics were compared for all parathyroidectomy and for each indication. The Cochran-Armitage test of trend was used to examine admission practice patterns over time for the overall cohort and by surgical indication.

RESULTS

Of 67,436 parathyroidectomies, most were outpatient with 45,352 (67.3%) same-day and 17,918 (26.6%) overnight discharges. Among 4,166 (6.2%) inpatient parathyroidectomies, median length of stay was 3 days (interquartile range, 2, 5). The most common indication was primary hyperparathyroidism (n = 45,937; 68.1%). Overall, from 2013 to 2019, there was an increase in the proportion of same-day parathyroidectomy with a decrease in overnight and inpatient status over time. This pattern was driven by the most common indication of primary hyperparathyroidism. In secondary and tertiary hyperparathyroidism, there was an increase in the proportion of same-day parathyroidectomy with an associated decrease in inpatient stays.

CONCLUSION

The trend towards outpatient, particularly same-day parathyroidectomy, has continued for primary hyperparathyroidism. Trend towards outpatient parathyroidectomy is emerging in secondary and tertiary hyperparathyroidism.

Changes in cardiac functions in patients treated with parathyroidectomy for secondary hyperparathyroidism

Our study aims to investigate the changes in cardiac functions, especially myocardial performance index (MPI), in patients who underwent parathyroidectomy for secondary hyperparathyroidism. Patients who underwent parathyroidectomy for secondary hyperparathyroidism between June 2010 and September 2021 were analyzed retrospectively. The patients were divided into two groups: those who underwent total parathyroidectomy (group 1) and those who underwent subtotal parathyroidectomy (group 2). The groups were compared according to the echocardiogram findings performed in the preoperative period and the postoperative sixth month. In addition, cardiac structure, and systolic and diastolic functions, especially myocardial performance index, were evaluated by echocardiography and Doppler imaging. Thirty-seven patients were examined; 16 (43.2%) underwent total parathyroidectomy, and 21 (56.8%) had subtotal parathyroidectomy performed. Group 1's mean left ventricular end-systolic diameter (LVES) decreased from 2.53 ± 0.57 to 2.35 ± 0.37 cm after parathyroidectomy. In Group 1, the postoperative value of LVES and end-systolic volume decreased significantly compared to the preoperative period (p = 0.042, p = 0.008, respectively). EF increased from 59.25 ± 0.05 to 67.81 ± 4.04. In Group 1, EF and EV postoperatively increased significantly compared to the preoperative period (p = 0.023, p = 0.021, respectively). The mean MPI decreased from 0.45 ± 0.07 to 0.39 ± 0.04 after parathyroidectomy in group 1. In group 2, it decreased from 0.46 ± 0.06 to 0.40 ± 0.04 (p < 0.001). The present study provides an improvement in myocardial functions after parathyroidectomy. While LVES, EF, ejection volume, end-systolic volume, and MPI improved in both groups, the MPI improvement was more evident in the total parathyroidectomy group.

US-guided Percutaneous Radiofrequency Ablation for Secondary Hyperparathyroidism: Long-term Outcomes and Prognostic Factors

Background Although favorable outcomes have been reported with radiofrequency ablation (RFA) for secondary hyperparathyroidism (SHPT), the long-term efficacy remains insufficiently investigated. Purpose To evaluate the long-term efficacy and safety of US-guided percutaneous RFA in patients with SHPT undergoing dialysis and to identify possible predictors associated with treatment failure. Materials and Methods This retrospective study included consecutive patients with SHPT with at least one enlarged parathyroid gland accessible for RFA who were undergoing dialysis at seven tertiary centers from May 2013 to July 2022. The primary end point was the proportion of patients with parathyroid hormone (PTH) levels less than or equal to 585 pg/mL at the end of follow-up. Secondary end points were the proportion of patients with normal calcium and phosphorus levels, the technical success rate, procedure-related complications, and improvement in self-rated hyperparathyroidism-related symptoms (0-3 ranking scale). The Wilcoxon signed rank test and generalized estimating equation model were used to evaluate treatment outcomes. Univariable and multivariable regression analyses identified variables associated with treatment failure (recurrent or persistent hyperparathyroidism). Results This study included 165 patients (median age, 51 years [IQR, 44-60 years]; 92 female) and 582 glands. RFA effectively reduced PTH, calcium, and phosphorus levels, with targeted ranges achieved in 78.2% (129 of 165), 72.7% (120 of 165), and 60.0% (99 of 165) of patients, respectively, at the end of follow-up (mean, 51 months). For the RFA sessions, the technical success rate was 100% (214 of 214). Median symptom scores (ostealgia, arthralgia, pruritus) decreased (all P < .001). Regarding complications, only hypocalcemia (45.8%, 98 of 214) was common. Treatment failure occurred in 36 patients (recurrent [n = 5] or persistent [n = 31] hyperparathyroidism). The only potential independent predictor of treatment failure was having less than four treated glands (odds ratio, 17.18; 95% CI: 4.34, 67.95; P < .001). Conclusion US-guided percutaneous RFA was effective and safe in the long term as a nonsurgical alternative for patients with SHPT undergoing dialysis; the only potential independent predictor of treatment failure was a lower number (<4) of treated glands. © RSNA, 2024 Supplemental material is available for this article.

