Clinical course after parathyroidectomy in adults with end-stage renal disease on maintenance dialysis

Abstract

BackgroundParathyroidectomy (PTX) is done in cases of secondary hyperparathyroidism from chronic kidney disease to improve renal osteodystrophy. Despite this widespread practice, clinical outcomes regarding the benefits of this procedure are still lacking. Most studies in the literature have opted to report the laboratory outcome instead. Our study aimed to evaluate the postoperative clinical course for patients who had undergone total PTX without autoimplantation.Methods and resultsAll patients who underwent PTX between January 2010 and February 2014 in a tertiary referral center were included in this study and followed up for 12 months. Laboratory outcome parameters include various preoperative and postoperative serial measurements of laboratory parameters. Patients’ hospitalizations and mortality records post-PTX were also retrieved and recorded. In all, 90 patients were included in this study. The mean age was 48 ± 18 years. The majority of the patients (54.4%) were male and 90% were on hemodialysis. The mean duration of dialysis was 8.0 ± 5.0 years. Indications for PTX were symptomatic bone pain (95.6%), fractures (3.3%) and calciphylaxis (1.1%). Mean preoperative values for serum calcium, phosphate, alkaline phosphatase and intact parathyroid hormone (iPTH) were 2.40 ± 0.23mmol/L, 1.92 ± 0.51 mmol/L, 689.60 ± 708.50 U/L and 311.90 ± 171.94 pmol/L, respectively. The majority (92.2%) had all four glands removed and 92.2% of the glands showed hyperplasic changes. One year after PTX, 90 patients (100%) had serum iPTH <8 pmol/L and 28 patients (31%) had unmeasurable iPTH levels. A total of 15% of patients had hospitalizations for various reasons and of these, 50% were within 90 days. The mean hospital stay was 14.4 ± 18.6 days. The mortality rate was 4.4% and of these, 25% were in first 30 days. Causes of death were mainly from sepsis (75%) and acute coronary syndrome (25%). One patient (1.1%) had a relapse.ConclusionsEven though PTX markedly reduces postoperative serum iPTH levels, it carries with it significant risk of morbidity and mortality.

Predictors of early postoperative hypocalcemia in patients with secondary hyperparathyroidism undergoing total parathyroidectomy

“…Risk factors proposed to date include a lower preoperative corrected serum calcium concentration, radiologic evidence of osteitis fibrosa cystica, a higher bone-specific ALP concentration, and a greater weight of the resected parathyroid glands. 16 , 19 , 48 – 50 Our multiple logistic regression analysis showed that the preoperative ALP concentration was an independent predictor of hypocalcemia: a higher preoperative ALP concentration was associated with a higher incidence of postoperative hypocalcemia. In agreement with our findings, patients with a high preoperative ALP concentration are reportedly more likely to develop postoperative hypocalcemia and even HBS.…”

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

“…However, these treatments do not always provide adequate control of SHPT, particularly among patients with severe parathyroid hyperplasia [8,9]. Successful parathyroidectomy can drastically decrease PTH levels, improve control of serum calcium and phosphorus levels, ameliorate symptoms related to SHPT, and reduce cardiovascular events and overall mortality in dialysis patients [10][11][12]. PTX is, thus, currently recommended in dialysis patients with severe SHPT who fail to respond to medical treatment [13].…”

Surgical Outcomes of Subtotal Parathyroidectomy for Renal Hyperparathyroidism

“…The surgical management of rHPT involves standard bilateral exploration with or without bilateral cervical thymectomy. Since the first parathyroidectomy for secondary hyperparathyroidism was performed by Fergusson in 1967, several surgical approaches have been reported, namely total parathyroidectomy alone, total parathyroidectomy with autotransplantation, subtotal parathyroidectomy, and resection of only the enlarged parathyroid glands [11]. However, the optimal timing, extent, and type of surgery for rHPT remain a constant matter of debate.…”