A roadmap to parathyroidectomy for kidney transplant candidates

Abstract

Chronic kidney disease Mineral and Bone Disorder may persist after successful kidney transplantation. Persistent hyperparathyroidism has been identified in up to 80% of patients throughout the first year after kidney transplantation. International Guidelines lack strict recommendations about the management of persistent hyperparathyroidism. However, it is associated with adverse graft and patients’ outcomes such as higher fracture risk and an increased risk of all-cause mortality and allograft loss. Secondary hyperparathyroidism may be treated medically (vitamin D, phosphate binders and calcimimetics) or surgically (parathyroidectomy). Guideline recommendations suggest medical therapy first but do not clarify optimal PTH targets or indications and timing of parathyroidectomy. There are no clear guidelines or long-term studies about the impact of hyperparathyroidism therapy. Parathyroidectomy is more effective than medical treatment although associated to increased short term risks. Ideally, parathyroidectomy should be performed before kidney transplantation to prevent persistent hyperparathyroidism and improve graft outcomes. We now propose a roadmap for the management of secondary hyperparathyroidism in patients eligible for kidney transplantation that includes the indications and timing (pre- or post-kidney transplantation) of parathyroidectomy, the evaluation of parathyroid gland size and the integration of parathyroid gland size in the decision-making process by a multidisciplinary team of nephrologists, radiologists and surgeons.

Surgical Management of Autosomal Dominant Polycystic Kidney Disease: Principles and Current Practice

“…Persistent hyperparathyroidism posttransplantation, which can be identified in up to 80% of transplant recipients, is associated with adverse graft and patient outcomes, including higher fracture risk and an increased risk of all-cause mortality and allograft loss. 49 Medical management including vitamin D, phosphate binders and calcimimetic agent (Cinacalcet) is successful in controlling hyperparathyroidism in the majority of patients. Parathyroidectomy is indicated in intractable cases of secondary and tertiary hyperparathyroidism.…”

Pre-Transplant Calcimimetic Use and Dose Information Improves the Accuracy of Prediction of Tertiary Hyperparathyroidism after Kidney Transplantation: A Retrospective Cohort Study

“…In patients treated with calcimimetics, the assessment of THPT risk can be challenging because of the drastic decrease in serum Ca and PTH levels [ 31 , 32 ]. Cianciolo et al [ 33 ] proposed evaluating the need for PTx in KTx candidates receiving calcimimetic treatment after ceasing treatment for 2–4 weeks. However, discontinuation of calcimimetic treatment leads to a rapid increase in PTH levels, which may cause hyperparathyroidism-related adverse events and complicate the optimal timing of KTx.…”

Parathyroidectomy and survival in a cohort of Italian dialysis patients: results of a multicenter, observational, prospective study

“…Secondary hyperparathyroidism (SHPT) in end-stage renal disease (ESRD) is associated with disturbances in mineral metabolism, metabolic bone disease and renal osteodystrophy, bone fractures, vascular calcifications [ 1 – 4 ] and the eventual increase of cardiovascular disease and mortality. Conventional treatment of SHPT with phosphate binders, vitamin D receptor activators (VDRAs) and calcimimetics [ 5 – 7 ] may not allow adequate biochemical control, and parathyroidectomy (PTX) is still recommended in severe cases failing to respond to medical therapy [ 8 ].…”