Morbidity and long-term outcome of surgery for renal hyperparathyroidism: results from a prospective cohort

PURPOSES

Surgery remains an important treatment option for renal hyperparathyroidism (rHPT). The number of long-term outcome studies of parathyroidectomy is limited.

METHODS

All consecutive patients with a parathyroidectomy for rHPT between 09/2009 and 04/2021 in a Belgian tertiary referral hospital were prospectively enrolled. The main outcomes were (long-term) cured proportion and postoperative morbidity (hypocalcemia, recurrent laryngeal nerve (RLN) palsy, re-intervention for bleeding, and wound morbidity).

RESULTS

Sixty patients with a median age of 57 years were analyzed, including 23 patients before kidney transplantation, 23 patients without kidney transplantation, and 14 patients after kidney transplantation. Median time to transplant was 15 (6-24) months after parathyroidectomy. Morbidity was low with only two non-urgent returns to theatre (wound infection and non-compressive hematoma), two temporary RLN paralyses, and no 30-day mortality. Length of hospital stay was longer in patients with parathyroidectomy before kidney transplant, due to a more severe and prolonged need for calcium supplementation. After a median follow-up of 63 months, 37 patients (62%) were still alive, and 11 patients (18%) developed a recurrence.

CONCLUSIONS

This single-surgeon, single-center cohort with long-term follow-up confirms the safety and excellent 'cure' proportions of surgery for rHPT but stretches the importance of long-term follow-up.

Ultrasound-guided microwave ablation for tertiary hyperparathyroidism in patients with renal transplantation

OBJECTIVE

To explore the safety and efficacy of ultrasound-guided microwave ablation (MWA) for tertiary hyperparathyroidism (THPT) in patients with renal transplantation (RT).

METHODS

In total, fifteen patients with THPT after renal transplantation who underwent MWA were enrolled in the study. The pre- and post-MWA intact parathyroid hormone (iPTH), serum calcium, phosphorus, creatinine, urea nitrogen and estimated glomerular filtration rate (eGFR) values were compared.

RESULTS

A total of 38 parathyroid hyperplastic nodules in 15 RT patients were treated with ultrasound-guided MWA. The mean (median, range) size of the hyperplastic parathyroid nodules was 11.5 mm (11 mm, 5-25 mm), and the average (median, range) ablation time was 163.5s (121 s, 44-406 s). The average levels of serum iPTH and calcium at 1 d, 7 d, 1 month, 3 months, 6 months, 1 year post-MWA and at the end of follow-up were significantly lower than those pre-MWA (all p < 0.05). Compared with the pre-MWA value (0.76 mmol/L), the serum phosphorus levels at 1 d post-MWA (0.63 mmol/L) were significantly decreased, and those at 7 d, 1 month, 3 months, 6 months, 1 year post-MWA and at the end of follow-up were significantly increased, but all were within the normal range. There was no significant difference in serum creatinine and eGFR pre-MWA and post-MWA. No major MWA-related complications occurred.

CONCLUSION

Ultrasound-guided MWA shows potential as a viable treatment for THPT in RT patients. However, further studies are required to confirm its safety and effectiveness in larger cohorts of longer duration.

Impact of parathyroidectomy among nondiabetic hemodialysis patients with severe hyperparathyroidism

Background

Parathyroidectomy (PTX) is a treatment for hyperparathyroidism (HPT) and has uncertain risks and benefits. The aim of this study was to evaluate the effect of PTX versus nonoperative treatment among nondiabetic hemodialysis patients.

