Parathyroidectomy: still the best choice for the management of severe secondary hyperparathyroidism

Abstract

Introduction: Management of secondary hyperparathyroidism (SHPT) is a challenging endeavor with several factors contruibuting to treatment failure. Calcimimetic therapy has revolutionized the management of SHPT, leading to changes in indications and appropriate timing of parathyroidectomy (PTX) around the world. Methods: We compared response rates to clinical vs. surgical approaches to SHPT in patients on maintenance dialysis (CKD 5D) and in kidney transplant patients (Ktx). A retrospective analysis of the one-year follow-up findings was carried out. CKD 5D patients were divided into 3 groups according to treatment strategy: parathyroidectomy, clinical management without cinacalcet (named standard - STD) and with cinacalcet (STD + CIN). Ktx patients were divided into 3 groups: PTX, CIN (cinacalcet use), and observation (OBS). Results: In CKD 5D we found a significant parathormone (PTH) decrease in all groups. Despite all groups had a higher PTH at baseline, we identified a more pronounced reduction in the PTX group. Regarding severe SHPT, the difference among groups was evidently wider: 31%, 14% and 80% of STD, STD + CIN, and PTX groups reached adequate PTH levels, respectively (p<0.0001). Concerning the Ktx population, although the difference was not so impressive, a higher rate of success in the PTX group was also observed. Conclusion: PTX still seems to be the best treatment choice for SHPT, especially in patients with prolonged diseases in unresourceful scenarios.

Severe secondary hyperparathyroidism: an increasing problem in CKD but the best management option is still unknown

“…What is harder to discern though is whether the more pronounced reductions in PTH with parathyroidectomy reported by Ramos et al 5 and other studies translates into superior patient-centered outcomes, especially with only one-year follow up reported. Given that SHPT seems to be directly correlated with patient risk of fracture and cardiovascular outcomes in CKD, use of serum PTH as a surrogate treatment target is attractive.…”

“…In this journal, Ramos et al 5 present a single-center, retrospective analysis of patients with SHPT who have kidney failure, either being treated with maintenance hemodialysis or were recipients of a kidney transplant (from a tertiary referral center with a dedicated CKD-MBD clinic). The authors compared three main treatment strategies: supportive measures alone (adjustments to dialysis, use of phosphate binders, and vitamin D-based compounds), or supportive measures with the addition of either cinacalcet or parathyroidectomy.…”

“…As Ramos et al 5 outline, with more liberal PTH targets according to current international clinical guidelines 1 , an increasing proportion of CKD patients may develop more severe SHPT refractory to medical therapy (including treatment with calcimimetics). Whether parathyroidectomy is the ‘best choice’ for the management of severe SHPT as described in their conclusion is yet to be determined; and as the authors themselves acknowledge, their study has inherent limitations due to its retrospective observational design.…”

“…As the authors discuss, in their setting and in Brazil in general, there is limited access to cinacalcet and parathyroidectomy, which would be expected to influence selection of individuals who receive these treatments. This could have resulted in imbalances between the analyzed groups, and likely accounts for differences in baseline demographics, including the parathyroidectomy group being younger and having higher baseline levels of PTH 5 . Arguably though, the parathyroidectomy group with evidence of more severe SHPT at baseline does not necessarily detract from their main contention of surgical intervention being associated with more significant reductions in serum PTH.…”