Methods

A retrospective matched cohort study was performed. Each PTX patient was matched with one patient who had severe HPT but rejected PTX. The patients were matched by sex, birth date, date of first dialysis, nondiabetic status, and left ventricular ejection fraction. The serum markers, survival, main adverse cardiovascular and cerebrovascular event (MACCE) rates, and hospitalization were compared between the PTX patients and matched non-PTX patients.

Results

There were 1143 patients at our center in the Chinese National Renal Data System (CNRDS) between 2010 and 2020. Of these, 75 PTX patients were matched with 75 non-PTX patients. Rapid decreases in the mean intact parathyroid hormone, calcium and phosphorus concentrations, and a gradual increase in hemoglobin concentration were observed in the PTX group. The mortality was 2.9 per 100 patient-years in the PTX group and 10.9 per 100 patient-years in the non-PTX group (p < 0.001). Compared with non-PTX patients, PTX patients had an adjusted HR for death of 0.236 (95% CI 0.108–0.518). The cumulative MACCE rates were 6.7 per 100 patient-years in the PTX group and 15.2 per 100 patient-years in the non-PTX group (p < 0.001). The adjusted HR of the occurrence of first MACCE for PTX patients compared with non-PTX patients was 0.524 (95% CI 0.279-0.982). The cumulative hospitalization rates were 50.3 per 100 patient-years in the PTX group and 66.5 per 100 patient-years in the matched non-PTX group (p < 0.001).

Conclusions

Compared with non-PTX patients, PTX was associated with an improvement in the biochemical measures and patient-level outcomes in nondiabetic hemodialysis patients with severe HPT.

Effect of total parathyroidectomy in patients with secondary hyperparathyroidism: a retrospective study

Purpose

To investigate the therapeutic efficacy, feasibility, and safety of total parathyroidectomy (tPTX) in the treatment of secondary hyperparathyroidism (SHPT).

Methods

The clinical data of 34 SHPT patients admitted to the Department of Nephrology, Yuxi People’s Hospital, from January 2018 to January 2021 who had received tPTX, were retrospectively analyzed. The indications for tPTX were severe SHPT that did not respond to medical treatment and was ineligible for kidney transplantation. tPTX without autotransplantation was adopted to compare the level of symptom relief and changes in serum intact parathyroid hormone (iPTH), blood calcium, and blood phosphorus pre- and postoperatively.

Results

In 34 patients, 142 parathyroid glands were removed, including 21 ectopic parathyroid glands (14.78%). Six patients (17.64%, 6/34) had supernumerary parathyroid glands. At 6 h postoperatively, arthralgia and bone pain were significantly reduced to almost zero in 94.12% (32/34) of patients. At 24 h postoperatively, relief of bone pain and improvement of limb movement were observed in 100% (34/34) of patients, and pruritus almost disappeared in 86.36% (19/22) of patients. There were significant differences in iPTH (χ2 = 134.93, P < 0.05), calcium (χ2 = 23.02, P < 0.05), and phosphorus (χ2 = 102.11, P < 0.05) levels preoperatively and 40 min, 24 h, 1 week, half a year, and last available (> 1 year) postoperatively.

The patients were followed up for 15–47 months (median 33 months). Hypoparathyroidism was observed in three patients, who underwent neck dissection or partial thymotomy concurrently for different reasons. No intractable hypocalcemia or adynamic bone disease occurred during the follow-up period.

Conclusion

In SHPT patients who were ineligible for renal transplantation, tPTX was effective, safe, and reliable, with a low recurrence rate. However, when tPTX was performed alone without autologous transplantation, bilateral neck exploration was sufficient, and central neck dissection and thymic resection were inadvisable.

A Deceptive Preoperative Imaging of an Ectopic Supernumerary Parathyroid Adenoma in a Secondary Hyperparathyroidism

Ectopic and supernumerary parathyroid glands in the neck is a real surgical challenge especially in multi-gland pathologies. We report a supernumerary ectopic gland at a rare site in the neck in a chronic kidney disease patient which required a re-exploration following a deceptively successful bilateral neck dissection.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism.

BACKGROUND

Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT.

METHODS

Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.

Efficacy and safety of radiofrequency ablation versus parathyroidectomy for secondary hyperparathyroidism in dialysis patients: a single-center retrospective study

We compared the efficacy and safety of ultrasound (US)-guided radiofrequency ablation (RFA) and parathyroidectomy (PTX) for the treatment of secondary hyperparathyroidism (SHPT). In this single-center retrospective study, we divided patients into PTX (n = 53) and RFA (n = 47) groups. The primary outcome was the proportion of patients who achieved the target intact parathyroid hormone (iPTH) concentration range (≤ 300 pg/mL). Secondary outcomes were the differences in the changes in iPTH, calcium, and phosphorus levels over time and prognosis. iPTH concentrations of 82.1% and 64.1% in the PTX and RFA groups, respectively, were within the recommended range at the endpoint (P = 0.07). iPTH concentrations in the PTX and RFA groups dropped sharply after treatment (82 ± 163 pg/mL and 280 ± 307 pg/mL, respectively, P < 0.001). There was no difference in the trends of iPTH, calcium, and phosphorus levels between the two groups (P > 0.05). Survival analysis revealed no differences in all-cause mortality and cumulative response rate between the two groups (P = 0.90, P = 0.14, respectively). Notably, the incidence of infection and length of the hospital stay in the RFA group were significantly lower. The preoperative bone-specific alkaline phosphatase concentration was a risk factor for postoperative hypocalcemia. US-guided RFA is minimally invasive and compared to PTX in terms of long-term efficacy and complications in the treatment of severe SHPT in maintenance dialysis patients. It may be used as an alternative technique to PTX; however, further studies are needed.

Implications of regulator of G-protein signaling 5 expression in the pathogenesis of primary and secondary hyperparathyroidism

OBJECTIVE

To study the protein and mRNA expressions of regulator of G-protein signaling 5 (RGS5) in the pathogenesis of hyperparathyroidism.

METHODS

The expression of RGS5 protein in 20 primary hyperparathyroidism (PHPT), 31 secondary hyperparathyroidism (SHPT), and 20 control cases were studied by immunohistochemistry (IHC). The expression of RGS5 mRNA in 15 PHPT, 102 SHPT, and 7 normal parathyroid tissue were measured by quantitative real-time PCR (qRT-PCR) method.

RESULTS

The expressions of RGS5 in PHPT tissues were significantly higher than that in SHPT and normal parathyroid tissues (P < 0.05). While the differences in RGS5 protein expressions between SHPT and respective control samples were not statistically significant (P > 0.05). Likewise, the RGS5 mRNA expression in PHPT was significantly higher than that in SHPT (P < 0.05) and normal parathyroid (P < 0.05) samples. In a similar line, the differences in RGS5 gene expressions between SHPT and control tissues were not statistically significant (P > 0.05).

CONCLUSIONS

The characteristic RGS5 protein and mRNA levels in hyperparathyroidism might be helpful in discovering the pathomechanism of hyperparathyroidism and novel therapeutic targets as well.

Minimally invasive video-assisted parathyroidectomy (MIVAP) versus conventional parathyroidectomy for renal hyperparathyroidism: a retrospective multicenter study

To compare minimally invasive video-assisted parathyroidectomy (MIVAP) versus conventional surgery for renal hyperparathyroidism (rHPT). Between 2006 and 2020, 53 patients underwent MIVAP and 182 underwent conventional parathyroidectomy for rHPT at the Kliniken Essen-Mitte and Knappschaftskrankenhaus Bochum, respectively. Two propensity score-matched groups were retrospectively analyzed: the MIVAP group (VG; n = 53) and the conventional group (CG; n = 53). To assess long-term results, the patients were questioned prospectively (VG; n = 17, and CG; n = 26). The VG had a smaller incision (2.8 vs. 4.8 cm), shorter operation duration (81.0 vs. 13.9 min), and shorter duration of stay (2.4 vs. 5.7 days) (p < 0.0001) but a smaller drop in parathyroid hormone (PTH) postoperatively (81.3 vs. 85.5%. p = 0.022) than the CG. The conversion rate was 9.4% (n = 5). The VG had better Patient Scar Assessment Scale (PSAS) scores (10.8 vs. 11.7 p = 0.001) but worse SF-12 health survey scores (38.7 vs. 45.8 for physical health and 46.7 vs. 53.4 for mental health) (p < 0.0001). The PTH level at follow-up was higher in the VG (162.7 vs. 59.1 ng/l, p < 0.0001). There were no differences in morbidity, number of removed parathyroid glands, disease persistence, late rHPT relapse and need for repeat surgery between groups. MIVAP was superior to conventional parathyroidectomy regarding aesthetic outcomes and cost effectiveness. Conventional surgery showed better control of PTH levels and health scores on follow-up than MIVAP, without any impact on rHPT relapse and need for repeat surgery.

Trail registration number and date of registration: DRKS00022545 on 14.12.2020.

Outcomes following parathyroidectomy for secondary hyperparathyroidism in patients with chronic kidney disease - a single-centre study

BACKGROUND

Surgical parathyroidectomy may be required for severe and refractory secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD). Parathyroidectomy is associated with long-term survival benefit despite an increase in short-term morbidity and mortality. Global variation in practice exists, with limited Australian data on outcomes following parathyroidectomy.

METHODS

We conducted a retrospective study of patients who underwent parathyroidectomy for SHPT between January 2010 and December 2019 at a single tertiary referral centre in Melbourne, Australia. Biochemical markers and medications were assessed 12 months pre- and post-surgery. Clinical outcomes, including hospital readmission, cardiovascular events and mortality were assessed following surgery.

RESULTS

During the 10-year study period, 129 patients underwent parathyroidectomy for SHPT (mean age 50.7 ± 15 years, 109 (85%) on dialysis). Significant immediate post-operative complications were seen in eight patients (6%), requiring admission to the intensive care unit (n = 6) or return to theatre (n = 2). Within the first 6 months, 24 patients (19%) required hospital readmission. Within 12 months post-parathyroidectomy, 100 (78%) and 103 patients (80%) experienced at least one episode of hypercalcaemia (corrected calcium >2.6 mmol/L) or hypocalcaemia (corrected calcium <2.1 mmol/L) respectively. Over a 12-month period there were six deaths (5%), and eight patients (6%) experienced a major cardiovascular event.

CONCLUSION

Significant fluctuations in serum calcium levels are common post-parathyroidectomy, however long-term morbidity and mortality in our cohort were lower than previously reported, highlighting that parathyroidectomy in a carefully selected cohort is safe for severe SHPT refractory to medical treatment. This article is protected by copyright. All rights reserved.

Microwave ablation versus parathyroidectomy for severe secondary hyperparathyroidism in patients on hemodialysis: a retrospective multicenter study

BACKGROUND

Microwave ablation is effective for severe secondary hyperparathyroidism, but the difference in efficacy between microwave ablation and parathyroidectomy remains unclear. In this multicenter retrospective cohort study, we compared the long-term clinical efficacy of microwave ablation and parathyroidectomy for severe secondary hyperparathyroidism undergoing hemodialysis.

MATERIALS AND METHODS

The patients were divided into microwave ablation and parathyroidectomy groups. The primary endpoint was the proportion of patients with intact parathyroid hormone (iPTH) concentrations within the target range (100-600 pg/mL) during the efficacy assessment phase. The secondary endpoints were (i) differences in iPTH concentrations over time between the two groups, and (ii) decreases in iPTH concentrations over time in the two groups.

RESULTS

Microwave ablation was performed in 47/92 patients and parathyroidectomy in 45/92. Primary endpoint: iPTH concentrations within the target range were achieved during the efficacy assessment phase in 26/47 patients (55.3%) and in 14/45 (31.1%) patients in the microwave ablation and parathyroidectomy groups, respectively (p = .02). Secondary endpoints: (i) Mean iPTH concentrations during the efficacy assessment phase were significantly higher in the microwave ablation versus parathyroidectomy groups (649 ± 519 pg/mL versus 136 ± 228 pg/mL, respectively; p < .01). (ii) Mean decrease in iPTH concentration from baseline was 725 ± 605 pg/mL versus 1369 ± 478 pg/mL in the MWA versus parathyroidectomy groups, respectively (p < .01).

CONCLUSIONS

Ultrasound-guided percutaneous microwave ablation provides higher iPTH target-achieving rates than parathyroidectomy in patients with severe secondary hyperparathyroidism undergoing hemodialysis.

Recent advances in understanding and managing secondary hyperparathyroidism in chronic kidney disease

Secondary hyperparathyroidism is a complex pathology that develops as chronic kidney disease progresses. The retention of phosphorus and the reductions in calcium and vitamin D levels stimulate the synthesis and secretion of parathyroid hormone as well as the proliferation rate of parathyroid cells. Parathyroid growth is initially diffuse but it becomes nodular as the disease progresses, making the gland less susceptible to be inhibited. Although the mechanisms underlying the pathophysiology of secondary hyperparathyroidism are well known, new evidence has shed light on unknown aspects of the deregulation of parathyroid function. Secondary hyperparathyroidism is an important feature of chronic kidney disease-mineral and bone disorder and plays an important role in the development of bone disease and vascular calcification. Thus, part of the management of chronic kidney disease relies on maintaining acceptable levels of mineral metabolism parameters in an attempt to slow down or prevent the development of secondary hyperparathyroidism. Here, we will also review the latest evidence regarding several aspects of the clinical and surgical management of secondary hyperparathyroidism.

Evaluation of laboratory parameters and symptoms after parathyroidectomy in dialysis patients with secondary hyperparathyroidism

Objectives: The aim of the study was to evaluate the laboratory parameters and symptoms after parathyroidectomy (PTX) in dialysis patients with secondary hyperparathyroidism (SHPT), and to briefly analyze the different therapeutic effects of the three surgical methods.

Methods: A total of 182 dialysis patients who underwent PTX between February 2012 and January 2018 at the Second Affiliated Hospital of Soochow University were included in this study and followed for 12 months. Laboratory parameters such as calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), and intact parathyroid hormone (iPTH) were measured before and after operation. According to the follow-up time and type of operation, we calculated the percentage of laboratory indicators reaching the recommended range of the KDIGO guidelines after surgery. We also analyzed the improvement of bone pain and pruritus, as well as surgical complications.

Results: After the operation, the levels of iPTH, Ca, and P decreased significantly at each time point. ALP increased at the first postoperative week and gradually decreased to normal range after 3 months. Symptoms, such as bone pain and pruritus, were significantly relieved. According to the follow-up time and three surgical methods (subtotal parathyroidectomy, total parathyroidectomy, total parathyroidectomy plus autologous transplantation), we found that the ratio of each laboratory parameter reaching the recommended range of KDIGO guidelines was significantly different.

Conclusion: PTX is a safe and effective therapy for treating SHPT that is refractory to medical therapies and accompanied by related signs and symptoms in dialysis patients. All three operative techniques were effective in controlling SHPT.

Subtotal parathyroidectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism: an updated systematic review and meta-analysis

PURPOSE

The optimal surgical approach of parathyroidectomy for patients with secondary hyperparathyroidism (SHPT) has been controversial. The updated meta-analysis aimed to compare the effectiveness of subtotal parathyroidectomy (SPTX) versus total parathyroidectomy with autotransplantation (TPTX + AT).

METHODS

A thorough systematic search was performed on the databases of PubMed, EMBASE, and Cochrane library to identify eligible studies. Data were extracted and pooled into a meta-analysis. The primary outcomes were the symptomatic improvement, radiological changes, hypocalcemia rate, the requirement for vitamin D analogues, time to recurrence, recurrence, persistence, and reoperation rates of SPTX versus TPTX + AT.

RESULTS

A total of 18 studies with 3656 patients (1864 patients in SPTX and 1792 patients in TPTX + AT group) were included, and 15 studies were included in quantitative synthesis. No significant difference was observed in symptomatic improvement (93.3%, 89.0%; P = 0.99), radiological changes (85.4%, 85.3%; P = 0.91), hypocalcemia rate (16.6%, 18.1%; P = 0.29), persistence rate (6.1%, 2.0%; P = 0.16), time to recurrence (mean difference 1.46; P = 0.87), recurrence rate (9.2%, 7.1%; P = 0.76), and reoperation rate (5.3%, 5.8%; P = 0.66) between SPTX and TPTX + AT groups. Longer operative time (150 vs. 120 min), prolonged in-hospital stay (5.0 vs. 4.1 days), lower 1-month serum calcium level, and higher requirement for vitamin D analogues at 12 months were significantly observed in patients who underwent TPTX + AT compared to SPTX.

CONCLUSIONS

The two surgical approaches were both effective at controlling SHPT in clinical and laboratory terms. However, most of the data shown were not statistically significant. It was acceptable that surgeons chose either SPTX or TPTX + AT for SHPT.